11/27/2013 Disclosure Pediatric Oral Health No relevant financial relationships with manufacturers of any commercial products to be discussed Do intend to discuss an unapproved use of a commercial product Melinda B. Clark MD, FAAP Women and Children’s Hospital, 2013 Goals and Objectives Why Oral Health? Emphasize the impact of oral health on the overall wellbeing of children Explain the infectious and transmissible nature of early childhood caries (ECC) and consequences of untreated caries. List risk factors for ECC and prevention methods. Review the AAP Oral Health Guidelines and recommendations for anticipatory guidance and referral. Discuss factors that may impede a child’s access to dental care Review oral health resources available to primary care providers Discuss integration of oral health prevention into the medical home. Surgeon General’s report on oral health “Silent Epidemic” Prevalence: most common unmet health need Effects of oral disease on health Access to care Cost Oral health disease is largely preventable Oral health in America. A Report of the Surgeon General; 2000. The Big Picture Why Us? “You are not healthyy without good oral health…” Prevention is the focus of primary care Medical care is frequent in early childhood ECC is a “family problem” Oral health links to systemic disease David Satcher, Surgeon General 2000 ECC is a preventable disease 10 visits by 2 years Behavior, diet, culture, socioeconomic, environment Pregnancy, diabetes, heart disease Dental community is overloaded and decreasing in capacity Only 3% of practicing dentists are pediatric dentists 25% of poor children do not see a dentist by age 5 5 1 11/27/2013 Why is this so important? 50 million Americans live in rural or poor areas where dentists do not practice Only y 43% of elderlyy visit the dentist 25% of poor children do not see a dentist by age 5 Only 34% of pregnant women visit the dentist Preventable dental conditions were the primary reason for 830,590 ED visits (2009) The Medical Home is often the Dental Home! The Disconnect Children are 2.5 times more likely to lack dental coverage than medical coverage > 50% of primary care providers have little or no oral health training Little communication and cooperation between medical and dental providers 8 Medical Prevention Paradigm Repair & Rehab Di Disease Suppression Anticipatory A ti i t Guidance Primary Prevention Pediatric community response Bright Futures AAP Top 3 pillars 2007 “Into the Mouths of Babes” Oral Health Initiative North Carolina, statewide Medicaid program initiated in 2000 Practice Guidelines Training programs 2 11/27/2013 AMERICAN ACADEMY OF PEDIATRICS Since 2000 POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children Section on Pediatric Dentistry 2001 American Academy of Pediatrics: Section on Oral Health 2003 Society of Teachers in Family Medicine: Smiles for Life 2003 AAP Policy statement Oral Health Risk Assessment Timing and Establishment of the Dental Home 2006 NY DPH: Oral Health During Pregnancy and Early Childhood 2008 AAP Policy Statement: Preventive Oral Health Intervention for Pediatricians 2009 American Dental Association: Access to Care Summit 2010 Dept. of Health and Human Services: Oral Health Initiative 2010 Physician Assistants Leadership Summit on Oral Health 2011 Healthy People 2020: Oral Health = Leading Health Indicators 2011 Institute of Medicine and Health Resources & Service Admin HRSA: Advancing Oral Health in America 2011 IOM: Improving Access to Oral Health Care for Vulnerable and Underserved Populations 2011 Assn. of American Medical Colleges: Oral health curricula 2012 Physician Assistant Education Association’s (PAEA) Annual Forum– focus was oral health 2012 Oral Health Care During Pregnancy Expert Workgroup: A National Consensus Statement. 2012. Summary of an Expert Workgroup Meeting, National Maternal and Child Oral Health Resource Center. Oral Health Risk Assessment Timing and Establishment of the Dental Home ABSTRACT. E ABSTRACT Early l childhood hildh d dental d t l caries i has h been b reported t d by b the th Centers C t for f Disease Di Control C t l and d Prevention to be perhaps the most prevalent infectious disease of our nation’s children. Early childhood dental caries occurs in all racial and socioeconomic groups; however, it tends to be more prevalent in low-income children, in whom it occurs in epidemic proportions. Dental caries results from an overgrowth of specific organisms that are a part of normally occurring human flora. Human dental flora is site specific, and an infant is not colonized until the eruption of the primary dentition at approximately 6 to 30 months of age. The most likely source of inoculation of an infant’s dental flora is the mother or another intimate care provider, through shared utensils, etc. Decreasing the level of cariogenic organisms in the mother’s dental flora at the time of colonization can significantly impact the child’s predisposition to caries. To prevent caries in children, high-risk individuals must be identified at an early age (preferably high-risk mothers during prenatal care), and aggressive strategies should be adopted, including anticipatory guidance, behavior modifications oral hygiene and feeding practices), and establishment of a dental home by 1 year of age for children deemed at risk. Pediatrics; Vol. 111 (5), 1113-1116; May 2003. Routine Visits Oral Health Risk Assessment AAP policy 2003: “Every child should begin to receive oral health risk assessments by 6 months of age...” Anticipatory guidance - diet, hygiene Referral to a dental home Improve access High-risk infants should be referred for establishment of a dental home no later than 6 months after the first tooth erupts or by 12 months of age “Ideal approach” to early childhood caries (ECC) prevention is early establishment of a dental home ~ 50% of 5-9 year olds 78% of 17 year-olds 85% of adults Most common chronic disease of childhood Insufficient # of dentists Age of patient: <3 years No insurance Patient and Family Concerns Cost Caries rates Access concerns: Motivation, priorities, transportation Early referral decreases dental expenditures per child NYS Dental Foundation Community health workers and case managers Early Childhood Caries (ECC) 5x more common than asthma Affects children under age 5 Destroys tooth structure Infectious and transmissible Previously called “Baby Bottle Tooth Decay” or “Nursing Caries” Affected by oral and dietary habits 3 11/27/2013 Epidemic of ECC ECC Prevalence Pathogenesis of Caries ~ 25% of all U.S. children 30-50% of children in low income pop p p ~70% in some Hispanic and Native American populations Teeth Bacteria Caries Time 80% of decay occurs in 20% of children Carbohydrate Bacteria Teeth Pathogens S. mutans primary S. sobrinus, Lactobacillus, Actinomyces Streptococci mutans is vertically transmitted from the primary caregiver Usually mother (71%) Just a spoonful of Sugar… How often sugar is ingested g is more important than how much sugar is ingested at once. • Enamel demineralizes and remineralizes • Acids produced by oral bacteria persist for 20-40 minutes • Frequent sugar intake allows demineralization to predominate 4 11/27/2013 ECC Risk Factors SES and cultural factors Enamel defects Caries in child, siblings or caretakers Feeding habits: ECC Frequent feeding and snacks Prolonged exposure to sugary beverages Coating pacifiers with sweeteners Decreased saliva production GERD: Increases enamel erosion ECC stages Consequences of ECC PREVENTION Upper incisors First molars Second molars ECC rarely affects lower incisors Canines less affected Poor oral hygiene Inadequate fluoride Chronic medical conditions and/or medications ECC can begin when teeth first erupt Affects teeth that erupt first and are least protected by saliva Pain Difficulty sleeping Tooth loss Impaired chewing and nutrition Below average weight gain Infection Poor self esteem School/work absences: Future dental work 51 million school hours per year Missed learning opportunities Pain and $$$ Increased caries in permanent dentition Prevention of ECC Tooth brushing Dietary counseling Delay Colonization Dental sealants Fluoride Professional consultation/referral 5 11/27/2013 Brushing Brush twice daily; bedtime most critical Brush all surfaces: Brushing Lift the lip to brush the gumline Brush behind the teeth Caregiver should brush child’s teeth until age 6 or 7 Spit, don’t rinse No food or drink after brushing Floss: 1x/day once teeth touch Prevention of ECC Tooth brushing Dietary counseling Delay Colonization Dental sealants Fluoride Professional consultation/referral Prevention of ECC Tooth brushing Dietary counseling Delay Colonization Dental sealants Fluoride Professional consultation/referral Dietary Counseling Eating Pattern Examples Candy, sipping juice or soft Frequent snacking: >2 times drink, graham crackers, between meals pretzels, breakfast cereals Sticky snacks, slowly dissolving carbohydrates Raisins, dried fruits, fruit rolls, caramels, candies, peanut butter/jelly sandwich Time of day eating occurs Juice or milk before bed Fluoride Systemic and topical mechanisms of action T i l effect Topical ff t mostt iimportant t t Inhibits demineralization Enhances remineralization* Inhibits bacterial metabolism Decreases bacterial acid production 6 11/27/2013 Fluoride Sources Community Water Fluoridation Community water fluoridation Initial caries reduction ((1945-78): ) 40-60% Modified reduction (1970-80’s): 15-40% Systemic supplements Toothpaste Topical: Rinses, varnish, gels Optimal fluoridation of water is 0.7 ppm Determine your patient’s source of water Fluoride is added to some community water supplies NY Fluoridation Health Department Town Water Board http://apps.nccd.cdc.gov/MWF/Index.asp Well water must be tested Consider filters and bottled water Fluoride Sources Fluoridation Percentage 0-24 Community water fluoridation Systemic supplements 25-49 50-74 75-100 Allow tablet to slowly dissolve (30 sec) Mixed data supporting supplementation Toothpaste Topical: Rinses, varnish, gels >100 http://apps.nccd.cdc.gov/MWF/Index.asp Fluoride Sources Community water fluoridation Systemic supplements Fluoridated Toothpaste Topical: Rinses, varnishes, gels Eff ti Effective, iinexpensive, i high hi h compliance li Mouthrinses: 10 mL for 60 seconds 0.05% sodium fluoride for daily home use (OTC) 0.2% for weekly use (prescription, public programs) Not for children less than 6 years of age Gels, foams Varnish 7 11/27/2013 Dental Update: Fluoride Varnish Applications Covered for Children up to Seven Years of Age • October 1, 2009 • Maximum of four (4) annual fluoride varnish applications covered for children from birth until 7y years of age g • Physicians, Dentists, and Nurse Practitioners treating Medicaid fee-for-service beneficiaries will be reimbursed up to $30.00 per application. • Procedure code "D1206" should be used by all Provider types • www.health.state.ny.us/health_care/medicaid/p rogram/update/2009/2009-09.htm#den Fluoride Varnish Topical 5% sodium fluoride lacquer professionally applied on any erupted tooth; 2.5-5 mg dose Resin slowly releases fluoride over 1 to 7 days (versus 10-15 10 15 minutes for gels/foams) Helps prevent new cavities from forming and slows progression of carious lesions in the primary teeth Over 110 studies and 40 clinical trials have documented effectiveness No clinical trials completed in the United States; so the FDA has not yet approved fluoride varnish for caries prevention (is FDA approved as a cavity liner, root desensitizer) Fluoride Varnish Strengthens teeth and reduces decay an average of 40% Slows progression of shallow carious lesions in the primary teeth Can be used on any erupted tooth Safety No acute toxic effects Plasma levels Small rise in plasma fluoride levels Comparable to ingesting a 1 mg fluoride tablet or brushing with a fluoridated dentifrice Use sparingly to prevent children from swallowing excess product during application Contraindications: Ulcerative gingivitis/stomatitis, open lesions Allergy to colophony/rosin* Allergy to pine or pine nuts* 3 cases in literature: 1 contact dermatitis and 2 stomatitis Caries reduction range g 30-63.2% Dose responsive, effectiveness enhanced by counseling Greatest effect when applied before onset of detectable caries What does this entail? Oral Health Risk Assessment AAP policy 2003: “Every child should begin to receive oral health risk assessments byy 6 months of age...” Anticipatory guidance Fluoride Varnish if high risk Referral to a dental home Document 8 11/27/2013 High Risk MCHB Expert Panel, 2007 Low-income children Qualify for Head Start, Start WIC, WIC National School Lunch Program, Medicaid, SCHIP Children with Special Health Care Needs CAT AAP Risk Groups AAP Risk Assessment Tool Risk Groups for Dental Caries Children with special health care needs Children of mothers (caretakers) with high caries rate Later-order offspring Children in families of low socioeconomic status Children who sleep with a bottle or breastfeed throughout the night Children with demonstrable caries, demineralization, plaque, or staining Rapid Checklist Parent factors: □ Caregiver’s oral heath □ Does pt have a dental home? Action: □ Education □ Referral to a dental home Child factors: Caries White spots Plaque Swollen gums Night feedings Frequent snacking/juice drinking □ Medicaid eligible □ Special health care need □ □ □ □ □ □ White “incipient” lesions 9 11/27/2013 Routine Visits Oral Health Risk Assessment Anticipatory guidance - diet, hygiene Fluoride Varnish ((if high g risk)) Referral to a dental home Barriers Time Disinterest Fast Important: Most common chronic disease Immediate and future impact of neglect Obesity message and caries nutrition messages parallel Not getting paid Will it matter? Bright Futures, AAP Start billing Burden of disease and relative impact of interventions Discuss oral health early and often Discuss the bacteria, not just the hygiene Address the “baby teeth don’t matter” myth Shift blame to something evil we can target Healthy eating Analogy to stopping abx course early Just a matter of “slime + time” Choose foods that look like something found in nature Concentrate on a single change each visit V07.31 (prophylactic fluoride administration) 521.00 (dental caries) Moving Beyond “Our Offices” Cannot just treat holes, infection still present OH assessment, anticipatory guidance, and fluoride varnish application Rate: $30 per application 4 times/year birth to age 7 High-risk children Did not specify provider education required, prior approval NOT required. Code: D1206 with V modifier Families do not want to hear it - messaging Messages Document Billing Someone else’s job High-risk infants should be referred for establishment of a dental home no later than 6 months after the first tooth erupts or 12 months of age “Ideal approach” to ECC prevention is early establishment of a dental home Medical and dental sitting on Head Start, WIC, school health committees W k together Work t th on water t fl fluoridation id ti campaigns State Task Force; State Oral Health Plans Teaching oral health through media messages, social marketing 10 11/27/2013 Work synergistically Support cross pollination of ideas: Dental supporting fluoride varnish done by p medical providers Medical supporting dental doing oral cancer screens, blood pressure monitoring, nutrition advice More inter-professional health in schools/residencies Resources AAP Children’s Oral Health Home: www2.aap.org Protecting All Children’s Teeth (PACT) www.aap.org/commpeds/dochs/oralhealth/pact.cfm Fluoride Information on the American Dental Association website: www ada org/public/topics/fluoride/index asp#overview www.ada.org/public/topics/fluoride/index.asp#overview Community water fluoridation info available at: http://apps.nccd.cdc.gov/MWF/Index.asp National Maternal and Child Oral Health Resource Center: www.mchoralhealth.org A Health Professional’s Guide to Pediatric Oral Health Management: www.mchoralhealth.org/PediatricOH/index.htm Smiles for Life. A National Oral Health Curriculum for Family Medicine: www.smilesforlifeoralhealth.org Bright Futures in Practice: Oral Health Pocket Guide; Casamassimo and Holt (eds); 2004 13 chapters, 11 CME credits www.aap.org/commpeds/dochs/oralhealth/pact.cfm Third Edition Questions? 11 11/27/2013 References 1. 2. 3. 4. 5. 6. 7. 8. US Department of Health and Human Services. Oral health in America. A Report of the Surgeon General. Rockville MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. www.nidcr.nih.gov/DataStatistics/SurgeonGeneral Krol DM. Educating Pediatricians on Children’s Oral Health: Past, Present, and Future. Pediatrics. 2004; 113(5): e487-93. Lewis CW et al. The role of the pediatrician in the oral health of children: A national survey. Pediatrics. 2000. 106(6):E84. Douglas AB et al. Smiles for Life. A National Oral Health Curriculum for Family Medicine STFM Group on Oral Health; 2006. 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