oral health in your office. introductions c eve j kimball, md pediatrician dilshad sumar-lakhani,...

Oral Health In Your Office

Introductions

C Eve J Kimball, MD

Pediatrician

Dilshad Sumar-Lakhani, DMD

Pediatric Dentist

• I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity.

• I do intend to discuss an “off label” use of a commercial product, fluoride varnish, that is currently approved for use as a cavity liner and tooth desensitization .

Disclosure Information

Support for this program is provided by:

The Oral Health 2020 Initiativeof the DentaQuest Foundationto the PA Chapter of the American Academy of Pediatrics

Healthy Teeth, Healthy ChildrenA Pennsylvania Medical/Dental Partnership

Contributors

• 3 M ESPE• MPL products• Premier Dental• Sentry Dental

Pictures:

Norman Tinanoff, DMD

PACT – AAP Oral Health Section

Mark Goldstein, DMD

Harry Goodman, DMD

Dilshad Sumar-Lakhani

Other in kind contributions:Smiles for Life

AAP- Oral Health Section

Understand Etiology and Progression of Early Childhood Caries

Provide Anticipatory Guidance to Parents or Caregivers

Perform Oral Health Risk Assessment

Understand the role of fluoride in prevention of decay

Apply Fluoride Varnish to children

Integrate oral healthcare practices into your office

Learning ObjectivesAt the conclusion of this presentation you should be able to:

WHY ORAL HEALTH IN A MEDICAL

OFFICE?

+

Sugar Calories

Teeth/oral flora

Obesity

Cavities

Sugar

+

Early Childhood Caries (ECC) isthe most prevalent chronic disease in U.S.

children,increasing in parallel with obesity

1. Primary teeth are important!

2. Caries are preventable/controllable if child receives 2-4 fluoride treatments per year

3. Cost effective health care with reimbursement

4. Minimal extra time

Why Bother ?

Oral Health Influences Overall Health

• Intra-oral abscesses•Facial cellulitis•Diabetes exacerbation•Poor pregnancy outcomes

•Even death – e.g., Deamonte Driver

Photo courtesy of Dr. Joel Berg

US Preventive Services Task Force

RecommendationCurrent RecommendationRelease Date: May 2014

•The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride.Grade: B recommendation.

•The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.Grade: B recommendation.

ECC Etiology

•Caries is a multi-step process that results in destruction of the tooth structure.

•Oral bacteria (mutans streptococci) metabolize the sugars from dietary carbohydrates into acid.

•The acid demineralizes the tooth enamel.

•If the cycle of acid production and demineralization continues, the enamel will become weakened and break down into a cavity.

What Causes Dental Caries?

Sugar Frequency

•Bacteria metabolize sugar into acid which destroys enamel.

•Frequency of sugar ingestion is more important than quantity.

•Saliva buffers the acid produced by the bacteria.

Early Childhood Caries

• Multi-factorial

• Infectious

• Fueled by fermentable carbohydrates (sugar)

• Chronic, progressive

PHOTO SOURCE: Smiles for Life Curriculum

Six Months laterwithout treatment

ECC Progression

Oral Health Screening

Oral Screening in the Medical Office

Options

Healthy Teeth• Creamy white with no signs of deviation in color,

roughness, or other irregularities

PHOTO SOURCE: Smiles for Life Curriculum

Primary Eruption Chart

Teeth AgeIncisors 6–12 monthsFirst molars 1st yearSecond molars 2nd yearCanines 1st to 2nd year

Anterior teeth remain until age 6 – 7 but primary molars remain until child is 10 –

12 years old.

Oral Screening is not designed to provide a definitive diagnosis

On the way to the tonsils, examine teeth and soft tissues for:

• White Spots• Dark Spots• Ulcers

• Bleeding gums• Heavy Plaque• Unusual Lumps and

BumpsOral screening helps to

determine:Anticipatory Guidance

Urgency of dental referral

Abnormal Conditions

When in doubt, refer out!

ECC Risk Assessment

Oral Health Risk Assessment Tool (OHRA)

** Risk should not be generalized. This is a useful tool for caries risk assessment that should be used in conjunction with clinical judgment and

other patient factors**

ECC Risk Assessment Summary

HIGH

Two or more moderate risk factorsBottle or sippy cup use between mealsCaregiver with active decay in past 12 monthsDevelopmental enamel defectsFamily with dental diseaseFrequent snackingGingivitisNo dental home for child or familyNo systemic fluoride exposureObvious decay / missing teethSpecial healthcare needs

MODERATE

Fillings/restorations presentUn- or underinsured / Medicaid eligibleVisible plaque accumulationWhite spots in the past 12 months

LOW

Fluoride in toothpaste and water, brushes 2x dailyHas dental homeHealthy teethNo family history of dental disease

Fluoride – A naturally occurring element

Effects• Inhibits tooth demineralization• Enhances remineralization• Inhibits bacterial metabolism • NOT a risk factor for fluorosis

Topical Fluoride

Effects• Strengthens enamel during tooth development

• Excessive amount can produce tooth staining (fluorosis)

Systemic Fluoride

Fluorosis

• Moderate and severe fluorosis - very uncommon in the US

• Cosmetic problem• At risk = children ≤8 years old who ingest excess

fluoride• Strategies to prevent fluorosis:

• Ideal toothpaste amount • under age 3 use a rice sized smear• over age 3 use a pea size amount

• No fluoride supplements if water supply is fluoridated

Fluorosis

Fluoride Varnish• Used in Europe and Canada for more than 20

years

• Can decrease caries 38 - 74% with 2 -4 applications per year

• Can reverse early caries

• Does not cause fluorosis

• Easy to use, cost effective

Who applies it?•Dental professionals

•Trained medical staff

•Physicians

•NPs

•PAs

•RNs

•LPNs

Moderate/High Risk• When the first tooth

appears • Every 3-6 months• Beneficial for all ages

How Often?

For Reimbursement in Pennsylvania• Up to 4 times per year• Up to age 5 for MA, up to age 6 for private insurance• Some private plans may vary

Facilitating ApplicationAssemble supplies in small

individual plastic bags• Gloves• Gauze 2x2• Fluoride varnish & brush• Directions for care after treatment

• Paper towel or bib (optional)

• Disposable mouth mirror (optional)

• Tongue blade (optional)

Anticipatory Guidance

1.Healthy teeth are important for overall health.

2.Brush your child’s teeth and tongue with a smear of fluoride toothpaste (pinky fingernail size) twice a day, everyday.

3.Visit the dentist by your child’s first birthday or when the first tooth erupts.

4.Limit juice, foods, and drinks with sugar, to once a day with a meal.

5.Drink only water in-between meals.

5 Key Oral Health Messages

Only Plain WaterIn Sippy Cups

andBetween Meals

Please!

Children with Special Health Care Needs

•Do Risk Assessment

•Must have dental home by age 1

• Immediate dental home if pathology is present at any age

•Emphasize prevention strategies

•Apply varnish at all checkups

Photo courtesy of Claudia Iatan

CSHCN – Provider Actions

Referral to a Dental Home

• First dental visit at 12 months (earlier if needed)

• Dental appointment within 2-4 weeks if:• White spots or tooth decay is observed

• Child is at moderate to high risk for ECC

• The first dental visit has not already occurred at age 1

• Immediate call to dentist if:• Brown spots or advanced progression of ECC is observed

• A dental trauma/emergency is evident

Goals for Referral to a Dental Home

•Dental office contact information• Insurance participation•Dentists who

•see kids at 12 months•see an emergency if you call•will provide “full service” if possible

•Get to know them personally•Make the dental appointment before the patient leaves the office

Dental Referrals

Making it Work for YOU

Preparation

• Office Champion

• Assembling bags

• Ordering Varnish

• Supplying rooms

• Referral list maintenance

• Set implementation date

• EHR template or paper check sheet

• Establish office policy• Billing• Start with one or two patients and refine your flow

Determine Staff RolesPolicies/Procedures

Coding and Reimbursement

Coding and Reimbursement

Commercial

• Use CPT 99188• Under age 6• No education requirement• Who applies? Providers now but trying to change this• Will be confusion and denials• Providers need to contact their provider reps to see

what their companies requirements are

• Reimbursement Rates: $18-$25 per fluoride

varnish application and risk assessment from

MCOs

• Reimbursement Rates from most commercial

insurers are undetermined at this time

• Expectation is that is will be in same range

• One commercial insurer has said $22.75

Reimbursement in PA

• Oral Health Risk Assessment and Fluoride Varnish application are in Bright Futures recommendations for checkups from 1-5 years old.

• Determine your office policy• Utilize EHR software for reminder “pop ups” for

regular oral health assessments and fluoride application

• Separate consent not necessary, covered under blanket agreement for care

Important Pearls

Repeat all steps every 3 months!

Risk Assessment

Examination of the teeth

Fluoride varnish application

Education of parents and child

Referral to dental home

PCPS can REFER:

Eve Kimball, MD, Chapter Oral Health Advocate610-463-8775, ekimball@aacpp.com

Thomas J. Maroon, MD, Chapter Oral Health Advocate

724- 832-0850, thomasmaroon1@gmail.com

Stephanie Chuipek, Chapter Oral Health Advocate610- 541-0155, stephjamie@aol.com

Additional Help or Information

Kristin Haegele HillHTHC Program Director

484-446-3059

hthc@paaap.org

www.healthyteethhealthychildren.org

Questions?