On the first day of National Oral Health Month in April, I was one of the volunteers hosting the Ottawa Dental Society booth at the Capital Parent and Kids Show. That day, I conducted an informal survey to find out how many kids in the Ottawa region had visited a dentist by age 1. The answer, as I soon discovered, was very few: less than 10% of the parents I surveyed had taken their children to the dentist before their first birthday.
Quite a few parents told me they had approached their dentist to schedule an appointment for their 12- to 24-month-old babies and were told to come back when their children reached age 3, 4 or even 5. Others were told to come back once all their child’s teeth came in. I understand that some dentists are uncomfortable seeing very young children. But actively discouraging well-informed parents from bringing their baby in for an examination falls embarrassingly short of supporting high value and trust in our profession. I could think of only one thing that we need—boot camp.
The Dental Care Void in the Very Young
Before I go further I must confess that, although I knew that the Canadian Academy of Pediatric Dentistry (CAPD) promoted the concept of a “dental home” by age 11 and that CDA recommended a dental assessment of infants within 6 months of the eruption of the first tooth or by age 12, it was not until I attended a compelling presentation on early childhood caries by Drs. Ian McConnachie and Stephen Abrams at the 2009 Ontario Dental Association annual spring meeting, that I began implementing these recommendations in my general practice. Until then, I thought that I did not need to see children until age 3.
Whether it was the novelty of treating an infant patient or my lack of experience with babies (my own stepchildren were 9 and 11 when they came into my life), I initially felt uncomfortable conducting dental exams on 1-year olds. Although many do not cry while being examined, many do. And we know how stressful it can be for everyone to hear a patient cry in a dental office, especially a little one. But even more discomforting were my clinical discoveries: plenty of plaque, early signs of caries with white or brown enamel spots and even gingivitis. I also discovered that many well-intentioned, caring parents experience daily struggles with their uncooperative toddlers and are unable to provide adequate daily oral care.
Recently, my colleague and friend Dr. Clive Friedman coached a small group of dental students while they performed oral health examinations on infants in London, Ontario. They saw 82 children under the age of 20 months. Of these children, 32 showed early signs of caries with ICDAS (International Caries Detection and Assessment System) scores of 1 or 2. Three children were afflicted with severe early childhood caries and would require sedation or general anesthesia. Similar stories have been shared by other colleagues across the province.
According to Dr. McConnachie, in 2009 in our nation’s capital, more than 2 children each month were hospitalized with facial cellulitis, a life-threatening condition resulting from severe tooth infection. Today, dentistry under general anesthesia accounts for the single greatest use of operating room time at the Children’s Hospital of Eastern Ontario.
After the successful reduction of tooth decay at the end of the 20th century, the dawning reality is that the incidence of early childhood caries, a preventable disease, has increased significantly in children between the ages of 2 and 5.
New Thinking About Caries Detection and Treatment
Shifting our general attitudes and practices to include 1-year-old patients is critical. This must be accompanied by a shift in awareness of the multifactorial nature of oral diseases. At the 2001 Consensus Development Conference on Diagnosis and Management of Dental Caries Throughout Life, commissioned by the U.S. National Institutes of Health, caries were described as a transmissible bacterial infection and a multifactorial disease that reflects changes in one or more significant factors in the oral environment. Diagnosis involves recognition of early and reversible enamel changes, rather than simply noting cavities—the irreversible, ultimate expression of the disease.
Even more critically, early detection and treatment of caries requires a shift in diagnostic methods and a solid understanding of risk assessment and management. This shift must include the regular use of nonoperative modalities, such as remineralization techniques, tailored to each patient’s risk level.
However, the best way to reverse the course of this disease is to educate parents. By pointing out changes in the enamel of their child’s teeth, we can increase parental awareness about early signs of tooth decay. By coaching parents on how to address conflicts around oral hygiene with their children, we can provide practical strategies for overcoming a resistance to toothbrushing.
Oral Health as the Foundation of Health
There is an emerging movement towards oral health as the foundation of overall health. A task team for Vision 2020—Shaping the Future of Oral Health convened at the 2012 FDI Annual World Dental Congress in Hong Kong and released a report3 that outlined strategies to address global oral health challenges, including an expanded role for dental professionals in helping people achieve health through good oral health.
Like a canary in a coal mine, the mouth offers clues regarding the state of balance in one's health and can be a warning of future health issues. Welcoming 1-year olds to our general dental practices is an opportunity to initiate conversations about overall health and to stimulate a shift towards dentists as health leaders.
Boot Camp for the Profession
This brings me back to boot camp. I invite dentistry’s governing bodies to help enlighten oral health professionals by developing nationwide programs that coach and inspire dentists to become leaders in health. The starting point would be the development of a comprehensive program focused on the successful implementation of a child’s first dental visit by the age of 1 across Canada.
I believe that many members of our profession have difficulty visualizing the examination process of a 1-year old and cannot see how this fits in the current restoration-focused business model of dentistry. I also believe a large number of my colleagues hold on to the belief that the recommendations to conduct dental assessments by age 1 apply to disadvantaged communities or perhaps only to pediatric dentists. I think that clarifying the concept of a “dental home” by age 1, along with the evidence-based knowledge that supports it, will motivate many colleagues to readily embrace recommendations on scheduling a child’s first dental visit, as specified by the CAPD and CDA. Those who choose not to treat infants can still support these recommendations by sharing their support of the concept with their administrative team and by offering to refer patients to a nearby colleague who welcomes infants.
Including infants in early oral health evaluations is a must. If we all commit to working towards the same goal of treating infants by their first birthdays, we can make inroads into the problem of early childhood caries and truly promote high value and trust in our profession.
- Canadian Academy of Pediatric Dentistry. Dental Home By Age One – Recognition and Treatment of ECC. Available from: http://www.capd-acdp.org/index.php?option=com_content&view=article&id=4:dental-home-by-age-one-recognition-and-treatment-of-ecc-&catid=2:hot-topics&Itemid=4
- Canadian Dental Association. CDA Position on First Visit to the Dentist. March 2012 Available from: http://www.cda-adc.ca/_files/position_statements/first_visit.pdf
- FDI World Dental Federation. FDI Vision 2020: Shaping the Future of Oral Health. Available from: http://www.fdiworldental.org/documents/10157/e5a69514-515e-401a-b6cc-838be48955ae