Pediatric Oral Health Disclosure 11/27/2013

11/27/2013
Disclosure
Pediatric Oral Health
No relevant financial relationships with
manufacturers of any commercial
products to be discussed
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Do intend to discuss an unapproved use
of a commercial product
„
Melinda B. Clark MD, FAAP
Women and Children’s Hospital, 2013
Goals and Objectives
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Why Oral Health?
Emphasize the impact of oral health on the overall wellbeing of children
Explain the infectious and transmissible nature of early
childhood caries (ECC) and consequences of untreated
caries.
List risk factors for ECC and prevention methods.
Review the AAP Oral Health Guidelines and
recommendations for anticipatory guidance and referral.
Discuss factors that may impede a child’s access to
dental care
Review oral health resources available to primary care
providers
Discuss integration of oral health prevention into the
medical home.
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Surgeon General’s report on oral health
“Silent Epidemic”
Prevalence: most common unmet health need
Effects of oral disease on health
Access to care
Cost
Oral health disease is largely preventable
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Oral health in America. A Report of the Surgeon General; 2000.
The Big Picture
Why Us?
“You are not healthyy without
good oral health…”
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Prevention is the focus of primary care
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Medical care is frequent in early childhood
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ECC is a “family problem”
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Oral health links to systemic disease
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David Satcher, Surgeon General 2000
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ECC is a preventable disease
10 visits by 2 years
Behavior, diet, culture, socioeconomic, environment
Pregnancy, diabetes, heart disease
Dental community is overloaded and decreasing in
capacity
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Only 3% of practicing dentists are pediatric dentists
25% of poor children do not see a dentist by age 5
5
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Why is this so important?
50 million Americans live in rural or poor areas
where dentists do not practice
„ Only
y 43% of elderlyy visit the dentist
„ 25% of poor children do not see a dentist by
age 5
„ Only 34% of pregnant women visit the dentist
„ Preventable dental conditions were the primary
reason for 830,590 ED visits (2009)
The Medical Home is often the Dental Home!
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The Disconnect
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Children are 2.5 times more likely to
lack dental coverage than medical
coverage
> 50% of primary care providers have
little or no oral health training
Little communication and cooperation
between medical and dental providers
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Medical Prevention Paradigm
Repair
&
Rehab
Di
Disease
Suppression
Anticipatory
A
ti i t
Guidance
Primary
Prevention
Pediatric community response
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Bright Futures
AAP Top 3 pillars 2007
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“Into the Mouths of Babes”
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Oral Health Initiative
North Carolina, statewide Medicaid program
initiated in 2000
Practice Guidelines
Training programs
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AMERICAN ACADEMY OF PEDIATRICS
Since 2000
POLICY STATEMENT
Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children
Section on Pediatric Dentistry
2001
American Academy of Pediatrics: Section on Oral Health
2003
Society of Teachers in Family Medicine: Smiles for Life
2003
AAP Policy statement Oral Health Risk Assessment Timing and Establishment of the Dental Home
2006
NY DPH: Oral Health During Pregnancy and Early Childhood
2008
AAP Policy Statement: Preventive Oral Health Intervention for Pediatricians
2009
American Dental Association: Access to Care Summit
2010
Dept. of Health and Human Services: Oral Health Initiative
2010
Physician Assistants Leadership Summit on Oral Health
2011
Healthy People 2020: Oral Health = Leading Health Indicators
2011
Institute of Medicine and Health Resources & Service Admin HRSA: Advancing Oral Health in America
2011
IOM: Improving Access to Oral Health Care for Vulnerable and Underserved Populations
2011
Assn. of American Medical Colleges: Oral health curricula
2012
Physician Assistant Education Association’s (PAEA) Annual Forum– focus was oral health
2012
Oral Health Care During Pregnancy Expert Workgroup: A National Consensus Statement. 2012.
Summary of an Expert Workgroup Meeting, National Maternal and Child Oral Health Resource Center.
Oral Health Risk Assessment Timing and
Establishment of the Dental Home
ABSTRACT. E
ABSTRACT
Early
l childhood
hildh d dental
d t l caries
i has
h been
b
reported
t d by
b the
th Centers
C t
for
f Disease
Di
Control
C t l and
d
Prevention to be perhaps the most prevalent infectious disease of our nation’s children. Early
childhood dental caries occurs in all racial and socioeconomic groups; however, it tends to be
more prevalent in low-income children, in whom it occurs in epidemic proportions. Dental caries
results from an overgrowth of specific organisms that are a part of normally occurring human
flora. Human dental flora is site specific, and an infant is not colonized until the eruption of the
primary dentition at approximately 6 to 30 months of age. The most likely source of inoculation
of an infant’s dental flora is the mother or another intimate care provider, through shared
utensils, etc. Decreasing the level of cariogenic organisms in the mother’s dental flora at the
time of colonization can significantly impact the child’s predisposition to caries. To prevent
caries in children, high-risk individuals must be identified at an early age (preferably high-risk
mothers during prenatal care), and aggressive strategies should be adopted, including
anticipatory guidance, behavior modifications oral hygiene and feeding practices), and
establishment of a dental home by 1 year of age for children deemed at risk.
Pediatrics; Vol. 111 (5), 1113-1116; May 2003.
Routine Visits
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Oral Health Risk Assessment
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AAP policy 2003: “Every child should begin to receive
oral health risk assessments by 6 months of age...”
Anticipatory guidance - diet, hygiene
Referral to a dental home
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Improve access
High-risk infants should be referred for establishment
of a dental home no later than 6 months after the
first tooth erupts or by 12 months of age
“Ideal approach” to early childhood caries (ECC)
prevention is early establishment of a dental home
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~ 50% of 5-9 year olds
78% of 17 year-olds
85% of adults
Most common chronic disease of
childhood
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Insufficient # of dentists
Age of patient: <3 years
No insurance
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Patient and Family Concerns
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Cost
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Caries rates
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Access concerns:
Motivation, priorities, transportation
Early referral decreases dental
expenditures per child
NYS Dental Foundation
Community health workers and
case managers
Early Childhood Caries (ECC)
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5x more common than asthma
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Affects children under age 5
Destroys tooth structure
Infectious and transmissible
Previously called “Baby Bottle Tooth
Decay” or “Nursing Caries”
Affected by oral and dietary habits
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Epidemic of ECC
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ECC Prevalence
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Pathogenesis of Caries
~ 25% of all U.S. children
30-50% of children in low income pop
p p
~70% in some Hispanic and Native American
populations
Teeth
Bacteria
Caries
Time
80% of decay occurs in 20% of children
Carbohydrate
Bacteria
Teeth
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Pathogens
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S. mutans primary
S. sobrinus, Lactobacillus, Actinomyces
Streptococci mutans is vertically
transmitted from the primary caregiver
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Usually mother (71%)
Just a spoonful of Sugar…
How often sugar
is ingested
g
is
more important
than how much
sugar is ingested
at once.
• Enamel demineralizes and remineralizes
• Acids produced by oral bacteria persist for 20-40 minutes
• Frequent sugar intake allows demineralization to
predominate
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ECC Risk Factors
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SES and cultural factors
Enamel defects
Caries in child, siblings or caretakers
Feeding habits:
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ECC
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Frequent feeding and snacks
Prolonged exposure to sugary beverages
Coating pacifiers with sweeteners
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Decreased saliva production
GERD: Increases enamel erosion
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ECC stages
Consequences of ECC
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PREVENTION
Upper incisors
First molars
„ Second molars
ECC rarely affects lower incisors
Canines less affected
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Poor oral hygiene
Inadequate fluoride
Chronic medical conditions and/or medications
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ECC can begin when teeth
first erupt
Affects teeth that erupt first
and are least protected by
saliva
Pain
Difficulty sleeping
Tooth loss
Impaired chewing
and nutrition
Below average
weight gain
Infection
Poor self esteem
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School/work absences:
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Future dental work
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51 million school hours
per year
Missed learning
opportunities
Pain and $$$
Increased caries in
permanent dentition
Prevention of ECC
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Tooth brushing
Dietary counseling
Delay Colonization
Dental sealants
Fluoride
Professional consultation/referral
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Brushing
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Brush twice daily; bedtime most
critical
Brush all surfaces:
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Brushing
Lift the lip to brush the gumline
Brush behind the teeth
Caregiver should brush child’s
teeth until age 6 or 7
Spit, don’t rinse
No food or drink after brushing
Floss: 1x/day once teeth touch
Prevention of ECC
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Tooth brushing
Dietary counseling
Delay Colonization
Dental sealants
Fluoride
Professional consultation/referral
Prevention of ECC
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Tooth brushing
Dietary counseling
Delay Colonization
Dental sealants
Fluoride
Professional
consultation/referral
Dietary Counseling
Eating Pattern
Examples
Candy, sipping juice or soft
Frequent snacking: >2 times drink, graham crackers,
between meals
pretzels, breakfast cereals
Sticky snacks, slowly
dissolving carbohydrates
Raisins, dried fruits, fruit
rolls, caramels, candies,
peanut butter/jelly sandwich
Time of day eating occurs
Juice or milk before bed
Fluoride
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Systemic and topical mechanisms
of action
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T i l effect
Topical
ff t mostt iimportant
t t
Inhibits demineralization
Enhances remineralization*
Inhibits bacterial metabolism
Decreases bacterial acid production
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Fluoride Sources
Community Water Fluoridation
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Community water fluoridation
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Initial caries reduction ((1945-78):
) 40-60%
Modified reduction (1970-80’s): 15-40%
Systemic supplements
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Toothpaste
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Topical: Rinses, varnish, gels
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Optimal fluoridation of water is 0.7 ppm
Determine your patient’s source of water
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Fluoride is added to some community water
supplies
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NY Fluoridation
Health Department
Town Water Board
http://apps.nccd.cdc.gov/MWF/Index.asp
Well water must be tested
Consider filters and bottled water
Fluoride Sources
Fluoridation
Percentage
0-24
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Community water fluoridation
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Systemic supplements
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25-49
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50-74
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75-100
Allow tablet to slowly dissolve (30 sec)
Mixed data supporting supplementation
Toothpaste
Topical: Rinses, varnish, gels
>100
http://apps.nccd.cdc.gov/MWF/Index.asp
Fluoride Sources
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Community water fluoridation
Systemic supplements
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Fluoridated Toothpaste
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Topical: Rinses, varnishes, gels
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Eff ti
Effective,
iinexpensive,
i
high
hi h compliance
li
Mouthrinses: 10 mL for 60 seconds
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0.05% sodium fluoride for daily home use (OTC)
0.2% for weekly use (prescription, public programs)
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Not for children less than 6 years of age
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Gels, foams
Varnish
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Dental Update: Fluoride Varnish Applications
Covered for Children up to Seven Years of Age
• October 1, 2009
• Maximum of four (4) annual fluoride varnish
applications covered for children from birth until
7y
years of age
g
• Physicians, Dentists, and Nurse Practitioners
treating Medicaid fee-for-service beneficiaries
will be reimbursed up to $30.00 per application.
• Procedure code "D1206" should be used by all
Provider types
• www.health.state.ny.us/health_care/medicaid/p
rogram/update/2009/2009-09.htm#den
Fluoride Varnish
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Topical 5% sodium fluoride lacquer professionally applied
on any erupted tooth; 2.5-5 mg dose
Resin slowly releases fluoride over 1 to 7 days (versus
10-15
10
15 minutes for gels/foams)
Helps prevent new cavities from forming and slows
progression of carious lesions in the primary teeth
Over 110 studies and 40 clinical trials have documented
effectiveness
No clinical trials completed in the United States; so the
FDA has not yet approved fluoride varnish for caries
prevention (is FDA approved as a cavity liner, root
desensitizer)
Fluoride Varnish
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Strengthens teeth and reduces decay an average
of 40%
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Slows progression of shallow carious lesions in
the primary teeth
Can be used on any erupted tooth
Safety
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No acute toxic effects
Plasma levels
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Small rise in plasma fluoride levels
Comparable to ingesting a 1 mg fluoride tablet or
brushing with a fluoridated dentifrice
Use sparingly to prevent children from swallowing
excess product during application
Contraindications:
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Ulcerative gingivitis/stomatitis, open lesions
Allergy to colophony/rosin*
Allergy to pine or pine nuts*
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3 cases in literature: 1 contact dermatitis and 2 stomatitis
Caries reduction range
g 30-63.2%
Dose responsive, effectiveness enhanced by counseling
Greatest effect when applied before onset of
detectable caries
What does this entail?
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Oral Health Risk Assessment
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AAP policy 2003: “Every child should begin to
receive oral health risk assessments byy 6
months of age...”
Anticipatory guidance
Fluoride Varnish if high risk
Referral to a dental home
Document
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High Risk
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MCHB Expert Panel, 2007
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Low-income children
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Qualify for Head Start,
Start WIC,
WIC National School
Lunch Program, Medicaid, SCHIP
Children with Special Health Care Needs
CAT
AAP Risk Groups
AAP Risk Assessment Tool
Risk Groups for Dental Caries
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Children with special
health care needs
Children of mothers
(caretakers) with high
caries rate
Later-order offspring
Children in families of
low socioeconomic
status
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Children who sleep
with a bottle or
breastfeed
throughout the night
Children with
demonstrable caries,
demineralization,
plaque, or staining
Rapid Checklist
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Parent factors:
□ Caregiver’s oral heath
□ Does pt have a dental
home?
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Action:
□ Education
□ Referral to a dental
home
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Child factors:
Caries
White spots
Plaque
Swollen gums
Night feedings
Frequent snacking/juice
drinking
□ Medicaid eligible
□ Special health care need
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□
□
□
□
□
White “incipient” lesions
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Routine Visits
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Oral Health Risk Assessment
Anticipatory guidance - diet, hygiene
Fluoride Varnish ((if high
g risk))
Referral to a dental home
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Barriers
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Time
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Disinterest
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Fast
Important: Most common chronic disease
Immediate and future impact of neglect
Obesity message and caries nutrition messages parallel
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Not getting paid
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Will it matter?
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Bright Futures, AAP
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Start billing
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Burden of disease and relative impact of interventions
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Discuss oral health early and often
Discuss the bacteria, not just the hygiene
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Address the “baby teeth don’t matter” myth
Shift blame to something evil we can target
Healthy eating
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Analogy to stopping abx course early
Just a matter of “slime + time”
Choose foods that look like something found in nature
Concentrate on a single change each visit
V07.31 (prophylactic fluoride administration)
521.00 (dental caries)
Moving Beyond “Our Offices”
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Cannot just treat holes, infection still present
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OH assessment, anticipatory guidance, and
fluoride varnish application
Rate: $30 per application
4 times/year birth to age 7
High-risk children
Did not specify provider education required,
prior approval NOT required.
Code: D1206 with V modifier
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Families do not want to hear it - messaging
Messages
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Document
Billing
Someone else’s job
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High-risk infants should be referred for establishment
of a dental home no later than 6 months after the
first tooth erupts or 12 months of age
“Ideal approach” to ECC prevention is early
establishment of a dental home
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Medical and dental sitting on Head Start,
WIC, school health committees
W k together
Work
t
th on water
t fl
fluoridation
id ti
campaigns
State Task Force; State Oral Health Plans
Teaching oral health through media
messages, social marketing
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Work synergistically
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Support cross pollination of ideas:
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Dental supporting fluoride varnish done by
p
medical providers
Medical supporting dental doing oral cancer
screens, blood pressure monitoring, nutrition
advice
More inter-professional health in
schools/residencies
Resources
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AAP Children’s Oral Health Home: www2.aap.org
Protecting All Children’s Teeth (PACT)
www.aap.org/commpeds/dochs/oralhealth/pact.cfm
Fluoride Information on the American Dental Association website:
www ada org/public/topics/fluoride/index asp#overview
www.ada.org/public/topics/fluoride/index.asp#overview
Community water fluoridation info available at:
http://apps.nccd.cdc.gov/MWF/Index.asp
National Maternal and Child Oral Health Resource Center:
www.mchoralhealth.org
A Health Professional’s Guide to Pediatric Oral Health Management:
www.mchoralhealth.org/PediatricOH/index.htm
Smiles for Life. A National Oral Health Curriculum for Family
Medicine: www.smilesforlifeoralhealth.org
Bright Futures in Practice: Oral Health Pocket Guide; Casamassimo
and Holt (eds); 2004
13 chapters, 11 CME credits
www.aap.org/commpeds/dochs/oralhealth/pact.cfm
Third Edition
Questions?
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References
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6.
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8.
US Department of Health and Human Services. Oral health in America. A Report of
the Surgeon General. Rockville MD: US Department of Health and Human Services,
National Institute of Dental and Craniofacial Research, National Institutes of Health;
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Krol DM. Educating Pediatricians on Children’s Oral Health: Past, Present, and
Future. Pediatrics. 2004; 113(5): e487-93.
Lewis CW et al. The role of the pediatrician in the oral health of children: A national
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Douglas AB et al. Smiles for Life. A National Oral Health Curriculum for Family
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Seow WK. Enamel hypoplasia in the primary dentition: a review. ASDC J Dent
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Lai PY et al. Enamel hypoplasia and dental caries in VLBW children: a casecontrolled, longitudinal study. Pediatr Dent. 1997; 19(1): 42-9.
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Brambilla E et al. Caries prevention during pregnancy: results of a 30-month
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Horowitz HS et al. Combined fluoride, school-based program in a fluoride
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Schneider, K and Segal G. Dental Abscess. E-Medicine, www.emedicine.com - updated 3/2006.
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Savage MF et al. Early preventive dental visits: effects on subsequent utilization
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Soderling E at al
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Topical Fluoride Recommendations for High-Risk Children: Development of Decision
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Cantrell C, Engaging Primary Care Medical Providers in Children’s Oral Health.
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Distribution of Dentists in the united States by Region and State. ADA, 2006.
Association of state and territorial dental directors fluorides committee. Fluoride
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Kumar JV, Green EL, et al. Trends in dental fluorosis and dental caries prevalence in
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Huston J, Wood AJ. Sharing Early Preventive Oral Health With Medical Colleagues: A
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