Dental Early Intervention in North Carolina

Rebecca King, DDS, MPHChief, Oral Health Section

NC Division of Public Health, DHHS919-707-5487

Rebecca.King@ncmail.net

Turn of the Century

• 1910 -- Dr. RM Squires:

function ... prevent rather than cure

• 1918 – NC Dental Society gets legislative funding– Reduce pain and infection

– Educate on importance of oral health

Oral Health Section Staff

• 6 Public health dentists• 58 Public health dental hygienists• 3 Health educators• 3 Equipment technicians• Support staff

GASTONCHEROKEE

SWAIN

MACON

GRAHAM

CLAY

JACK-SON

HAY-WOOD

HENDER-SONTRAN-

SYLVANIAPOLK

RUTHER-FORD

BUN-COMBE

YAN-CEYMADISON

MITCHELLAVERY

CLEVE-LAND

LINCOLN

CATAWBABURKE

MECKLEN-BURG

UNION

CABARRUS

ROWAN

IREDELL

STANLY

DAVID-SON

MONT-GOMERY

RANDOLPH

MOORE

ANSONRICH-MOND

HOKE

CHATHAM

LEE

HARNETT

CUMBER-LAND

ROBESON

SCOT-LAND

BLADEN

SAMPSON

COLUMBUS

BRUNSWICK

NEWHANOVER

PENDER

ALA-MANCE

ORANGE

DURHAM

CASWELLPERSON GRAN-

VILLE

VANCEWARREN

FRANKLIN

WAKE

NASH

JOHNSTON

WAYNE

DUPLIN

GREENE

LENOIR

PITT

JONES

ONSLOW CARTERET

PAM-LICO

BEAU-FORT

CRAVEN

HYDE

DARETYRRELLWASH-INGTON

BERTIE

MARTIN

HERT-FORD PASQUO-

TANKCHO-WAN

CAM-DEN

PER-QUIMANS

CURRITUCKNORTH-AMPTON

GATES

HALIFAX

EDGE-COMBE

ROCKING-HAM

STOKESSURRY

FORSYTHGUILFORD

YADKIN

DAVIE

ASHE

WATAUGA WILKES

ALLE-GHANY

CALDWELL ALEX-ANDER

MCDOWELLWILSON

Central 10 Hygienists

4 Local Hygienists

22 Counties

Western21 Hygienists

1 Field Dentist

2 Local Hygienists

40 Counties

Oral Health Section Regions and Staff Assignments

Eastern 19 Hygienists

1 Field Dentist

1 Local Hygienist

38 Counties

Hygienists

Field Dentists

Supervisors

Local Hygienists Under State Supervision

Revised 9/05

Program Components

• Dental disease prevention

• Oral health assessment

• Dental health education and promotion

• Access to dental care

• Dental public health residency

Dental Disease

Prevention

Water fluoridation Preschool dental

preventive programs Dental sealants Fluoride mouthrinse

11

Water Fluoridation

NC: 85% on municipal water supplies receive the benefits of

water fluoridation

Preschool Dental Preventive Programs

Much more later.

Dental Sealants

• Statewide goal is 50% - a top OHS priority

• OHS target populationK-3 high-risk children15,000 per year

• Fifth graders with sealants increased from 28% (1996) to 44% (2006)

Fluoride Mouthrinse

• School-based program from mid-1970s to 2002

• Increasingly targeted in early 1990s

• Discontinued due to budget cuts and lack of recent data

Fluoride Mouthrinse Resurgence

• Survey data showed decreased disparities

• Obtained expansion budget funding in 2006

• Targeting schools with highest decay rates who promise compliance

• Plan to begin rinsing in January 2007

Oral Health Assessment

Statewide dental surveys

Oral health surveillance

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Statewide Dental Surveys

Provide evidence base for program:

• Early 1960s

• 1976-1977

• 1986-1987

• 2003-2004

2003-2004 Statewide Dental Survey

• Sample: 8000 children K-12• Study how well NC decay prevention

programs are reducing decay• Measure

DisparitiesParents’ knowledge and opinionsHow dental health affects quality of life

• Results used for Section strategic planning

Select Survey Findings

• Rates of decay in preschoolers have deteriorated slightly.

• Past improvements in decay rates in permanent teeth have leveled off.

• Whites (19%) are least likely to have untreated decay, followed by blacks (30%), then “Others” (mostly Latinos) (38%).

• Not including early decay (non-cavitated lesions) underestimates disease levels by 35-40%.

• 40% do not think baby teeth are important.

Trends in Untreated Decay in Permanent Teeth

30

19

35

77

92

15

60

34

0102030405060708090

100

1960-62 1976-77 1986-87 2003-04

BlacksWhites

Percent

YearNC OHS Statewide Dental Survey Data

Oral Health Surveillance

Calibrated dental assessments By PH RDHsGrades K and 5

• County oral health status data

• Referral for treatment needs

Surveillance Results

• 21% K, 5% fifth graders have untreated decay

• Proportion of kindergartners who have had tooth decay has increasing, maybe leveling off

• Proportion of fifth graders who have had tooth decay is low but fluctuating

• Fifth graders with sealants increased from 28% to 44% (1996-97 to 2005-06)

Dental Health Education

School-based education and

Community outreach Professional education Educational materials

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School-based Education

• 176,000 children thru classroom education

• 16,600 AdultsParent educationTeacher support

• Also health professionals

Exhibit Promotions

Aging, consumerism, diabetes, careers, sealants, early childhood caries, fluorides, oral hygiene, nutrition, tobacco, injury prevention, OHS program

Access to Dental Care

Referral/follow-up for care Improved access for low-

income families “Under direction” activities

44

Oral Health Surveillance

• Referral for treatment needs>129,000 K,5 screenedIdentified >28,400 in need of dental

careHelped get dental care for 10,800

• Additional 67,800 screened for sealants, GKAS! and at request of school nurses

Improved Access

• 1999 NC IOM Task Force on Dental Care Access had 23 recommendations, e.g. Increased fees for Dental Medicaid servicesFunding for physician-based dental preventive services “Under Direction”Medicaid Dental Advisory Committee (PAG)Licensure by credentials

• 2005 NC Oral Health Summit – latest update and new action steps

2006 Give Kids a Smile!

• NC Dental Society initiative to provide free dental care for underprivileged children

• To date:– 7000 volunteers– 54,000 children served– > $4 million free care

• OHS PH Dental Hygienists screen and coordinate

Local Dental Safety Net Clinics

• OHS provides TA for new clinics

• OHS provides temporary dentist coverage on limited basis

• Number increased dramatically from the early 1990s to 114 fixed, mobile and “free” clinics in 2005

Dental Public Health Residency

Training for dental public health specialists Growth for the Division

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Preschool Dental Prevention Programs in North Carolina

Smart Smiles

An Appalachian Regional Collaborative Partnership to

Improve Dental Health

The Beginning

• Appalachian Regional Consortium/NC Partnership for Children/Smart Start health assessment (fall 1996)

• 1/3 kindergarten children in western part of state had untreated decay

• Primary needreduce early childhood cariesimprove dental health

Motivating Assumptions

• ECC is a serious public health problem

• Its burden can be reduced through prevention targeted to very young, high risk children

• Virtually all infants & toddlers obtain care at medical offices and it is a logical place to provide services

Additional Assumptions

• Physicians and their staff know that ECC is a problem and they are willing to help prevent it

• Primary medical care providers need help to learn procedures and to implement them in their practices

• Innovations must be evaluated for adoption rates, quality of care, clinical effectiveness, costs and political concerns

Fluoride Varnish Safety and Effectiveness

• Safe, easy to use and accepted

• No studies of effectiveness in 1-2-year-olds

• Emerging evidence of effectiveness in primary teeth of older children

• Supported by a larger body of evidence effective in permanent teeth other topical fluoride applications are effective

Partners/Advisory Board

• Local community leaders

• State and regional Smart Start agencies

• NC Oral Health Section

• UNC School of Dentistry

• UNC School of Public Health

• Ruth & Billy Graham Health Center

• Local health departments

• Pediatric offices

Medical Community Preparation

• Worked with licensing boards:medicaldentalnursing

• Sample standing orders

Smart Smiles Preventive Package

• Medical settingtargeted oral health education for caregiversdental screeningfluoride varnish application

• First visit ~ age 9 months

• Repeat every 6 months until age 3

Why Preventive Medical Model?

• This is where young children are• Multiple services at one visit• Most general dentists uncomfortable seeing

children this age• Interest and willingness of medical community• Few pediatric dentists• Treatment is expensive• This was the best idea anyone had

Targets

• Children, 9 - 36 months, high risk for caries.

• Medical risk factors & socioeconomic indicators families 200% Federal Poverty Levelmedically compromised childrenolder siblings with poor oral health

Challenges

• Effectivenessidentifying the high risk childrengetting them in for the service on a regular

schedule

• Financinggrant stipulated that providers provide service

at no cost to patientseconomics was an issue for medical practices

Effectiveness Issues

• Provide services to high risk children80-85% decay in 20-25% children

• Begin prevention before decay begins (~ 9 months)

• Provide services on a regular basis

Finances

Medicaid agreed to reimburse (July 1999)• Medical offices - required training, recognized

Smart Smiles trainers• Six visits between 9 months and age 3 (90 day

interval)• Reimburse for:

dental health education for parent/care-giveoral screening and referral for childfluoride varnish application for child

Smart Smiles Evaluation (8/2001)

• $2.2 million, 5 year grant

• NIDCR, National Institutes for Health

• Effectiveness - does program reduce cavities?Does it work in this setting?Can we provide package frequently enough?

• Data collection completed

Smart Smiles Evaluation Aims

• Short term effects on cavities (dmf scores) in 3-year-old children

• Intermediate effects on cavity-related treatments, Medicaid costs, hospital use, and quality of life

• Longer-term effects on cavities in 5-year-old children after 2-year gap in services

Into The Mouths of Babes

Statewide Medicaid Dental Prevention Program for Young

Children

Goals

• Increase access to preventive dental care for low-income children

• Reduce the prevalence of ECC in low-income children

• Reduce the burden of treatment needs on a dental care system already stretched beyond its capacity to serve young children

IMB Statewide Pilot

• December 1999

• Pediatricians and family practitioners

• Used Smart Smiles training session and educational materials, modified over time

• Added training on billing procedures

Statewide IMB Progression

• Pilot – volunteer trainers

• June 2000, RFA from HCFA to Medicaid agencies for Innovative ECC programpartners: Medicaid, UNC Schools of Public

Health and Dentistry, NC Pediatric Society, NC Academy of Family Physicians, Oral Health Section

evaluate level of training required for MDs

Dental Support

• Fall 1999 NC Academy of Pediatric Dentistry endorsement

• Spring 2000 NC Dental Society resolution of support

• Fall 2001 NC Academy of Pediatric Dentistry reaffirmed support

Dental Prevention Service Package

• Oral screening and risk assessment

• Referral for dental care

• Caregiver education

• Fluoridesupplementstoothpastetopical fluoride application (varnish)

Oral Screening

• Not intended as a diagnosis

• Done by provider also doing physical exam

• Accuracy for ECC = 90%

• Patients with abnormal findings referred

Oral Screening

Encounter form used to identify risk factors

• Family history

• Dietary practices

• Oral hygiene behaviors

• Fluoride exposures

Caregiver Education

• Uses risk assessment to guide emphasislimiting exposures to risk factorsgeneral advice about dental care

• Age-specific handouts provided in English and Spanish

Fluoride Application

• Fluoride varnish is cornerstone• Performed by licensed professionals

MD, PA, NP, RN, LPN

Results: MD Training Evaluation

Amount of Training Required

• Types of training– Traditional CME– Add telephone learning collaboratives– Add on-site assistance

• More was not better

Into the Mouths of Babes2006

• >100,000 visits for dental preventive package

• ~ 425 physician practices, residency programs, local heath departments trained and supported

• OHS position for trainer (2005)• 3-year MCH funding to support training

activities

Number of IMB Visits

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2,000

4,000

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8,000

10,000

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14,000

16,000

18,000

20,000

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Quarter/Year

No

. o

f vi

sits

Follow-up visits

Initial visits

% Health Check Screenings Receiving IMB Services

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15

20

25

30

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40

Q12000

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Quarter/Year

% C

hild

ren

Emerging Data

Dose related response:

• Even one application produces significant caries reduction (Weintraub, UCSF)

• Children with four or more applications before age 3 showed significant caries reductions compared to children with less than four (Rozier, UNC).

Questions on IMB:

Kelly HauptKelly.Haupt@ncmail.net

Early Head Start

• Surveys and focus groups to find needsTeachersParents

• Developing and piloting training materialsExpand the concept that baby teeth are

importantUrge parents to seek early preventive care

HRSA Access to Dental Care Grant

• Carolina Dental Home• ~$120,000/year for three years• Bring folks together to pilot test how to best get

more dental referrals for very young high-risk children

• Collaborators:Local dentists and Pediatric Dentist/s, Family Physicians,

Pediatricians, Medicaid, NC Dental Society, Oral Health Section, UNC Schools of Dentistry and Public Health, community leaders, others

Questions?