dental care access and prevention strategies for underserved

Dental Care Access and Prevention Strategies for Underserved Populations

Abscess

Peter Milgrom DDSdfrc@u.washington.edu

May 18, 2006

Objectives

• Learn the basic concepts regarding maternal and child oral health with a focus on pregnancy outcomes and prevention of early tooth decay in children.

• Become familiar with how two community-based intervention programs are addressing these issues.

Basic Issue #1

Poor Oral Health Results in Poorer Pregnancy Outcomes

Dental Care During Pregnancy

Dental treatment can be rendered safely any time during pregnancy*

*American College of Obstetrics and Gynecology, 2000

Spontaneous preterm birth in women with gum disease

0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%

10.0%

No treatment Polish Cleaning

Jeffcoat et al. (2003) Periodontal disease and preterm birth: results of a Jeffcoat et al. (2003) Periodontal disease and preterm birth: results of a pilot intervention study. pilot intervention study.

Spon

tane

ous

Pret

erm

Bir

ths

Gum Problems

• Pregnancy Gingivitis

– Red edges

– Swollen or puffy

– Tender

– Bleed easily during brushing

Basic Issue #2

Treating Dental Disease in Pregnant Women & New

Mothers Reduces Tooth Decay in Children

Maternal Transmission

Preventive care for children requires redefining prenatal care to include oral health.Mother is generally the vector for infection of the child

Anticipatory Guidance?

Xylitol gum--impact of preventing

transmission

Xylitol is a naturally occurring sugar alcohol with 1/3 less calories than sucrose. FDA approved food

additive.

Effective dose 6-10 g/day in gum or mints in 3 doses per day

Treatment of the Mother Resulted in Less Disease in

the Child

• Mothers chewed gum for 2 y beginning 3 mo post partum

• At 5 years the need for treatment was 71-75% lower in the Xylitol group

CHX

Control

Xylitol

Age

dmf

3

2

1

00 1 2 3 4 5 6

(Isokangas et al., JDR 2000)

Basic Issue #3

When a child is born with dental disease, treatments

for that disease must begin as part of well baby

care.

EARLY CHILDHOOD CARIES

• Bacteria grow in a biofilm and are largely resistant to bodily defenses

• Bacteria produce lactic acid as a by product of metabolism of simple sugars and demineralize the teeth

Oral health is important to overall health

• ECC has been associated with failure to thrive• Low-income children suffer 12 times the

number of restricted activity days due to dental problems compared to more affluent children*

*Lewis et. al., Pediatrics, December 6, 2000

White Spots/Before Cavitation

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Home Visits

• Can improve attendance, parental knowledge, and tooth brushing skills

• Unlikely to reduce tooth decay alone

• Message must be succinct, targeted• Need to use MI strategies*Blinkhorn et al., Brit Dent J 2003;195:395-400

When should children been seen?

AAP and AAPD recommend that the first dental visit should occur at 1 year of age

Toothpaste=A highly effective fluoride delivery

system

A small pea size amount of toothpaste weighs 0.4 gm=0.6 mg Fluoride

Manchester Postal Study

• Distributed toothpaste to 5 year olds at home by mail in a randomized design

• Low income families, no fluoridation• Reduced tooth decay by about 16%• Cost effective

*Davies et al., Community Dental Health 2003;20(4):207-10 & 2002;19(3):131-6

Fluoride Varnish

33% reduction in tooth decay in 2 per year applications*

*Helfenstein and Steiner, Community Dentistry and Oral Epidemiology, 1994**Cochrane Library, Issue 4, 2003.

Topical Fluoride in Medical and Public Health Settings

• Varnish can be applied by family doctors, pediatricians, nurses.

• Medicaid reimbursement in some states

• Can be tied to well baby visits

Adapting Fluoride Varnish to Migrant Populations

• Use massed applications• Apply fluoride 3 times within 2

weeks once per year• Equivalent to 2 times per year

Kwoj konan ke bwe en Emman Ni ko nin ajiri nejim?Kwoj konan ke bwe en Emman Ni ko nin ajiri nejim?

Kojerbal Bouta in ni ko ewor Fluoride ie

Kojerbal Bouta in ni ko ewor Fluoride ie

University of Washington Northwest/Alaska Center to

Reduce Oral Health Disparities

Xylitol reduces cavity-causing bacteria

Example #1

Interventions During the Perinatal Period for Mothers

and Child

Early Caries Prevention Community Partners

• Klamath County Health Department• Advantage Dental Plan, Capitol

Dental• WIC• Oregon Institute of Technology• CHC and Medical Plans• University of Washington• Oregon Department of Health

Program Goal

100% of 2-year old children on Medicaid will have no cavities.

Program Components Based on Solid Research

• Home visits – Parent education on dental disease

transmission/ECC. – Follow-up at WIC.– Tool Kits

• Case management to eliminate barriers to dental care.

• Fluoride toothpaste provided to mother and child with instructions to apply to teeth daily from 1st tooth.

• Every pregnant woman and newborn assigned a dental home (managed care) for necessary treatment.

• Chlorhexidine rinses during pregnancy and xylitol gum for the new mother. Fluoride varnish for child per risk.

Challenge: Increase the proportion of pregnant

women who receive anticipatory guidance at

home

80.5%

339/421*

* 2/2004 to 1/2006

Challenge: Increase the number of pregnant women

using dental care

55.8% (eligibles)

69.3%(of those who received a prenatal visit)

No show rate = 9%

Challenge

Keep in contact with the new moms and get the babies in to the dental home

Solution: Staff training, motivational interviewing, better contact information

Example #2

Interventions for Young Children

The ABCD Program The ABCD Program in Washington Statein Washington State

A Partnership to Make Medicaid Child Dental

Services Work

ABCD Goals

• Focus on preschool children from birth

• Intervene early to prevent disease• Set children up for positive dental

experiences• Teach parents to care for their

children’s teeth

Partners

• Local dental societies• Medicaid• Local health departments• University of Washington• Washington Dental Service

Foundation• United Way

Getting Dentists Involved• Appropriate

services for high risk children

• Enhanced skills• Eliminate no-

shows • Pay fair fees• Pay promptly

The Client Perspective

ABCD Administration

EarlyChildhoodAgencies

DentalOffices

UWTraining

Proportion of children with at least one claim in

Spokane County

AGE NON ABCD ABCD<12 135/5577 (2.4%) 45/1004

(4.5%)12-23 72/2295 (3.3%) 257/882 (29.1%)24-35 159/2069 (7.7%) 377/943 (39.9%)36-47 363/2112 (17.2%) 519/908 (57.1%)48-60 958/2638 (36.3%) 346/407 (85.0%)

AGE NON ABCD ABCD<12 135/5577 (2.4%) 45/1004

(4.5%)12-23 72/2295 (3.3%) 257/882 (29.1%)24-35 159/2069 (7.7%) 377/943 (39.9%)36-47 363/2112 (17.2%) 519/908 (57.1%)48-60 958/2638 (36.3%) 346/407 (85.0%)

Mom & Me-Yakima Outcomes: Focus on a Latino Agricultural

Community

• 4,705 children enrolled (1999-2001)

• 51% visited a dentist• MAA dentists increased from 15

to 38• No show rate: 7.3%• Spanish speaking outreach

worker• Access to packing sheds

Nagahama et al. JADA 133:1251-1257, Sept. 2002

Alaska Community Health Aides

• Midlevel dental primary care providers

• High school plus experience, 2 yrs training

• Provide basic pediatric and adult dental care including anesthesia, fillings and extractions

• Work under distant supervision by dentists

Thanks to …

National Institute of Dental and Craniofacial Research, NIH