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Connect Oral Health to Every Child’s Medical Care

Massachusetts Department of Public HealthOffice of Oral Health

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Objectives

1. Understand the child health provider’s role in oral health

2. Understand the etiology of oral diseases3. Understand the relationship between

systemic and oral health4. Gain knowledge and skills to perform oral

health assessments5. Identify appropriate oral disease

prevention strategies6. Understand when and how to apply

fluoride varnish

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1. Pretest

2. Children’s Oral Health/CSHCN

3. BLOCK Oral Disease Strategy

4. BLOCK Oral Disease Materials

5. Oral Health Assessments and Fluoride Varnish

6. Closing Discussion

7. Post test

Outline

Note. Pass out the pretests and give the participants 5 to 10 minutes max. Stress to participants that they must remain through the entire 60 minute presentation and take the pre/posttests and course evaluation to get the certificate of completion. Also mention that they need to write legibly on these forms so we can read their name/address to send the certificate to.

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Training Instructions1. Complete the Pretest via Survey Monkey

LINK. http://www.surveymonkey.com/s.aspx?sm=7546uI4J7mSEoDwh49rSvA_3d_3d

2. Read the entire PowerPoint3. At the end, you will link to a Survey Monkey posttest4. After completing the posttest, you will have an

opportunity to request the mailing of a BLOCK Oral Disease ToolkitIn order to receive a certificate of completion, you MUST complete the entire training, pretest, and posttest!!!

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Why talk about ORAL HEALTH in MEDICINE?

Note. The overall goal of this session is to help you think of oral health as a component of overall systemic health. Oral health is not a separate entity! Just as systemic health and oral health have influences on each other. Therefore, it is in the medical community’s interest to talk about oral health in the context of primary care.

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The Problem1. Dental caries is the most common chronic disease in

children. Citation, CDC, 2005.

2. Dental caries is transmissible from caregiver to child

3. The general public lacks knowledge about oral health

4. Many children lack access to preventive dental care

5. Certain child populations are at a higher risk for oral diseases

Note. Low socioeconomic status and special health care needs are risk indicators for oral disease.

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Oral Disease In Massachusetts’ Children in 2008

1. Dental caries experience.a. 25% of kindergarten children, 52%

untreatedb. 40% of third graders, 42% untreated

2. Overall, lower income and minority children experienced a 1.7 times greater prevalence of dental caries than non Hispanic White children

Note. These data are from the Catalyst Institute’s report: The Oral Health of Massachusetts’ Children, January 2008.Many children who experience dental caries at the highest rates are children who receive their medical care at community health centers. This high risk population of minority and low income children is a population you see every day at your medical facility. You might be the only source of preventive oral health education and service these high risk children receive.

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Children with Special Health Care Needs

• High risk for dental caries and periodontal infections

• Dental care is the number 1 unmet health care need

• Need to increase access to oral disease prevention interventions

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Percent of CSHCN Needing Specific Health Services

Health Service1. Prescription Drugs 86.4%

2. Preventive Dental Care such as cleanings, x rays, fluoride treatments, and exams 81.1%

3. Routine Preventive Care 77.9%

4. Specialty Care 51.8%

5. Eyeglasses/Vision Care 33.3%

6. Mental Health Care 25%

7. Other Dental Care such as restorative, orthodontic, periodontic, cosmetic, etc. 24.2%

8. Physical, Occupational, or Speech Therapy 22.8%

9. Disposable Medical Supplies 18.6%

10. Durable Medical Equipment 11.4%

11. Hearing Aids/Hearing Care 4.7%

12. Home Health Care 4.5%

13. Mobility Aids/Devices 4.4%

14. Substance Abuse Treatment 2.8%

15. Communication Aids/Devices 2.2%

Note. These data are from the National Survey of Children with Special Health Care Needs, 2005 to 2006. It indicates that 81% of CSHCN were in need of preventive dental care, which includes cleanings, x rays, fluoride, and exams. 24% of CSHCN needed other dental care, which could include fillings, orthodontic, periodontic, and cosmetic procedures.

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Percent of CSHCN with Reported Health Services Needed but Not Received

0 2 4 6 8

Preventive dental care

Mental health care

Physical, occupational, or speechtherapy

Specialty care

Other dental care

Routine preventive care

Source. National Survey of Children with Special Health Care Needs, 2005 to 2006.

Note. The previous slide showed that 81% of CSHCN needed preventive dental care. This slide displays that many CSHCN did not receive preventive care that was needed. Preventive dental care is the number 1 unmet healthcare need for CSHCN.

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Note. For children at higher risks for oral disease such as minority, low income, and CSHCN, you could be an extremely important influence on promoting oral disease prevention.

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AAP Oral Health Risk Assessment Timing and Establishment of the Dental Home

Policy Statement, 20031. Every child should begin to receive oral health risk

assessments by 6 months of age from a pediatrician or qualified pediatric health care professional.

2. Infants identified as having significant risk of caries should be entered into an aggressive anticipatory guidance and intervention program provided by a dentist between 6 and 12 months of age.

3. Pediatricians should support the establishment of a dental home for all children between 6 and 12 months of age.Source. Hale, K., Weiss, P., Czerepack, C., Keels, M., Huw, T. & Webb, M. (2003). American Academy of Pediatrics Policy Statement: Oral Health Risk

Assessment Timing and Establishment of the Dental Home. Pediatrics; 111(5): 1113 to 111 AAP Section on Pediatric Dentistry and Oral Health (2008). Preventive oral health intervention for pediatricians. Pediatrics; 122;1387 to 1394One of the most recent oral health policy statements published by the AAP, December 2008Tell participants that there is a printed copy of the most recent AAP publication about oral health in the blue folder they receive.Contains evidence based recommendations for pediatricians regarding oral disease prevention in the medical homeThe AAP has become an influential leader for oral health integration. The AAP has published many articles about oral health and launched an Oral Health Initiative, which includes a website that contains a wealth of oral health information and resources.

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BLOCK Oral Disease

There is a lot being done to address the topic of oral health in primary care, however, there is a lack of specific information covering the direct links and associations between oral disease and systemic disorders/conditions/diseases. This presentation gives you a basic introduction to children’s oral health and the specific oral health needs of CSHCN. The corresponding toolkit provides detailed information and clinical reference tools. You will have the opportunity to request a copy of the toolkit that can be mailed to you.

The BLOCK Oral Disease Strategy is a way to think of oral health in the context of overall health. It’s an integration strategy.

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BLOCK Toolkit Components

Note. After you complete the posttest for this training, you will be able to request your toolkit.

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Note. The first part of the BLOCK Oral Disease strategy includes connecting systemic and oral health. Oral diseases can effect physical, mental, and social well being in addition to being infectious and transmissible. One can not be “healthy” without oral health. Furthermore, we now have an increasing amount of data to support the relationship and associations between oral disease and the effects on systemic health. Some of these include diabetes and blood glucose control, cardiovascular disease, respiratory diseases, preterm births, and many others.

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The Picture of Oral Health

1. Primate Spaces

2. Shiny, White Enamel

3. Gums, Pink and Firm

4. No demineralization or cavities

5. No plaque or food accumulationNote. What does oral health look like?Primate spaces are integral in that they create space for larger permanent teeth to erupt as the jaw and maxilla grow and develop. If a child has very crowded primary teeth, they erupt as the jaw grows and develops. If a child has a very crowded primary teeth, they might have serious malocclusion issues. Malocclusion needs to be addressed because it can increase dental caries risk and lead to problems with speaking and eating. Children with malocclusion might need to see dental professionals early for orthodontic assessments and treatments.

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Enamel Structure

1. Enamel is the hardest, most mineralized tissue in the human body

2. 97% mineral by weight3. Composed of

hydroxyapetite mineral and trace elements

Note. Let’s first review some basic dental anatomy. The tooth is composed of 3 major layers which are the enamel, dentin, and pulp chamber. The Enamel is composed of hydroxyapetite with trace elements of fluoride, chloride, sodium, and magnesium. Even though enamel is the hardest mineralized substance in the body, it is still porous. The second layer of the tooth is dentin. Dentin is a less mineralized structure compared to enamel. The innermost part of the tooth is the pulp chamber. The pulp chamber houses the blood vessels and nerve that give the tooth life. From the pulp chamber, the blood vessles and nerves connect to the circulatory and nervous systems. Tooth decay begins on the outer enamel surface and can then continue into the deeper tooth structures. Unfortunately, pain from tooth decay is only felt when the infection has destroyed much of the tooth and has entered the pulp chamber. It is important to know what the very early of enamel decay look like so the decay can be arrested and not left to destroy the tooth.

Source. www.usc.edu/.../Bits/2000fw/Achievement.htm & www.dent.unc.edu/research/defects/aigenes.cfm

Source. www.childrenshospital.org/.../Images/tooth.gif

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How does this happen?

IT’S ALL PREVENTABLE!

No child should experience this severity of oral disease, especially when we know how to prevent it. Being proactive and assessing whether medical conditions or treatments could compromise oral health can help reduce the incidence and severity of oral disease.

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BACTERIA

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Bacteria and Oral Disease

Different bacteria are responsible for tooth decay and periodontal or gum disease.

a. DECAY. streptococcus mutans, gram +

b. PERIO. gram, anaerobes, facultative anaerobes

Note. If “bad” bacteria are left in the mouth, they proliferate and colonize. Once this occurs, the bacteria are more destructive. They can destroy tooth structure AND the gum and bone support.

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From Health to DiseaseIt’s a COMPLEX SEQUENCE of events

1. Start with that just cleaned smooth, shiny feeling.2. Within minutes, glycoproteins in saliva coat enamel for

protection, but also create a “sticky” coating called the pellicle to which a bacterial biofilm, plaque, can adhere.

3. Once you eat any carbohydrate, mainly simple sugars, amylase enzymes begin breaking down sucrose molecules.

4. Bacteria sticking close to the enamel via the pellicle metabolize sucrose molecules, proliferate, and release acid as a byproduct.

5. Acid then penetrates the porous mineral structure of the enamel and diffuses Calcium and Phosphorus out of the tooth, called demineralization.

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What are ‘plaque’ and ‘tartar’?

Plaque is SOFT1. Composed of bacteria, food debris, glycoprotein2. Can be brushed away

Tartar, calculus, is HARD1. Mineralized plaque2. Can not be brushed away, need professional

cleaning to remove3. Creates a substrate for bacterial growth and

colonization

Plaque can mineralize in only 24 hours!

Note. It is very important to brush your teeth at least twice a day, and floss at least one time every day. Flossing and brushing remove plaque when it is soft so that it does not remain on the tooth to either initiate demineralization or mineralize into calculus onto the tooth.

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Enamel Demineralization

Flora

ToothSubstrateSaliva

1. Buffering Capacity

2. Flow Rate pH

3. pH Composition

Note. The very first stages of tooth decay are demineralization of the porous enamel surface. Demineralization is influenced by three factors.1. Fermentable carbohydrates, substrate2. Cariogenic microorganisms such as Streptococcus mutans and Lactobacilli3. Susceptible tooth surface, host

Can be restored through the natural process of remineralization via saliva and the addition of topical fluorideAll three factors must be present for the dental caries process to initiate and continue. The addition of fluoride to the natural minerals in saliva

supports reversing demineralization.

Caries

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Source. http://www.dentaleconomics.com/display_article/284037/55/none/none/Feat/Treating-Caries-Chemically:-Fact-or-Fiction?host=www.dentalofficemag.com

GERD is a pH of 1

“Sippy Cup” is a pH of 3

Note. The pH of the oral cavity is a very important factor in caries development. Medical conditions such as GERD and Bulimia combined with poor dietary habits can seriously impact oral PH and contribute to rapid caries initiation and progression. Sippy cups filled with anything other than water should only be used in short increments of time, and should never be given to a child as they sleep. GERD causes gastric acids to enter the oral cavity. These gastric acids have a very low pH and can cause generalized enamel erosion and dental caries. Children with such medical conditions must be placed on a preventive oral health regimen to include fluoride therapy and routine dental home appointments.

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Dental Caries

Source. PennWell.com

Note. There is a delicate balance between pathological and protective factors. The goal is to have more protective factors than pathologic. Unfortunately, CSHCN have an increased risk for more pathological factors and therefore need additional protective factors such as fluoride varnish at regular intervals.

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Enamel Remineralization

Four conditions or events must occur at the same time.

1. • Sufficient minerals must be present in the saliva2. • A molecule of carbonic acid must be produced in

proximity to a mineral molecule, which then dissolves into its ionic components

3. • Proximity to a clean and accessible demineralized spot in the hydroxyapetite requiring the exact mineral ion

4. • Convertion of carbonic acid to carbon dioxide and water and precipitation of a mineral ion out of solution into the structure of the enamel

Source. An Update on Demineralization/Remineralization, ME Jensen, http://www.dentalcare.com/soap/conteduc/index.htm

Note. Remineralization is the process of restoring mineral ions to the tooth structure, like replacing the missing links in a chain. Remineralization with fluoride actually replaces the hydroxyapetite with fluorapetite. Fluorapetite is stronger and more resistant to demineralization compared to the original hydroxyapetite mineral. Minerals also come from food and saliva.

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Incipient Carious Lesions: Demineralization

Caries disease process initiated, but CAN BE REMINERALIZED

Note. Demineralization has occurred. The caries disease process has been initiated, but this is not a “cavity” yet. The tooth can be restored naturally with fluoride therapy until the point of cavitations. Once the tooth is fully cavitated, a hole in the tooth, it must be restored by a dentist.

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Remineralizing Effects of Fluoride Varnish

Arrows indicate areas of enamel demineralization.

Source: www.uiowa.edu/~c090247/fluoride_varnish.htm

Evidence of remineralization 3 months after fluoride varnish application.

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Cavitations

Needs Immediate Restorative Treatment!

Note. This is severe dental caries, however, in primary teeth it often does not take long for the caries disease to progress to this severity. Primary teeth are more susceptible to caries because the enamel is much thinner than the enamel of permanent teeth. Adding an additional pathologic factor such as medication that contains sucrose or has the side effect of xerostomia can significantly expedite the disease progression.

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What Chronic Conditions Could Increase Dental Caries Risk?

1. Physical challenge or disability

2. Immunsuppression

3. Defect in enamel development

4. Xerostomia, either condition or medication induced

5. Gastrointestinal disorders or GERD

6. Frequent snacking and drinking beverages containing simple sugars and low pH

Note. A physical challenge or disability could inhibit a child’s manual dexterity enough to impede effective oral hygiene behaviors, such as flossing and brushing. Some physical disabilities also make it difficult for dental staff to provide services.

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XerostomiaAbnormal reduction of saliva

• Saliva’s functions. Lubrication, protection against mucosal drying, digestion, neutralization, taste, irrigation of debris and microbes

• Can result as a symptom of disease or as a side effect of over 500 medications

• Can be chronic as a result of damage to salivary glands during chemotherapy and head/neck radiation

• Significantly increases the risk for dental caries and periodontal infections

Note. Xerostomia is the most common adverse drug related effect in the oral cavity. The absence of saliva increases the risk for oral diseases for several reasons. Saliva is the mouth’s natural cleansing mechanism. It helps to protect the soft and hard tissues in the mouth by delivering immune components and lubrication for soft tissues, and a it provides a constant delivery of minerals to hard tissues. Many people with xerostomia experience rampant dental caries and other oral infections like fungal candidiasis.

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Prevention Strategies: Anticipatory Guidance

1. Proactive developmentally based counseling technique that focuses on the needs of a child at particular stages of life

2. CD ROM 2 in the Toolkit can provide you with great educational materials to discuss oral health anticipatory guidance with caregivers.

3. You can also find these on the Office of Oral Health Webpage under Resources and Fact Sheets

Note. Anticipatory guidance is about arming caregivers with knowledge of their child’s growth and development so they know what to expect and they can prepare to decrease disease risk by promoting healthy behaviors. CD ROM 2 has many multi lingual anticipatory guidance materials for various children’s oral health topics. These can be useful educational tools for caregivers.

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Prevention Strategies: Plaque Control

1. Brush twice daily 2. WITH CAREGIVER SUPERVISION

3. Children 2 years and under use a smear of fluoride toothpaste

4. Children over 2 years and use a pea sized amount of fluoride toothpaste

5. Floss at least once daily

6. Children over age 6 can rinse with fluoride or antimicrobial

Smear

Pea sized

Note. Children should always be supervised when brushing, flossing, and rinsing up to age 8. First, it is important to make sure they child is not only using the appropriate amount of fluoride toothpaste and he/she is not swallowing excess amounts of it. Fluorosis of the teeth often occurs because of too much fluoride ingested via toothpaste. Second, children might need help with brushing and flossing their teeth to make sure they are being effective and cleaning all of the plaque off. Young children do not have the manual dexterity to brush all teeth surfaces effectively with a toothbrush.

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Prevention Strategies: Dietary Counseling

1. Children of all ages with poor dietary habits are at a high risk for developing early childhood caries. It is not just children drinking from bottles or sippy cups

2. Limit the frequency of consuming any liquid or food containing sugar and/or simple carbohydrates

3. Even “healthy” foods and drinks can be cariogenic.a. Animal crackers/cookies/cheeriosb. Gummy and chewable vitaminsc. Raisinsd. Citrus juicese. Diet Sodas

Note. A healthy diet is not only good for the teeth and oral health. It is also vital for a child’s overall growth and development. After consuming foods that are cariogenic, it is good to wash the mouth with plenty of water and brush the teeth if possible. This action buffers the oral pH and inhibits plaque bacteria from forming.

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Prevention Strategies: FluorideAssess for adequate fluoride exposure.

1. Topical sourcesa. Toothpasteb. Community water fluoridationc. Fluoride varnishd. OTC fluoride rinsese. Professional fluoride treatments at dental

officesf. School based fluoride mouth rinse

programs

2. Systemic sourcesa. Community water fluoridationb. Foods and drinks produced using

fluoridated waterc. Fluoride supplements

Note. Assess fluoride exposure from all possible sources, and decipher whether the source is systemic or topical. Fluorosis only occurs if too much SYSTEMIC fluoride is ingested. Usually, this occurs because a child is consuming fluoride toothpaste instead of rinsing thoroughly and spitting it all out. It is important to ask whether a child lives in a community that has fluoridated water. It is also important to find out if the child is actually drinking the water. If the child only drinks bottled water, they might not be getting the public health benefit of fluoridated community drinking water. The most updated list of Massachusetts’ communities that fluoridate their water supply is located in your blue folder. Some communities only partially fluoridate their water, so make sure to look closely at what areas within one community have fluoridated water

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Fluoride Supplementation Schedule

Massachusetts has 140 fluoridated communities!Note. This is also available on CD ROM 1 in the toolkit.

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Prevention Strategies: Access to a Dental Home

1. Frequent dental examinations2. Routine dental radiographs3. Oral hygiene education4. Prophylaxis, cleaning, and fluoride

treatments5. Dental sealants on permanent molars

Note. Many parents do not think baby teeth are important, and they do not see the need to take their children to the dentist. Your opinion on this issue might influence them to change these misperceptions about oral health. Oral disease in childhood is indicative of oral disease in adulthood. Preventing oral disease in childhood is equally as important as preventing it in adulthood. The AAP recommends that child health providers encourage caregivers to establish a dental home for their child by age 1. This might be even sooner if a child is at moderate to high risk for developing oral diseases.

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Prevention Strategies: Dental Sealants1. Plastic material placed into the deep groves and fissures of

posterior permanent teeth

2. Painless procedure for children, no tooth structure is removed

3. Recommended when first molars fully erupt, usually by age 6, and when second molars erupt around age 12

Source. http://www.dentalcarekids.com/new_techniques.htm

Note. Dental sealants protect back teeth from dental caries because the think plastic fills up the deep grooves, pits, and fissures in the teeth. This prevents food and plaque from remaining stuck in these areas. Dental sealants differ from fluoride varnish. Sealants are a plastic material that is placed in pits and fissures of the posterior teeth to block plaque from getting stuck there. Fluoride varnish is a topical fluoride that can remineralize enamel to prevent caries.

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Let’s talk about the GUMS…

Healthy teeth are not good unless they have healthy SUPPORT

Gums and alveolar bone SUPPORT the teeth. Periodontal health is the foundation for COMPLETE oral health and function.

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Gingival/Soft Tissue Anatomy

Source. http://medical-dictionary.thefreedictionary.com/Gum+(anatomy)

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Periodontal Infections

Source. www.rideaudental.ca/tips.html

Bacterial, plaque induced

1. Gingivitis .Localized and reversible

2. Periodontal DiseaseProgressive and irreversible

3. ANUG a. Acute Necrotizing

Ulcerative Gingivitis

b. treatable, but damage not always reversible

Source. www.drrafia.com/ServicesWeOffer/Periodontal.aspx

Note. ANUG is sometimes associated with stress or immunosuppression. The gingiva can become very red and tender. The gum that fills the space between teeth is “punched out” or cratered in appearance. ANUG needs to be treated by both medical and dental professionals since it is often associated with something systemic. Sometimes the gingiva do not return to the natural contour around the tooth even after the infection is treated and the infection is gone.

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Diseased vs. Healthy Gingiva

Source. OraPharma, Inc.,www.arestin.com

Source. www.rideaudental.ca/tips.html

Note. In periodontal disease, destruction of the clinical attachment includes both that of the gingival connective tissue and the alveolar bone. Dental professionals measure this destruction with a periodontal probe.

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Conditioned Gingival Enlargement

1. Medication Induceda. Anticonvulsantsb. Calcium Channel Blockersc. Immunosuppressants

2. Hormonal Changes3. Vitamin C and B deficiencies4. Immunosuppression

a. Leukemiab. Lymphomac. Aplastic Anemia

5. Conditions associated with systemic inflammation6. Diabetes

Note. The key to reducing the risk of conditioned gingival enlargement is to maintain very meticulous plaque control. Studies have suggested that the risk of conditioned gingival enlargement can be reduced with strict oral hygiene routines beginning at least 10 days prior to when the medication therapy begins. If the enlargement is severe, it might need to be treated by a dental professional such as a gum specialist, or periodontist.

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Viral Oral InfectionHerpes Simplex

1. Keratinized epithelium. Hard palate, lip, attached gingiva

2. Multiple vesicles that coalesce

3. Highly contagious4. Virus remains on trigeminal

nerve5. Often induced during

immunosuppression, trauma, or stress

Note. Caregivers should know that “cold sores” are very contagious and can spread on different locations on a child’s body as well as between family members and other children. This is a virus that remains with the child for life, and many people are not aware of this.

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Aphthous Ulcers1. Often misdiagnosed as herpetic lesions

2. Occur on nonkeratinized tissue including the soft palate, buccal and labial mucosa, vestibules, and non attached gingiva.

3. Painful, clearly defined, shallow round or oval 1 to 3 millimeter ulcers

4. Often reoccurring, called Recurrent Aphthous Stomatitis

5. Predisposing factors includea. Oral traumab. Emotional disturbances or stressc. Family historyd. Hypersensitivity to foodse. Drug therapyf. Immunosuppression/deficiency

Note. Aphthous ulcers are often called “canker sores,” and usually have a prodromal period of approximately 24 to 48 hours in which symptoms of localized burning or pain can occur. Shortly after, clinical manifestations include an ulcer with a shallow necrotic center covered with a yellow gray pseudomembrane surrounded by minimally raised margins and an erythematous halo. They are often painful, and usually subside in 3 to 4 days. O. TC topical anesthetics can be used to relieve pain.

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Fungal Oral Infection

Oral Candidiasis1. Usually indicates

immunosuppression2. Can occur as

complication of xerostomia

3. White, curd like lesions

4. Treat with anti fungal, either topical or systemic.

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Gingival Infection Prevention

1. Identify risk and reinforce meticulous oral hygiene and care under a dental professional

2. Implement strict oral hygiene at least 10 days before induction of pharmaceutical treatment with known gingival side effects

3. Assess for adequate saliva flow

4. Consider consulting with a dentist about prescription antimicrobial mouthrinse, such as a 0.12% solution of chlorhexidine gluconate or low dose doxycycline to control gingival infection and inflammation

Note. Healthy children do not usually have periodontal problems, but CSHCN might experience problems because they have more risk factors for developing gingival infections. Chlorhexidine gluconate is often used to treat adult periodontal infections, but has not extensively been studied in the pediatric population.

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ReviewTo Bridge Systemic Health with Oral Disease Risk, Ask Three Questions.1. Does the child have any conditions,

diseases, or special health care needs today that may increase his or her risk for oral disease/injury in the future?

2. Will any recommended or prescribed treatment increase the risk for oral disease/injury? If so, what can be done to prevent it?

3. If oral disease occurs, how could it affect the child’s overall health and normal growth and development?

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1. History of access to dental care

2. Current access to dental care

3. Caregiver/family history of oral disease

4. Current caregiver oral health status

5. Oral Health Knowledge, Attitudes, and Behaviors

Note. The next important step in the BLOCK Oral Disease Strategy is to Learn about families’ access to dental care and dental health history. Caregivers’ and families’ oral health histories are predictive of the child’s oral health status.

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LOOK For

1. Fillings

2. Plaque on teeth

3. Red puffy gums

4. White spots on teeth = demineralization

5. Soft tissue lesions

6. Oral trauma

7. Severe decay/abscess

8. Adequate saliva flow

Note. The next BLOCK Oral Disease Strategy step is to do a quick and simple oral health assessment. Once you complete the posttest and request a copy of the Toolkit, you will have access to many more resources. In the Toolkit, CD ROM 1 provides oral health assessment forms and tips. The printed clinical reference tools in your folder today also have pictures of oral disease indicators and the Caries Risk Assessment Tool or CAT. You will need the CAT to establish caries risk when considering the application of fluoride varnish.

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Assessing Caries History

Decay Prepped Restored

Source. www.dentalcarekids.com/new_techniques.htm

Note. It’s important to ask caregivers about caries history. Don’t just rely on visual examination! As you can see, it’s difficult to detect tooth colored fillings!

52Note. The next step in the BLOCK Oral Disease Strategy is to calculate the information you gathered from your assessment to determine the child’s oral disease risk.

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1. What do you see?

2. What does the caregiver need to know and understand?

3. What is the next step for the caregiver to take in regards to his/her child’s oral health?

4. Refer to www.mass.gov/dph/oralhealth for anticipatory guidance materials

5. Document all oral health services rendered and when to follow up

Note. Use the anticipatory guidance materials on CD ROM 2 to communicate with parents about their child’s oral health. You can also find resources on the Office of Oral Health’s webpage. These resources will give parents something to take home, which will reinforce what you discussed about oral health at the medical visit. CLICK ON LINK TO BRING UP ORAL HEALTH ASSESSMENT LABELS FOR DOCUMENTATION

54Note. Know how to apply the oral health assessment data that you gather, and follow up with the children and their caregivers at subsequent appointments.

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Fluoride Varnish

1. Delivers remineralization benefits like other topical fluoride sources

2. Can slow, arrest, and reverse the caries disease process by 30%

3. Intended for children who are at moderate to high risk for dental caries

Note. CSHCN might benefit greatly from receiving fluoride varnish in the medical setting. This is something any medical provider should consider when treating a child with any risk for dental caries, especially since it is a sustainable service. MassHealth now reimburses $24.00 per application. Dollar amount subject to change.

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Source. AAP Oral Health Initiative, www.aap.org/commpeds/dochs/oralhealth/reimbursement.cfm

Note. Massachusetts is now included among 24 other U.S. states with Medicaid coverage for fluoride varnish application in the medical setting!

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Why Consider Fluoride Varnish in the Medical Setting?

1. A dental cleaning is not needed prior to application

2. No special dental equipment is needed3. It is quick and easy to apply, and dries

immediately upon contact with saliva4. Little training and skill is needed to apply

fluoride varnish5. It is safe and well tolerated by infants, children,

and children with special health care needs6. It is a sustainable service

Note. Fluoride varnish should take less than 2 minutes to apply. Many health professionals can potentially qualify to apply fluoride varnish if they complete a MassHealth approved training. Contact MassHealth directly about other available training opportunities.

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Who Can Apply Fluoride Varnish?

After completing a MassHealth approved training, the following health care professionals are eligible to apply fluoride varnish.1. Physicians2. Physician assistants3. Nurse practitioners4. Registered nurses5. Licensed practical nurses

Note. You MUST complete a MassHealth approved training before you can apply fluoride varnish on patients’ teeth. This training is approved by MassHeatlh, however, you must remember to complete the posttest and provide your contact information so the Office of Oral Health can send you a certificate of completion.

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MassHealth Coverage Eligibility

Limitations and Restrictions1. Not recommended to exceed one application

every 180 days per provider type from first tooth eruption, usually 6 months, to the third birthday

2. Recommended during a well child visit and will be delivered along with oral health anticipatory guidance and a dental referral if necessary

Intended for children ages 3 and younger, but will be considered for members who are1. Under age 212. Eligible for dental services3. At high risk as determined by a Caries Risk

Assessment Tool, CAT

Note. Contact MassHeatlh directly for specific coverage eligibility questions.

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Preparation1. Perform an Oral Health

Assessment, and the CAT

2. Assess coverage eligibility

3. Assess for contraindications such as pine nut and/or colophony allergy

4. Informed consent and educate caregiver

5. Have caregiver assist with managing a young child during application

Note. Examples of informed consent and caregiver education for fluoride varnish application are on CD ROM 1 and 2 in the toolkit.

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Fluoride Varnish Supplies

1. Gloves

2. 2x2 gauze or cotton rolls

3. Varnish and applicator

4. Mirror or tongue depressor

Note. As you can see, very few supplies are needed to apply fluoride varnish.

Source. www.aap.org/oralhealth/cme/page46.htm

Source. www.uiowa.edu/~c090247/fluoride_varnish.htm

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Application

1. For young children, sit knee to knee with caregiver

2. For older children, stand in front and tilt his or her head back

3. Provider dry’s teeth with gauze and “paints” varnish onto child’s teeth on all accessible surfaces

Note. The entire process should take no more than 2 minutes. Fluoride varnish doesn’t have to be painted “perfectly” onto the teeth. Just get it onto the most teeth surfaces that you can and don’t worry about “painting in the lines.” The varnish will not harm the soft tissues and gingiva if it comes into contact. Before applying it on children, practice applying fluoride varnish onto one of your colleague’s teeth.

Source. North Carolina Department of Public Health, http://www.communityhealth.dhhs.state.nc.us/dental/Into_the_Mouths_of_Babes.htm

Source. www.mohealthysmiles.com/2008/02/index.html

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Caregiver Instructions

1. Teeth will look dull, but will be back to normal once varnish is removed

2. Brush the varnish off the next day

3. Child can eat and drink normally for the rest of the day

4. Varnish is applied every 3 to 6 months depending on moderate to high risk status

5. Reinforce the dental home

Note. It is important that informed consent is given by the parent before fluoride varnish is applied to the child’s teeth.

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Billing for Fluoride Varnish1. Community Health Centers or CHC, must bill

MassHealth with CDT code D1206 on the MassHealth Claim form number 9, or transmitted through the 837P electronic transaction

2. CHCs may bill for fluoride varnish provided by a physician or qualified staff member under the supervision of a physician for the same member, the same date, and the same location as a visit, a treatment, or a procedure

3. CHCs may not bill for a visit in addition to billing for the application of fluoride varnish, if the sole purpose of the visit was to apply the fluoride varnish. In this instance, CHCs may bill for the fluoride varnish code only.

Note. Keep up to date by communicating with MassHealth about any policy changes that might affect coverage and reimbursement for fluoride varnish in the medical setting.

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Making an Action PlanQuestions to ask in preparing for implementation.

1. Whom do you need to talk to and educate about oral health? Do you need to educate your administrators to gain their support? Support staff? Medical billing personnel? Use the BLOCK materials to educate others.

2. What staff members will be involved? Do you want to involve other health professionals such as physician assistants and nurses? They will need to take approved training before they can apply fluoride varnish. Again, use the BLOCK Materials to educate other health professionals who might be involved.

3. How will supplies be purchased and paid for? Identify who will need to budget for the cost of fluoride varnish supplies.

4. Who will do oral health assessment/fluoride varnish application? The BLOCK Oral Disease Toolkit contains information about various companies that can supply fluoride varnish. It is generally very inexpensive, but you will need to designate a staff member to be responsible for ordering and supplying the fluoride varnish.

5. How will this be documented and followed up? Every facility has different documentation standards and procedures. If you use paper charts, you might use the printable oral health assessment labels. They are quick and easy to fill out and document oral health assessments, education, and fluoride varnish application.

6. How and to whom will dental referrals be made? Try establishing and building relationships with dental providers in your CHC. They are great resources for you.

7. How will billing for fluoride varnish be completed? Identify who needs to be educated about the billing procedures, as well as what the CHC will do for children who need fluoride varnish are covered under a private health insurance that does not reimburse for fluoride varnish.

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Check out the Massachusetts Department of Public Health Office of Oral Health Website for fact sheets, publications,

and reports!

www.mass.gov/dph/oralhealth

For any additional questions or comments about the BLOCK Oral Disease training and materials, please contact

Lynn Bethel, RDH, BSDH, MPH

Director, Office of Oral Health

Lynn.Bethel@state.ma.us

617-624-6074

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Please Complete Your Posttest!Please Remember to do the

following.1. Go to this link to complete the

posttest: http://www.surveymonkey.com/s.aspx?sm=jPbZLjXgNF4SU9Q76Pj9iQ_3d_3d

2. Request a toolkit at the end of your posttest

3. If you want a certificate mailed to you, provide your name and mailing address when prompted on the post test