Traction and the dental home
In the mid-1990s, the American Academy of Pediatric Dentistry (AAPD) and the American Academy of Pediatrics (AAP) published a joint document regarding the concept of the "dental home." In this article, Robert L. Delarosa, DDS, president of the American Academy of Pediatric Dentistry, explores the dental home concept and why it hasn't gained traction in our dental practices, our referral patterns, and our sister organizations in an attempt to lend clarity.
Robert L. Delarosa, DDS
In the mid-1990s, the American Academy of Pediatric Dentistry (AAPD) and the American Academy of Pediatrics (AAP) published a joint document regarding the concept of the "dental home." This followed the AAP's release in 1991 of the definition of the "medical home," and it seemed to be symmetrical . . . frankly, a no-brainer to implement. During this time, we pediatric dentists often referred to ourselves as the "pediatricians" of dentistry, as we shared common goals for our patients, specifically preventive and interceptive strategies.
Our pediatric physician colleagues have long touted the benefits of infant and early childhood care. As a parent myself, my wife and I had already selected our twins' pediatrician prior to their births, and we were given useful tips and information from our pediatrician during our new-baby classes. From how to feed, change, and bathe our infants, to vaccinations and safe transportation, we were taught many strategies to keep our children safe and healthy. So, having the dental home established early seemed simply an extension of sound pediatric care for our patients.
With this said, the question is, why hasn't the dental home concept gained traction in our practices, our referral patterns, and our sister organizations? I would say the reasons are complex and confusing, but if we examine the definition of the dental home, perhaps we can add some clarity to the concept.
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In the 2015-2016 edition of the AAPD Reference Manual, the dental home is defined as "the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. The dental home should be established no later than 12 months of age and includes referral to dental specialists when appropriate."1
I think the first statement speaks for itself, as this is what we try to do every single day with our patients and families. We want to have an ongoing, comprehensive, accessible, and coordinated relationship with our patients where we can provide the best care possible. We all have the "emergency patient" who shows up only when there is pain. Most of the time, the problem could have been prevented, but as importantly, it is now a bigger, more serious, and costly issue. And, we have all lost patients to "plans" that we don't participate in because in some ways these plans are not in our patients' best interests. I have often wondered if the relationship with that family was as ongoing, comprehensive, accessible, and coordinated as it could have been, because many of our families will choose to stay with us even when we are out of network. It does take a huge effort to educate and build trust with our families, but it pays off when you can work with them and still provide the treatment they have come to expect even though they may have to pay more. There are many other examples of the benefits of the dental home, but I don't believe this part of the definition is the issue.
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From what I've been told, the biggest issue surrounds the age-one visit. I've heard of both general and pediatric dental colleagues and pediatricians who tell families it isn't necessary to see children before age three or four. I would say for the three-year-old with early childhood caries that requires a general anesthetic to have a full-mouth rehabilitation (multiple crowns, pulpotomies, extractions, etc.) an age-one dental visit would have potentially prevented this costly and serious experience. I would also argue that it isn't a self-serving economic incentive to see patients this young. Dental care is expensive-there is no denying that fact-but preventive care is less expensive and potentially has more benefit per cost than does a restoration in a high-risk patient . . . a restoration that will probably need to be replaced due to recurrent decay. We know that by the time decay is visible to the eye, it has already progressed beyond any preventive recovery, so early examinations can detect the problems before they become obvious and much larger in scope.
In spite of the many dental schools that are teaching infant oral health care, I certainly accept the fact that it isn't practiced to the degree we would like it to be. I can also accept the fact that some practitioners may not be comfortable treating an infant, and I have no problem with that either. I would humbly ask those who are reluctant to do so to consider referring the infant to a pediatric specialist or at least consult with one if you have concerns.
What is the solution to reach a critical mass of acceptance for the dental home? For us, it is educating our colleagues and legislators, going directly into communities with the message of the dental home, teaching infant oral health care in hospitals that deliver babies, and finally having researchers and practitioners evaluate and publish meaningful, evidenced-based guidelines supporting the efficacy of the age-one visit. The AAPD touts the dental home concept as one of its biggest priorities, and we are committed to getting our message out whenever opportunities present themselves. We can do the same in our practices and programs. As we say in our practice, we look for the reality of a "cavity-free generation," and it can start in our dental home.
For more information on the dental home, or any other pediatric dental issues, please visit the American Academy of Pediatric Dentistry website: mychildrensteeth.org.
1. Definitions, Oral Health Policies, and Clinical Practice Guidelines Reference Manual. American Academy of Pediatric Dentistry. 2015-16;37(6):12. aapd.org.
Robert L. Delarosa, DDS, is president of the American Academy of Pediatric Dentistry and founding partner in a group private practice in Baton Rouge, Louisiana. A graduate of the Louisiana State University School of Dentistry, he received his certificate in pediatric dentistry from the University of Texas Health Science Center at San Antonio. He is a fellow in the American College of Dentists. Dr. Delarosa has had leadership roles in numerous dental professional organizations.