dental care access and prevention strategies for underserved
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Dental Care Access and Prevention Strategies for Underserved Populations
Abscess
Peter Milgrom [email protected]
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