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Early Childhood Oral Health:Improving Collaborative Care in

Clinical Practice

Rocio Rocio QuiñonezQuiñonez, DMD, MS, MPHRocio Rocio QuiñonezQuiñonezQuiñonez, DMD, MS, MPH, DMD, MS, MPHUNC Schools of Dentistry and MedicineUNC Schools of Dentistry and Medicine

Vegas, 2017

Objectives

• Trends in early childhood oral health • Rationale and evidence of collaborative care in

early childhood• Opportunities to promote collaborative oral health

care in clinical practice

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Spring 2000

Pediatric Medical Guidelines

2003: American Academy of Pediatrics- Oral health screening in the first year of life.

If high-risk, referral to a dentist.

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2006

New York State Prenatal Oral Health

Guidelines

Caries Progression

Cavity-free smile

Cavities

White spots

Cavities with abscess

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How can we break the cycle of break the cycle of poor oral health?

Early Early interventions are interventions are key…

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Heckman Equation: Heckman Equation: Return to a Unit Dollar Invested

http://heckmanequation.org/content/resource/presenting-heckman-equation

Interprofessional and collaborative systems

approach to care

Institute of MedicineInstitute of Medicine-Institute of Medicine2011

A successful oral health care system:• Include collaborative and

multidisciplinary teams working across the health care system

Two principles to guide its deliberation:1. Oral health is an integral part of

overall health- essential to comprehensive care.

2. Oral health promotion and disease prevention are key

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2011

Changing landscape of Changing landscape of health care delivery

All preventive interventions graded A or B-Fully Covered $

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Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary

tooth eruption (B).

NEW CPT CODE

99188

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Changing landscape

CARE COORDINATION

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Lessons from NC

• 47th in the number of all dentists• 45th in the number of pediatric dentists• 44th in dentists’ participation in Medicaid• 1st in percent growth in its Hispanic

population between 1990 and 2000• had a child born into poverty every 23 minutes

47th in the number of all dentists

1990’s47th in the number of all dentists

1990’s-47th in the number of all dentists47th in the number of all dentists47th in the number of all dentists

1990’s- NC ranked:

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0102030405060708090

100

< 1 yr 1-5 yrs 6-14 yrs 15-20 yrs

Dental Medical

Age

Perc

ent

Percentage of NC Medicaid Recipients Percentage of NC Medicaid Recipients Utilizing Medical and Dental Services Utilizing Medical and Dental Services

in 1998

1999Recommendation #18:

“… develop new service package and payment method to cover early caries screening, education and administration of fluoride varnish provided by physicians and physician extenders to children between the ages of 9 to 36 months.”

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Goals of Into the Mouths of Goals of Into the Mouths of Babes (IMB)

• Increase access to preventive dental services• Reduce the prevalence of ECC• Reduce the burden for treatment on dentists

CONTROVERSY!

Who’s practicing dentistry?

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October 2001

SO…HAS IT WORKED?

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Pediatric practice (N=157)

Family Physician practice (N=153)

Health Department (N=83)

NorthNorth CarolinaCarolina Adoption of OralNorthNorthHealth

CarolinaCarolina Adoption of OralAdoption of OralNorth CarolinaCarolinaHealthHealth Preventive

Adoption of OralAdoption of OralPreventivePreventive Care

Adoption of OralAdoption of OralCareCare Package

November 2005

• Raleigh• Asheville

• Wilmington

*

• Charlotte

* The Family Physician practice in Virginia provides care to NC Medicaid patients.

Annual number of visits with preventive oral health services in NC medical offices: 2000-2014

Source: NC DMA.

45-50% of well-child visits

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Physician Screening & Referral

• Identify disease presence or absence: 93% accuracy

Pierce et al. Pediatrics. 2002;109:E82-2.

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Effect of IMB on Dental CariesEffect of IMB on Dental Caries-Effect of IMB on Dental Caries-related Effect of IMB on Dental CariesTreatments per 1,000 Medicaid

Effect of IMB on Dental CariesTreatments per 1,000 MedicaidTreatments per 1,000 Medicaid-

Effect of IMB on Dental CariesEffect of IMB on Dental CariesEffect of IMB on Dental Caries related related related Effect of IMB on Dental CariesEffect of IMB on Dental CariesTreatments per 1,000 MedicaidTreatments per 1,000 Medicaid--enrolled ChildrenNumber of IMB Visits

Age in Monthsat IMB Visit

Change inCRTs (95% CI)

% Change

1234

>4

1212, 2412, 15, 1812, 18, 24, 3512, 15, 18, 24, 35

-7 (-85, 84)19 (-82, 124)49 (-88, 163)

-281 (-469, -58)-458 (-623, -204)

-0.3%0.7%2.9%

-10.9%-17.7%

Number of children with 0 IMB visits = 194,730.Number of children with 1 IMB visit = 55,561.Number of children with 2 IMB visits = 37,353.Number of children with 3 IMB visits = 21,353.Number of children with >4 IMB visits = 13,424.Number of children with 5 or 6 IMB visits = 4,327.Confidence intervals generated based on 200 bootstrap iterations.

Impact of IMB on Oral Health Status Impact of IMB on Oral Health Status Kindergarten Students, NC

Kranz AM, Preisser JS, Rozier RG. Effects of Physician-Based Preventive Oral Health Services on Dental Caries. Pediatrics 2015;136(1):107-14.

• 4+ medical visits was associated with better overall oral health than 0 visits.

• No significant reduction on amount of untreated caries.

N=29,173

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Successes and Opportunities• Into the Mouth of Babes has been very successful

• >1000 providers trained• Increased access by 30-fold• More than 140,000 visits per year• Reduction in caries-related treatment needs

But…

Quinonez RB, Kranz A, Lewis CW, Barone L, Boulter S, O’Connor KG, Keels MA. Oral health opinions and practices of pediatricians: Updated results from a national survey. Acad Pediatr. 2014;14(6):616-23.

CHALLENGESCHALLENGESREFERRING TO A REFERRING TO A

DENTAL HOME

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GD willingness to accept a pediatrician’s GD willingness to accept a pediatrician’s

referral of an 18 month old…

Low-risk: No caries

High-risk: WSL

High risk: Cavitation

Long M, Quinonez RB, Rozier RG, Kranz A, Lee JY. Barriers to Pediatrician’s Adherence to AAP Oral Health Referral Guidelines: NC General Dentists’ Opinions. Pediatr Dent. 2014:36.

NC General Dentists Acceptance of NC General Dentists Acceptance of Pediatrician Referrals (N=423)

0%

10%

20%

30%

40%

50%

60%

70%

80%

Low Risk & No caries High Risk & WSL High Risk & Cavitation

75%

35%44%

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COMFORT

•Train future dental workforce•Improve access to care

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www.babyoralhealthprogram.org

2013

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Tablet Friendly

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bOHPReport Card

Clinical Exam

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bOHP business card

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Promoting Promoting bOHP

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• Lunch and Learn/Staff Meeting

Training Videos (2)“Provider Training” Role Play

“Caregiver Interview”

Talking points“Resources”

Review website

www.prenataloralhealth.org

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www.prenataloralhealth.org

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www.prenataloralhealth.org

Prenatal Oral Health

Infant Oral Health

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Prenatal Messages

Oral and Systemic Health

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3 min videos for moms

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Initiatives in North Carolina

2000 -Into the Mouths of Babes

2006 - 09Carolina Dental Home

2009 -PORRT Initiative

2010 -Connectingthe Docs

2009 -ZOE

•Educate teachers in oral health and communication

•Link families with providers

•Evaluate how it works

1Business Assessment &

Enhancement Plan 2Practice/FinancialEfficiency

&Clinic Flow 3Baby and Prenatal

Oral Health

Phase 1

1 2 3Implement Changes Using Quality Improvement

Phase 2

Pilot: Federally Qualified Community Health Centers

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Coordinated Coordinated Care

How Can We Work Hand in Hand?

New CDT 2017 codes

• Consultation with medical professional

• Dental Case Management- Care coordination- Addressing appointment compliance barrier- Motivational interviewing- Patient education to improve oral health literacy

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Dental VisitN=141 (35.6%)

ReferredN=396 (32.9%)

No Dental VisitN=255 (64.4%)

Dental VisitN=97 (12.0%)

Not referredN=808 (67.1%)

No Dental VisitN=711 (88.0%)

ECCECCN=1,204 (4.9%)

(Total N = 24,403)

Effectiveness of Physicians’ Effectiveness of Physicians’

Dental Effectiveness of Physicians’

Dental Dental REffectiveness of Physicians’ Effectiveness of Physicians’ Effectiveness of Physicians’

RRRReferrals

0-36 m oldsB

ED

TIM

E R

OU

TIN

ES

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Body Mass Index

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Electronic Health Record

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FDA and General Anesthesia

•• 31% of day surgery for preschoolers•

31% of day surgery for preschoolers31% of day surgery for preschoolers31% of day surgery for preschoolers••• 19,000 surgeries per year

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RESOURCES

American Academy of Pediatrics

http://www2.aap.org/oralhealth/COHA.html

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• Era of health care transformation• Important time for our profession to help define

the role of dentistry in this transformation

• Don’t stop balls that are already rolling

Be a steward of change!

Summary

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ThankThank-Thank-you!