Early Preventive Dental Visits Effectiveness

Abstract

The purpose of this study is to evaluate the available literature regarding the effectiveness of early preventive dental visits and dental care management that may be available to children aged six months, two years, and five years. The variety of recommendations for future dental care indicates that the current state of affairs in dental care management is not where it should be, and dentists, as well as parents, have to clarify their possible contributions to the promotion of dental health for children. Studies from such research databases as Cochrane, PubMed, PsycINFO, and SAGE were reviewed to investigate what evidence can be used in the analysis of childhood dental care. The results show that early preventive dental visits at the age of two are more effective in comparison to beginning the same visits at the age of five years.

Background Information

Dental caries, also known as tooth decay, are one of the most common childhood diseases, with an influence on different parts of the population, including children and their families, and on the existing health care systems. In different countries, numerous efforts are regularly undertaken to prevent the disease and to promote oral health. In the United States (US), there are two specific organizations, the American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA), that deal with the prevention of childhood caries and aim to develop effective programs to support patients and guide dentists and other healthcare providers. At this moment, there are two well-known policies that promote the importance of oral risk assessment and early dental visits: Bright Futures and Dental Home. Both programs aim to improve the population’s knowledge and explaining why parents need to pay more attention to the dental services that should be offered to their children aged between two and five years.

Despite the attempts of these organizations to improve dental health and promote healthy dental habits for children, the incidence of dental caries continues to increase among children, and their parents are in need of additional help and guidance on how to protect a young population against dental disease (Zwicker, Dudley, & Emery, 2016). Early childhood preventive visits to dentists are the most effective and widely available method to promote oral health and provide pediatric patients with the required level of care and support (Bhaskar, McGraw, & Divaris, 2014; Divaris et al., 2014; Vujicic, 2015). The reasons for these problems and the numerous discussions about them include poor knowledge of health management, unhealthy food and lifestyles, and poorly developed relationships between dentists and patients. In this review, the evaluation of the effectiveness of early preventive dental visits (EPDVs) will be based on an analysis of the available literature and the results of studies conducted in the United States between 2012 and 2017.

Statement of the Problem

The initiatives introduced by the American Academy of Pediatric Dentistry and the American Dental Association provide concrete steps for caregivers to improve their children’s oral health. These steps include an oral examination, risk assessment, dental cleaning, that is also called prophylaxis, fluoride varnish treatment, and following oral health instructions. These organizations believe that the first visits of children to their dentists should begin during the first year of life even if there are no evident dental problems in order not to simply be treated or assessed but to be educated and informed about the particular needs of their children’s oral health.

A dental visit at a young age is a possible way to avoid serious health complications for school-age children. However, a constant increase of dental problems among the younger population and its recognition as an issue of epidemic proportions points to a number of contradictions and uncertainties concerning the effectiveness of these initiatives (Zwicker et al., 2016). The main problem is the inability to understand what may influence the effectiveness of early preventive dental visits in patients aged between two and five years and recognize the roles of pediatricians, dentists, and parents in managing child’s dental health.

Purpose of the Study

Taking into consideration the fact that the effectiveness of EPDVs for children cannot be ignored, it is necessary to investigate what different people think of this issue, what assessments have already been made, and what results of these studies can be used in the promotion of public health. The purpose of this project is to gather sufficient evidence-based literature published during the last five years and evaluate how effective early preventive dental visits among two- and five-year-old children can be in terms of preventing childhood caries. Investigating the role of health care providers, the essence of dental preventive visits, and care management aspects available to children and their parents is necessary in order to create a list of recommendations for a future approach to managing childhood dental health.

Research Questions

The main research question addressed by this evidence-based literature review is: “Regarding the information taken from the evidence-based literature, how effective are early preventive dental visits at avoiding childhood caries for two-year-old children as compared to five-year-old children?”. To address this question, it is necessary to clarify several other important aspects:

1. What are the current recommendations for dental preventive visits for children aged two years and five years?
2. What is the role of a dentist as a primary dental care provider during preventive child visits?
3. What is the role of parents in preventing childhood caries?
4. What improvements and recommendations can be given in terms of preventive dental care for children aged two and five years?

The answer to each question is a significant step toward understanding whether preventive visits at the age of two differ from similar visits at the age of five. This discussion should help to investigate the improvements that can be made in the field of childhood dentistry and to develop recommendations for preventive dental care.

Significance of the Study

Communication between dental care providers, pediatricians and caretakers has to be properly developed at different ages. The characteristic feature of tooth caries is its unpredictability and the importance of treatment. Even if parents make sure that their children clean their teeth regularly, there is always a threat of having dental problems and the necessity to visit a dentist. As a rule, dental services are not always available, and not all children are covered under healthcare programs have coverage for such service. Therefore, parents have to understand their responsibilities and options in terms of the dental care that is obligatory for their children. This study helps to explain why dental care services are necessary for children at any age and if there are any differences in dental care management for two-year-old children and five-year-old-children.

Definition of Terms

In this study, several important terms have to be defined. First, early childhood caries, also known as tooth decay, is defined as a common chronic childhood health condition that may be prevented or lead to pain and a low quality of life in the case it is left neglected and untreated (Braun et al., 2017). Preventive medications and risk assessment are the two main steps in dental care management for children. These activities may take different forms and may have a different impact on children (Moyer, 2014). In this study, the American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA) and their programs and initiatives are chosen for analysis in light of the results of Bhaskar et al.’s (2014) studies and the work of Cruz and Chi (2017). The terms “early preventive visits”, “child comprehensive dental visits”, and “child periodic dental visits” are interchangeable in the project because they indicate the same cases when parents have to bring their children to dentists for assessment.

Review of the Studies

Dentistry, like other branches of medicine, undergoes considerable changes regularly, including certain improvements in care, management, and communication (Zwicker et al., 2016; Divaris et al., 2014). Today, much attention is given to the development of pediatric dentistry (Cruz & Chi, 2017). In comparison to the use of dental care services by adults, which has dramatically decreased, the utilization of children’s dental care has risen during the last decade (Vujicic, 2015). In modern literature, researchers indicate that early oral health care should be well documented and advocated so that parents and other caregivers have access to it whenever they want (Bhaskar et al., 2014). Wellness visits, dental preventive services, child dental screening, and childhood caries will be discussed in this literature review.

This evidence-based literature review helped to identify the steps that could be used to promote pediatric dental care, recommendations, and suggestions that may be offered to caregivers. Dental diseases create unpleasant and even dangerous conditions for children that are usually characterized by pain, eating disabilities, and frequent visits to emergency departments (Beil, Rozier, Preisser, Stearns, & Lee, 2014; Blackburn, Morrisey, & Sen, 2017; Braun et al., 2017; Moyer, 2014). Unfortunately, only 30-40% of dentists recommend that the first dental visits occur at the age of one year, even if they are aware of the warnings issued by different organizations (Clark, Duong, & Fontana, 2014). Therefore, the findings of different researchers on the topic of the effectiveness of early preventive dental visits should help to clarify the positions of different dentists and the reasons they use to support their opinions.

Methodology

This section will focus on the research method chosen for this study. Data collection and data analysis have to be properly organized with respect to the available sources of information and the goals. The sampling method and the studies selected will depend on exclusion and inclusion criteria.

Research Methods

Systematic review is the method of research in this study. This type of literature review is characterized by a properly developed research question and the use of systematic approaches while selecting and identifying the results taken from studies that have been previously published and are connected to the chosen topic. In this project, ten original articles were chosen for a systematic review according to several important inclusion criteria. All studies were published during the last five years, and articles from 2012 or earlier were excluded. The studies had to be conducted in the United States, meaning that studies from other countries had to be excluded. The reason for excluding other countries from the study is based on the necessity to focus on American patients and use the health care insurance programs and organizations, like the AAPD and ADA, located in the United States Finally, all studies had to contain such keywords as “dental care”, “early preventive dental visits”, and “childhood caries” in their titles or abstracts, meaning that the study population (children age 0-5 years) and the type of dental services were the main inclusion criteria.

A purposive sample was used in the study and included articles found in such databases as Cochrane, PubMed, TRIP, PsycINFO, and SAGE Journals Online between September 2012 and September 2017. All these databases provided the researcher with access to numerous academic sources on the chosen medical topic. It was easy to use the sources and identify the articles that met the including criteria. The information found in sources published in 2012 and 2013 was similar to the information offered in the sources published later. Therefore, it was decided not to use the sources from 2012 and 2013. There were several additional reasons to remove the studies, including the fact that several articles were co-authored by one of the authors chosen for the analysis (the possibility to avoid possible biased information) and the fact that the information of the found sources was not relevant to the main subject or the chosen population or did not meet the including criteria of the study. The articles contained information about different aspects of EPDVs for young patients at the age of two and five years.

Data Collection

The data collection process was organized in three main steps, including the identification of the databases, the clarification of the keywords for search, and the recognition of publication dates. A comprehensive literature search using the chosen databases helped to identify relevant studies that discussed the essence and effects of early preventive dental visits, outcomes, and age difference when the first visit of a child should occur. Such keywords as “childhood caries”, “dental care”, “early preventive dental visits”, “parents”, and “dentists” were used in different combinations with the main limitation of a publication date that was between 2012 and 2017. First, it was necessary to review the title and abstract of the study. Then full texts of the articles were obtained and read several times to make sure that the studies met the inclusion and exclusion criteria. Finally, the main information on the topic was underlined in order to be used in the analysis.

Data Analysis

The results of the evaluation of the studies were organized in table format, including the following information: authors, publication years, study types, goals, population, and outcomes. The information introduced in the table helps to clarify recent investigations and achievements in the field of dental care for children aged between 0 and 5 years at the time of writing and to identify if there are any gaps in the research. A thematic analysis was developed regarding four main aspects for consideration: recent recommendations, dentists’ roles, parental involvement, and future improvements in order to clarity at what age, 2 or 5 years, early preventive dental visits can be more effective for childhood caries avoidance.

Results

Wellness Visits and the Role of Healthcare Organizations

A wellness visit, also known as a “hands-off” visit, is a visit to a dentist during which age-appropriate screening and education are offered, health history and risk factors are considered (Blackburn et al., 2017). Such visits are usually recommended by organizations such as the American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA) as soon as children celebrate their first birthday, as this is the period when the first teeth usually appear (Bhaskar et al., 2014). Wellness visits aim at helping parents understand what kind of dental care they can offer to their children, what preventive steps they should take, how to promote normal growth and development for their children’s teeth, and how to develop appropriate oral habits. Beil et al. (2014) explain that parents should remember that professional preventive dental care may promote good oral health; however, the age that parents choose for a first dental visit continues to be unclear. Some researchers suggest the importance of dental visits at the age of 6-7 years (Zwicker et al., 2016). The investigations of Clark et al. (2014) and Moyer (2014) are based on visits from birth through the age of five years.

Early childhood caries is one of the most frequent chronic childhood health problems (Braun et al., 2017). With the help of an analytical cohort, Divaris et al. (2014) came to the conclusion that approximately 90% of infants and children of the pre-school age have visited a dentist. However, there are several stages of infancy, and each year is characterized by certain developmental changes and achievements demonstrated by children. Therefore, the age of children is an integral factor in the promotion of child’s dental health. If a parent neglects to visit a dentist during the first year of life, there is a risk that some dental problems will not be identified. Today, parents have access to numerous clinical guidelines and recommendations with the help of which they can organize their children’s dental care. In many cases, parents choose an appropriate guideline and follow it during many years till some extreme changes are required by their pediatricians or other health care provides. In addition to the recommendations developed by the AAPD and ADA, Cruz and Chi (2017) recognize the Centers for Medicare and Medicaid Services (CMS) where it is recommended to make first visits to a dentist by the age of three. This example proves that it is easy to mislead a parent and offer a credible source of information without any clear explanations and suggestions. It is used to explain why recent dental health recommendations cannot be identified as perfect for American parents. These guidelines may confuse and make parents think about their inabilities to decide properly to support their children and reduce the number of dental diseases.

At the same time, the investigations of Braun et al. (2017) show that Medicaid is a program that offers many helpful tips and guidelines, supporting the idea of participation by various non-dental health care providers in childhood oral health promotion, as with their help it is possible to reduce the number of organizational barriers. The recent recommendations that available to parents in their intentions to provide their children with the best dental health care and services are based on the necessity to cooperate with dentists, increase the number of dental visits, and ask questions in order to clarify all new points and misunderstandings. However, parents do not have clear guidelines concern when they have to begin their dental care. The period between one year of life and five years is defined. This period is long enough to miss some significant change in child’s health. Therefore, these recommendations have to be investigated in terms of the roles of dental health organizations, dentists as the main health caregivers, and parents as the representatives of young patients in order to clarify the age criterion for further improved recommendations and guidelines.

The Role of Healthcare Organizations

The AAPD and the ADA are the organizations which work to develop guidelines and opportunities for people to improve their health and avoid complications, including effective preventive strategies to address the problem of caries among preschool-aged children (Divaris et al., 2014). “Bright Futures” is a well-known initiative introduced by the AAPD which offers oral risk assessments to children between their six- and nine-month wellness visits (Beil et al., 2014). Additionally, the establishment of the AAPD’s “Dental Home” policy encourages building relationships between dentists and their patients and promotes comprehensive pediatric care with a single dentist to create a series of oral evaluations and higher awareness of dental management (Bhaskar et al., 2014). These initiatives and policies ensure that children or their parents can ask for help and feel confident that they will get it, but not all parents understand what steps they should take to support their children’s dental health. Some of them consider it enough to only clean teeth and regularly neglect dental visits until the pain starts bothering a child (Vujicic, 2015). For this reason, the establishment of a good relationship between the primary dental care provider and the parent should be among the first steps taken.

Medicaid is a social health care program which provides many people with health coverage. This program also provides patients, especially children, with comprehensive dental care as well as educational meetings during which doctors communicate with parents to explore opportunities for their children to have good dental health (Cruz & Chi, 2017). It is recommended that parents learn about these programs and initiatives so that they may use all available opportunities.

Early Preventive Dental Visits

According to the AAPD guidelines, early preventive dental visits (EPDVs) may be either primary or secondary dental care, including caries examination, prophylaxis, fluoride varnish, nutrition, and home care guidance (Bhaskar et al., 2014). As a rule, well-child visits start at the age of six months and continue for the next three years (Braun et al., 2017). Follow-up visits should also be discussed during these EDPVs, though at the age of four years, many children start visiting schools where their health falls under the control of specially educated health care providers.

Parents may use the services that these providers offer to diagnose a health problem, understand when to visit a dentist, and to learn what kind of care they should be offering to their children. Sometimes, parents want to make their own decisions about the importance of their cooperation with dentists. In some cases, parents are in need of additional guidance and explanations that dentists, nurses, or other healthcare professional can offer.

The effectiveness of early dental visits has been considerably discussed in many recent articles from different perspectives. Despite this, many parents continue putting their children’s health at risk by avoiding dental visits for no immediately evident reasons (Cruz & Chi, 2017). Therefore, this study will be developed to consider the question of if the current body of modern evidence-based literature is enough for parents to consistently schedule early preventive dental visits among children between the ages of two years, five years, and the period before children are commonly enrolled in schools.

Pre-school children should be provided with a solid portion of care and education because they may recognize pain and report it, address dentists, and ask parents for help. Poorly developed dental care leads to a number of problems for children and their families, including the possibility of missing school when it is necessary to treat tooth decay, possibly leading to poor school performance (Blackburn et al., 2017; Braun et al., 2017). Preschool children should be provided with the chance to avoid dental problems in future, and their parents must take responsibility for the provision of such opportunities due to the fact that children cannot understand the true worth of dental visits and are instead guided by their fears and poor knowledge of dental hygiene.

The results of the literature search found more than 150 studies in the chosen databases that met the inclusion and exclusion criteria. After an evaluation of the titles, abstracts, and publication dates as described in the methodology section, 10 studies were selected for analysis to avoid repetitions, biases, and contradictions in the evaluations.

Table 1: Results of studies

At the time of research, several recommendations were given parents to improve the quality of children’s dental health and to prevent tooth decay. First, it was recommended to make their first dental visits before the age of 5 years. Second, it was suggested to emphasize the role of health care providers. Finally, it was decided to develop new fluoride varnish interventions with the help of which parents may improve their children’s dental health. However, the analysis of the chosen studies showed that there was a certain research gap because many health care providers fail to understand what age was preferable for first dental visits. Zwicker et al. (2016) focused on 6-month-old children, Beil et al. (2014) addressed the children of kindergarten age, and Moyer (2014), Braun et al. (2017), and Bhaskar et al. (2014) discussed the importance of first EPDVs at an age between two and six years.

Role of Dentists in Early Preventive Dental Visits

The role of dentists was shown to be crucial because this group was responsible for the promotion of knowledge for parents and other caregivers and the explanation of available interventions (Blackburn et al., 2017; Clark et al., 2014; Zwicker et al., 2016). Vujicic (2015) emphasized that dentists had to cooperate with parents in order to inform them about the development of possible dental problems and the complications their children may be exposed to in case they fail to visit a clinic in time. It was not enough for dentists to demonstrate a high level of knowledge. They also had to make sure that parents understand what they have to do to promote their children’s dental care. Dentists may have a solid background knowledge and experience in providing children with effective dental care and cooperating parents. However, there are not many studies that prove how effective dentists can be in their intentions to assist parents and explain to them the basics of dentistry and tooth hygiene for little children. The level of knowledge and the possibility to predict the development of possible dental problems that modern dentists demonstrate are impressive. Therefore, they should learn how to share their knowledge with parents in order to reduce the number of dental problems that are usually developed at the time of kindergarten (Beil et al., 2014). Cooperation between dentists, other health care providers, and parents is appreciated to promote the effectiveness of early preventive dental visits.

The Role of Parents in Early Preventive Dental Visits

Divaris et al. (2014) faced the problem of caregivers’ dental neglect and the inability of children to enter special dental care programs where effective care and prevention could be offered. The role of parents was important for the improvement of dental health and the increase in children’s quality of life. Most researchers supported the idea that parents improved their children’s chances of avoiding dental problems in the future if they visited dentists before the age of 5 years (Beil et al., 2014; Cruz & Chi, 2017; Divaris et al., 2014; Vujicic, 2015). The studies reported that preventive visits aimed at improving children’s health and avoiding serious dental complications when children became older. However, some parents could be misled with a variety of suggestions and recommendations given. They should know whom they can address to if they want to know more about dental health care to offer to their children. In addition, parents should understand that they are primary caregivers for their children, and their decisions define the quality of their children’s lives.

Discussion

In this paper, the goal was to identify what had already been known about EPDVs, the role of dentists and parents in child dental care, and the most effective time for first dental visits in order to clarify what improvements in children’s oral health could be made and what recommendations should be given to parents and dentists at the present time. In view of the results obtained from a database search, several main conclusions and recommendations were developed.

Major Conclusions

The American Academy of Pediatric Dentistry and the American Dental Association continue to recommend to parents that their children should begin their first visits to dentists during the first year of life. However, such recommendations are given without taking into consideration such issues as the level of knowledge parents may have about dental care, the level of dentists’ involvement in different regions, and the educational opportunities for the chosen population. Therefore, it is necessary to understand the factors that may influence the promotion of dental care in different regions of the United States. As of now, early preventive dental visits have been shown to be desirable and effective practices for children of different ages as an opportunity to reduce the risks of having dental problems and frequent caries (Beil et al., 2014; Divaris et al., 2014; Zwicker et al., 2016). The opinions of the researchers about the effectiveness of dental visits at the age of 2 and 5 years are not definite because many studies prove that the earlier the first dental visit occurs, the more opportunities parents provide to their children to avoid dental complications (Bhaskar et al., 2014; Cruz & Chi, 2017; Moyer, 2014). Therefore, the evidence-based literature chosen for this systematic review can be used to conclude that early preventive dental visits are more effective at preventing childhood caries for two-year-old children as compared to five-year-old children or older.

To support these positions, it is necessary to follow specific dental guidelines and be ready to identify and combine different components of early prevention, including the use of fluoride varnish, counseling with healthcare providers, frequent examination, and personal observations of recent changes in children’s teeth (Beil et al., 2014; Braun et al., 2017; Moyer, 2014; Zwicker et al., 2016). The role of parents and dentists has to be re-evaluated in order to understand that dentists need to demonstrate their enthusiasm for supporting young patients and their parents. In turn, parents need to learn new aspects of care for their children at the early stages because EPDVs are more effective at a younger age. Children whose parents choose to wait until the first dental problems appear and remain untreated until the age of 5 years are exposed to more problems with caries and other complications. Parents need to understand the level of their responsibility and start visiting dentists as early as possible to make sure that no problems or negative changes are observed in the oral health of their children.

In general, the main recommendations that can be given in terms of dental care management are:

1. Increase parental involvement in childhood caries prevention

The role of parents has been proved as integral in dental health care for children. It is recommended to investigate the areas in which parents may be properly involved. First, they have to know what people they can address in order to have enough knowledge about care for their children. Second, parents must think about the outcomes of their neglect in dental care and the possibility of increased dental problems. Finally, they should have access to education (Zwicker et al., 2016). They may need to ask questions and require answers in a short period of time, identify their financial opportunities and income challenges, and take the steps that lead to positive results in their children’s health.

2. Improve dentists’ cooperation with parents of children younger than 5 years

Communication between dentists and parents is important for dental care. This type of communication may have different forms: written assessments and questionnaires, oral phone calls and interviews, open meetings and discussions. Dentists should understand that not all parents with children who are aged 5 or younger are aware of what health care organizations and services they may address for help and support. Dentists must play active roles to involve parents in discussions and their obligations in regards to their children’s health.

3. Promote education of parents and dentists about the worth of EPDVs

New programs, free call centers, and specialized meetings may be developed in different regions of the United States. It is possible to open several organizations in different states and observe recent local changes and the attendance of such meetings by the population. If people are interested, they are eager to participate in new programs and learn the opportunities their children and they may have.

4. Create appropriate conditions for children to begin their first dental visits at the age of two years

Children should not be afraid to visit dentists and obtain a portion of help. It should be an adventure or a lesson that children want to learn. New improvements may touch upon the conditions parents and children are able to use in their dental medical centers.

Limitations and Biases

This study was based on an evaluation of already published material and knowledge about early preventive dental visits and their effectiveness for children at the age of 2 and 5 years. The gathered data was limited to studies offered by such sources as Cochrane, PubMed, PsycINFO, and SAGE Journals Online. No individual geographical data was gathered in order to understand the effects of such factors as family incomes, the age of parents, and family type on the promotion of dental care for children. In addition, the study is based on other researchers’ opinions and studies. No personal investigation, direct communication with parents or dentists, or observations were added to this study. Finally, only the patients in the United States were chosen as the sample. The frequency and cost of dental visits were also not identified in the study.

Conclusion

This review can be used in future research about the effectiveness of early preventive dental visits for children of different ages. In this work, findings taken from different studies are identified and explained in order to answer the main research question about the age of children for first dental visits. Medical providers can rely on this study to clarify what research gaps exist in the field and what recommendations may be given. Additional work and investigation are required to promote a better understanding of different factors in child dental care and the decisions of parents concerning the time of their first communication with dentists.

References

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Blackburn, J., Morrisey, M. A., & Sen, B. (2017). Outcomes associated with early preventive dental care among Medicaid-enrolled children in Alabama. JAMA Pediatrics, 171(4), 335-341.

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Zwicker, J., Dudley, C., & Emery, J.C.H. (2016). It’s not just about baby teeth: Preventing early childhood caries. SPP Research Paper, 9(14), 1-19.