Dental Early Intervention in North Carolina Rebecca King, DDS, MPH Chief, Oral Health Section NC Division of Public Health, DHHS

Turn of the Century 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

GASTON CHEROKEE SWAIN MACON GRAHAM CLAY JACK- SON HAY- WOOD HENDER- SON TRAN- SYLVANIA POLK RUTHER- FORD BUN- COMBE YAN- CEY MADISON MITCHELL AVERY CLEVE- LAND LINCOLN CATAWBA BURKE MECKLEN- BURG UNION CABARRUS ROWAN IREDELL STANLY DAVID- SON MONT- GOMERY RANDOLPH MOORE ANSON RICH- MOND HOKE CHATHAM LEE HARNETT CUMBER- LAND ROBESON SCOT- LAND BLADEN SAMPSON COLUMBUS BRUNSWICK NEW HANOVER PENDER ALA- MANCE ORANGE DURHAM CASWELL PERSON GRAN- VILLE VANCE WARREN FRANKLIN WAKE NASH JOHNSTON WAYNE DUPLIN GREENE LENOIR PITT JONES ONSLOW CARTERET PAM- LICO BEAU- FORT CRAVEN HYDE DARE TYRRELL WASH- INGTON BERTIE MARTIN HERT- FORD PASQUO- TANK CHO- WAN CAM- DEN PER- QUIMAN S CURRITUCK NORTH- AMPTON GATES HALIFAX EDGE- COMBE ROCKING- HAM STOKES SURRY FORSYTH GUILFORD YADKIN DAVIE ASHE WATAUGA WILKES ALLE- GHANY CALDWELL ALEX- ANDER MCDOWELL WILSON Central 10 Hygienists 4 Local Hygienists 22 Counties Western 21 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 1

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 population  K-3 high-risk children  15,000 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 2

Statewide Dental Surveys Provide evidence base for program: Early 1960s

Statewide Dental Survey Sample: 8000 children K-12 Study how well NC decay prevention programs are reducing decay Measure  Disparities  Parents’ knowledge and opinions  How 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 Percent Year NC OHS Statewide Dental Survey Data

Oral Health Surveillance Calibrated dental assessments  By PH RDHs  Grades 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% ( to )

Dental Health Education  School-based education and  Community outreach  Professional education  Educational materials 3

School-based Education 176,000 children thru classroom education 16,600 Adults  Parent education  Teacher 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 4

Oral Health Surveillance Referral for treatment needs  >129,000 K,5 screened  Identified >28,400 in need of dental care  Helped 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 services  Funding 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 5

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 need  reduce early childhood caries  improve 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:  medical  dental  nursing Sample standing orders

Smart Smiles Preventive Package Medical setting  targeted oral health education for caregivers  dental screening  fluoride 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, months, high risk for caries. Medical risk factors & socioeconomic indicators  families  200% Federal Poverty Level  medically compromised children  older siblings with poor oral health

Challenges Effectiveness  identifying the high risk children  getting them in for the service on a regular schedule Financing  grant stipulated that providers provide service at no cost to patients  economics was an issue for medical practices

Effectiveness Issues Provide services to high risk children  80-85% 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-give  oral screening and referral for child  fluoride 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 program  partners: 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 Fluoride  supplements  toothpaste  topical 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 emphasis  limiting exposures to risk factors  general 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 Babes 2006 >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

% Health Check Screenings Receiving IMB Services Quarter/Year % Children

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 Haupt

Early Head Start Surveys and focus groups to find needs  Teachers  Parents Developing and piloting training materials  Expand the concept that baby teeth are important  Urge 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?