Integrating Oral Health Into Overall Health Care to Prevent Early Childhood Caries: Need, Evidence, and Solutions.

Medicaid data shows that few one- to two-year-olds receive a preventive dental visit, indicating our limited success implementing the existing policy paradigm of dental home establishment by 12 months of age. Few pediatricians refer children for early dental care, few dentists are comfortable seeing children younger than two-years-old, fewer still provide restorative care, and many dentists do not accept Medicaid insurance. These realities mandate new strategies to meet the needs of children and families and effectively tackle early childhood caries (ECC). Primary care medical providers have frequent contact with families, providing opportunities to incorporate oral health promotion and prevention in non-dental settings. Components of such an approach include: screening; risk assessment; oral health counseling; fluoride varnish application; successful referral for children needing intense intervention; policy support; and financial incentives to sustain change. Current research indicates that oral health counseling, particularly motivational interviewing, and fluoride varnish applied in the non-dental setting positively affect patient outcomes. Cost savings may only be realized if ECC prevention programs use: support professionals; integrative disease management; and innovative insurance structures. The purpose of this paper was to examine the evidence for the effectiveness of the provision of oral health preventive services in the primary care setting.

The experience of medical clinicians implementing fluoride varnish in Connecticut.

PURPOSE: The purpose of this study was to evaluate the success and barriers encountered by Connecticut medical clinicians providing and billing for infant oral health screenings and fluoride varnish. METHODS: Clinicians trained and registered in providing oral health services were surveyed about practice demographics, training effectiveness, and implementation barriers. RESULTS: Fifty-seven of 156 surveys (37 percent) were returned and analyzed. Most respondents were female (61 percent), worked at least 10 years (74 percent), and had at least 25 percent of their patients on Medicaid (79 percent). Respondents varied in how prepared they felt to offer services (P<.00). Sixty percent felt "well prepared" to provide oral screenings vs. 40 percent and 39 percent for fluoride varnish and billing services, respectively. Only 30 percent of respondents provided fluoride varnish. Clinicians were more likely to provide fluoride varnish and bill for the services if they felt well prepared after the training (P<.00). Referrals for an age one dental visit were not routine; 23 percent of clinicians did not refer, and 50 percent reported barriers. CONCLUSIONS: Few trained and registered clinicians provide fluoride varnish and bill for oral health services, despite feeling prepared to provide them. Additional support is required to help medical clinicians provide oral health services more consistently.

Factors associated with sealant outcome in 2 pediatric dental clinics: a multivariate hierarchical analysis.

PURPOSE: This study's purpose was to determine whether one-time sealants placed by pediatric dental residents vs dental students have different outcomes. The effect of isolation technique, behavior, duration of follow-up, and caries history was also examined. METHODS: Records from 2 inner-city pediatric dental clinics were audited for 6- to 10-year-old patients with a permanent first molar sealant with at least 2 years of follow-up. A successful sealant was a one-time sealant that received no further treatment and was sealed or unsealed but not carious or restored at the final audit. RESULTS: Charts from 203 children with 481 sealants were audited. Of these, 281 sealants were failures. Univariate analysis revealed longer follow-up and younger age were associated with sealant failure. Operator type, child behavior, and isolation technique were not associated with sealant failure. After adjusting for follow-up duration, increased age at treatment reduced the odds of sealant failure while a history of caries reduced the protective effect of increased age. After adjusting for these factors, practitioner type, behavior, and type of isolation were not associated with sealant outcome in multivariate analysis. CONCLUSIONS: Age at sealant placement, history of caries prior to placement, and longer duration of follow-up are associated with sealant failure.

Educating pediatricians and family physicians in children's oral health.

Publication of Oral Health in America: A Report of the Surgeon General (SGROH) alerted the public and health professionals to the importance of oral health and the vulnerability of poor and underserved children to dental disease. In response, the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the Society of Teachers of Family Medicine (STFM) have initiated training programs for residents and practicing physicians, allowing them to conduct oral health screenings, apply preventive strategies, and facilitate appropriate referrals to dentists. Training programs are increasingly available on the Web, but their quality and effectiveness are rarely assessed. To ensure greater inclusion of oral health in graduate medical education, voluntary curricular guidelines have been developed, and education in oral health is mandated in family medicine residency programs. Several initiatives engaging practicing physicians in oral health activities have demonstrated improved access and reduced dental disease in children, but evaluation of all programs is essential to determine cost effectiveness and outcomes. The actions of AAP, AAFP, STFM, and other large-scale initiatives have helped break down the traditional separation between medicine and dentistry. Collaboration between physicians and dentists should be encouraged at all levels of education to ensure improvement of the oral health of America's children.

Association of mutans streptococci between caregivers and their children.

The purposes of this literature review were to: (1) review the sources of mutans streptococci (MS) colonization in children and the effect of MS levels of primary caregivers on children's MS colonization; and (2) evaluate studies examining interventions to reduce transmission of MS from caregivers to their children. Forty-six studies were reviewed. Strong evidence demonstrated that mothers are a primary source of MS colonization of their children. A few investigations showed other potential sources of children's MS colonization, notably fathers. The role of other factors influencing transmission, such as socioeconomic status (SES) and specific cultural or behavioral practices, are unclear. There were at least 12 reports of microbiological interventions to reduce transmission of MS from caregivers to their children. Even though most studies found a reduction of MS in the children and 2 showed significant caries reduction, these studies generally lock consistent findings regarding caries reduction, hove a small sample size and inadequate control groups, and lock blindness of investigators and subjects. The efficacy of microbiological approaches on the caregivers to reduce caries risk in children still needs to be established through more rigorously designed clinical trials.

Practices and opinions of pediatric and general dentists in Connecticut regarding the age 1 dental visit and dental care for children younger than 3 years old.

PURPOSE: This study aimed to determine the percentage of general and pediatric dentists in Connecticut that were aware of, and practice, the current AAPD guidelines for the age one dental visit and to determine the services they provide to 0-2-yr-old patients. METHODS: A survey was mailed to Connecticut general and pediatric dentists seeking information on practice type, years in practice, training, ages of children seen, procedures performed and opinions regarding the age one dental visit. RESULTS: The response rate was 42% for general dentists and 84% for pediatric dentists, giving a sample of 113 and 60 dentists, respectively. All responding pediatric dentists reported seeing 0-2-yr-olds as compared to 42% of general dentists. Although not statistically significant, general dentists who were female or in practice less than 10 years were more likely to see 0-2-yr-olds. The majority of pediatric dentists reported performing all procedures surveyed, however, only just over half of general dentists provided topical fluoride or restorative care. Among pediatric dentists, 98% were aware of the AAPD guidelines and 92% agreed with them compared to 41% and 45% of general dentists respectively. CONCLUSIONS: Nearly all Connecticut pediatric dentists are caring for 0-2-yr-olds compared to 42% of Connecticut general dentists.

Oral health during pregnancy.

Oral health care in pregnancy is often avoided and misunderstood by physicians, dentists, and patients. Evidence-based practice guidelines are still being developed. Research suggests that some prenatal oral conditions may have adverse consequences for the child. Periodontitis is associated with preterm birth and low birth weight, and high levels of cariogenic bacteria in mothers can lead to increased dental caries in the infant. Other oral lesions, such as gingivitis and pregnancy tumors, are benign and require only reassurance and monitoring. Every pregnant woman should be screened for oral risks, counseled on proper oral hygiene, and referred for dental treatment when necessary. Dental procedures such as diagnostic radiography, periodontal treatment, restorations, and extractions are safe and are best performed during the second trimester. Xylitol and chlorhexidine may be used as adjuvant therapy for high-risk mothers in the early postpartum period to reduce transmission of cariogenic bacteria to their infants. Appropriate dental care and prevention during pregnancy may reduce poor prenatal outcomes and decrease infant caries.

The effect of care coordination on pediatric dental patient attendance.

PURPOSE: The objectives of this retrospective study were to determine if care coordination improved appointment-keeping behavior, and identify factors associated with patient attendance at an urban Medicaid dental clinic. METHODS: Children with sedation appointments received care coordination comprising telephone reminders, education regarding the appointment, and were mailed reminders or home visits if necessary. Collected chart audit data included age, behavior, appointment history and caries status. After several months, care coordination services were extended to routine, nonsedation appointments. Sedation and routine appointment controls were matched by appointment date and selected from the previous year. Attendance information was obtained from appointment and patient records. RESULTS: Sixty-one sedation appointments and 698 routine appointments were analyzed along with 61 and 931 control appointments, respectively. Sedation patients with care coordination had an attendance rate of 59% compared to 53% in the control group (P>.05). Routine patients with care coordination had an attendance rate of 70% compared to 62% in the control group (P<.001).) Data trends suggest that the children least likely to attend their appointments are those with: (1) high caries scores; (2) poor behavior; (3) long wait times between appointments; (4) multiple missed appointments; and (5) lack of a serviceable phone. CONCLUSIONS: Care coordination can improve attendance at an urban Medicaid dental clinic, but improvements are modest. Prospective studies are needed to better delineate which interventions and which patient predictors result in the most improvement in attendance-keeping behavior.

Infant oral health education for pediatric and family practice residents.

PURPOSE: The purpose of this study was to investigate whether an infant oral health curriculum implemented in pediatric and family medicine residency programs could improve physicians' oral health knowledge and practice behaviors and promote the age 1 dental visit. METHODS: Residents and faculty members completed a baseline current practices survey and knowledge test before receiving a 1- or 2-hour training session followed by a knowledge post-test. Existing well child care forms were updated with oral health prompts to reinforce newly learned skills. At 1-year follow-up (1 YFU), participants completed a current practices survey and knowledge test. In addition to the residency programs, medical students and advanced practice registered nurses participated in baseline data collection, training, and immediate posttest data collection. RESULTS: A total of 245 people participated, with 78% trained in person and 22% trained via the Web. Of these, 120 were the targeted residents and faculty-of whom 82% completed the 1 YFU. Practice behaviors improved from baseline to 1 YFU, with only 28% of practitioners at baseline referring children to the dentist at age 1, compared to 73% at 1 YFU (P<.05). Knowledge scores were greater at 1 YFU than at baseline (P<.05), and the mode of training showed no difference in knowledge outcomes. Knowledge and prescribing practices regarding fluoride were poor at baseline and showed limited improvement at 1 YFU. CONCLUSIONS: An infant oral health education program can improve physicians' oral health knowledge and behaviors, particularly regarding promoting the age 1 dental visit. Behavior changes regarding fluoride prescribing, however, appear harder to achieve. Web-based training had similar success to in-person training.

Mobile dental vans: planning considerations and productivity.

OBJECTIVES: Many children, especially those from lower socio-economic families, have limited access to dental care, transportation problems and poor appointment attendance. Mobile dental clinics have been implemented in many communities to address these issues. METHODS: Structured surveys were sent to the three mobile programs in Connecticut to collect information on the age of the program, issues encountered in planning and implementation, and ongoing costs and productivity. RESULTS: Each mobile clinic had two operatories and operated 140-200 days per year. Programs provided 2921-3417 diagnostic and preventive procedures and 359-721 treatment procedures per year for an average daily production of 18-24 procedures. All programs required external funding to remain financially solvent. CONCLUSION: Implementation and management of these programs is complicated. However, they provide an innovative solution to bringing dental care to underserved children and when operated in conjunction with schools can eliminate transportation problems and missed appointments.

A practical guide to infant oral health.

Early childhood caries is the most common chronic disease in young children and may develop as soon as teeth erupt. Bacteria, predominately mutans streptococci, metabolize simple sugars to produce acid that demineralizes teeth, resulting in cavities. Physicians should examine children's teeth for defects and cavities at every well-child visit. Any child with significant risk factors for caries (e.g., inadequate home dental care and poor oral hygiene, a mother with a high number of cavities, a high sugar intake, enamel defects, premature birth, special health care needs, low socioeconomic status) should be referred to a dentist by 12 months of age. Promoting appropriate use of topical and systemic fluoride and providing early oral hygiene instruction can help reduce caries in young patients, as can regularly counseling parents to limit their child's consumption of sugar.

Prevalence of dental caries and enamel defects in Connecticut Head Start children.

PURPOSE: The aim of this study was to determine the prevalence of dental caries and enamel defects in a sample of predominantly African American and Hispanic children from an inner city Head Start program located in Connecticut. METHODS: A total of 517 children were examined for dental caries and enamel defects. Children's caries experience was described using the dmfs/t indices, and dental defects were described using a modified developmental defects of enamel index. RESULTS: The mean dmfs was 3.0, and 38% of the children had caries. The prevalence of enamel defects was 49%. When analyzed by race/ethnicity no significant differences in dmfs scores or the prevalence of defects were observed. The majority of defects were located on anterior teeth, and the type of defect varied with the location. On the buccal surface of canines, hypoplasia accounted for 70% of the lesions. On maxillary anterior teeth, linear opacities accounted for 50% of the lesions. A positive association between enamel defects and caries was observed. CONCLUSIONS: The prevalence of caries and defects in these Head Start children was high, with most defects located on anterior teeth. Enamel defects were associated with an increased caries incidence.

Common dental emergencies.

Dental caries, a bacterial disease of teeth characterized by destruction of enamel and dentine, is often the underlying cause of dental pain. When a carious lesion impinges on the dental pulp, pulpitis follows and, ultimately, necrosis of the pulp occurs. Untreated necrosis may lead to a localized abscess or a spreading infection into the surrounding soft tissue that results in cellulitis. Immediate treatment involves antibiotic therapy for cellulitis, perhaps with drainage of abscesses, while definitive treatment requires root canal therapy or extraction of the involved tooth. Pericoronitis is an inflammation of the soft tissue overlying a partially erupted tooth. Localized cases respond to irrigation. Secondary cellulitis can develop. Definitive treatment may require surgical extraction of the underlying tooth or excision of the gum flap. Avulsion of a permanent tooth secondary to trauma is a true dental emergency. The tooth should be reimplanted on the spot, and the patient should be seen immediately by a dentist for splinting and antibiotic prophylaxis. Most dental problems can be prevented with regular dental care and steps to minimize risks of oral trauma.

Clinical decision making for caries management in children.

The aim of this review of clinical decision making for caries management in children is to integrate current knowledge in the field of cariology into clinically usable concepts and procedures. Current evidence regarding the carious process and caries risk assessment allows the practitioner to go beyond traditional surgical management of dental caries. Therapy should focus on patient-specific approaches that include disease monitoring and preventive therapies supplemented when necessary by restorative care. The type and intensity of these therapies should be determined utilizing clinical data as well as knowledge of the caries process for that child. Changes in the management of dental caries will require health organizations and dental schools to educate students, practitioners, and patients in evidence- and risk-based care.