Karen L Carson MD, FAAP
Dental varnish application as a covered benefit first presented by Dr. Ben Hoffman and Albert Bourbon, PA November, 2007 at the NM Pediatric Society Council Meeting
Who is the Pediatric Council?
NM Pediatric Society Pediatric Council Composed of: New Mexico Pediatric Society Members from across the state in various practice roles. (Rural Medicine, Inpatient Medicine, Specialty Practice) Medical Chief Officers from all 4 Saluds and United Healthcare State Health Representatives Meet 3 times per year Goal: Liason between Pediatricians, Health Plan Officials and State Officials
Pediatric Council Meeting - November 2007 Medical Chief Officers of Saluds, other state officials present. NM Pediatric Society Council requested Dental Varnish application by non-dental provider be covered by NM Medicaid (D1206). Payment per procedure by Medicaid fee schedule: Approximately $15.00
STATES with MEDICAID Funding for Physician Oral Health Screening and Fluoride Varnish MD: July 09 GA: Jan 09 = Medicaid coverage approved AL: Jan 09 = In certain circumstances = Considering = Coming Soon http://www.mchoralhealth.org/feedback/reimbursementchart6_08.pdf Version: 11/08
NM Pediatric Council Chair + Keith Gardner(R) + Britt Catron = Chaves County Dental Varnish Project
BCA Medical Associates: 8 Pediatricians About 18,000 Pediatric patients Serves Chaves County and surrounding areas 2 Clinic sites 90% Medicaid insured Low Socioeconomic populace Fluid
BCA Medical Training on Dental Varnish application and oral health by local dentists: Dr. Michelle Luikens, DMD Dr. Max Kerr, DMD Dr. Michelle Carter, DMD Additional training by completing online dental varnish application module.
June 2009: BCA Medical
Prevalence of Dental Caries 5 times more common than asthma 7 times more common than hay fever Caries Rate 18% aged 2 to 4 years 52% aged 6 to 8 years 67% aged 12 to 17 years
Early Childhood Caries (ECC) A severe, rapidly progressing form of tooth decay in infants and young children Affects teeth that erupt first, and are least protected by saliva Initial lesions white decalcification with beginning enamel breakdown Late stage lesions moderate to severe enamel and dentin destruction
Cariogenic bacteria are transmitted from mother (or primary caregiver) who harbors these bacteria to the infant at or before the eruption of the first tooth. Because bacteria are transmitted through the saliva, pretasting, pre-chewing, and sharing of utensils should be avoided. When a mother/primary caregiver puts the baby s feeding spoon into his or her mouth, or cleans a pacifier in his or her mouth, the bacteria from the mother/caregiver are transmitted to the baby s mouth, and the risk of caries is increased.
Caries are promoted by carbohydrates, which break down to acid. Acid causes demineralization of enamel. Foods with complex carbohydrates (breads, cereals, pastas) are major sources of hidden sugars. High sugar content in sodas is a source of these substrates.
Tooth Decay Plaque + sugars + microorganisms (primarily streptococcus mutans) acid that etches the enamel of the teeth which results in the beginning of caries (the process), leading to a cavity (the hole).
Caries develops when there is a susceptible tooth exposed to pathogenic flora (bacteria) in the presence of substrate. Under these conditions, the bacteria metabolize substrate to form acid that decalcifies teeth.
Fluoride's Influence on Oral Flora Promotes remineralization of enamel, and may arrest or reverse early caries Decreases enamel solubility, inhibits the growth of cariogenic organisms, thus decreasing acid production. Primarily topical even when given systemically
Socioeconomic Factors The rate of early childhood dental caries is near epidemic proportions in populations with low socioeconomic status. No health insurance and/or dental insurance Parental education level less than high school or GED Families lacking usual source of dental care Families living in rural areas
Percent of Children with Decayed and Filled Primary Teeth by Household Income Level (% of Federal Poverty Level) 50 40 30 20 10 0-100% 101-200% 201-300% 301%+ 0 Decayed 2-5 year olds Decayed 6-12 year olds Filled 2-5 year olds Filled 6-12 year olds Vargas, Crall, Schneider. Analysis of NHANES III data. JADA, 1998.
Percent of children 50 ` Minority children are more likely to have untreated tooth decay (regardless of family income) Ethnic groups White African American Mexican American 40 30 20 10 0 Fed. Poverty level 2-5 years 6-12 years 6-14 years 15-18 years Primary dentition Permanent dentition Vargas, Crall, Schneider: JADA 1998;129:1229-1238.
The AAP policy statement Oral Health Risk Assessment Timing and Establishment of the Dental Home identifies that the following groups are at risk for early childhood dental caries: Children with special health care needs Children of mothers with a high caries rate Children with demonstrable caries, plaque, demineralization, and/or staining Children who sleep with a bottle or breastfeed throughout the night Children in families of low socioeconomic status If an infant is assessed to be within 1 of these risk groups, it is recommended that he or she be referred to a dentist as early as 6 months of age and no later than 6 months after the first tooth erupts or 12 months of age (whichever comes first).
Sad Reality: 50% of tooth decay in low income children goes untreated 1 in 8 children never see the dentist (while more than half of children with private insurance received dental care in the preceding year (Government Accountability Office)). GAO estimated that in 2005, 724,000 2-18 year olds could not get needed dental care.
Change in Paradigm for Dealing with Dental Caries Old Paradigm --> Surgical / Drill and Fill (deal with the consequences of the disease) Later Paradigm: Prevention!!! (but generally one size fits all ) Current Paradigm: Early Intervention, Risk Assessment, Anticipatory Guidance, Individualized Prevention and Disease Management PREVENTION IS KEY! Early, consistent dental health screenings Prevention education
Mom/Parent Questions (The Caregiver Oral Assessment) How are your teeth? Have you had a lot of cavities? Do you have a regular dentist? When was your last visit to the dentist? Have you ever had a tooth filled? Have you had a lot of dental work done? Mothers/primary caregivers should be referred to a dental home if oral health problems are identified, because active dental disease significantly increases the transmission and early colonization of cariogenic bacteria in the child.
Ethnocultural Factors Increased rate of dental caries in certain ethnic groups Diet/feeding practices and child-rearing techniques influenced by culture Yes, my daughter still drinks from a bottle. Deal with it. Vivian Manning-Schaffel: My daughter is almost two and still drinks milk from a bottle to go to sleep. And you know what? I've got better things to do than care. Of course, for a few weeks there, I really cared. With my oldest, I strictly adhered to most milestone transitions because I had the time to know what they were. But now, as a working parent with two kids in the picture, the path of least resistance is often the path that seduces. (MomLogic.com)
Not Just What You Eat, But How Often Increased acidity produced by bacteria after sugar intake persists for 20 to 40 minutes With each ingestion of sugar, another wave of increased acidity lasting for 20-40 minutes Frequency of sugar ingestion is more important than quantity Better to drink 16 oz. of Cola in one long gulp than continually over 8 hours.
Sugar in 12 ounce can of pop Soda Pop: Sugar: (in teaspoons) Orange Slice 11.9 Minute Maid Orange 11.2 Mountain Dew 11.0 Barq s Root Beer 10.7 Pepsi 9.8 Dr. Pepper 9.5 Coca-Cola 9.3 Sprite 9.0
Sugars in beverages Beverage: Sugar (in teaspoons): Powerade (32 oz.) 15 Sunny Delight 9 Gatorade 8 Capri Sun 6 Apple Juice (12 oz.) 10
High Risk Eating Patterns Eating Pattern Frequent snacking Two or more times between meals Sticky, retentive snacks, slow dissolving carbohydrates Sequence of eating & time xamples Candy, sippy cup of juice or soft drink, graham crackers, cookies Raisins, dried fruit, fruit rolls, bananas, caramels, jelly beans, peanut butter/jelly sandwich Chewable vitamins at end of meal, food or drink after brushing and before bed
Not Just What You Eat, But How Often Acids produced by bacteria after sugar intake persist for 20 to 40 minutes. Frequency of sugar ingestion is more important than quantity.
Anticipatory Guidance: Do not put the infant to sleep with a bottle or sippy cup or allow frequent and prolonged bottle feedings or use of sippy cups containing beverages high in sugar (e.g., fruit drinks, soda, fruit juice), milk, or formula during the day or at night to prevent sugary fluids from pooling around the teeth, which can increase the infant s risk for tooth decay.
Child s Oral Risk Assessment (beginning at age 2 weeks) Preexisting risk factors Early tooth eruption (<6 months) Overlapping/crowded incisors White spots (none; 1; >1) Plaque (none; present on anterior front teeth) Gingivitis (absent; present) Past caries experience of child Past caries experience of primary caregiver Past caries experience of older siblings Bottle to bed (nap; night) containing sugared liquids Frequent/continual access to bottle/sippy cup containing sugared liquids during day when awake Snacking (none; 1-2 times between meals; >2 times between meals)
Oral Screening Identify abnormalities and refer children with suspicious findings (false positives are OK) No different from other screenings done as part of well-child care Oral health screening/risk assessment checklist (handout) Risk assessment questions can guide caregiver education
How to Position the Child Place the child in knee-to-knee position or whatever works best
Screaming Child/ Tired Clinician Recommendation Reality Position the child in the caregiver's lap facing the caregiver. Sit with knees touching the knees of caregiver. Lower the child's head onto your lap. Lift the lip to inspect the teeth and soft tissue.
What to Look For Presence of plaque Presence of white spots or dental decay Presence of tooth defects (enamel) Presence of dental crowding Provide education on brushing and diet during examination.
Lift the Lip!!!! Look for presence of plaque on maxillary central and lateral incisors Run gloved fingernail along gum line of child s incisors
Dental Plaque Dental Plaque contains: Bacteria Food debris Dead mucosal cells Salivary components
White spots (first visual evidence of demineralization) where tooth meets gums of maxillary central and lateral incisors (buccal and lingual aspects)
Decay process advances
Brown Spots - Advancing decay process
Decay process advances
Check for Advanced/Severe Decay (continuous dissolution of the outer enamel surface)
Prevention: Xylitol for Mothers Xylitol gum or mints used 4 times a day may prevent transmission of cariogenic bacteria to infants. Helps reduce the development of dental caries. A sugar that bacteria can t use easily. Resists fermentation by mouth bacteria. Reduces plaque formation. Increases salivary flow to aid in the repair of damaged tooth enamel.
Toothpaste and Children Children ingest substantial amounts of toothpaste because of immature swallowing reflex. Early use of fluoride toothpaste may be associated with increased risk of fluorosis. Once permanent teeth have mineralized (around 6-8 years of age), dental fluorosis is no longer a concern.
Toothbrushing Recommendations < 1 year Clean teeth with soft toothbrush 1 2 years Parent performs brushing 2 6 years Pea-sized amount of fluoride-containing toothpaste 2x/day Parent performs or supervises. Floss close-spaced teeth. > 6 years Brush with fluoridated toothpaste 2x/day. Floss closespaced teeth.
Sources of Fluoride Systemic Water fluoridation Fluoride supplements Topical Fluoride toothpastes Gels, foams, mouthwashes Fluoride varnish
Education Offer anticipatory guidance to caregivers of all children (fluoridated water; proper feeding practices; risk for dental decay; oral hygiene instructions; dental home by age 1) Discuss behavior modifications with caregivers of children identified as high-risk Apply fluoride varnish according to risk status (low not needed; mid 2 times/year; high 4 times/year)
Fluoride: Who is in need? Fluoride supplements should be considered if the water supply does not have adequate fluoridation (naturally (wells); lack of public fluoridation; home reverse osmosis filter; bottled), consider, however, other sources of fluoride Infants younger than six months do not require fluoride supplements Infants six months and older who are breast-fed may have the greatest need for dietary fluoride supplements
Failure to clean the child s teeth 1-2 times/day Inadequate exposure to fluoridated water (reverse osmosis filter); fear of water (dysentery) Nonuse of fluoridated toothpaste (ADA seal of approval) Fluoride supplements Inability to maintain good oral hygiene (dental or orthodontic appliances) Continual exposure to sugar-containing medications (chronic illnesses) Xerostomia (Dry Mouth) (drugs for chronic illness) Pacifier use (caregiver wets with own saliva) Pretasting/prechewing of food (caregiver saliva) Bottle sharing (saliva) Infrequent or no regular dental care Complete AAPD Policy Statement with Caries Risk Assessment Tool available at: http://www.aapd.org/pdf/policycariesriskassessmenttool.pdf
Fluoride Supplement Schedule Fluoride Concentration in Community Drinking Water Age <0.3 ppm 0.3 0.6 ppm >0.6 ppm 0 6 months None None None 6 mo 3 yrs 0.25 mg/day None None 3 yrs 6 yrs 0.50 mg/day 0.25 mg/day None 6 yrs 16 yrs 1.0 mg/day 0.50 mg/day None MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the US (2001): http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.
Fluoride Varnish 5% sodium fluoride or 2.26% fluoride in a viscous resinous base in an alcoholic suspension with flavoring agent (eg, bubble gum) Has not been associated with fluorosis Application does not replace the dental home nor is it equivalent to comprehensive dental care
Facts about Fluoride Varnish Easy to apply protective coating that is painted on the surfaces of teeth. It adheres to the enamel and slowly releases the fluoride in high concentration. Its presence prevents new cavities from forming and helps stop the caries process that may have started (white spots). Because it adheres, there is no concern of child swallowing the product. Can be used on babies' teeth. Minimal chance of ingestion. Protective effect will continue to work for several months.
Facts about Fluoride Varnish Fluoride varnish will have a yellow color to it when it sets up (Vanish Varnish (Omni) is white) Parent can be involved by assisting in holding the child in the knee-to-knee position Children may cry because they do not like to be held down and to have foreign objects in their mouth (however, makes application easier) To prevent being bitten, tongue blades taped together Used off label but so is aspirin and many drugs given to children
Indications Moderate and high risk children without caries Children with white spots Children with caries Generally applied twice per year beginning when teeth erupt Varnish is not a replacement for appropriate diet, regular brushing, indicated systemic fluoride supplements, or routine dental care!
Benefits Can be quickly and easily applied Application does not have to be done by a physician Dry tooth surface facilitates fluoride uptake Sets on contact with moisture Taste is tolerable Can reverse early decay ( white spots ) and slow enamel destruction in active ECC 28
Supplies Microbrush applicators 2 x 2 gauze squares Gloves Disposable mirror (not critical since all surfaces will be painted) Direct light source Toothbrush (optional)
Available Preparations 0.25ml CavityShield unidose 5% NaF (2.26% F) OMNII $1.00 per dose Enamel Pro Varnish Primier $1.60 per dose Duraflor Medicom $1.00 per dose All Solutions Dentsply $1.60 per dose 31
Applying Fluoride Varnish Step One: Drop of varnish in small dish or on gloved hand (multidose tube) or from unit dose container
Applying Fluoride Varnish Visually inspect all the child s teeth and document any white spots and/or cavities for future follow-up Hints Use the knee-to-knee exam Show the toothbrush to prompt opening of the mouth 37
Applying Fluoride Varnish Use gentle downward finger pressure against the labial sulcus on lower incisors to open the child s mouth If child has a lot of plaque present, brush or wipe with gauze
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Applying Fluoride Varnish Apply a thin layer of varnish to all tooth surfaces in dried quadrant. Do not wipe again. Repeat procedure until all quadrants have been varnished
Applying Fluoride Varnish Apply varnish to all the surfaces of the dry teeth Note: The varnish will not adhere if it is applied to wet teeth, but saliva contamination after the application is fine
Applying Fluoride Varnish Once the varnish is applied: It sets quickly You need NOT worry about moisture contamination
Tell the caregiver: The child s teeth will be discolored for 24-48 hours Do not brush the child s teeth for 12-24 hours Avoid giving the child hot, sticky or hard foods for 24 hours Applying Fluoride Varnish
Post Application Information/Instructions The applied fluoride varnish will leave a yellow film on teeth (Vanish Varnish is white); it will gradually disappear over several days The child may drink immediately after the application but should not eat for 2 hours after the application (soft diet only for the day) Do NOT brush the child s teeth until the next morning Have varnish applied based on risk assessment at 3-6 month intervals
Product Safety Following application of varnish on the teeth of four children ages 4, 5, 12, and 14, peak plasma fluoride concentrations of 3.2-6.3 micromoles were found within two hours after application. These levels were comparable with those found after brushing with a fluoridated toothpaste or after ingesting a 1 mg fluoride tablet and were considerably lower than from use of fluoridated gels (Catalanotto, 2002)
The BCA Experience All physicians quickly certified to apply dental varnish by online program Program started July 2009 All children age 6 months and older or at first tooth eruption administered varnish application at well child checks every 6 months up to age 3. (6mo,12mo, 18mo, 24 mo, 30 mo, 36mo) Total varnish application: 1,811 applicatons in 9 months Approx. $25,000 paid to provider from Medicaids
The Bottom Line Early Childhood Caries Can Lead to... Extreme pain Spread of infection Difficulty chewing, poor weight gain Falling off the growth curve Extensive and costly dental treatment Risk of dental decay in adult teeth Crooked bite (malocclusion)
The Bottom,Bottom Line BCA Medical Associates performed approximately 45 Dental Pre-op physicals in the past 12 months. Typically patient travels to Las Cruces or Albuquerque with an overnight stay. ($150.00 approx with travel stipend and hotel stipend). Parent off work for 2-3 days. Inpatient anesthesia and dental surgery costs ranging from $5000-$6000 per patient. (Covered by Medicaid) Total: $237,150.00 Continued dental follow-up and outpatient procedures.
Resources POLICY STATEMENTSAbstractFull TextPDFSection on Pediatric Dentistry and Oral HealthPreventive Oral Health Intervention for PediatriciansPediatrics 2008 122: 1387-1394. POLICY STATEMENTSAbstractFull TextPDFSection on Pediatric DentistryOral Health Risk Assessment Timing and Establishment of the Dental HomePediatrics 2003 111: 1113-1116. National Center for Chronic Disease Prevention and Health Promotion 2008 Synopses of State and Territorial Dental Public Health Programs New Mexico Dental Association The New Mexico Dental Association Web site has been developed with both the member dentist and dental consumer in mind. Complete with dental facts, links, a listing of New Mexico Dentists, Medicaid information, and much more. The Oral Health of Children: A Portrait of States and the Nation-2005 Portraits are based on data from the National Survey of Children's Health; US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau Centers for Disease Control and Prevention Division of Oral Healthhttp://www.cdc.gov/OralHealth/index.htm