Transcript Slide 1

Children’s Oral Health & the
Primary Care Provider
Overview of Children’s Oral Health
Module 1
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Module 1 Objectives:
Become familiar with dental terms
Understand definition of Early Childhood Caries
Be familiar with caries as a public health crisis
Understand barriers to access to dental care
Understand the consequences of untreated dental
disease
 Understand the components of caries prevention
 Understand the role of the primary care provider in
caries prevention
 Understand how to incorporate oral health into the
medical home
Definitions
Glossary of Dental Terms for
the Primary Care Provider
Dental Caries:
 Infectious disease process that results in damage or
destruction of the structure of the tooth
 Periods of tooth demineralization & remineralization
occur continuously as a dynamic process
 When periods of demineralization exceed
remineralization over a prolonged period: dental
caries result
Glossary of Dental Terms for the
Primary Care Provider
White Spot Lesions:
 Earliest manifestation of dental caries
 Result from demineralization of enamel, which is
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still relatively intact (no cavity or hole in enamel)
Also referred to as “noncavitated lesions” or
“incipient decay (lesion)”
Reversible characteristic: early identification of
incipient lesions is extremely important, because it
is during this stage that the carious process can be
arrested or reversed
Dental Terms cont’d
Cavitated Lesion:
 Formation of a cavity or hole in the tooth
as the enamel is destroyed and the second
layer of the tooth (dentin) is exposed
 Appears as yellow or dull brown
 Tooth structure is soft (not intact anymore)
 Irreversible characteristic: dental treatment to
restore tooth is required
 If carious process is left untreated, it may
progress and reach the tooth pulp (nerve)
Dental Terms cont’d
Arrested Caries:
 Remineralization of incipient lesions prior to
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cavitation
Results in a shiny white or yellow/brown area at
the area of previous incipient decay (tooth
structure is intact)
Types of Caries
Smooth Surface Caries:
 Occur on any smooth tooth surface
 Buccal or Labial or Facial: tooth surface that faces the
outside of the mouth
 Lingual or palatal: tooth surface that is closest or next to
the tongue
 Mesial and distal: tooth side surface that come into
contact with adjacent teeth
Pit & Fissure Caries:
 Caries on the "top" of a tooth. Surface of the back
(molar and premolar) teeth used for chewing
Periodontal (gum) Disease
 Chronic bacterial infection involving plaque &
calculus below the gum line
 Gingivitis: mild disease associated with inflamed,
bleeding gums
 Periodontitis: gums separate from
teeth causing pockets that become
infected. Bone structure supporting
teeth is gradually destroyed. Tooth
loss may result
Source: American Academy
of Periodontology
Treatment of Dental Caries
in Children
Goal:
 Preserve tooth structure
 Prevent further destruction of the tooth or
surrounding teeth
 Restore function
 Eliminate pain
 Restore aesthetic appearance
Treatment of Dental Caries
in Children
 Dental restoration: area of decay is removed and destroyed
tooth structure is replaced
 In children, the most common restorative materials are
dental amalgam, glass ionomer, composite resin, and
stainless steel crowns
 Endodontic therapy (root canal): extensive decay with
destruction of tooth pulp requires removal of nerve and
vascular structures, leaving only non-vital tooth structure
 Tooth extraction: may be necessary if decay has destroyed
enough tooth to make restoration impossible
Treatment of Dental Caries
in Children
Early treatment: limited carious lesions
 Can often be done in a dental office using local anesthesia
 Less extensive; less expensive
Late treatment: extensive caries involving multiple teeth
 Often requires oral rehabilitation under general anesthesia in
the operating room
 Limitation of amount of topical anesthetics that can be used at one time
 Children often unable to comply with requirements of extensive dental
treatment
 Extensive; highly expensive
2011 Cost of Dental
Treatment under
General Anesthesia:
Age: 2.5 years
Caries: 16/20 teeth
Treatment:
1 pulp treatment
8 Composite Resin
Restorations
9 Stainless Steel
Crown’s
Dental Fees:
$ 3,600.00
Medical Fees:
~ $15,000.00
Before Surgery
After Surgery
Early Childhood Caries (ECC):
 Presence of 1 or more decayed (non-cavitated
or cavitated lesions), missing (due to caries), or
filled tooth surfaces in any primary tooth in a
child 71 months of age or younger
Non-cavitated lesions
(aka: white spot lesions)
Cavitated lesions = decay
= caries = cavities
Upper front teeth extracted
due to caries; stainless steel
crowns and white filling
Crowns
White filling
Severe Early Childhood Caries
(S-ECC):
Children younger than 3 years of age
 Any sign of smooth-surface caries (including
white spot lesions) is indicative of severe ECC
Smooth-surface caries = white
spot lesions = non-cavitated
lesions
Severe Early Childhood Caries
(S-ECC):
Children ages 3 through 5 years
 1 or more cavitated, missing (due to caries) or filled smooth
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surfaces in primary maxillary anterior teeth or:
Decayed, missing, or filled score (DMFS) of >4 (age 3 yrs),
>5 (age 4 yrs), or >6 (age 5 yrs) surfaces
Cavitated lesions = decay
= caries = cavities
Alloy fillings
Upper front teeth extracted due
to caries; stainless steel crowns
The Status of Children’s Oral
Health
Early Childhood Caries:
A Public Health Crisis
Dental caries
 Now the most common chronic disease of childhood
 One of the most prevalent transmissible, infectious diseases of
childhood
Early Childhood Caries:
Disparity in Disease Prevalence
 ECC occurs disproportionately among children
in poverty & those belonging to some
racial/ethnic groups
 ECC occurs in:
 5% of all children
 30-50% of low income children
• Much more likely to go untreated in this group
 79% of 2-5 yr old Native American (American
Indian/Alaskan Native) children
 80% of decay occurs in 20% of children
Disparities in Children’s Oral
Health: the effect of poverty
Poverty results in huge disparities in oral health status &
access to dental care among children of all ethnic groups
Disparities in Children’s Oral
Health: Cultural & Ethnic factors
Regardless of household income level, African-American and Hispanic
children are disproportionately affected by untreated dental decay
Disparities in Preventive
Dental Care: Etiology
 Lack of dental insurance
 Proportion of dentists participating in Medicaid
& SCHIP
 Medicaid & SCHIP eligibility levels
 Lack of pediatric dentists
 < 3% of dentists are trained in pediatric dentistry
Barriers to Dental Care
 Severe limitations in public & private funding
 Perception that dental care is less important
than health care
 Workforce shortage;
 No capacity to provide needed service
 Lack of providers has resulted in
services in some areas
demand for
The Reality of Access to
Dental Care
 For every child that lacks medical insurance, 2.5 lack
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dental insurance
85% of toddlers have had a well-child visit
Only 20% of toddlers have had a dental visit
86% of Head Start children experience ECC
Many dentists don’t accept new Medicaid clients
 In 2000, 25% of US dentists received some payment from
public insurance
• Only 9.5% received more than $10,000
 More than 50% of Iowa Dentists are not accepting new
Medicaid clients
Iowa Medicaid Children Receiving Dental Care:
2005-2006
% of Medicaid children 1-3 years having first dental exam or recall exam
Dental Workforce Shortage
 The number of dentists per capita is
declining nationwide
 Dental workforce is aging
 Insufficient number of dental students
entering training to replace retiring dentists
 Iowa is one of many designated dental
shortage areas
 Rural areas are particularly underserved
Dental Workforce Shortage
 General (family) dentists often reluctant to see
children < 3 years of age
 Prefer to refer young children to pediatric
dentists
 Pediatric Dentistry
 Requires 2 additional years of training
 <3% of all dentists are trained pediatric
dentists
Early Childhood Caries: (ECC)
 Multifactorial infectious disease
 Begins prior to 36 months of age
 Rampant characteristic
 Difficult and costly to treat
How Do Cavities Develop?
Streptococcus mutans
Carbohydrates
Acid formation
Demineralization
Tooth destruction
Teeth
Sugar
Decay
Bacteria
How Do Cavities Develop?
Streptococcus mutans
Carbohydrates
Acid formation
Demineralization
Tooth destruction
Teeth
Sugar
Decay
Bacteria
Consequences of Untreated
Oral Disease
 Pain
 Painful chewing interferes with eating
 May result in failure to thrive/malnutrition
 Interferes with learning
 Pain makes concentration difficult
 Causes school absence
• 51 million school hrs lost yearly
Consequences of
Untreated Oral Disease
 Tooth loss
 May lead to malocclusion, difficulty eating
 Poor self-esteem
 Infection
 Dental abscess
 Local extension into bone & contiguous structures
 Distant, blood borne infection
Consequences of
Untreated Oral Disease
 ETC visits, hospitalizations, surgeries
 Extensive, costly treatments
 Operative oral rehabilitation
 High Cost
 FY 2005 IA:
• Operative dental care for Medicaid Children ~ $8 million
Consequences of Gaps in
Dental Care
Deamonte Driver
Maryland boy, 12, dies after bacteria from tooth spread to his brain
Washington Post; Feb, 28, 2007
Relationship of Oral Health to
General & Systemic Health
 The mouth is part of the body & reflects the
individual’s overall health & wellbeing
 Many systemic disorders have specific oral
manifestations
 Viral, bacterial & fungal infections
 Immune-mediated disorders
 Inflicted trauma/child abuse
 Diseases that originate in the mouth may also have
systemic manifestations or complications
Poor Oral Health May Predict
Poor Health Outcomes in Adults
 Periodontal disease is associated with:
 Heart disease & stroke
 Poor control of diabetes
 Adverse pregnancy outcomes:
• Low birthweight
• Preterm labor
 Fewer than 8% of Iowa Medicaid enrolled
mothers receive preventive dental care
during pregnancy
(Personal communication: Bob Russell DDS, IDPH)
ECC is Preventable
 Requires early 1st dental visit (no later than age 1)
 Requires caries risk assessment:
 Identify children at “high risk” for ECC
 Identify caries process before cavitation
 Implement preventive strategies
All children need a dental home;
just as they need a medical home
Timing of First Dental Visit:
Professional Recommendations
 American Dental Association (ADA)
 American Academy of Pediatric Dentists (AAPD)
 American Academy of Pediatrics (AAP)
 American Academy of Family Physicians (AAFP):
 Recommend the first dental visit:
 Within 6 months of eruption of the first tooth or
 No later than 12 months of age
Components of Caries
Disease Prevention
 Community:
 Fluoridated water supply
 Public health dental program
 Provide oral health screening, anticipatory
guidance, preventive measures (fluoride varnish
& sealants), some treatment, referral
 May provide care in multiple settings
• Child care centers/Head Start Programs
• Schools
• Health department
• MCH/WIC programs
Components of Caries
Disease Prevention
Health practitioner
 Dental health care providers
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General dentists
Pediatric dentists
Oral surgeons/endodontists
Dental hygienists
• Public health
• Private practice
 Primary health care providers
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Pediatricians
Family physicians
Nurse practitioners
Physician assistants
Components of Caries
Disease Prevention
Individual & Family
 Parent responsibility:
 Follow anticipatory guidance/recommendations:
• Brushing with fluoridated toothpaste
– Direct control/supervision until age 7-8 years
• Limitation of sweet & acidic foods & beverages
• Dental visits
• Fluoride varnish/sealants
 Older child & adolescent responsibility:
 Follow recommendations:
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Diet
Brushing
Flossing
Dental visits
Who Should Do Caries
Risk Assessments?
 Dentists:
 Unfortunately >50% of Iowa dentists don’t see
high-risk, low income (Medicaid/SCHIP) patients
 Who Else Should Do Caries Risk Assessments?
 Health professionals and all
professionals in contact with
young children
Primary Care Providers as
Oral Health Care Providers
Primary Health Care Providers (PCP):
 See children at well-child visits ~ 12 times
in the first 3 years
 Already have an established, trusting
relationship with families
 Already providing anticipatory guidance &
performing screening (development,
maternal depression, etc.)
Positive Effect of Having a
Personal Doctor
 More likely to receive preventive dental
care in the previous year
 Children with special health care needs
(CSHCN) less likely to have unmet dental
care need
Other Non-Dental Professionals as
Oral Health Care Providers
Other professionals who work regularly with
children:
 School nurses
 Head start teachers
 Dental hygienists
 Public health personnel
 Women, Infants & Children (WIC) clinic
personnel
Role of the Primary Care
Provider: New Emphasis
on Millennial Morbidities
Children’s Oral health:
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Oral health risk assessment
Anticipatory guidance for caries reduction
Oral health exam
Fluoride varnish application
Referral for high risk children
Dental Home: for children under 3 years who lack
access to dental care
Integrating Oral Health
into Primary Care
 Need for integration of health services with
large unmet needs (such as oral & mental
health) into primary care model
 Stress prevention & early intervention
 Most cost effective
 Can be provided by the PCP in the medical home
Necessary Components
for Successful Integration
 Adequate reimbursement for:
 Cognitive services
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Parent interview
Risk assessment
Oral exam
Parent education
 Procedures
• Fluoride varnish application
 Care coordination
 Referral resources in the community
 Pediatric & general dentists
Incorporating Oral Health
into Your Practice
 Oral health risk assessment
 Identify children at increased risk
 Anticipatory guidance
 Prevent caries in high risk children
 Oral screening exam
 Restrain child’s head
movement
 Lift the Lip: examine
soft & hard tissue
Incorporating Oral Health
into Your Practice
 Fluoride varnish application
 For high risk infants & children (Medicaid &
SCHIP)
 Physician applies varnish after the oral exam or
 Nurse/assistant applies the varnish
• After she puts on gloves
• Just before giving vaccines
 Get to know your I-Smile Coordinator
I-Smile Coordinators
I-Smile coordinators are dental hygienists who serve as
prevention experts and liaisons between families, health care
professionals, & dental offices to ensure completion of dental
care. Coordinators are located in regional public health
agencies & provide local community support throughout Iowa.
A coordinator can:
• Assist with dental referrals for young children.
• Provide Medicaid dental billing information.
• Offer education for healthcare professionals regarding children’s oral
health, including screening and fluoride varnish training.
I-Smile Coordinator contact information can be found at:
www.idph.state.ia.us/hpcdp/oral_health.asp or
I-Smile hotline 1-866-528-4020
Summary:
Overview of Children’s Oral Health
2008 Training Module 1
 Dental disease in young children is a public health crisis
 There are disparities in oral health & access to dental care
 Barriers to care include work force shortages, lack of payer,
perception that dental care is unimportant
 Untreated oral disease leads to pain, early tooth loss,
abnormal growth and development
 Primary care provider has an important role in caries
prevention
 Oral health must be incorporated into the medical home