It All Started With a Phone Call!

Rebecca King, DDS, MPH; Kelly Close, RDH, MHA;William Vann, Jr., DMD, PhD; Larry Myers, DDS, MPH;

July 16, 2008

2008 NC Statewide Dental Public Health Conference

What’s This Presentation About?

• PROGRAM EVOLUTION, using ECC individual pilots, programs and opportunities

• How things evolve depending on the latest science, lessons learned, community needs, etc.

• How programs relate to each other

The Beginning

BURKE

Smart Start Regional Meeting December 1996 Morganton

desire and willingness to try to do something about “bottle rot” for the children in their centers.

Meeting Outcomes

• Selected dental as focus

• Submitted a multiyear grant with DEHNR (summer 1997)

• ARC grant funded

Morganton Meeting

1996

The Need

Appalachian Regional Consortium/NCPartnership for Children/Smart Start health assessment (fall 1997)

• 1/3 kindergarten children in western part of state had untreated decay

• Primary need– reduce early childhood caries– improve dental health

Goals

• Increase access to oral preventive care for low-income children

• Reduce prevalence of ECC in low-income children

• Reduce treatment needs on a dental care system already stretched beyond its capacity to serve young children

Smart Smiles

An Appalachian Regional Collaborative Partnership to Improve Dental Health

ARC Counties

CHEROKEE

SWAIN

MACON

GRAHAM

CLAY

JACK-SON

HAY-WOOD

HENDER-SONTRAN-

SYLVANIA POLK

RUTHER-FORD

BUN-COMBE

YAN-CEYMADISON

MITCHELLAVERY

BURKE

STOKESSURRY

FORSYTHYADKIN

DAVIE

ASHE

WILKES

ALLE-GHANY

CALDWELL ALEX-ANDER

McDowell

WATAUGA

Funded Sept 1998

Public Health Dental Hygienist

ARC CountiesARC Counties-Special Project

March 23, 1998

Partners/Advisory Board

• Local community leaders

• State and regional Smart Start agencies

• NC Oral Health Section

• UNC School of Public Health

• UNC School of Dentistry

• Local health departments

• Ruth & Billy Graham Health Center

• Physicians

Pilot Rationale

• Need preventive services as soon as teeth erupt• Fluoride varnish

– safe, easy to use, effective – no studies of effectiveness in 1-2-year-olds but

supported by a larger body of evidence• topical fluorides effective

– effective in permanent teeth– effective in primary teeth of older children

• Hygienists successful with parents, children, community groups

Why Preventive Model in Medical Office?

• ECC is public health problem - must start early• Able to reduce disease and need for treatment

at young age• Infants and toddlers already in medical offices –

get multiple services at one visit• Medical community interested and willing• Most general dentists don’t see young children• Few pediatric dentists in NC• Treatment is expensive• This was the best idea anyone had

Smart Smiles Services

• Oral health education for caregivers• Screening and referral• Fluoride varnish application

Targets

• Children, 9 - 36 months, high risk for caries– 80% decay in 20% children

• Risk factors & socioeconomic indicators – families 200% Federal Poverty Level– medically compromised children– older siblings with poor oral health

Dental Support

• NC Academy of Pediatric Dentistry endorsement - fall 1999

• NC Dental Society resolution of support - spring 2000

• NC Academy of Pediatric Dentistry reaffirmed support - fall 2001

Challenges

• Learning and implementing dental procedures in medical practices

• Securing licensing board support (medical, dental, nursing)

• Evaluating (adoption rates, quality of care, clinical effectiveness, costs and political concerns)

Challenges

• Administration– Identifying the “high-risk” children– Getting them in for service on a “regular

schedule”

• Financing– Grant stipulated service at no cost to

patients– Economics was an issue for medical

practices

Morganton Meeting

1996

ARC: Smart Smile

1998

Finances

• NC IOM Task Force on Dental Care Access (spring, 1999) recommendation #18

• Medicaid agreed to reimburse– Medical offices - required training, recognized Smart

Smiles trainers– February 2000, reimburse for:

• dental health education for parent/care-giver• oral screening and referral for child as needed• fluoride varnish application for child

– Birth of Into the Mouths of Babes

Morganton Meeting

1996

Medicaid Funding

2000

ARC: Smart Smile

1998

Into The Mouths of Babes (IMB)

Statewide Medicaid Oral Preventive Program for Young Children

IMB Statewide Pilot

• December 1999• Pediatricians and family practitioners• Used Smart Smiles training session and

educational materials, modified over time• Added training on billing procedures

Goals (same as Smart Smiles)

• Increase access to oral preventive care for low-income children

• Reduce prevalence of ECC in low-income children

• Reduce treatment needs on a dental care system already stretched beyond its capacity to serve young children

Statewide IMB Progression

• Pilot – volunteer trainer• June 2000, RFA to Medicaid agencies for

innovative ECC program– Partners: Medicaid, UNC Schools of Public

Health and Dentistry, NC Pediatric Society, NC Academy of Family Physicians, Oral Health Section

• NC was funded– Evaluate level of training required for MDs– Funds for coordinator position

Oral Preventive Package (children 0-36 mo.)

• Oral screening and referral for dental care as needed

• Caregiver education• Fluoride

– Toothpaste– Topical fluoride application (varnish)

Morganton Meeting

1996

Medicaid Funding

2000

ARC: Smart Smile

1998

Into the Mouths of Babes

2000

Results: MD Training Evaluation

Training Required

• Types of training - three randomly chosen groups:– Traditional AMA approved CME– Add telephone learning collaborative– Add on-site technical assistance

• Study results showed that procedure adoption rates were not influenced by amount of training

Morganton Meeting

1996

Medicaid Funding

2000

ARC: Smart Smile

1998

Medical Provider Training

Evaluation

2001

Into the Mouths of Babes

2000

IMB 2007• >100,000 visits for dental

preventive package• ~ 425 sites trained and

supported• Increase in eligibility to

age 3 ½ (42 mo)• Decrease in time interval

to accommodate well child check up schedule

• 26 state Medicaid programs reimbursing medical providers

Number of IMB Preventive Visitsin NC Medical Offices and Health Departments

0

20,000

40,000

60,000

80,000

100,000

120,000

2000 2001 2002 2003 2004 2005 2006 2007

Percent of Health Check Screenings Receiving IMB Services *

0

5

10

15

20

25

30

35

40

45

* Includes 1 and 2 yr olds only.

Emerging Data

Dose related response:

• Children with four or more applications before age 3 showed reduced caries treatment needs in anterior teeth compared to children not receiving the procedure (Rozier, UNC)

• Similar results found in a UCSF study (Weintraub, 2005)

Morganton Meeting

1996

Medicaid Funding

2000

ARC: Smart Smile

1998

Early Head Start

2005

Into the Mouths of Babes

2000

Medical Provider Training

Evaluation

2001

Early Head Start Activities

• Focus groups, staff and parent surveys, health coordinator planning meeting (2004-2006)

• Oral Health Initiative Grants (2006-2008)– Guilford Child Development

•Staff training•Pilot-testing of draft oral health curriculum

– East Coast Migrant Head Start Program

• Carolina Dental Home meeting with Coastal Community Action to continue piloting curriculum (2008)

Upcoming EHS Activities

“Healthy Teeth Toolkit”• IMB Information• Oral Health Basics

– Include pregnancy, baby teeth, cleaning teeth, dental visits, special needs, parent page

– Fluoride and healthy foods will be incorporated into the basic topics

• Communicating with Parents– Information on listening reflectively, asking open

ended questions, expressing empathy

Upcoming EHS Activities

• Healthy Teeth Toolkit distribution– Short training session (18 EHS programs)

• 1 trainer to ensure standardization

– OHS staff as support• Resource for staff and parents, e.g. brushing

– Support is NOT• Classroom screening and education• Taking on responsibility of securing dental

treatment for program

Pediatric News

• Bright Futures revision– Supports ADA and AAPD recommendation

to refer ALL CHILDREN for dental exam by age one (if feasible)

• Pacifier use– Protective effect on

incidence of SIDS

• WIC: juice discontinued In 2009

AAPD/Head Start Project

National network of dentists to• Provide dental homes,• Train dentists and HS personnel,• Assist HS programs in obtaining services,• Provide the latest evidence-based

information on how to prevent tooth decay and establish a foundation for a lifetime of oral health.

http://www.aapd.org/headstart/

• Regional consultants will assist state leadership teams to develop collaborative networks.

• Networks: local dentists, HS staff and other community leaders.

• Aim: identify strategies to overcome barriers to HS children’s access to dental homes.

Carolina Dental Home Genesis

• RFA released by RWJ Foundation for “Dental Access Grants” (April 2002)

• Proposal submitted (June 2002)

“Carolina Dental Access: a demonstration in eastern NC”

• Proposal selected for RWJ site visit (August 2002)

Carolina Dental Access at a Glance…

• Expand dental delivery system capacity though dental providers’ training

• Delivery of risk-based services• Facilitation collaboration among

community physicians and dentists• Rely on case managers and outreach

series for coordination and integration

Carolina Dental Access - Nuts and Bolts

• Move beyond IMB - provide access to care for kids 0-60 months

• Train physicians - risk assessment for kids 0-60 months.– Refer some– Provide preventive dental care in medical setting

• Provide seamless dental referral process for IMB practices

• Enlist and train GP dentists to provide more care for kids 0-60 months

Looking Backwards

• RWJ Site Visit (August 2002)

• Carolina Dental Access unfunded

• Fast forward to HRSA announcement (Summer 2006): Grant to States to Support Oral Health Workforce Activities

• OHS responds with Carolina Dental Home - funded (2006)

Carolina Dental Home (CDH) at a Glance…

• Enhance effectiveness of risk-based dental referral

• Promote availability and adequacy of dental workforce

• Educate parents about importance of oral health

CDH Site Selection

• County data mined, deliberated & debated by Operations Committee

• Representatives from 5 possible sites invited to discuss project

• Five pediatric dentists from 4 counties met with committee (January 2007)

CDH Implementation

• Site determined (February 2007) Craven/Pamilco/Jones

• Power broker meeting in New Bern (March 2007)

• GP Dentist recruitment (April 2007)

• Team building and training (summer and fall 2007)

CDH Team

• 1 Pediatric dentist• 7 GPs including one each in Jones and

Pamilco Counties• 3 IMB-trained pediatric offices (1 practice with

3 offices + a fantastic Case Manager)• Craven County Heath Director and Mobile

Dental Van Team • Regional OHS public health dental hygienist

Moving Forward…

• Games began (April 2008)First referral was made

• Where are we now?

Challenges & Lessons Learned?

Morganton Meeting

1996

Medicaid Funding

2000

ARC: Smart Smile

1998

Early Head Start

2004

Carolina Dental Home

2006

Into the Mouths of Babes

2000

Medical Provider Training

Evaluation

2001

Infant and Toddler Oral Health Care

Morganton Meeting

1996

Medicaid Funding

2000

ARC: Smart Smile

1998

Into the Mouths of Babes

2000

Early Head Start

2005

Carolina Dental Home

2006

BOHP

2008

Medical Provider Training

Evaluation

2001

What Is PORRT?Priority Oral Health Risk Assessment

and Referral Tool

Goal is to increase the number of highest risk NC children who have a dental home and use dental care by one year of age.

PORRT at a Glance…

• Refine Risk Assessment Tool– Develop guidelines to accompany PORRT

• Develop and implement educational intervention for medical providers.

• Evaluate – Adoption of tool and guidelines– Referral quality – Referral effectiveness

• Refine/revise and expand statewide

What We Know

• Dental services belong in dental offices– No substitution of physicians for dental

services– IMB increases overall preventive visits– IMB increases visits to dentists, particularly

those with disease• Physicians have difficulty referring for dental

care– Workforce shortages– Lack of confidence in screening

Referral Effectiveness

IMBVisit

Referred (33%)

NotReferred

(67%)

Referred1%

Not Referred

99%

Visit

35.6%

12.0%

0.2%

0.1%

Diseased5%

NotDiseased

(95%)

N=24,403

PORRT

Systematic Review Question

What are the modifiable risk factors for Early Childhood Caries (ECC) in

children 0-5 years of age?

Systematic Review: Flow Diagram of Selection

Potentially relevantn=1783

Studies retrieved for evaluation n=303

Relevant studies includedN=44

Cohort studiesn=29

Case-control studies n=15

Prospectiven=10

Retrospectiven=19

Citations excludedn=1480

Studies excludedn=259

Summary Results of Systematic Review

• Evidence supports a number of modifiable factors as risk for caries– Good evidence for biological factors

(except visible plaque)– Good to fair evidence for diet, but particularly

good for frequency of sweets– Poor evidence for oral hygiene– Poor evidence for caries in family members

Develop Tool Guidelines• Define “significant” risk for referral• Refer to appropriate professionals (“triage”)

– Low risk – receive preventive care in medical home until age 3

– Moderate risk – have non-cavitated lesions but nothing more severe and are referred to GPs

– High risk – have cavitated lesions and are referred to pediatric dentist

• Present guidelines in short, easily understandable format for busy physicians

What’s Next?

• Materials on how to use guidelines (pilot in 5 medical practices)

• Evaluate quantity, quality and effectiveness in 75 medical practices

XXX25 IMB practices

In-office educationGuidelinesPORRT

XX25 IMB practices

XX25 Non-IMB practices

• Implement statewideImplement statewide

PORRT Summary

• It is practical for physicians to use risk assessment/referral checklists during the well-child visit

• Some modifiable risk factors are highly prevalent

• Referral guidelines will need to define “significant” risk and referral for a child without evidence of ECC

Morganton Meeting

1996

Medicaid Funding

2000

ARC: Smart Smile

1998

Early Head Start

2005

Carolina Dental Home

2006

PORRT

2007

Into the Mouths of Babes

2000

BOHP

2008

Medical Provider Training

Evaluation

2001

It all started with a phone call

and continues to evolve

depending on

oral health needs of North Carolinians,

disease developments,

and

latest science…

Where Do We Go From Here?

Questions?