Results from this study are similar to findings reported in the literature on the general population: few children access dental care under 24 months of age.7,9–12
Half of parents took children to their first dental visit of their own accord, often prompted by visible dental problems, child’s complaint of pain, the caregiver’s concern it is time for a checkup, or to avoid future dental problems. The other half of parents was motivated by pediatricians [physicians], school requirements, or other people. In this study, these low-income, Mexican-origin parents are taking their children to the dentist around 3 years of age, which is around 2 years later than the recommended age of 1 year for high-risk children. Results support the benefits of early first dental visits, with 94% of the sample reporting subsequent regular dental visits or establishment of a “dental home” after the first visit.
Findings from this study provide a valuable contribution to a currently sparse area of the literature. One of this study’s primary strengths is that it is one of the first to describe motivation for first dental visits in a high-risk, low-income, Mexican-American population. While epidemiological surveys can tell us the proportion of children at specific ages who have seen a dentist, this style of research has not examined when the first dental visit was undertaken, nor can it examine what influences that visit. Very little is currently reported on caregivers’ thoughts, beliefs, motivations and behaviors surrounding first dental visits. This research provides some key information about those thoughts, beliefs and motivation and lays a foundation for further research examining these important psycho-social and behavioral components. However, the limitations of this study must be kept in mind when interpreting results. This is not a representative sample. A limitation of particular concern is recall bias because mothers were recalling age at first dental visit, sometimes three or four years after the fact. There is also an issue that multiple children from a single family were included in child data analysis, as there may be family characteristics influencing the data. In this primarily qualitative study, however, inclusion of data from all siblings in a family revealed important information not otherwise discernable: older children’s dental experiences influenced mothers to begin seeking professional oral health care at an earlier age for the younger children in the family. Caution must be used in generalizing findings to a larger population, though in some instances the findings from this study suggest a focus for future studies using larger representative samples. Caution must also be exercised in generalizing results to other Latino populations such as those from a different socioeconomic class, immigrant status, or geographic location. Other limitations of this study include single location, self-report data, and social desirability bias. The distribution and proportion of parental motivations for first dental visit cannot be generalized beyond the study sample, but this study has contributed knowledge about what those motivations are and how they come about, providing a key first step for future studies with larger representative samples.
We found pediatricians to be important sources prompting a child’s first dental visit, resulting in a visit on average around 2.5 years of age. This is similar to other reports noting that despite the current recommendations,5,6
only 5% of physicians are referring children under 1 year old to dentists, and most pediatricians are not referring children for dental visits until an average age of 2.5 years.9,12,27
Because more young children visit a medical provider (85%) than a dental provider (20%), pediatricians can – and do – play a key role in influencing timing of the first dental visit through oral health screenings and dental referrals.28–30
However, only half of practicing physicians that see young children are trained in oral health screening or early childhood caries (ECC) and only 10% know about ECC prevention therapies.12,31
There is ample research to show that physicians with proper training can accurately identify children with and without caries.29,32
Pediatricians have been reported elsewhere to refer children to dental services,9,12,27
and oral health is one of the American Academy of Pediatrics’ (AAP) top 3 priorities and was the focus of the 2008 Peds21 Summit.33
The timing of first dental visit reported in our sample, however, is later than the recommended age. In May 2003, the AAP updated their oral health policy to include risk assessment by 6 months, with high-risk children getting a dentist referral within 6 months of eruption of first tooth or by 1 year of age. The AAP identifies factors that place a child at high–risk for caries including low-income, high sugar diet, poor oral hygiene, having older siblings with caries experience, and parents with poor oral health.34,35
All the children in this study are low-income, a third of them have older siblings with caries, and 60% of caregivers reported themselves to have untreated dental problems. As a high-risk population, they should have been referred to dental treatment much earlier.
There is a possibility that pediatricians referred children at the recommended age and there was a delay between the time of referral and the time when parents actually achieved a first dental visit,31
a topic warranting further research. However, if pediatricians are going to be successful gatekeepers to getting high-risk children to their first dental visit, children need to be screened and referred earlier to allow for this delay.
Pediatricians cannot control the dental environment to which they are referring these children and many pediatricians report difficulty referring children.31
There is a large literature on barriers to access to dental care, including dentists not accepting young children, particularly those on public insurance.31,36–39
There is some debate about whether the dental workforce is trained, equipped, and willing to see and treat such young children, particularly those with severe need, such as many of those with public insurance.7,36–42
Only 36% or fewer dentists agree with the ADA’s recommended age 1 year dental visit.7, 36,42
Smith et al. found that just 3% of dental practices would see publicly insured children under age 1 year for a preventive visit compared to 15% of dental practices who would see publicly insured children over age 5 years for a preventive visit.36
These dentist characteristics do affect access to care and may be a distinctive influence in determining the proportion of children achieving the ADA and AAPD recommended age 1 dental visit. Three parents in our study mentioned dentists discouraging early dental visits. These particular cases involved children with severe ECC that most likely was exacerbated between the parents’ attempts at a first visit, and actually achieving a visit at age 3. This underscores the need for more dentists to treat young children and more dental schools to adequately train dentists to be able to do so.7,36,42
Additionally, there is a need for community organizations to continue to help caregivers overcome barriers to access to care.30,43
Schools also serve as an important prompt to initiate dental care, triggering caregivers who have either not received or not followed suggestions from other sources. Rules at both the preschool and elementary school level44
were important in getting children into the dentist for the first time. In California, legislation passed in 2006 requires a dental visit before the end of the child’s first year in school, whether that be kindergarten or first grade.44
Head Start has requirements that encourage children to visit a dentist and establish a dental home, and parents feel the program helps support them in overcoming access barriers.38,42
However, school age is too late for first dental visits for a high-risk population, such as low-income Mexican-American children (many with older siblings and parents with caries experience or untreated dental problems). Schools should not be relied upon as a primary prompt for first dental visits, but do serve an important function in reinforcing the need for children to receive dental care.
It is important to increase and tailor education for parents, pediatricians, and other service providers to encourage and facilitate the first dental visit by age 1 for this population. At the same time, the dental workforce needs to be better equipped to handle an increase in young patients. For this at-risk population, increasing preventive treatment at a young age may help decrease their later caries experience and cost of care as well as increase their quality of life.