The Oregon Oral Health Program in collaboration with the Oregon Oral Health Coalition’s (OROHC) Early Childhood Cavities Prevention Committee (ECCP) created.

The Oregon Oral Health Program in collaboration with the Oregon Oral Health Coalition’s (OROHC) Early Childhood Cavities Prevention Committee (ECCP) created a workforce development project called “First Tooth”. The goal of the project is to reduce early childhood caries, known as tooth decay, in Oregon by training medical and dental providers to implement preventive oral health services for infants and toddlers ages three and under. In addition, “First Tooth” works to establish collaborative relationships between medical and dental providers so that all children have access to a dental home. Introduction- name, association with FT and ECC prevention, thank sponsors if there are food sponsors, introduce all attendees. Sign in sheet Show materials Show contents of toolkit, binder and folders. Preventing early childhood caries through medical and dental provider education and collaboration

Module 1: The prevalence and impact of oral disease
Let’s get started with discussing the prevalence and impact of oral disease.

Early childhood caries can lead to…
1 Early childhood caries can lead to… Extreme pain Spread of infection and possible cellulitis Crooked bite (malocclusion) Extensive and costly dental treatment Inability to concentrate Impaired language development High risk of developing tooth decay in permanent teeth – chronic condition There are many short-term and long-term affects early childhood caries can have on children. The child may experience acute pain, with infection and risk of cellulitis, but chronic pain can manifest itself in inability to concentrate, malaise, impaired language development, and low self-esteem. Long-term affects of early childhood caries include malocclusion, extensive and costly dental treatment initially and over the lifetime of the child, and increased likelihood of chronic caries even in permanent teeth. Adapted from The American Academy of Pediatrics Oral Health Initiative Oral Health Risk Assessment Training for Pediatricians and Other Child Health Professionals 3 3 3

Current status of children’s oral health
1 Current status of children’s oral health Every 5 years the State oral health unit conducts a smile survey, which gives us a snapshot of the current oral health of Oregon’s children. Between 2002 and 2007, we saw an increase in caries experience, untreated decay, and rampant decay. This increase spurred the state to look at ways to prevent the decay. First Tooth was created to address the prevention of decay early in the child’s life. Sealant programs throughout the state also increased, preventing decay in permanent molars. We know these programs have worked since there was a decrease in decay experience from 2007 to Continuing to provide fluoride varnish, education, sealants, and early access to a dental home should keep Oregon children on the path to better oral health.

Disparities in Oregon children’s oral health
1 Hispanic/Latino children have higher Rates of decay, untreated decay and Rampant decay. Black/African American children have Higher rates of untreated decay. Not surprisingly, the Smile survey also showed the disparities in oral health between Ethnic diverse children, and socioeconomically disadvantaged children. Why might children from ethnically diverse backgrounds, primarily Hispanic and African American, have higher rates of decay? What puts children from lower socioeconomic homes at higher risk of decay? Children from lower income homes have nearly twice the decay rates, untreated decay and rampant decay than children from higher income homes.

Why providers of pediatric patients?
1 Why providers of pediatric patients? They have frequent contact with infants and children. They can help prevent or reduce the risk of tooth decay. They can provide appropriate referrals to a dentist for early intervention and/or treatment. Pediatric providers ideally see young children 7 times in the first year of life and 11 times in the first 3 years for well child visits. These interactions provide a great opportunity for anticipatory guidance, screening, and oral health maintenance. Studies on low-income toddlers' dental services utilization have shown that while only 20% had a dental visit, 85% had at least one well-child check- up. In a recent survey of U.S. pediatricians, 90% recognized their role in screening for oral health problems and providing caries prevention anticipatory guidance. A study published in the American Academy of Pediatrics journal found that parents are 3 times more likely to take their child to the dentist if their medical provider referred them specifically. Pediatrics 2004 OCT; 114(4): e418-23 The vast minority of children visit a dentist prior to their third birthday, despite the American Academy of Pediatric Dentistry, American Dental Association, and now American Academy of Pediatrics policies encouraging initial dental visits at 1 year of age. Several factors contribute to this, including limited # of dentists who treat children under 3, few dentists who see Medicaid patients, parents not understanding the importance of preventative services, etc There is an opportunity for and a responsibility of pediatricians to incorporate oral health into daily practice so that children in areas where access to pediatric dental care is limited can maintain good oral health until they are able to access the appropriate dental professionals. Limited access to preventive and restorative dental care makes disease prevention paramount. . 6

American Academy of Pediatrics policy statement, 2003
1 American Academy of Pediatrics policy statement, 2003 Every child should begin to receive oral health risk assessments by 6 months of age from a pediatrician or qualified pediatric health care professional. Infants identified as having significant risk of caries should be entered into an aggressive anticipatory guidance and intervention program provided by a dentist between 6 and 12 months of age. Pediatricians should support the establishment of a dental home for all children between 6 and 12 months of age. The AAP has become an influential leader for oral health integration in the medical setting. They have published many articles about oral health and they launched an oral health initiative, which includes a website containing a wealth of information and resources. For over ten years the Aap has been a strong advocate for risk assessments and early establishment of a dental home. Medical providers should start assessing a child’s caries risk as early as 6 months old, and children who have been determined to be at risk of development of dental caries or who fall into recognized risk groups should be referred to a dentist no later than 12 months of age, or when the first tooth erupts, whichever is first. A study published in the American Academy of Pediatrics journal found that parents are 3 times more likely to take their child to the dentist if their medical provider referred them specifically. National organizations such as the AAPD, ADA, ADHA and the AAP support the concept of a dental home, which is the delivery of oral heath care in a continuously accessible, comprehensive, family centered, coordinated, compassionate, and culturally effective. It should be delivered by a well-trained dental professional who implements preventive dental health habits that meet each child’s unique needs and keep the child free from oral disease. The medical provider may be, in some instances, the ONLY place some children are getting preventable oral health services, so may be considered a member of the global concept of the dental home. See : AAP Dental Home Policy Statement Source. Hale, K., Weiss, P., Czerepack, C., Keels, M., Huw, T. & Webb, M. (2003). American Academy of Pediatrics Policy Statement: Oral Health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics; 111(5): 1113 to 111

Early Childhood Caries Preventative (ECCP) services
1 Early Childhood Caries Preventative (ECCP) services Assess Screen Educate Intervene Refer What are early childhood caries preventative services that can be provided in medical offices? Medical providers can assess caries risk, screen for decay (particularly looking for those earliest sings of decay,) provide education on prevention and treatment of decay, intervene with behavior modifications and fluoride varnish and make a referral to a dental home. Again we are looking to medical providers because they are in the best position to provide these services, they see children up to 11 times the first 3 years of a child’s life. But- as you can imagine the services they can provide is limited as they only have on average about 20 minutes for the entire well-child visit. We are relying on dental providers to provide similar, yet more comprehensive, ECCP services. We will go over each of these prevention services in more detail and you will see how easy it is to implement these into your well child visit. Keep in mind, medical providers, that you are already doing many of these things during your regular well child visit. I will show you how to continue what you are already doing, but modify how you say things, or what you are already looking at, to see earlier signs of decay and get the child on a path of oral health early. 8 8 8

Module 2: Risk assessment
Module 2 takes us through the assessment for caries by looking first at the decay process.

Defining early childhood caries
2 Defining early childhood caries Process of demineralization to cavities in primary dentition Lesions can progress rapidly Affects teeth least protected by saliva Often associated with bottle or sippy cup use throughout the day or at night Caries is a process of actual decay from early demineralization of the tooth structure to actual cavities, or holes, in the tooth. Early childhood caries occurs in the primary teeth of infants and young children. This condition can progress very rapidly due to the enamel of primary teeth being thinner than that of permanent teeth. ECC affects the teeth that are least protected by saliva. While ECC is often associated with the use of frequent feeding at nap time and bedtime, this is not the exclusive cause. .

First clinical signs of caries
2 First clinical signs of caries First clinical signs of caries White spots Acids have demineralized enamel First appear at gumline of upper front teeth High risk for developing cavities White spots can be remineralized with early intervention Fluoride Behavior modification: improved brushing & dietary habits Indication for dental referral Photo: Crest Slide Set and ICOHP The first sign of caries is demineralization producing a “white spot”. White spots place the child at high risk for developing cavities and require immediate intervention because white spot lesions can be remineralized. White spot lesions first appear at the gumline of the upper front teeth, areas often missed while brushing and where there is limited saliva contact. As the child erupts more teeth, the gumline area is the first area to show signs of white spot lesions. Immediate interventions include fluoride varnish, the use of fluoridated toothpaste, and behavioral modification for improved brushing and dietary habits. Where dental care is available, make a timely referral to a dentist. Dentists will apply extra topical fluoride and provide comprehensive treatment. Where dental care is delayed or unavailable, good oral hygiene and monthly applications of varnish for 3-6 months may reverse this early decay. Used with permission by the Washington Dental Service Foundation 11

Example of fluorosis 2 Mild fluorosis Severe fluorosis
Fluorosis, a complication of ingesting excessive levels of fluoride while the teeth are forming, can also leave white spots. However, fluorosis affects the permanent teeth, giving them an overall lacy look, whereas demineralization white spots occur mainly at the base of the tooth along the gumline. Mild fluorosis Severe fluorosis

Severe caries 2 Abscess See AAP Flip Chart and Office Pocket Guide
These pictures show the pattern of early childhood caries. Notice how cavity free the lower front teeth are, those teeth that are bathed in saliva the most. Also note the abscess in the lower left picture. It is important to lift the lip to assess the tissue at the area where the end of the tooth’s root is to determine if the tooth has abscessed. See AAP flipchart for progression of early childhood caries- after showing the AAP book, particularly the progression of disease page, pass the book around See pocket guide flipchart- This pocket guide also shows the progression of disease. Notice it also gives instructions on behavior modifications, and what the provider should do. It also helps the provider know what the should be the urgency of the referral. Pass this around after you show it, also. See AAP Flip Chart and Office Pocket Guide Used with permission by the Washington Dental Service Foundation 13

Caries process 2 Requires 4 factors Tooth Bacteria Food source Time
There are four factors responsible for dental caries. Bacteria in dental plaque adheres to the tooth surface. There are many types of bacteria in the mouth and not all bacteria cause caries. What is the bacteria we most commonly associate with caries? Dental caries occurs when Streptococcus Mutans ingest dietary carbohydrates- sucrose, fructose and lactose. Their byproduct is acid, which, over time, demineralizes, or breaks down, the tooth structure. Used with permission by the Washington Dental Service Foundation 14

Caries process: ongoing balance
2 Caries process: ongoing balance Protective Factors Strength of enamel -Fluoride Adequate salivary flow Pathologic Factors Strep mutans Carbohydrates Reduced salivary flow Caries, like other diseases our bodies are fighting, is a constant battle between protective factors and pathologic factors. Protective factors include the strength of the enamel and the amount of salivary flow. Has there been adequate fluoride available to build and maintain hard tooth structure? Fluoride strengthens the structure of the teeth as they are forming when ingested systemically and makes the outer layer of enamel stronger when given topically. We also consider the amount of salivary flow. There should be adequate amounts of saliva present to buffer the acids and bring the mouth back to healthy pH levels, as well as rinse away food particles. Pathologic factors include caries-causing bacteria, amount and frequency of fuel source for those bacteria, and reduced salivary flow. When there are too many pathological factors present, the teeth are at higher risk for caries. These must be counteracted by decreasing the pathological factors and increasing the protective factors. No caries Caries Used with permission by the Washington Dental Service Foundation Note: A printable version of the CAT is located in Section 3 of the speaker’s kit. Instructions for using the CAT can be obtained from the AAPD Web site at Note: A printable version of the CAT is located in Section 3 of the speaker’s kit. Instructions for using the CAT can be obtained from the AAPD Web site at 15

Used with permission by the Washington Dental Service Foundation
2 Caries process and diet ← Plaque level acids → Regular meals Regular meals plus frequent snacks This graph shows the difference between eating carbohydrates at mealtimes versus mealtimes and frequent snacking. Bacteria produce acids in the mouth for minutes after the ingestion of carbohydrates. The steady source of sugar/carbs results in almost continual exposure of the teeth to acid. Remineralization occurs when acid is buffered, primarily by saliva. Frequent ingestion of carbohydrates, or the fuel source for the bacteria, then, results in virtually no rest period for the enamel to remineralize. Is the mouth able to recover from the increase in acid production, or is it in a steady state of demineralization? Practically speaking, the child will, at least occasionally, eat snacks or drink beverages with carbohydrates between meals. Encourage carbohydrate rich foods to be limited to mealtimes, and encourage drinking water after snacks to help return the mouth to a healthy pH. Used with permission by the Washington Dental Service Foundation 16

There are certain foods that are more “tooth friendly” than others
There are certain foods that are more “tooth friendly” than others. This take home sheet for parents is a guide to choosing healthy snacks for oral health. This handout, like all our other handouts for parents, comes in English and Spanish. It is on your flash drive.

Caries process and transmission
2 Caries process and transmission Bacteria established by age 2 Natural process occurs through normal activities Encourage regular dental care for pregnant women and mothers of infants How do children get these cavity-causing bacteria? Transmission of oral bacteria is through saliva, in normal day-to-day activities. The transmission of oral bacteria appears to be primarily from mother to child, or from the person who spends the most waking hours with the child. Surprisingly, the child’s oral bacteria is determined by the time he is 2 years old! What kind of activities could increase this transmission of bacteria through saliva? (Babies put their hands in the mouths of their mothers and into their own mouths, mothers clean pacifiers with their own mouths, saliva is shared by sharing utensils and toothbrushes.) Recognizing that these bacteria are passed from mother to child makes it important to instill the message to the mother that her own oral health is important. If she can minimize the bacteria load in her mouth by improved oral health, she is less likely to pass pathologic bacteria to her child. In addition to recommending regular dental care to pregnant women and mothers of young children, good oral hygiene, the use of xylitol gum, and chlorohexidine rinses can decrease bacterial loads in the mouth. Key Messages then, are: Don’t decrease loving contact with infants, but Do decrease maternal oral bacteria Consider Dental Referral of expectant mothers and those with infants and toddlers See Handout and : Guidelines for Oral Health In Pregnancy 18

Why do pregnant women need a healthy mouth?
2 Why do pregnant women need a healthy mouth? Reduces bacteria in mouth that can cause caries and gingivitis Less bacteria passed to baby in the first two years of baby’s life Research has shown that having gum disease while pregnant may cause pre-term births or low birth weight Mother learns importance of early dental intervention for her baby Recognizing that these bacteria are passed from mother to child makes it important to instill the message to the mother that her own oral health is important. If she can minimize the bacteria load in her mouth by improved oral health, she is less likely to pass pathologic bacteria to her child. There is also research that supports the link between gum disease in the pregnant woman and unfavorable birth outcomes, low-birth weight or preterm deliveries. Lastly, when the mother accesses dental care during pregnancy, she is usually given great information on the importance of early oral health care for her baby to prevent disease. Research has shown that whether or not a pregnant pt had dental insurance benefits did not increase utilization of dental services, so it is important to educate pregnant women on the importance of getting proper dental care during pregnancy. JADA 2009;140; 19

Is dental treatment safe during pregnancy?
2 Is dental treatment safe during pregnancy? All dental treatment safe during pregnancy, including xrays, cleanings, fillings and extractions Getting regular dental care during pregnancy can prevent gingivitis and improve the health of the gums, which often get red and puffy during pregnancy Getting a dental infection during pregnancy can be dangerous to the mother and baby There are many conflicting messages regarding safety of dental care during pregnancy. The national Consensus Statement on oral health care during pregnancy is an excellent resource for medical and dental providers. It outlines the importance of good oral health as well as early referral to a dental home for the pregnant woman. You can access this document at the website listed here. Many people don’t know that good oral hygiene and regular dental care is important for the pregnant woman. Pregnant women who have a dentist should continue their regular schedule of routine care. All pregnant women should see a dentist no later than the second trimester to make sure that they don’t have cavities that could lead to infection. Additionally, the dental provider may recommend xylitol gum or chlorohexidine rinses to reduce harmful bacteria. Pregnant women often have gingivitis and/or periodontitis while pregnant. By seeing the dental provider early in pregnancy, the pregnant woman will get valuable education on care of her mouth. Neglecting dental care during pregnancy can lead to a more severe dental infection, which can put the mother and unborn child at risk, particularly if the treatment involves more aggressive medications and treatment options. There is no evidence that shows having dental procedures completed during pregnancy is harmful. In fact, it is more harmful to the mother and the baby to put off dental treatment. The dental provider will time treatments to make the patient most comfortable and be able to complete treatment, particular urgent needs. Women on OHP who don’t qualify for dental benefits usually qualify while pregnant, so this is a great time to encourage they use this benefit. Now with the additional CAWEM benefits reaching all corners of the state has increased women who have dental benefits. Many women who are pregnant do not know that it is safe to get dental treatment during pregnancy, so advocating for them to access their benefits is very important. Please note, we cannot get more copies of this document any more. You can show YOUR copy of this consensus statement, but they will have to download it for themselves on this website address. See : Oral Health During Pregnancy Consensus Statement 20

Giving your baby a head start on a healthy mouth
2 Giving your baby a head start on a healthy mouth Mother is often the family member who establishes good eating and brushing habits for entire family Mothers should model good brushing and eating habits Start brushing baby’s teeth as soon as the first tooth erupts Only put breast milk, formula or plain water in bottles and sippy cups Educating the pregnant mother on oral health for her and for her young child is a great way to encourage healthy oral health habits that can last a lifetime. The mother is often the person in the family who establishes eating patterns and hygiene patterns, so when she understands the importance of a healthy mouth and good nutrition, these habits can be instilled in the family early. Here are some specific tips for pregnant women and mothers of babies. Changes to your body when you are pregnant may make your gums sore, puffy, and red if you do not brush and floss every day. - If you can’t brush your teeth because you feel sick, rinse your mouth with water or a mouth rinse that has fluoride. If you vomit, rinse your mouth with water. It is best to add a teaspoon of baking soda to the water to neutralize the acid in the mouth. Brushing twice a day with fluoridated toothpaste will help keep the enamel of the teeth strong. Use just a small smear of toothpaste to reduce the likelihood of toothpaste causing nausea. Minimize eating high carbohydrate snacks throughout the day, but choose tooth healthy snacks. Start brushing babies teeth as soon as they erupt with a small smear of fluoridated toothpaste. Avoid the temptation to put juice or sweet beverages in bottles or sippy cups. Establish the habit early of putting just plain water, or milk/formula in bottles and sippy cups. 21

Why is risk assessment important?
2 Why is risk assessment important? Risk status determines: Age of first dental visit – as early as when the first tooth erupts Use of fluoride Extent of nutritional and hygiene counseling The first thing we are asking medical providers and dental providers to do is to determine the patient’s risk for caries. What is the purpose of the risk assessment? When risk of caries is assessed, it is a much better utilization of time and resources to address the problems to the children who need it most, just as you would spend more time talking about diabetes when a child is at high risk for diabetes. A child with a high risk of early childhood caries will need to be referred to a dental home sooner than a child at low risk. It was earlier mentioned that referrals to a dental home should take place as early as 6 months old, or when the first tooth erupts, for children at high risk for caries. Aggressive intervention of fluoride varnish and daily fluoride use is dependent on the risk. The US Preventative Task force has now recommended that all children under the age of 5 should get at least twice yearly fluoride varnish. Children at high risk of decay would benefit from more frequent varnish applications. The twice daily use of fluoridated toothpaste is recommended as soon as the first tooth erupts for all children. The amount of time spent on anticipatory guidance and education will also be determined by the level of caries risk. Putting time and resources into children at high risk for caries has the greatest benefit. Used with permission by the Washington Dental Service Foundation 22

2 Who is most at risk? Fortunately, the medical provider has already gathered much of the information needed to assess caries risk. Medical histories and intake forms often have built in triggers to help gathering information. This is the OrOHC Caries Risk assessment for children 0-5. The AAP, AAPD and ADA all have caries risk assessments that can be used to determine the child’s risk for caries. As you can see, many of these are things you are already determining when asking about dietary habits and contemplating medical issues. We already discussed the transmissable nature of the disease, as well as food choices which can contribute to caries. We also discussed how fluoride strengthens the enamel and makes it less prone to acid attack. If a child has no access to a dental home or fluoride varnish through other sources, they are at higher risk. Children from a low socioeconomic group have a higher risk of early childhood caries for many reasons. (If possible, have the attendees list these reasons, or at least some of them…A high risk factor for unmet dental needs is lack of dental insurance. OR has a complex Medicaid system that is often daunting and difficult to navigate, so sometimes even when children have insurance, they have unmet medical and dental needs. Parents without a regular source of dental care for themselves may not have a regular dentist or may not have resources to pay for dental care. In addition, they may have significant dental fears or they may not understand the importance of oral health for themselves or their children. Children in rural areas suffer more untreated decay than children living in cities. There are fewer options for low income dental care in rural sites, and minimal transportation options to dental providers make accessing the care challenging. Parents with less education are less likely to seek preventative dental services for themselves and their children. Persons of low socioeconomic status may have a lower oral health literacy level, or the ability to understand and apply oral health messages. The cost of fresh foods and healthy snack options is higher than for unhealthy snacks.) Children with special health care needs are at particularly high risk for caries and other serious health problems. Even brushing the teeth on some children with special needs can be more challenging than for healthy children. ( I let the participants list how these children might be at higher risk than other children) Additionally, many medications can put the teeth at risk for caries. Many medications reduce saliva flow. Oral suspensions for chronic diseases are usually high in sugar and have a thick, sticky texture. (I let the participants come up with this on their own by guiding them with questions) It is important to educate parents on ways to minimize the destructive nature of these medications on the teeth. Brushing the teeth, or at least having the child rinse the mouth with water after taking the medications are two educational tips for parents. Tooth brushing techniques may need to be modified depending on the child’s health care needs. Sometimes powered toothbrushes or toothbrushes with larger handles are easier for parents and children to use. It was mentioned that bacteria harbored in plaque puts a child at risk for caries, as does any white spot lesions. If a child has two or more of these risk factors, they are at high risk of decay. See handout and : OrOHC Caries Risk Assessment <6 Ref –Featherstone,JDB. The continuum of dental caries--evidence for a dynamic disease process. J Dent Res 2004, 83 Spec No C:39-C42, Note: A printable version of the CAT is located in Section 3 of the speaker’s kit. Instructions for using the CAT can be obtained from the AAPD Web site at

Be conscientious of cultural diversity
2 Increased rate of dental caries in certain ethnic groups. Beliefs about health, disease, diet and hygiene in different cultures may impact practices and child- rearing habits. While ethnicity alone is not a risk factor for dental caries, there are certain populations are at higher risk for dental caries than others. American Indian, African American and Hispanic children are disproportionately affected by caries, even controlling for socioeconomic factors. Among these populations there is an increased rate of dental caries and decrease in dental visits. (2000 surgeon general’s report) Beliefs about health, disease, diet, and hygiene in different cultures may create additional oral health risk factors through dietary/feeding practices and child-rearing habits. I usually take this time to let the group discuss their particular population of patient diversity and what they have encountered that might play into increased caries risk. 24

Oral health education and anticipatory guidance for parents/caregivers
Module 3: Oral health education and anticipatory guidance for parents/caregivers Are there any questions before we move on to the next module? Our next module takes us through the education and anticipatory guidance to give the parents. It is one thing to understand the concepts as health care providers, but it is sometimes difficult to teach using words or concepts that parents understand or are motivated towards change. Providing anticipatory guidance that is consistent with messages the parent hears from other sources in a way that they can put it into practice is the key to behavior change.

Healthy primary teeth are important!
3 Healthy primary teeth are important! For normal development For space maintainers For cavity-free permanent teeth For keeping treatment costs low First Dental Visit Ave. 5 Year Cost Before age 1 $263 After age 1 $447 Misconceptions about the importance of baby teeth contribute to the reason children are not accessing dental care. It is new information for some people that primary teeth are important for normal development of their child. We have already discussed how baby teeth are important for normal development and overall health of the child. Costs of treating severe Early childhood caries in the hospital can cost up to $10, According to CareOregon statistics, CareOregon hospital dentistry costs paid per member doubled between 2003 and Low-income children who have their first preventive dental visit by age one are not only less likely to have subsequent restorative or emergency room visits, but their average dentally related costs are almost 40% lower ($263 compared to $447) over a five year period than children who receive their first preventive visit after age one.

Anticipatory guidance
3 Anticipatory guidance Early childhood caries is: TRANSMISSIBLE PREVENTABLE TREATABLE When providing specific anticipatory guidance for parents, keep the message simple! Caries are transmissible, preventable and treatable! Our educational tools can aid you in providing timely information for parents. 27

Motivational interviewing (MI)
3 Motivational interviewing (MI) Goal of MI is to establish rapport with the parent/caregivers and then discuss a “menu of options” for infant oral health and caries preventive behavior. MI focuses on techniques such as: Open-ended questioning Affirmations Reinforcement of self-efficacy Reflective listening Summarizing MI is a technique to engage the parent in the active participation of improving the health of the child. MI includes establishing a rapport with the parent and providing a menu of options for improved oral health and caries prevention behavior. They help the parent to identify discrepancies between their current behavior and the goal of oral health for their child. MI differs from traditional medical counseling by creating a collaborative effort where the patient and practitioner are equal partners and work together to improve the health of the child. Engaging the parent while gathering information by asking open-ended questions, building on their strengths and advocating small incremental changes helps encourage partnership rather than the provider telling them the laundry list of changes that are needed. If you want more information on motivational interviewing, we included more tips on how to implement motivational interviewing. We adapted the Explore-Offer-Explore guide from WIC to be oral health specific. See handout and Explore-Offer-Explore

3 MI menu of options This tool was adapted from the Indian Health service to help with motivational interviewing. This tool can be used chair side to give the parent a visual of changes they could choose to make in regards to the health of their child. (Pull out laminated version from the toolkit, also direct them to the one in their folder.) For example, you could say, “Here is a list of topics that came up so far during our conversation. Which of these would you like to focus on during our last few minutes together?” And then circle the one or two changes they would like to make by the next appointment. Notice that the tool has more pictures and less words. It is often helpful when teaching new information to limit the message to simple messages, such as “choose fruits and vegetables for snacks” or “drink plain water between meals” rather than go into details about the reasoning behind the suggestion. If the patient wants more information, you can provide it. This tool is in your binder, in English and Spanish. It is also on your flashdrive. See handout and : Motivational Interviewing Tool

Anticipatory guidance/education
3 Anticipatory guidance/education **We no longer provide posters free of charge. They can print them off the flash drive or our website, or can order them from us at cost We designed our educational posters with the clinical office in mind with regards to size and content. There are posters which address pregnancy, babies and toddlers, as well as toothbrush and toothpaste tips. The posters are available in English and Spanish. Our educational materials are designed to provide anticipatory guidance from pregnancy through toddlers. Anticipatory guidance is a teaching technique that focuses on the needs of a child at each stage of life. Practical, timely information for parents and other caregivers allows them to anticipate impending changes and maximize their child's oral and general health potential. We have created posters to help emphasize key messages to give the parents. The pregnancy poster gives parents information about the importance of minimizing the transmission of disease to their child. The babies and preschooler posters summarize preventing caries through behavior modification. We share our posters with WIC , Head Start and Early Head Start to improve the consistent messaging for the parents. Our goal is to encourage medical providers, dental providers, WIC counselors and Head Start counselors to teach consistent messages so that the parents can understand that they can prevent dental disease in their children. Consistent messages decreases confusion and reinforces oral health messages in the various places that patients and parents are receiving oral health messages. The posters are also on the flash drive if you want to reprint more, or if you want to print in a smaller, hand out form to send home with families. See : Posters 30

Use diverse formats for delivering oral health education
3 Use diverse formats for delivering oral health education AAP flip chart Pocket guide Posters Handouts Puppets or plastic models Elmo You Tube Video ** we do not have more DVD’s. I added the You Tube video link to help with brushing at home, or can be played in the office. Using different modes of education can reinforce key messages. There are many different ways to teach oral health to your patients. The DVD Early Childhood caries can be played in the waiting room or the exam rooms. We also have provided the AAP flip chart and the pocket guide that are great educational tools. We have added several handouts on oral health and healthy eating tips in your binders. There are many other great resources available, and we have included those in the resource section of the flash drive. Language barriers make gathering information and educating a challenge. Whenever possible, use interpreters or materials printed in the patient’s primary language to decrease misunderstandings. While language barriers exist, often the more important thing to consider is the differences in health literacy. Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health care decisions. Use an appropriate literacy level of medical terms, limiting unnecessary statistics or difficult concepts when collecting data and providing education to the caregiver, respecting the care giver’s level of health literacy, as well as the possible language barrier. Using handouts that include more pictures than words can help bridge these gaps in health literacy, as well as using more common words interchangeably with medical terms. Strive to keep the information accurate while simplifying the message.

Diet and feeding: 0-12 months
3 Diet and feeding: months Breastfeeding does not increase the risk for caries Hold infant for bottle and breastfeeding No bottles at bedtime/nap (or use plain water only) Introduce cup at 6 months, wean bottle at months Avoid constant use of sippy cup, pacifier Introduce appropriate snacks Encourage rinsing the mouth out with water Specific information for prevention of ECC through diet and feeding are similar to information medical providers are already giving their parents for healthy dietary habits. While breastfeeding does not increase the risk for caries, any prolonged feeding, or grazing, without cleaning the mouth, can put a child at risk for decay. Encourage to hold the baby during feedings and not prop the baby against a bottle or the breast. Use water at night time to prevent pooling of milk in the mouth if the infant falls asleep with a bottle. We suggest weaning the infant from the bottle between months. Children should not constantly use a sippy cup unless there is only plain water in it. Clean pacifiers (not dipped in honey or sugar) are fine, however it is good to remind parents that using a pacifier or thumb sucking can affect the shape of the mouth and how the top and bottom teeth line up, so pacifiers should be dropped between 2 and 3 years old. We discussed how snacking on carbohydrate rich foods, or “grazing,” doesn’t allow for saliva to buffer the acids in the mouth and return it to a healthy pH. Some parents will continue to give several snacks throughout the day regardless of our suggestions. Encouraging rinsing the mouth with water after snacks or juice can help return the mouth to a healthy balance. 32

Diet and feeding: toddlers
3 Diet and feeding: toddlers 1 – 2 years Discontinue bottle feeding at months Avoid excess juice Avoid sweet, sticky snacks – dried fruit, crackers, candy Reserve soda, candy and sweets for “special occasion” treats 2 and older Choose fresh fruits, vegetables, or whole grain snacks As medical providers you are already encouraging parents to make healthy choices when preparing meals and snacks for their children. Since so much of this information is information you already give to your patients/ parents, adding a tag-line such as, “keep in mind that these healthy snack choices also can prevent your child from getting cavities” is a way to integrate anticipatory guidance. Good preventive medicine for obesity too! Used with permission by the Washington Dental Service Foundation 33

Oral hygiene 3 < 1 year Clean mouth with cloth or soft toothbrush
As teeth erupt, use smear of fluoridated toothpaste 2x/day 1-6 years Brush 2X/day using half-pea-sized amount of fluoridated toothpaste Parent/caregiver performs and supervises > Age 6 years Brush 2X/day with pea-sized amount of fluoridated toothpaste Practicing good oral hygiene is another way to prevent caries, and giving tips for improving daily oral hygiene can improve risk for caries and outcomes. Show the parent how to use lap method of viewing children’s teeth, much like you will use for the knee-to-knee screening. Another way is to have the child sit in the parents crossed ankles and rest his head in the lap of the parent. This allows the parent to see in the mouth with adequate lighting. Use doll to demonstrate knee-to-knee and this method Wipe a baby’s gums with a soft cloth before teeth erupt. Use an appropriate sized toothbrush with smear of fluoridated toothpaste. Remember to have the child spit out the toothpaste and not rinse the mouth with water afterward. This method allows the teeth to bathe in fluoride after brushing. Young children do not always spit out their toothpaste, so it is important to use just a very small amount of toothpaste. We recognize that there is confusing information about when to start using fluoridated toothpaste, so we have created a cheat sheet that you may use. It is NOW recommended by ADA, AAPD , AAP, and the US Prev Services Task Force that all children at use fluoridated toothpaste twice daily when the first tooth erupts. Be consistent with brushing before bed and after breakfast, but brushing at nighttime is most important if the parent will only commit to once daily. Brush all surfaces of the teeth, lifting the lip to ensure plaque removal at the gumline. Young children have difficulty brushing all surfaces, so daily supervision is important. As providers teaching tooth brushing techniques, it is helpful to use the tell-show-do method to ensure comprehension. . See handout and : Recommendations for Fluoride Usage 34

Adapted from the Washington Dental Service Foundation
3 Sources of fluoride Systemic Water fluoridation % in Oregon Fluoride supplements Fluoridated bottled water Topical Fluoride toothpastes Fluoride varnish Water fluoridation Fluoride rinses Gels, foams We talked about fluoride’s role in strengthening teeth. System fluoride is fluoride designed to be ingested. Many years of research has shown that without a doubt the most cost-effective way to reduce caries is optimum levels of fluoridation in the water supply. Despite the research on safety in water fluoridation, OR ranks low in the number of water systems with 1 ppm fluoride in the water, at only 22.6 %. The Centers for Disease Control and Prevention reports that for every $1 invested in fluoridation, $38 in dental treatment costs is saved. In addition, Medicaid dental programs costs as much as 50% less in fluoridated communities compared to non-fluoridated communities. Supplementation in the form of drops and tablets is still advocated when fluoridated tap water is not available. Depending on the level of risk for caries the child has will determine how much added fluoride will be recommended. That being said, the Center for Disease Control reported in 1999 that “ Laboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children.” There are many topical fluoride modalities designed to strengthen the outer layer of the enamel of the erupted teeth. In addition to the many modalities patients can use at home, high concentrated professional applications can be applied in clinical settings. Medical professions may apply fluoride varnish for children at high risk of caries. Fluoride varnish is the preferred in-office fluoride treatment because there is little to no risk of fluoride toxicity when properly applied, as apposed to gels and foams which are easily ingested. Adapted from the Washington Dental Service Foundation 35

3 Fluoridated water How much fluoride is in my patient’s drinking water? To learn how much fluoride is in a community water system, link to the Centers for Disease Control’s “My Water’s Fluoride” at: Knowing how much fluoride is in the water is important. It is also important to remember that many people do not drink tap water, so optimum levels of fluoride in the water may not provide adequate fluoride amounts to children who drink bottled water. Ask the parent if the child drinks the tap water in fluoridated communities. Fluoridated bottled water is now available in stores. This link directs you to a great website that shows how much fluoride is in a community’s water system.

Fluoride supplementation
3 Fluoride supplementation ADA, AAPD, AAP and CDC recommendations Age <0.3 ppm ppm >0.6 ppm 0-6 mo None 6 mo-3 y 0.25 mg/d 3-6 y 0.50 mg/d 6-16 y 1.0 mg/d The ADA, AAPD, AAP and CDC all recommend fluoride supplementation for children who do not drink tap water that is optimally fluoridated. No doubt this is the chart many of you use to determine supplementation. 37

Fluoride varnish 3 Effective Safe Easy 30% - 69% decrease in caries
No preservatives, BPA, dyes No evidence-based contraindications Easy Takes 30 seconds to apply Photo: ICOHP, WDSF Applying fluoride varnish is effective in caries reduction. Research studies show that the application of fluoride varnish can reduce tooth decay between 30% - 69% in primary teeth of high-risk children. Fluoride varnish is also safe. There are no preservatives, BPA or added dyes. Fluoride varnish does not absorb through the stomach wall, so it does not make a person’s stomach irritated and you cannot get toxic amounts when properly applied. Since fluoride varnish is not systemic, it does not increase the risk of fluorosis. The only known contraindication to some fluoride varnishes is pine nut allergy, although there have been reports of sensitivity when there is a irritation to the gum tissue present. Please see manufacturer’s recommendations. And applying fluoride varnish may only take an additional 30 seconds to apply when done during the oral exam. Off label use reference- J Am Dent Assoc. 2006;137: 1151–1159 Use of fluoride varnish for caries prevention has been endorsed by the ADA, but remains an “off-label” use of the product, because it is not cleared for marketing by FDA for this purpose.

3 Treatable Success in treating caries is dependent upon parents/caregivers taking an active role in their child’s oral health. Intervention with fluoride varnish can reverse early stages of caries. Early access to a dental home with regular maintenance schedule is important. Help parents/caregivers understand that their involvement is key to managing their child’s risk of oral disease. Success in treating early childhood caries happens when caregivers understand that they are responsible to take an active role in preventing disease by changing improving daily oral hygiene and dietary behaviors. In addition, intervention with fluoride varnish at the early stages of decay can reverse the decay process and decreases the chance of more invasive treatment later. It is important we access these children earlier to minimize expensive and invasive dental treatment. Lastly, accessing a dental home early can decrease the prevalence of severe early childhood caries by careful management of oral health habits and disease progression. Once the child is established in a dental home, the dental home will applying f- varnish, and the medical provider can just reiterate the importance of dental visits, and provide additional applications of varnish if the child needs them. If there are challenges with access to the dental home, the child may only be receiving the varnish in the dental home once or twice a year. Other places they might get varnish is at WIC or Head Start. Do you know if the children in your area receive varnish at WIC or Head Start?

Module 4: Implementation and workflow
Are there any questions before we move on to the next module? Time to move on to how to implement early childhood caries prevention services

The early oral screening
4 The early oral screening Your oral exam of the child may take no more than 1 minute: Knee-to-Knee, Lift the Lip Start Finish 1 minute Photo: Nick George / The Chronicle <<<<<<<<<<<<<use doll (I got mine at ToysRUs)>>>>>>>>>>>>>>>>>>>>>>> As a primary care provider, the visual screening of the child may take no more than one extra minute of your time, since you are already looking in the mouth. Place the child on the parent’s lap, facing and straddling the parent. Sitting knee-to knee with the parent, lay the child back onto your lap. This allows you to use the overhead lights to see, and allows both you and the parent to see inside the child’s mouth. The parent holds the child’s hands and legs so you can cradle the head in your hands and use your fingers to look into the mouth. If you are more comfortable using an exam table, position yourself in a similar manner, near the head, and have the parent hold the child’s hands and arms. Used with permission by the Washington Dental Service Foundation 41

What to look for 4 Lift the lip to inspect soft tissue and teeth
Eruption sequence Summarized in the AAP flip chart Assess oral hygiene Presence of plaque Presence of white spots or dental decay Signs of abscesses in the gums Provide education on brushing and diet during examination Apply fluoride varnish When looking in the mouth it is important to lift the lip, allowing you to see the entire teeth and gums. Use this time to show and explain to the parent what you are doing and what you are assessing. Make sure teeth are coming in when and where they are supposed to. It is not important to memorize eruption sequences, but a general understanding of approximate eruption is helpful. For instance, a 2 ½ year old should have most or all her 20 primary teeth. This is summarized in your AAP flipchart Assess oral hygiene (eg, presence of plaque or debris on the teeth). Plaque is often tooth colored, but gives a textured look to the tooth surface, as apposed to a shiny smooth texture of a clean tooth. Remove plaque with gauze to look for white spots. Lift the lip to assess the area of the gums where the ends of the roots are for abscessed teeth. Provide education about removal of plaque and debris using the appropriate-sized toothbrush. Discuss dietary/snacking habits, giving appropriate recommendations as needed. Apply fluoride varnish for those children at high risk of caries. See AAP Flip Chart and Office Pocket Guide Used with permission by the Washington Dental Service Foundation Note: The following slides provide participants with examples of healthy teeth and dental decay.

Fluoride Varnish Video
4 Fluoride Varnish Video We have an example of how a risk assessment, screening, and fluoride varnish can be done in the medical office. Make sure this is set up in advance… or you can hyperlink it.

Fluoride varnish application
4 Fluoride varnish application Have supplies ready Position the child Knee-to-knee Table top exam Toothbrush often prompts opening! Lift the lip Quick visual inspection This document will take you through the steps of fluoride varnish application. It may be handy to post it near where the fluoride varnish toolkit is stored. Have Everything Ready–it may be easiest to have individual set-ups made in advance, wrapped in a paper towel, to be in the exam room so the supplies are handy. Some providers find it helpful to stir the fluoride varnish and put it on your glove first, so it is close to the child and you are not trying to hold the dispenser at the same time. Position the Child either knee to knee, or table top Use toothbrush to prompt opening, if needed. Slide the toothbrush between the teeth and cheek, and use the toothbrush as leverage to open the mouth. Lift the lip Visual inspection See Handout and : Fluoride Varnish Application Used with permission by the Washington Dental Service Foundation 44

Fluoride varnish application
4 Fluoride varnish application Dry teeth with cotton gauze Dry teeth are ideal, as it better facilitates fluoride uptake, but is not absolutely necessary. So swipe the gauze quickly across the teeth Photos: ICOHP Used with permission by the Washington Dental Service Foundation 45

Apply fluoride to all surfaces with applicator or finger
4 Fluoride varnish application Apply fluoride to all surfaces with applicator or finger “bendabrush” Quickly paint the varnish on both sides of the teeth and chewing surfaces. I usually put the varnish on my fingers and smear it on the teeth, but you can use the applicator. Ask if the attendees have used it and how they have found it works best for them. If you have a very uncooperative child and think that you can only get the varnish on a few teeth, remember which teeth are most vulnerable and be sure to start at those areas. You can then sit the child up, and have the parent cuddle them while post-varnish instructions are given. Reassure the child by rubbing his back while giving the instructions. These pictures and instructions are summarized in the AAP flipchart See AAP Flip Chart Photos: ICOHP Used with permission by the Washington Dental Service Foundation

Post varnish instructions
4 Post varnish instructions Child may take a drink of water immediately No brushing until the next day Can skip fluoride supplement for the day Ok to drink as usual Avoid hard, crunchy and sticky foods the rest of the day Advise caregiver teeth may be yellow for a day (based on varnish) Repeat every 3 months for children at high risk for caries Fluoride varnish instructions are different than fluoride treatments many of us had as children. The varnish sets with saliva and water, so it isn’t necessary to wait 30 minutes before drinking or eating. However, keep in mind that hard, crunchy foods or hot beverages may wear the varnish off faster, so encourage cool drinks and soft diet for the rest of the day. The varnish ideally should be on the teeth for several hours, and it is ok to encourage the parent to wait on tooth brushing until the next day. Fluoride varnish should be applied 4 times a year for children at high risk for caries. Give take-home instructions provided. These are available in English and Spanish. As you sit the child up after the varnish and the parent is cuddling the child, you can review quickly what the parent is doing well and simple recommendations, using the motivational interviewing guide as a reminder. I might conclude by saying something like, “As you could see, you are doing a great job brushing the front teeth. By lifting her lip in the front while you are brushing, you can make sure you are continuing to do a great of a job at the gumline of those front teeth that are prone to cavities. Work that brush to the back of the mouth by sliding the toothbrush in from the cheek side to reach the grooves of the back teeth that are also prone to cavities.” Lastly, since fluoride varnish is not systemic, it is not necessary for the parent to skip the supplement for the day. However, if the parent is concerned, it certainly won’t hurt if they skip the supplement. See Handout and : What you need to know for parents Used with permission by the Washington Dental Service Foundation 47

Other interventions for ECC
4 Other interventions for ECC Interim Therapeutic Restorations- ITR Stabilizes and treats some caries Minimizes fear for child and parent No anesthetic is needed, quick procedure Silver Nitrate/Silver Diamine Fluoride Used by some dentists to treat infection Initially turns infection black, but follow up care includes tooth colored filling In the past considered controversial, the use of interim therapeutic restorations has become more commonplace in the stabilization of early childhood caries. The American Association of Pediatric Dentistry recommends ITR to restore teeth and prevent caries in young patients, children with special needs, uncooperative patients or in situations where traditional restorations are not feasible. With little to no discomfort, early to moderate ECC can be stabilized in a manner of minutes, decreasing the need for referral and extensive hospital-based dentistry. Another intervention used by some dentists is Silver Nitrate Silver nitrate treats the infection, turning the infected area black. Usually there are follow up visits that could include removing the black area and restoring with tooth colored materials. If someone wants more information on Silver Nitrate, and the local providers use silver nitrate, have the local provider supply this information. **since silver nitrate is not yet considered “best practice” and “evidence based” we cannot support or criticize it’s use when wearing our FT hat. Please refrain from making any judgement yay or nay on silver nitrate, but offer to provide contact information of a provider who uses it to give the information. Or, if it is your office, come back at a different time with your “office hat” on. See : AAPD Policy on ITR 48 48

Key Messages - interventions
4 Key Messages - interventions Fears may keep parent from seeking dental care for their child New methods of treating ECC may minimize traumatic experiences It is not the responsibility for medical providers, community health workers, or child care providers to treatment plan for dental care. But these partners often find themselves in position to encourage families to seek dental care even if they have fears, and to discuss the many contemporary options for treatment of decay. Not all children go to the operating room for treatment of severe ECC and some cases can be stabilized or treated with non-traumatic methods. 49 49

Behavior management 4 Tips for managing child behavior – in office
Utilize your staff who have good rapport with 0-3 year olds. Engage the parent during the exam. Recognize that the child will most likely cry the first few appointments. Utilize knee-to-knee technique or have child in parent’s lap or chest while reclined in the dental chair. Explain to the parent what you are looking for in the mouth. Positive reinforcement – for child and parent. Medical-Most of you are very comfortable with managing children in the office. Engaging the parent so that you can educate him/her is important. Many of these techniques are mostly to help a dental provider who is not comfortable seeing young children. Having a 0-3 year old in a general dentist office is not common and many general dentists are not comfortable treating or even examining the very young child. Use the knee-to-knee technique to see in the mouth. The young child is much more comfortable with the parent holding their hands and resting on their lap. Using a calm soothing voice and minimizing additional noises decreases anxiety. Provide positive reinforcement of good behavior, as well as positive reinforcement for good habits the parent and child have adopted at home. As the child gets older, explain to both the parent and toddler what you are doing and engage them in practicing tooth brushing skills. Giving positive reinforcement for good behavior and results makes the appointment much more pleasant for the parent and the child. If you are having difficulty getting the child to open, you can slide the toothbrush into the corner of the mouth and leverage the mouth open. This will no doubt cause the child to cry for a moment, but then you will have access to seeing the teeth! The child will stop crying after you are done, and the child will be more cooperative at subsequent appointments. As the parent also continues to check the child’s mouth daily, the child will have no trouble at the next appointment. Lack of cooperation at home is a common excuse for parents not being diligent at home. Remind the parent that this habit is no different than other habits we teach our kids to do for their benefit, like taking vitamins or washing hands. The key to habits being formed is consistency, consistency, consistency. If a parent requests tips for behavioral management at home, these techniques are effective at home, also. See : Guideline on Behavior Guidance

Documenting oral health services and findings
4 Documenting oral health services and findings Exam forms Electronic medical records Chart labels/stickers Smart or dot phrases Documenting services is important for many reasons. Not only is it important for billing purposes, but it will help you determine if the child has an improved risk for caries based on what was discussed at the last visit. You can also track whether the patient is regularly seeing a dentist. It will improve the utilization of your time, so you aren’t repeating the same information if it is unnecessary. If you are using paper charts, there are labels available to stick in the charts. Otherwise, in electronic charts, you can add smart phrases to your intake forms to ensure all ECCP elements are covered. . See : chart label template, Smart or Dot Phrases

Parent/Caregiver and Child Arrives for Well Child Visit
(or other visit) Posters, ed materials in waiting room Vitals Signs Taken Medical Assistant tells parent about ECCP (Parent/Caregiver Education) Well Child Exam Medical Provider – Risk assessment, oral screening, anticipatory guidance orders for fluoride based on risk There are many ways a clinic can implement ECCP services into their work flow. Here is an flow chart that diagrams one scenario. No Access to a Dental Home Referral to a Dental Home Immunization Medical Assistant applies fluoride Dental Home

Parent/Caregiver and Child Arrives for Exam
Posters, ed materials in waiting room Dental assistant/hygienist Medical history, ECCP DVD for parents, caries risk assessment, anticipatory guidance, education on oral care specific to child (Parent/Caregiver Education) Dentist Reviews DA/DH findings and education provided, exam, applies F varnish if risk dictates, explain interventions if needed **remove this slide if there are no dental providers at your training There are many ways to implement adding 0-3 year olds in the dental office. Some offices may wish to block off time in the day to devote to babies, while others may want to disperse the appointments throughout the day. Another option is to have a Baby Days and schedule a group of families in a 1 ½ hour block, do all the education at one time, and do the exam at the end of the educational element. I can help you to determine the best approach for your office and design a work flow that best meets your needs. Here is an example of how it might look in your office. (take them through this chart.) Recall determined by caries risk Dentist Interventions including ITR, caries management Pediatric referral If behavioral management or extensive treatment needs necessitate

Parent and Child make appt for Baby Days
WIC, Head Start, medical office, dental office Parent and child arrive for Baby Days Check in, pay, medical history Dental assistant/hygienist ECCP DVD for parents, OHI from front of room, show parents how to provide OH, assist parents individually as parents practice Dentist/Hygienist caries risk assessment, anticipatory guidance specific to child, exam, fluoride varnish, treatment plan review with parent This is an example Baby Days workflow, which is a way to block off a set amount of time, usually an hour to 1 ½ hours, and have a group education session and individual one-on-one instruction and exams. Recall determined by caries risk Dentist Interventions including ITR, caries management Pediatric referral If behavioral management or extensive treatment needs necessitate

4 Baby Days Baby Days is an excellent option for integrating ECCP services for 0-3 year olds in your medical or dental office. Virginia Garcia Memorial Health Center and Multnomah County use this model for the young dental patient. The family units watch a DVD on early childhood caries first. Then they have a group OHI and nutrition lesson. Each parent and child practice brushing while staff goes around individually to give additional assistance and answer questions. Used with permission by the Virginia Garcia Memorial Health Center 55 55

4 Baby Days Then each child gets a knee-to-knee exam and fluoride varnish. Referrals to more comprehensive care are given, if needed. Used with permission by the Virginia Garcia Memorial Health Center 56 56

Oral Assessment (D0191) 4 Service to include:
Anticipatory guidance & counseling. Referral to a dentist to establish a dental home. Documentation in chart of risk assessment findings & services provided. Utilizing a standardized Caries Risk assessment tool that is endorsed by one of the following organizations: Oregon Oral Health Coalition American Dental Association American Academy of Pediatric Dentistry American Academy of Pediatrics For reimbursement of D0191, these services must be included and recorded in the patient chart. Anticipatory guidance/oral health counseling/education, referral to a dentist to establish a dental home, risk assessment, and other services provided all must be included in chart notes. The caries risk must follow a standardized tool by OrOHC (First Tooth,), the Amer dental association, amer academy of pediatric dentistry or amer academy of pediatrics. The OrOHC risk assessment tool is on our website, and the other organizations have theirs on their respective websites. See : OrOHC Caries Risk Assessment 0-5

Fluoride varnish 99188- medical
4 99188 CPT code for fluoride varnish Replaces CDT code D1206, although you may still receive reimbursement for D1206 Is reimbursed twice yearly, and up to 4 times a year with patients documented at high risk The current CPT code for FV is It can be used in place of the CDT code D1206 in the medical home. Both medicaid and private insurers are more likely to reimburse this CPT code. It will be reimbursed twice yearly, unless the child is at high risk and needs it 4 times a year. High risk needs to be documented in the chart. ***Pass out handout and/or give to billing person******* See and handout: Billing and Reimbursement

OHP benefits and eligibility
4 OHP benefits and eligibility OHP clients have increased dental benefits OHP clients should have their DCO listed on their card Providers can check OHP client eligibility and managed care enrollment by using the following methods: Provider Web Portal located on the Web at Automated Voice Response (AVR) at (toll-free); or 270/271 Electronic Data Interchange Batch Transactions The landscape for medicaid benefits has changed greatly in the last few years, and is in constant motion as Oregon determines reimbursable services. See our website to keep updated on which services are covered. In the past, the only way to find out if the client had dental coverage was through the Provider Web Portal. Now that information should be on the client card. There also should be a phone number linking the patient to the DCO to help find a dental home. The CCO usually has a contact person if there is difficulty getting access. See : Simplified Chart of OHP Coverage, OHP Plus Dental Benefits

Adapted from the Washington Dental Service Foundation
4 Ready…set…implement!!! Determine who will deliver the services. Decide when the services will be delivered. Identify an oral health champion. Create a plan for fluoride varnish and materials. Decide who will coordinate dental referrals. Establish process for chart documentation. Create process for eligibility and billing. We have provided a check list to help implement ECC prevention services. It is important to determine who will deliver which services. This could be a combination of the medical assistant, RN, or medical provider, depending on the flow of appointment you will be delivering services during. Decide when the services will be delivered (ex: Coordinate fluoride varnish with immunizations/well-child visits 6 mo, 9 mo, 12 mo, mo, 24 mo, 36 mo. Separate visits for high-risk patients). ) Identify an oral health champion in the office to: (Order supplies (varnish and materials, and that information is on our website) and oral health education materials, Identify and incorporate prompts for providers and patients, Ensure new employees receive training) Create plan for fluoride varnish and oral health education materials (Who will order, where will they be stored, For patient visit, who will get supplies ready (ex: clip dose to chart)) Who will coordinate dental referrals and ensure that dental referral information is in exam room or at front desk Establish process for documentation (ex: for paper charts- stickers or other prompts, intake form, exam form, determine location for tracking-immunization flip tab, dental tab, graphs, history section, etc.) This is important to keep a record of risk assessed, screening done, ant guidance given and referral made if needed Create process for eligibility determination (ex: flag chart) and billing See and toolkit: Ready, Set, Implement Adapted from the Washington Dental Service Foundation

4 It can be done! ECC prevention services can be incorporated into the medical well-child visit, immunization schedule or when the child comes in for treatment of illness. Utilize staff creatively to provide ECC prevention services. DVDs, posters and brochures can increase awareness of oral health and decrease the amount of time ECC prevention services occupy during the visit. There are many models to implement ECC prevention services to your young patients. Well-child visits, immunization recalls, or even if a child comes in for a check up after an illness are all appointments that these services can be implemented. Use posters, brochures and DVDs to teach ECC prevention tips. The website has additional resources, information about how to re-order supplies, and references for the First Tooth project. See for additional resources and references

“First Tooth” training and technical assistance contacts
Karen Hall, RDH EPDH First Tooth trainer/technical assistance or You can also access our website for materials First Tooth Website You can change my contact info to yours… 62

Questions? Please fill out the training feedback form
Are there any questions? Please fill out your training feedback forms. Please fill out the training feedback form

Thank you! Oregon Oral Health Coalition’s Early Childhood Caries Prevention Committee Ford Family Foundation DentaQuest Washington Dental Service Foundation American Academy of Pediatrics National Maternal and Child Oral Health Resource Center

The Oregon Oral Health Program in collaboration with the Oregon Oral Health Coalition’s (OROHC) Early Childhood Cavities Prevention Committee (ECCP) created.

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The Oregon Oral Health Program in collaboration with the Oregon Oral Health Coalition’s (OROHC) Early Childhood Cavities Prevention Committee (ECCP) created.

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Presentation on theme: "The Oregon Oral Health Program in collaboration with the Oregon Oral Health Coalition’s (OROHC) Early Childhood Cavities Prevention Committee (ECCP) created."— Presentation transcript:

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