Children living in rural areas face numerous barriers to dental care, including living in a family with lower income, inadequate insurance coverage and/or having to travel long distances to receive specialty care. In addition, operating rooms (ORs) are not readily accessible in rural areas for dental procedures that require general anesthesia.
The American Academy of Pediatric Dentistry (AAPD) Pediatric Oral Health Research and Policy Center has sounded the alarm after finding OR space for dental procedures is decreasing. In a nationwide survey of AAPD members, more than 50% reported access to hospital ORs has worsened since March 2020, and 74% indicated that wait time has increased (Vo AT, et al. Pediatr Dent. 2021;43:33-41).
Due to these barriers, strategies to improve oral health and access to dental care are important for children living in rural areas.
Most children with cavities can be treated in a dental office. Some, however, require general anesthesia in an operating room because they are unable to cooperate due to young age, extreme fear and anxiety or special health care needs.
Burden of disease
Early childhood caries is the most prevalent infectious disease in children. Caries affects approximately 20% of U.S. children, according to the Centers for Disease Control and Prevention (https://bit.ly/3s5wjkn), and the percentage is higher among those in rural areas (https://bit.ly/3Ax5Obk).
Untreated caries results in pain, life-threatening infections, poor nutrition, early loss of teeth with subsequent orthodontic and cosmetic challenges, sleep disturbances and decreased quality of life. Children with cavities also miss more school days and perform worse in school.
Limited access to ORs
Most children with cavities can be treated in a dental office, but some are unable to cooperate due to young age, extreme fear and anxiety or special health care needs. These children require general anesthesia, which is difficult to access in urban areas (with wait times up to 12 months) and even more challenging in rural areas.
Even if a family in a rural community can find a pediatric dentist for consultation, the dentist may not be credentialed to treat children in an OR. In addition, pediatric anesthesiologists or intensive care units may not be available. The COVID-19 pandemic has reduced OR capacity further and increased competition among surgical providers for OR space.
Prevention is key
The U.S. Preventive Services Task Force and Bright Futures recommend that pediatricians apply fluoride varnish to all children from tooth eruption to age 5. However less than 20% of pediatricians do this regularly, according to an AAP Periodic Survey of Fellows (https://bit.ly/3fY4fcl).
Applying fluoride varnish, coupled with oral health risk assessment, anticipatory guidance on oral hygiene and diet, and dental referral by age 1 could greatly decrease the number of children who need to access the OR for dental issues. Many resources are available to help pediatricians provide preventive oral health services (see resources).
Stopgap interventions to address caries
If a child needs care in the OR but it is not available, referral to a dentist for stopgap and minimally invasive therapies, such as silver diamine fluoride, may be helpful. However, these options are limited, and tooth decay still may worsen.
Children referred for this care should be monitored for disease progression. Those experiencing dental pain can be treated temporarily with antibiotics and pain medication. However, the AAP recommends against continual exposure to antibiotics (https://bit.ly/3FXVVnV), and long-term liver damage is a risk of continuous acetaminophen administration, particularly in young children.
Collaborate, advocate to increase OR access
Pediatricians also can encourage payers to enhance approval of medical necessity and advocate for relief of financial, access and administrative barriers.
The AAPD, in collaboration with the American Dental Association, the American Association of Oral and Maxillofacial Surgeons and the AAP, is working with Centers for Medicare & Medicaid Services to address a major issue in payment affecting access to hospital and ambulatory surgery center ORs for dental cases.
Dr. Webb is a member of the AAP Section on Oral Health. Dr. Moursi is the liaison from the American Academy of Pediatric Dentistry to the section’s executive committee.
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