Pediatric TrainingPediatric TrainingSt. Christopher’s St. Christopher’s

Hospital For ChildrenHospital For ChildrenPhiladelphia, PAPhiladelphia, PA

December 14, 2010December 14, 2010

Improving the Oral Improving the Oral Health of Health of

Children and YouthChildren and YouthThe Role of the Primary Care The Role of the Primary Care

Medical Provider in the Medical Provider in the Prevention of Childhood Prevention of Childhood

CariesCaries

Dental Health Dental Health Screening and Fluoride Screening and Fluoride Varnish Application Varnish Application Dr. Amos Deinard, MD, MPH Dr. Amos Deinard, MD, MPH

deina001@umn.edu and deina001@umn.edu and

Suzanne Tessier, RDH, CDHC Suzanne Tessier, RDH, CDHC

Sue.L.Tessier@HealthPartners.orgSue.L.Tessier@HealthPartners.org

This program and the personnel involved This program and the personnel involved with it have no financial association with with it have no financial association with any company that manufactures or any company that manufactures or markets fluoride products or dental markets fluoride products or dental supplies; however, we do recommend supplies; however, we do recommend that medical providers use the unit dose that medical providers use the unit dose fluoride varnish product. We do use a 3M fluoride varnish product. We do use a 3M ESPE Fluoride Varnish product in ESPE Fluoride Varnish product in presentations and as part of a “starter presentations and as part of a “starter kit” that we provide to clinics which are kit” that we provide to clinics which are in the process of integrating the primary in the process of integrating the primary caries prevention intervention into the caries prevention intervention into the menu of well-child services because 3M menu of well-child services because 3M has donated the product for use with has donated the product for use with high-risk children. As part of the “starter high-risk children. As part of the “starter kit”, we also provide information on kit”, we also provide information on other fluoride varnish products. other fluoride varnish products.

““You are not healthy without You are not healthy without good oral health.” good oral health.”

-Dr. C. Everett Koop -Dr. C. Everett Koop

Past Surgeon General Past Surgeon General

Surgeon General’s Surgeon General’s Report, 2000Report, 2000 THE MOUTH IS PART OF THE BODYTHE MOUTH IS PART OF THE BODY Oral Health is part of overall healthOral Health is part of overall health Childhood caries is the most common Childhood caries is the most common

chronic disease of childhood (20%-2 chronic disease of childhood (20%-2 yr; 30%-3 yr; 40%-4 yr; 50%-5 yr)yr; 30%-3 yr; 40%-4 yr; 50%-5 yr)

5 times more common than asthma5 times more common than asthma 7 times more common than hay 7 times more common than hay

feverfever More than four million children in the More than four million children in the

United States suffer needlessly on a United States suffer needlessly on a daily basis because of caries daily basis because of caries

Called for non-dental practitioners to Called for non-dental practitioners to become involved in promoting oral become involved in promoting oral health and to integrate oral health health and to integrate oral health care into overall health carecare into overall health care

In response, the American Academy In response, the American Academy of Pediatrics issued a policy of Pediatrics issued a policy statement urging physicians to statement urging physicians to become more involved in primary become more involved in primary prevention of dental pathology, prevention of dental pathology, particularly for children covered by particularly for children covered by public programs (Medicaid and public programs (Medicaid and SCHIP) or those who are uninsured, SCHIP) or those who are uninsured, all of whom have difficulty gaining all of whom have difficulty gaining access to dental care. access to dental care.

Dental care is the most common Dental care is the most common health need of high-risk children health need of high-risk children (Newacheck et al., 2005)(Newacheck et al., 2005)

SESSES EthnicityEthnicity GeographyGeography CSHCNCSHCN

Yet, according to GAO, only about one Yet, according to GAO, only about one third of the 20 million children covered third of the 20 million children covered by Medicaid/SCHIP received any dental by Medicaid/SCHIP received any dental care in 2007care in 2007

Children are 2.6 times more likely to Children are 2.6 times more likely to have medical coverage than dental have medical coverage than dental coverage coverage

Only 20-30% of Medicaid-eligible Only 20-30% of Medicaid-eligible children receive preventive health carechildren receive preventive health care

Based on 2005 enrollment levels in Medicaid, Based on 2005 enrollment levels in Medicaid, GAO estimated that 6.5 million Medicaid-GAO estimated that 6.5 million Medicaid-eligible children 2-18 years of age had eligible children 2-18 years of age had untreated tooth decay and more than 5 untreated tooth decay and more than 5 percent had urgent conditions (fractures, percent had urgent conditions (fractures, chronic pain) chronic pain)

1.1 million children 2-18 years of age had 1.1 million children 2-18 years of age had conditions that warranted seeing a dentist conditions that warranted seeing a dentist within two weekswithin two weeks

Compared to those with private insurance, Compared to those with private insurance, children on Medicaid/SCHIP were more than 4 children on Medicaid/SCHIP were more than 4 times as likely to be in need of urgent dental times as likely to be in need of urgent dental carecare

Preventive dental care has been shown to be Preventive dental care has been shown to be cost-effective. A North Carolina study found cost-effective. A North Carolina study found that average dental-related costs for low that average dental-related costs for low income preschool-aged children were over income preschool-aged children were over 50% less if the first visit was at age one 50% less if the first visit was at age one rather than age 4-5 yearsrather than age 4-5 years

Sad Reality:Sad Reality: 50% of tooth decay in low income 50% of tooth decay in low income

children goes untreatedchildren goes untreated 1 in 8 children never see the 1 in 8 children never see the

dentist (while more than half of dentist (while more than half of children with private insurance children with private insurance received dental care in the received dental care in the preceding year (GAO)).preceding year (GAO)).

GAO estimated that in 2005, GAO estimated that in 2005, 724,000 2-18 year olds could not 724,000 2-18 year olds could not get needed dental care. get needed dental care.

‘‘Minority children’ are more Minority children’ are more likely to have untreated tooth likely to have untreated tooth decaydecay(regardless of family income)(regardless of family income)

Vargas, Crall, Schneider: JADA 1998;129:1229-1238.Vargas, Crall, Schneider: JADA 1998;129:1229-1238.

`

0

10

20

30

40

50

Percent of children

Ethnic groupsWhite African American Mexican American

Permanent dentitionPrimary dentition

2-5 years 6-12 years 6-14 years 15-18 years

Fed. Poverty level

Percent of Children with Decayed and Filled Primary Teeth by

Household Income Level (% of Federal Poverty Level)

0

10

20

30

40

50

Decayed 2-5 yearolds

Decayed6-12year

olds

Filled 2-5yearolds

Filled 6-12yearolds

0-100%

101-200%

201-300%

301%+

Vargas, Crall, Schneider. Analysis of NHANES III data. JADA, 1998.Vargas, Crall, Schneider. Analysis of NHANES III data. JADA, 1998.

Symptoms/Signs/Symptoms/Signs/ConsequencesConsequences

Cavitation with acute pain, cellulitis, Cavitation with acute pain, cellulitis, abscess, tooth loss, failure to thrive, abscess, tooth loss, failure to thrive, dysfunctional speech patterns, dysfunctional speech patterns, diminished facial appearance diminished facial appearance

Lost school days (51 X 10Lost school days (51 X 106 6 hrs -1999)hrs -1999) Low income children missed 12 times Low income children missed 12 times

more days than children from more more days than children from more affluent familiesaffluent families

Loss of wages and potential loss of jobLoss of wages and potential loss of job

If in school with tooth decay and If in school with tooth decay and associated pain, poor school performance, associated pain, poor school performance, disruptive behavior affecting other’s disruptive behavior affecting other’s learninglearning

High cost of hospital outpatient surgery High cost of hospital outpatient surgery ($12,000/case charged )($12,000/case charged )

Emergency room visits; antibiotics; pain Emergency room visits; antibiotics; pain medications; “See your dentist in the medications; “See your dentist in the morning” ($400-$500/visit)morning” ($400-$500/visit)– But alas, for most there is no dentist in But alas, for most there is no dentist in

the morningthe morning

Change in Paradigm for Change in Paradigm for Dealing with CariesDealing with Caries

Dentists should also emphasize prevention and Dentists should also emphasize prevention and be paid for that effort in addition to getting paid be paid for that effort in addition to getting paid for proceduresfor procedures

Until dentists emphasize prevention and begin Until dentists emphasize prevention and begin to see high-risk children, primary care medical to see high-risk children, primary care medical providers should take advantage of the providers should take advantage of the frequent well-child examination to provide frequent well-child examination to provide caries prevention services: gross oral caries prevention services: gross oral examination, 30-second paper-and-pencil caries examination, 30-second paper-and-pencil caries risk assessment, caregiver education about risk assessment, caregiver education about caries etiology and the caregiver’s role in caries etiology and the caregiver’s role in prevention, quarterly application of fluoride prevention, quarterly application of fluoride varnish, and counseling the caregiver that varnish, and counseling the caregiver that varnish is not a substitute for sealants or varnish is not a substitute for sealants or having a source of regular, comprehensive having a source of regular, comprehensive dental care starting by age 1 year dental care starting by age 1 year

History over the past 40+ History over the past 40+ yearsyears From the dawn of dentistry until the mid-From the dawn of dentistry until the mid-

nineties, dentists generally saw all children nineties, dentists generally saw all children starting at age 3 years starting at age 3 years

With the advent of Medicaid (late 60’s) and With the advent of Medicaid (late 60’s) and CHIP, dental care became a covered serviceCHIP, dental care became a covered service

Starting in the mid-90s, however, gaining Starting in the mid-90s, however, gaining access to private practice dentists became access to private practice dentists became more difficult for the Medicaid/CHIP-enrolled more difficult for the Medicaid/CHIP-enrolled children to achieve. In addition, sliding fee children to achieve. In addition, sliding fee schedule care for the working poor is only schedule care for the working poor is only available through Federally qualified Health available through Federally qualified Health Centers and Community Health CentersCenters and Community Health Centers

In 2005, AAP and AAPD created a policy that In 2005, AAP and AAPD created a policy that dental care should start by age 1. dental care should start by age 1.

History over the past 40+ History over the past 40+ yearsyears

Complicating factorsComplicating factors– Matriculation: Retirement = 5: 7 Matriculation: Retirement = 5: 7 – More care, especially in rural areas, More care, especially in rural areas,

is provided by general dentists who, is provided by general dentists who, having had little if any exposure to having had little if any exposure to 1-3 year olds in dental school, do not 1-3 year olds in dental school, do not feel comfortable caring for them feel comfortable caring for them despite AAP and AAPD policiesdespite AAP and AAPD policies

Caries prevention by Primary Care Medical Caries prevention by Primary Care Medical ProvidersProviders

WhoWho– Medical providers (MD, DO, NP, PA, PHN)Medical providers (MD, DO, NP, PA, PHN)– Other venues (WIC clinic; Head Start/Early Head Start)Other venues (WIC clinic; Head Start/Early Head Start)

WhyWhy– To promote To promote primary/secondary preventionprimary/secondary prevention

Cornerstone of primary care of childrenCornerstone of primary care of children Fill void/address needFill void/address need

WhenWhen– Ideally, third trimester of pregnancy (need to involve OB)Ideally, third trimester of pregnancy (need to involve OB)– Well-child visits (2 weeks through 5 years (Well-child visits (2 weeks through 5 years (NN = 12)) = 12))

WhatWhat– AAP Policy (Tooth Decay Prevention)AAP Policy (Tooth Decay Prevention)

Medical providers to assess patients’ dental health and add Medical providers to assess patients’ dental health and add caries prevention services oral examination, 30 second caries prevention services oral examination, 30 second paper-and-pencil caries risk assessment, caregiver paper-and-pencil caries risk assessment, caregiver education about caries etiology and the caregiver’s role in education about caries etiology and the caregiver’s role in prevention, quarterly application of fluoride varnish, and prevention, quarterly application of fluoride varnish, and counseling the caregiver that varnish is not a substitute for counseling the caregiver that varnish is not a substitute for sealants or having a source of regular, comprehensive sealants or having a source of regular, comprehensive dental care starting by age 1) to well-child care menu of dental care starting by age 1) to well-child care menu of servicesservices

– Dental “Home” (age 12 mo., not 3 years)Dental “Home” (age 12 mo., not 3 years) But, is it really a “home”? (inconsistency of coverage). But, is it really a “home”? (inconsistency of coverage).

Rather, emphasize regular care (medical and dental) i.e., Rather, emphasize regular care (medical and dental) i.e., health homehealth home

Caries Risk Assessment (beginning at Caries Risk Assessment (beginning at age 2 weeks) age 2 weeks)

PPreexisting risk factorsreexisting risk factors– Early tooth eruption (<6 months)Early tooth eruption (<6 months)– Overlapping/crowded incisorsOverlapping/crowded incisors

Preterm – more likely to develop enamel hypoplasia Preterm – more likely to develop enamel hypoplasia White spots (none; 1; >1) – lift-the-lipWhite spots (none; 1; >1) – lift-the-lip Plaque (none; present on anterior front teeth)Plaque (none; present on anterior front teeth) Gingivitis (absent; present)Gingivitis (absent; present) Past caries experience of childPast caries experience of child Past caries experience of primary caregiverPast caries experience of primary caregiver Past caries experience of older siblingsPast caries experience of older siblings Bottle to bed (nap; night) containing sugared liquidsBottle to bed (nap; night) containing sugared liquids Frequent/continual access to bottle/sippy cup Frequent/continual access to bottle/sippy cup

containing sugared liquids during day when awakecontaining sugared liquids during day when awake Snacking (none; 1-2 times between meals; >2 times Snacking (none; 1-2 times between meals; >2 times

between meals)between meals)

Failure to clean the child’s teeth 1-2 times/dayFailure to clean the child’s teeth 1-2 times/day Inadequate exposure to fluoridated water (Inadequate exposure to fluoridated water (reverse reverse

osmosis filterosmosis filter); fear of water (dysentery)); fear of water (dysentery) Nonuse of fluoridated toothpaste (ADA seal of Nonuse of fluoridated toothpaste (ADA seal of

approval)approval)– Fluoride supplementsFluoride supplements

Inability to maintain good oral hygiene (dental or Inability to maintain good oral hygiene (dental or orthodontic appliances)orthodontic appliances)

Continual exposure to sugar-containing Continual exposure to sugar-containing medications (chronic illnesses)medications (chronic illnesses)

Xerostomia (Dry Mouth) (drugs for chronic illness)Xerostomia (Dry Mouth) (drugs for chronic illness) Pacifier use (caregiver wets with own saliva)Pacifier use (caregiver wets with own saliva) Pretasting/prechewing of food (caregiver saliva)Pretasting/prechewing of food (caregiver saliva) Bottle sharing (saliva)Bottle sharing (saliva) Infrequent or no regular dental careInfrequent or no regular dental care

Complete AAPD Policy Statement with Caries Risk Assessment Tool available at: http://www.aapd.org/pdf/policycariesriskassessmenttool.pdf

Education/VarnishEducation/Varnish Discuss caries’ etiology and prevention (a Discuss caries’ etiology and prevention (a

balance between risk and protective factors)balance between risk and protective factors) Caries is a transmittable infectious disease Caries is a transmittable infectious disease

and is thus theoretically preventableand is thus theoretically preventable The cariogenic bacteria (primarily The cariogenic bacteria (primarily

streptococcus mutans) of primary caregiver streptococcus mutans) of primary caregiver can be transferred to child by:can be transferred to child by:

– Wetting pacifier with salivaWetting pacifier with saliva– Prechewing the child’s foodPrechewing the child’s food– Tasting the child’s foodTasting the child’s food– Kissing child on the lipsKissing child on the lips– Sharing Bottle (older siblings)Sharing Bottle (older siblings)

Education/VarnishEducation/Varnish

Offer anticipatory guidance to Offer anticipatory guidance to caregivers of all children (fluoridated caregivers of all children (fluoridated water; proper feeding practices; risk water; proper feeding practices; risk for dental decay; oral hygiene for dental decay; oral hygiene instructions; dental home (whenever instructions; dental home (whenever and for whatever) by age 1)and for whatever) by age 1)

Discuss behavior modifications with Discuss behavior modifications with caregivers of children identified as caregivers of children identified as high-riskhigh-risk

Apply fluoride varnish according to risk Apply fluoride varnish according to risk status (low – not needed; moderate – 2 status (low – not needed; moderate – 2 times/year; high – 4 times/year)times/year; high – 4 times/year)

Dental PlaqueDental Plaque

Dental Plaque contains: Dental Plaque contains: BacteriaBacteria Food debrisFood debris Dead mucosal cellsDead mucosal cells Salivary componentsSalivary components

Tooth DecayTooth Decay

Plaque + sugars + microorganisms Plaque + sugars + microorganisms (primarily streptococcus mutans) (primarily streptococcus mutans) acid acid that etches the enamel of the teeth which that etches the enamel of the teeth which results in the beginning of caries (the results in the beginning of caries (the process), leading to a cavity (the hole).process), leading to a cavity (the hole).

Sugar in 12 ounce can of Sugar in 12 ounce can of poppop

Soda Pop:Soda Pop: Sugar: (in teaspoons)Sugar: (in teaspoons)

Orange SliceOrange Slice 11.9 11.9 Minute Maid OrangeMinute Maid Orange 11.2 11.2 Mountain DewMountain Dew 11.0 11.0 Barq’s Root BeerBarq’s Root Beer 10.7 10.7 PepsiPepsi 9.8 9.8 Dr. PepperDr. Pepper 9.5 9.5 Coca-ColaCoca-Cola 9.3 9.3 SpriteSprite 9.0 9.0

Sugars in beveragesSugars in beverages

Beverage:Beverage: Sugar Sugar (in (in teaspoons):teaspoons):

Powerade (32 oz.) Powerade (32 oz.) 1515 Sunny Delight Sunny Delight 99 Gatorade Gatorade 88 Capri Sun Capri Sun 66

Not Just What You Eat, Not Just What You Eat, But How OftenBut How Often Increased acidity produced by bacteria Increased acidity produced by bacteria

after sugar intake persists for 20 to 40 after sugar intake persists for 20 to 40 minutesminutes– With each ingestion of sugar, another With each ingestion of sugar, another

wave of increased acidity lasting for 20-40 wave of increased acidity lasting for 20-40 minutesminutes

Ph < 5.5, calcium (CaPh < 5.5, calcium (Ca++++) is displaced in ) is displaced in enamel by Henamel by H++ (from acid) (from acid)

Frequency of sugar ingestion is more Frequency of sugar ingestion is more important than quantityimportant than quantity– Better to drink 16 oz. of Cola in one long Better to drink 16 oz. of Cola in one long

gulp than continually over 8 hours.gulp than continually over 8 hours.

Fluoride*: What does it do?Fluoride*: What does it do?

A lacquer-based product containing fluoride (NaF) (2.6% A lacquer-based product containing fluoride (NaF) (2.6% fluoride)fluoride)

Retards growth of cariogenic bacteria and inhibits Retards growth of cariogenic bacteria and inhibits bacterial enzymes thereby inhibiting the process by bacterial enzymes thereby inhibiting the process by which cariogenic bacteria metabolize carbohydrates to which cariogenic bacteria metabolize carbohydrates to produce acidic excrementproduce acidic excrement

Localizes in the enamel where it releases fluoride ion Localizes in the enamel where it releases fluoride ion into the enamel in high concentration, remineralizing the into the enamel in high concentration, remineralizing the enamel of the tooth (e.g., white spot)enamel of the tooth (e.g., white spot)

Decreases enamel solubilityDecreases enamel solubility Offers protective effect that is more from topical Offers protective effect that is more from topical

exposure than from ingestion (i.e., supplements; fluids)exposure than from ingestion (i.e., supplements; fluids) Extends exposure time of fluoride in the mouth Extends exposure time of fluoride in the mouth

compared to other topical fluoridescompared to other topical fluorides

* Fluoridated community water should have 0.7-1.2 ppm fluoride to * Fluoridated community water should have 0.7-1.2 ppm fluoride to be effectivebe effective

Fluoride: Who is in need?Fluoride: Who is in need?

Fluoride supplements should be Fluoride supplements should be considered if the water supply does considered if the water supply does not have adequate fluoridation not have adequate fluoridation (naturally (wells); lack of public (naturally (wells); lack of public fluoridation; home reverse osmosis fluoridation; home reverse osmosis filter; bottled), consider, however, filter; bottled), consider, however, other sources of fluorideother sources of fluoride

Infants younger than six months do not Infants younger than six months do not require fluoride supplementsrequire fluoride supplements

Infants six months and older who are Infants six months and older who are breast-fed may have the greatest need breast-fed may have the greatest need for dietary fluoride supplementsfor dietary fluoride supplements

None0.50 mg/day1.0 mg/day6 yrs–16 yrs

None0.25 mg/day0.50 mg/day3 yrs–6 yrs

NoneNone0.25 mg/day6 mo–3 yrs

NoneNoneNone0–6 months

>0.6 ppm0.3–0.6 ppm<0.3 ppmAge

Fluoride Concentration in Community Drinking Water

Fluoride Supplement Fluoride Supplement ScheduleSchedule

MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the US (2001): http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.

Lift the Upper LipLift the Upper Lip Look for presence of Look for presence of plaque on maxillary central and plaque on maxillary central and lateral incisorslateral incisors

Run gloved fingernailRun gloved fingernailalong gum linealong gum lineof child’s incisors (plaque OR white spot)of child’s incisors (plaque OR white spot)

White spots (first visual White spots (first visual evidence of demineralization) evidence of demineralization) where tooth meets gums of where tooth meets gums of maxillary central and lateral maxillary central and lateral incisors (buccal and lingual incisors (buccal and lingual aspects)aspects)

Brown Spots - Brown Spots - Advancing Advancing decay process decay process

Check for Check for Advanced/Severe Decay Advanced/Severe Decay (continuous dissolution of the outer (continuous dissolution of the outer enamel surface)enamel surface)

Decay process Decay process advancesadvances

Decay process Decay process advancesadvances

Facts about Fluoride Facts about Fluoride VarnishVarnish

Easy to apply protective coating that is Easy to apply protective coating that is painted on the surfaces of teeth. It adheres painted on the surfaces of teeth. It adheres to the enamel and slowly releases the to the enamel and slowly releases the fluoride in high concentration. Its presence fluoride in high concentration. Its presence prevents new cavities from forming and helps prevents new cavities from forming and helps stop the caries process that may have stop the caries process that may have started (white spots (won’t vanish but will not started (white spots (won’t vanish but will not progress to brown spot))progress to brown spot))

Because it adheres, there is no concern of Because it adheres, there is no concern of child swallowing the product. Can be used on child swallowing the product. Can be used on babies' teeth. Minimal chance of ingestionbabies' teeth. Minimal chance of ingestion

Protective effect will continue to work for Protective effect will continue to work for several monthsseveral months

Fluoride varnish will have a yellow color to Fluoride varnish will have a yellow color to it when it sets up (Vanish Varnish (Omni) is it when it sets up (Vanish Varnish (Omni) is white)white)

Parent can be involved by assisting in Parent can be involved by assisting in holding the child in the knee-to-knee holding the child in the knee-to-knee positionposition

Children may cry because they do not like Children may cry because they do not like to be held down and to have foreign objects to be held down and to have foreign objects in their mouth (however, makes application in their mouth (however, makes application easier)easier)

To prevent being bitten, tongue blades To prevent being bitten, tongue blades taped together (“bite block”)taped together (“bite block”)

Used “off label” but so is aspirin and many Used “off label” but so is aspirin and many drugs given to childrendrugs given to children

How to Position the How to Position the ChildChild

Place the child in knee-to-knee Place the child in knee-to-knee position or whatever works position or whatever works

bestbest

SuppliesSupplies

Microbrush applicatorsMicrobrush applicators 2 x 2 gauze squares2 x 2 gauze squares GlovesGloves Disposable mirror (not Disposable mirror (not critical since all surfaces critical since all surfaces will be painted)will be painted) Direct light sourceDirect light source

SuppliesSupplies Forms Forms

– Multiply dose tube (but don’t recommend)Multiply dose tube (but don’t recommend)– Unit dose kitUnit dose kit

BrandsBrands– Duraphat–10 ml tubeDuraphat–10 ml tube– Duraflor – unit doseDuraflor – unit dose– Omni – unit dose (ecru; white varnish)Omni – unit dose (ecru; white varnish)

Sources:Sources:– Colgate Pharmaceuticals Inc. 1-800-225-3756Colgate Pharmaceuticals Inc. 1-800-225-3756– Sullivan-Schein Dental 1-800-472-4346Sullivan-Schein Dental 1-800-472-4346– 3MESPE Dental Product 1-800-445-33863MESPE Dental Product 1-800-445-3386

Applying Fluoride Applying Fluoride VarnishVarnish

Step One: Leave varnish in unit Step One: Leave varnish in unit dose tray or move varnish to dose tray or move varnish to gloved handgloved hand

Applying Fluoride Applying Fluoride VarnishVarnish

Use gentle downward finger Use gentle downward finger pressure against the labial sulcus on pressure against the labial sulcus on lower incisors to open the child’s lower incisors to open the child’s mouthmouth

If child has a lot of plaque present, If child has a lot of plaque present, brush or wipe with gauzebrush or wipe with gauze

Applying Fluoride Applying Fluoride VarnishVarnish

Step Two: Dry quadrant of teeth Step Two: Dry quadrant of teeth with gauze square with gauze square

Applying Fluoride Applying Fluoride VarnishVarnish

Step Three: Apply a thin layer of Step Three: Apply a thin layer of varnish to all tooth surfaces in dried varnish to all tooth surfaces in dried quadrant. Do not wipe again.quadrant. Do not wipe again.

Repeat procedure until all quadrants Repeat procedure until all quadrants havehave

been varnishedbeen varnished

Applying Fluoride Applying Fluoride VarnishVarnish Once the varnish is applied:Once the varnish is applied:

It sets quicklyIt sets quickly

You need NOT worry about moisture You need NOT worry about moisture contaminationcontamination

Post Application Post Application Information/InstructioInformation/Instructionsns The applied fluoride varnish will leave a The applied fluoride varnish will leave a

yellow film on teeth (Vanish Varnish is white); yellow film on teeth (Vanish Varnish is white); it will gradually disappear over several daysit will gradually disappear over several days

The child may drink immediately after the The child may drink immediately after the application but should not eat for 2 hours application but should not eat for 2 hours after the application (soft diet only for the after the application (soft diet only for the day)day)

Do NOT brush the child’s teeth until the next Do NOT brush the child’s teeth until the next morningmorning

Have varnish applied based on risk Have varnish applied based on risk assessment at 3-6 month intervalsassessment at 3-6 month intervals

Product SafetyProduct Safety

Following application of varnish on the Following application of varnish on the teeth of four children ages 4, 5, 12, and teeth of four children ages 4, 5, 12, and 14, peak plasma fluoride concentrations 14, peak plasma fluoride concentrations of 3.2-6.3 micromoles were found within of 3.2-6.3 micromoles were found within two hours after application.two hours after application.

These levels were comparable with those These levels were comparable with those found after brushing with a fluoridated found after brushing with a fluoridated toothpaste or after ingesting a 1 mg toothpaste or after ingesting a 1 mg fluoride tablet and were considerably fluoride tablet and were considerably lower than from use of fluoridated gels lower than from use of fluoridated gels (Ekstrand, L., 1980, 1987)(Ekstrand, L., 1980, 1987)

How to Bill State-Supported How to Bill State-Supported Health Care Programs for the Health Care Programs for the ProcedureProcedure Nationally, 43 Medicaid programs are Nationally, 43 Medicaid programs are

reimbursing primary care medical providers reimbursing primary care medical providers for providing caries prevention as part of for providing caries prevention as part of well-child care to those covered by Medicaid well-child care to those covered by Medicaid or CHIPor CHIP

Two states (AZ and NH) have legislated Two states (AZ and NH) have legislated reimbursement but have not funded the reimbursement but have not funded the legislationlegislation

The following states are neither reimbursing The following states are neither reimbursing nor have they legislated reimbursement: HI, nor have they legislated reimbursement: HI, OK, LA, AR, TN, IN, DE, DCOK, LA, AR, TN, IN, DE, DC

= Medicaid reimbursement approved but not funded

= Medicaid reimburses

Revised: 09/10

= Medicaid reimburses in certain circumstances

= Reimbursement not yet approved

AKWA

ORID

CA

NV

HI - F**AZ - C**

MT

WY

MN

SD

UT CO

NM

TX

OK - C**AR -F**

LA-F**

NE

KS

IA

MO

ND

WI MI

ILOH

IN-D**

TN - C**

KY

MS AL GA

FL

NC

SC

ME

NY

CTRIMA

VT

NH - B**

PA

WVDE - F**

MDVA

NJ - F**

DC - D**

States With and Without MEDICAID Reimbursement for

Primary Care Medical Providers to Perform Caries Prevention Services

DC

DERI

NJ

** Indicates state grade from The Cost of Delay: State Dental Policies Fail One in Five Children, Pew Children’s Dental Campaign

Commercial medical insurers are not Commercial medical insurers are not reimbursingreimbursing

All but three of the states (FL, TX, UT) are using All but three of the states (FL, TX, UT) are using the dental CDT code (C-1206) or its predecessor the dental CDT code (C-1206) or its predecessor D-1203. Billing is on the medical CMS-1500 D-1203. Billing is on the medical CMS-1500 (formally HCFA-1500) along with all the SPT and (formally HCFA-1500) along with all the SPT and ICD-9 codes. The three states are using a CPT ICD-9 codes. The three states are using a CPT code. Some payors may require ICD-9 code code. Some payors may require ICD-9 code V07.31 (prophylactic fluoride administration) to V07.31 (prophylactic fluoride administration) to be used in conjunction with D-1206be used in conjunction with D-1206

Each Medicaid program sets its own criteria: Each Medicaid program sets its own criteria: billing code, age of child, number of billing code, age of child, number of reimbursable applications a year, who can bill, reimbursable applications a year, who can bill, to whom can task(s) be delegated (e.g., RN, to whom can task(s) be delegated (e.g., RN, LPN, NA, MA, CMA), required training LPN, NA, MA, CMA), required training

StateName

Providers Currently Reimbursed$/Service(s)*

Procedure Code(s) Used*

Age Limit for Service(s)

# Varnish Applications Reimbursed Annually

Training Required? Yes/No If yes, please specify training expectation

Delegation Allowed **(e.g., RN, LPN, CMA, MA) please specify

Payors (Fee For Service, (FFS), Managed Care Organizations (MCOs) (please specify)

Does the payment come from the medical or dental Medicaid/CHIP dollar (please specify)

In what year did Medicaid begin to reimburse?

Was it necessary to get legislative approval to reimburse medical providers?

Comments

Template for 50 State and DC Survey

Places of Service Places of Service (Minnesota)(Minnesota)

03 = School 04 = Homeless shelter 11 = Office 12 = Home 20 = Urgent care facility 22 = Outpatient hospital 31 = Skilled nursing facility 32 = Nursing facility 33 = Custodial care facility 54 = Intermediate Care Facility/Mentally Retarded (ICFMR) 60 = Mass immunization center (e.g. mall or pharmacy) 71 = Public health clinic 72 = Rural public health clinic

Provider Types Provider Types (Minnesota)(Minnesota) 01 = Hospital 01 = Hospital 09 = School district 09 = School district 16 = Child and teen checkup clinic 16 = Child and teen checkup clinic 20 = Physician 20 = Physician 22 = Ambulatory surgery center 22 = Ambulatory surgery center 30 = Dentist 30 = Dentist 31 = Dental Hygienist 31 = Dental Hygienist 51 = Indian health facility provider 51 = Indian health facility provider 52 = Federally qualified health center 52 = Federally qualified health center 53 = Rural health clinic 53 = Rural health clinic 56 = Dental Lab 56 = Dental Lab 57 = Public health clinic 57 = Public health clinic 58 = Community health clinic 58 = Community health clinic 61 = Public health nursing organization 61 = Public health nursing organization 65 = Nurse practitioner 65 = Nurse practitioner 68 = Clinical nurse specialist 68 = Clinical nurse specialist 69 = Physician assistant 69 = Physician assistant 73 = WIC clinics73 = WIC clinics 74 = Early Head Start and Head Start programs74 = Early Head Start and Head Start programs

General ExpectationsGeneral Expectations Train all primary care medical providers – MD/DO, NP, Train all primary care medical providers – MD/DO, NP,

PA, PHN on all aspects: gross oral examination, 30 PA, PHN on all aspects: gross oral examination, 30 second paper-and-pencil caries risk assessment, second paper-and-pencil caries risk assessment, caregiver education about caries etiology and caregiver education about caries etiology and caregiver’s role in prevention, application of fluoride caregiver’s role in prevention, application of fluoride varnish, counseling of caregiver that varnish is not a varnish, counseling of caregiver that varnish is not a substitute for sealants or for having a source of regular, substitute for sealants or for having a source of regular, comprehensive dental care starting by age 1comprehensive dental care starting by age 1

Need for medical oversight if duties assigned to LPN, Need for medical oversight if duties assigned to LPN, NA, MA, CMA, volunteer (all of whom need to be trained NA, MA, CMA, volunteer (all of whom need to be trained in infection control and HIPAA)in infection control and HIPAA)

Training per Medicaid requirementTraining per Medicaid requirement Within a practice, decide times to offer caries Within a practice, decide times to offer caries

prevention: EPSDT, episodic, immunization-only, prevention: EPSDT, episodic, immunization-only, varnish-onlyvarnish-only

Within the state, advocate for WIC, HeadStart/Early Within the state, advocate for WIC, HeadStart/Early HeadStart venues HeadStart venues

Engage at least one medical provider (usually Engage at least one medical provider (usually medical director) and one administrative person medical director) and one administrative person who, together, will identify perceived barriers to who, together, will identify perceived barriers to integration of the intervention integration of the intervention

Next, engage rest of medical staff to discuss Next, engage rest of medical staff to discuss solutions to overcoming barriers and solutions to overcoming barriers and implementation of solutions implementation of solutions

For clinics that are interested, I will assist in For clinics that are interested, I will assist in training and provide “starter kit” – 100 unit training and provide “starter kit” – 100 unit doses of FV with applicator brush, Atlas of doses of FV with applicator brush, Atlas of Common Dental Pathology, print material to Common Dental Pathology, print material to educate providers, caregivers, and ancillary educate providers, caregivers, and ancillary clinic staff about caries etiology and prevention, clinic staff about caries etiology and prevention, caries risk assessment tool, FV vendors, link to caries risk assessment tool, FV vendors, link to website (film clips of a lift-the-lip examination website (film clips of a lift-the-lip examination and application of fluoride varnish)and application of fluoride varnish)

Periodic all-staff discussions to check on Periodic all-staff discussions to check on progressprogress

How to start in your clinic How to start in your clinic

Oral Health Zone - Oral Health Zone - AdvocacyAdvocacy

If you want to train clinics in greater PA, try to create an If you want to train clinics in greater PA, try to create an Oral Health ZoneOral Health Zone

Convene stakeholders – MD/DO; DDS; PHN, RDH Convene stakeholders – MD/DO; DDS; PHN, RDH (collaborative agreement), schools, mayor’s office, city (collaborative agreement), schools, mayor’s office, city council, business leaders, educators, clergy, parents, council, business leaders, educators, clergy, parents, social service, state and federal legislators, Medicaid, social service, state and federal legislators, Medicaid, Department of Health, local lawyers (pro bono) Department of Health, local lawyers (pro bono)

Share caries dataShare caries data Get stakeholders to take ownership of the problemGet stakeholders to take ownership of the problem Ideally, involvement of medical providers doing Ideally, involvement of medical providers doing

prevention will lead to more referrals to and increased prevention will lead to more referrals to and increased participation by dentists who will do necessary participation by dentists who will do necessary restorative procedures leading, hopefully to a greater restorative procedures leading, hopefully to a greater opportunity for children to have a source of opportunity for children to have a source of comprehensive dental care by age 1comprehensive dental care by age 1

Website Website

http://www.oralhealthzone.umn.edhttp://www.oralhealthzone.umn.edu/u/

Acknowledgement Acknowledgement

ADTAADTA Santa Fe GroupSanta Fe Group Ruben-Bentson Chair in Pediatric Ruben-Bentson Chair in Pediatric

Community HealthCommunity Health Delta DentalDelta Dental Medica FoundationMedica Foundation UCARE Minnesota UCARE Minnesota

““Knowing is not enough, we must Knowing is not enough, we must apply. apply.

Willing is not enough, we must do.”Willing is not enough, we must do.” - Johann Wolfgang von Goethe - Johann Wolfgang von Goethe