Preventing early childhood caries through medical and dental provider education and collaboration.

Preventing early childhood caries through medical and dental provider education and collaboration

Module 1:The prevalence and

impact of oral disease

Early childhood caries can lead to…

• Extreme pain

• Spread of infection and possible cellulitis

• Crooked bite (malocclusion)

• Extensive and costly dental treatment

• Inability to concentrate

• Impaired language development

• High risk of developing tooth decay in permanent teeth – chronic condition

Adapted from The American Academy of Pediatrics Oral Health Initiative Oral Health Risk Assessment Training for Pediatricians and Other Child Health Professionals

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http://www.mchoralhealth.org/PDFs/learningfactsheet.pdf, http://www.mchoralhealth.org/PDFs/ECCFactSheet.pdf

Current status of children’s oral health

https://apps.state.or.us/Forms/Served/le8667.pdf

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Disparities in Oregon children’s oral health

Children from lower income homeshave nearly twice the decay rates, untreated decay and rampant decaythan children from higher income homes.

Hispanic/Latino children have higher Rates of decay, untreated decay and Rampant decay.Black/African American children haveHigher rates of untreated decay.

https://apps.state.or.us/Forms/Served/le8667.pdf

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Why providers of pediatric patients?

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• They have frequent contact with infants and children.

• They can help prevent or reduce the risk of tooth decay.

• They can provide appropriate referrals to a dentist for early intervention and/or treatment.

American Academy of Pediatrics policy statement, 2003

• Every child should begin to receive oral health risk assessments by 6 months of age from a pediatrician or qualified pediatric health care professional.

• Infants identified as having significant risk of caries should be entered into an aggressive anticipatory guidance and intervention program provided by a dentist between 6 and 12 months of age.

• Pediatricians should support the establishment of a dental home for all children between 6 and 12 months of age.

Source. Hale, K., Weiss, P., Czerepack, C., Keels, M., Huw, T. & Webb, M. (2003). American Academy of Pediatrics Policy Statement: Oral Health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics; 111(5): 1113 to 111

See www.orohc.org : AAP Dental Home Policy Statement

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Early Childhood Caries Preventative (ECCP) services

• Assess• Screen• Educate• Intervene• Refer

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Module 2:Risk assessment

Defining early childhood caries

• Process of demineralization to cavities in primary dentition

• Lesions can progress rapidly

• Affects teeth least protected by saliva

• Often associated with bottle or sippy cup use throughout the day or at night

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First clinical signs of caries• White spots • Acids have demineralized enamel• First appear at gumline of upper

front teeth• High risk for developing cavities

White spots can be remineralized with early intervention

• Fluoride• Behavior modification: improved

brushing & dietary habits• Indication for dental referral

Used with permission by the Washington Dental Service Foundation

First clinical signs of caries2

Photo: Crest Slide Set and ICOHP

Example of fluorosis

Mild fluorosis Severe fluorosis

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Severe caries

Used with permission by the Washington Dental Service Foundation

Abscess

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See AAP Flip Chart and Office Pocket Guide

Caries process

Requires 4 factors

Used with permission by the Washington Dental Service Foundation

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Caries process: ongoing balance

No caries

Protective FactorsStrength of enamel

-FluorideAdequate salivary flow

Pathologic FactorsStrep mutans

CarbohydratesReduced salivary flow

Used with permission by the Washington Dental Service Foundation

Caries

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Regular meals

Regular meals plus frequent snacks

← Plaque level acids →

Caries process and diet

Used with permission by the Washington Dental Service Foundation

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Caries process and transmission2

See Handout and www.orohc.org : Guidelines for Oral Health In Pregnancy

• Bacteria established by age 2

• Natural process occurs through normal activities

• Encourage regular dental care for pregnant women and mothers of infants

Why do pregnant women need a healthy mouth?

• Reduces bacteria in mouth that can cause caries and gingivitis

• Less bacteria passed to baby in the first two years of baby’s life

• Research has shown that having gum disease while pregnant may cause pre-term births or low birth weight

• Mother learns importance of early dental intervention for her baby

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Is dental treatment safe during pregnancy?

• All dental treatment safe during pregnancy, including xrays, cleanings, fillings and extractions

• Getting regular dental care during pregnancy can prevent gingivitis and improve the health of the gums, which often get red and puffy during pregnancy

• Getting a dental infection during pregnancy can be dangerous to the mother and baby

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See www.orohc.org : Oral Health During Pregnancy Consensus Statement

Giving your baby a head start on a healthy mouth

• Mother is often the family member who establishes good eating and brushing habits for entire family

• Mothers should model good brushing and eating habits

• Start brushing baby’s teeth as soon as the first tooth erupts

• Only put breast milk, formula or plain water in bottles and sippy cups

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Why is risk assessment important?

• Risk status determines:

– Age of first dental visit – as early as when the first tooth erupts

– Use of fluoride

– Extent of nutritional and hygiene counseling

Used with permission by the Washington Dental Service Foundation

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http://www.uspreventiveservicestaskforce.org/uspstf12/dentalprek/dentchfinalrs.pdf

Who is most at risk? 2

See handout and www.orohc.org : OrOHC Caries Risk Assessment <6

Be conscientious of cultural diversity

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• Increased rate of dental caries in certain ethnic groups.

• Beliefs about health, disease, diet and hygiene in different cultures may impact practices and child-rearing habits.

Module 3: Oral health education and

anticipatory guidance for parents/caregivers

Healthy primary teeth are important!

• For normal development• For space maintainers• For cavity-free permanent teeth• For keeping treatment costs low

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First Dental Visit Ave. 5 Year Cost

Before age 1 $263

After age 1 $447

Anticipatory guidance

Early childhood caries is:

TRANSMISSIBLE

PREVENTABLE

TREATABLE

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Motivational interviewing (MI)3

See handout and www.orohc.org Explore-Offer-Explore

• Goal of MI is to establish rapport with the parent/caregivers and then discuss a “menu of options” for infant oral health and caries preventive behavior.

• MI focuses on techniques such as:– Open-ended questioning– Affirmations– Reinforcement of self-efficacy– Reflective listening– Summarizing

http://www.mchoralhealth.org/PDFs/AWayWithWords.pdf

MI menu of options3

See handout and www.orohc.org : Motivational Interviewing Tool

Anticipatory guidance/education

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See www.orohc.org : Posters

•https://www.youtube.com/watch?v=wxMrtK-kYnE

3 Use diverse formats for delivering oral health education

•AAP flip chart

•Pocket guide

•Posters

•Handouts

•Puppets or plastic models

•Elmo You Tube Video

Diet and feeding: 0-12 months3

• Breastfeeding does not increase the risk for caries

• Hold infant for bottle and breastfeeding• No bottles at bedtime/nap (or use plain

water only)

• Introduce cup at 6 months, wean bottle at 12-18 months

• Avoid constant use of sippy cup, pacifier

• Introduce appropriate snacks

• Encourage rinsing the mouth out with water

Diet and feeding: toddlers

1 – 2 years

• Discontinue bottle feeding at 12-18 months

• Avoid excess juice• Avoid sweet, sticky snacks –

dried fruit, crackers, candy• Reserve soda, candy and sweets

for “special occasion” treats

2 and older

• Choose fresh fruits, vegetables, or whole grain snacks

Used with permission by the Washington Dental Service Foundation

Good preventive medicine for obesity too!

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Oral hygiene

< 1 year – Clean mouth with cloth or soft

toothbrush– As teeth erupt, use smear of

fluoridated toothpaste 2x/day1-6 years

– Brush 2X/day using half-pea-sized amount of fluoridated toothpaste

– Parent/caregiver performs and supervises

> Age 6 years– Brush 2X/day with pea-sized

amount of fluoridated toothpaste

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See handout and www.orohc.org : Recommendations for Fluoride Usage

.

Sources of fluoride

Systemic– Water fluoridation- 22.6 % in Oregon– Fluoride supplements

– Fluoridated bottled water

Topical– Fluoride toothpastes– Fluoride varnish– Water fluoridation– Fluoridated bottled water – Fluoride supplements– Fluoride rinses– Gels, foams

Adapted from the Washington Dental Service Foundation

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Fluoridated water

How much fluoride is in my patient’s drinking water? • To learn how much fluoride is in a community water system,

link to the Centers for Disease Control’s “My Water’s Fluoride” at: http://apps.nccd.cdc.gov/MWF/Index.asp

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Fluoride supplementation

ADA, AAPD, AAP and CDC recommendations

Age <0.3 ppm 0.3-0.6 ppm >0.6 ppm

0-6 mo None None None

6 mo-3 y 0.25 mg/d None None

3-6 y 0.50 mg/d 0.25 mg/d None

6-16 y 1.0 mg/d 0.50 mg/d None

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http://apps.nccd.cdc.gov/MWF/Index.asp

Fluoride varnish

Effective• 30% - 69% decrease in caries

Safe• No preservatives, BPA, dyes• No evidence-based

contraindications

Easy• Takes 30 seconds to apply

Photo: ICOHP, WDSF

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Use of fluoride varnish for caries prevention has been endorsed by the ADA, but remains an “off-label” use of the product, because it is

not cleared for marketing by FDA for this purpose. http://www.mchoralhealth.org/PDFs/FlVarnishfactsheet.pdf

Treatable

• Success in treating caries is dependent upon parents/caregivers taking an active role in their child’s oral health.

• Intervention with fluoride varnish can reverse early stages of caries.

• Early access to a dental home with regular maintenance schedule is important.

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Module 4:Implementation

and workflow

The early oral screening

Your oral exam of the child may take no more than 1 minute: Knee-to-Knee, Lift the Lip

Start Finish1 minute

Photo: Nick George / The Chronicle

Used with permission by the Washington Dental Service Foundation

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What to look for

• Lift the lip to inspect soft tissue and teeth• Eruption sequence

– Summarized in the AAP flip chart• Assess oral hygiene

– Presence of plaque– Presence of white spots or dental decay– Signs of abscesses in the gums

• Provide education on brushing and diet during examination

• Apply fluoride varnish

Used with permission by the Washington Dental Service Foundation

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See AAP Flip Chart and Office Pocket Guide

Fluoride Varnish Video

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1. Have supplies ready2. Position the child

– Knee-to-knee – Table top exam– Toothbrush often

prompts opening!– Lift the lip– Quick visual inspection

Fluoride varnish application

Used with permission by the Washington Dental Service Foundation

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See Handout and www.orohc.org : Fluoride Varnish Application

Photos: ICOHP

Used with permission by the Washington Dental Service Foundation

Fluoride varnish application

Dry teeth with cotton gauze

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Apply fluoride to all surfaces with applicator or finger

Used with permission by the Washington Dental Service Foundation

Photos: ICOHP

“bendabrush”

Fluoride varnish application 4

See AAP Flip Chart

Post varnish instructions

• Child may take a drink of water immediately

• No brushing until the next day

• Can skip fluoride supplement for the day

• Ok to drink as usual

• Avoid hard, crunchy and sticky foods the rest of the day

• Advise caregiver teeth may be yellow for a day (based on varnish)

• Repeat every 3 months for children at high risk for caries

Used with permission by the Washington Dental Service Foundation

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See Handout and www.orohc.org : What you need to know for parents

Other interventions for ECC

See www.orohc.org : AAPD Policy on ITR

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Interim Therapeutic Restorations- ITR

•Stabilizes and treats some caries

•Minimizes fear for child and parent

•No anesthetic is needed, quick procedure

Silver Nitrate/Silver Diamine Fluoride

•Used by some dentists to treat infection

•Initially turns infection black, but follow up care includes tooth colored filling

•No anesthetic is needed, quick procedure

Key Messages - interventions

• Fears may keep parent from seeking dental care for their child

• New methods of treating ECC may minimize traumatic experiences

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Behavior management4

See www.orohc.org : Guideline on Behavior Guidance

Tips for managing child behavior – in office

• Utilize your staff who have good rapport with 0-3 year olds.

• Engage the parent during the exam.

• Recognize that the child will most likely cry the first few appointments.

• Utilize knee-to-knee technique or have child in parent’s lap or chest while reclined in the dental chair.

• Explain to the parent what you are looking for in the mouth.

• Positive reinforcement – for child and parent.

Documenting oral health services and findings

• Exam forms• Electronic medical records• Chart labels/stickers• Smart or dot phrases

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See www.orohc.org : chart label template, Smart or Dot Phrases

Referral to a Dental Home

Well Child ExamMedical Provider – Risk assessment, oral screening, anticipatory guidance orders

for fluoride based on risk

Vitals Signs Taken Medical Assistant tells parent about

ECCP (Parent/Caregiver Education)

ImmunizationMedical Assistant applies fluoride

Parent/Caregiver and Child Arrives

for Well Child Visit (or other visit)

Posters, ed materials in waiting room

Dental Home

No Access to a Dental

Home

DentistInterventions

including ITR, caries management

DentistReviews DA/DH findings and education provided, exam, applies F varnish if risk dictates, explain interventions if

needed

Dental assistant/hygienistMedical history, ECCP DVD for parents, caries risk assessment, anticipatory guidance, education on oral care specific to child

(Parent/Caregiver Education)

Pediatric referralIf behavioral management

or extensive treatment needs necessitate

Parent/Caregiver and

Child Arrives for Exam Posters, ed materials in

waiting room

Recall determined

by caries risk

DentistInterventions

including ITR, caries management

Dentist/Hygienistcaries risk assessment, anticipatory guidance specific to child, exam, fluoride varnish, treatment plan review with

parent

Parent and child arrive for Baby DaysCheck in, pay, medical history

Dental assistant/hygienist ECCP DVD for parents, OHI from front of room, show parents how

to provide OH, assist parents individually as parents practice

Pediatric referralIf behavioral management

or extensive treatment needs necessitate

Parent and Child make

appt for Baby Days WIC, Head Start, medical

office, dental office

Recall determined

by caries risk

Baby Days

Used with permission by the Virginia Garcia Memorial Health Center

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Baby Days

Used with permission by the Virginia Garcia Memorial Health Center

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Oral Assessment (D0191)

• Anticipatory guidance & counseling.

• Referral to a dentist to establish a dental home.

• Documentation in chart of risk assessment findings & services

provided.

• Utilizing a standardized Caries Risk assessment tool that is endorsed

by one of the following organizations:

– Oregon Oral Health Coalition

– American Dental Association

– American Academy of Pediatric Dentistry

– American Academy of Pediatrics

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Service to include:

See www.orohc.org : OrOHC Caries Risk Assessment 0-5

Fluoride varnish 99188- medical4

See www.orohc.org and handout: Billing and Reimbursement

99188 •CPT code for fluoride varnish•Replaces CDT code D1206, although you may still receive reimbursement for D1206•Is reimbursed twice yearly, and up to 4 times a year with patients documented at high risk

OHP benefits and eligibility

• OHP clients have increased dental benefits• OHP clients should have their DCO listed on their card• Providers can check OHP client eligibility and managed care

enrollment by using the following methods:– Provider Web Portal located on the Web at https://www.or-

medicaid.gov/ProdPortal/default.aspx; – Automated Voice Response (AVR) at 866-692-3864 (toll-free); or

270/271 Electronic Data Interchange Batch Transactions

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See www.orohc.org : Simplified Chart of OHP Coverage, OHP Plus Dental Benefits

Ready…set…implement!!!

• Determine who will deliver the services.

• Decide when the services will be delivered.

• Identify an oral health champion.

• Create a plan for fluoride varnish and materials.

• Decide who will coordinate dental referrals.

• Establish process for chart documentation.

• Create process for eligibility and billing.

Adapted from the Washington Dental Service Foundation

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See www.orohc.org and toolkit: Ready, Set, Implement

It can be done!

• ECC prevention services can be incorporated into the medical well-child visit, immunization schedule or when the child comes in for treatment of illness.

• Utilize staff creatively to provide ECC prevention services.

• DVDs, posters and brochures can increase awareness of oral health and decrease the amount of time ECC prevention services occupy during the visit.

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See www.orohc.org for additional resources and references

“First Tooth” training and technical assistance contacts

Karen Hall, RDH EPDHFirst Tooth trainer/technical assistance

[email protected]

[email protected]

You can also access our website for materials

First Tooth Websitehttp://www.orohc.org/

Questions?

Please fill out the training feedback form

Thank you!

www.kidsoralhealth.org

• Oregon Oral Health Coalition’s Early Childhood Caries Prevention Committee

• Ford Family Foundation• DentaQuest• Washington Dental Service

Foundation• American Academy of Pediatrics• National Maternal and Child Oral

Health Resource Center