Most caregivers understand that the primary teeth will be lost and replaced by permanent teeth. Losing the first primary tooth is sign of growth and development and, therefore, receives much attention. When children begin to exfoliate primary anterior teeth, parents and children focus oral care not on the posterior portion of the mouth but on the eruption of the emerging permanent anterior teeth. At approximately the same time that the primary central incisors are being exfoliated and replaced by the permanent incisors, the first permanent molar emerges posterior to the last primary molar. It is easier to see visible decay on an anterior tooth than on a molar, so thorough oral hygiene and self-care are often neglected for newly erupted molars, which can result in oral environments that are conducive to dental caries. Therefore, early screening for childhood caries is critical to children’s overall health and development.

Primary and permanent teeth have different anatomical features: The occlusal surface of primary molars has shallow pits and fissures, but the occlusal surface of permanent molars has deeper pits and fissures, allowing not only for better mastication of food but also for increased collection of plaque biofilm and food debris. If parents and children focus oral care primarily on newly emerging anterior teeth, newly erupting posterior teeth (e.g. molars) may not be cleaned as well as needed, thus creating oral environments that are conducive to development of dental caries.

In the US, there are 4,230 geographic areas that experience dental care shortages, many of which are rural or remote areas without dental professionals [1]. In 2009–2010, the number of individuals without health insurance in the US increased by over a million [18]. The resulting statistics indicate there are currently 108 million people in the US without dental insurance; furthermore, there are only approximately 141,800 working dentists and 174,100 working dental hygienists [18]. Because of the low numbers of working dentists and dental hygienists and the high number of individuals who need dental care, individuals in rural areas are less likely to have access to care due to location of health services and lack of health-care providers.

People living in both rural and urban areas can experience trouble accessing dental care. According to the U. S. 2010 census, 82.3 % of the US population lived in urban areas where dental health-care professionals prefer to live and work. Access to care in urban areas is not due to a deficit of oral care providers, but like people living in rural areas, those living in urban areas share some of the same concerns that often prevent people from seeking care and that contribute to disparities in care (e.g., lack of funds, insurance, transportation, education, knowledge, and beliefs that dictate oral health-seeking behaviors [19].

Health insurance does not always include dental coverage because traditionally, health insurance has meant medical coverage exclusive of dental coverage. In fact, more people have health or medical insurance than dental insurance [20]. People who have health insurance without dental coverage typically obtain dental coverage through a separate policy for only dental insurance.

In 2012, Congress passed the Patient Protection Affordable Care Act (PPACA) to fill coverage gaps left by traditional health insurance [21]. Because PPACA is still being developed and implemented, the extent of dental care coverage provided through PPACA is still unclear, although it does seem as if PPACA will help make dental coverage available for children [21]. Nevertheless, exactly who and what will be actually covered in the PPACA is still a concern, especially because of the $64 billion spent annually on dental care, only 4.0 % was paid by government programs [1].

In addition to geographical location and lack of dental coverage, access to dental care is further restricted by lack of uniform regulations in licensing dental professionals [22]. Licensure of dental professionals and the tasks assigned to each specific professional group of dental professionals are governed by each state. Individual states establish their own dental practice acts containing rules and regulations governing practices and functions of oral care professionals and levels of supervision required for non-dentists who provide care for patients, including dental hygienists.

There are a few states (e.g., Colorado and California) where dental hygienists can practice either independently from or collaboratively with dentists [23]. In these states, dental hygienists can screen for disease, diagnose, plan, and provide services without the permission or authorization of licensed dentists. Unlike dental hygienists, midlevel practitioners with specific licensure and expanded-functions certifications have more flexibility to practice oral care in Arizona and Minnesota [23–25]. For example, midlevel practitioners in Minnesota and Alaska not only provide preventive services but also perform restorative services and simple extractions. Many dental hygienists have the skills and knowledge to perform expanded functions and are licensed by their states and by the American Dental Association National Board for Dental, so practice restrictions for dental hygienists reduce the ability to meet the dental needs of the population and impede the access to oral care.

In summary, health-care disparities and barriers such as SES, geographical location, lack of insurance, and lack of uniform regulations inhibit reliable access to proper screening and treatment for dental caries. These barriers and disparities have lead dental health professions to look for new ways to connect with patients. Some researchers believe that these barriers to care can be overcome through the use of telehealth and teledentistry, which represent the next frontier of medicine [26].