Early Childhood Caries:Early Childhood Caries:Do We Have Sufficient Evidence of Effective Do We Have Sufficient Evidence of Effective Interventions to Reverse National Trends?Interventions to Reverse National Trends?

Gary Rozier, DDS, MPH

USPHS Symposium Dental Category Day

Atlanta, GA

June 2, 2009

Surgeon General’s ReportSurgeon General’s Report on Oral Health, 2000on Oral Health, 2000

• Dental caries is the most common chronic disease of childhood, affecting about half of children by middle childhood, and over 80% by late adolescence.

• Research demonstrates that oral and dental diseases have a significant impact on children and families.

• Many Americans lack access to needed oral health care, including many infants and young children.

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

1971-74 1988-94 1999-04

%

Trends in Caries Experience byTrends in Caries Experience by Dentition Type, U.S., 1971 - 2004Dentition Type, U.S., 1971 - 2004

Permanent teeth,6-11 years of age

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

1971-74 1988-94 1999-04

%

Trends in Caries Experience byTrends in Caries Experience by Dentition Type, U.S., 1971 - 2004Dentition Type, U.S., 1971 - 2004

Permanent teeth,6-11 years of age

Primary teeth,2-5 years of age

……U.S. GAO report concluded, referring to the federal/state health program for poor people.

…about 6.5 million children enrolled in Medicaid had untreated tooth decay in 2005.

The GAO report was ordered after…Deamonte Driver, a 12-year-old boy…died last year in suburban Washington when an untreated infected tooth led to a brain infection.

http://www.cnn.com/2008/US/09/23/dentalcare.medicaid/ind

Millions of poor American children have untreated tooth decay, some of them because they cannot find a dentist willing to treat them, a federal report issued Tuesday said. Only 1 in 3 children in Medicaid received any dental care over a year time span...

ABC News- March 6, 2009ABC News- March 6, 2009

Brandon had an astounding 16 baby root canals completed at one visit--nearly every tooth in his mouth. "He comes walking out of that door…and he had blood dripping from his mouth. And all I could see was silver shining through.“ [Mother]

Hunter, another child who received the same treatment and was just starting pre-kindergarten, was teased by other children as a "metal mouth" and said "it just made me feel, like, bad." "I feel like they took my son's smile away." [Mother]

% parents reporting child dental problems or treatment affecting child or family “occasionally, often or very often” among parents of children with obvious caries experience (d2mfs>0)

Impact PercentChild overall impacts 35

Eating, drinking, talking, daycare 26

Pain 17

Sleeping, irritable 16

Smiling, talking 4

Parent overall impacts 45

Upset, guilty 36

Work, finances 23

Both child and parent impacts 58

ImpactsImpacts of Dental Diseaseof Dental Disease

ResponseResponse

• Growing concern over pediatric oral health

• States are experimenting with new models

• Physicians are being called upon to provide dental services– Surgeon General’s Report & Conference (2000)– ADA Future of Dentistry Report (2001)– AAP Policy Statements (2003, 2008)– Bright Futures Guidelines, 3rd Ed., 2008

“Maine has 2 DDS for every 2,300 people, compared to 1 MD for every 640. Nationally there is 1 DDS for every 1,600 people.”

“In Maine, training MDs in dentistry provides a dental safety net for the rural poor.”

March 3, 2009Short of Dentists, Maine Adds Teeth to Doctors’ Training

Ronald Smart who had not been to a dentist in 5 years, came to Fairfield clinic to have an infected tooth pulled; he has had 3 pulled there before, and likely Will have more.

AssumptionsAssumptions

• ECC is a serious public health problem

• Its burden can be reduced through prevention targeted to young children

• Virtually all infants & toddlers obtain care at medical offices and it is a logical place to provide preventive dental services

• Physicians know that ECC is a problem and they want to help prevent it

AssumptionsAssumptions

• Primary medical care providers need help to learn procedures and to implement them in their practices

• Evidence of effectiveness is limited and these Innovations should be evaluated for effectiveness

Aims of PresentationAims of Presentation

• Review evidence for prevention of ECC

• Review efforts in North Carolina and elsewhere to involve non-dental primary care clinicians in oral health promotion and dental disease prevention

• Discuss potential for model to reduce disparities in oral health

• Future directions

Caries Prevention MethodsCaries Prevention Methods

FoodFood

HostHost

BacteriaBacteria

Plague controlFluoride therapy

Sealants

Fluoride therapy

Antimicrobials

Anti-cariesVaccine

Diet Counseling

Multifactoral DiseaseMultifactoral Disease

.... a quick look

at preventive methods for

primary care setting.....

USPSTF Systematic ReviewUSPSTF Systematic Review1) How accurate is Primary Care Clinicians’

(PCC) screening in identifying children 0 to 5 years of age who:a) have dental caries requiring referral to a dentist?b) are at elevated risk of future dental caries?

2) How effective is PCC referral of children 0 to 5 years to dentists in terms of the proportion of referred children making a dental visit?

3) How effective is PCC prescription of supplemental fluoride in terms of:a) appropriateness of the supplementation decision?b) parental adherence to the dosage regimen?c) prevention of caries?

USPSTF Systematic ReviewUSPSTF Systematic Review4) How effective is PCC application of fluoride

in terms of : a) appropriateness of the application decision?b) achieving parental agreement for application?c) prevention of caries?

5) How effective is PCC counseling for caries preventive behaviors* as measured by:a) adherence to the desired behaviorb) prevention of dental caries

* diet, oral hygiene, dental attendance, fluoride use

Summary of EvidenceSummary of Evidence

Of the 11 questions….

• 8 questions have no studies or poor evidence

• 3 questions have fair evidence– Professional adherence to guidelines for

prescribing fluoride supplements– Caries reducing benefits from fluoride

supplements– Caries reducing benefits from fluoride varnish

Bader, Rozier et al. Am J Prev Med 2004.

Fluoride VarnishFluoride Varnish • First introduced in 1964; has been used

widely in European countries since 1980’s.

• Approved by the FDA for use in the U.S. in 1994 as a cavity liner and for treatment of hypersensitive teeth.

• Caries prevention is considered an off-label use.

Fluoride Varnish ProductsFluoride Varnish Products• 5% NaF in resin carrier

(2.26% F, 22.6 mg/mL or 22,600 ppm F)– Duraphat (Colgate)– DuraFlor (Medicom)– CavityShield (Omnii)– Vanish (3M ESPE)

• 1% difluorsilane in polyurethane

(0.1% F, 1.0 mg/mL F or 1,000 ppm F)– Fluor Protector (Ivoclar-Vivadent)

NO CLINICAL TRIALS

Is Fluoride Varnish EffectiveIs Fluoride Varnish Effectivein Primary Teeth?in Primary Teeth?

• 6 studies– 4 Duraphat (5% NaF)– 2 Fluor Protector (1% difluorsilane)

• 3 RCTs had consistent findings – reductions of 37% to 63%

• 3 CCTs found consistent benefit– 1 of 3 statistically significant

Fluoride Varnish StudyFluoride Varnish Study

A 2-year randomized, dental examiner masked clinical trial to determine the efficacy of FV and parental counseling in preventing ECC

Counseling + FV 2x/yearCounseling + FV 1x/yearCounseling only

Weintraub et al., 2005

Dental Caries IncidenceDental Caries Incidence by Treatment Groupby Treatment Group

0

5

10

15

20

25

30

35

40

45

0 1 2

p < 0.001; n=280

3-4

%

Number of Applications

PreventiveFraction 95% CI

Varnish 40% 9-72%

Gel 21% 14-28%

Rinse 26% 22-29%

Toothpaste 24% 21-28%

Fluoride TherapyFluoride Therapy

Marinho Adv Dent Res 2008

27%27%

61%61%

63%63%

29%29%

Geographic Disparities in ECCGeographic Disparities in ECC

Response in NCResponse in NC

• 1997: Pilot “Smart Smiles”

• 2000: Medicaid demonstration “Into the Mouths of

Babes” (IMB)

Primary medical care model

Goals of IMBGoals of IMB

• Increase access to preventive dental care for low income, preschool-aged children

• Reduce the prevalence of ECC in low-income children

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

Will it work?Will it work?“The North Carolina study…. related the impact of a 2-hour infant oral health training course on pediatricians’ practices...

I cannot imagine that a 2-hour crash course in any scientific discipline can make a meaningful

impact, particularly on something as complex as caries risk assessment.”

John RutkauskasExecutive Director, AAPDOctober 2003

Questions?Questions?• What services should PCCs provide?

• What is the best way to train them?

• How many will adopt once trained?

• Will access to preventive services increase?

• How are dental outcomes affected? – Caries-related treatments

– Costs

– ECC experience

– Oral-health related quality of life

• Oral evaluation / referral

• Counseling

• Fluoride therapy

Scope of ServicesScope of Services

What We’ve LearnedWhat We’ve Learned

• Preventive services– More than 3,000 providers trained– Easily integrated into practice– More than 400 participating practices– Wide geographic distribution– Increased access

- 40% of well-child visits- Physician preventive visits 4x greater than dentists- Multiple visits 20 times greater in medical offices

– Parents report high levels of satisfaction

Number of Visits Per YearNumber of Visits Per Year

0

20,000

40,000

60,000

80,000

100,000

120,000

2000 2001 2002 2003 2004 2005 2006 2007

Average annual increase = 21%

Visits

What We’ve LearnedWhat We’ve Learned

• Physicians’ referral practices– Overall rate = 2.8%– With tooth decay = 33% (vs. 0.2%)– 3-fold increase in use (36% vs. 12%)

• Oral health outcomes– Reduced caries-related treatment needs

by 12% to 39%– Reduced tooth decay by 24% to 36%

Referral EffectivenessReferral Effectiveness

IMBVisit

N=24,403

Referred (33%)

NotReferred

(67%)

Referred(1%)

Not Referred

(99%)

Visit 35.6%

12.0%

11.9%

2.5%

ECC(5%)

No ECC(95%)

Response in NC (Con’t)Response in NC (Con’t)

• 1997: “Smart Smiles”

• 2000: “Into the Mouths of Babes”

• 2006: “Carolina Dental Home”• 2007: “Priority Oral Health Risk Assessment

and Referral Tool” (PORRT) Initiative

• 2008: “ZOE” Early Head Start Initiative

Expansion of primary medical

care model

“Every infant should receive an oral health risk assessment from his/her primary health care provider or qualified health care professional by 6 months of age.”

“Parents or caregivers should establish a dental home for infants by 12 months of age.”

Guidelines for Infant Oral Health Care. AAPD Reference Manual, V29 No7, 2008.

AAP Committee on Practice / Ambulatory Medicine and Bright Futures Steering Committee Recommendations for Preventive Pediatric Health. Pediatrics, 2007.

AAPD & AAP Guidelines for AAPD & AAP Guidelines for Age of 1Age of 1stst Dental Visit Dental Visit

37

Question % Agree

Parents≠

All children should be checked by a dentist around the time the first baby tooth comes in.

Physicians†

Referral to a dentist by 12 months of age should be part of routine well-child care visits?

43.8%

26.5%Dentists‡

A child should receive his or her first dental exam by one year of age.

48.4%

≠All EHS programs in NC. †dela Cruz et al., Pediatrics, 2004.‡Prada E et al., 2008.

Guideline AwarenessGuideline Awareness

Reviewer’s Name

• Review of risk-assessment guidelines

• Systematic review of the literature on risks

• Experience with PORRT in Carolina Dental Home

PPriority riority OOral Health ral Health RRisk Assessmentisk Assessment & & RReferral eferral TTool (PORRT)ool (PORRT)

0 10 20 30 40 50 60 70

Percent

Sleep with bottleFamily has dental problems

No fluoride in waterFluoride toothpaste not used

Drink juice between meals

Other oral conditionDental caries

Enamel defectsWhite spot lesions

Visible plaque

Behavioral

Clinical

Percent of PatientsPercent of Patients with Risk Factorswith Risk Factors

n-=1,825;Not mutually exclusive categories

Referral GuidelinesReferral Guidelines

Cavitationor CSHCN

White spot lesionsEnamel defectsOther concerns>3 risk factors

<3 risk factors

Pediatric dentist

General dentist

Physician manages caries risk

Yes (6%)

No

Yes (23%)

No (72%)

Percent of Children ReferredPercent of Children Referred

63

24

6

71

59

3

0

10

20

30

40

50

60

70

80

Cavitated White spots > 2 risk factors

Baseline

Followup

%

Sufficient Evidence?Sufficient Evidence?• Physicians will expand oral health services,

increasing access:– Risk assessment – Fluoride varnish

• Evidence is emerging to support effectiveness of model as a way to address disparities

• Medical, dental, pubic health and social services are yet to be fully integrated, and evidence about how to do this is lacking

73-2001. Resolved, that it be policy of the American Dental Association that topical application of fluoride varnish is a part of comprehensive dental care which requires an examination and supervision by a licensed dentist.

ADA Resolution:ADA Resolution:Application of Fluoride VarnishApplication of Fluoride Varnish

Trans.2001:430-432.ADA House of Delegates

Expected Medical PracticeExpected Medical Practice

• Oral health risk assessment

• Help establish dental home at 12-18 mo.

• Counsel parents

• If no dental home, continue to:

– Counsel parents

– Apply fluoride varnish

Preventive Oral Health for Pediatricians. Pediatrics. 2008;122:1387-94.

Stage of Adoption of Medical Model by State Medicaid Programs

= No Initiative in place; no plans for one (n=13)

= Existing Program (n=28)= Plans to implement initiative in next 12 months (n=10)

3 states confirmed by telephone (Mississippi, Illinois, West Virginia)

1 state by guidelines (Wisconsin)

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TN

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INOH

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PAMD

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MACT

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Delaware

Sams et al., 2009.

AAPD ‘Talking Points’AAPD ‘Talking Points’“AAPD policy does not support the application of fluoride varnish absent a comprehensive dental exam. Current AAPD policy supports the delegation of fluoride application to auxiliary dental personnel or other trained allied health professionals, by prescription or order of a qualified dentist, after a comprehensive oral examination has been performed. Fluoride varnish interventions are not a substitute for the establishment of a dental home.”

AAPD perspective on physicians or other non-dental providers applying fluoride varnish. Talking points. June 2006.

It’s been a It’s been a wild ride!wild ride!

Screenin

g?

Referral?

Counseling?

Fluoride?

Diet?

Risk Assessment?CME?

Tx?

AcknowledgementsAcknowledgements Funding sources

– Appalachian Regional Commission– Centers for Medicare and Medicaid Services– Health Resources and Services Administration– Centers for Disease Control and Prevention– National Institutes of Health (NIDCR)– NC Department of Health and Human Services

Early Childhood Oral Health Collaborative (ECOHC)– NC Division of Medical Assistance– NC Chapter AAP– NC Academy of Family Physicians– NC Oral Health Section– UNC-CH School of Dentistry– UNC-CH Gillings School of Global Public Health– NC Division of Child Development, Head Start Collaboration Office

– NC Dental Society– El Pueblo, Inc.

……coordination of preventive and treatment services coordination of preventive and treatment services

among physicians, dentists and community programs among physicians, dentists and community programs

will allow communities to manage and improve the oral will allow communities to manage and improve the oral

health of all children so that they begin school with no health of all children so that they begin school with no

untreated tooth decay…untreated tooth decay…

Thank You!