The findings from this study provide useful insights into the oral health risk assessment practices of physicians, the prevalence of risk factors found in this age group of children, and the effects of these factors on physicians’ opinions about the need for a dental referral. These findings are particularly relevant to understanding risk assessment and referral practices of physicians who have been trained to provide oral health services. Participants in this study had received training in risk assessment, counseling and fluoride therapies, but had not participated in any training or community-wide interventions to facilitate dental referrals by physicians.
We found that behavioral risk factors were much more prevalent in this very young patient population than clinical risk factors or dental disease. Three of the six behavioral risk factors were highly prevalent. Limited fluoride exposures and over exposure to sweetened beverages were widespread, with physicians reporting that nearly 50% of their patients had these risks. These findings emphasize the importance of early intervention to reduce the risk of subsequent disease.
Although some of the individual behavioral risk factors were highly prevalent, they had little influence on physicians’ opinions about the need for a dental evaluation. The reasons for this finding could not be explored using information available in this study. However, anticipatory guidance is a major part of well-child visits, with both parents of young children and providers reporting high rates of anticipatory guidance for traditional topics [3
]. For example, more than 70% of parents of infants and toddlers report discussing food and feeding issues during health supervision visits [18
]. Some of these topics target behaviors that are common risk factors for both dental and medical problems. Because pediatric providers are experienced in providing anticipatory guidance for many behaviors, it is possible that they are confident in providing counseling to address behavioral risk factors for oral health, particularly consumption of sweetened beverages, the most common of the behavioral risk factors found in this study and a primary target for obesity counseling. Because counseling for some of these common risks is so much a part of their usual practice, physicians might not see the need to refer patients to dentists for similar services, particularly when parents will be faced with many difficult challenges in finding a dentist. Primary care physicians might consider their relationship with dentists similar to that of other health specialists to whom they refer mostly when the child has a medical condition that they are unable to treat in their own office.
A history of family dental disease was the only behavioral risk factor independently associated with need for dental evaluation in either of the regression models. The existing literature offers some support for the importance of this finding as there are many parental characteristics associated with increased risk for ECC. [19
] For example, maternal untreated caries is reported to nearly double the odds of their children having untreated dental disease and increased risk of disease severity [22
]. Evidence on the significance of caregiver transmissibility of oral flora to the child is well documented, with limited evidence, however, that caregiver reduction of Streptococcus mutans
subsequently reduces ECC [23
]. It is likely that family dental disease as a variable captures other environmental risks for dental disease that are common for all family members.
All clinical conditions included in this study were strongly associated with the need for dental evaluation. Dental caries was the strongest predictor, with the presence of cavitated (OR = 17.5; 95% CI = 8.08, 37.97) and non-cavitated (OR = 6.9, 95% CI = 4.47, 10.82) lesions greatly increasing the odds of a needed evaluation by a dentist. A previous survey of pediatric primary care providers found that physicians are more likely to refer young children if they have untreated dental caries (85% early disease; 98% extensive disease among those who refer) than if they have a low probability of disease (25.6%) [24
]. While early identification and referral of those with disease is important, another goal of screening and risk assessment is to refer children at high risk prior to the onset of disease so that services can be provided to prevent the development of ECC [2
Considering that the consensus recommendation for professional dental organizations is the universal age 1 dental visit, the large number of risk factors present in this population, and the published literature on the rate of dental referrals by primary care providers, the opinions of physicians about the need for dental evaluation (6.8%) appears to be less than optimal. A national study found that 44.6% of low-income parents of children 2-5 years of age were advised by a non-dental provider to schedule a dental check-up [4
]. A study of dental referrals by physicians participating in IMB found an overall referral rate of 2.8%, lower than the one found in this study [5
The literature reveals a number of factors that can help explain the low dental referral rates for infants and toddlers [24
]. Among these are physicians’ confidence in identifying the need for a referral, the availability of dentists, and a practice with a high patient volume of young children. The low rate of referral for children in this study who were observed by physicians to have elevated risk status because of harmful behaviors but no disease adds the possibility of another potential barrier to referral. Physicians might not refer for services done in the dental office that they commonly provide in their own offices. Further study is needed to better understand why referral practices of physicians do not adhere to recommended guidelines, but in the interim, interventions can be undertaken to encourage dental referrals in geographic areas having an adequate dental workforce.
Physicians’ determinations of a child’s overall caries risk as recorded on the risk scale included in the PORRT was a stronger predictor of a needed dental evaluation than any of the individual risk factors in the regression analysis. Those children judged to be at high risk on the scale had a 10-fold greater likelihood of requiring a dental evaluation compared to those judged to be at other risk levels. Although caries risk assessment is used commonly in clinical practice, our use of the overall risk scale has specific methodological considerations. The risk assessment scale was scored after all individual risk factors were recorded on the structured form, preventing providers from scoring the scale without influence from the list of risk factors. So we do not know how the scale would perform if used alone. Use of an overall risk assessment scale to determine priority referral status also has practical disadvantages. An assessment, identification, and record of individual risk factors is useful in selecting counseling strategies and content during a visit, and for monitoring behaviors over time.
Our classification of children according to the number and type of risk factors provides some insights into providers’ possible perceived urgency of a referral. Children with obvious disease (cavitation from caries) or with special healthcare needs should have an immediate referral. Those with early stage disease or a significant number of risk factors can be considered to have a high degree of referral urgency. Those with only a few modifiable risk factors but no disease or special health care need should be referred if the supply of dentists is adequate, but the urgency of that referral can be consider low in young children. The predicted probability of pediatricians’ indicating the need for dentist evaluation for patients with risk factors that would require an immediate referral was only 0.36. This finding is consistent with the study by Pahel and colleagues [5
] where referral rates for children with obvious dental disease was only 33%, leaving an opportunity for improvement in the timely establishment of a dental home for those children in need of treatment.
Results of this study need to be considered in the context of its limitations. The presence of clinical risk factors and caries risk assessments were performed by pediatricians without an independent validation of the children’s oral health condition. So the accuracy of their risk assessments and the need for follow-up by a dentist are unknown. Furthermore, like other oral health risk assessment tools for oral health, PORRT has not been tested for its reliability and validity. Age and other potentially important covariates related to risk for dental disease and outcomes were not available, but all children included in the study were enrolled in Medicaid and were younger than 3 years of age. The study population thus represents a fairly homogenous group of children.
A final consideration is that our primary explanatory variable assessed the provider’s opinion about the need for dental evaluation. We do not know to what extent this opinion would result in an actual recommendation for a referral. With a number of factors ultimately influencing whether a referral is made or not, the effectiveness of PORRT in helping to improve access to dental care remains unclear. However, this initial experience with PORRT has provided evidence that physicians are willing to use structured forms to help identify ECC risk factors and the need for an oral evaluation by a dentist.