From The First Tooth An early childhood caries prevention program to improve the oral health of Maine children Funded by the.

From The First ToothAn early childhood caries prevention program to improve the oral health of Maine children

www.fromthefirsttooth.org

Funded by the Sadie and Harry Davis FoundationA partnership of MaineHealth, MaineGeneral and Eastern Maine Health Services

Northeast Center for Research to Evaluate and Eliminate Dental Disparities

The purpose is to improve the oral health of Maine’s children by:

• Increasing children’s access to preventive oral health services • Integrating early oral health as the standard of care for children in medical practices through:

• Oral health screening • Fluoride varnish• Parent/caregiver education and counseling• Referral to a dentist

From The First Tooth

Dental Caries is a Chronic Infectious Disease

From The First Tooth

• Transmissible• Bacterial by-products (acids) dissolve the enamel of teeth• Loss of tooth structure, pain, tooth loss, systemic infections

• Dental caries is the single most common chronic disease of childhood

• Approximately one third or more of Maine children has dental caries

• Early childhood caries is the best predictor of lifelong dental caries

From The First Tooth

Source: National Health and Nutrition Examination Survey, 1999 -2002National Center for Health Statistics, CDC

Source: National Health and Nutrition Examination Survey, 1999–2002. National Center for Health Statistics, CDC.

Tooth Decay Over the Lifespan

28%50%

95% 93%87%68%

0%

50%

100%

2–5 12–15 16–19 20–39 40–59 >60

Age in Years

Perc

enta

ge

What are the Consequences?

• Pain & infection

• Hospitalization, surgical intervention, death

• Missed work/school

• Distraction from normal activities

• Speech and eating dysfunction

• Growth delay

Low-income children who have their first preventive dental visit by age one:

• Less likely to have subsequent restorative or emergency room visits

• Average dental related costs are almost 40% lower ($263 compared to $447) over a five year period than children who receive their first preventive visit after age one.

Prevention Reduces Disease and Saves Money

From The First Tooth

Recommended by:• American Academy of Pediatrics• American Dental Association• American Academy of Pediatric Dentistry

Endorsed by:• Maine Chapter of the American Academy

of Pediatrics• Maine Dental Association• Maine Medical Association• Maine Academy of Family Physicians• Maine Osteopathic Association• Maine Primary Care Association

Dental/Medical Home By Age One

• Oral health is part of overall health!• Patients are seen more regularly at the

medical offices• Part of oral health prevention strategies

• Screen for disease and risk • Monitor oral-systemic health interactions• Initially manage oral emergencies• Referral for dental care• Provide anticipatory guidance• Apply fluoride varnish

Preventive Dental Care is linked to Good Overall Health!

Role of the Primary Care Physicians

Dental Caries

Tooth

Substrates

Oral Flora

SubstratesOral hygieneSalivaCarbohydratesFrequency of eating

ToothAgeFluorideNutritionPit & Fissures

FloraStrep. MutansOral HygieneFluoride in Plaque

Factors Necessary for Dental Caries

13

Streptococci Mutans Transmission

Bacteria are transmitted mainly from mother or primary caregiver to infant.

Window of infectivity is first 2 years of life.

The earlier a child is colonized, the higher the risk of caries.

You Are What You Eat

• Caries development is promoted by carbohydrates which act as substrate for bacteria to produce acid

• Acid causes demineralization of enamel

• Beware “hidden carbohydrates”

Frequency vs. Quantity Acids produced by bacteria after carbohydrate intake

persist for 20-40 minutes lowering pH

Examples of Sugar Content of Food and Drinks

Sucrose Content of Some Medicines

Amoxicillin 17-50%Ceclor 56-58%Erythromycin 45-65%Penicillin 40-70%Bactrim 50%Benadryl 60-77%

Oral Health Assessment of Child• Position child in caregiver’s lap facing the caregiver

• Sit with knees touching the knees of the caregiver

• Lower the child’s head onto your lap

What to Look For:

Lift the lip, retract the cheeks and inspect the soft tissues and teeth to assess for:

Presence of plaque

Presence of white spot lesions or dental caries

Presence of tooth defects

Presence of dental abscess

Dental Plaque

A biofilm that attaches to the tooth surfaces. It is composed of primarily streptococci mutans and other bacteria. Nourished by food and beverages high in sugar, they produce an acid that initiates the demineralization of the teeth.

Healthy Teeth

White Spot Lesions

Cavitated Lesions

Urgent Dental Care

Urgent Dental CareDental Abscess

Caries Risk Assessment

Higher Risk: One of the belowLow income - (i.e. MaineCare)Special healthcare needsParents/siblings have decayExisting decay/fillingsLimited/no dental careFrequent sugar intakeNo access to fluoridated water or tabletsLower Risk:None of the above

Fluoride

Demineralization <------------ > Remineralization

•Frequent carbohydrate intake•Frequent exposure to acids•Plaque presence•Decreased salivary flow

•Exposure to fluoride•Removal of plaque•Balanced diet•Limited exposure to carbohydrates

SYSTEMIC

• Water• Tablets• Drops• In Vitamins

TOPICAL

• Toothpaste• Anti-Cavity Rinses• Fluoride Applications

Varnish, gel or foam

29

System and Topical Fluoride Delivery

Fluoride Varnish

• 5% sodium or 22,600 PPM fluoride resin

• Inhibits the growth of cariogenic organisms thus decreasing acid metabolism

• Reduces enamel solubility

• Promotes remineralization of enamel and may arrest or reverse early caries

Efficacy of Fluoride Varnish in Preschool Children

Study Country % Caries Decrease

Holm 1979 Sweden 44

Grodzha et al. 1982 Poland 10

Clark et al. 1985 Canada 9

Petersson et al. 1998 Sweden 7

Frostell et al. 1991 Sweden 37

Twetman et al. 1996 Sweden 30

Weintraub et al. 2006 US 50

Application of Fluoride Varnish

Using gentle finger pressure, open the child’s mouth.

Gently remove excess saliva or plaque with a gauze sponge.

Use your fingers and sponges to isolate the dry teeth and keep them dry.

Isolate a quadrant of teeth at a time, or a few teeth at a time.

Apply a thin layer of the varnish to all surfaces of the teeth.

Once the varnish is applied, you need not worry about moisture (saliva) contamination. The varnish sets quickly.

Post Application Instructions

• Soft diet for the rest of the day.

• Do not brush or floss the child's teeth until the next morning.

• It is normal for the teeth to appear dull and yellow until they are brushed.

• Tell the parent that the teeth will not be white and shiny until the next day

Efficacy on the Number of Fluoride Varnish of Applications

Children stratified by number of actual fluoride-containing varnish applications received N= 280

Weinstraub et al. J Dent Res 2006

Age Distribution of Children Receiving Fluoride Varnish Waterville Pediatrics

0

100

200

300

400

500

600

<6 m

os

6 m

os<9m

os

9mos

<12m

os

12m

os<15

mos

15m

os<18

mos

18m

os<24

mos

24m

os<27

mos

27m

os<30

mos

30m

os<33

mos

33m

os<36

mos

36m

os<39

mos

39m

os<42

mos

42 a

nd ab

ove

Age Distribution of Children Receiving Fluoride

From The First Tooth

MaineCare is reimbursing medical providers for the therapeutic application of fluoride varnish for members with moderate to high caries risk. MC will cover 2 applications per calendar year. For members with high caries rates and new decay within 18 months as documented, MC will cover 3 times per year.

In Maine, commercial insurers and self insured companies and beginning to pay for the varnish procedure.

All three health systems (MaineHealth, Eastern Maine Health Systems, and MaineGeneral Health) now pay for the procedure for their age-eligible dependents who are covered by their health plans.

Infant and Toddler Oral HealthAnticipatory Guidance

Advise to parents and caregivers • The importance of healthy teeth • How to take care of their child’s teeth• The importance of healthy food choices

Infant and Toddler Oral HealthAnticipatory Guidance Schedule

6 Months• Bottles are for nutrition. They should only be used to feed babies who are not breast feeding. • Discuss and demonstrate brushing of infant teeth as soon as they erupt.• Instruct the parent to conduct "Lift the Lip" procedures.

9 Months• Monitor progress in weaning infant from bottle to cup.• Offer appropriate guidance in limiting juice in sippy cup.

Infant and Toddler Oral HealthAnticipatory Guidance Schedule

12 Months• Infants are weaned from the bottle.• Infants should see the dentist by year one.• Review healthy eating habits and snacking.• Sippy cups at mealtimes only. Water between meals• Parents continue to brush and check their teeth

24 Months• Monitor healthy behaviors and snacking• Discuss and evaluate the toddler’s ability to begin to use fluoridated toothpaste.• Parents should continue to monitor the child’s brushing and checking their teeth

Referral to a Dental Home

Well Child ExamMedical Provider - Oral Screening,

Orders for fluoride based on risk(Parent counseling)

Vitals Signs Taken Medical Assistant tells parent of the

FTFT(Parent Counseling)

ImmunizationMedical Assistant Applies Fluoride

Parent/Child Arrives for Well Child Visit

(or other visit)Posters, ed materials

in waiting room

Dental Home

No Access to a Dental

Home

Documentation

Caries Risk Assessment – (LOWER) (HIGHER) Guidelines

Higher Risk: One of the belowLow income - (i.e. MaineCare)Special healthcare needsParents/siblings have decayExisting decay/fillingsLimited/no dental careFrequent sugar intakeNo access to fluoridated water or tabletsLower Risk:None of the above

Dental Caries – Y or NOral health education – Y or NFluoride varnish applied (Code D1206) – Y or N

In Chart Notes, document urgent dental needs, such as abscessesand other clinical findings and referral to dentist

www.fromthefirsttooth.com

We are committed to ensure every child within our organizations and affiliates has access

to early childhood caries prevention program.

From The First Tooth

Questions?

Contact Information:www.fromthefirsttooth.org

Susan Cote, RDH, MSProgram ManagerMaineHealth110 Free Street Portland, ME 04101(207) 662-6309(207) [email protected]