Key points

Early childhood caries (ECC) is a major unmet population health care need that negatively affects the overall health of children, especially those from diverse racial/ethnic backgrounds and disadvantaged socioeconomic groups. In 2000, the Surgeon General’s seminal report, Oral Health in America , asserted that ECC was a “silent epidemic” of significant proportions. Yet, 5 times more common than asthma, ECC remains the most common chronic disease of childhood. Oral health is one of the Healthy People 2020 (HP2020) leading health indicators. All of the HP2020 oral health goals have shown improvement except for the number of children and adolescents who see a dentist. Data from 2015 to 2016 reveal that 43% of children ages 2 to 19 had cavities, which was down from 50% 4 years earlier ; the proportion of children from ages 3 to 5 and 6 to 9 years with experience of dental caries in at least one primary or permanent tooth has been reduced from 33% to 29.7% for ages 3 to 5 years and 54.4% to 51.7% for ages 6 to 9 years. School-age children lose 34 million school hours annually as a consequence of oral health problems related to pain, infection, and disrupted sleep and attentiveness. The social determinants also affect oral health; children from families with lower levels of education and low socioeconomic status as well as specific racial/ethnic minority groups have higher rates of ECC. For example, Hispanic children had the highest prevalence of cavities at 52%.

Oral health has been a neglected but important component of pediatric overall health. The historic separation of the mouth from the body, education and clinical practice silos, a fee-for-service, and individual versus a population-focused health delivery system all contribute to the omission of oral health as a required component of clinical education and practice.

There are 4 million registered nurses, including 270,000 nurse practitioners and 13,000 midwives, the largest component of the in the United States health care workforce. Nurses and nurse practitioners who work with young children and their families, as well as nurses and midwives who work with pregnant women, have a unique opportunity to positively influence the oral health and overall health of this population. With appropriate education to build their knowledge base and clinical practice competencies, the nursing profession has a unique opportunity to have a major impact on improving children’s access to oral care and influencing oral health and overall health outcomes of this population.

In the past decade, interprofessional organizations have challenged the belief that oral health is solely the domain of the dental profession. The American Academy of Pediatrics (AAP), American Academy of Pediatric Dentistry (AAPD), American Academy of Physician Assistants, and the Oral Health Nursing Education and Practice Program (OHNEP) have played an interprofessional leadership role in developing numerous education, practice, and regulatory policies and products aimed at increasing the oral health knowledge, practice behaviors, and reimbursement of nondental providers, thereby decreasing barriers to oral health care for children. Moreover, oral health primary prevention requires more workforce capacity than the dental community alone can provide. Development of interprofessional oral health primary care workforce capacity is integral to increasing access to oral health care for the most vulnerable populations: pregnant women, children, and the poor, elderly, and infirm. Improving children’s oral health outcomes is a leading population health goal; however, curricula preparing pediatric health professionals have had a dearth of oral health content and clinical experiences. The nursing profession now plays a leadership role in addressing the oral health needs of vulnerable populations across the lifespan, most notably children, their families, and communities.

Pregnancy

Evidence supports that lack of oral health care during pregnancy is associated with negative outcomes for both mothers and their newborns. Building interprofessional oral health workforce capacity is integral to improving the overall health outcomes for mothers and babies. During pregnancy, a woman’s oral health can affect her health and the health of her unborn child. Nurses, nurse practitioners, and midwives are essential health care providers who can recognize and prevent many oral health problems during pregnancy. Nurses, while caring for pregnant women, can use the Oral Health Delivery Framework ( Box 1 ) as a model for integrating oral health in clinical encounters. They also can use the HEENOT approach when conducting the health history and physical examination. The HEENOT approach includes assessing the head, ears, eyes, nose, lips, mucous membranes, teeth, gums, and tongue rather than only the head, ears, eyes, nose, and throat (HEENT). Prevention of oral health problems during pregnancy includes dispelling myths about the dangers of dental care during pregnancy. It includes information about oral hygiene, such as the importance of regular brushing twice a day and flossing daily. Preventing enamel erosion in women who experience pregnancy-induced vomiting includes instructing women to rinse with a solution of baking soda after vomiting. Mothers need to know that if they have dental caries, Streptococcus mutans , the bacteria associated with dental caries, can be transmitted to their child, infect the child’s teeth, and increase the risk for ECC.

An example of the oral health impact of nurses during pregnancy is provided by a 2015 to 2016 pilot program with the Nurse Family Partnership (NFP), a nationwide home-visiting program of nurses assigned to first-time at-risk mothers. These nurses visit a pregnant woman throughout her pregnancy and continue until the child is aged 2 years. The NFP nurse provides the mother with education, support, and guidance throughout her pregnancy and the child’s early development and care. The 2015 to 2016 pilot program, led by the OHNEP team, trained 32 NFP nurse home visitors in Florida to implement the Cavity Free Kids (CFK) oral health curriculum. The nurse home visitors were asked to use the CFK oral health curriculum during their home visits with first-time pregnant women and first-time mothers of children ages 0 to 2. Data from surveys were collected at 3 points in time (baseline, 30 days after implementing CFK education, and 90 days after implementing CFK education) from nurses and home-visit clients to measure improvements in their oral health knowledge and practices. Survey findings reveal that the NFP nurses increased integration of oral health into 100% of their visits for both pregnant women and their young children. The survey also showed a significant increase ( P <.05) in the amount of oral health information clients reported receiving, as well as a significant increase ( P <.05) in the number of mothers cleaning their child’s mouth twice a day. The most rewarding response was that of the 10 children graduating at the Two Year NFP Program Graduation Ceremony, none had any white or brown spots on their teeth. The long-term goal is that this program will be integrated into the National NFP education program.

Since 2011, the OHNEP program has collaborated with the American College of Nurse Midwives (ACNM) to advance integration of oral health in midwifery education and practice, thereby strengthening interprofessional oral health midwifery workforce capacity to address this population health issue by sponsoring workshops and symposia at ACNM meetings, conducting webinars, disseminating publications, and cultivating oral health champions among midwifery leaders. These strategies have increased the visibility of oral health as an essential component of whole-person midwifery care. The latest editions of 4 required midwifery program textbooks now feature a chapter on oral health and pregnancy. Oral health test items are included on the Midwifery Comprehensive Examination. According to the findings of a recent national survey, 33 of 39 (84%) midwifery programs in the United States report including oral health topics and/or clinical experiences in their curriculum.

Pediatric primary and acute care

The pediatric nursing workforce, that is, nurses and nurse practitioners who work with children from infancy through adolescence, can be prepared in their undergraduate or graduate education or through clinical professional development programs to integrate oral health competencies as a standard component of their scope of practice. Nursing interventions to reduce the incidence of ECC can be woven into existing pediatric primary and acute care. Integration should begin during the mother’s pregnancy during antepartum visits when the mother’s oral health status and its influence on her child can be woven into antepartum visits by the nurse or midwife, especially for high-risk populations. It can also be highlighted by the newborn nursery nurse providing information to parents about the oral health care of their newborn during their postpartum stay in the hospital or birthing center. For example, an oral health education program for new mothers at a public hospital in an urban setting was devised to determine the mothers’ knowledge base about the oral health of newborns and young infants and assess the effectiveness of an oral health education program viewed before the mother’s discharge from the postpartum unit. New mothers ( n = 94) either viewed an evidence-based DVD about oral health care of their newborns or a DVD on newborn nutrition. Baseline data on a pretest revealed a significant lack of knowledge related to the need for infants’ gums or teeth to be cleaned following eating or drinking ( P <.02), and a significant number of mothers in the oral health education group responded yes ( P <.01) about the benefits of fluoride varnish in ECC prevention. High attrition related to the transient nature of the study population was associated with low mother-infant response at 6- and 12-month follow-up visits. However, of the 10 infants who did return from the oral health education group, there was no evidence of white spots or dental caries on any tooth surface in the 8 to 12 erupted teeth. Each of the mothers had established a dental home for her infant by 1 year of age, which is consistent with recommendations from the AAPD and the AAP.

Pediatric primary care settings are ideal for integrating oral health into the overall health care of young children who have 12 well-child visits to their primary care provider team by age 3 years. The pediatric office-based nurse, nurse practitioner, and/or community health nurse is in a position to reinforce oral health information, including guidance during well-child or home visits, about establishing a dental home by age 1 year. For example, nurses can coach parents about food and drinks, including formula, milk, breast milk, and juice, that play an important role in the development of ECC in primary teeth. They can reinforce that infants are at greater risk for developing tooth decay in primary teeth when they fall asleep with breast milk, a bottle of formula, sweetened drinks, or sweetened pacifier on their gums and teeth. Also vulnerable are toddlers who walk around all day with a bottle or “Sippy” cup filled with soda or juice. They need to emphasize that promoting oral hygiene practices, beginning with cleaning the gums of newborns with a gauze or washcloth after feeding to supervised tooth brushing once the first teeth erupt, is essential for removing foods that stick to the teeth or are high in sugar content.

School settings, starting with Day Care, Head Start, and Elementary Schools, are ideal locations for oral health screenings, cariogenic nutrition education, fluoride varnish, and sealant applications. From 2012 to 2015, the Los Angeles Trust for Children’s Health developed a school-based oral health program that established a District Oral Health Nurse position to coordinate oral health services, and implemented a universal school-based oral health screening and fluoride varnishing program, with referral to a dental home. School nurses implemented the parent, staff, and student education as well as the referrals and collaboration with community dental partners who did the screening and fluoride varnishing. The program had a positive impact on reducing tooth decay in school-age children. Outcome data from 2015 to 2016 reveal that for 6 elementary schools with 3 dental provider groups, 491 parents received oral health education and 89 parents served as community volunteers. For this sample, 3399 screenings and 2776 fluoride varnish applications were completed. Sixty-six percent of the children had active disease, 27% had visible tooth decay, and 6% required emergent care. Of the 623 children who participated for 2 consecutive years, 56% had fewer or no visible caries at follow-up. Only 17% had additional disease. The annual cost was $69.57 per child, less than the cost of one cavity restoration.

Pediatric nurse practitioners at New York University (NYU) Rory Meyers College of Nursing collaborate with NYU dental students on outreach to Head Start centers where they learn and practice the oral examination and fluoride varnish application with dental students; they assist the dental students to learn about and practice behavior management of children. The nursing profession is well positioned to have a positive impact on children’s oral health and, in so doing, their overall health.

To encourage both interprofessional collaboration and oral health education, NYU College of Nursing, College of Dentistry, and School of Medicine have developed an interprofessional pediatric oral health experience as part of the College of Nursing’s Teaching Oral Systemic Health program funded through an Advanced Nursing Education grant from the Health Resources and Services Administration (HRSA). The clinical experience consists of teams of NYU nurse practitioner, MD, and dental surgery doctorate students, working together with a trained pediatric dental resident facilitator in the pediatric dental clinic and pediatric primary care clinic during a 4-hour clinical session to develop both oral health and interprofessional competencies. Students complete a pre– and post–Interprofessional Collaborative Competency Attainment Survey (ICCAS), which is a 20-item Likert scale based on self-reported interprofessional competencies. Data from the pre- and post-ICCAS demonstrate a significant increase in self-reported interprofessional competencies from pre to post experience for students across all 3 types and all 6 competencies. Survey data from 2015 to 2016 reveal that all students had an improved mean score from pretest to post-test after the experience, and these changes were statistically significant for all students: College of Nursing ( P <.01), College of Dentistry ( P <.01), and School of Medicine ( P <.001). The mean change from pretest to post-test was statistically significant for each of the 6 interprofessional competency domains ( P <.01) and in both pediatric dental and primary care settings, the changes from pre to post were significant ( P <.001). These findings suggest that a clinical approach is an effective strategy for influencing the development of interprofessional and oral health competencies in all students.

It is important to consider that not all children are attending school or having pediatric well visits because of either serious acute or chronic illness, and may not be accessing routine preventive dental care. Children being treated for cancer are at high risk for oral health problems, yet preventive dental care is not usually a priority during this time. Early assessment can identify oral complications of cancer treatment, and oral health intervention can reduce the severity of oral soft-tissue disorders, mucositis, and/or fungal infections or dental caries. To address this serious problem, advanced practice nurses, registered nurses, and oncology providers at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, part of Hassenfeld Children’s Hospital at NYU Langone, and the NYU College of Dentistry have been collaborating in an oral health program since 2011. The program, Chemo Without Cavities, has become a practice standard that integrates oral assessment and fluoride varnish into the care of all pediatric oncology patients. All pediatric oncology patients, whether inpatient or outpatient, are screened by a pediatric dental resident before treatment begins, continuous oral assessment throughout treatment occurs at each visit by an interprofessional team of nurse practitioners, registered nurses, MDs, and pediatric dental residents, and each patient receives fluoride varnishing every 3 months. Patients are assured immediate access to dental care, if needed, by the NYU College of Dentistry.