Dental screening and referral of young children by pediatric primary care providers
OBJECTIVE: Several health care organizations recommend that physicians provide preventive dentistry services, including dental screening and referral. This study is the first to investigate characteristics of medical providers that influence their referral to a dentist of children who are at risk for dental disease.
METHODS: A cross-sectional survey was undertaken of primary care clinicians in 69 pediatric practices and 49 family medicine practices who were enrolled in a study to evaluate a pediatric preventive dentistry program targeted toward Medicaid-eligible children in North Carolina. A 100-item, self-administered questionnaire with 23 items on some aspect of dental referral elicited providers' knowledge and opinions toward oral health, their provision of dental services, and their confidence in providing these services. We hypothesized that providers' dental knowledge, opinions about the importance of oral health, and confidence in providing oral health services would be associated with their propensity to refer children who are younger than 3 years and are suspected of having risk factors for future dental disease or a few teeth in the beginning stages of decay. We also hypothesized that providers' perceived referral difficulty would affect their referral activities. Patient characteristics (tooth decay status, insurance status, immigrant status, English speaking), practice characteristics (setting, number of providers, patient volume, busyness), practice environment (perceived and actual availability of dentists), and other provider characteristics (gender, type, practice experience, board certification, training in oral health during or after professional education, hours worked, teaching of residents, preventive behaviors) were assessed and used as control variables. Preliminary bivariate analysis (analysis of variance, chi2) identified characteristics associated with referral activity. Multivariable logistic regression analysis using backward stepwise logistic regression tested the posed hypotheses, with provider, practice, and patient characteristics included as potential control variables.
RESULTS: Nearly 78% of 169 primary care clinicians who participated in the survey reported that they were likely to refer children who had signs of early decay or high risk for future disease. Approximately half (54%) call a dental office sometimes or more frequently to make an appointment for a child whom they refer, but the most common method is to give the caregiver the name of a dentist without additional assistance (96%). Bivariate analysis revealed that providers who had high confidence in their ability to perform screenings and reported low overall referral difficulty were more likely to refer children. Bivariate analyses also found that providers who were not in group practices, were board certified, graduated 20 years ago or more, saw 80 or more patients per week, had >60% of their total patients who were infants and toddlers, and saw >3.5 patients per hour were significantly less likely to refer at-risk children for dental care. No patient characteristics were associated with referral. The regression model revealed that an increase in odds of referral was significantly associated with confidence in screening abilities (odds ratio [OR]: 5.0; 95% confidence interval [CI]: 1.7-15.1), low referral difficulty (OR: 6.0; 95% CI: 1.0-34.5), and group practice (OR: 4.2; 95% CI: 1.4-12.1). Having a patient population of >60% infants or toddlers was significantly associated with a decrease in odds of referral (OR: 0.2; 95% CI: 0.1-0.7). Oral health knowledge and opinions did not help to explain referral practices.
CONCLUSIONS: Tooth decay remains a substantial problem in young children and is made worse by existing barriers that prevent them from obtaining dental care. Because most children are exposed to medical care but not dental care at an early age, primary care medical providers have the opportunity to play an important role in helping children and their families gain access to dental care. This study has identified several factors that need consideration in the further exploration and development of primary care physicians' role in providing for the oral health of their young patients. First, instructional efforts to increase providers' dental knowledge or opinions of the importance of oral diseases are unlikely to be effective in increasing dental referral unless they include methods to increase confidence in providers' ability to identify and appropriately refer children with disease. Medical education in oral health may need to be designed to include components that address self-efficacy in providing risk assessment, early detection, and referral services. Traditional, didactic instruction does not fulfill these requirements, but because the effectiveness of instructional methods for teaching medical providers oral health care, particularly confidence-building aspects, is untested, controlled evaluations are necessary. A second conclusion from this study is that the referral environment is more important than provider knowledge, experience, opinions, or patient characteristics in determining whether medical practitioners refer at-risk children for dental care. Most providers in this study held positive opinions about providing dental services in their practices, had relatively high levels of knowledge, screened for dental disease, accessed risk factors in their patients, and referred; they can be instrumental in helping young children get dental care, yet most providers face difficulties in making dental referrals, and changes in the availability of dental care will be necessary to decrease these barriers before referral can be most effective. The longer-term approach of increasing the number of dental graduates can be complemented in the shorter term by other approaches to increase dentists' participation in Medicaid, such as increases in reimbursement rates; training general dentists to treat young children; and community organization activities to link families, physicians, dentists, and public programs such as Early Head Start. Finally, pediatric primary health care providers can provide oral health promotion and disease prevention activities, thereby eliminating or delaying dental disease and the need for treatment at a very young age. However, effective and appropriate involvement of pediatric primary care clinicians can be expected only after they receive the appropriate training and encouragement and problems with the dental referral environment are addressed.