In a perfect world, everyone would have access to consistent and comprehensive dental care from the time their first tooth erupts. Unfortunately, this is not the case for many Americans. In fact, only 63% of adults visited a dentist in 2020.1 Too many children and adults are left without basic preventive services and education, let alone restorative treatments, due to financial constraints or a lack of accessible dental professionals.2 Dental hygienists are specialists in prevention and are an integral part of the health care delivery system. So, what can we do to improve oral health inequalities?
As RDH, we are uniquely positioned to change the oral and overall health of our country’s most vulnerable populations. We are able to provide the necessary care to children, especially in rural areas. This includes taking steps to prevent dental anxiety and fear by using painless and non-invasive procedures. Innovation in dental materials allows us to apply traditional resin as well as glass ionomer sealants and silver diamine fluoride (SDF). Now we can play an important role in prevention as well and caries arrest.
Many children aged 2 to 11 years have untreated tooth decay, and economically disadvantaged and minority groups represent a disproportionate share of this number. While 27.9% of all 2- to 5-year-olds and 51.17% of 6- to 11-year-olds have tooth decay, those in underserved populations are 1 1/2 to 2 times more likely to have tooth decay. More than half (54.40%) of all children whose families fall below the poverty line will have one or more carious lesions, and 32.52% of these will be untreated.3
The Centers for Disease Control and Prevention (CDC) reports: “For children ages 2 to 5, 17% of children from low-income households have untreated cavities in their primary teeth, three times the rate of children from households higher income. Between the ages of 12 and 19, 23% of children from low-income families have untreated decay in their permanent teeth, twice as much as children from higher-income households.”2
Tools for dental hygienists
Oral health disparities are not a new problem, but the fact that dental hygienists working independently can do something about it is a new solution. Mobile and mobile clinics are rapidly changing who has access to services. Dental hygienists use mobile clinics to provide fair services in schools, community centers, nursing facilities, WIC and more. Where once a public health clinician working in a remote setting might have felt powerless in the face of the overwhelming amount of caries they were seeing, the addition of SDF and glass ionomer allowed us to do something about it! These innovative products are not just for public health.
At what age do you or the office you work recommend that children be seen? The American Dental Association (ADA) and the American Association of Pediatric Dentistry (AAPD) recommend that a child’s first dental visit occur after the first tooth appears and no later than their first birthday.4
SDF and glass ionomer sealants save children from traumatic visits to the dentist, especially if the visit involves local anesthesia, general anesthesia, or tooth extraction. Have you ever had a 2-year-old patient with deep grooves in his molars and brown stains that indicate early tooth decay? You may have thought, “I wish I could do something to stop this without the child having to go through a difficult process.” Were you concerned about what those areas would look like 6 and 12 months later when the child was old enough to handle the treatment? First visits are much more important than we give them credit for. We try to build relationships with a child, help prevent tooth decay and create good oral hygiene habits.
What if you could do more? RDH are experts in placing resin sealants, but do we feel the same about placing glass ionomer sealants? Are you placing glass ionomer sealants in your office? If not, why not?
How to approach treatment
Risk assessments and social determinants of health, such as access to nutritious food, transportation, and household income can play a critical role in treatment planning. It is important that we do everything we can for our patients when we have them in our chair. There are so many barriers to access and it is often unclear when we will see a patient again or if they will be able to return for rehabilitation treatment.
The ADA states, “Pit and fissure sealants are one of the most effective, yet underutilized, interventions for caries prevention, especially among children.” Unfortunately, sealants are not an option for many children. “Children ages 6 to 19 from low-income households are about 15 percent less likely to receive sealants and twice as likely to have untreated tooth decay compared to children from higher-income households.”5 Studies have concluded that sealants are effective in preventing and arresting occlusive caries with cavities and fissures of permanent and primary molars in children. Some have also concluded that sealants could minimize the progression of initial lesions.
What if you applied SDF when you saw early caries and then placed glass ionomer sealers over the area? Innovative products—such as the amorphous calcium phosphate (ACP) found in the glass ionomer material used in the SDI Riva Protect glass ionomer fissure and tooth guard—enhance the remineralization of the glass ionomer to help shape natural tooth structure. It is a relief to be able to use these preventive measures to change the oral health outcomes of vulnerable populations. The ease of application with glass ionomer means that unlike resin sealants, moisture control is not a concern.
Working with new patients
Placing sealants on newly erupted primary teeth is not without its challenges. Young patients probably won’t care about the taste of the material or having your fingers in their mouths. They may get upset and even scream, but rest assured that the benefits of placement outweigh the discomfort of the situation. In my experience, parents are so grateful and understand that their child is not in pain. Although children may get upset during placement, this is short-lived and often forgotten before they leave the office.
There will always be those times when you can’t do as much as you would like. Applying fluoride varnish may be the only thing you can do for a child who bites or refuses to open. This is where oral health education is so critical. Even with the bare minimum, you have the opportunity to improve oral and overall health by recommending the right toothbrush and toothpaste. My patients love the new Crest Kids Toothpaste with Strawberry Enamel and Cavity Protection.
The role played by RDHs continues to expand, in part because a large portion of the population does not have the luxury of consistent access to oral health providers. We must offer oral health education and care to those most in need. Now, starting with the youngest patients, we have options to use breakthrough treatments like SDF and glass ionomer to delay and prevent painful tooth decay.
For further discussion on oral health disparities, visit ruralhealthinfo.org/topics/oral-health.
Editor’s note: This article appeared in the April 2022 print edition RDH magazine. Dental hygienists in North America are eligible for a free print subscription. Register here.
bibliographical references
- Mouth and oral health. CDC.
- Inequalities in oral health. CDC.
- Dental caries in (caries) in children aged 2 to 11 years. National Institute of Dental and Cranial Research.
- Your baby’s first visit to the dentist. Mouth Healthy.
- Beauchamp J, Caufield PW, Crall JJ, et al. Evidence-based clinical practice guidelines for the use of hole and fissure sealants. 139;8(3)257-268. J Am Dent Assoc. doi.org/10.14219/jada.archive.2008.0155
