Tackling oral health in primary care: A task that’s worth the time

‘Strep tooth’

Dental cavities are caused by bacteria – mainly Streptococcus mutans – that eat sugars or carbohydrates in the mouth. That process causes acid, which can erode teeth. In that way, the development of caries is a fully preventable infectious disease process, Dr. Fisher-Owens said.

“I think if people looked at this disease as ‘strep tooth,’ it would get a lot more people interested,” she said.

Bacteria that cause caries can spread from caregiver to child, such as when a parent tries to clean a dropped pacifier in their own mouth, or from child to child.

Caries can be prevented with proper diet and oral hygiene: toothbrushing and then applying fluoride to strengthen teeth or restrengthen teeth that have been weakened by the disease process, Dr. Fisher-Owens said.

The biggest risk factor for having cavities in adult teeth is having them in primary teeth, she said. “There is a common misconception that it doesn’t matter what happens with baby teeth. They’ll fall out,” she said. “But actually it does because it puts you on a trajectory of having cavities in the adult teeth and worse outcomes with other adult conditions, such as diabetes.”

At the 2022 annual meeting of the American Academy of Pediatrics in Anaheim in October, Dr. Fisher-Owens and Jean Calvo, DDS, MPH, also with the University of California, San Francisco, trained colleagues to apply fluoride varnish to primary teeth – so-called baby teeth – in the doctor’s office. This session is a regular feature at these conferences.

Since 2014, the U.S. Preventive Services Task Force has recommended that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children.

Many pediatricians may not do this regularly, however.

Researchers recently reported that, despite insurance coverage, less than 5% of well-child visits for privately insured young children between 2016 and 2018 included the service.

Nevertheless, the practice may be helping, according to the NIDCR report.

Since 2000, untreated tooth decay in primary teeth among children younger than 12 years has fallen from 23% to 15%, according to the report. For children aged 2-5 years, untreated tooth decay decreased from at least 19% to 10%. For children aged 6-11 years, the prevalence of dental cavities in permanent teeth fell from 25% to 18%, the report states.

“Fluoridated water, toothpastes, and varnish – as well as dental sealants – can work together to dramatically reduce the incidence of caries,” according to the NIDCR. “Integrating dental care within family and pediatric medical care settings has been another important advancement. The delivery of preventive oral health services, such as fluoride varnish, during well-child visits in medical offices is showing promise in reducing dental caries among preschool-age children.”

Integrating oral health care with medical primary care has met challenges, however, including “resistance by providers, lack of training, and the need for insurance reimbursement for services,” the report notes.

Clinicians can already bill for the application of fluoride varnish using Current Procedural Terminology (CPT) code 99188, and additional oral health care procedures may be on the horizon.

The American Medical Association this fall established a new Category III CPT code for the application of silver diamine fluoride to dental cavities.

Silver diamine fluoride is a newer product that was approved as a desensitizing agent by the Food and Drug Administration in 2014. It has antimicrobial and remineralizing properties, and researchers have found that it can stop the progression of early tooth decay and is more effective than fluoride varnish in preventing cavities.

Several dental groups supported the creation of this new code, which is expected to be made available by electronic health records vendors in July.

Some dentists have reservations, however. The Academy of General Dentistry in October expressed concerns that allowing “nondental health care workers to administer silver diamine fluoride is a temporary solution to a growing oral health crisis.”

Silver diamine fluoride may stop about 80% of cavities. Although the CPT code for silver diamine fluoride has been established, whether insurers will reimburse health care professionals for the service is another matter, said Richard Niederman, DMD, professor and chair of epidemiology and health promotion at New York University College of Dentistry.