integrating oral health into routine well...
TRANSCRIPT
Integrating Oral Health into Integrating Oral Health into Routine Well CareRoutine Well CareCathy Ballance MD, FAAPCathy Ballance MD, FAAP
Yasmi O Crystal, DMD, FAAPDYasmi O Crystal, DMD, FAAPD
DisclosureDisclosureWe have no present or past financial interest or We have no present or past financial interest or involvement with any of the products /companies involvement with any of the products /companies that will be mentioned in this presentation. that will be mentioned in this presentation.
In this lecture, we will discuss the In this lecture, we will discuss the ““offoff--labellabel”” use of use of an FDAan FDA--approved pharmaceutical (fluoride approved pharmaceutical (fluoride varnish).varnish).
Severe early childhood caries on 18 mo
Severe early childhood caries on 18 mo
This child has been to the pediatrician 5-6 times
Learning Objectives For This Learning Objectives For This SessionSession1) Review of the 10 key concepts about dental caries and 1) Review of the 10 key concepts about dental caries and oral health oral health
2) Discuss Bright Futures and AAP recommendations for 2) Discuss Bright Futures and AAP recommendations for practitionerspractitioners
3) Share tips and tools for implementing oral health risk 3) Share tips and tools for implementing oral health risk assessments into your practiceassessments into your practice
10. Caries Prevalence10. Caries Prevalence
Caries PrevalenceCaries PrevalenceSuccessesSuccesses-- Prevalence and severity trends have changedPrevalence and severity trends have changed-- 75% of kids have only 25% of the disease75% of kids have only 25% of the disease
ChallengesChallenges-- 25% of children have 80% of the disease25% of children have 80% of the disease-- Caries Experience:Caries Experience:
-- 11 % of 2 year olds, 11 % of 2 year olds, -- 44 % of 5 year olds.44 % of 5 year olds.
High caries experience is associated with:High caries experience is associated with:-- low sociolow socio--economic level/ low health literacyeconomic level/ low health literacy-- parental education levelparental education level-- ethnic minorities and recent immigrantsethnic minorities and recent immigrants
Severe late clinical stages of Early
Childhood Caries (ECC)
Overall impact of the underlying disease on generalhealth and quality of life
CariesCaries a diseasea disease
CavitiesCavities consequence consequence or a sequelae of the or a sequelae of the disease disease
9.9. What is dental caries?What is dental caries?
Dental caries is an infectious, Dental caries is an infectious, transmissible diseasetransmissible disease
Modified by dietary carbohydratesModified by dietary carbohydratesand critically regulated by saliva.and critically regulated by saliva.
Complex and Multifactorial
Dental caries is an , transmissibleDental caries is an , transmissible diseasedisease
Modified by dietary carbohydrates Modified by dietary carbohydrates and critically regulated by saliva.and critically regulated by saliva.
INFECTIOUS
Caused by specific bacteria:Caused by specific bacteria:Mutans streptococci Mutans streptococci : : Strep mutansStrep mutans
Strep sobrinusStrep sobrinusLactobacilliLactobacilliseveral new species identified with ECCseveral new species identified with ECC
complex and different than regular infections complex and different than regular infections
8.
Acid producing bacteria are usually less than 1 percent of the total flora in the biofilm
SEM of Dental Plaque
(biofilm) on a tooth surface
Dental caries is an infectious, Dental caries is an infectious, diseasedisease
Modified by dietary carbohydrates and critically regulated by Modified by dietary carbohydrates and critically regulated by saliva.saliva.
TRANSMISSABLE
Primarily Vertical TransmissionPrimarily Vertical Transmissioncariogenic bacteria are transmitted via saliva cariogenic bacteria are transmitted via saliva from mother or caretaker to child before from mother or caretaker to child before teeth erupt and colonize the teeth shortly teeth erupt and colonize the teeth shortly after their eruptionafter their eruptionHorizontal transmission seems to be Horizontal transmission seems to be more common than previously thoughtmore common than previously thoughtin early childhood and prein early childhood and pre--school age school age childrenchildren
Parental caries status is criticalParental caries status is critical
7.
Oral Flora: How Does Infection Occur?
•• Transmitted mainly from Transmitted mainly from mother or primary caregiver mother or primary caregiver to infantto infant
•• Babies can be infected even Babies can be infected even before the eruption of teethbefore the eruption of teeth
•• Earlier child colonized, the Earlier child colonized, the higher the risk of carieshigher the risk of caries
•• Maternal caries status is Maternal caries status is critical critical
Dental caries is an infectious, transmissible diseaseDental caries is an infectious, transmissible disease
and critically regulated by saliva.and critically regulated by saliva.Modified by dietary carbohydrates
Diet relatedDiet relatedsugars and carbohydrates (especially refined) sugars and carbohydrates (especially refined) promote bacterial growth and provide substrate promote bacterial growth and provide substrate for bacteria to produce acidfor bacteria to produce acid
. Frequency of exposure is critical. . Frequency of exposure is critical. (Vipeholm Study)(Vipeholm Study)
Lifestyle dependentLifestyle dependenthome care and hygiene practices limit the action home care and hygiene practices limit the action of diet on bacteria because it is a time dependent of diet on bacteria because it is a time dependent process.process.
6.
Streptococcus mutans culture showing active cell division. Sucrose leads to
extracellular polysaccharides that stick the plaque together
Substrate: You Are What You Eat
•• Caries is promoted by carbohydrates, Caries is promoted by carbohydrates, which break down to acid.which break down to acid.
•• Acid causes demineralization of enamel.Acid causes demineralization of enamel.
•• Frequent snacking promotes frequent Frequent snacking promotes frequent acid acid attack.attack.
•• Foods with complex carbohydrates Foods with complex carbohydrates (breads, cereals, pastas) are (breads, cereals, pastas) are major sources of major sources of ““hiddenhidden”” sugars.sugars.
•• High sugar content in sodas and High sugar content in sodas and ““naturalnatural”” sugars in juice are a major sugars in juice are a major source of these substrates.source of these substrates.
Dental caries is an infectious, transmissible diseaseDental caries is an infectious, transmissible diseasemodified by dietary carbohydrates and modified by dietary carbohydrates and
CRITICALLY REGULATED BY SALIVA
SalivaSaliva’’s flow and composition alter the s flow and composition alter the caries process on the tooth surfacecaries process on the tooth surfaceHas a major impact on biofilm, plaque Has a major impact on biofilm, plaque and bacterial colonizationand bacterial colonizationSaliva flow is greaty reduced at nightSaliva flow is greaty reduced at night
5.
Diet - Not Just What You Eat, But How Often
• Acids produced by bacteria after sugar intake persist for 20 to 40 minutes.
• Frequency of sugar ingestion is more important than quantity.
Protective Factors
Calcium phosphates
Enamel Plaque/ saliva
Calcium phosphates
Acid pH
neutral pH
remineralization
demineralization
The Caries BalanceThe Caries BalanceProtective Factors
• Saliva flow and components• Fluoride - remineralization• Antibacterials:-
chlorhexidine, xylitol, new?
No CariesCaries
Pathological Factors• Acid-producing bacteria• Frequent eating/drinking of
fermentable carbohydrates •Sub-normal saliva flow and
function
JDB Featherstone
Caries is a dynamic process and reversible up to a specific point4.
When protective factors prevail the result is remineralization
When harmful factors prevail the result is further demineralization that quickly progresses into cavitation which is irreversible
Once the enamel breaks, the process Once the enamel breaks, the process is irreversible and progressiveis irreversible and progressive
Treatment gets progressivelymore invasive, expensive….
cavities only get larger, and fast
…and complicated
Fluoride works primarily via Fluoride works primarily via topical (surface) mechanismstopical (surface) mechanisms
•• Fluoride inhibits demineralization Fluoride inhibits demineralization by adsorbing from solution onto tooth mineral by adsorbing from solution onto tooth mineral
crystal surfaces crystal surfaces
•• Fluoride enhances remineralization Fluoride enhances remineralization combining with calcium and phosphate to make a combining with calcium and phosphate to make a low solubility veneer of fluorapatitelow solubility veneer of fluorapatite--like minerallike mineral. .
•• Fluoride can inhibit plaque bacteria: Fluoride can inhibit plaque bacteria: interferes with enzymes in the cell interferes with enzymes in the cell
3.
Protective Factors
Calcium phosphates
Enamel Plaque/ saliva
Calcium phosphates
Acid pH
neutral pH
Fluoride speeds up remineralization -> less soluble
mineral
Fluoride: Evaluate all sourcesFluoride: Evaluate all sources
•• Check on water fluoridation, and testing well Check on water fluoridation, and testing well waterwater
•• Fluoride prescriptions, giving optimal Fluoride prescriptions, giving optimal instructions for timing and form.instructions for timing and form.
•• Fluoride WaterFluoride Water•• Counsel on toothpaste as a source of fluoride.Counsel on toothpaste as a source of fluoride.•• Encourage on use of tap water when the water Encourage on use of tap water when the water
is fluoridated.is fluoridated.•• Cultural ConsiderationsCultural Considerations
Systemic F Systemic F -- Prescription Prescription SupplementsSupplements
•• Available from physician or dentistAvailable from physician or dentist•• Determine water fluoride level before Determine water fluoride level before
writing prescription!writing prescription!•• Multiple sources of F make prescribing Multiple sources of F make prescribing
challenging!challenging!•• Recommended for patients at Recommended for patients at high risk high risk
who have no F in tap water starting at 6 who have no F in tap water starting at 6 months*months*
•• *JADA 2010;141;1480*JADA 2010;141;1480--14891489
• Fluoride concentrations are up to .7 or .8 ppm
• 8 oz bottles contain aprox. .20 mg F ion
Professionally applied FluoridesProfessionally applied FluoridesBy Pediatrician, family practitioner, or dentist By Pediatrician, family practitioner, or dentist
when children at high risk when children at high risk
Brushing twice daily with a FLUORIDE containing dentifrice is one of the MOST effective ways to control dental decay. Evaluate each child before recommending training toothpaste.
Supervised use of fluoride toothpasteSupervised use of fluoride toothpaste
Curnow, Pine, et al, 2002 reported 56% reduction with supervised brushing twice daily
Cochrane review 2003 reports 24% caries reduction with twice daily brushing
Primary preventive procedure. Twice daily use has greater benefits than once daily. Counsel: child’s caries risk, dispensing right volume of toothpaste onto soft, age- appropriate sized toothbrush, frequency of brushing, and performing/assisting brushing on young children.
A “smear” of fluoridated toothpaste for children less than 2 years of age
A “pea-size” amount for children ages 2 to 5
http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf
2. Caries is an entirely 2. Caries is an entirely preventable diseasepreventable disease
Early identification of risk is crucialHealth providers should work as a team
On reducing caries rates:On reducing caries rates:
fluoride varnish aids in preventing further decay and fluoride varnish aids in preventing further decay and remineralizing incipient lesions on some children remineralizing incipient lesions on some children
On reducing caries rates:On reducing caries rates:
Behavior modification is just as important as Behavior modification is just as important as fluoride varnish or restorative treatmentfluoride varnish or restorative treatment
J ADA, June 2004
On reducing caries rates:On reducing caries rates:
Behavior modification ideally should start with the Behavior modification ideally should start with the mothers.mothers.
J ADA, June 2004
It is important to control the It is important to control the disease process early because:disease process early because:•• 40 percent of Early Childhood Caries (ECC) 40 percent of Early Childhood Caries (ECC)
patients treated for restoration under General patients treated for restoration under General Anesthesia (GA) relapsed, experiencing tooth Anesthesia (GA) relapsed, experiencing tooth decay within the first year after dental surgery. decay within the first year after dental surgery. (Berkowitz RJ, Ca Dent Assoc 2003)(Berkowitz RJ, Ca Dent Assoc 2003)
•• An eightAn eight--year study of children ages three to five year study of children ages three to five found that children having tooth decay in their found that children having tooth decay in their primary teeth were three timesprimary teeth were three times more likely to more likely to develop decay in their permanent teeth. develop decay in their permanent teeth. (Li Y, Wang W, J Dent Res 2002)(Li Y, Wang W, J Dent Res 2002)
•• Mothers who have high caries experienceMothers who have high caries experience•• Lower socioLower socio--economic status and lack of dental economic status and lack of dental
homehome•• EthnicityEthnicity•• Parental education levelParental education levelHowever,However,•• Poverty alone (or being on Medicaid) is not an Poverty alone (or being on Medicaid) is not an
indicator of high riskindicator of high risk•• Belonging to a racial minority or being a recent Belonging to a racial minority or being a recent
immigrant does not automatically place a child immigrant does not automatically place a child on high riskon high risk
Higher caries experience is associated with:
Caries Activity vs. Caries RiskCaries Activity vs. Caries Risk
•• Caries Activity describes the status of Caries Activity describes the status of the caries process (remin/demin) on the caries process (remin/demin) on an individual tooth surfacean individual tooth surface
•• Caries Risk describes the status of Caries Risk describes the status of the whole patient, defined as the the whole patient, defined as the likelihood of the patient of getting a likelihood of the patient of getting a new cavitationnew cavitation..
Risk assessment. Risk assessment. use a form to aid in identification of risk factors and followuse a form to aid in identification of risk factors and follow--upup
Diet RecommendationsDiet Recommendations•• Transition from the breastfeeding / bottle Transition from the breastfeeding / bottle
starting at 9 mo. agestarting at 9 mo. age•• Bottle can be used with only water at nightsBottle can be used with only water at nights•• Sippy cup can be used with regular Sippy cup can be used with regular
beverages during meals or water only beverages during meals or water only between mealsbetween meals
•• Watch for hidden sugars in starches and Watch for hidden sugars in starches and beverages (apple juice and rice)beverages (apple juice and rice)
•• Sticky sweets are the most dangerousSticky sweets are the most dangerous
Targeted counseling: directed Targeted counseling: directed towards modifying the individualtowards modifying the individual’’s s
specific risk factorsspecific risk factors..
Not only for cariesNot only for cariesobesity/diabetesobesity/diabetes
Fight risk factors:Fight risk factors:•• Instruct parents about vertical transmission and Instruct parents about vertical transmission and
frequency of sugar intakefrequency of sugar intake•• Discourage frequent snacking Discourage frequent snacking •• Discourage frequent consumption of sweet Discourage frequent consumption of sweet
drinks. Bottle, sippy cup?drinks. Bottle, sippy cup?
Not only for cariesobesity/diabetes
Oral Hygiene RecommendationsOral Hygiene Recommendations•• Start tooth brushing as soon as the first tooth Start tooth brushing as soon as the first tooth
erupts. Even better, have the baby do the erupts. Even better, have the baby do the teething with a frozen toothbrushteething with a frozen toothbrush
•• Use a smear of fluoridated toothpaste as soon Use a smear of fluoridated toothpaste as soon as the first tooth erupts on high risk children.as the first tooth erupts on high risk children.
•• Supervised vs. unsupervised brushingSupervised vs. unsupervised brushing•• Children should brush alone at ageChildren should brush alone at age……•• Recommend flossing asap if there are no Recommend flossing asap if there are no
spaces between the teeth. Or when the first spaces between the teeth. Or when the first tooth gets loose if there are spaces.tooth gets loose if there are spaces.
Promote Protective FactorsPromote Protective Factors::Encourage supervised brushing with Encourage supervised brushing with fluoride toothpastefluoride toothpasteEncourage drinking of fluoridated waterEncourage drinking of fluoridated waterRecommend healthy snacksRecommend healthy snacks
8 oz bottles contain approx. .20 mg F ion
1. Dental Home1. Dental HomeAAP Oral Health Policy. May, 2003AAP Oral Health Policy. May, 2003
AAPD and ADA PoliciesAAPD and ADA Policies
Infants should have a dental home by age 1 Infants should have a dental home by age 1 or 6 months after the eruption of the first or 6 months after the eruption of the first
tooth.tooth.
AAP Policy Statement Oral Health Risk Assessment Timing and Oral Health Risk Assessment Timing and
Establishment of the Dental HomeEstablishment of the Dental Home”” (2003, policy reaffirmed in 2009)(2003, policy reaffirmed in 2009)
andand ““Preventive Oral Health Intervention for Preventive Oral Health Intervention for
PediatriciansPediatricians””(2008(2008))
•• Assess mother/caregivers oral health statusAssess mother/caregivers oral health status•• Assess oral health risk in infants and childrenAssess oral health risk in infants and children•• Recognize signs and symptoms of dental cariesRecognize signs and symptoms of dental caries•• Make timely referral to a dental homeMake timely referral to a dental home
AAP policy statements……
•• Provide anticipatory guidance and instruction on Provide anticipatory guidance and instruction on proper brushing and flossing as well as proper proper brushing and flossing as well as proper nutrition and dietary practices. nutrition and dietary practices.
•• Make timely referral to a dental home (6 months Make timely referral to a dental home (6 months after the first tooth erupts or by 12 months of after the first tooth erupts or by 12 months of age, whichever comes first)age, whichever comes first)
•• Assess childAssess child’’s exposure to fluoride and s exposure to fluoride and administration of all fluoride modalities based on administration of all fluoride modalities based on an individualan individual’’s caries risk. s caries risk.
Why do we recommend fluoride varnish for Why do we recommend fluoride varnish for very young children?very young children?
•• 41% of US children 2 to 11 have had caries in 41% of US children 2 to 11 have had caries in their primary teeththeir primary teeth
•• To prevent dental caries and in some cases To prevent dental caries and in some cases reverse early dental cariesreverse early dental caries
•• Children with early childhood decay are more Children with early childhood decay are more likely to get more decay likely to get more decay
•• In addition to pain and infectionIn addition to pain and infection……....––
Affects their speechAffects their speech
––
Affects their ability to eatAffects their ability to eat––
Affects their ability to learnAffects their ability to learn
––
Affects the way they feel about themselvesAffects the way they feel about themselves
Possible Barriers to Implementation of Oral Possible Barriers to Implementation of Oral Health Risk Assessment Tool and Fluoride Health Risk Assessment Tool and Fluoride
Varnish Program during well child care visitsVarnish Program during well child care visits
•• AttitudesAttitudes•• EducationEducation•• Lack of time in a routine well care visitLack of time in a routine well care visit•• Lack of insurance payment for procedureLack of insurance payment for procedure•• Lack of manpower (assistants) in the office to Lack of manpower (assistants) in the office to help with the assessments and varnish help with the assessments and varnish procedure. procedure.
Tools to Implement Preventive Oral Tools to Implement Preventive Oral Health Program in Primary Care Health Program in Primary Care
Practice SettingPractice Setting
•• Printed forms for you to keep valuable Printed forms for you to keep valuable resourcesresources
•• AAP/NJ website AAP/NJ website –– www.aapnj.orgwww.aapnj.org•• Oral Health training modules online:Oral Health training modules online:
––
Smiles for Life (endorsed by the AAP)Smiles for Life (endorsed by the AAP)
Risk assessment. Risk assessment. use a form to visualize the caries balance weighing in risk factuse a form to visualize the caries balance weighing in risk factors vs. protective ors vs. protective factors from parent interview to complement the clinical findingfactors from parent interview to complement the clinical findingss
--parent or caregiver with recent parent or caregiver with recent or current caries or current caries --White spots White spots --obvious decay obvious decay
=high risk=high risk
Risk assessment facts: Risk assessment facts: --parent or caregiver parent or caregiver with recent or current with recent or current caries caries --White spots White spots --obvious decay obvious decay
=high risk=high risk
belonging to a low belonging to a low socioeconomic level socioeconomic level does NOT make a child does NOT make a child high risk high risk
use risk factors recorded as basis for counseling and use risk factors recorded as basis for counseling and anticipatory guidanceanticipatory guidance
Supplies Needed to Perform Fluoride Supplies Needed to Perform Fluoride Varnish ProcedureVarnish Procedure
•• Varnish Varnish •• Disposable mirrorsDisposable mirrors•• Exam glovesExam gloves•• GauzeGauze•• Light source/Light source/
head lamphead lamp
Cost of SuppliesCost of Supplies
•• Fluoride varnish kitFluoride varnish kit--approx. $0.86approx. $0.86--$2.00/application$2.00/application
•• Disposable mirrorsDisposable mirrors-- $0.19$0.19--$0.22/each$0.22/each
•• 22”” x 2x 2”” gauzegauze-- $1.12/pk of 200$1.12/pk of 200
•• Head lamp (bicycle)Head lamp (bicycle)-- $10.00$10.00--$15.00$15.00
•• Disposable glovesDisposable gloves-- $0.17/pair $0.17/pair (PVC exam gloves)(PVC exam gloves)
CAN EASILY BE DONE FOR LESS THAN $2.00/PATIENTCAN EASILY BE DONE FOR LESS THAN $2.00/PATIENT
Fluoride Varnish ApplicationFluoride Varnish Application
Clean and Dry TeethClean and Dry Teeth
Apply Varnish with small brushApply Varnish with small brush
covering covering anterior anterior
and and posterior posterior
teethteeth
Fluoride Varnish ApplicationFluoride Varnish Application
•• The varnish hardens The varnish hardens quickly after quickly after application as a application as a yellow filmyellow film
•• The child can have a The child can have a drink of waterdrink of water
Post application instructions for Post application instructions for parentsparents
•• Varnish will set on contact with saliva.Varnish will set on contact with saliva.•• Child can eat or drink right after application Child can eat or drink right after application
but avoid hot beverages and hard or crunchy but avoid hot beverages and hard or crunchy foods for 4 hours. foods for 4 hours.
•• Do not brush your childDo not brush your child’’s teeth tonight. Start s teeth tonight. Start brushing them tomorrow morningbrushing them tomorrow morning
Anticipatory GuidanceAnticipatory Guidance•• Infectious processInfectious process-- vertical transmissionvertical transmission•• DietDiet-- healthy snacks, avoid frequent snacking, avoid healthy snacks, avoid frequent snacking, avoid
sugary drinks, use of sippy cup (only for water), bottle sugary drinks, use of sippy cup (only for water), bottle use, use,
•• BrushingBrushing-- when first tooth eruptswhen first tooth erupts•• FlossingFlossing-- when 2 teeth touchwhen 2 teeth touch•• Need to see a dentist by 1year of ageNeed to see a dentist by 1year of age•• Fluoride sourcesFluoride sources-- smear of toothpaste on small brush smear of toothpaste on small brush
under 2 years; peaunder 2 years; pea--sized amount for ages 2sized amount for ages 2--5 years.5 years.•• Use flipUse flip--chartchart
Follow up from dentistFollow up from dentist
•• Standardized referral form/card that is sent Standardized referral form/card that is sent with patient to dentist and returned to with patient to dentist and returned to primary care providerprimary care provider
•• EHREHR-- template available on oral health template available on oral health websitewebsite
•• Telephone communication between local Telephone communication between local dentist and pediatrician dentist and pediatrician
Medicaid Reimbursement in Medicaid Reimbursement in NJ/billing and codingNJ/billing and coding
• Range for payment for fluoride varnish application in NJ is $15 (Horizon) to $25 (United HC). All Medicaid HMOs as of January 2012 must participate.
• Currently no payment for oral health risk assessment
• Can delegate procedure to NP’s or PA’s• Coding: 99420 DA (CPT) • ???Private insurances to follow?
ExampleExample•• Mary is in your office Mary is in your office
for a 18 month well for a 18 month well child visitchild visit
•• Height and weight Height and weight have progressed have progressed well and she is now well and she is now in the 45in the 45thth% for % for length and the 50length and the 50thth% % for weightfor weight
Risk AssessmentRisk Assessment•• Mary has 12 teeth and Mary has 12 teeth and
has some enamel has some enamel hypoplasia secondary to hypoplasia secondary to her prematurityher prematurity
•• The familyThe family’’s home is in a s home is in a trailer park with water trailer park with water from a wellfrom a well
•• Her mother has decay in Her mother has decay in her teeth and she does her teeth and she does not currently have a not currently have a dentistdentist
Risk FactorsRisk Factors•• History reveals that Mary History reveals that Mary
drinks sugar containing drinks sugar containing beverages from both a beverages from both a bottle and sippy cup and bottle and sippy cup and she is unable to sleep she is unable to sleep without her bottlewithout her bottle
•• MaryMary’’s diet is rich in s diet is rich in simple and complex simple and complex carbohydratescarbohydrates
Protective FactorsProtective Factors•• As her pediatrician you had put As her pediatrician you had put
F varnish on her teeth at her 1 F varnish on her teeth at her 1 year old and 18 month old year old and 18 month old visits and referred her to a visits and referred her to a dental homedental home
•• Mary has Medicaid with dental Mary has Medicaid with dental insurance but mother was insurance but mother was unable to find a participating unable to find a participating dentistdentist
•• Mother has been following your Mother has been following your advice by brushing with a advice by brushing with a smear of fluoride toothpaste smear of fluoride toothpaste twice a daytwice a day
Risk StatusRisk Status•• Is Mary low or high risk for Is Mary low or high risk for
early childhood caries?early childhood caries?•• What are her risk factors?What are her risk factors?•• Is Mary a candidate for F Is Mary a candidate for F
supplements?supplements?•• How can you find out if the How can you find out if the
well water contains F?well water contains F?•• Can you help find a dental Can you help find a dental
home for Mary and how?home for Mary and how?
= High risk = High risk
Summary of RecommendationsSummary of Recommendations•• Begin the oral hygiene conversation with family before Begin the oral hygiene conversation with family before
first tooth eruptsfirst tooth erupts•• Use risk assessment tool starting at 6 month well visitUse risk assessment tool starting at 6 month well visit•• Prescribe fluoride supplements based on patient risk Prescribe fluoride supplements based on patient risk
level and all fluoride sourceslevel and all fluoride sources•• Promote protective factors:Promote protective factors:
–– Tooth brushingTooth brushing–– Fluoridated waterFluoridated water–– Healthy snacksHealthy snacks
•• Fluoride varnish application for high risk patientsFluoride varnish application for high risk patients•• Refer to dental home by age one or at eruption of first Refer to dental home by age one or at eruption of first
toothtooth
AcknowledgementsAcknowledgementsFunding for program has been Funding for program has been
provided by:provided by:
Delta DentalDelta Dental
Special thanks to: Special thanks to:
NJ Dental AssociationNJ Dental AssociationNJ Pediatric Dental AssociationNJ Pediatric Dental AssociationDentaQuest FoundationDentaQuest Foundationand to our Curriculum and to our Curriculum
CommitteeCommittee::Cathy Ballance, MD, FAAPCathy Ballance, MD, FAAPYasmi Crystal, DMD, FAAPDYasmi Crystal, DMD, FAAPDSid Whitman, DMD, FAAPDSid Whitman, DMD, FAAPD
Integrating Oral Health into Well Integrating Oral Health into Well Care is a program of PCORE, the Care is a program of PCORE, the quality improvement arm of the quality improvement arm of the American Academy of Pediatrics, American Academy of Pediatrics, New Jersey Chapter. New Jersey Chapter.
Cathy Ballance, MD, FAAPCathy Ballance, MD, FAAPMD ChampionMD Champion
Fran Gallagher, MEdFran Gallagher, MEdExecutive DirectorExecutive Director
Harriet Lazarus, MBAHarriet Lazarus, MBAAssociate Director of ProgramsAssociate Director of Programs
Juliana David, MEd PsychJuliana David, MEd PsychProgram DirectorProgram Director
Cortney Mott, MEdCortney Mott, MEdProgram ManagerProgram Manager
AAP/NJ & PCORE * 3836 Quakerbridge Road * Hamilton * NJ * 08619 * www.aapnj.org
THANK YOU!THANK YOU!