USA - First dental visit by first birthday

First dental visit by first birthday
by Carol Harrison, 1/15/2007
Judging by the impression made by Dr. Francisco Ramos-Gomez at the Potawot Health Village, making prevention of tooth decay an integrated concern of all health care and social service providers might be the best hope for tackling an entirely preventable disease that affects more than two-thirds of the nation’s elementary school children. Tuesday, Ramos-Gomez lectured and trained United Indian Health Services health care professionals to recognize and prevent what Head Start has identified as its most prevalent health problem for children. UIHS had more than 50 participants exposed to a multidisciplinary approach that acknowledges prevention of tooth decay cannot be seen as the responsibility of only the overwhelmed dental community. With many dentists not taking patients until the age of 3, the burden of outreach about early childhood caries is falling on others. Those likeliest to make earlier and more regular contact with pregnant women, mothers and children through the age of 4 are the health care and social service providers who go into the homes, provide nutrition counseling or see to the immunizations and checkups that dominate the early years of life. “Early childhood caries isn’t just a dental problem,” said UIHS Executive Director Jerome Simone. Instead, it is an infectious disease that can be passed from caregiver to child. It is caused by two bacteria, mutans stereptococci and lactobacilli species. The bacteria stick to the film on teeth and feed on what each individual consumes. The sugar-loving bacteria produce acid that can break through the outer surface of the tooth, causing it to decay and rot.
Saliva can protect against the acid attacks, but it can’t overcome too many bacteria. Nor can it protect during the 20 to 30 minutes after eating or when saliva becomes more acidic and less alkaline. “The mouth is like a kitchen,” said Dr. Greg Jaso, director of the UIHS dental clinic. “If the kitchen’s cleaned up and taken care of, the mess that comes out of it won’t be quite so bleak.”
Ramos-Gomez lectured about the causes of early childhood caries and how to spot its telltale signs. He also spoke about the identification of at-risk children and strategies to prevent decay. Among those strategies: educating parents, making use of one of two economical tests to detect the decay-causing bacteria, use of sugar-free gum that lists xylitol as its first ingredient, drinking fluoridated water and application of fluoride varnish.
“We’re going to learn about (early childhood caries) and become actively involved in facing and communicating dental prevention,” Simone promised. The Potawot Village he’s led for more than 32 years is already a one-stop shop for Native American health care, making it easier to bridge what Simone sees as the biggest problem the campaign against tooth decay faces: fragmentation of care.
The Food and Drug Administration licensed fluoride varnish in 1994. According to the October 2006 edition of The Indian Health Service Primary Care Provider, is has been used for caries prevention in Europe for more than 40 years and has been reported to reduce caries 40-55 percent in selected populations.
Ramos-Gomez reported research showing decay in 8 percent of at-risk 1-year-olds and 67 percent of 4-year-olds. He also said the results of his own study showed conclusively that children who did not receive fluoride varnish were more than twice as likely to develop tooth decay as those that received it annually. Additionally, those who did not receive fluoride varnish were nearly four times as likely to develop tooth decay than those who received four treatments over two years. “We know it works. We’ve been doing it for three years,” said Dr. Wendy Ring of the mobile medical unit. Ramos-Gomez said Medi-Cal reimburses for fluoride varnish up to three times a year.
The chief barrier to fluoride varnish is not its cost, but its delivery to infants and preschool children before they develop tooth decay. “Access to dental care for preschool children is problematic nationwide and also within the Indian Health Service,” the October 2006 IHSPCP issue stated.
That is especially true in Humboldt County.
“We have rampant early childhood caries in this county,” said Laura McEwen, the county’s oral health coordinator. “We have a shortage of providers and an overabundance of decay.” “Dentists are overwhelmed treating the madness,” Ramos-Gomez said. “You have parents saying, ‘It’s only baby teeth, doctor. Who cares?’ But if they don’t have good teeth, they can’t chew. It affects their nourishment. It causes psychological damage and they’re in constant pain. They are not school ready and they cannot focus.”
Locally, the chances of getting early childhood care for at-risk newborns and preschoolers is not good. The Web site of the American Academy of Pediatric Dentists lists three within a 100-mile radius of Eureka: Kerisa Elloway, Garrison Tucker and Wesley Wieman. Tucker has a two-year waiting list; the other two are taking new patients. None of the three accept Medi-Cal, which makes them no different than the overwhelming majority of dentists in the area.
Calls to four other area dentists found none taking children under the age of 3 despite the fact that the AAPD Web site recommends a visit when the first tooth comes in, usually between 6 to 12 months of age. “I talked to someone the other day who pays cash. She’s a nurse, the dad’s a physician. She said she still can’t get their child in to see a dentist because they just don’t see children before 3 years of age,” said UIHS dietitian Kari Gullingsrud, R.D. “Many dentists are terrified of screaming and crying babies,” Ramos-Gomez said. “So — get over it. Learn to differentiate between a good cry and a bad one.” Medical providers got over it long ago as they regularly give shots to screaming children. However, they tend to treat the mouth as the only orifice they won’t violate. Other than depressing a tongue, it’s treated as the domain of dentists.
That’s the main reason why funding from the California Endowment and the Humboldt Area Foundation enabled the Maternal, Child and Adolescent Health Branch of the Humboldt County Department of Health and Human Services to bring Ramos-Gomez north for a three-day swing through the county. MCAH reasons other health care professionals, caregivers, pediatric specialists and parents must take the lead on early prevention. That’s exactly what UIHS nurse Eric Gordon did when he examined a squealing volunteer’s mouth and applied fluoride varnish after Ramos-Go mez’ presentation.“Being a nurse on the medical side, I’ve never experienced having a small child in my lap and applying a dental varnish. This was my first time,” Gordon said.
He used the recommended knee-to-knee technique that allowed mom to function as a warm and familiar dental chair. With the child’s legs encircling her waist, mom lowers the child’s head to the lap of the provider. The mother provides the necessary restraint while the provider checks the teeth and applies the topical varnish. “I didn’t know it could go on so quickly,” said surprised UIHS physician Dennie Schultheis. “I was trying to paint a picket fence.” Ramos-Gomez said putting a drop in each quadrant and rubbing quickly would do the trick. “After four or five tries, you’ll have it down.” Making it easy is key to convincing all health care providers and outreach coordinators to participate in getting the early childhood caries epidemic under control.
Almost 70 percent of Native American children aged 2 through 4 suffer from tooth decay — a prevalence almost triple the rate of the Hispanic population and six times the rate of white children. “We see a community considered at-risk for just about everything,” Simone said. “The biggest value of this is the interdisciplinary approach to health care. The biggest problem we face now is the fragmentation. We’re trying to bring it together.”
Part of pulling it together is getting everyone on the same page, beginning with when children should make a first trip to the dentist. “Talking about getting a child into a dentist before the age of 3 is off the radar for most people. But a lot can be done for better health by dealing w ith bacteria before the first tooth comes in,” Gillingsrud said. “This was a beginning,” said Donna Troyer, the dental clinic manager for UIHS.
Troyer is excited and hopeful the integrated approach will check the tooth decay that led to surgeries for 20 young UIHS children in the past year.
“If we are all going out with the same information and people are hearing it in several places, that’s one of the most impactful things we can do,” said Gullingsrud. “Oral health is the forgotten component of health.” Not if Simone, Jaso, McEwen and Ramos-Gomez have anything to say about it.

One year old's getting fluoride who are bound to swallow the stuff apart from having it in the water as well. Can't get too much!