1. Deamonte Driver
A 12-year old boy from Maryland who died of a toothache in 2007 when the bacteria from a dental abscess spread to his brain
An $80 tooth extraction could have saved him
A $1 fluoride varnish could have prevented the abscess to begin with

2. Shannon C. Wirth Samuel Merritt University
Addressing an Epidemic Implementing a Fluoride Varnish Program for Adolescents at School Based Health Centers
Shannon C. Wirth
Samuel Merritt University

3. Objectives The objective of this presentation is to:
Examine the evidence that justifies providing a fluoride varnish program to adolescents in school based health centers.
After this presentation, the participant will understand:
The epidemiology of the dental caries rate among various populations
The barriers to access of dental care
The benefits of dental fluoride varnishes
The proposed intervention to address the dental carries rate among adolescents

4. OVERVIEW Dental Caries
Dental decay is the leading chronic disease of childhood in the United States
5 times more common than asthma
3 times more common than obesity
Through the use of fluoridated water and fluoridated toothpastes, considerable progress has been made over the last 50 years to improve the oral health of children and adolescents. Yet dental disease, in particular dental decay, continues to be the leading chronic disease of childhood in the United States. In his first-ever report on oral health, the Surgeon General stated, 泥ental caries is the single most common chronic childhood disease—5 times more common than asthma and 7 times more common than hay fever,� and called the disparities in oral health among sectors of our population a 都ilent epidemic.� Dental care continues to be the most widespread unmet health need for children in the US. Among the states of our nation, California demonstrates particular need when considering the oral health of its children. In a recent National Survey of Children’s Health, California ranked second to last in children’s oral health status. Only Texas ranked lower.

5. OVERVIEW Adolescent Population
59% of adolescents have had dental caries in their permanent teeth
23% have untreated decay

6. OVERVIEW Fluoride Varnish
The regular application of fluoride varnish
on permanent teeth can
reduce dental decay by 46%
The regular application of fluoride varnish on permanent teeth can reduce dental decay by 46%. It is a safe, cost-effective approach to address the dental needs of our at-risk adolescents.

7. FLUORIDE VARNISH What is it?
Highly concentrated varnish that is painted directly onto the teeth
Does not adhere permanently, but instead holds a high concentration of fluoridated material close to the teeth, repairing and strengthening the enamel over time
Fluoride is a substance that inhibits the process by which bacteria in the mouth metabolize carbohydrates (sugars) to produce acid that injures the tooth enamel. It also remineralizes the enamel of the tooth. Fluoride varnish is a highly concentrated varnish that is painted directly onto the teeth. It hardens as soon as the varnish comes in contact with saliva, prolonging contact between fluoride and tooth enamel. It does not adhere permanently, but instead holds a high concentration of fluoridated material close to the teeth, repairing and strengthening the enamel over time.
Various healthcare professionals, including Nurse Practitioners, apply fluoride varnish. First, the teeth are dried with a piece of gauze. The varnish is painted with a brush onto all of the exposed dental surfaces. The application dries almost instantaneously, at which point the patient can rinse their mouth. The patient is instructed to not eat or drink for 1 hour, to avoid hard foods for the remainder of the day, and to resume brushing their teeth the following morning

8. DEFINITIONS/THEORY Adolescent Dental Caries Fluoride Varnish
Nancy Milio “A Framework for Prevention:
Personal choice-making in the context of societal option-setting

9. EPIDEMIOLOGY Overall rate of dental caries is decreasing
Remains highest during adolescence
59% of adolescents have had caries in permanent teeth
23% have untreated decay
Distribution of dental caries in permanent teeth in different age groups:
50% in 12- to 15-year-olds
78% in 17-year-olds

10. WHY ADOLESCENTS?
Distinct need for oral health as compared to other stages of childhood:
Dental carries is a progressive condition
Immature permanent tooth enamel
Increase in susceptible tooth surface
Change in nutritional habits
Increase in sugary food/liquids
Use of tobacco, alcohol, other drugs
Pregnancy and eating disorders
Low priority for oral hygiene
Ability to avoid care through gain in independence
Why is the carries rate highest during adolescence?

11. COST OF DENTAL DECAY Diminished quality of life School absences
Diet, nutrition, sleep, social interactions
School absences
Missed opportunities for learning
Loss in school funding
Increased cost of care
Systemic health ramifications
Death
Absence from school results in missed opportunities for learning and school funding. Nationwide, approximately two million school days are missed per year due to dental health issues. When children are present and experiencing dental pain, they can become distracted, and possibly unable to concentrate on schoolwork. Missed school days also result in loss of funding to schools. In California, school districts receive funding based on attendance. In the school years, absences due to dental problems resulted in a $29.7 million dollar loss for school districts in California.
Children from low SES miss more school as a result of poorer oral health, and therefore have more missed learning opportunities than children with access to dental care. In 2008, California had approximately 7,240,000 school age children ages Approximately 7% (514,000) missed one school day or more due to dental problems. Of the children missing school days due to dental problems, 40% report missing two or more days. Children missing two or more school days were more likely to have poorer oral health, come from a lower income household, be without dental insurance, or be unable to afford dental care. Consequently, children and adolescents from low SES families bear the brunt of these missed opportunities for learning.
The financial cost of dental decay is measured not only is lost school funding, but also in cost of care. Like most health issues, without access to preventive care, what begins as a small problem can become a large and costly problem as the issue progresses. Preventive dental care can be postponed, but can no longer be ignored once symptoms become acute. A toothache or facial abscess can become so acute that care may be sought in the hospital emergency room. A comprehensive oral exam alone costs double in an emergency room compared to a dental office ($172 vs. $60). A three-year comparison of Medicaid reimbursement for emergency room treatment for dental problems versus preventive treatment highlights this cost differential. The study showed that 鍍he cost to manage symptoms related to tooth decay in the emergency room ($6, 498) is approximately ten times more than if preventive care is provided in a dental office ($660) for the same patients.�
Similar to the ballooning cost of delayed dental care, untreated dental disease can lead to health ramifications much larger than the original offense, even death. While death from untreated dental decay is extreme, the connection between dental disease and more serious health consequences is well documented. In 2000, the Surgeon General pointed toward the connection between periodontal disease and diabetes, cardiovascular disease, and premature births, and called for research to further understand the 登ral-systemic disease connection.� Poor oral health in childhood and adolescence leads to poor oral health in adulthood, and if left untreated, can cause more expensive chronic issues for adults.
Though death from dental decay is rare, it is not unprecedented. This was tragically illustrated in 2007 when a child died due to the spread of bacteria from an untreated dental infection. Deamonte Driver, a 12-yearold from Maryland, died when a bacterial infection from a tooth abscess traveled to his brain. Two years before, Taran Fracis, a 13-year-old from the Brox, suffered a similar fate. An $80 tooth extraction could have saved them both. A $1 fluoride varnish could have prevented the original tooth decay, avoiding infection all together.

12. EPIDEMIOLOGY Digging Deeper
Distribution of dental decay follows the 80/20 rule
80% of decay is found in 20% of the population
The burden of dental decay is disproportionately carried by low income and minority children
Highest rates in Latino children
High rates also seen in African American and Native American children
Low socioeconomic status (SES) is the common denominator
Now that we’ve taken a general look at dental carries and their ramifications, Let’s tease apart the epidemiological numbers a little more to better understand this issue….
Children participating in the free lunch program have a higher incident of untreated decay and urgent dental care needs. In a California specific study, there was a 20% higher prevalence of tooth decay in this low SES population compared to their non-participant counterparts.

13. STATISTICS Dental Visits
Latino and multiracial children were found to have the highest risk of never having seen a dentist (18% and 16%)
Native American children (15%), Latino children (12%) and African American children (11%) made no preventive dental visit in the past year, compared to 5-7% of other racial or ethnic groups

14. ACCESS
Adolescents are less likely to visit a dentist the older they become
Having private dental coverage doubles the likelihood of a teen having a dental visit
Adolescent specific statistics at the state and national level are very limited in terms of evaluating adolescents’ access to dental care. Using the data available, the Children’s Dental Health project found that Medicaid enrolled adolescents are only 1/5th as likely to obtain dental care as medical care, and 1/3 less likely than 4-9 years olds. They also concluded that 塗aving private dental coverage doubles the likelihood of a teen having a dental visit,� and that only 40% of adolescents have dental coverage as compared to medical coverage. In Alameda County, adolescents are less likely to visit a dentist the older they become. In 2006, 93% of Alameda County year olds visited a dentist, compared to 81% of their year old colleagues, and 60% of year olds.

15. ACCESS Is insurance the barrier to access?
Low-income parents have problems with access despite insurance status
Healthy Family dental visits
2008: 56% of the enrollees saw a dentist
2007: 57% of the enrollees saw a dentist
2006: 62% of the enrollees saw a dentist
Medi-Cal
2007: 31% of the enrollees saw a dentist
While having private dental coverage doubles the likelihood of a teen having a dental visit, insurance is not the barrier to access.
Healthy Families is a state sponsored medical and dental insurance coverage for children and teens who do not have insurance and do not qualify for free Medi-Cal. In 2008, only 56% of the enrollees saw a dentist. This number is a trend down from 59% in 2007 and 62% in The numbers are even lower for Medi-cal enrolled children. In 2007, only 31% of children enrolled in this benefit had a dental visit.

16. ACCESS Financial vs. Non-Financial Barriers
$1,500 yearly limit on dental services for children covered by the Healthy Families program
Families pay for half of all dental expenditures, while only one third are paid by dental insurance
In their research on disparities, Liu et al point to income as an indicator independent of insurance status. 典he associations of poverty with preventive dental care suggest that low-income parents may still have problems with access even holding insurance status constant.� This may in part be due to a $1,500 yearly limit on dental services for children covered by the Healthy Families program, which can be reached in quick succession if restorative care is required. Income may also play an important role in access to dental care when taking into consideration that families pay for half of all dental expenditures, while only one third are paid by dental insurance.

17. ACCESS Financial vs. Non-Financial Barriers
Dentists providing Medicaid services
Finding a dentist who accepts Medicaid can be difficult, or such is the perception
Language
Children from ESL households have triple the odds of unmet dental care needs
Culture
Foreign born children receive less preventive care, despite insurance status
Cultural concept of dental care
Importance of preventive care
Navigation of the US medical/dental system
In many areas, finding a dentist who accepts Medicaid can be difficult. In other areas, the perception of minimal dental providers in the area accepting public coverage is what impacts access. An evaluation of the San Mateo County Healthy Kids enrollees and their utilization of dental coverage found a widely held perception of decreased provider acceptance of public coverage despite adequate capacity to serve all enrollees in San Mateo County. This points to case management to link families to services as an area of need to address access to dental care.
More than one fourth of Asian/Pacific Islander children’s paretns attribtued their unmet dental care need to their dentist not knowing how to provide care (27%); Native American paretns (11%) also frequently cited this reason.

18. ADDRESSING THE NEED FOR PREVENTION
Intervention
Apply fluoride varnishes at every sports physical and well-child exam at the School Based Health Clinics of the Native American Health Center in Oakland, CA.
The School Based Health Department at the Native American Health Center (NAHC) serves four high schools and two middle schools in Alameda and Oakland, California. To expand preventive oral health services for at-risk adolescents, this paper proposes the application of fluoride varnish at every sports and well exam.

19. WHY SCHOOL BASED HEALTH CENTERS?
Targets preventive services directly to underserved, low-income youth
Mitigates many of the barriers to care
SBHC of NAHC:
4 high school and 2 middle schools
Meets the kids where they’re at

20. WHY FLUORIDE VARNISH?
46% reduction of dental carries in permanent teeth
Highest recommendation from the CDC and ADA for at-risk youth
Benefits the child, the clinic and the therapeutic relationship between patient and provider
Widely used in Europe and Canada for caries prevention for over 20 years, fluoride varnish has become available in the United States over the last decade. Fluoride varnish application at regular intervals is supported by evidence and recommended by a variety of professional organizations. The American Dental Association, the American Academy of Pediatric Dentistry, the British Society of Paediatric Dentistry and the European Academy of Paediatric Dentistry all have guidelines outlining their recommendation for fluoride varnish application.
Various systematic reviews and meta-analyses have evaluated the effectiveness of fluoride varnish application at varying intervals. Agencies such as the Center for Disease Control (CDC), the Cochrane Review, and the American Dental Association (ADA) have independently reviewed the data and come to the same conclusion: when targeting the at-risk adolescent population, evidence supports the application of dental varnishes to delay caries progression and prevents future caries. The Cochrane Review, in their meta-analysis of studies evaluating the effectiveness of fluoride varnish on dentition, found a 46% reduction in decayed, missing and filled tooth surfaces associated with the use of fluoride varnish on permanent teeth. The CDC and the ADA have both given their highest recommendation for fluoride varnish use in the prevention and control of dental caries for at-risk youth.

21. FLUORIDE VARNISH Benefits Cost effective:
$0.82-$2.36/ unit
Reimbursable by Medicaid
Minimal provider time and materials required
Fits well in SBHC/Primary Care
No special dental equipment
No special preparation of teeth
Natural fit with healthy lifestyle / healthy habits discussion
The application of fluoride varnish is easily implemented in the school based health center patient visit. It fits well in the primary care setting because it does not require special dental equipment, such as suction or dental trays, nor does it require special preparation of the teeth. It fits particularly well in Nurse Practitioner provided care, as the assessment for oral health risk and education regarding oral hygiene easily ties into the discussion with patients regarding healthy lifestyle and healthy habits, such as diet, smoking, and personal grooming/hygiene habits. Furthermore, it encourages discussion regarding preventive oral care, including the decreased consumption of sugary snacks and liquids, reduction of tobacco exposure, regular oral health hygiene, and the establishment of a dental home.

22. IMPLEMENTATION PLAN Stakeholder identification and buy-in
Staff-training
Pilot program implementation
Evaluation
Expansion
Upon completion of a dental varnish, providers will complete an Oral Health Encounter Report (Appendix B). This document will allow for tracking of the total number of visits with an oral health component, the total number of patients identified as at risk for dental disease, and the number of fluoride varnishes completed. Other components of a visit with an oral health component will be tracked, such as the number of patients who receive anticipatory guidance on nutrition, sugar/soda intake frequency, the number of referrals made for dental home, and the number of referrals made for identified urgent dental problem. Tracking of these figures will allow for the evaluation of services provided vs. missed opportunities for preventive care. Upon completion, the data will be reviewed and evaluated in consideration of program continuation.

23. IN CONCLUSION Good oral health requires good overall health
Untreated dental decay leads to infection, pain, and absence from school - leading to reduced quality of life and lost opportunities for learning
The regular application of fluoride varnish can reduce dental decay in permanent teeth by 46%
The application of fluoride varnish is an ideal intervention to address the oral health epidemic in this nation