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.

Progress in Early Childhood Caries and Opportunities in Research, Policy, and Clinical Management.

The 2014 Early Childhood Caries Conference encompassed evidence-based reviews on the state of the science regarding early childhood carries (ECC) epidemiology, etiology, prevention, and disease management. The purpose of this paper was to discuss the work presented at the conference and identify opportunities in research, policy, and clinical management that may improve early childhood caries outcomes and lower costs of care. While great progress has been made since the 1997 ECC Conference, there remains a paucity of high-quality evidence from randomized controlled trials on what are the most effective means to prevent and manage ECC. Analyses of studies indicate that some approaches, such as chlorhexidine, iodine, and remineralizing agents, have not shown consistent findings in preventing ECC. However, evidence exists to yield recommendations in some areas. There are useful risk assessment indicators to identify preschool children at risk for caries. Fluoridated toothpaste and fluoride varnish currently are the most effective chemotherapeutic strategies to prevent ECC. Motivational interviewing, a form of patient-centered counseling, is effective for motivating oral health behaviors and shows promise for reducing caries. Additionally, evidence is emerging that shows the value of chronic disease management approaches and integrating ECC oral health care within medical care settings. Recommendations for future directions in ECC research and policy were also key outcomes of the conference.

Impact of fee increases on dental utilization rates for children living in Connecticut and enrolled in Medicaid.

BACKGROUND: In 2008, Connecticut's Medicaid program administration increased children's dental fees to match approximately the 70th percentile of what the market fees were for dental care in 2005. These Medicaid program changes occurred at the same time as a national economic recession, which took place from 2007 through 2009. METHODS: The authors obtained Medicaid eligibility, claims, and provider data before and after the fee increase, in 2006 and 2009 through 2012, respectively. Their analysis examined changes in utilization rates, service mix, expenditures, and dentists' participation. The authors qualitatively assessed the general impact of the recession on utilization rate changes. RESULTS: The Medicaid fee increase, program improvements, and the recession resulted in a dramatic increase in utilization rates. For children continuously enrolled in Medicaid, utilization rates increased from 45.9% in 2006 to 71.6% in 2012. Rates increased across sex, race, ethnicity, and geographic areas. These increased utilization rates eliminated the disparities in access to dental services between children with private insurance and children receiving Medicaid benefits. Children enrolled in Medicaid now have utilization rates that are similar to or higher than privately insured children. Expenditures increased $62 million; this represents less than 1% of 2012 State Medicaid expenditures. Dentist participation increased by 72%. These results suggest that dentists will participate in the Medicaid program if adequately compensated, and low-income families will seek dental services. CONCLUSION: The Medicaid fee increase, program improvements, and the recession had a dramatic impact on reducing disparities in children's access to dental care in Connecticut. PRACTICAL IMPLICATIONS: One solution to the substantial disparities in access to dental care is to increase Medicaid fees to competitive levels.

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.

Prenatal nutrition intervention to reduce mutans streptococci among low-income women.

OBJECTIVES: The objective of this study is to assess the effectiveness of a prenatal nutrition intervention to reduce sugar intake and mutans streptococci (mutans) among low-income women. METHODS: Pregnant women were recruited from the obstetrics service at a community health center in Connecticut. Inclusion criteria were ≥18 years of age; mutans levels >10, 000 colony forming units/ml as determined by Dentocult SM® kits (Orion Diagnostica Oy, Espoo, Finland); and >3 months pregnant. Women were randomized to receive education alone [education intervention (EI)] or education and a 1-hour nutrition group session at 9 months and 6 weeks postpartum [education and nutrition intervention (EIN)]. Mutans and questionnaire data were collected at baseline, 9 months, 6 weeks, and 3 months postpartum. One hundred twenty completed the baseline visit and 93 (77%) completed all four visits. Sugar intake was assessed by the Food Frequency Questionnaire and clinical information was abstracted from medical charts. RESULTS: Mean age was 26.3 years [standard deviation (SD)= 6], 73% were Hispanic, 29% had lived in the United States < 6 years; 48% completed high school; 27% were married; mean total sugar intake at baseline was 149g (SD = 85). Repeated measures analysis of variance showed that mutans levels declined significantly in both groups, but that the EI group had significantly lower mutans levels at the final assessment compared with EIN. Sugar intake also declined significantly, but there were no significant differences between groups. CONCLUSIONS: The study demonstrated the following: a) the feasibility of conducting the intervention at community health center sites among low-income pregnant women; b) the effectiveness of education to reduce mutans/sugar intake; and c) the need to improve the nutrition intervention to obtain additional gains in mutans reduction.

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.

Practices and opinions of Connecticut general dentists regarding dental treatment during pregnancy.

This study aimed to evaluate the opinions and practices of general dentists in Connecticut regarding dental care during pregnancy. A survey was mailed to Connecticut general dentists to acquire data regarding age, gender, training, type of practice, years in practice, payment types accepted, procedures provided for pregnant women according to trimester, provider comfort level with treating pregnant patients, reasons for not treating pregnant patients, and provider opinions about dental care during pregnancy. The response rate was 42%, yielding a sample of 116 dentists. The majority of respondents (97%) reported treating pregnant patients; however, only 45% felt "very comfortable" treating these patients. All dentists in the sample agreed that physicians need to include an oral health evaluation and appropriate referral for patients' prenatal care. However, 70% of respondents had never received a dental referral for a pregnant patient. The majority of dentists favored providing dental treatment during the second trimester of pregnancy. Most dentists (77%) would take a radiograph for a patient 10 weeks into the pregnancy seeking treatment for dental pain, but only 2% would take routine radiographs regardless of the pregnancy trimester. There was a lack of consensus about medications dentists reported acceptable to prescribe for pregnant patients, and female dentists were significantly less likely than males to prescribe ibuprofen (P < 0.05). At least half of the respondents reported not being completely comfortable treating pregnant patients. Further, many dentists appear to not follow medication prescribing guidelines for this population. While additional research is needed, these initial results indicate that additional education regarding the treatment of pregnant patients would be a beneficial addition to dental school and continued education course curricula.

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.

The dental safety net in Connecticut.

BACKGROUND: Many poor, medically disabled and geographically isolated populations have difficulty accessing private-sector dental care and are considered underserved. To address this problem, public- and voluntary-sector organizations have established clinics and provide care to the underserved. Collectively, these clinics are known as "the dental safety net." The authors describe the dental safety net in Connecticut and examine the capacity and efficiency of this system to provide care to the noninstitutionalized underserved population of the state. METHODS: The authors describe Connecticut's dental safety net in terms of dentists, allied health staff members, operatories, patient visits and patients treated per dentist per year. The authors compare the productivity of safety-net dentists with that of private practitioners. They also estimate the capacity of the safety net to treat people enrolled in Medicaid and the State Children's Health Insurance Program. RESULTS: The safety net is made up of dental clinics in community health centers, hospitals, the dental school and public schools. One hundred eleven dentists, 38 hygienists and 95 dental assistants staff the clinics. Safety-net dentists have fewer patient visits and patients than do private practitioners. The Connecticut safety-net system has the capacity to treat about 28.2 percent of publicly insured patients. CONCLUSIONS: The dental safety net is an important community resource, and greater use of allied dental personnel could substantially improve the capacity of the system to care for the poor and other underserved populations.

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.