Implementation of Oral Health Screening and Referral Guidelines in Primary Health Care

To determine the oral health screening and referral practices of pediatric providers, their adherence to American Academy of Pediatrics oral health guidelines, and barriers to adherence.

Providers in 10 pediatric practices participating in the North Carolina Quality Improvement Initiative, funded by the Child Health Insurance Program Reauthorization Act of 2009, were asked to complete a 91-item questionnaire. Questions on risk assessment and referral practices were based on those recommended by the American Academy of Pediatrics. Adherence to oral health guidelines was assessed by practitioners' evaluation of 4 vignettes presenting screening results for an 18-mo-old child with different levels of risk and caries status. Respondents chose referral recommendations assuming adequate and inadequate dentist workforces. Logit models determined the association between barriers specified in Cabana's framework and adherence (count of 6 to 8 adherent vignettes vs. 0 to 5).

Of 72 eligible providers, 53 (74%) responded. Almost everyone (98.1%) screened for dental problems; 45.2% referred in at least half of well-child visits. Respondents were aware of oral health guidelines, expressed strong agreement with them, and reported confidence in providing preventive oral health services. Yet they underreferred by an average of 42% per vignette for the 7 clinical vignette-workforce scenarios requiring an immediate referral. Frequently cited barriers were providers' beliefs that 1) parents are poorly motivated to seek dental care, 2) oral health counseling has a small effect on parent behaviors, 3) there is a shortage of dentists in their community who will see infants and toddlers, and 4) information systems to support referrals are insufficient.

Pediatric clinicians' beliefs lead to a conscious decision not to refer many patients, even when children should be referred.

Evidence suggests that the primary care-dental referral process needs improvement. This study identifies barriers to delivering recommended preventive oral health services in pediatrics. The information can be used to improve the screening and referral process and, thus, the quality of preventive oral health services provided in primary care. Results also can guide researchers on the selection of interventions that need testing and might close gaps in the referral process and improve access to dental care.