1. Integrating Oral Health into Pediatric Primary Care
Alison Days, MD, MPH
TxOHC Oral Health Summit
Dec. 2, 2011

2. Objectives Observe a pediatrician’s view of oral health
Observe a pediatrician’s view of oral health
Learn how to incorporate dental education into a quick childhood visit
Learn how dental decay and/or dental abnormalities impact pediatric care

3. Why I decided to enter the world of oral health
Left NY and moved to El Paso, TX. Saw more children with teeth, gum or mouth problems in first few months than ever before.
Why so many in El Paso? Why so many in Horizon City?
Began a pilot project with a pediatric colleague working in Tornillo, TX and with the EPCC Dental Assisting Program (Sharon Dickinson).
Objective was to determine the prevalence of dental decay and gum disease among children 6 months-5 years of age in the areas of El Paso served by the Child Wellness Center of Horizon and the Tornillo Wellness Center.

4. Horizon City, TX
Population in July 2009: 13,753. Population change since 2000: +162.8% Males: 6,636  (48.3%)Females: 7,117  (51.7%)
Median resident age:  31.6 yearsTexas median age:  32.3 years
Zip codes: 79927.
Estimated median household income in 2009: $53,654 (it was $48,589 in 2000) Horizon City:
$53,654Texas:
$48,259
Read more: 

5. What the studies showed about kids
Fewer than 1 in 5 Medicaid-covered children received at least one preventive dental service within the previous year (CDC, 2004).
Only 7% of general dentists report treating patients with Medicaid coverage (Seale NS et. al., 2003).
NHANES data from and report that Mexican-American children had higher prevalence of caries of their primary (2-11 years of age) and permanent teeth (6-19 years of age) (54.9% and 48.8%, respectively) than African-American (43.3% and 39.9%) and non-Hispanic white children (37.9% and 38.8%).
Beltrán-Aguilar, ED. Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis --- United States, and 1999—2002; CDC MMWR Surveillance Summaries, Aug

6. What the studies showed about the El Paso area
Of Hispanics surveyed in a national study, only 45% of those living in Texas vs. 66.1% living in NY State had visited a dentist in the previous year (CDC, 1999 data).
El Paso County data for 2001 showed the ratio of population per dentists to be 5,784 vs. a ratio of only 2,820 for the state of Texas (Texas Department of Health, 2001).
Of 147 practicing El Paso dentists only 30 accepted Medicaid in 2006 (unpublished communications).

7. Results of our study done in 2006
Of 300 children surveyed, 281 met full criteria
The average age of a subject was months
254 (88%) of patients surveyed had Medicaid as primary form of insurance
269 (94%) described themselves as being of Hispanic (primarily Mexican) origin
270 (94%) were born in the United States (the other 5% born in Mexico)
175 (61%) of patients drink primarily bottled water vs. only 27% tap water.
To determine the prevalence of dental decay and gum disease among children 6 months-5 years of age in the areas of El Paso served by the Child Wellness Center of Horizon and the Tornillo Wellness Center.
To assess the relationship between the prevalence of dental decay and access to care using prevalence ratios
To determine primary contributing factors of tooth decay in these areas
Cross-sectional/ descriptive design looking at prevalence of tooth decay within the two communities of Horizon City and Tornillo.
Study subjects were children ages 6 months to 12 years seen at each of the two wellness centers.
Inclusion criteria: age within study range, a visit to one of the centers for a Well Child Check (WCC), and either Spanish or English as the primary language.
Sample size was 200 children from Horizon and 100 from Tornillo, for a total of 300 children. Our target population is that of all children in these rural areas within that age range.
Subjects were selected on the basis of showing up for their WCC
Multiple children from same household were enrolled as long as they fit inclusion criteria.

8. Results of our study (cont’d)
The number of subjects with affected teeth was 58 (20%). The number of affected teeth ranged from 1-20.
The number of subjects who were still using pacifier at time of study was 105 (40%).
Number of children who still drink from bottle or cup at night was 84.3 (30%).
Other dental conditions such as trauma, gingivitis, and malocclusion were seen in 7 children.
Children and parents were surveyed regarding oral history and habits
Children were assessed for decay and gum disease using a standardized oral screening tool. 
Prior to the start of the study, all participating physicians were trained by local dental educators and dentist on how to perform a complete oral screening, how to apply topical fluoride varnish, and how to provide dental health education and nutrition counseling.
Based on the findings of the exam, pediatricians assisted in locating the child with a dental home within the community.

9. Preliminary Conclusions
In this sample group the prevalence of caries was only 20% as compared to the NHANES data reporting that prevalence of caries in primary teeth of Hispanic-American children was 54.9%.
However, the NHANES surveyed children 2-11 years, while we surveyed 6 months to 5 years.
Additionally, in those children with decay, many had more than half the number of teeth affected.
This suggests that, the overall prevalence is significant for this age group and the morbidity for a small group of children is noteworthy.
Moreover, risk factors such as pacifier use and using a bottle at night are still prevalent in this population despite education about these practices.

10. Personal Effects of study results
I wanted to know more about dental care and how to prevent/treat some of these problems
I have learned and taught how to apply fluoride varnish to children’s teeth
I have referred patients to local dentists for both routine care and for dental emergencies
I have incorporated oral health into new curriculum for second year medical students at Texas Tech

11. A need to change our way of thinking
Teeth
Tongue
Throat
Teeth and Gums
Tongue and Cheeks
Throat

12. Pediatric Oral Health Issues
Teeth
Gums
Cheek and glands
Tongue
Throat
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13. Practical Considerations aka Comments you might hear
I only give her a bottle at night when she wants to sleep (15 month old)
She wakes up every night and cries so I give her a bottle (9 month old)
He still sucks his fingers all the time (4 year old)
He won’t let me brush his teeth (2 year old)
He wants clearance to play football this year (15 year old)
Need to discuss with parent’s that the night bottles tend to be the worst ones due to the kids sleeping with carbohydrate (milk) on the teeth. Additionally, she is over a year old and should be switching to a cup.
Same discussion as in comment number 1, except with addition of discussion about nighttime awakenings—baby may be waking because of teething and constant nighttime bottles may predispose him/her to waking at night.
OK if child still sucks fingers—difficult to stop this behavior. Positive reinforcement (star chart) or natural consequences may be only way to eliminate
Should still be brushing a child’s teeth for them up to at least 5 years of age. Make brushing fun—parents and children all brush together, sing a song while brushing, etc.
Kids involved in contact sports (football, basketball, hockey, motorcross, etc.) should wear mouthguards.
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14. How to incorporate into Well Child Visit
Have CMAs/nurses ask when child was seen last by dentist and/or if family has a dentist
If child is less than 4 months, talk about what type of water is used for formula and about cleaning baby’s gums. Also mention infectious nature of caries
At 6 months, talk about beginning to wean bottle (esp. falling asleep with bottle). No pre-chewing food.
At 9-12 months, begin discussing dental home and brushing/wiping teeth
American Academy of Pediatrics. A Pediatric Guide to Children’s Oral Health. Elk Grove Village, IL: AAP 2009

15. How to incorporate into Well Child Visit
Discourage bottle use, encourage cups/sippy cups at meal times.
Teach injury prevention
For older kids, begin conversation about child’s growth and development by talking about food choices—what and when the child eats—discourage sticky or acidy choice and encourage limitation of snacking behavior.
Reinforce brushing and flossing
Assure dental visits are regular
Address any abnormalities seen in mouth immediately.
American Academy of Pediatrics. A Pediatric Guide to Children’s Oral Health. Elk Grove Village, IL: AAP 2009

16. How to examine a child’s mouth
Have child open mouth wide:
Look at throat
Look at buccal mucosa
Look at biting surfaces of teeth
Have child bite down and smile:
Check tooth enamel
Check occlusion of teeth
Check gums/gingiva

17. Case #1
CC: Richard is crying in pain and can’t seem to eat or sleep well.
HPI: Richard has a long history of chronic diseases which are stable. For the past two days he has been more clingy and fussy, throwing tantrums and crying out in pain stating that his “mouth hurts.” Mother says he has had low grade fever off and on also and she thinks maybe it is a throat infection because his sister was sick a week ago with similar symptoms.
PMH: Patient born full-term but with spina bifida, kidney failure. Birth weight 2.8kg. Patient has had a repaired myelomenigocele and a VP shunt since 3 weeks of age.
ROS: Mother reports decreased appetite in patient and maybe some “swollen gums”. All rest of ROS negative.
PE: weight-11.97kg ht-92cm Temp-98.7 Pulse-80 Resp. 24
Appearance: patient awake and alert, mild distress sitting upright in Mom’s lap.
HEENT: tympanic membranes intact and normal b/l; EOMI, PERRLA; dry lips and reddened tongue; patient mouth-breathing; ulceration of second molar on left lower gum. Inflammation and pus with surrounding erythema and tenderness to palp of nearby cheek.
Rest of Physical Exam WNL for this patient
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18. Case #1 Why isn’t this child eating? What is the diagnosis?
How should it be treated?
What should be the pediatrician’s next step?
What advice should be given to the mother?
Pain with eating
Severe dental decay with secondary abscess
Abx (amox/pcn) & pain control (NSAIDS or Tylenol & codeine)
Urgent referral to a dentist
Oral health and hygiene very important especially in children with special needs. If child not eating, look at teeth first.
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19. Case #2
CC: Dwight is a healthy 1 year old boy who presents with persistent skin rash/dryness. 
HPI: Dwight has a history of dry skin since age 2 months, allergies since age 6 months. His mother is convinced that he is allergic to rice, eggs, peas, pears, wheat, strawberries, soy products, and granola and has been severely limiting his food choices. When asked if she has any other concerns, the mother reports that she is worried about his teeth because they look “sort of weird.” She says she brushes his teeth every day at least twice a day, although she just started that recently. His first tooth erupted at age 10 months and he currently has four teeth.  
General allergies, eczema and episodes of mild wheezing
Drug allergies: none documented, but mother claims he is allergic to PCN
Meds: Zyrtec
FH: mother with history of PCN allergy and egg allergy, dad with history of childhood asthma, sister with mild eczema as infant, PGF with hypertension, PGM with diabetes, distant relatives on both sides with history of cancer
SH: Lives at home with mother, father and older sister aged 6 years. Does not attend daycare
Physical Exam: vitals stable
Appearance—well appearing 1 year old boy with no apparent distress. He is currently sucking on his bottle.
HEENT—mild runny nose with boggy turbinates, pt with 4 teeth (2 upper, 2 lower incisors). Upper front teeth have small white spots near gumline. All else within normal limits
Skin-- very dry skin all over body with large, dry reddened and excoriated patches in several locations on arms and legs.
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20. Case #2 What diagnosis would you give? What should the mother be told?
What can his pediatrician do in the office to help prevent further progression of cavities?
This shows early caries. This is the time to intervene before the decay worsens into frank cavity
Continue brushing or wiping child’s teeth every night.
She may want to use a fluoride containing toothpaste since he is at high risk, but keep him from swallowing too much
This child needs to see a dentist soon for evaluation and further management
Attempt to avoid sugary or sticky sweets and take away the baby bottle from child
Application of fluoride varnish to all visible enamel surfaces, especially areas of white spots.
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21. Case #3
CC: Jacob is a 10 year old boy who presents for mouth pain and swelling. 
HPI: Jacob is in good health in general but today was running at school during recess and was tripped by a classmate. He fell headlong onto the pavement, hitting his mouth and chin. He reports instantly seeing and feeling blood from his mouth and nose and pain at his gums/lips. A nearby teacher put pressure on the wound immediately to stop the bleeding. The school nurse evaluated patient and noted a cut on bottom lip, a cut on top lip and gums and a loose tooth. Patient was sent to physician’s office for further evaluation. Patient complains of mouth pain and some numbness/swelling of lower lips, but denies headache, nausea/vomiting, dizziness, neck pain, ear pain or trouble hearing, trouble breathing or visual changes.
Physical Exam: wt-33.5 kg Temp Pulse- 67 Resp-24
Appearance- age-appropriate child sitting quietly with hand holding tissue pressed over his mouth. Appears in no significant distress
HEENT— Head, ear, eyes, all WNL. Dried blood seen at bilateral nares, but no active bleeding and no deviation of septum. Upper lip swollen with tear at frenulum, no loose maxillary teeth or lacerations at upper gum. Lower lip swollen with small laceration at inner surface. No active bleeding. The two lower central incisors appear crooked and are loose when palpated. Patient reports pain with movement of these teeth and some active bleeding occurs with evaluation. Tenderness with palpation of the lower jaw, especially inferior to the central incisors and slight movement felt with evaluation of jaw. Patient exhibits a malocclusion of teeth when attempting to hold a tongue blade in place with teeth..
Neck—WNL. Patient able to move neck fully without pain or stiffness.
All else normal on this patient during physical exam except minor abrasions at hands, elbows and knees.
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22. Case #3 Of all his injuries, which is most worrisome?
What needs to happen emergently?
This patient has two concerning injuries:
1. The loose and bleeding central incisors are permanent teeth. A loose permanent tooth is a dental emergency that requires prompt treatment. In most cases, the tooth can be returned to its correct position and monitored over time. However, it may be necessary to use anesthesia (to prevent pain) and stitches or splints (to hold the tooth in place). A dentist with experience in treating dental injuries in children is the best person to evaluate and treat children with loose permanent teeth.
2. The movement and tenderness in the lower jaw plus malocculsion are signs of probable mandible fracture. The mandible is reportedly the most commonly fractured bone in facial trauma. This is also an emergency and must be evaluated immediately. Treatment requires fixation of the bony pieces either via external wires or internal plates and screws. Additionally, the numbness the patient reports may indicate injury to the inferior alveolar nerve.
This child needs to be sent to a dentist’s office or emergency room where a panoramic X-ray or CT scan of the jaw can be performed. A maxillofacial surgeon will need to be consulted. Antibiotics are also good to prescribe to prevent infection.
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23. Thanks!!
Questions?

24. References
CDC Surveillance summaries. Dental Caries and Periodontal Disease Among Mexican-American Children from Five Southwestern States, MMWR. July 1, 1988; 37 (SS-3): 33-45
CDC. Dental Health of School Children—Oregon, MMWR. November 26, 1993: 42(46):
Barnes GP et al. Ethnicity, Location, Age and Fluoridation Factors in Baby Bottle Tooth Decay and Caries Prevalence of Head Start Children. Public Health Reports. 1992; 107:
Weinstein P et al. Mexican-American parents with children at risk for baby bottle tooth decay: Pilot Study at a migrant farmworkers clinic. J. of Dentistry for Children. Sept-Oct. 1992:
Blen M et al. Dental caries in children under age three attending a university clinic. Pediatric Dentistry. 1999; 21(4):
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25. References
American Academy of Pediatrics policy Statement. Section on Pediatric Dentistry. Oral Health Risk Assessment Training and Establishment of the Dental Home. Pediatrics. 2003, 111(5):
CDC Chronic Disease Prevention statistics. Preventing Daily Caries Fact Sheet. National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, 2004
Georgia G. dela Cruz, R. Gary Rozier and Gary Slade. Dental Screening and Referral of Young Children by Pediatric Primary Care Providers. Pediatrics. 2004; 114(5): e
Keels MA. Pediatric Dental Pearls: what you need to know for excellent patient care. American Academy of Pediatrics Presentation, Washington, DC: October 2005.
National Oral Health Surveillance System. Texas Oral Health Profile. CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, 1999
National Oral Health Surveillance System. Tracking of Dental Visits Texas vs. New York. CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, 1999
Oral Health in America: A Report of the Surgeon General. US Department of Health and Human Services, NIH, National Institute of Dental and Craniofacial Research. Rockville, MD, 2000:2
American Academy of Pediatrics. A Pediatric Guide to Children’s Oral Health. Elk Grove Village, IL: AAP 2009
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26. Internet References http://www.drashouri.com
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