Transcript Dental Early Intervention in North Carolina

Dental Early Intervention in
North Carolina
Rebecca King, DDS, MPH
Chief, Oral Health Section
NC Division of Public Health, DHHS
919-707-5487
[email protected]
Turn of the Century
• 1910 -- Dr. RM Squires:
function ... prevent rather than cure
• 1918 – NC Dental Society gets
legislative funding
– Reduce pain and infection
– Educate on importance of oral health
Oral Health Section Staff
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6 Public health dentists
58 Public health dental hygienists
3 Health educators
3 Equipment technicians
Support staff
Oral Health Section Regions and Staff Assignments
Central
10 Hygienists
4 Local Hygienists
22 Counties
ASHE
ALLEGHANY
SURRY
WARREN
VANCE
STOKES
ROCKING- CASWELL
PERSON GRANHAM
WILKES
VILLE
ORANGE
MITCHELL
YADKIN FORSYTH
FRANKLIN
AVERY
GUILFORD
YANCALDWELL ALEXNASH
ALADURHAM
EDGEDAVIE
CEY
ANDER IREDELL
WASHMANCE
MADISON
COMBE
DAVIDDARE
MARTIN
INGTON TYRRELL
WAKE
SON
BURKE
WILSON
BUNCHATHAM
RANDOLPH
HAYCATAWBA
MCDOWELL
BEAUPITT
ROWAN
COMBE
WOOD
HYDE
FORT
JOHNSTON
LINCOLN
RUTHERGREENE
LEE
HENDERCABARRUS
JACKWAYNE
FORD
HARNETT
CLEVE- GASTON
MONTSON
TRAN- SON
LENOIR
STANLY GOMERY MOORE
POLK
LAND
CRAVEN
SYLVANIA
MECKLENPAMBURG
LICO
JONES
SAMPSON
RICHHOKE CUMBERDUPLIN
UNION
ANSON
LAND
MOND SCOTLAND
CARTERET
ONSLOW
WATAUGA
SWAIN
GRAHAM
MACON
CHEROKEE
CLAY
CAMCURRITUCK
GATES
NORTHDEN
HERTAMPTON
PERPASQUOFORD
QUIMAN
HALIFAX
TANK
S
CHOBERTIE
WAN
Western
ROBESON
21 Hygienists
BLADEN
PENDER
COLUMBUS
1 Field Dentist
BRUNSWICK
NEW
HANOVER
2 Local Hygienists
Hygienists
Eastern
40 Counties
Field Dentists
19 Hygienists
Supervisors
1 Field Dentist
Local Hygienists Under
State Supervision
1 Local Hygienist
Revised 9/05
38 Counties
Program Components
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Dental disease prevention
Oral health assessment
Dental health education and promotion
Access to dental care
Dental public health residency
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Dental Disease
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
Prevention
Water fluoridation
Preschool dental preventive
programs
Dental sealants
Fluoride mouthrinse
Water Fluoridation
NC: 85% on municipal water
supplies receive the benefits of
water fluoridation
Preschool Dental Preventive
Programs
Much more later.
Dental Sealants
• Statewide goal is 50% - a top OHS priority
• OHS target population
K-3 high-risk children
15,000 per year
• Fifth graders with sealants increased from
28% (1996) to 44% (2006)
Fluoride Mouthrinse
• School-based program from mid-1970s to
2002
• Increasingly targeted in early 1990s
• Discontinued due to budget cuts and lack of
recent data
Fluoride Mouthrinse Resurgence
• Survey data showed decreased disparities
• Obtained expansion budget funding in 2006
• Targeting schools with highest decay rates
who promise compliance
• Plan to begin rinsing in January 2007
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Oral Health
Assessment
 Statewide dental
surveys
 Oral health surveillance
Statewide Dental Surveys
Provide evidence base for program:
• Early 1960s
• 1976-1977
• 1986-1987
• 2003-2004
2003-2004 Statewide Dental
Survey
• Sample: 8000 children K-12
• Study how well NC decay prevention
programs are reducing decay
• Measure
Disparities
Parents’ knowledge and opinions
How dental health affects quality of life
• Results used for Section strategic planning
Select Survey Findings
• Rates of decay in preschoolers have deteriorated
slightly.
• Past improvements in decay rates in permanent
teeth have leveled off.
• Whites (19%) are least likely to have untreated
decay, followed by blacks (30%), then “Others”
(mostly Latinos) (38%).
• Not including early decay (non-cavitated lesions)
underestimates disease levels by 35-40%.
• 40% do not think baby teeth are important.
Trends in Untreated Decay in
Permanent Teeth
Percent
100
90
80
70
60
50
40
30
20
10
0
92
77
Blacks
Whites
60
34
35
30
19
15
1960-62
1976-77
NC OHS Statewide Dental Survey Data
Year
1986-87
2003-04
Oral Health Surveillance
Calibrated dental
assessments
By PH RDHs
Grades K and 5
• County oral health
status data
• Referral for
treatment needs
Surveillance Results
• 21% K, 5% fifth graders have untreated decay
• Proportion of kindergartners who have had
tooth decay has increasing, maybe leveling
off
• Proportion of fifth graders who have had
tooth decay is low but fluctuating
• Fifth graders with sealants increased from
28% to 44% (1996-97 to 2005-06)
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Dental Health
Education
 School-based education and
 Community outreach
 Professional education
 Educational materials
School-based Education
• 176,000 children thru classroom
education
• 16,600 Adults
Parent education
Teacher support
• Also health professionals
Exhibit Promotions
Aging, consumerism, diabetes, careers, sealants,
early childhood caries, fluorides, oral
hygiene, nutrition, tobacco, injury prevention,
OHS program
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Access to Dental
Care
 Referral/follow-up for care
 Improved access for low-income
families
 “Under direction” activities
Oral Health Surveillance
• Referral for treatment needs
>129,000 K,5 screened
Identified >28,400 in need of dental care
Helped get dental care for 10,800
• Additional 67,800 screened for sealants,
GKAS! and at request of school nurses
Improved Access
• 1999 NC IOM Task Force on Dental Care Access
had 23 recommendations, e.g.
 Increased fees for Dental Medicaid services
 Funding for physician-based dental preventive services
 “Under Direction”
 Medicaid Dental Advisory Committee (PAG)
 Licensure by credentials
• 2005 NC Oral Health Summit – latest update and
new action steps
2006 Give Kids a Smile!
• NC Dental Society initiative to provide free dental
care for underprivileged children
• To date:
– 7000 volunteers
– 54,000 children served
– > $4 million free care
• OHS PH Dental Hygienists screen and coordinate
Local Dental Safety Net Clinics
• OHS provides TA for new clinics
• OHS provides temporary dentist coverage
on limited basis
• Number increased dramatically from the
early 1990s to 114 fixed, mobile and “free”
clinics in 2005
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Dental
Public Health
Residency
 Training for dental public
health specialists
 Growth for the Division
Preschool Dental Prevention
Programs in North Carolina
Smart Smiles
An Appalachian Regional
Collaborative Partnership to
Improve Dental Health
The Beginning
• Appalachian Regional Consortium/NC
Partnership for Children/Smart Start health
assessment (fall 1996)
• 1/3 kindergarten children in western part of
state had untreated decay
• Primary need
reduce early childhood caries
improve dental health
Motivating Assumptions
• ECC is a serious public health problem
• Its burden can be reduced through
prevention targeted to very young, high risk
children
• Virtually all infants & toddlers obtain care
at medical offices and it is a logical place to
provide services
Additional Assumptions
• Physicians and their staff know that ECC is a
problem and they are willing to help prevent it
• Primary medical care providers need help to learn
procedures and to implement them in their
practices
• Innovations must be evaluated for adoption rates,
quality of care, clinical effectiveness, costs and
political concerns
Fluoride Varnish Safety and
Effectiveness
• Safe, easy to use and accepted
• No studies of effectiveness in 1-2-year-olds
• Emerging evidence of effectiveness in primary teeth of
older children
• Supported by a larger body of evidence
 effective in permanent teeth
 other topical fluoride applications are effective
Partners/Advisory Board
• Local community
leaders
• State and regional
Smart Start agencies
• NC Oral Health
Section
• UNC School of
Dentistry
• UNC School of Public
Health
• Ruth & Billy Graham
Health Center
• Local health
departments
• Pediatric offices
Medical Community Preparation
• Worked with licensing boards:
medical
dental
nursing
• Sample standing orders
Smart Smiles Preventive Package
• Medical setting
targeted oral health education for caregivers
dental screening
fluoride varnish application
• First visit ~ age 9 months
• Repeat every 6 months until age 3
Why Preventive Medical Model?
• This is where young children are
• Multiple services at one visit
• Most general dentists uncomfortable seeing
children this age
• Interest and willingness of medical community
• Few pediatric dentists
• Treatment is expensive
• This was the best idea anyone had
Targets
• Children, 9 - 36 months, high risk for caries.
• Medical risk factors & socioeconomic indicators
families  200% Federal Poverty Level
medically compromised children
older siblings with poor oral health
Challenges
• Effectiveness
identifying the high risk children
getting them in for the service on a regular
schedule
• Financing
grant stipulated that providers provide service
at no cost to patients
economics was an issue for medical practices
Effectiveness Issues
• Provide services to high risk children
80-85% decay in 20-25% children
• Begin prevention before decay begins
(~ 9 months)
• Provide services on a regular basis
Finances
Medicaid agreed to reimburse (July 1999)
• Medical offices - required training, recognized
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Smart Smiles trainers
Six visits between 9 months and age 3 (90 day
interval)
Reimburse for:
dental health education for parent/care-give
oral screening and referral for child
fluoride varnish application for child
Smart Smiles Evaluation (8/2001)
• $2.2 million, 5 year grant
• NIDCR, National Institutes for Health
• Effectiveness - does program reduce
cavities?
Does it work in this setting?
Can we provide package frequently enough?
• Data collection completed
Smart Smiles Evaluation Aims
• Short term effects on cavities (dmf scores)
in 3-year-old children
• Intermediate effects on cavity-related
treatments, Medicaid costs, hospital use,
and quality of life
• Longer-term effects on cavities in 5-yearold children after 2-year gap in services
Into The Mouths of Babes
Statewide Medicaid Dental
Prevention Program for Young
Children
Goals
• Increase access to preventive dental care for
low-income children
• Reduce the prevalence of ECC in lowincome children
• Reduce the burden of treatment needs on a
dental care system already stretched beyond
its capacity to serve young children
IMB Statewide Pilot
• December 1999
• Pediatricians and family practitioners
• Used Smart Smiles training session and
educational materials, modified over time
• Added training on billing procedures
Statewide IMB Progression
• Pilot – volunteer trainers
• June 2000, RFA from HCFA to Medicaid
agencies for Innovative ECC program
partners: Medicaid, UNC Schools of Public
Health and Dentistry, NC Pediatric Society,
NC Academy of Family Physicians, Oral
Health Section
evaluate level of training required for MDs
Dental Support
• Fall 1999 NC Academy of Pediatric
Dentistry endorsement
• Spring 2000 NC Dental Society resolution
of support
• Fall 2001 NC Academy of Pediatric
Dentistry reaffirmed support
Dental Prevention Service Package
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Oral screening and risk assessment
Referral for dental care
Caregiver education
Fluoride
supplements
toothpaste
topical fluoride application (varnish)
Oral Screening
• Not intended as a diagnosis
• Done by provider also doing physical
exam
• Accuracy for ECC = 90%
• Patients with abnormal findings referred
Oral Screening
Encounter form used to identify risk factors
• Family history
• Dietary practices
• Oral hygiene behaviors
• Fluoride exposures
Caregiver Education
• Uses risk assessment to guide
emphasis
limiting exposures to risk factors
general advice about dental care
• Age-specific handouts provided in
English and Spanish
Fluoride Application
• Fluoride varnish is cornerstone
• Performed by licensed professionals
MD, PA, NP, RN, LPN
Results: MD Training Evaluation
Amount of Training Required
• Types of training
– Traditional CME
– Add telephone learning collaboratives
– Add on-site assistance
• More was not better
Into the Mouths of Babes
2006
• >100,000 visits for dental preventive
package
• ~ 425 physician practices, residency
programs, local heath departments trained
and supported
• OHS position for trainer (2005)
• 3-year MCH funding to support training
activities
Number of IMB Visits
No. of visits
20,000
18,000
Follow-up visits
16,000
Initial visits
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Q1
2000
Q3
2000
Q1
2001
Q3
2001
Q1
2002
Q3
2002
Q1
2003
Quarter/Year
Q3
2003
Q1
2004
Q3
2004
Q1
2005
% Health Check Screenings
Receiving IMB Services
40
35
30
% Children
25
20
15
10
5
0
Q1
2000
Q3
2000
Q1
2001
Q3
2001
Q1
2002
Q3
2002
Q1
2003
Quarter/Year
Q3
2003
Q1
2004
Q3
2004
Q1
2005
Emerging Data
Dose related response:
• Even one application produces significant
caries reduction (Weintraub, UCSF)
• Children with four or more applications
before age 3 showed significant caries
reductions compared to children with less
than four (Rozier, UNC).
Questions on IMB:
Kelly Haupt
[email protected]
Early Head Start
• Surveys and focus groups to find needs
Teachers
Parents
• Developing and piloting training materials
Expand the concept that baby teeth are
important
Urge parents to seek early preventive care
HRSA Access to Dental Care Grant
• Carolina Dental Home
• ~$120,000/year for three years
• Bring folks together to pilot test how to best get
more dental referrals for very young high-risk
children
• Collaborators:
Local dentists and Pediatric Dentist/s, Family Physicians,
Pediatricians, Medicaid, NC Dental Society, Oral
Health Section, UNC Schools of Dentistry and Public
Health, community leaders, others
Questions?