WELL CHILD, WELL SMILE

Transcription

1 WELL CHILD, WELL SMILE What Primary Care Providers Can Do To Improve Children s Oral Health Heidi Baines, MD Anchorage Neighborhood Health Center Alaska Academy of Family Physicians 27 th Annual Scientific Congress, 2012

2 Tooth Decay-a nation-wide issue Tooth decay--single most common chronic childhood disease 5 x more common than asthma 7 x more common than hay fever 6 out of 10 children in the US have 1 or more diseased or filled teeth by 5 years of age 20% of the population experience 80% of decay NIH statistics: 20% of children age 2-4, 80% by age 17 have caries

3 Percent of children receiving services Medicaid Dental Access for Enrolled Children, FFY Medicaid - Percent of children receiving dental services by age & type of service, FFY Any dental service Dental preventative services 70 Dental treatment services Alaska Total Total 3-20 < Source: AK MMIS CMS-416 Annual EPSDT Participation Report 3/31/2011

4 number Alaska Dentists: Number by Age Group Alaska Dentist Distribution by Age Group: 2000 and age group

5 Limited Access Distribution of dentists in cities ~85% of dentists live in the top 5 populated cities, serving ~54% of the population General dentists receive little pedodontic training Refusal of medicaid patients Aging of the population

6 Impact of dental disease Pain and infection Eating Speaking Sleeping Inability to play normally Diminished growth (chronic disease) Absence from school

7 Opportunities we have Well child checks Immunization visits Emergency Department visits Home visits Public Forums

8 Pediatric Oral Health Training 35% received no oral health training 73% had <3 hours of training 21% felt well prepared for oral health risk assessments (but felt confident in anticipatory guidance) Majority believed pediatricians should do basic oral health screening. Pediatrics Aug;122(2):e Perceptions of oral health training and attitudes toward performing oral health screenings among graduating pediatric residents. Caspary G, Krol DM, Boulter S, Keels MA, Romano-Clarke G.

9 Pediatrician Dental Knowledge: true/false Only bottle-fed children get early childhood caries (baby bottle tooth decay) A 3 month old baby living in a non-fluoridated area needs fluoride supplementation Cavity-causing bacteria can be transmitted between mother and child Dental sealants are usually applied to a child s primary teeth

10 9% answer all four correctly Question Correct Answer % with correct answer Early Childhood Caries Fluoride supplements False 78.8% False 60.8% Transmission True 39.5% Sealants False 37.3%

11 Early Childhood Caries (ECC) Triad of Etiology Bacteria (mutans streptococci) Teeth Sugars Pattern of eating matters Upper front teeth are most susceptible

12 Streptococcus Mutans Vertical Transmission can occur Saliva contact Higher caregiver decay = higher likelihood of transmission Decrease transmission through Excellent oral hygiene Limiting sugar in diet Using preventive agents (topical fluoride, chlorhexidine mouth wash and xylitol gum)

13 What happens at the WCC? 89% inquire about bottle to bed 88% examine teeth for cavities 86% counsel on going to dentist 85% counsel on toothbrushing 73% assess fluoride intake 8% ask about mother s dental health

14 How can we improve? Well Child Check Risk Assessment More thorough exam Knee to Knee and Lift the Lip Anticipatory guidance with dental focus [Adds 1-5 minutes] Preventive Therapy Fluoride varnish [Adds 3 minutes]

15 Risk Factors for Early Childhood caries Low birth weight, pre-term pregnancy, perinatal complications Mother with untreated cavities or one or more permanent teeth extracted because of decay Siblings with experience of decay in baby teeth Visible plaque on child s teeth Cavities, white spots or hypoplastic teeth No Fluoride (tablets, toothpaste, water)

16 Oral Examination You need: Toothbrush Mouth mirror Give the child an unwrapped toothbrush Ask How do you take care of your child s teeth? Watch them brush the child s teeth

17 Oral Examination-2 Look at front teeth while child is sitting or lying on exam table Use knee-to-knee position for the rest of exam, and for fluoride varnish application Child faces parent, sitting on lap Give your child a hug and parent holds hands and lowers child back with head in examiner s lap

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19 Oral Examination-3 QUICKLY! Use child s toothbrush and mirror, LIFT THE LIP, and assess: Teeth: plaque, white spots, dark spots, holes Gums: redness, sores, infections, abscesses, bleeding

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23 Anticipatory Guidance-General Adult must also clean teeth until age 5 No access to toothpaste without adult Use only a pea-sized amount of paste Make it a habit-bedtime/bathtime

24 Anticipatory Guidance-infant Familiarize self with child s normal teeth and gums so you can identify problems Many children need extra sucking, give pacifier, thumb 6 months: begin to introduce cup Fluoride supplements as prescribed 9 months: encourage cup drinking, if bottle fed, start to wean

25 Anticipatory Guidance-child 12 months: begin to brush with pea-sized amount of paste, encourage cup drinking 3 years: begin to teach child to brush 4 years: brushes 2x daily with supervision, begin to intervene on pacifier, thumb Avoid trauma throughout childhood

26 Anticipatory Guidance- older child Begin flossing at age 8 Protective gear for sports Seatbelts Teach child what to do in dental emergency

27 Which child is safest?

28 Dental Vocabulary Concussion: tooth is tender but not mobile Subluxation: tooth is mobile but not displaced Luxation: tooth is loose with some displacement Intrusion: tooth is pushed deeper into socket Extrusion: tooth is partially displaced Avulsion: tooth completely knocked out

29 Dental Trauma: Avulsion Primary teeth are not repositioned Permanent teeth: put tooth back in space if possible within 5 minutes. DO NOT SCRUB! If impossible, place in milk or water, or hold in mouth, there are options within 1 hour Consider tetanus Call Dentist for immediate referral

30 Anticipatory Guidance-Teens Seat belt, helmet, face protector, mouth guard No tobacco Risks of piercing Tooth injury, stud aspiration, allergy, nerve damage, gingival recession, infection Brush and floss daily

31 Fluoride--how does it work? Increases resistance of tooth structure to demineralization Enhances remineralization of early lesions Reduces cariogenic activity of dental plaque by disruption of bacterial metabolism

32 Fluoride-Tooth Cycle

33 Evidence Based Recommendations

34 Systemic Fluoride <50% of population in AK have access to fluoridated public water Enhances resistance to later acid demineralization Give during tooth forming years (6 mo-16 years old) First permanent tooth erupts around age 5-6, last around age 16

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36 Systemic Fluoride Supplementation (for < 0.3 ppm) (Average Anchorage water supply has 1.06 ppm; but most wells have background level 0.2 ppm) AGE Birth 6 months FLUORIDE SUPPLEMENT None 6 months 3 years 0.25 mg/day 3 6 years 0.50 mg/day 6 16 years 1.0 mg/day

37 Topical Fluoride Acidulated fluoride phosphate (APF) Varnishes developed in 1960 s Longer contact time=more uptake Inhibits metabolism of bacteria Stabilizes mineralization of enamel Varnishes adhere in presence of saliva at surface and deeply and may act as ph controlling reservoir of fluoride

38 Fluoride Varnish is Safe Nephrotoxic plasma level = 850 ng/ml Fluoride varnish Fluoride gel (APF) Dose mg 30 mg Bioavailability Very low Almost 100% Peak plasma level ng/ml in one hour 1500 ng/ml bolus possible

39 Fluoride Varnish is Effective Cochrane Library Reviews 2002: Nine studies, 2700 children, 2-4 x/year Permanent teeth: 46% reduction in dmfs/yr NNT 1.4 in population with caries increment of 1.6 (middle range) NNT 3.2 for population with caries increment of 0.7 (low end) Baby teeth: 33% reduction in dmfs NNT similar to above

40 COVERAGE FOR DENTAL FLOURIDE VARNISH PROVIDED BY PHYSICIANS, NURSE PRACTITIONERS, AND PHYSICIAN ASSISTANTS Effective July 1, 2010, Alaska Medical Assistance will allow reimbursement for dental fluoride varnish applications and oral evaluations performed by physicians, nurse practitioners and physician assistants who have successfully completed an Oral Health or Caries Risk Assessment training program. Credentials Each medical provider will be responsible for successfully completing an Oral Health or Caries Risk Assessment training that includes oral evaluation and topical fluoride varnish applications. Accepted trainings include online and in-person training courses and workshops that provide a certificate of completion. A certificate of completion from the training program is required and must be presented to Alaska Medical Assistance upon request. Numerous acceptable training courses are available online, including the American Academy of Pediatrics Oral Health Risk Assessment training at To find additional information on acceptable training courses, please contact Brad Whistler at (907) Limitations of Coverage Alaska Medical Assistance will cover a maximum of 4 fluoride varnish applications (D1206) per calendar year. Coverage of oral evaluations (D0145) is limited to 2 exams per calendar year and is limited to patients under 3 years of age. Only those services performed on/after July 1, 2010 are reimbursable. Billing Topical fluoride varnish and oral evaluations performed by physicians, nurse practitioners, and physician assistants must be billed on the CMS-1500 or 837P using the following dental procedure codes: D topical fluoride varnish D oral evaluation for a patient under three years of age and counseling with primary caregiver If you have questions or require additional assistance, please contact the ACS Provider Inquiry Unit at (907) , option 1, or (800) , option 1, 1 (toll-free in Alaska). Reimbursement 100% of Dental Fee Schedule 85% of Dental Fee Schedule D1206 $28.00 $23.80 D0145 $56.70 $48.20 Affiliated Computer Services P.O. Box Anchorage, AK

41 Alaska: the updated Facts D0145: Oral evaluation for patient under 3 yo and counseling with primary care giver $57.72 for a physician $49.06 for Midlevel D1206: topical fluoride varnish $28.50 for a physician $24.23 for Midlevel Certification required: 5&pagekey=62948&s1= Free, 8.5 prescribed credits by AAFP

42 Fluoride Varnish Application You will need: 2x2 gauze gloves Unit dose fluoride varnish

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44 Fluoride Varnish Application Procedure: Knee-to-knee position Dry the teeth a little at a time, and apply varnish as you go to ALL surfaces of teeth (varnish will set upon contact with saliva) No brushing until the next day No crunchy foods

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48 Fluoride Varnish done by YOU! No special equipment is needed Teeth do not need a professional prophylaxis prior to application Potential for fluoride ingestion very low Can be used on current decay and to prevent new decay Application is less than 5 minutes

49 REMEMBER: The mouth and teeth are an important part of the whole child! Take the Well Child Check as an opportunity for: Risk Assessment Oral Exam Dental Anticipatory Guidance Fluoride Varnish

50 Alaska: the updated Facts D0145: Oral evaluation for patient under 3 yo and counseling with primary care giver $57.72 for a physician $49.06 for Midlevel D1206: topical fluoride varnish $28.50 for a physician $24.23 for Midlevel Certification required: 5&pagekey=62948&s1= Free, 8.5 prescribed credits by AAFP

51 Alaska Specific Issues Access to dentists (rural vs. urban; native vs. non-native) Change in traditional diet to increased carbohydrates Water not all fluoridated High cost of toothpaste, etc. (in bush) Chewing tobacco (manufactured vs. homemade) Cultural/societal norms Premastication of foods

52 Role of the Pediatric Provider 1100 pediatricians studied nationwide <25% had no previous dental health training 54% report examining teeth of more than half of 0-3 yo pts 4% regularly apply fluoride varnish 74% had difficulty getting successful referrals for 0-3 yo Medicaid patients >90% agreed that they had an important role in identifying dental problems and counseling families on prevention of caries. Oral health and pediatricians: results of a national survey. Lewis CW, Boulter S, Keels MA, Krol DM, Mouradian WE, O'Connor KG, Quinonez RB. Acad Pediatr Nov-Dec;9(6):

53 Dental History Birth Hx: birth weight, pre-term, complications at birth Hx of tooth decay in family? Fluoride inventory Tooth cleaning Diet, snacking hx