aap recommendations for first dental visit

Healthy Living

Good oral health starts early: aap policy explained.

By: David Krol, MD, MPH, FAAP & Kaitlin Whelan, MD, FAAP

Tooth decay (dental caries) is one of the most common chronic childhood diseases in the United States. The good news is there are ways to prevent it.

Even the tiniest teeth can decay. There are habits you can start now to keep your baby's teeth healthy. And when that first tooth shows up, there are ways your pediatrician can keep it healthy, too.

In the clinical report, " Maintaining and Improving the Oral Health of Young Children ," the American Academy of Pediatrics explains key risk factors for tooth decay, and ways to keep your child's teeth healthy. Here is what you need to know.

Can babies get tooth decay & cavities?

Everyone, even babies , can get tooth decay. Children living in poverty, in an ethnic or racial minority groups, or with special health care needs are at more risk for dental decay. There are other reasons a child could be high risk:

The child's mother or main caregiver had tooth decay in the past 12 months or does not have a regular source of dental care.

There are white spots on the child's teeth. These spots are a sign that the tooth is losing calcium and minerals that keep it strong.

There are tan, brown or black spots or you see cavities (pits) on the teeth. This is a sign that the tooth is decaying.

How water helps prevent tooth decay

Fortunately, your family's tap water probably has fluoride added to it. Fluoride is a safe and useful cavity-fighting ingredient that has been added to drinking water since 1945 .

Fluoride is a natural mineral that can slow down or stop cavities from forming. When you drink water every day, the fluoride makes it hard for bacteria in your mouth to make acid. Fluoride also rebuilds tooth enamel (the outer layer of the tooth) and it even makes teeth stronger.

Check with your local water utility agency to find out if your water has fluoride . The health benefits work when the drinking water has 0.7 mg/L of fluoride. If your community water supply does not have fluoride or you live on a private well, ask your doctor if you should get a prescription for fluoride drops or chewable tablets for your child.

When to start using fluoride toothpaste

As soon as your baby's first tooth erupts, it's time to start using fluoride toothpaste . Here's how to do it:

Use a tiny smear—the size of a grain of rice—until age 3. Clean the teeth at least twice a day. It's best to clean them right after breakfast and before bedtime .

Use a pea-sized amount of fluoride toothpaste when your child is 3 years old. Teach your child to spit without rinsing.

Assist or supervise kids during toothbrushing until they master the task, usually at around 10 years of age.

A toothbrush should be the last thing to touch your child's teeth every night....

Do not put your baby to bed with a bottle at night or at naptime. It is also not a good idea to let your baby use a bottle filled with a sweet drink or dip your baby's pacifier in anything sweet like sugar or honey. If you do put your baby to bed with a bottle, fill it only with water. You can give your baby about 4-8 ounces of water per day starting at around 6 months. (Remember, the American Academy of Pediatrics (AAP) recommends breastfeeding as the sole source of nutrition for your baby for about 6 months.)

Special steps stop tooth decay in children

When your baby is 6 months, your pediatrician will start to do oral health checkups and apply fluoride varnish . Pediatricians are trained to apply fluoride varnish because many young children do not see or have access to a dentist until they are older. All infants and children should have fluoride varnish every 6 months until age 5. Children might need it every 3 months if they have a higher risk of dental decay.

Varnish is used to help prevent or slow down tooth decay. It is painted on the top and sides of each tooth and hardens quickly. The process is safe and does not hurt.

Fluoride varnish: it's in your plan

Finding a dental home for your child.

Oral health starts early. Be ready to discuss your family's plan for a "dental home." All children need access to a dentist for regular care. See your child's dentist by their first birthday or within six months of their first tooth. At this first visit, your dentist can easily check your child's teeth and determine the frequency of future dental checkups .

More information

• AAP Identifies Key Risk Factors for Tooth Decay in Children
• Baby's First Tooth: 7 Facts Parents Should Know
• Fluoride for Children: FAQs
• Recommended Drinks for Children Age 5 & Younger

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Brush Up on Oral Health

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Promoting the Age 1 Dental Visit

This Brush Up on Oral Health tip sheet discusses the importance of the age 1 dental visit. It also offers tips to help Head Start staff explain to parents what happens during the dental visit.

Importance of the Dental Visit

Some parents believe that because primary (baby) teeth are going to “fall out anyway” they do not need to take care of them. However, primary teeth are important to a child’s growth and development. The American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Dental Association all recommend that children have their first dental visit by age 1. A state’s Medicaid and Children’s Health Insurance Program (CHIP) dental fees and payment policies must line up with the state’s pediatric dental periodicity schedule. The American Academy of Pediatric Dentistry maintains a webpage with the dental periodicity schedule for each state.

The age 1 dental visit is a foundation for building a lifetime of good oral health. By beginning visits early, children learn that dental visits are usually not associated with pain or fear of the oral health professional. The visit is also an important opportunity to learn if a child is at high risk for developing tooth decay. During the visit, the oral health professional can talk to parents about steps to reduce their child’s risk for decay.

Explaining to Parents What Happens During the Dental Visit

• Describes what they will do during the visit and asks the parents if they have any questions. Parents should be encouraged to ask questions about their child’s oral health and their own oral health.
• Checks the child’s mouth and teeth. Using a small mirror, the oral health professional checks the child’s lips, cheeks, gums, and roof of the mouth for any problems and the teeth for signs of tooth decay.
• Checks the child’s bite and their jaw’s growth. The child’s teeth and jaw will be checked to make sure that they are developing in the right way. The oral health professional may also describe what to expect for the child’s oral development during the next few months.
• Provides preventive care. The oral health professional may provide care to prevent tooth decay. This care may include cleaning the child’s teeth with a toothbrush and applying fluoride varnish. Fluoride varnish is a liquid that is painted onto children’s teeth to prevent tooth decay and to repair early stages of tooth decay. This can be done up to four times a year depending on the child’s risk for developing tooth decay.
• Informs parents about healthy oral hygiene habits. Because home care is a vital part of good oral health, parents may be shown how to brush their child’s teeth and how much fluoride toothpaste to use. The oral health professional may also teach parents how and when to start flossing the child’s teeth. Other topics that may be discussed with parents include the timing of the next dental visit and setting goals to promote their child’s oral health. For example, a goal may be brushing their child’s teeth with fluoride toothpaste twice a day instead of once a day.
• Talks about foods, drinks, and habits that can cause oral problems. The oral health professional may ask questions about feeding practices and the use of sippy cups. Answers to these questions help determine if the child is at high or low risk for developing tooth decay. Parents may also be asked about their child’s thumb sucking, use of pacifiers, and other habits that may cause oral problems.
• Offers tips on how to prevent oral injuries. Injuries to the head, face, and mouth are common in young children, especially when they are learning to walk and climb. The oral health professional may offer tips on how to prevent oral injuries and what to do if an injury occurs.

Even if a child is fearful or cannot cooperate during the dental visit, the visit is still helpful. The child may enjoy riding up and down in the dental chair or seeing how dental tools work, such as the air, water, and suction hoses, and mouth mirror. Often, the oral health professional can get a quick look into the child’s mouth to see if there are any problems.

Download a PDF version to print and share.

Resource Type: Article

National Centers: Health, Behavioral Health, and Safety

Audience: Teachers and Caregivers

Series: Brush Up on Oral Health (BUOH)

Last Updated: April 26, 2023

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A Child's First Dental Visit Fact Sheet

When should your child first see a dentist? You can take your child at a younger age, but experts recommend taking him or her within 6 months of the first tooth coming in (erupting), or by about 12 months at the latest.

At this time, the dentist can give you information on:

Baby bottle tooth decay

Infant feeding practices

Mouth cleaning

Pacifier habits

Finger-sucking habits

Prepare your child

If possible, schedule morning appointments so young children are alert and fresh.

Prepare a preschooler or older child for the visit by giving him or her a general idea of what to expect. Explain why it is important to go to the dentist. Build excitement and understanding.

Prepare yourself

Discuss your questions and concerns with the dentist. Remember that your feeling toward dental visits can be quite different from your child's. Be honest with your view of the dentist. If you have dental anxieties, be careful not to relate those fears or dislikes to your child. Parents need to give moral support by staying calm while in the dental exam room. Children can pick up parents' anxieties and become anxious themselves.

Prepare the dentist

At the first visit, give the dentist your child's complete health history. For a restoration visit, such as getting a cavity filled, tell the dentist if your child tends to be stubborn, defiant, anxious, or fearful in other situations.

Watch how your child reacts. Many parents are able to guess how their child will respond and should tell the dentist. Certain behaviors may be linked to your child's age:

10 to 24 months. Some securely attached children may get upset when taken from their parents for an exam.

2 to 3 years. A securely attached child may be able to cope with a brief separation from parents. In a 2-year-old, "no" may be a common response.

3 years. Three-year-olds may not be OK being apart from a parent when having a dental procedure such as getting a cavity filled. This is because most 3-year-olds are not socially mature enough to separate from parents.

4 years. Most children should be able to sit in another room from parents for exams and treatment procedures.

The first visit

Your child's first dental visit is to help your child feel comfortable with the dentist. The first dental visit is recommended by 12 months of age, or within 6 months of the first tooth coming in. The first visit often lasts 30 to 45 minutes. Depending on your child's age, the visit may include a full exam of the teeth, jaws, bite, gums, and oral tissues to check growth and development. If needed, your child may also have a gentle cleaning. This includes polishing teeth and removing any plaque, tartar, and stains. The dentist may show you and your child proper home cleaning such as flossing, and advise you on the need for fluoride. Baby teeth fall out, so X-rays aren’t often done. But your child's dentist may recommend X-rays to diagnose decay, depending on your child's age. X-rays are also used to see if the root of a jammed baby tooth may be affecting an adult tooth. In general, it is best that young children not have dental X-rays unless absolutely needed.

The second visit

Just like adults, children should see the dentist every 6 months. Some dentists may schedule visits more often, such as every 3 months. This can build comfort and confidence in the child. More frequent visits can also help keep an eye on a development problem.

Protect your children's teeth at home

 Here are some tips to protect your children's teeth:

Before teeth come in, clean gums with a clean, damp cloth.

Start brushing with a small, soft-bristled toothbrush and a very small amount of toothpaste (the size of a grain of rice) when your child's first tooth appears. Use a pea-sized dab of fluoridated toothpaste after 3 years of age. This is when the child is old enough to spit out the toothpaste after brushing.

Prevent baby bottle tooth decay. Don't give children a bottle of milk, juice, or sweetened liquid at bedtime or when put down to nap.

Limit the time your child has a bottle. Your child should empty a bottle in 5 to 6 minutes or less.

Help your child brush his or her own teeth until age 7 or 8. Have the child watch you brush, and follow the same brushing pattern to reduce missed spots.

Limit foods and treats that increase tooth decay. This includes hard or sticky candies, fruit leather, and sweetened drinks and juice. Offer fruit rather than juice. The fiber in fruit tends to scrape the teeth clean. Juice just exposes the teeth to sugar.

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A Child’s First Dental Visit

An exploration of why the age 1 visit is a game changer in terms of overall oral health and childhood caries.

EDUCATIONAL OBJECTIVES

After reading this course, the participant should be able to:

• Explain the concept and value of a dental home and the Age 1 dental visit, as well as utilization rates for this model of care.
• Describe fundamental clinical practices and challenges when caring for infants and young children.
• Detail key issues surrounding childhood caries and the need to educate parents and caregivers of young pediatric patients.

For the better part of the last 100 years, dentistry followed the “see and treat” concept; meaning that oral health care was, for the most part, treatment oriented. Dentists did what they were trained to do, which was to treat dental caries. Most patients visited the dentist to address a specific problem (usually prompted by the occurrence of pain). Many did not consider primary teeth important, since they were looked upon as being transitional, and would soon be exfoliated and replaced by permanent teeth. In fact, in the 1950s some dental offices had signs in their waiting rooms proclaiming, “No children under age 13 treated.”

With an increase in the knowledge of the dental caries process, dentists gradually began to see children at earlier ages. Many dentists were ill equipped to communicate with and/or treat such young patients; consequently, the recommended age for the child’s first dental visit was on or after the 3rd birthday. Dentistry for patients under the age of 3 was largely approached didactically and not clinically. Prevention of dental disease for this group was a mere afterthought.

PARADIGM SHIFT

Once dental caries was understood as a chronic bacterial disease with a behavioral component, the paradigm shifted from treating the resulting damage to addressing the cause (prevention). In turn, this shift had a significant impact on determining the optimal age for the first dental visit.

Dentistry will never “drill its way out” of the early childhood caries (ECC) epidemic. For practitioners to succeed in the fight against ECC, they must improve preventive efforts and manage lesions in their earliest stages. A patient’s risk of developing dental caries starts with the introduction of oral pathogens into an infant’s mouth; therefore, first seeing the dentist at age 3 could prove too late. The age 1 visit not only allows for preventive therapies and early treatment, it also benefits the child by helping to establish optimal feeding and oral hygiene habits.

In a 1992 policy statement, the American Academy of Pediatrics proposed a definition of the medical home and referred to the “delivery of advanced primary care, with the goal of addressing and integrating high quality health promotion, acute care, and chronic condition management in a planned, coordinated and family centered manner.” 2 In 2001, the AAPD adopted its Policy on the Dental Home, based on the American Academy of Pediatrics’ medical home concept. Children who have a dental home are more likely to receive appropriate and routine preventive care and thus have a reduced risk of dental disease. 3

The recommendation for a child’s first dental visit to occur at or before age 1 has been the standard since 2001. Yet, practically speaking, dentistry for patients under the age of 3 continues to be largely spoken of didactically, and not widely implemented clinically in general practice. This is not a criticism as much as an observation. Dentists are busy addressing the functional and physical effects of dental caries and have little time to address the process. Many have not been adequately trained to understand the purpose and method of introducing the age 1 patient to clinical practice. This article will explain the rationale, benefit and technique for implementing the age 1 dental visit. The goal is to make dental practitioners comfortable and competent in meeting this standard of care.

RATIONALE FOR EARLY CARE

Dental caries is a preventable, chronic disease that is influenced by social and behavioral factors. Improving access to — and the use of — preventive and disease management strategies, along with early dental visits, will contribute to better patient outcomes, reduction of per capita health care expenses, and improved utilization of services.

According to research, annual treatment costs for children who had their first dental visit by age 1 are significantly less than for patients who wait until they are older. 4 Children seen by a dentist before age 1 are more likely to see the dentist on an ongoing basis, and less likely to require restorative or emergency visits. By comparison, those seen for the first time at age 2 and age 3 have an increased need for preventive, restorative and emergency visits over time. 5

Unfortunately, 23% of children continue to experience dental caries, with children from ages 2 to 5 experiencing increasing rates. 6 In 2015, 57% of children on Medicaid did not receive preventive oral health services. 7 Previous research showed that Medicaid patients ages 1 to 5 accounted for 45% of total dental costs, even though this age group represented only 5% of the insured population. 6 In a 2015 retrospective review of privately insured patients, only 1% had their first dental visit by age 1. 8

It is logical to ask, “If so much could be done to enhance oral health with effective preventive strategies implemented in the first year of life, why hasn’t dentistry been more effective in this regard?” This is a good question with a complex answer.

Seldom is a patient under the age of 3 cooperative in the dental office. If the dentist’s role is only restorative, there is a dilemma of how to perform complicated procedures on kicking, screaming and crying patients. In years past, many dentists were ill prepared to cope with such patients, therefore treatment was delayed until after the patients were better able to cooperate, usually after their 3rd birthday.

Only recently have the age 1 visit, the value of a dental home, and the clinical skills to complete an infant oral examination been emphasized in dental school curricula. While practicing general dentists may have been exposed to these concepts, as previously noted, many have not been trained in the delivery of care for such young patients.

In addition, dentists are trained to diagnose and restore the consequences of dental disease. Far too often, dentistry is viewed as a surgical specialty, and the schedules of many dentists are customarily filled with patients having broken-down teeth needing immediate attention. If this pattern is to be reversed, there must be a complete paradigm shift emphasizing preventive care and, when possible, nonsurgical management.

THE THREE PILLARS

A proper infant oral examination visit rests upon three pillars:

• Risk assessment
• Oral examination
• Anticipatory guidance

Risk Assessment: Effective infant preventive dentistry begins with an assessment of individual risk factors, as established through the medical, social and dental histories (Table 1). Preventive strategies are subsequently developed to address the patient’s specific risk. These activities occur before the patient’s oral exam and are aimed at providing the primary caregiver with adequate information to reduce the risk of dental caries.

Special attention should be given to the primary caregiver’s dental history. The infant’s oral pathogens are the result of vertical transmission from the primary caregiver. Untreated caries and high bacterial counts from periodontal conditions in the caregiver’s mouth result in the infant having a bacterial flora conducive to caries development. 9

Feeding habits affect caries risk through both what is eaten, and how it is eaten. Carbohydrate-rich diets are highly cariogenic and should be limited. Feeding on demand and/or at night leads to what was formerly referred to as “baby bottle decay,” but now is now known as ECC. 10 The American Academy of Pediatrics recommend infants be breastfed until age 1. 11 Breastfeeding or bottle-feeding should not be ad lib. Feeding at night increases the risk of caries formation. During sleep, the body’s systems slow and respirations and the heart rate decreases. There is also reduced salivary flow, and this diminishes the natural cleaning and buffering effect of saliva.

Oral Examination: The examination of the infant’s oral cavity takes place in a knee-to-knee fashion (Figure 1). The dentist cradles the infant’s head in his or her lap while supporting the head. The caregiver holds the infant’s hands and feet. It is normal and beneficial for the infant to cry, as this ensures the mouth is open and an adequate visual examination is possible. The dentist should communicate throughout the examination and remain complimentary of the infant and caregiver. Clinical observations should be pointed out, and the provider should demonstrate proper technique for cleaning the teeth using a gauze, toothbrush or washcloth. Finally, fluoride varnish should be applied. (Additional clinical resources are found in Table 2.)

Anticipatory Guidance: In terms of diet and feeding habits, breastfeeding should be encouraged and added carbohydrates avoided. Feeding should be on a schedule and infants should never be put to bed with a bottle. Water after feeding should also be encouraged.

The child should be introduced to toothbrushing when the first tooth erupts. A soft-bristle brush with an age-appropriate amount of fluoridated toothpaste is recommended (refer to the AAPD’s guideline on fluoride use). As noted, the dentist should demonstrate the technique to the caregiver during the knee-to-knee examination. Other sources of fluoride include drinking fluoridated water and use of fluoride varnish, which should be placed on primary teeth at each dental visit.

TOOTH ERUPTION

NONNUTRITIVE HABITS

Nonnutritive oral habits are common in infants. The caregiver should be assured these are normal and that most infants discontinue them in time. Persistent habits that are causing distortion of the oral cavity can be addressed when the patient is mature enough to want to quit. Until then, the dentist should monitor the habit and any resulting oral changes it is causing.

RECALL VISITS

High-risk patients should be placed on a three-month recall schedule. Fluoride varnish should be applied at these visits. Additional anticipatory guidance information should be reemphasized at each appointment. More information on the infant examination can be found in the AAPD Guideline for Infant Oral Health Care ( aapd.org/ media/ Policies_ Guidelines/ G_ InfantOralHealthCare.pdf ).

Dentists who provide care for pediatric patients are highly encouraged to adopt the age 1 visit. It is the standard of care for young patients and supported by the AAPD, American Dental Association and American Academy of Pediatrics. While preventive measures are important for all patients, waiting to institute these measures at age 3 would be too late for patients at high risk of dental caries. The patient with ECC will require more dental care, incur more expense, and is likely to face a lifetime of caries. For dentistry to address this dilemma in any significant way requires intervention upon the eruption of the first primary tooth.

Just as pediatricians are the primary medical care providers for infants, dentists are the primary oral health care providers for this patient population. The role and responsibility of the dentist is to provide education and training to the parents/caregivers and, when appropriate, the child, too. The value of the child’s first dental visit, and subsequent routine appointments, is not merely the dental prophylaxis. It is the supervision and educational information the parent/caregiver and patient receives from the dental team that will provide a lifetime of value in terms of oral and overall health.

• American Academy of Pediatrics. Maintaining and improving the oral health of young children. Section on oral health. Pediatrics. 2014;134:1224–1229.
• American Academy of Pediatrics. Medical Home definition. Available at: https://www.aap.org/en-us/professional-resources/practice-transformation/ medicalhome/Pages/home.aspx. Accessed January 17, 2019.
• American Academy of Pediatric Dentistry. Definition of Dental Home. Available at: http://www.aapd.org/ media/policies_guidelines/d_dentalhome.pdf. Accessed January 17, 2019.
• Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011–2012. NCHS Data Brief . 2015;191:1–8.
• Nowak A, Christensen JR, Mabry TR, Townsend JA, Wells MH. Pediatric Dentistry: Infancy through Adolescence . 6th ed. Philidelphia: Saunders; 2018:137.6.
• Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining the cost-effectiveness of early dental visits. Pediatr Dent . 2006;28:102–105.
• Casamassimo PS, Hammersmith K, Gross EL, Amini H. Infant oral health: an emerging dental public health measure. Dent Clin North Am . 2018;62:235–244.
• Kolstad C, Zavras A, Yoon RK. Cost-benefit analysis of the age one dental visit for the privately insured. Pediatr Dent . 2015;37:376–380.
• Dye BA, Vargas CM, Lee JJ, Magder L, Tinanoff N. Assessing the relationship between children’s oral health status and that of their mothers. J Am Dent Assoc . 2011;142:173–183.
• Kierce EA, Rainchuso L. Comprehensive approach to early childhood caries. Decisions in Dentistry. 2017;3(12):34–36,39.
• The American Academy of Pediatrics Policy on Breastfeeding. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/ Breastfeeding/Pages/AAP-Policy-on-Breastfeeding.aspx. Accessed   January 17, 2019.

Featured image by ONDROOO/ISTOCK/GETTY IMAGES PLUS

From Decisions in Dentistry.  February 2019;5(2):30—32,35.

Orpheus L. Triplett, DDS, is an associate professor in the Department of Pediatric Dentistry and Community Oral Health at the University of Tennessee Health Science Center College of Dentistry, where he serves as director of Community Relations and Outreach. Triplett has more than 20 years experience in private practice and has also served as dental director for Christ Community Health Services, a multisite federally qualified health center in Memphis.

Larry Dormois, DDS, MS, is chair of Pediatric Dentistry and Community Oral Health at the University of Tennessee Health Science Center College of Dentistry in Memphis. Board certified by the American Board of Pediatric Dentistry, he is also a fellow of the American Academy of Pediatric Dentistry and American College of Dentists. Dormois serves as an examiner for the American Board of Dentistry and is a site visitor for the Council on Dental Accreditation with the American Dental Association. He can be reached at [email protected].

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Brushing is should start as soon as teeth appear, which can be as early as 4 months. Babies usually get bottom teeth first, then top ones. Don’t get too worked up about when baby teeth come in.

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• Int J Clin Pediatr Dent
• v.15(4); Jul-Aug 2022

First Dental Visit: Age Reasons Oral Health Status and Dental Treatment Needs among Children Aged 1 Month to 14 Years

Neha padung.

1-3 Department of Pediatric and Preventive Dentistry, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India

Sukhdeep Singh

Neha awasthi.

The aim of this study was to see the age and also the reasons for the child's first dental visit and to assess the oral health status and treatment desires.

Materials and methods

The study involved 133 children aged between 1 month and 14 years, who reported to the department of pediatric and preventive dentistry. All parents/legal guardians of the study participants gave written consent for participation in the study. Information on the child's age and reason for the dental visit were collected from a questionnaire given to parents. The children's dental condition was assessed by decayed, missing, and filled teeth (dmft) and DMFT values.

Statistical analysis used

Statistical Package for Social Sciences (SPSS) version 21 and categorical data were compared by using Chi-square test. The level of significance was set at 0.05.

Age of the child for first dental visit was male: 85.7% at 9 years and female: 75.00% at 4 years. Majority of children who visited the dentist were age 7 years. The most common chief complaint about the primary visit was caries, and the second was tooth pain.

Children report for the primary dental visit most commonly solely after 7 years and for complaints like caries and tooth pain. Children make their first dental visit too late (usually at the age of 7 years) in reference to medical recommendations (between 6 and 12 months of life). More of restoration was the treatment of need by 47.00%. The results of this study indicate unhealthy oral health creating their first dental visit and low health awareness of parents and guardians.

How to cite this article

Padung N. First Dental Visit: Age Reasons Oral Health Status and Dental Treatment Needs among Children Aged 1 Month to 14 Years. Int J Clin Pediatr Dent 2022;15(4):394-397.

I ntroduction

Dental caries is one of the most common chronic diseases affecting children in developing countries. Early childhood caries, or tooth decay in children younger than 6 years, is the most common chronic disease among children. 1 - 3 Early childhood caries prevalence increases and leads to psychosocial, functional, and growing problems among children. Early childhood tooth decay is preventable and largely reversible in its early stages through self-care, use of professional services, and exposure to community interventions such as water fluoridation. During dental visits, children can receive an assessment for disease risk, early detection and treatment services, preventive care such as fluoride therapy, and anticipatory guidance. To ensure exposure to prevention early in life, professional organizations recommend that children have a dental home by 12 months of age. 4 One of the reasons for unsatisfactory dental health among the youngest population is the delay in the first visit of the child to the dentist. The American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA) recommends that the child's first visit to the dentist should take place within 6 months of eruption of the first primary tooth and no later than at the age of 12 months (AAPD, 2014; ADA, 2000), 5 , 6 while other sources suggest 12–18 months as the optimal time for the first visit (Adamowicz-Klepalska, 2009; Marcinkowska et al., 2013). 7 , 8 Argentine researchers Furze and Basso indicate that the first dental visit of a preventive character should take place in the fourth month of intrauterine life. During this visit, the expectant mother receives information about caries, its infectivity, is instructed that the mother is the main source of transmittable Streptococcus mutans , and is advised on how to provide oral care to the child and possible preventive procedures. The aim of this visit is to stimulate the interest of the pregnant woman in her own health but also in the health of her unborn child (Furze and Basso). 9 The information offered to parents at the first visit could inspire greater interest in the child's dental health and could accordingly mitigate the course of caries. The child's first dental visit has a significant impact on shaping a positive attitude and tolerance towards further treatments and helps to develop trust in the dentist. Thus, exposing children to the dental setting at a very early age can diminish their dental anxiety, whereas early dental education may improve the parent's self-efficacy in managing the oral health of their children. 10 The ADA recognizes the patient's chief complaint as an essential component for the delivery of competent and quality oral health care. It serves as a source of information for both the care provider and the patient. Hence, the main aim of this study was to know the average age at which parents first seek dental care for their children and also to find out the common reasons for seeking dental care at the first visit to the School of Dental Sciences, Sharda University, Uttar Pradesh, India. 11

M aterials and M ethods

The research protocol obtained approval from the Institutional Ethics Committee, Ref. No. SU/SMS&R/76-A/2019/142 on 18 th October 2019. The study group consisted of 133 children who had their first dental visit. All subjects were patients and parents reporting to the outpatient department in the department of pediatrics and preventive dentistry. Sample selection of children in the age group of 1 month to 14 years, reporting to the department of pediatrics and preventive dentistry. Informed consent was obtained from parents. Data on the child's age and reason for the dental visit were collected by interviewing the parents; a clinical pro forma was designed to record data. The state of oral health and dental treatment needs were assessed based on clinical examination using mouth mirror and a dental probe. The reasons for their visit were divided into the following five categories:

• Prophylactic examination,
• Tooth pain,
• Tooth decay,
• Injury to tooth and associated structures,

Data were analyzed using SPSS version 21. Categorical data were compared by using Chi-square test. Continuous data were tested for normality by using Shapiro–Wilk test. Parametric tests of significance (independent t -test and one-way analysis of variance) were used for inferential statistics. Else, the nonparametric tests (Kruskal–Wallis test and Mann–Whitney U test) were used. The level of significance was set at 0.05.

A total of 134 children visited the department of pediatric and preventive dentistry for the first time between November 2019 and January 2020. Records of 133 children were utilized, of which 77 were male (mean 8.32 ± 3.147) and 56 were female (mean 8.02 ± 3.446) p -value shows 0.595, NS ( Table 1 ).

Mean age association between sex

Table 2 shows the mean DMF(T) among males (0.41 ± 1.122) was high as compared to females (0.41 ± 1.385) p -value shows 0.998 NS, the decayed, missing, filled surface [DMF(S)] among males (0.72 ± 1.933) was high as compared to females (0.77 ± 2.565) p -value shows 0.898 NS, DMF(T) among males (mean 2.37 ± 3.080) was high as compared to females (mean 2.13 ± 3.015) p -value 0.645 NS, DMF(S) among males (mean 5.06 ± 6.493) was high as compared to females (mean 4.20 ± 6.493) p -value 0.477 NS.

Oral health status

Majority of children who visited the dentist were of age 7 years ( Fig. 1 ). Most common chief complaint for their visit was tooth decay (male 43.60% and female 33.90%) ( Fig. 2 ). The predominant reason for the child's first dental visit was caries, the need for treatment was restoration with 47.00%, followed by pulp therapy 29.90% and extraction 21.60% ( Fig. 3 ). The youngest patient who required treatment due to caries-related complications was a boy aged 2 years, visiting the dentist due to toothache.

Mean age at first dental visit

Reason for the first dental visit

Prevalence of need for various treatments

D iscussion

The child oral health care ought to be seen because the foundation on which a lifetime of preventive education and dental care are often built so as to help assure the best oral health into childhood. Oral examination, anticipatory guidance together with preventive education, and acceptable therapeutic intervention for the child will enhance the chance for a lifetime of freedom from preventable oral unwellness, emphasized in education regarding the importance of oral health for general health and adequate dietary and healthful habits, moreover as basic info concerning dental caries, so as to encourage the parents to stick to a program. 12 The longer a child's initial dental visit is delayed, more the chances he or she is to develop serious dental issues that might doubtless deteriorate rapidly in the absence of correct care and treatment. Unobserved and untreated dental caries will result in infection and moderate to severe pain, which may actively prevent children from eating, sleeping, and enjoying daily activities, additionally ultimately resulting in high-priced dental treatment and, in some cases, early loss of teeth. These consequences might have an effect on children's overall health and development. Given these problems, the investigation of early dental visitation is warranted. 13

Most of the kids within the current study visited dental clinics for the primary time at the age of 7 years. These results were not in accordance with the American Academy of Pediatrics (AAP) and AAPD tips. The mean age of kids visiting the dental workplace was more than the age suggested by the AAP, and therefore the AAPD, and this influences the dearth of information of parents about the age of the primary dental visit. The foremost common reasons for the primary dental visit were the presence of decayed teeth and dental pain perception. Only 2.60% of males and 4.40% females of children had visited the dentist for dental check-ups. Asymptomatic dental clinic attendance was not common in this report. This could provide evidence that parents are neither aware nor conscious of oral health prevention for their children. Very similar findings were presented by Wilk-Sieczak et al., who reported that 63% of children made their first dental visit due to the need for treatment (tooth decay and pain). 14 Daou et al. reported the reason for the first consultation; the most common was the presence of decayed teeth (50.9%) and dental pain perception (29.5%). 4 Yahya et al., Soxman, and Masiga in their respective studies suggested that the most common reason for the child's first dental visit was dental caries and its related complications. 15 - 17 Some study shows different reasons; Olatosi et al. reported the most common reason for visiting the dental clinic was dental pain (33.1%). 10 Ramakrishnan and Dharsini, in this retrospective study, the maximum number of children who reported their first dental visit was between 13 and 17 years (46%). The most common chief complaint for the visit was pain (47%) and the second common complaint was malocclusion (20%). 11

Results from the present study and other previous studies clearly suggest that universally, there are still no established practices for parents/caregivers to take their infants to visit the dentist at the recommended age. 12 Indian researchers reported an older age range for the child's first dental visit: Nino et al. indicated that children visit the dentist for the first time at age 7, 18 while a retrospective study by Meera et al. found that 59% of children have their first visit at the age of 6–12 years, and only 8.52% by the age of 3 years. 19 Studies carried out in Bulgaria by Mileva and Kondeva revealed that the greatest number of children making their first dental visit was 3–6 years old (51.9%), and the smallest number were those younger than 1 year (1.73%). 20

Ghimire et al. reported that in Nepal, most children making their first dental visit were 7–11 years old (52.7%), and only 7% were younger than 3 years. 21 Studies by Murshid found that in Saudi Arabia, most children visit the dentist at the age of 3–5 years (52.9%) and less often at the age under 3 years (32.2%). 22

In order to enhance oral health among children, it is essential that oral health-related education and education for motivating the parents of young children are provided throughout each dental visit. This additionally concerns pregnant women, who have been found to be a lot willing to follow all kinds of counsel throughout this period. 23 Cooperation in early childhood dental caries interference is additionally expected of non-dental medical employees (including pediatricians, general practitioners, and nurses). They should encourage their patients to schedule the primary dental visit for the child within 6 months of the eruption of the first tooth, and also make sure visits take place regularly. 24

Limitation of this study is that few children were included (smaller sample size). It is counseled that in children below the age of 6 years, brushing with fluoridated dentifrice should be supervised so as to stop general systemic. Regarding the preventive program, most of the children need pit and fissure sealant application. However, the practicability of pit and fissure sealants in the Indian state of affairs is questionable. However, on a priority basis for selected clusters of school children, pit and fissure sealant application can be taken as preventive measures. An honest protocol for dental and oral care should be necessary, and skilled dental follow-up should be integrated into the medical follow-up.

C onclusion

Within the limitations of the study, children report for the first dental visit most commonly only after 7 years, and for complaints such as tooth decay and tooth pain. Children make their first dental visit too late in relation to medical recommendations (between 6 and 12 months of life). Parents sought dental care for their children, mainly for curative reasons, and the most predominant reason for the first dental visit was dental caries. The results of this study indicate that bad oral health, making their first dental visit too late, and low health awareness of parents and guardians.

Source of support: Nil

Conflict of interest: None

R eferences

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Preventive Care/Periodicity Schedule

The Bright Futures/American Academy of Pediatrics (AAP)  Recommendations for Preventive Pediatric Health Care ,  also known as the "Periodicity Schedule," is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence.  

Each child and family is unique; therefore, these recommendations are designed for the care of children who are receiving nurturing parenting, have no manifestations of any important health problems, and are growing and developing in a satisfactory fashion. Additional visits also may become necessary if circumstances suggest concerns. Developmental, psychosocial and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits.  

These recommendations represent a consensus by the AAP and Bright Futures. The AAP continues to emphasize the great importance of continuity of care in comprehensive health supervision and the need to avoid fragmentation of care. Refer to the specific guidance by age as listed in the  Bright Futures Guidelines  (Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. 4th ed. American Academy of Pediatrics; 2017).  

Recommendations for Preventive Pediatric Health Care— Periodicity Schedule  (PDF)  

For more background information, click  here  to review the related  Bright Futures Guidelines , 4th Edition  Evidence and Rationale  chapter.  

At selected visits, Bright Futures recommends universal screening for issues such as child development, maternal or adolescent depression, behavior/social/emotional concerns, or oral health. A number of screening tools have been developed and are commonly used. Click here  for a list of links to tools for use at specific Bright Futures visits at the discretion of the health care professional. The links go to the author and/or the owner to ensure accessibility to the most up-to-date version of the specific tool.

For implementation and coding information for each visit on the Periodicity Schedule, please see the  Bright Futures and Preventive Medicine Coding Fact Sheet .  

Review and comply with any copyright and permissions requirements before use.

• The HIV screening recommendation has been updated to extend the upper age limit from 18 to 21 years (to account for the range in which the screening can take place) to align with recommendations of the US Preventive Services Task Force and AAP policy (“Adolescents and Young Adults: The Pediatrician’s Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis”).
• Footnote 30 has been updated to read as follows: “Screen adolescents for HIV at least once between the ages of 15 and 21, making every effort to preserve confidentiality of the adolescent, as per ‘Human Immunodeficiency Virus (HIV) Infection: Screening’ ( https://www. uspreventiveservicestaskforce.org/uspstf/recommendation/human-immunodeficiency-virus-hiv-infection-screening ); after initial screening, youth at increased risk of HIV infection should be retested annually or more frequently, as per ‘Adolescents and Young Adults: The Pediatrician’s Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis’ ( https://doi.org/10.1542/peds.2021-055207 ).”

Hepatitis B Virus Infection

• Assessing risk for hepatitis b virus (HBV) infection has been added to occur from newborn to 21 years (to account for the range in which the risk assessment can take place) to be consistent with recommendations of the USPSTF and the 2021–2024 edition of the AAP Red Book: Report of the Committee on Infectious Diseases .
• Footnote 31 has been added to read as follows: “Perform a risk assessment for hepatitis B virus (HBV) infection according to recommendations per the USPSTF and in the 2021– 2024 edition of the AAP Red Book: Report of the Committee on Infectious Diseases , making every effort to preserve confidentiality of the patient.”

Sudden Cardiac Arrest and Sudden Cardiac Death

• Assessing risk for sudden cardiac arrest and sudden cardiac death has been added to occur from 11 to 21 years (to account for the range in which the risk assessment can take place) to be consistent with AAP policy (“Sudden Death in the Young: Information for the Primary Care Provider”).
• Footnote 33 has been added to read as follows: “Perform a risk assessment, as appropriate, per ‘ Sudden Death in the Young: Information for the Primary Care Provider ’.”

Depression and Suicide Risk

• Screening for suicide risk has been added to the existing depression screening recommendation to be consistent with the GLAD-PC and AAP policy.
• Footnote 16 has been updated to read as follows: “Screen adolescents for depression and suicide risk, making every effort to preserve confidentiality of the adolescent. See ‘ Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management ’, ‘ Mental Health Competencies for Pediatric Practice ’, ‘ Suicide and Suicide Attempts in Adolescents ’, and ‘ The 21st Century Cures Act & Adolescent Confidentiality ’.”

Behavioral/Social/Emotional

• The Psychosocial/Behavioral Assessment recommendation has been updated to Behavioral/Social/Emotional Screening (annually from newborn to 21 years) to align with AAP policy, the American College of Obstetricians and Gynecologists (Women’s Preventive Services Initiative) recommendations, and the American Academy of Child & Adolescent Psychiatry guidelines.
• Footnote 14 has been updated to read as follows: “Screen for behavioral and social-emotional problems per ‘ Promoting Optimal Development: Screening for Behavioral and Emotional Problems ’, ‘ Mental Health Competencies for Pediatric Practice ’, ‘ Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders ’, and ‘ Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women’s Preventive Services Initiative ’. The screening should be family centered and may include asking about caregiver emotional and mental health concerns and social determinants of health, racism, poverty, and relational health. See ‘ Poverty and Child Health in the United States ’, ‘ The Impact of Racism on Child and Adolescent Health ’, and ‘ Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health ’.”

Fluoride Varnish

• Footnote 37 has been updated to read as follows: “The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. Once teeth are present, apply fluoride varnish to all children every 3 to 6 months in the primary care or dental office based on caries risk. Indications for fluoride use are noted in ‘ Fluoride Use in Caries Prevention in the Primary Care Setting ’.”

Fluoride Supplementation

• Footnote 38 has been updated to read as follows: “If primary water source is deficient in fluoride, consider oral fluoride supplementation. See ‘ Fluoride Use in Caries Prevention in the Primary Care Setting ’.”

Developmental

• Footnote 12 has been updated to read as follows: “Screening should occur per ‘ Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening ’.”

Autism Spectrum Disorder

• Footnote 13 has been updated to read as follows: “Screening should occur per ‘ Identification, Evaluation, and Management of Children With Autism Spectrum Disorder ’.”

Hepatitis C Virus Infection

• Screening for hepatitis C virus (HCV) infection has been added to occur at least once between the ages of 18 and 79 years (to be consistent with recommendations of the US Preventive Services Task Force and Centers for Disease Control and Prevention).
• Footnote 32 has been added to read as follows: “All individuals should be screened for hepatitis C virus (HCV) infection according to the USPSTF and Centers for Disease Control and Prevention (CDC) recommendations at least once between the ages of 18 and 79. Those at increased risk of HCV infection, including those who are persons with past or current injection drug use, should be tested for HCV infection and reassessed annually.”

Maternal Depression

• Footnote 16 has been updated to read as follows: “Screening should occur per ‘ Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice ’.”   

Blood Pressure

• Footnote 6 has been updated to read as follows: "Screening should occur per 'Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents.' Blood pressure measurement in infants and children with specific risk conditions should be performed at visits before age 3 years."  
• Footnote 24 has been updated to read as follows: "Perform risk assessment or screening, as appropriate, per recommendations in the current edition of the AAP  Pediatric Nutrition: Policy of the American Academy of Pediatrics  (Iron chapter)."  
• Footnote 25 has been updated to read as follows: "For children at risk of lead exposure, see 'Prevention of Childhood Lead Toxicity' and 'Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention'."  
• Timing and follow-up of the screening recommendations for hearing during the infancy visits have been delineated.  
• The accompanying footnotes (#8 & #9) has been updated and added.  
• Adolescent hearing risk assessment has changed to screening once during each time period  
• An accompanying footnote (#10) has been added​.  

​​Psychosocial/Behavorial Assessments​  

• An accompanying footnote (#13) has been added.  

Tobacco, Alcohol or Drug Use Assessment  

• The header was updated to be consistent with recommendations.  

​Depression Screening

• Adolescent depression screening begins routinely at 12 years of age.  

Maternal Depression Screening

• Screening for maternal depression at 1-, 2-, 4-, and 6-month visits has been added.  
• An accompanying footnote (#16) has been added.  

Newborn Blood  

• Timing and follow-up of the newborn blood screening recommendations have been delineated.  
• The accompanying footnotes (#19 & #20) has been updated and added.  

Newborn Bilirubin  

• Screening for bilirubin concentration at the newborn visit has been added.  
• An accompanying footnote (#21) has been added.  

DyslipIdemia  

• Screening for dyslipidemia has been updated to occur once between 9 and 11 years of age, and once between 17 and 21 years of age.  

Sexually Transmitted Infection (STIs)  

• An accompanying footnote (#29) has been added.  
• Screening for HIV has been updated to occur once between 15 and 18 years of age.  
• A subheading has been added for the HIV universal recommendation to avoid confusion with STIs selective screening recommendation.  
• An accompanying footnote (#30) has been added.  

Oral Health

• Assessing for a dental home has been updated to occur at the 12-month and 18-month through 6-year visits.  
• The accompanying footnotes (#32 & #33) have been updated.  
• A subheading has been added for fluoride supplementation, with a recommendation from the 6-month through 12-month and 18-month through 16-year visits.  
• An accompanying footnote (#35) has been added.   

Last Updated

American Academy of Pediatrics

When Should Baby Visit the Dentist for the First Time?

Medical review policy, latest update:, when to schedule baby's first dental visit, how to choose a dentist for your child, read this next, what happens at baby's first dentist visit, tips to make your child’s dentist visit easier, how often to visit the dentist.

Based on how your toddler’s teeth look, your dentist will let you know when to make the next visit. Most experts recommend that toddlers see the dentist about every six months — as long as there are no major problems. So don’t forget to schedule your child’s second appointment on your way out the door!

What to Expect the First Year , 3rd Edition, Heidi Murkoff. What to Expect the Second Year , Heidi Murkoff. WhatToExpect.com, Toddler Dental Care , March 2019. WhatToExpect.com, Is Your Toddler Teething? , April 2020. WhatToExpect.com, Preventing Cavities and Keeping Baby's Teeth Healthy , April 2020. WhatToExpect.com, Brushing Baby's Teeth , July 2020. American Academy of Pediatrics, Baby's First Tooth: 7 Facts Parents Should Know , November 2020. American Academy of Pediatrics, Good Oral Health Starts Early , November 2020 American Academy of Pediatric Dentistry, Frequently Asked Questions , 2021. American Dental Association, Taking Care of Your Child’s Smile , May 2014.

Go to Your Baby's Age

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Importance of the Age One Dental Visit

June 4, 2023.

Dental caries is the most common childhood disease in the United States. National surveys report that more than 50 percent of children still experience caries in their primary teeth. If left untreated the child can experience pain and infection causing problems with eating, speaking, and learning.

The American Academy of Pediatric Dentistry (AAPD), American Dental Association (ADA), American Public Health Association and American Academy of Pediatrics currently recommend that all children have their initial dental visit during the first year of life.

The age one dental visit allows the dentist to identify the individual child risk factors for caries and provide advice on behavior modification, dietary habits, fluoride therapies, oral hygiene practices and importance of regular dental checkups for prevention of dental disease. Early detection of caries and use of conservative methods such as silver diamine fluoride (SDF) and fluoride varnish for caries management and prevention are also made possible with the age one dental visit.

The longer the first dental visit is delayed, the more likely the possibility that dental disease can no longer be prevented or arrested but will require some surgical intervention. Younger kids often need to be moderately or deeply sedated in the hospital settings for caries treatment. Conservative therapies such as fluoride and SDF can prevent and arrest tooth caries and can minimize or delay the need for restorations (fillings) and other more involved procedures like pulpotomies and stainless-steel crowns, reducing the risk and adverse outcomes associated with sedation and general anesthesia.

In addition to the savings on restorative dental care rendered in the office and hospital settings, preventive dentistry has the potential to save considerable amount per year on dental related emergency visits and hospitalizations. The cost of dental caries is not just the actual cost of treating decay which can exceed several thousand dollars, but also lost time from school and work and other family disruptions which could be effectively prevented by timely dental checkups.  Providing education to parents on the importance of age 1 dental visit and regular dental checkups can help prevent a great amount of pain and distress associated with dental decay.

To learn more about the importance of the age one dental visit, please visit the following AAPD publication link: https://www.aapd.org/globalassets/media/policy-center/year1visit.pdf

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Decision trees, estimated effects of implementing the recommended policies, sensitivity analysis, estimated impact of competing policy recommendations for age of first dental visit.

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Kari Jones , Scott L. Tomar; Estimated Impact of Competing Policy Recommendations for Age of First Dental Visit. Pediatrics April 2005; 115 (4): 906–914. 10.1542/peds.2004-1687

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Objective. To compare levels of dental utilization and untreated dental decay among children aged 1 to 3 years that are likely to occur under 2 potential guidance policies: (1) pediatricians refer all toddlers to dentists for screening (consistent with American Academy of Pediatric Dentistry and the American Dental Association recommendations; DENT), and (2) pediatricians receive training in caries risk assessment, screen toddlers, and refer at-risk children to dentists (consistent with American Academy of Pediatrics recommendations; PED).

Methods. Using decision analysis, we estimated the impact of PED and DENT assuming alternately unlimited dental capacity for Medicaid-insured patients and fixed Medicaid dental capacity.

Results With unlimited capacity, if DENT were implemented, then dental utilization is estimated to increase from 27% under the status quo to 65% and untreated decay to decrease from a mean of 0.60 surfaces to 0.52 surfaces per child. If PED were implemented, then dental utilization and untreated decay would decrease from status quo levels to an estimated 11% and 0.47 surfaces, respectively, assuming that diagnostic sensitivity and specificity both equaled 1; they would decrease to 13% and 0.53 surfaces, respectively, if sensitivity equaled 0.76 and specificity equaled 0.95. With fixed capacity, under DENT, untreated decay is estimated to increase to 0.63 surfaces because low-risk private-pay patients would crowd out at-risk Medicaid-insured children, whereas under PED, untreated decay would still be less than under the status quo.

Conclusions. Implementing PED will decrease untreated decay under most plausible scenarios, whereas switching to DENT will increase the burden of disease if Medicaid dental capacity is limited.

Over the past several years, much discussion has centered on the age at which a child without identified dental problems should first visit a dentist. 1 , 2   Several dental professional organizations have offered a strong rationale for making that first visit by age 1. 3   A visit by age 1 may provide the opportunity to evaluate craniofacial and dental development, assess risk for common dental conditions, and counsel parents and caregivers on primary prevention interventions before disease progresses, poor habits become well established, or irreversible harm occurs. 3  

Currently, the American Academy of Pediatric Dentistry, 3   the American Dental Association, 4   and the Bright Futures Project of the National Center for Education in Maternal and Child Health 5   recommend that dentists examine toddlers by their first birthday. In addition, an expert panel was convened by the Health Care Financing Administration (now Centers for Medicare and Medicaid Services) and the National Center for Quality Assurance and charged with evaluating and developing performance measures for the assessment of oral health services delivered to Medicaid-insured children and other pediatric populations. The panel suggested revising the current HEDIS measure, Annual Dental Visit, to extend the age range to children age 1 year and younger. 6   Currently, the measure includes the proportion of Medicaid-enrolled people, ages 4 through 21 years, who had at least 1 dental visit during the preceding year.

The American Academy of Pediatrics (AAP) previously recommended first dental visit at age 3 and recently adopted a policy statement that advocates an oral health assessment of infants by a pediatrician or other qualified pediatric health care professional by 6 months of age. 7   The policy statement recommends that children who are deemed to be at high risk for dental caries be referred to a dentist no later than 6 months after the eruption of the first tooth or by 12 months of age, whichever comes first. The policy statement concludes, “The ideal deterrence to early childhood caries is the establishment of the dental home when indicated by the unique needs of the child. Although not always feasible because of manpower and participation issues, best practice dictates that whenever feasible, all patients should have a comprehensive dental examination by a dentist in the early toddler years.” Presumably, the pediatrician would continue to conduct periodic oral health assessments when feasible if manpower issues preclude early establishment of a dental home.

Toddlers from low-income families have been shown to be at higher risk than higher income children for dental caries. 8   They are also more likely to utilize pediatric or primary care services than dental services: a recent study found that among children aged 1 to 4 years, ∼85% had at least 1 office-based visit to a primary care provider but only 20% visited a dental care provider. 9   Medicaid agencies in at least 2 states now reimburse pediatricians and primary care physicians and extenders for dental screenings and provision of fluoride varnish. 10 , 11   A recent publication that addressed disparities in children's oral health and access to dental care called for greater integration of medicine and dentistry at multiple levels and, among other strategies, advocated advancing the oral health knowledge and skills of primary care practitioners who see children before they are referred to the dentist. 12  

There seems to be a growing consensus that pediatricians should take an active role in promoting children's oral health. At present, however, it is unclear how frequently pediatricians screen for common oral conditions such as dental caries, which methods they use to conduct screenings, how they document findings, and how accurate such screenings are. 10   For example, although 90% of pediatricians in a recent survey responded that they had an important role in both identifying dental caries and providing counsel on caries prevention, 50% of respondents reported no previous training in dental health during medical school or residency and only 9% of respondents correctly answered 4 questions on scientific dental knowledge. 13   There are, however, low-cost, evidence-based models for caries risk assessment, 14   and 2 recent studies have shown that after a few hours of training, pediatricians can diagnose overt caries in children with probabilities ranging from 76% 10   to 100% 15   and identify children without caries with probabilities ranging from 87% 15   to 95%. 10  

There may not be sufficient dental capacity for all children aged 1 to 3 years to be seen by a dentist. Parents of children who participate in the Head Start Program, which requires each child to have an oral examination, identified access to oral health services as their main health concern. 16   Limited access has been attributed to a low number of dentists accepting Medicaid payment for services, long wait times for appointments, and extensive travel time in rural areas. 16   Fifty percent of surveyed pediatricians reported difficulty in successfully referring noninsured children, and 38% reported difficulty in successfully referring Medicaid-insured children. 13   Access may be even more limited for very young children. Studies suggest a shortage of pediatric dentists 16   ; many general dentists, who make up 80% of the dentist workforce, report that they are reluctant to see very young children. 14   In light of these problems, the debate continues as to effect and efficacy of dental referrals at age 1.

In this study, we compare estimated utilization of dental services (defined as the proportion of children with a dental visit within the preceding 12 months) and levels of untreated dental caries among 1- to 3-year-olds under competing guidance policies: (1) DENT, in which, consistent with dental professional organizations' recommendations, pediatricians refer all children to dentists by age 1, and (2) PED, a more integrated approach, consistent with AAP guidelines, in which pediatricians receive training in risk assessment and refer to a dentist at-risk children who are younger than 3 years, and dentists, in turn, agree to accept these referrals. The expected outcomes of these proposed policies are compared with each other and with the status quo (SQ), in which pediatricians and other primary care providers screen and refer, and dentists examine and treat very young children to varying degrees under conflicting and uncoordinated guidance for children aged <3 years. These policies are analyzed alternately under assumptions of unlimited and limited (or fixed) dental care capacity for publicly insured children (eg, children who are covered by Medicaid or the State Children's Health Insurance Program [SCHIP]).

We used decision analysis to estimate the effects of the proposed guidance policies on (1) dental utilization, the proportion of toddlers, aged 1 to 3 years, with a past-year dental visit (Fig 1 ), and (2) the average number of tooth surfaces with untreated decay among toddlers aged 1 to 3 years (Fig 2 ). We compared the values of these outcomes expected under each policy with those observed in the SQ, under 2 different scenarios. First, we assumed unlimited dental capacity; that is, at current public insurance reimbursement levels, all caregivers who want to take a child to the dentist can obtain a visit. We next assumed fixed dental capacity, the more likely scenario because some publicly insured children are unable to obtain dental visits under the current system. Fixed capacity results in the crowding out of some low-income children because increased utilization by higher compensation private patients is offset by lower utilization among lower compensation publicly insured children.

This crowd out is predicted by the dual market model, which has been used in previous studies to measure the impact of Medicaid/SCHIP fee increases on dentist and physician participation. 17 – 19   Dental practices are assumed to serve 2 markets: the private and/or self-insured market and the Medicaid/SCHIP market. In the private market, dentists face a downward-sloping demand curve, and, therefore, marginal revenue decreases as a practice takes on additional patients 20   ; in the Medicaid/SCHIP market, marginal revenue is constant at the government-determined reimbursement rate. The standard economic assumptions are that a practice will take on an additional patient as long as the additional revenue generated from that patient (marginal revenue) exceeds the additional cost (marginal cost) of doing so and that practices prefer to take on patients who generate the highest marginal revenue. We assume, as anecdotal evidence suggests, that marginal revenue in the private-pay market exceeds that in the Medicaid market over some relevant range. As a result, the dental capacity available to publicly insured children is unlimited only if the cost of seeing an additional patient (marginal cost) never increases and this cost is less than or equal to the Medicaid/SCHIP reimbursement rate.

We used data from the US Census Bureau's March 2001 Current Population Survey (for children <6 years of age) to estimate the proportion of 1- to 3-year-olds who are covered by Medicaid or SCHIP using the proportion of children who live in families with incomes ≤200% of the federal poverty line, the typical threshold for Medicaid/SCHIP eligibility. 21   This value is labeled p_low in the decision tree. (Note that the names of decision tree variables appear in italics.) These children are hereafter referred to as Medicaid children, Medicaid toddlers, low-income children, or low-income toddlers; all other 1- to 3-year-olds are collectively referred to as high-income children or high-income toddlers.

We used interview and clinical examination data from the Third National Health and Nutrition Examination Survey (NHANES III; conducted between 1988 and 1994) to estimate utilization and disease parameters. Additional information on NHANES III sampling methods and diagnostic criteria has been published previously. 22   No data were available for 1-year-olds regarding utilization of dental services, mean level of caries (filled or untreated decay), or mean level of untreated decay. Thus, we assumed that these values equaled those values for 2- and 3-year-olds. Utilization parameters include (1) the proportion of children who were aged 2 or 3 years (proxy for 1- to 3-year-olds) and had a past-year dental visit as reported by a responsible household adult (decision tree variables labeled pSQdvisithigh and pSQdvisitlow for high-income and Medicaid toddlers, respectively), (2) the proportion of children who were aged 4 or 5 years and had a past-year dental visit as reported by a responsible household adult (variables labeled pDENTdvisithigh and pDENTdvisitlow for high-income and Medicaid toddlers, respectively), and (3) the proportion of children who were aged 2 or 3 years and had a past-year visit to a pediatrician or other primary care provider as reported by a responsible household adult (variable labeled ppedvisithigh and ppedvisitlow for high-income and Medicaid toddlers, respectively). Estimates of the income and utilization parameters are found in Table 1 .

Disease parameters among 2- and 3-year-olds include prevalence of untreated decay (decision tree variables labeled pdh and pdl for high-income and Medicaid toddlers, respectively), severity of untreated decay (variables labeled dh and dl for high-income and Medicaid toddlers, respectively), prevalence of caries experience (ie, treated or untreated decay; variables labeled pch and pcl for high-income and Medicaid toddlers, respectively), and severity of caries experience (for high-income and Medicaid toddlers, variables labeled ch and cl , respectively). For this same age group, we also calculated the proportion with a past-year dental visit by caries prevalence and, among children with a past-year dental visit and caries experience, the proportion of caries experience that was untreated decay. To estimate the impact of increased dental utilization on untreated decay, we calculated the percentage reduction in untreated decay among 4- and 5-year-olds attributable to a past-year dental visit (decision tree variables labeled PFh and PFl for high-income and Medicaid children, respectively). Estimates of the disease parameters are found in Table 2 .

Because NHANES III was a complex survey sample, we used SUDAAN statistical software to calculate all point estimates and standard errors and to conduct statistical tests. 23   Finally, in our subsequent sensitivity analysis, we used data from a published study to estimate feasible bounds on the probabilities of a pediatrician's or primary care provider's correctly identifying untreated decay (variable labeled sensitivity ) and correctly identifying healthy teeth (variable labeled specificity ). 10  

In analyzing our decision trees, we made the following assumptions.

Baseline levels of sensitivity and specificity both are 100%.

Because it is already recommended that 4- and 5-year-olds visit the dentist, implementing DENT increases demand for dental services among 1- to 3-year-olds of each income group to levels comparable to the current utilization rates of 4- and 5-year-olds in that group.

Because 1- to 3-year-olds generally do not have a dental home and pediatricians are the primary source of health care advice for their parents, under PED, pediatricians become the de facto gatekeeper for dental visits among these children. We further assume that all those with untreated decay are diagnosed and successfully referred to a dentist, and only those who receive a dental referral will seek dental care. Thus, among toddlers with a pediatric visit, the proportion who visit the dentist will equal the proportion with caries, and among toddlers without a pediatric visit, the probability of visiting a dentist and mean level of disease equal those values under the SQ.

Most dentists prefer to see older children 14 , 24   ; therefore, increases in demand for dental services among higher income 1- to 3-year-olds will not crowd out utilization among older low-income children.

Figure 1 shows the decision tree used to analyze the level of dental utilization among 1- to 3-year-old children that is both observed in the SQ and expected under DENT and PED, assuming unlimited dental capacity. The decision tree in Fig 2 shows the amount of untreated decay in the SQ and the amount of untreated decay expected if DENT or PED were implemented, assuming unlimited capacity. Plugging the parameter estimates found in Tables 1 and 2 into the decision models, we calculated the utilization rates and untreated decay levels both observed in the SQ and expected under the competing policy recommendations. For example, assuming unlimited capacity, the utilization expected under DENT is found by summing the products of the probabilities along each branch coming from the DENT trunk in Fig 1 : [ p_low × pDENTdvisitlow × 1)] + [ p_low × (1 − pDENTdvisitlow ) × 0] + [(1 − p_low ) × pDENTdvisithigh × 1] + [(1 − p_low ) × (1 − pDENTdvisithigh ) × 0] = [0.4 × 0.5391 × 1] + [0.4 × (1 − 0.5391) × 0] + [(1 − 0.4) × 0.7206 × 1] + [(1 − 0.4) × (1 − 0.7206) × 0] = 0.65. Likewise, assuming unlimited capacity, the amount of decay expected under DENT is found by summing the products of all probabilities and the end-node decay value along each branch coming from the DENT trunk in Fig 2 : [ p_low × pDENTdvisitlow × (1 − PFl ) × dl )] + [ p_low × (1 − pDENTdvisitlow ) × dl ] + [(1 − p_low ) × pDENTdvisithigh × (1 − PFh ) × dh ] + [(1 − p_low ) × (1 − pDENTdvisithigh ) × dh ] = [0.4 × 0.5391 × (1 − 0.1536) × 1.28] + [0.4 × (1 − 0.5391) × 1.28] + [(1 − 0.4) × 0.7206 × (1 − 0.6162) × 0.14] + [(1 − 0.4) × (1 − 0.7206) × 0.14] = 0.52.

The same decision trees were used to analyze outcomes under the assumption of limited capacity. However, the probability of a low-income child's visiting a dentist under DENT was changed to 0 (from pDENTdvisitlow ), because all low-income children are crowded out by higher paying, high-income children. (If Medicaid capacity were fixed, then any increase in utilization among private-pay patients would have to be offset by a decrease in Medicaid patients. Under DENT, 72.06% of high-income 1- to 3-year-olds are expected to seek dental appointments, ie, the percentage of high-income 4- and 5-year-olds who are already referred to and seek dental appointments under the SQ.) In addition, the amount of untreated decay in the mouths of low-income children who do not visit the dentist equals cl under the assumption of fixed capacity (instead of dl ). (Because no low-income children visit the dentist under this scenario, the amount of both untreated decay and treated decay that is observed under the SQ will be untreated under DENT.) So, for example, the expected utilization under DENT with the assumption of fixed capacity is as follows: [ p_low × 0 × 1)] + [ p_low × 1 × 0] + [(1 − p_low ) × pDENTdvisithigh × 1] + [(1 − p_low ) × (1 − pDENTdvisithigh ) × 0] = [0.4 × 0 × 1] + [0.4 × 1 × 0] + [(1 − 0.4) × 0.7206 × 1] + [(1 − 0.4) × (1 − 0.7206) × 0] = 0.43. Likewise, the amount of decay expected under DENT with the assumption of fixed capacity is as follows: [ p_low × 0 × (1 − PFl ) × cl )] + [ p_low × 1 × cl ] + [(1 − p_low ) × pDENTdvisithigh × (1 − PFh ) × dh ] + [(1 − p_low ) × (1 − pDENTdvisithigh ) × dh ] = [0.4 × 0 × (1 − 0.1536) × 1.47] + [0.4 × 1 × 1.47] + [(1 − 0.4) × 0.7206 × (1 − 0.6162) × 0.14] + [(1 − 0.4) × (1 − 0.7206) × 0.14] = 0.63.

At present, ∼40% of children who are aged 6 years or younger live in families with incomes ≤200% of the federal poverty level. 21   Under the SQ, past-year dental visits among high-income 1- to 3-year-olds were estimated to be 48% higher than among their Medicaid-insured counterparts, whereas past-year pediatric/primary care visits among the high-income group were only 8% higher (Table 1 ). The mean number of tooth surfaces with untreated decay and mean number of surfaces with caries experience (filled or untreated decay) among Medicaid toddlers in the SQ (1.28 and 1.47, respectively) are ∼8 times higher than those values among high-income toddlers (0.14 and 0.19; Table 2 ). In fact, ∼86% of all untreated decay ([0.4 × 1.28]/[0.4 × 1.28 + 0.6 × 0.14]) was found in low-income children.

Unlimited Capacity

A summary of utilization rates and untreated decay observed in the SQ and expected under the competing policy recommendations is found in Table 3 . If dental capacity were unlimited, then implementing DENT would increase utilization rates from 27% (in the SQ) to 65% and decrease mean untreated decay per child from 0.60 surfaces to 0.52 surfaces. Implementing PED would decrease dental utilization to 11%; however, because more toddlers with untreated decay then would visit the dentist, the mean number of untreated decayed surfaces would decrease to 0.47 surfaces. Thus, selecting PED would result in 0.05 fewer decayed surfaces per toddler on average than would DENT.

Fixed Capacity

Implementing DENT increases demand for utilization among high-income toddlers to an estimated 72.06%, thus crowding out all Medicaid toddlers. As a result, Medicaid toddlers then would have a mean of 1.47 tooth surfaces with untreated decay because there would be no dental care access. Overall untreated decay in this age group is expected to increase to 0.63 surfaces. Because implementing PED does not increase overall dental utilization, no crowding out of Medicaid patients would occur. Thus, even with constrained capacity, the level of untreated decay is expected to decrease to 0.47 surfaces under PED.

Implementing PED becomes less attractive as diagnostic sensitivity and specificity decrease from our assumed value of 1. For example, if diagnostic sensitivity equaled 76% and diagnostic specificity equaled 95%, the values observed in a recent study of the accuracy of pediatrician screenings, 10   then utilization and untreated decay under PED would equal 13% and 0.53 surfaces, respectively. Assuming that specificity is only 95%, PED is expected to reduce untreated decayed surfaces relative to the SQ if sensitivity is at least 44%; PED is expected to result in fewer decayed surfaces than DENT if sensitivity is at least 81%. If specificity is <100%, then untreated decay is unaffected under unlimited capacity because mistakenly classifying children as being at risk for dental decay when they in fact are not at risk does not increase their chances of developing decay.

Fixed Dental Capacity

The assumption that dental capacity is fixed decreases the attractiveness of DENT because increases in utilization among higher income children, who are at lower risk for caries, will absorb current Medicaid dental capacity. For no crowding out of Medicaid children to occur (ie, to achieve the unlimited capacity outcome), we would have to assume that we could almost double the dental capacity available to 1- to 3-year-olds without increasing costs per additional patient seen. (To see this, recall that implementing DENT would increase utilization among high-income children to an estimated 72.06% [ pDENTdvisithigh ]. This means that, overall, 52% of 1- to 3-year-olds would desire a dental visit [0.6 × 0.7206 + 0.4 × 0.2088] under DENT, whereas only 27% of 1- to 3-year-olds visit the dentist under the SQ [0.3098 × 0.6 + 0.2088 × 0.4].)

Inaccuracies in pediatricians' determination of the risk of caries in toddlers also have an affect on the expected outcomes under PED when capacity is limited. The effect of changes in sensitivity under limited capacity are the same as the effect under unlimited capacity because as sensitivity falls below 100%, fewer children are referred to a dentist, leading to less strain on capacity. Decreases in specificity , however, mean more unnecessary referrals. The capacity constraint becomes binding at levels of specificity below 100% if sensitivity is assumed to be 100%, and at levels of specificity below 94% for sensitivity of 76%. Assuming sensitivity were only 76%, at levels of specificity higher than 39%, the expected decay under PED is less than the SQ, and even if specificity were 0%, expected decay is still lower under PED than under DENT.

If, under PED, we relax the assumption that pediatricians become the de facto gatekeeper and instead assume that children who visit the dentist under the SQ would also do so under PED, then fixed capacity would become an issue and some crowding out would result. The worst-case scenario for crowd out is if all at-risk children who are recommended for a dental visit try to schedule an appointment and children who are deemed not to be at risk continue to demand appointments in the same proportions as under the SQ. In this case, assuming sensitivity and specificity of 1, utilization drops to 28.8% and the expected decay is 0.565 surfaces; assuming sensitivity and specificity of 0.76 and 0.95, respectively, utilization is 28.4% and expected decay is 0.557 surfaces. In both cases, the number of decayed surfaces expected per child is still fewer than under SQ or DENT.

Approximately 11% of 1- to 3-year-old children have experienced dental caries (Table 2 ). Among these toddlers, the condition can be fairly severe: a mean of 5.33 tooth surfaces had fillings or untreated decay (Table 2 ). A total of 84% of the disease is concentrated in low-income toddlers, who at present are less likely to utilize dental services. Implementing DENT may decrease or increase the burden of disease, depending on the dental capacity available to Medicaid patients. Implementing PED, however, is expected to decrease the burden of untreated disease, regardless of assumptions about dental capacity.

We used a well-established model to analyze the possible consequences of changing the AAP recommended age of first dental visit; however, multiple factors affect demand for and supply of dental services. Thus, the issue of increasing utilization of dental services among low-income children has more complexities than modeled. Although our results do not provide margins of error for our untreated decay or utilization estimates, we do provide plausible point estimates of outcomes under a best-case (unlimited Medicaid dental capacity) and worst-case (fixed Medicaid dental capacity) scenario and sensitivity analysis regarding other assumptions, which can be used as a launching point to discuss the various tradeoffs associated with implementing 1 of the 2 widely advocated policies, DENT or PED.

Our analysis of utilization levels and untreated decay under PED is limited by 2 factors. First, our estimates of sensitivity and specificity come from a study of pediatricians' abilities to identify caries and not precavitated lesions, the more difficult but important task for preventing decay. 10   Thus, we include extensive sensitivity analysis of the effects that these values have on expected outcomes. In addition, pediatricians in the study did not refer a substantial proportion of at-risk children for a dental visit. 10   If pediatricians did not refer all at-risk children for dental visits, then the expected decay under PED would be higher than our model predicts. However, the study's authors state that “primary care providers may not have referred because they did not have a dental provider to whom they could refer.” 10   If capacity is constrained, then the crowd out resulting from DENT could only exacerbate this situation.

Several of our assumptions bias our analysis toward finding DENT more attractive than the SQ or PED. First, if utilization and disease levels among 1-year-olds were less than those of 2- and 3-year olds, then our estimates of current utilization and untreated decay would be inflated. Therefore, DENT would result in an even greater increase in utilization among children without caries, and if dental Medicaid capacity were limited, then that would in turn result in even greater crowding out of at-risk children. The assumption that increased dental demand by 1- to 3-year-olds had no impact on capacity available to older children could also underestimate the impact on untreated decay. In reality, because they generate higher compensation for dentists, younger low-risk children could crowd out older at-risk children who have more disease.

We also assumed that higher prices in the private-pay market resulting from increased demand did not reduce utilization among the private-pay group. For example, we assumed that DENT would increase utilization among high-income children >2-fold to 72.06%. If capacity did not expand by this same amount or if higher prices deterred some visits, then untreated decay among the high-income group would be understated. Finally, we assumed that the lower effectiveness of a past-year dental visit in preventing decay observed among Medicaid toddlers was independent of capacity. If the lower prevented fraction were attributable to existing crowding out (eg, Medicaid children have difficulty in scheduling follow-up appointments for treatment), then reducing crowding out by adopting PED would result in an even greater decrease in untreated decay. Our finding that, among Medicaid children with a past-year dental visit, 76% of caries experience was untreated decay (compared with 39% among their higher income counterparts) suggests that crowd out may indeed be present in the SQ.

The attractiveness of DENT depends on assumptions about capacity constraints. The dental capacity available to Medicaid patients is limited to current levels if 3 conditions are met: (1) demand for dental services exceeds supply of dental services in the Medicaid market currently, (2) the cost of seeing additional patients is increasing (ie, the supply curve is upward-sloping), and (3) supply does not expand. Medicaid parents' and pediatricians' difficulties in obtaining dental appointments for their children in the SQ suggest that demand already exceeds supply. If we assume that the dentist either examines or supervises the examination of each patient, then seeing additional patients requires additional units of dental time. If the number of dentists is fixed, then, at some point, the cost of seeing additional patients must increase. This is because when deciding whether to see an additional patient, the dentist compares the value of his time spent working with the value of that time spent not working. As more hours are worked in a given period, income increases and available leisure time decreases; the value of additional leisure time increases relative to the value of additional income. Because, from the dentist's perspective, the cost of treating an additional patient includes the value of the leisure forgone, dentists view marginal cost (of treating an additional patient) as increasing. Findings from a recent study suggest that indeed both the supply of dentists is fixed and dentists are forgoing additional income to consume additional leisure. The number of practicing dentists has been declining since 1991, and decreases in dental school enrollment suggest that this trend may continue. In addition, the average number of hours worked per dentist is decreasing: the number of part-time dentists increased by 68% from 1982 to 1995, and in 1998, dentists averaged only 33.3 hours per week treating patients. 25  

Implementing PED would require additional time of pediatricians and other primary care providers. Whereas dental capacity has been declining, physician capacity has been increasing over the past 40 years 25   and physicians average 51.6 hours per week treating patients, 55% more time than their dental counterparts. Furthermore, the supply of general pediatricians is expected to increase by 33% from 2000 to 2010 and by 58% from 2000 to 2020, outpacing the growth of the child population. 26   As a result, pediatricians then may look to expand into delivery of other services. 26   Although dental capacity may be augmented by increased use of dental auxiliaries, eg, dental hygienists and assistants, requirements that auxiliaries must work under the supervision of a dentist suggests that the declining number of dentists still restricts dental capacity.

The scope of this study was to compare the competing guidance policies on the basis of utilization rates and untreated dental decay expected under each policy. Before implementing any policy, all benefits of the strategy should be considered and compared with the costs of achieving these benefits. PED and DENT will yield different additional benefits. For example, we did not determine whether children who visited a dentist by age 1 year were more likely to utilize dental services in the future or to have established better dental habits than those who had their first visit at age 3 years, and we did not quantify the benefits from increased access to primary prevention. In addition, we did not consider the benefit obtained from pediatricians' or other primary care providers' delivering primary prevention. For example, Medicaid programs in at least 2 states now reimburse primary care providers for application of fluoride varnish. 10 , 11  

The costs of the policies will differ as well. DENT will require more dental resources than will PED because more toddlers will use dental services, especially those at low risk for dental caries. PED, however, will require more primary care resources in terms of both additional training to identify caries and additional time consumed in examination, assessment, and referral.

In conclusion, both PED and DENT have been recommended as ways to improve the dental health of toddlers. The success of DENT in directly lowering untreated decay will depend on Medicaid dental capacity and parental compliance, especially among parents of at-risk children, and ability to locate dentists who are willing to see Medicaid-eligible toddlers. If Medicaid dental capacity is currently limited, then implementing DENT without an increase in the Medicaid dental supply will result in decreased utilization among Medicaid children and thus an overall increase in untreated decay. The success of PED depends on primary care providers' accuracy in diagnosing at-risk toddlers and their willingness to participate in such programs, dentists' willingness to work with primary care providers to establish a referral base for at-risk toddlers, and compliance among parents of at-risk children who receive a referral. All of these factors should be considered in the formulation of policy regarding the recommended age of a child's first dental visit.

Decision tree showing utilization under baseline assumptions with unlimited capacity. The character # equals 1 minus the probability of the branch above; end nodes indicate the probability of a past-year dental visit.

Decision tree showing untreated decay under baseline assumptions with unlimited dental capacity. The character # equals 1 minus the probability of the branch above; end nodes indicate the amount of untreated decay.

Estimated Income and Utilization Parameters *

Labels used in the decision trees are shown in italics; standard errors are in parentheses.

χ 2 test shows this variable statistically dependent with family income at 5% significance level.

Estimated Disease Parameters *

All values are for 2- and 3-year olds as a proxy for 1- to 3-year-olds; labels used in the decision trees are shown in italics; standard errors are in parentheses

χ 2 test shows this variable statistically dependent with family income at the 5% significance level.

t test shows low-income and high-income values differ at the 5% significance level.

Mean number of tooth surfaces with untreated decay among children with and without past-year dental visit equaled 2.59 and 3.06, respectively.

Mean number of tooth surfaces with untreated decay among children with and without past-year dental visit equaled 0.38 and 0.99 surfaces, respectively.

Estimated Utilization and Untreated Decay Observed in the SQ and Expected Under Competing Policy Recommendations Under Baseline Assumptions

No conflict of interest declared.

This work was completed while Dr Jones was at the Terry College of Business, University of Georgia, Athens, Georgia.

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