“In older children, especially older adolescents, I sometimes see periodontal [gum] disease. We are learning that gum disease may have effects on diabetes, heart disease, and preterm birth,” he said in an interview.
The mouth and the teeth also can be indicators of systemic diseases, said Dr. Krol. “Problems such as anemia, leukemia, Crohn's disease, and others can manifest themselves in the mouth. In addition, some children are more susceptible to problems if they have dental or oral disease.
“Children who are undergoing bone marrow transplant and chemotherapy can have significant problems if they have oral fungal infections or mucositis, and children with heart problems can be especially at risk for problems if they have dental disease.”
Martha Ann Keels, D.D.S., division chief in pediatric dentistry at Duke Children's Hospital in Durham, N.C., pointed out that more serious problems can occur in conjunction with dental disease.
“We recently had a child die at Duke of a brain abscess caused by his untreated dental caries,” Dr. Keels said in an interview.
“He had Down syndrome and a cyanotic heart condition in addition to severe gastroesophageal reflux disease. He was on Medicaid and had been on a waiting list to be seen for several months. His infection spread from his teeth to his brain. By the time he got to Duke, it was too late for me to be able to fix his teeth and rectify his brain abscess.”
At Small Smiles, Dr. Williams told a similar story of dental caries out of control. “The worst case involved an 18-year-old who presented with a substantial radiographic abscess subjacent to a lower molar. The infection was rapidly spreading through the soft tissue of the neck from the angle of the mandible, approaching the midline of the neck,” he said.
“This is ultraserious because once the infection hits the midline there is a direct path to the heart.”
In this case, however, the clinic intervened in time to refer the patient to nearby Children's National Medical Center. “Children's immediately put the patient on massive amounts of IV antibiotics, with good result,” Dr. Williams reported.
The Small Smiles dental clinic in Washington had 1,000 patients pre-enrolled when it opened in November 2006.
Dr. Williams with his commendation for service on 9/11 at the Pentagon. Denise Napoli/Elsevier Global Medical News
Mouth 'Is Part of Our Responsibility' in Well-Child Visits
So how can pediatricians and family physicians ensure that their patients' mouths stay healthy?
“At every well-child visit [a physician] should be asking about how patients take care of their teeth, if they have a dentist, and looking at the teeth and the rest of the oral structures to see if there are problems that need to be referred to the dentist,” said Dr. Krol. “The mouth is a part of the body. There is no reason why the mouth should be separate. It is part of our responsibility, just like the heart and the lungs.”
Dr. Keels pointed out that many physicians feel too unfamiliar with the mouth to know whether what they see there is normal or unhealthy.
“Certainly, large brown or black holes in the teeth should be easily recognizable as severe caries. It is the subtle findings such as white spots or dental defects that should trigger the doctor to help find a dental home for the child so aggressive prevention strategies can be employed to reverse the disease process,” she said.
“There are also other red flags such as [a] toddler's consumption of juice or frequent carbohydrate snacking, lack of adequate toothbrushing and flossing, and/or a family history of dental disease.” These things all warrant referral to a dentist, Dr. Keels said.
But what if patients lack access to dental insurance, or are on Medicaid and are having trouble finding a provider? “[Physicians] can help families find a dentist by knowing where the dentists are that see children, see children on Medicaid, or see children who may not have insurance,” said Dr. Krol.
“They can also find ways to build a relationship with dentists who will see needy children when requested by the physician.”
Dr. Keels agreed. “Many of my Medicaid recipients have special needs, such as cerebral palsy, autism, or cleft lip and palate. These families have so many challenges to deal with, as many times it is their child's illness that resulted in the family's need for Medicaid. We have to be creative and come up with techniques to help make oral hygiene successful. That takes time to get to know each child and their unique issues.”