Overview of Children’s Oral Health Module 1

1. Children’s Oral Health & the Primary Care Provider Overview of Children’s Oral Health Module 1

2. Module 1 Objectives: • 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

3. Definitions

4. Glossary of Dental Terms for the Primary Care Provider Dental 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

5. Glossary of Dental Terms for the 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

6. Dental Terms cont’d Cavitated 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)

7. Dental 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)

8. Types of Caries Smooth 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

9. Periodontal (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

10. Treatment of Dental Caries in Children Goal: • Preserve tooth structure • Prevent further destruction of the tooth or surrounding teeth • Restore function • Eliminate pain • Restore aesthetic appearance

11. Treatment of Dental Caries in 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

12. Treatment of Dental Caries in 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

13. 2011 Cost of Dental Treatment under General Anesthesia: Before Surgery After Surgery Age: 2.5 years Caries: 16/20 teeth Treatment: 1 pulp treatment 8 Composite Resin Restorations 9 Stainless Steel Crown’s Dental Fees: $ 3,600.00 Medical Fees: ~ $15,000.00

14. Early Childhood Caries (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 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 Crowns White filling

15. Severe Early Childhood Caries (S-ECC): Children younger than 3 years of age • Any sign of smooth-surface caries (including white spot lesions) is indicative of severe ECC Smooth-surface caries = white spot lesions = non-cavitated lesions

16. Severe Early Childhood Caries (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) surfaces Cavitated lesions = decay = caries = cavities Upper front teeth extracted due to caries; stainless steel crowns Alloy fillings

17. The Status of Children’s Oral Health

18. Early Childhood Caries: A Public Health Crisis Dental caries • Now the most common chronic disease of childhood • One of the most prevalent transmissible, infectious diseases of childhood

19. Early Childhood Caries: Disparity in Disease Prevalence • 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

20. Disparities in Children’s Oral Health: the effect of poverty Poverty results in huge disparities in oral health status & access to dental care among children of all ethnic groups

21. Disparities in Children’s Oral Health: Cultural & Ethnic factors Regardless of household income level, African-American and Hispanic children are disproportionately affected by untreated dental decay

22. Disparities in Preventive Dental 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

23. Barriers 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

24. The Reality of Access to Dental 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

25. Iowa Medicaid Children Receiving Dental Care: 2005-2006 % of Medicaid children 1-3 years having first dental exam or recall exam

26. Dental 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

27. Dental 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

28. Early Childhood Caries: (ECC) • Multifactorial infectious disease • Begins prior to 36 months of age • Rampant characteristic • Difficult and costly to treat

29. Teeth Sugar Decay Bacteria How Do Cavities Develop? Streptococcus mutans Carbohydrates Acid formation Demineralization Tooth destruction

30. Teeth Sugar Decay Bacteria How Do Cavities Develop? Streptococcus mutans Carbohydrates Acid formation Demineralization Tooth destruction

31. Consequences of UntreatedOral 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

32. Consequences of Untreated 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

33. Consequences of Untreated 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

34. 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

35. Relationship of Oral Health to General & Systemic Health • 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

36. Poor Oral Health May Predict Poor Health Outcomes in Adults • 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)

37. ECC 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

38. Timing of First Dental Visit: Professional 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

39. Components of Caries Disease 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

40. Components of Caries Disease Prevention 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

41. Components of Caries Disease 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

42. Who Should Do Caries 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

43. Primary Care Providers as Oral 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.)

44. Positive Effect of Having a Personal 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

45. Other Non-Dental Professionals as Oral Health Care Providers Other professionals who work regularly with children: • School nurses • Head start teachers • Dental hygienists • Public health personnel • Women, Infants & Children (WIC) clinic personnel

46. Role of the Primary Care Provider: New Emphasis on Millennial Morbidities Children’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

47. Integrating Oral Health into 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

48. Necessary Components for 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

49. Incorporating Oral Health into 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

50. Incorporating Oral Health into 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