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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, [email protected]
Thomas J. Maroon, MD, Chapter Oral Health Advocate
724- 832-0850, [email protected]
Stephanie Chuipek, Chapter Oral Health Advocate610- 541-0155, [email protected]
Additional Help or Information
Kristin Haegele HillHTHC Program Director
484-446-3059
www.healthyteethhealthychildren.org
Questions?
