Overview of Children’s Oral Health Module 1

Children’s Oral Health & the Children’s Oral Health & the Primary Care ProviderPrimary Care Provider

Become familiar with dental terms

Understand definition of Early Childhood Caries

Be familiar with caries as a public health crisis

Understand barriers to access to dental care

Understand the consequences of untreated dental disease

Understand the components of caries prevention

Understand the role of the primary care provider in caries prevention

Understand how to incorporate oral health into the medical home

Module 1 Objectives:Module 1 Objectives:

DefinitionsDefinitions

Glossary of Dental Terms Glossary of Dental Terms for the Primary Care for the Primary Care

ProviderProviderDental Caries: Infectious disease process that results in damage

or destruction of the structure of the tooth

Periods of tooth demineralization & remineralization occur continuously as a dynamic process

When periods of demineralization exceed remineralization over a prolonged period: dental caries result

Glossary of Dental Terms for Glossary of Dental Terms for the Primary Care Providerthe Primary Care Provider

White Spot Lesions: Earliest manifestation of dental caries Result from demineralization of enamel,

which is still relatively intact (no cavity or hole in enamel)

Also referred to as “noncavitated lesions” or “incipient decay (lesion)”

Reversible characteristic: early identification of incipient lesions is extremely important, because it is during this stage that the carious process can be arrested or reversed

Dental Terms cont’dDental Terms cont’dCavitated Lesion: Formation of a cavity or hole in the

tooth as the enamel is destroyed and the second layer of the tooth (dentin) is exposed Appears as yellow or dull brown Tooth structure is soft (not intact anymore) Irreversible characteristic: dental treatment

to restore tooth is required If carious process is left untreated, it may

progress and reach the tooth pulp (nerve)

Dental Terms cont’dDental Terms cont’d

Arrested Caries: Remineralization of incipient lesions prior to

cavitation Results in a shiny white or yellow/brown

area at the area of previous incipient decay (tooth structure is intact)

Types of CariesTypes of CariesSmooth Surface Caries: Occur on any smooth tooth surface

Buccal or Labial or Facial: tooth surface that faces the outside of the mouth

Lingual or palatal: tooth surface that is closest or next to the tongue

Mesial and distal: tooth side surface that come into contact with adjacent teeth

Pit & Fissure Caries: Caries on the "top" of a tooth. Surface of the

back (molar and premolar) teeth used for chewing

Periodontal (gum) DiseasePeriodontal (gum) Disease Chronic bacterial infection involving plaque &

calculus below the gum line Gingivitis: mild disease associated with inflamed,

bleeding gums Periodontitis: gums separate from

teeth causing pockets that become

infected. Bone structure supporting

teeth is gradually destroyed. Tooth

loss may result

Source: American Academy of Periodontology

Treatment of Dental Caries Treatment of Dental Caries in Childrenin Children

Goal: Preserve tooth structure Prevent further destruction of the

tooth or surrounding teeth Restore function Eliminate pain Restore aesthetic appearance

Treatment of Dental Caries Treatment of Dental Caries in Childrenin Children

Dental restoration: area of decay is removed and destroyed tooth structure is replaced In children, the most common restorative materials

are dental amalgam, glass ionomer, composite resin, and stainless steel crowns

Endodontic therapy (root canal): extensive decay with destruction of tooth pulp requires removal of nerve and vascular structures, leaving only non-vital tooth structure

Tooth extraction: may be necessary if decay has destroyed enough tooth to make restoration impossible

Treatment of Dental Caries Treatment of Dental Caries in Childrenin Children

Early treatment: limited carious lesions Can often be done in a dental office using local

anesthesia Less extensive; less expensive

Late treatment: extensive caries involving multiple teeth

Often requires oral rehabilitation under general anesthesia in the operating room Limitation of amount of topical anesthetics that can be used at

one time Children often unable to comply with requirements of extensive

dental treatment

Extensive; highly expensive

Age: 2.5 years

Caries: 16/20 teeth

Treatment:1 pulp treatment8 Composite Resin Restorations9 Stainless Steel Crown’s

Dental Fees: $ 3,600.00

Medical Fees: ~ $15,000.00

Before Surgery

After Surgery

2011 Cost of Dental Treatment under General Anesthesia:

Early Childhood Caries Early Childhood Caries (ECC):(ECC):

Presence of 1 or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger

Crowns

White filling

Upper front teeth extracted due to caries; stainless steel

crowns and white filling

Non-cavitated lesions (aka: white spot lesions)

Cavitated lesions = decay = caries = cavities

Severe Early Childhood Caries Severe Early Childhood Caries (S-ECC):(S-ECC):

Children younger than 3 years of age

Any sign of smooth-surface caries (including white spot lesions) is indicative of severe ECCSmooth-surface caries =

white spot lesions = non-cavitated lesions

Severe Early Childhood Severe Early Childhood CariesCaries

(S-ECC): (S-ECC):Children ages 3 through 5 years

1 or more cavitated, missing (due to caries) or filled smooth surfaces in primary maxillary anterior teeth or:

Decayed, missing, or filled score (DMFS) of >4 (age 3 yrs), >5 (age 4 yrs), or >6 (age 5 yrs) surfacesCavitated lesions = decay = caries = cavities

Upper front teeth extracted due to caries; stainless steel crowns

Alloy fillings

The Status of Children’s The Status of Children’s Oral HealthOral Health

Early Childhood Caries: Early Childhood Caries: A Public Health Crisis A Public Health Crisis

Dental caries Now the most common chronic disease of childhood One of the most prevalent transmissible, infectious diseases of childhood

Early Childhood Caries: Early Childhood Caries: Disparity in Disease Disparity in Disease

PrevalencePrevalence ECC occurs disproportionately among

children in poverty & those belonging to some racial/ethnic groups

ECC occurs in: 5% of all children 30-50% of low income children

• Much more likely to go untreated in this group 79% of 2-5 yr old Native American (American

Indian/Alaskan Native) children

80% of decay occurs in 20% of children

Disparities in Children’s Oral Disparities in Children’s Oral Health: the effect of povertyHealth: the effect of poverty

Poverty results in huge disparities in oral health status & access to dental care among children of all

ethnic groups

Disparities in Children’s Oral Disparities in Children’s Oral Health: Cultural & Ethnic Health: Cultural & Ethnic

factorsfactors

Regardless of household income level, African-American and Hispanic children are disproportionately affected by

untreated dental decay

Disparities in Preventive Disparities in Preventive Dental Care: EtiologyDental Care: Etiology

Lack of dental insurance Proportion of dentists participating in

Medicaid & SCHIP Medicaid & SCHIP eligibility levels Lack of pediatric dentists

< 3% of dentists are trained in pediatric dentistry

Barriers to Dental CareBarriers to Dental Care

Severe limitations in public & private funding

Perception that dental care is less important than health care

Workforce shortage; No capacity to provide needed service

Lack of providers has resulted in demand for services in some areas

The Reality of Access to The Reality of Access to Dental CareDental Care

For every child that lacks medical insurance, 2.5 lack dental insurance

85% of toddlers have had a well-child visit Only 20% of toddlers have had a dental visit 86% of Head Start children experience ECC Many dentists don’t accept new Medicaid clients

In 2000, 25% of US dentists received some payment from public insurance

• Only 9.5% received more than $10,000

More than 50% of Iowa Dentists are not accepting new Medicaid clients

Iowa Medicaid Children Receiving Dental Care: 2005-2006

% of Medicaid children 1-3 years having first dental exam or recall exam

Dental Workforce ShortageDental Workforce Shortage

The number of dentists per capita is declining nationwide

Dental workforce is aging Insufficient number of dental students

entering training to replace retiring dentists

Iowa is one of many designated dental shortage areas

Rural areas are particularly underserved

Dental Workforce ShortageDental Workforce Shortage

General (family) dentists often reluctant to see children < 3 years of age

Prefer to refer young children to pediatric dentists

Pediatric Dentistry Requires 2 additional years of training <3% of all dentists are trained

pediatric dentists

Early Childhood Caries: Early Childhood Caries: (ECC)(ECC)

Multifactorial infectious disease

Begins prior to 36 months of age

Rampant characteristic

Difficult and costly to treat

How Do Cavities Develop?How Do Cavities Develop?

Streptococcus mutans

Carbohydrates

Acid formation

Demineralization

Tooth destruction

Teeth Sugar

Bacteria

DecayDecay

How Do Cavities Develop?How Do Cavities Develop?

Streptococcus mutans

Carbohydrates

Acid formation

Demineralization

Tooth destruction

Teeth Sugar

Bacteria

Decay

Consequences of UntreatedConsequences of UntreatedOral DiseaseOral Disease

Pain Painful chewing interferes with eating May result in failure to thrive/malnutrition

Interferes with learning Pain makes concentration difficult Causes school absence

• 51 million school hrs lost yearly

Consequences of Consequences of Untreated Oral DiseaseUntreated Oral Disease

Tooth loss May lead to malocclusion, difficulty eating

Poor self-esteem Infection

Dental abscess Local extension into bone & contiguous

structures Distant, blood borne infection

Consequences of Consequences of Untreated Oral DiseaseUntreated Oral Disease

ETC visits, hospitalizations, surgeries Extensive, costly treatments Operative oral rehabilitation

High Cost FY 2005 IA:

• Operative dental care for Medicaid Children ~ $8 million

Consequences of Gaps in Dental Care

Deamonte Driver

Maryland boy, 12, dies after bacteria from tooth spread to his brain Washington Post; Feb, 28,

2007

Relationship of Oral Health Relationship of Oral Health to General & Systemic to General & Systemic

HealthHealth The mouth is part of the body & reflects the

individual’s overall health & wellbeing Many systemic disorders have specific oral

manifestations Viral, bacterial & fungal infections Immune-mediated disorders Inflicted trauma/child abuse

Diseases that originate in the mouth may also have systemic manifestations or complications

Poor Oral Health May Predict Poor Oral Health May Predict Poor Health Outcomes in Poor Health Outcomes in

AdultsAdults Periodontal disease is associated with:

Heart disease & stroke Poor control of diabetes Adverse pregnancy outcomes:

• Low birthweight• Preterm labor

Fewer than 8% of Iowa Medicaid enrolled mothers receive preventive dental care during pregnancy (Personal communication: Bob Russell DDS, IDPH)

ECC is PreventableECC is Preventable

Requires early 1st dental visit (no later than age 1) Requires caries risk assessment:

Identify children at “high risk” for ECC

Identify caries process before cavitation Implement preventive strategies

All children need a dental home;

just as they need a medical home

Timing of First Dental Visit: Timing of First Dental Visit: Professional RecommendationsProfessional Recommendations

American Dental Association (ADA)

American Academy of Pediatric Dentists (AAPD)

American Academy of Pediatrics (AAP)

American Academy of Family Physicians (AAFP):

Recommend the first dental visit: Within 6 months of eruption of the first tooth or No later than 12 months of age

Components of Caries Components of Caries Disease PreventionDisease Prevention

Community: Fluoridated water supply

Public health dental program Provide oral health screening, anticipatory

guidance, preventive measures (fluoride varnish & sealants), some treatment, referral

May provide care in multiple settings• Child care centers/Head Start Programs• Schools• Health department• MCH/WIC programs

Health practitioner Dental health care providers

General dentists Pediatric dentists Oral surgeons/endodontists Dental hygienists

• Public health• Private practice

Primary health care providers Pediatricians Family physicians Nurse practitioners Physician assistants

Components of Caries Components of Caries Disease PreventionDisease Prevention

Components of Caries Components of Caries Disease PreventionDisease Prevention

Individual & Family Parent responsibility:

Follow anticipatory guidance/recommendations:• Brushing with fluoridated toothpaste

– Direct control/supervision until age 7-8 years• Limitation of sweet & acidic foods & beverages• Dental visits • Fluoride varnish/sealants

Older child & adolescent responsibility: Follow recommendations:

• Diet• Brushing• Flossing• Dental visits

Who Should Do Caries Who Should Do Caries

Risk Assessments?Risk Assessments? Dentists:

Unfortunately >50% of Iowa dentists don’t see high-risk, low income (Medicaid/SCHIP) patients

Who Else Should Do Caries Risk Assessments? Health professionals and all

professionals in contact with

young children

Primary Care Providers as Primary Care Providers as Oral Health Care ProvidersOral Health Care Providers

Primary Health Care Providers (PCP): See children at well-child visits ~ 12

times in the first 3 years Already have an established, trusting

relationship with families Already providing anticipatory

guidance & performing screening (development, maternal depression, etc.)

Positive Effect of Having a Positive Effect of Having a Personal DoctorPersonal Doctor

More likely to receive preventive dental care in the previous year

Children with special health care needs (CSHCN) less likely to have unmet dental care need

Other Non-Dental Other Non-Dental Professionals as Oral Health Professionals as Oral Health

Care ProvidersCare ProvidersOther professionals who work regularly

with children: School nurses Head start teachers Dental hygienists Public health personnel Women, Infants & Children (WIC)

clinic personnel

Role of the Primary Role of the Primary Care Provider: New Care Provider: New

Emphasis on Emphasis on Millennial MorbiditiesMillennial MorbiditiesChildren’s Oral health: Oral health risk assessment Anticipatory guidance for caries reduction Oral health exam Fluoride varnish application Referral for high risk children Dental Home: for children under 3 years who

lack access to dental care

Integrating Oral Health Integrating Oral Health into Primary Careinto Primary Care

Need for integration of health services with large unmet needs (such as oral & mental health) into primary care model

Stress prevention & early intervention Most cost effective Can be provided by the PCP in the medical

home

Necessary Components Necessary Components for Successful Integrationfor Successful Integration

Adequate reimbursement for: Cognitive services

• Parent interview• Risk assessment• Oral exam• Parent education

Procedures• Fluoride varnish application

Care coordination Referral resources in the community

Pediatric & general dentists

Incorporating Oral Health Incorporating Oral Health into Your Practiceinto Your Practice

Oral health risk assessment Identify children at increased risk

Anticipatory guidance Prevent caries in high risk children

Oral screening exam Restrain child’s head movement Lift the Lip: examine soft & hard tissue

Incorporating Oral Health Incorporating Oral Health into Your Practiceinto Your Practice

Fluoride varnish application For high risk infants & children (Medicaid

& SCHIP) Physician applies varnish after the oral

exam or Nurse/assistant applies the varnish

• After she puts on gloves• Just before giving vaccines

Get to know your I-Smile Coordinator

I-Smile Coordinators I-Smile Coordinators

I-Smile coordinators are dental hygienists who serve as prevention experts and liaisons between families, health care professionals, & dental offices to ensure completion of dental care. Coordinators are located in regional public health agencies & provide local community support throughout Iowa. A coordinator can:

I-Smile Coordinator contact information can be found at: www.idph.state.ia.us/hpcdp/oral_health.asp or

I-Smile hotline 1-866-528-4020

• Assist with dental referrals for young children.• Provide Medicaid dental billing information.• Offer education for healthcare professionals regarding

children’s oral health, including screening and fluoride

varnish training.

Dental disease in young children is a public health

crisis

There are disparities in oral health & access to

dental care

Barriers to care include work force shortages, lack

of payer, perception that dental care is unimportant

Untreated oral disease leads to pain, early tooth

loss, abnormal growth and development

Primary care provider has an important role in

caries prevention

Oral health must be incorporated into the medical

home

Summary: Summary: Overview of Children’s Oral Overview of Children’s Oral

HealthHealth2008 Training Module 12008 Training Module 1