WE HAVE COME A LONG WAY
There has been a technological explosion in pediatric dentistry during the last 25 years. This has been characterized by new and improved restorative materials that allow us to remove less tooth structure. We have finally been able to reach the treatment goals found in delivering more minimally invasive dentistry. We have a better understanding of the complex caries process and, importantly, how to prevent it. Instead of drilling incipient lesions, now noncavitated lesions can be remineralized with fluoride varnishes. Nowhere has there been more activity and interest than in the area of pulp therapy. Our specialty has created greater success in primary tooth pulpotomies by switching from a chemical approach (formocresol) to using mineral trioxide aggregate (MTA). Because of new and improved glass ionomer cements, there has been a renewed interest in the one-visit indirect pulp cap (IPC). The IPC has created shorter dental visits for the pediatric dental patient and is a procedure whose success is much greater (more than 90%) than a pulpotomy regardless of the material used.
However, in some areas, not much has changed since the late 1990s when many were predicting an end to dental caries in children and, therefore, less of a need for pediatric dentists. Caries is far from conquered, and it remains as the most common disease in children worldwide. There are still certain segments of the population, such as the poor and underserved, where 25% of the children still get 75% of the caries.
FUTURE CHALLENGES
There will be future challenges. The first challenge is that there are too few pediatric dentists available to treat children. There are presently about 5,000 pediatric dentists in the United States. Pediatric dentists comprise less than 3% of the total dentist population, and they see only 30% of all the children treated. The majority of pediatric dental patients are treated by a general dentist. By the year 2020, the fastest-growing segment of the population will be those ages 18 years and younger. By then, there will be 80 million children, a larger group than what was seen with the baby boomer generation. Because more general dentists are agreeing to accept children into their practice, more children are being treated for caries. However, one recent study asked dental school graduates if their dental education prepared them for treating children. A majority of them said it did not. Thus, more children are being treated by dentists who feel they are not competent in the latest pediatric dental techniques to treat them. Clearly, there is a need to improve and strengthen dental school education to include more in-depth training in pediatric dentistry for current and future dental students. There is a need to create mentoring programs for general dentists after graduation with pediatric dentists.
The second future challenge is the result of the recently passed Affordable Care Act (ACA). It is clear the ACA was a reaction to the ever-increasing cost of the social safety net that could no longer be sustained at its previous levels of increasing costs, limited resources, and limited funds. While coverage for adult dentistry appears to have been largely omitted in the ACA, the dental needs of children are a covered benefit, although not mandated. Consequently, pediatric dentistry and general dentistry need to prepare for an increase in the number of pediatric dental patients who have never been to the dentist. It has been estimated that by 2018, there will be 5 million children with new dental benefits; this translates to about 9 million additional dental visits a year. Pediatric dentistry cannot do it alone! We need the help of our general practitioner colleagues. It remains to be seen if there will be sufficient dentists to meet the demand.
THE NEW CLINICAL PARADIGM SHIFT
The ACA has created a turning point. It has ushered in an era of dental consumerism. As dental care becomes more managed, there will be an increase in accountability to do dental procedures that are based on sound scientific principles and predictable outcomes. There will be increases in out-of-pocket expenses for the family, while the insurance companies will reimburse the dentist at lower rates than in the past. Parents will do comparison shopping, become more cost-conscious, and expect and require the latest dental techniques in order to get more value for their spending dollars.
This increased demand for value and cost containment from the insurance companies and parents will change the dental practice landscape. First, there will be pressure to have multisite offices with many providers, because these can be more efficient. Secondly, as a result of the increase in dental school debt, many new general dentists and pediatric dentists will be unable to buy a practice and thus will gravitate toward the larger practices. This will create fewer choices for the patient but will increase competition for those consumer dollars. Third, to contain costs, dentists will have to realize that many of our dental procedures are unnecessary and some have been done empirically for up to 100 years without being evaluated scientifically. For example, do we need to do a prophylaxis and fluoride treatment every 6 months on every child, including the patient at very low risk for caries (as evaluated by Caries Management By Risk Assessment [CAMBRA])? In some respects, the American Academy of Pediatric Dentistry has addressed this issue in its recent Reference Manual. There are only 6 clearly delineated indications for doing a dental prophylaxis, and the reduction of caries and increased fluoride uptake are not among those mentioned. Also, does every child need to have every first and second permanent molar sealed? Determining the necessity for sealants and other common procedures, including early intervention in orthodontics, will require more clinical and scientific research so that dental dollars can be directed to where they are needed the most.
TREATING CHILDREN IN THE FUTURE
Treating children in the future will be very different than it is done today. In order to succeed in an environment of cost containment, more preventive procedures will be performed, especially when the insurance companies realize it is best to reimburse more for preventive than restorative procedures. Some dental insurance administrators have hinted, for example, that they may pay for an occlusal restoration on, say, tooth No. 30, but deny payment in the future for a restoration on another surface of that same tooth because the dentist should have used measures to prevent the caries from recurring.
One will also see a change to more personalized dentistry where an individualized treatment plan for each patient will be based on CAMBRA. Caries risk assessments are becoming more common in dental schools and in postgraduate dental education programs. The result is a custom treatment plan that is specific for each patient instead of a one-size-fits-all approach.
Because of the recent advances in materials, techniques, and increased dental knowledge, there will a shift from doing “reparative” dentistry toward one of monitoring, much like the medical model. For example, multiple office visits to apply fluoride varnish to not only prevent new caries for those at risk but also to remineralize noncavitated lesions will decrease the need to do reparative procedures and improve the efficiency of treatments, reduce cost, and give more pediatric patients a positive dental experience.
CLOSING COMMENTS
The general dentist and the pediatric dentist must be prepared for a paradigm shift toward a new model of treating children. It will not be the dentistry they were taught. They will be required to keep abreast of new discoveries, information, and use techniques that are a proven part of evidence-based dentistry. Dental school education will also need to prepare to meet this change by teaching dental students the knowledge, competency, and critical thinking skills needed to treat their future patients. And, we cannot forget those doing research—researchers will need to help clinicians bridge the gap between theoretical and the clinical application of information.
This is a critical time for pediatric dentistry. With the shift to more prevention and fewer restorative procedures, we may ultimately reach the goal of creating a generation of patients with less caries and a more positive dental experience. Hopefully, this will also include more of the children who reside in poor and underserved areas who, up until now, have had little chance of attaining optimal dental health. The pediatric dentist can help the general dentist with the many challenges facing the future of pediatric dentistry. By facing this new reality together, we can chart our own course that will satisfy our personal and professional needs while meeting the goal of optimal dental health for all children.
Dr. Kisby is a 1976 graduate of Tufts University School of Dental Medicine. He completed his pediatric dentistry residency training at New England Medical Center Hospital in 1978. He is currently associate professor in pediatric dentistry at Meharry Medical College School of Dentistry in Nashville, associate clinical instructor at the Temple University Kornberg School of Dentistry in the department of pediatric dentistry, and clinical instructor in pediatric dentistry at Tufts University School of Dental Medicine. For 30 years, he has been lecturing nationally on updates in pediatric dentistry on the topics of prevention, pulp therapy, restorative dentistry, and dental trauma. He can be reached via email at boomalaka93@hotmail.com.
Disclosure: Dr. Kisby reports no disclosures.
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