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Tooth decay remains a substantial problem in young children and is made worse by existing barriers that prevent them from obtaining dental care. Because most children are exposed to medical care but not dental care at an early age, primary care medical providers have the opportunity to play an important role in helping children and their families gain access to dental care. This study has identified several factors that need consideration in the further exploration and development of primary care physicians' role in providing for the oral health of their young patients. First, instructional efforts to increase providers' dental knowledge or opinions of the importance of oral diseases are unlikely to be effective in increasing dental referral unless they include methods to increase confidence in providers' ability to identify and appropriately refer children with disease. Medical education in oral health may need to be designed to include components that address self-efficacy in providing risk assessment, early detection, and referral services. Traditional, didactic instruction does not fulfill these requirements, but because the effectiveness of instructional methods for teaching medical providers oral health care, particularly confidence-building aspects, is untested, controlled evaluations are necessary. A second conclusion from this study is that the referral environment is more important than provider knowledge, experience, opinions, or patient characteristics in determining whether medical practitioners refer at-risk children for dental care. Most providers in this study held positive opinions about providing dental services in their practices, had relatively high levels of knowledge, screened for dental disease, accessed risk factors in their patients, and referred; they can be instrumental in helping young children get dental care, yet most providers face difficulties in making dental referrals, and changes in the availability of dental care will be necessary to decrease these barriers before referral can be most effective. The longer-term approach of increasing the number of dental graduates can be complemented in the shorter term by other approaches to increase dentists' participation in Medicaid, such as increases in reimbursement rates; training general dentists to treat young children; and community organization activities to link families, physicians, dentists, and public programs such as Early Head Start. Finally, pediatric primary health care providers can provide oral health promotion and disease prevention activities, thereby eliminating or delaying dental disease and the need for treatment at a very young age. However, effective and appropriate involvement of pediatric primary care clinicians can be expected only after they receive the appropriate training and encouragement and problems with the dental referral environment are addressed.