1. The Indian Health Service Early Childhood Caries (ECC) Initiative

2. Early Childhood Caries
ECC is defined as the presence of one or more decayed, missing (due to caries), or filled tooth surfaces in any primary tooth in a child under 6 years of age.
We have adopted the definition for ECC from the American Academy of Pediatric Dentistry.
(read slide) Unfortunately, what we see in American Indian and Alaska Native children is usually a severe form of ECC.

3. ECC and AI/AN Children
According to the 1999 IHS Oral Health Survey, 76% of AI/AN children ages 2-5 have experienced dental caries, a prevalence far higher than that of the general U.S. population.

4. Why are Primary Teeth Important?
Eating and nutrition
Talking
Saving space for permanent teeth
Smiling

5. Costs of ECC
ECC can cost thousands of dollars to treat each child, even exceeding $8,000 when a child is hospitalized and treated under general anesthesia.
Traditional dental treatment of ECC is expensive and largely ineffective at reducing the bacteria that cause the disease.
More importantly, these children often experience pain and infection.

6. What is the IHS ECC Initiative?
The IHS Early Childhood Caries Initiative is a new program designed to promote prevention and early intervention of dental caries in young children through an multi-disciplinary approach.
It is both comprehensive (includes prevention and early intervention) and collaborative (multi-disciplinary).
The goal of the ECC Initiative is to increase access for AI/AN children and their families to both preventive and early intervention services by implementing a multi-disciplinary approach.
The ECC Committee was asked to make this Initiative both comprehensive, including both prevention and early intervention services, and collaborative.

7. How is this Initiative any different than ECC initiatives of the past?
It includes the establishment of a national oral health surveillance system to monitor the prevalence of ECC.
It includes a more formal approach at reaching out to multiple community partners.
It involves not just prevention of ECC but also early intervention.
It includes printed materials, online courses, and support at the Area and National levels.
For those of you who have been around for awhile, you may be wondering how this Initiative is different from others in the past?
This initiative includes the establishment of a national oral health surveillance system to monitor the prevalence of ECC.
This initiative involves medical and community partners through a formal structure of training and documentation of services.
This initiative goes beyond primary prevention to include adoption of caries stabilization techniques including Interim Therapeutic Restorations to stabilize caries in the primary dentition.
This initiative has various products including two new online courses and printed resources for dental programs, medical programs, and community partners.
IHS has already met with key staff from the IHS Medical Programs, CHRs, Head Start, and other community partners at the national level. It will be up to dental program staff to meet with their local community partners.

8. ECC Initiative Objectives
Overall Goal: Reduce the prevalence of ECC among 0-5 year old AI/AN children by 25% by FY 2015.
Increase dental access for 0-5 year old AI/AN children by 10% in FY 2010 and 50% by FY 2015.
Increase the number of children 0-5 years old who received a fluoride varnish treatment by 10% in FY 2010 and 25% by FY 2015.
The overall goal of the ECC Initiative is to reduce the prevalence of ECC among AI/AN children. As each Area collects and submits community-based survey data, we will be establishing measurable objectives to reduce ECC.
We have established four measurable objectives to track our progress on the ECC Initiative.
The first objective is to increase dental access for 0-5 year olds, but we need to focus specifically on increasing access for 0-2 year olds. During FY 2008, only 10% of the medical user population ages birth to two years of age received a dental screening or exam. We know that in order to prevent ECC, we must reach children and their families before two years of age.
If we are successful in increasing access for 0-2 year olds, we will easily increase the number of fluoride varnish treatments in this age group. We will be tracking fluoride varnish applied by both dental and medical staff. The goal for 0-2 year olds is to apply four fluoride varnish treatments between the ages of 6-24 months of age.

9. ECC Initiative Objectives
Increase the number of sealants among children 0-5 years old by 10% in FY 2010 and 25% by FY 2015.
Increase the number ITRs provided for children ages 0-5 by 10% in FY 2010 and 50% by FY 2015.
All four objectives will be tracked separately
for 0-2 year olds and 3-5 year olds.
3. The third objective is to increase the use of both resin and glass ionomer sealants on the primary teeth.
The final objective requires a change in the way we think about treating dental caries in the primary dentition. We need the support of the ADOs and DSCs to encourage local dental staff to participate in training opportunities and to provide caries stabilization for young children with the ultimate goal of earlier intervention and less dental treatment under general anesthesia.
The objectives will be tracked using both RPMS data and the Basic Screening Survey. For each objective, we will track the objectives separately for 0-2 year olds and 3-5 year olds to be sure that we are adequately reaching children before they develop ECC.

10. Medical and Public Health Programs
The ECC Team
IHS DOH ECC Initiative
Dental Programs
CHR s
Head Start
Tribal Organizations
WIC
Medical and Public Health Programs
Again, the ECC Initiative was designed to be both comprehensive and collaborative. IHS is already working with our medical and community partners at the national level. IHS will be presenting the ECC Initiative at various national conferences during this coming year.
Once again, it is up to you to collaborate with these partners in your community.
Let me describe the different components of the ECC Initiative.

11. Key Components of the ECC Initiative
Best Practices to prevent ECC
Dental Access for prenatal and 0-5 year olds
Caries Stabilization using fluoride, sealants, and Interim Therapeutic Restorations.
Data Collection: Tracking RPMS data and implementation of the Basic Screening Survey (BSS)
There are four key components of the ECC Initiative: Best Practices, Dental Access, Caries Stabilization, and Data Collection
Best Practices: The ECC Initiative Committee was tasked with producing a document of evidence-based best practices and key oral health messages to prevent ECC. It is vital that dental providers, medical providers, and community partners all share an understanding of the best practices to prevent ECC and that we deliver consistent messages to pregnant women and families across the country.
Dental Access: Best practices are of little use if we don’t improve dental access for pregnant women and children from birth to five years of age. This is why we are bringing in our medical and community partners to assist us in reaching more pregnant women and children.
Caries Stabilization: As our medical and community partners join us, we know that there will be an increase in dental referrals for the first incidence of dental caries in 1-2 year olds. General dentists and their staff need to be prepared to treat these early carious lesions, avoiding lengthy and expensive referrals to pediatric dentists.
Data Collection: Data Collection will be twofold 1) using RPMS data to track our objectives, and 2) collection of BSS community-based data to document and track the prevalence of ECC nation-wide.

12. The ECC Initiative: Products
ECC Initiative Packet
Two Online Courses
How To Apply Fluoride Varnish
Caries Stabilization
ECC Initiative webpage
Now. Let’s look more specifically at the products of the ECC Initiative. (Read slide.)

13. Together we can prevent ECC!!!
ECC Initiative Packet
Together we can prevent ECC!!!
The ECC Initiative packet is one of the products of the ECC Initiative. The packet was distributed to ADOs, DSCs, community partners, and every IHS and Tribal and Urban dental program in the country during March All of the ECC packet materials are also available on the new webpage.

14. Left Side of Packet: Medical & Community Partners
Customized information for medical & community partners
Includes:
ECC Initiative Fact Sheet for Community Partners
Head Start’s Role in ECC Prevention and Early Intervention
The WIC Staff’s Role in ECC Prevention & Early Intervention
The CHR’s Role in ECC Prevention and Early Intervention
The PHN’s Role in ECC Prevention and Early Intervention
The Medical Provider’s Role in ECC Prevention
The Tribal Council’s/Governing Body’s Role in ECC Prevention
Left side of the ECC Packet
On the left side of the ECC Packet, you will find an ECC Fact Sheet and handouts specifically developed for each of our Community Partners.
These handouts will help you work with these partners to define their roles in the prevention of ECC in each community.

15. Right Side of Packet: Dental Team
ECC Initiative Goals & Objectives
Promoting Awareness of Early Childhood Caries (fact sheet)
Key Oral Health Messages and Setting Goals
Who are the key contacts in your community?
Dental Sealants
Interim Therapeutic Restorations
RPMS and Coding Questions on the IHS ECC Initiative
The Basic Screening Survey
Getting Your Community Involved
ECC Initiative Course & Presentation Summaries
ECC Program Planning
You will also find information on Glass Ionomer sealants, Interim Therapeutic Restorations, and coding to better track progress on the ECC Initiative objectives.

16. ECC Initiative Online Courses
How To Apply Fluoride Varnish
Caries Stabilization
Two courses have been developed as part of the ECC Initiative:
1. How To Apply Fluoride Varnish is an online course that was developed in collaboration with the IHS Head Start Program. This course is for medical and community partners who want to provide fluoride varnish. After completing the course, participants must receive a posttest score of 80% in order to print a certificate. The participant must then demonstrate application of fluoride varnish before receiving standing orders. It will be up to local physicians and dentists to oversee these programs.
2. Caries Stabilization is an online course developed to promote the use of resin and glass ionomer sealants on the primary teeth, and glass ionomer restorations on the primary teeth, termed Interim Therapeutic Restorations. Our goal is to increase early intervention techniques to decrease the number of children with severe ECC and to reduce the number of children requiring full-mouth restorative work under general anesthesia.
Both of these courses are available online and also in PowerPoint format with scripts for presentations at conferences, meetings, and via WebEx.

17. http://www.doh.ihs.gov/ecc Models to Improve Dental Access
ECC Packet (download and print)
Links to the online courses
Links to ECC resources and updates on best practices.
ECC Initiative Webpage on the Dental Portal
Each month on the webpage, IHS will highlight a local program that has increased access for 0-5 year olds. We know that there are already some champions who are working hard to improve access for this age group. By highlighting these programs, we hope to encourage other dental programs to develop local ECC programs. Let us know if you have a program in your Area that is already working with community partners, using ITR, or using unique strategies to improve access and prevent ECC.
The ECC webpage will have all of the materials in the ECC packet in formats you can download and print.
It will also include links to the online courses, links to ECC resources, and updates on best practices.

18. Best Practices during Pregnancy
Educate mother about ways to prevent ECC.
Support breastfeeding. Discourage tobacco use.
Provide an oral exam, periodontal disease screening, prophylaxis, and recommendations for completing dental treatment, caries control, and appropriate recall.
Assess caries risk and prescribe
anti-bacterials like chlorhexidine or
xylitol for high-risk mothers after the
baby is born.
Let’s look closer at the best practices that we will be supporting. The best practices are outlined in greater detail in the ECC Packet.
This is an overview of the best practices during pregnancy. You will need to rely on your medical and community partners to deliver key oral health messages and refer pregnant women to the dental clinic.

19. Best Practices 0-2 year olds
Oral health assessment soon after
the first tooth erupts.
Fluoride varnish treatments 4 or
more times during the period from
9-24 months of age.
Brush twice daily with a small smear of fluoride toothpaste beginning when the first tooth erupts.
Consider sealants and caries stabilization with GI as appropriate.
For 0-2 year olds, each community will need to work with their medical and community partners to provide oral health assessments, fluoride varnish treatments, and education.
The dental programs will likely be called upon to provide fluoride varnish for these programs.
This recommendation is based on the work of Dr. Steve Holve, a pediatrician in Tuba City, who published his research documenting that children who received 4 or more fluoride varnish treatments during well-child visits between the ages of 9-24 months of age had a 35% reduction in decayed surfaces. This is published in the IHS Primary Care Provider, October 2006.
We are strongly promoting the use of fluoride toothpaste beginning with eruption of the first primary teeth. We know that it is difficult to motivate families to brush their children’s teeth, but we are convinced that if they did this, beginning with eruption of the first teeth, it would make a difference.
We also recommend caries stabilization with glass ionomer sealants and interim therapeutic restorations as appropriate.
While we recognize that there are various chemotherapeutics currently being tested with young children, including iodine and chlorhexidine, they are lacking the clinical trials to make them best practices at this time. We are, however, encouraging local dental programs to participate in pilot-testing of these products.

20. Best Practices 3-5 year olds
Yearly dental exam.
Fluoride varnish treatments 3-4 times a year.
Brush twice daily with a pea-size dab of fluoride toothpaste.
We also recommend caries stabilization with GI sealants and restorations as appropriate.
These are the best practices for 3-5 year olds.
Head Start
For children in Head Start, we encourage you to explore new models to deliver exams, fluoride varnish, and dental treatment. One viable model is to provide caries stabilization using ITRs for as many children as possible and referring only those children who have the most extensive dental treatment needs to pediatric dentists. Currently, many Head Start children never receive dental treatment. Using caries stabilization, we can deliver more dental treatment to the population of Head Start children.

21. Caries Stabilization Glass Ionomer Sealants
Glass ionomer sealants are recommended in situations where moisture control cannot be achieved.
Endorsed by the Indian Health Service Division of Oral Health
Let’s take a closer look at the use of GI sealants and Interim Therapeutic Restorations since these will require the greatest change in the way we currently provide dental services for young children.
Keep in mind that it is almost always better to do something than to do nothing at all, because we know that dental caries, left untreated, almost always progresses
Resin sealants are stronger and therefore, a resin sealant should be placed if a dry field can be maintained. Glass Ionomer Sealants are endorsed by the IHS Division of Oral Health only when moisture control cannot be achieved and a resin sealant is not feasible. GI sealants are particularly useful in the primary dentition on young children. The steps for GI sealant placement are similar to the technique for placing Interim Therapeutic Restorations. This is outlined in detail in the ECC Initiative packets and is also covered in the course on Caries Stabilization.
GI sealants should be coded 1351 until they are into the dentin.
Children with GI sealants benefit from frequent recall appointments; however children for whom follow-up cannot be ensured should still receive GI sealants. .

22. Caries Stabilization Interim Therapeutic Restorations (ITR)
Prevent the progression of caries.
Reduce the levels of cariogenic bacteria.
Follow-up care including OHI, fluoride toothpaste, and the use of fluoride varnishes may improve the treatment outcome.
ITRs are endorsed by the AAPD and the IHS, DOH
Previously called ART and often referred to as a “scoop and fill” technique, the new name for these fluoride-releasing glass ionomer restorations is Interim Therapeutic Restorations or ITR. The full procedure for ITRs is covered in the new online course on Caries Stabilization and the steps are outlined in detail in the ECC Packet. We want to cover a few important points about ITR here today:
ITR is recognized as a viable treatment option by the American Academy of Pediatric Dentistry and also the IHS Division of Oral Health.
There is not an ADA code specific to ITRs. We will be using 2940 to code ITRs.
It is a simple procedure that requires no high-speed drills and no local anesthesia. The goal is to stabilize carious lesions.
While these restorations are considered temporary, they often last the life of the primary tooth.
Early intervention and caries stabilization is a key component of the ECC Initiative.

23. National Oral Health Surveillance
We are using the Basic Screening Survey (BSS) to document ECC and track our progress.
The BSS is used by states to assess oral health status. Developed by the American Association of State and Territorial Dental Directors, this survey can be done in the dental clinic, at health fairs, at other screening opportunities, and through a retrospective chart review.
We plan to build a national ECC database by encouraging local use of the Basic Screening Survey (BSS).
This is a survey currently used by states to assess oral health status. BSS data collection would allow us to compare oral health status not only to other AI/AN communities, but also to the states where each AI/AN community is located.

24. The BSS Form Screen Date: __ __ / __ __ / __ __ __ __ Site/Tribe:
Screener’s Initials:
ID/Chart Number:
Birth Date:
Age:
Gender (circle one):
1=Male
2=Female
Sealants on Permanent Molars (circle one):
0=No Sealants
1=Sealants
2=Cannot be determined or does not apply
Untreated Cavities (circle one):
0=No untreated cavities
1=Untreated cavities
Severe Early Childhood Caries (circle one):
0=Five or less primary teeth with caries experience
1=Six or more primary teeth with caries experience
Caries Experience (circle one):
0=No caries experience
1=Caries experience
Treatment Urgency (circle one):
0=No obvious problem
1=Early dental care indicated
2=Urgent care (within 24 hours) indicated
Comments:
As you can see, the BSS collects data about caries experience, ECC, sealants, and treatment needs. The data is not tooth specific and so it is very easy to train clinicians to collect these data.

25. More about the BSS… Advantages: fast, frequent, and can be customized
Disadvantage: not same level of detail as NHANES or OHS
The BSS requires some planning – where are you going to do it, how often are you going to do it, etc.
Area Dental Support Centers will be trained and calibrated.
Beginning in the Fall of 2010, Support Centers will conduct a BSS on a sample size to be determined by an epidemiologist.
The BSS will be conducted annually thereafter and can show us whether the IHS ECC Initiative is meeting its goals.
While the BSS is a quick and efficient way to collect information about oral health status, it does not provide the level of detail that the IHS Oral Health Survey provided us in 1999.

26. ECC Initiative That’s why our community partners
Dental alone cannot prevent ECC because nationally our access to care rate is low, and children don’t often come to the dentist at an early age.
That’s why our community partners
are critical to the success of
this initiative.
In summary, I want to reiterate that the ECC Initiative was designed to be both comprehensive and collaborative.
We must work with our medical and community health partners to improve access for pregnant women and young children.
Our community partners are critical to the success of this initiative.

27. What can dental staff do?
Collaborate with dental, medical and community partners in your community to develop an ECC program plan.
Encourage Caries Stabilization with ITRs and take the online course.
Support medical and community partners as they get certified and begin fluoride varnish programs in your community.
Apply for mini-grants to support the prevention of ECC.
Work with your ADO or DSC to collect BSS survey data.
All of the dental staff are critical to promoting the ECC Initiative to American Indian and Alaska Native communities.
Here are some of the ways that you can become involved.
(read slide)

28. Together, we CAN make a difference!
Together, we really can make a difference!