Oral Health Assessment in Acute Care Pediatric Nursing

Rachel McCormick, MSN, CRNP; Alec Thomas Robin, DMD; Joan Gluch, PhD, RDH, PHDHP; Terri H. Lipman, PhD, CRNP, FAAN


Pediatr Nurs. 2019;45(6):299-307, 309. 

In This Article

Abstract and Introduction


Oral health is integral to general pediatric health. Many children in the United States suffer from untreated tooth decay, and oral health disparities exist for under-resourced families. A shortage of dental providers is expected to continue into 2025. The role of acute care nurses and nurse practitioners to augment this shortage has not been fully explored. Many children in acute care settings have chronic medical problems and receive medications that may predispose them to additional oral health complications. However, oral and dental assessments are rarely completed in a thorough and organized manner in pediatric acute care settings. This article describes oral health assessment, three assessment tools that can be completed by acute care nurses and nurse practitioners, and the impact of asthma, diabetes, leukemia, Crohn's disease, and selected medications on children's oral health. Recommendations are presented to empower nurses to play a more active role in oral health by educating patients and caregivers, and making timely referrals to dental providers.


Oral health plays a central role in overall health and quality of life. Symptoms of systemic disease, nutritional status, and immune disorders can be detected with a thorough oral examination. The phrase the mouth is a mirror points to the importance of the oral cavity as an indication of overall health (U.S. Department of Health and Human Services [DHHS], 2000). In the United States, many children suffer from oral health conditions. Tooth decay is the most common chronic disease in children (Benjamin, 2010). Among children aged 2 to 19 years, 45.8% have experienced dental decay with a prevalence of 13% for untreated caries (Fleming & Afful, 2018). Dental caries experience is associated with family income levels, with 56.3% of children from families living below the federal poverty level experiencing dental decay as compared with 34.8% of children from families with income levels greater than 300% of the federal poverty level (Fleming & Afful, 2018). Untreated tooth decay can lead to pain, infection, and further complications, and may impact eating, speaking, sleeping, school attendance, and self-image (DHHS, 2000). Tooth decay, as well as other oral health problems, is preventable with regular dental examinations, good oral hygiene, and sufficient fluoride intake.

The DHHS (2015) projects that all 50 states will experience a shortage of dentists through 2025 as the demand for dentists continues to increase at a rate greater than the supply. Health care providers in different settings will be integral in collaborating with dentists to assess oral health, determine risk, provide primary prevention teaching, and refer for care when needed. The Health Resources and Services Administration (HRSA) has recommended a fundamental system change to integrate oral health into the scope of practice for primary care providers, including nurse practitioners (NPs), to address this shortage (DHHS, 2014).

Oral assessment and care are included in many NP graduate programs. In a recent survey of primary care NP programs by Dolce, Haber, Savageau, Hartnett, and Riedy (2018), the presence of a faculty champion for oral health was positively associated with integration of oral health education into the curriculum. Additionally, teaching by a dental or oral health faculty expert and at least one evaluation method to assess learner performance positively influenced integration of oral health into the curriculum and impacted graduates' levels of competence (Dolce et al., 2018). Smiles for Life: A National Oral Health Curriculum provides open-access, modular lessons across the lifespan that faculty can use for teaching resources (Clark et al., 2010). Dissemination of Smiles for Life has been an important step in engaging the larger health care community in recognizing oral health as integral to systemic health. The addition of educational modules on oral health in a pediatric and family primary care NP curriculum improved knowledge and comfort level, and reinforced the importance of oral health examinations at well-child visits (Claiborne & Poston, 2018).

If NPs are to make a significant contribution to addressing oral health disparities and access to care, graduate programs and professional organizations need to reflect that oral care is a priority. After review of pediatric primary care NP programs, Hallas and Shelley (2009) recommended research to evaluate curriculum innovations, the development of partnerships between stakeholders, and incentives from credentialing organizations to increase oral health teaching in curricula by adding more questions to credentialing examinations. Interprofessional education holds promise. A course that combined medical, dental, and NP students significantly increased knowledge of pediatric oral health topics and confidence in the ability to provide oral health services (Cooper et al., 2017). An interprofessional curriculum and practice innovation at New York University has implemented a transition from the traditional head, ears, eyes, nose, and throat examination (HEENT) to a HEENOT: head, ears, eyes, nose, oral cavity, and throat examination as part of the history and physical examination (Haber et al., 2015). Primary care NPs and nurse midwifery students demonstrated competence in assessing oral health, and the program increased dental-primary care referrals (Haber et al., 2015).