Early Childhood Oral Health a Toolkit

7/24/2019 Early Childhood Oral Health a Toolkit

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Contents

ntroduction

arly Childhood &ral Health$reventing and treating early childhood caries

A model of oral health assessment and early contact aimed at reducing early childhoodcaries

#ho /hould Be nvolved;$rimary health care services and professionals8$H&s


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Introduction

6he +e -ealand Health /trategy provides an overarching frameork for the healthsector and is supported by key national strategies and policy documents that include:

$rimary Health Care /trategy

He @oroai &ranga: Mori Health /trategy

#hakattaka 6uarua: Mori Health Action $lan !!?!))

Health of &lder $eople /trategy

+e -ealand Disability /trategy $acific Health and Disability Action $lan

=educing ne>ualities in Health.

mproving oral health is one of the )* population health obectives for the Ministry ofHealth and District Health Boards 4DHBs5 in the +e -ealand Health /trategy and issupported by the strategic vision for oral health !ood Oral Health for All, for $ife4Ministry of Health !!?b5.

=e2orientating child and adolescent oral health services is one of the seven actionareas identified in !ood Oral Health for All, for $ife, hich are considered key toachieving improved oral health 4ibid5. #hile appro'imately (! percent of five2year2oldchildren are free of dental caries, there are significant differences in oral health statusassociated ith ethnicity, region and access to ater fluoridation. ne>ualities in oralhealth, particularly ine>ualities in oral health beteen Mori and non2Mori, have

idened and there are significant differences in the severity of oral disease in young


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Early Childhood Oral Health

Children7s primary teeth begin to erupt into the mouth from appro'imately si' months ofage, and by the second birthday, children ill have many of their primary teeth presentin the mouth.

6eeth are at risk of dental caries 4dental decay5 from the time they start to appear in themouth, and, therefore, children from appro'imately si' months of age onards are atrisk of dental caries. Hoever, not all children develop dental caries, and many

preschool children ill develop little or no decay. 6he influences of oral health2relatedenvironments, such as the oral health of the child7s main caregiver, access to aterfluoridation and oral health2related behaviours 4including regularity of brushing teethith fluoride toothpaste, diet content and dietary habits5 ill largely determine hethera child gets dental caries, and if so, ho severely.

n !!(, ust over half of five2year2old +e -ealand children 4( percent5 ere cariesfree. 6he proportion of children caries2free at five years of age ranged from

*).3 percent to ?(.0 percent in +e -ealand DHBs. Hoever, this also means that anaverage of ust over 3" percent had e'perienced dental caries by the end of thepreschool years, and hile many children e'perience relatively little dental caries intheir primary teeth, a small group e'perience significant disease. nternationalresearch into the patterns of dental caries indicates that the highest levels of dentalcaries in any area ill be concentrated in appro'imately )! to ! percent of thechildren.


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increasing the resistance of teeth to dental caries ith the appropriate use offluorides.

A model of oral health assessment and early contact aimed at reducingearly childhood caries

6he age of a child7s first visit to a dental clinic has been a topic of debate for manyyears. +oak stated in an article for %ediatric Dentistry4+oak )0015:

... only tradition supports 4the5 age three years as the best time for the first dental

visit. vidence about oral disease, its initiation, and the benefits of acomprehensive preventive programme all point to a first dental visit at one year ofage.

Child oral health services in +e -ealand have traditionally enrolled children fromappro'imately years of age, although in some DHB regions, programmes toroutinely enrol children earlier than years have been in place for a number of years.

6he Child &ral Health /ervices /ervice /pecification re>uires all enrolled children tobe e'amined on average every ) months. 6hose services unable to provide eachchild ith an annual completion are re>uired to have a strategy for managing thosechildren 4Ministry of Health !!3a5. Currently, children under years of ageidentified at higher risk of dental caries or ith apparent dental problems should beenrolled and managed by oral health services.

vidence about the prevention and early management of early childhood caries

t hild b i ll d d d d h d


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caries of each child and the application of a targeted strategy for management basedupon this assessment.

t is recognised that earlier attendance by some preschool children ill re>uirereallocation of clinical and staff resources. 6his toolkit does not recommend ane'amination of every preschool child every ) months as the caries risk level ofchildren varies.

6his toolkit recommends:

the development of a standardised national programme of enrolment and early riskassessment

an enrolment and risk assessment process to be undertaken beteen 0 and )months by #ell Child86amariki &ra and other non2oral health providers ith theresulting documents sent to the community oral health services

early contact at appro'imately ) months of age for e'amination and herenecessary preventive and treatment services ith an oral health provider for children

identified at highest risk of early childhood caries from the risk assessment process contact ith an oral health service for all preschool children by years of age

the development of subse>uent individualised revie appointments, hich may varydepending upon the assessed risk of dental caries development

continued monitoring of early childhood oral health ine>ualities to assess theeffectiveness of the approaches recommended in this toolkit.

6h d ti ill i d l t f


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"ho #hould $e Involved%

6he risk of dental caries starts from the time teeth begin to erupt into the mouth 4atappro'imately si' months of age5. 6here is a significant opportunity for differentprimary health care and public health programmes and health professionals to orktogether to prevent early childhood caries and provide early intervention if disease isidentified.

Primary health care services and &rofessionals'PHOs

Australian research into early childhood oral health has confirmed that children havenumerous contacts ith primary health care providers in the first ) months of life andthat many of these contacts provide an opportunity for anticipatory guidance 4Fussyet al !!?5. Hoever, the same study also reported a need for clear consistentmessages and agreed roles and responsibilities. n +e -ealand, general medicalpractices 4F$s and practice nurses5 are fre>uently contacted in regard to childrenyounger than five years of age.

$rimary health care providers are ell positioned to provide early anticipatory guidance4in the first si' months5 about the prevention of dental caries, to follo up on theanticipatory guidance provided by other carers 4


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Hoever,


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ensure that every child has a dental caries risk assessment profile completed and isenrolled ith a dental service by ) months of age and that the information from the

assessment is sent to the local DHB child oral health services provider.

Community oral health services

Community oral health services have an important role in the prevention andmanagement of early childhood caries. &ral health professionals include dentists,dental therapists, dental hygienists and dental assistants. Community oral healthservices provide:

oral health e'amination and assessment and advice in the management of earlydental caries lesions

preventive advice and guidance to reduce the risk of future dental caries

professional preventive treatments, including the use of high concentration fluoridevarnish to reduce the risk of dental caries in some children

treatment services, including dental fillings and e'traction of teeth for children ith

advanced dental caries ho re>uire interceptive treatment.

Children ho e'perience CC are at greater risk of subse>uent caries development,and so aggressive preventive and therapeutic measures such as regimentedapplications of topical fluoride and restorative treatments, including tooth croncoverage treatments and tooth e'traction, are often necessary. 6he oral health careprovider must assess the patient7s developmental level, comprehension skills and thedisease process to decide the most appropriate management for the oral situation andth i di id l hild


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"hat is (ift the (i&%

ue for screening infants7 and toddlers7 teeth fordental caries. t involves understanding the easiest ays to manage infants andtoddlers so that the lip can be retracted to e'pose the teeth and understanding theappearance of early and ell2developed dental caries in anterior primary teeth.

6he techni>ue can be learned >uickly and easily by non oral2health professionals,including parents and caregivers. t provides the skills to identify infants and toddlers

ho have early and active dental caries so that they can be referred for management tooral health services.


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Reducing Ine-ualities

=educing ine>ualities in oral health outcomes and access to oral health services is oneof the seven key action areas identified in !ood Oral Health for All, for $ife4Ministry ofHealth !!?b5. =educing ine>ualities is also one of the goals of the +e -ealandHealth /trategyand is an important component of the #hnau &ra /trategic%rameork articulated in He &oro'ai Oranga: ()ori Health #trategy4Minister of Healthand Associate Minister of Health !!5

vidence2based guidelines and systematic revies of oral health promotion 4/cottishntercollegiate Fuidelines +etork !!( /prod et al )00?5 have reported that uniformapproaches to community2based health programmes can have the effect of increasingine>ualities, but strategies targeting high2risk groups ithin a hole population mighthelp to reduce ine>ualities in oral health.

6his toolkit focuses particularly on the use of primary health care and oral healthservices resources to facilitate earlier and increased contact ith preschool children

ho are at the highest risk of dental caries. 6he intent is to reduce the level of CC inat2risk groups, thereby reducing ine>ualities in oral health among preschool and earlyprimary school aged children.

6he purpose of this early contact is to provide improved opportunities for earlyanticipatory guidance and increased preventive clinical activities, including the use oftopical fluorides. ne>ualities in child oral health are also affected by the ider socialdeterminants of health. t is important that oral health programmes that target early

hildh d i l id th i t l ti hi ith id l h lth 4I i


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"ater /luoridation

arly childhood caries is affected by children7s access to fluoridated ater. +e-ealand research and international revies confirm that appro'imately )( percent morechildren ith access to optimally fluoridated ater are caries2free and that the level ofdental caries in five2year2old children is appro'imately *! percent loer 4McDonaghet al !!! ualities.

Advocacy for access to fluoridated ater should be a fundamental part of strategies toreduce early childhood caries.


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Resource Im&lications of this Toolkit

6he Business Case !uidelines for "nvestment in Child and Adolescent Oral Health#ervices4Ministry of Health !!?a, section . page )5 outlines anticipated targetservice coverage levels by age group.

%or children aged ! years, the recommended enrolment target is (! percent ofeligible children, and this is "( percent for children aged *3 years.

6his toolkit has developed a more detailed and targeted approach to the allocation oforal health programme resources for the infant and early childhood group. 6able 4Appendi' 5 outlines the number of assessment and prevention visits for )!! childrenpotentially anticipated by the toolkit versus a simple application of the guidanceprovided in the Business Case !uidelines for "nvestment in Child and Adolescent OralHealth #ervices4ibid5

6he targeted programme does involve a potentially higher number of visits for the

population group than the percentage enrolment figures in the Business Case!uidelines for "nvestment in Child and Adolescent Oral Health #ervices Hoever, thisassessment does not take into account the length of the visits it is anticipated thatmany of the intermediary visits 4identified by an asterisk in 6able 5 ill be relativelyshort. 6he intermediary visits ill reassess for active caries, reinforce preventive oralhealth advice and apply topical fluoride. t may be possible for some of the activities4for e'ample, reinforcing preventive advice5 to be undertaken by associated oral healthstaff such as dental assistants.


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/urther Information

6heChildOral Health #ervices #ervice #pecification4Ministry of Health !!3a5 outlinesthe range of dental services provided by DHB2delivered and8or funded oral healthservices, and these services include:

diagnostic services: including oral e'aminations, radiographs here necessary,identification of a child7s dental needs and consultation ith the parent8guardian andchild

preventive care: including scaling, cleaning, fluoride treatments and fissure sealinghere appropriate

oral health promotion and educative services: including the provision of individual,group and caregiver advice on oral hygiene, diet, fluoride and other factors affectingoral health

treatment of oral disease:

restorative 4or reparative5 services: including the treatment of dental disease and

restoration of tooth tissue. #here necessary, this ill re>uire co2ordination andreferral to other health services and providers, including referral under the /pecialDental Benefits scheme, and

minor surgical services: including the e'traction of deciduous teeth.


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Professionally A&&lied /luoride Regimens

6his toolkit recommends that children ho are seen by oral health services becausethey have been assessed as being at high caries risk be placed on a professionallyapplied topical fluoride programme.

6he toolkit does not advocate a particular method for delivering professionally appliedfluoride and notes that the literature includes a variety of fluoride vehicles andrecommendations. t is also noted that a recent Cochrane Collaboration revie4Marinho et al !!35 concluded that fluoride toothpastes, mouth rinses and gels reducetooth decay in children and adolescents to a similar e'tent that toothpastes are morelikely to be regularly used and that there is no strong evidence that varnishes are moreeffective than other types of topical fluoride.

f a topical, professionally applied fluoride regimen is selected, it is important to ensurethat the product is used according to appropriate programme guidelines that areconsistent ith the regulatory environment for the fluoride product and is applied by

appropriately trained and registered health professionals.

Recommendation

t is recommended that guidelines be developed for the use of professionally appliedfluorides in early childhood caries in +e -ealand.


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References and $iliogra&hy

American Academy of $aediatric Dentistry. $olicy on arly Childhood Caries 4CC5:Classifications, Conse>uences, and $reventive /trategies. E=


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+H/ /cotland. Childsmile. E=


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A&&endi 1

6able ): Age guide to the model of care and pattern of health service involvement up to age fiveyears to reduce early childhood caries

0312 months .312 months 1232! months 2324 years 23! years !3!4 years ) years

@ey healthprofessionalsand8orservices


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@ey healthsystem points4continued5

$rimary health careproviders have multiplecontacts for preventive,health promotion andacute health issues. 6heyshould also have accessto the enrolment andcaries risk assessment

forms and, for childrenaged from nine months,should be checkinghether these forms beencompleted. Encompletedforms should be filled outand sent to the local DHBoral health service.

DHB oral health servicesshould be set up toreceive the forms, reviethem for caries riskassessment and establishsystems to contact andsee for assessment andpreventive care

programmes and herenecessary treatmentchildren in the highest risk!.

&ral health servicesshould have ell2developed feedback linksith #ell Child86amariki&ra providers and primaryhealth care providers toprovide feedback onchildren ho have beenenrolled but cannot becontacted and shouldovervie monitoring of thesuccess of enrolment andcontact systems.

Children e'amined by oralhealth services becausethey have been identifiedas having high caries riskfrom the enrolment andcaries risk assessmentforms should bee'amined, and the oral

health professional shouldconfirm hether theassessment of a highcaries risk is appropriate.f the child is assessed asbeing in the highest cariesrisk group of the service7spopulation group, theyshould continue on theoral health service7s highcaries risk programme,including receiving si'2monthly professionallyapplied topical fluorideand si'2monthlyreinforcement of oralhealth anticipatoryguidance and assessmentof oral health status.

&ral health servicesshould provide ongoingtraining to #ellChild86amariki &ra,primary health careprofessionals and childhealth professionals toimprove the focus on oralhealth enrolment andcaries risk assessment bychildren before ) monthsof age and theidentification of at2riskchildren through risk

assessment and


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@ey oral healthadvice

Advice recommended.

=efer to 3ood and+utrition !uidelines forHealthy "nfants and-oddlers 4Aged 516years74Ministry of Health!!15 for detailed nutritionadvice.

Children are at risk ofdeveloping dental cariesfrom eruption of the firsttooth at appro'imately si'months of age.

Bottle feeding: do not puta baby or infant to bedith a bottle.

At first tooth eruption,commence cleaning theteeth ith a small softtoothbrush and a smear offluoride toothpaste.

6ooth cleaning shouldoccur tice a day.

Children ith any sign ofchalky hite, yello,bron or blackdiscolouration to the teethor ith teeth that appearto be broken or to haveholes should be referredimmediately to an oralhealth provider.

Food parental, particularlymaternal, oral health is animportant influencingfactor on child oral health.

As for !) months plusall children should have anoral health serviceenrolment and caries riskassessment formcompleted at the nine2month check in thereneed #ell Child8

6amariki &ra frameork.

=efer to 3ood and+utrition !uidelines forhealthy "nfants and-oddlers 4Aged 516years74Ministry of Health!!15 for detailed nutritionadvice.

Avoid putting toddlers tosleep ith a bottle. f thechild ill not settle ithouta bottle, do not useanything in the bottlee'cept plain ater.

6eeth should be cleanedtice daily ith a smallsoft toothbrush and asmear of fluoridetoothpaste. 6oothbrushing should beundertaken ith an adultassisting the child toensure all teeth arebrushed.

Children seen by oralhealth services at this agebecause they have beenassessed as being at highcaries risk should beplaced on a professionallyapplied topical fluorideprogramme. 6hisprogramme shouldprovide ?2mothlyreapplication of theprofessionally appliedfluoride and reinforcementof oral health ant icipatoryguidance and assessmentor oral health status.+ecessary treatment

should be provided orarranged.

As for )3 months pluschildren should attendtheir first oral healthe'amination ith an oralhealth professional,unless they had earlierbeen identified as being athigh caries risk and

commenced in the oralhealth programme.

6eeth should be cleanedtice daily ith a smallsoft toothbrush and asmear of fluoridetoothpaste. 6oothbrushing should beundertaken ith an adultassisting the child to

ensure all teeth arebrushed.

Consumption of foods anddrinks high in sugars,including natural fruituices, cordials and softdrinks, should be avoidedbeteen meals. #ater orplain milk are thepreferred drinks forbeteen2mealconsumption.

Cheese is a good high2energy food for toddlers,is not dental cariespromoting and may be

protective against dentalcaries.

As for 3 years. As for 3 years.

@ey oral healthadvice4continued5

Ese of fluoride varnishapplied si'2monthly by anoral health professional isthe recommendedprofessional topicalfluoride programme.

1, Early Childhood Oral Health Toolkit


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A&&endi 2

Tale 25 An e'ample comparison of resource allocation in assessment and preventive visits for children managed under this targeted programmeversus a visit regime applied from the Business Case !uidelines for "nvestment in Child and Adolescent Oral Health #ervices 4Ministryof Health !!?a5

$irth 1 year 612 months7

1, months8 2 years62! months7

0 months8 years6* months78

!2 months8 ! years6!, months7

)! months8 ) years6*0 months7

6argetedprogramme)!! children

High2risk childrento see

! ! ! ! ! ! ! ! !

ncreased2riskgroup identified

)! )! )! )! )! )!

Documents

Early Childhood Oral Health a Toolkit