From The First Tooth An early childhood caries prevention program to improve the oral health of Maine children www.from

1. From The First Tooth An early childhood caries prevention program to improve the oral health of Maine children www.fromthefirsttooth.org Funded by the Sadie and Harry Davis Foundation A partnership of MaineHealth, MaineGeneral and Eastern Maine Health Services Northeast Center for Research to Evaluate and Eliminate Dental Disparities

2. The purpose is to improve the oral health of Maine’s children by: From The First Tooth • Increasing children’s access to preventive oral health services • Integrating early oral health as the standard of care for children • in medical practices through: • Oral health screening • Fluoride varnish • Parent/caregiver education and counseling • Referral to a dentist

3. From The First Tooth Dental Caries is a Chronic Infectious Disease • Transmissible • Bacterial by-products (acids) • dissolve the enamel of teeth • Loss of tooth structure, pain, • tooth loss, systemic infections

4. From The First Tooth • Dental caries is the single most common chronic disease of childhood • Approximately one thirdor more of Maine children has dental caries • Early childhood caries is the best predictor of lifelong dental caries Source: National Health and Nutrition Examination Survey, 1999 -2002 National Center for Health Statistics, CDC

5. Source: National Health and Nutrition Examination Survey, 1999–2002. National Center for Health Statistics, CDC.

6. What are the Consequences? • Pain & infection • Hospitalization, • surgical intervention, death • Missed work/school • Distraction from normal activities • Speech and eating dysfunction • Growth delay

7. Low-income children who have their first preventive dental visit by age one: Less likely to have subsequent restorative or emergency room visits Average dental related costs are almost 40% lower ($263 compared to $447) over a five year period than children who receive their first preventive visit after age one. From The First Tooth Prevention Reduces Disease and Saves Money

8. Dental/Medical Home By Age One Recommended by: American Academy of Pediatrics American Dental Association American Academy of Pediatric Dentistry Endorsed by: Maine Chapter of the American Academy of Pediatrics Maine Dental Association Maine Medical Association Maine Academy of Family Physicians Maine Osteopathic Association Maine Primary Care Association

9. Oral health is part of overall health! Patients are seen more regularly at the medical offices Part of oral health prevention strategies Screen for disease and risk Monitor oral-systemic health interactions Initially manage oral emergencies Referral for dental care Provide anticipatory guidance Apply fluoride varnish Preventive Dental Care is linked to Good Overall Health! Role of the Primary Care Physicians

13. Factors Necessary for Dental Caries Tooth Age Fluoride Nutrition Pit & Fissures Tooth Oral Flora Dental Caries Flora Strep. Mutans Oral Hygiene Fluoride in Plaque Substrates Oral hygiene Saliva Carbohydrates Frequency of eating Substrates 13

14. Streptococci Mutans Transmission Bacteria are transmitted mainly from mother or primary caregiver to infant. Window of infectivity is first 2 years of life. The earlier a child is colonized, the higher the risk of caries.

15. You Are What You Eat • Caries development is promoted by carbohydrates • which act as substrate for bacteria to produce acid • Acid causes demineralization of enamel • Beware “hidden carbohydrates”

16. Frequency vs. Quantity Acids produced by bacteria after carbohydrate intake persist for 20-40 minutes lowering pH

17. Examples of Sugar Content of Food and Drinks

18. Sucrose Content of Some Medicines Amoxicillin 17-50% Ceclor 56-58% Erythromycin 45-65% Penicillin 40-70% Bactrim 50% Benadryl 60-77%

19. Oral Health Assessment of Child • Position child in caregiver’s lap facing the caregiver • Sit with knees touching the knees of the caregiver • Lower the child’s head onto your lap

20. What to Look For: • Lift the lip, retract the cheeks and inspect the soft tissues and teeth to assess for: • Presence of plaque • Presence of white spot lesions or dental caries • Presence of tooth defects • Presence of dental abscess

21. Dental Plaque A biofilm that attaches to the tooth surfaces. It is composed of primarily streptococci mutans and other bacteria. Nourished by food and beverages high in sugar, they produce an acid that initiates the demineralization of the teeth.

22. Healthy Teeth

23. White Spot Lesions

24. Cavitated Lesions

25. Urgent Dental Care

26. Urgent Dental CareDental Abscess

27. Caries Risk Assessment Higher Risk: One of the below Low income - (i.e. MaineCare) Special healthcare needs Parents/siblings have decay Existing decay/fillings Limited/no dental care Frequent sugar intake No access to fluoridated water or tablets Lower Risk: None of the above

28. Fluoride Demineralization <------------ > Remineralization • Exposure to fluoride • Removal of plaque • Balanced diet • Limited exposure to carbohydrates • Frequent carbohydrate intake • Frequent exposure to acids • Plaque presence • Decreased salivary flow

29. System and Topical Fluoride Delivery SYSTEMIC Water Tablets Drops In Vitamins TOPICAL • Toothpaste • Anti-Cavity Rinses • Fluoride Applications Varnish, gel or foam 29

30. Fluoride Varnish • 5% sodium or 22,600 PPM fluoride resin • Inhibits the growth of cariogenic organisms thus decreasing acid metabolism • Reduces enamel solubility • Promotes remineralization of enamel • and may arrest or reverse early caries

31. Efficacy of Fluoride Varnish in Preschool Children

32. Application of Fluoride Varnish Using gentle finger pressure, open the child’s mouth. Gently remove excess saliva or plaque with a gauze sponge. Use your fingers and sponges to isolate the dry teeth and keep them dry. Isolate a quadrant of teeth at a time, or a few teeth at a time. Apply a thin layer of the varnish to all surfaces of the teeth. Once the varnish is applied, you need not worry about moisture (saliva) contamination. The varnish sets quickly.

33. Post Application Instructions • Soft diet for the rest of the day. • Do not brush or floss the child's teeth • until the next morning. • It is normal for the teeth to appear dull • and yellow until they are brushed. • Tell the parent that the teeth will not be white • and shiny until the next day

34. Efficacy on the Number of Fluoride Varnish of Applications Children stratified by number of actual fluoride-containing varnish applications received N= 280 Weinstraub et al. J Dent Res 2006

35. Age Distribution of Children Receiving Fluoride

36. From The First Tooth MaineCare is reimbursing medical providers for the therapeutic application of fluoride varnish for members with moderate to high caries risk. MC will cover 2 applications per calendar year. For members with high caries rates and new decay within 18 months as documented, MC will cover 3 times per year. In Maine, commercial insurers and self insured companies and beginning to pay for the varnish procedure. All three health systems (MaineHealth, Eastern Maine Health Systems, and MaineGeneral Health) now pay for the procedure for their age-eligible dependents who are covered by their health plans.

37. Infant and Toddler Oral HealthAnticipatory Guidance • Advise to parents and caregivers • The importance of healthy teeth • How to take care of their child’s teeth • The importance of healthy food choices

38. Infant and Toddler Oral HealthAnticipatory Guidance Schedule 6 Months • Bottles are for nutrition. They should • only be used to feed babies who are • not breast feeding. • Discuss and demonstrate brushing of • infant teeth as soon as they erupt. • Instruct the parent to conduct • "Lift the Lip" procedures. 9 Months • Monitor progress in weaning • infant from bottle to cup. • Offer appropriate guidance • in limiting juice in sippy cup.

39. Infant and Toddler Oral HealthAnticipatory Guidance Schedule 12 Months • Infants are weaned from the bottle. • Infants should see the dentist by year one. • Review healthy eating habits and snacking. • Sippy cups at mealtimes only. Water between meals • Parents continue to brush and check their teeth 24 Months • Monitor healthy behaviors and snacking • Discuss and evaluate the toddler’s ability • to begin to use fluoridated toothpaste. • Parents should continue to monitor the child’s • brushing and checking their teeth

40. Parent/Child Arrives for Well Child Visit (or other visit) Posters, ed materials in waiting room Vitals Signs Taken Medical Assistant tells parent of the FTFT (Parent Counseling) Well Child Exam Medical Provider - Oral Screening, Orders for fluoride based on risk (Parent counseling) No Access to a Dental Home Referral to a Dental Home Immunization Medical Assistant Applies Fluoride Dental Home

41. Documentation • Caries Risk Assessment – (LOWER) (HIGHER) • Guidelines • Higher Risk: One of the below • Low income - (i.e. MaineCare) • Special healthcare needs • Parents/siblings have decay • Existing decay/fillings • Limited/no dental care • Frequent sugar intake • No access to fluoridated water or tablets • Lower Risk: • None of the above • Dental Caries – Y or N • Oral health education – Y or N • Fluoride varnish applied (Code D1206) – Y or N In Chart Notes, document urgent dental needs, such as abscesses and other clinical findings and referral to dentist

42. www.fromthefirsttooth.com

43. From The First Tooth We are committed to ensure every child within our organizations and affiliates has access to early childhood caries prevention program.

44. Questions?

45. Contact Information:www.fromthefirsttooth.org Susan Cote, RDH, MS Program Manager MaineHealth 110 Free Street Portland, ME 04101 (207) 662-6309 (207) 252-9056 cotes4@mainehealth.org