Partnering with Community Health Centers to Prevent ECC   Nancy R. Kressin, PhD, Paul Geltman, MD, Norman Tinanoff, DDS
Background <ul><li>How best to work on preventing ECC? </li></ul><ul><li>While most young children do not see dentists, mo...
Our prior work (forthcoming, Medical Care) <ul><li>Provider knowledge increased after session teaching pediatricians to us...
Minah, et al.  Early Childhood Caries Prevention at an Urban Pediatric Clinic.  Pediatric Dentistry  30:211-216, 2008 . Ob...
MEAN CARIOUS SURFACES 1.0 0.50 Carious dental surfaces in prevention and comparison group subjects. Comparison group  at i...
15 MEAN MS x 10 4 7.5 MS levels in prevention and comparison group subjects. Comparison group  at initial visit. Mean age ...
Primary Project Aim <ul><li>To decrease the incidence and prevalence of ECC among children most at risk  </li></ul><ul><li...
Project methods <ul><li>Arm 1 </li></ul><ul><ul><li>Attending Physicians and nurses receive training in patient centered c...
Year 2 Study Design Baseline Year 1 24 month olds 36 month olds Caries Exam Mutans test Caries Exam Mutans test FV+PCC FV ...
Summary of Provider Training ‘algorithm’  <ul><ul><li>Three domains of risk factors to address: </li></ul></ul><ul><ul><ul...
Methods, continued <ul><li>At the time of a well child office visit in peds clinic: </li></ul><ul><li>Hygienist/research a...
Clinical Exam <ul><li>Record the presence, number, and location (by tooth number and surface)   </li></ul><ul><ul><li>cavi...
Questionnaire <ul><li>“ Patient Exit Interview” – assesses parent’s view of content of interactions with clinicians </li><...
Challenges faced <ul><li>‘ Buy in’ from pediatrics </li></ul><ul><li>Pediatric collaborator turnover </li></ul><ul><li>Get...
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Partnering with Community Health Centers to Prevent ECC

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Partnering with Community Health Centers to Prevent ECC

  1. 1. Partnering with Community Health Centers to Prevent ECC Nancy R. Kressin, PhD, Paul Geltman, MD, Norman Tinanoff, DDS
  2. 2. Background <ul><li>How best to work on preventing ECC? </li></ul><ul><li>While most young children do not see dentists, most see pediatricians </li></ul><ul><li>Compelling evidence that patient centered counseling by physicians can make a big (10%) difference in clinical outcomes </li></ul><ul><li>Where are most of the ‘at-risk’ children seen for pediatric care? CHC’s </li></ul>
  3. 3. Our prior work (forthcoming, Medical Care) <ul><li>Provider knowledge increased after session teaching pediatricians to use patient centered counseling </li></ul><ul><li>Providers at the intervention site used more counseling strategies, even after adjustment for sociodemographic characteristics and ECC risk factors. </li></ul><ul><li>Children at the intervention site had a 77% reduction in risk for developing ECC at follow up, after controlling for age and race/ethnicity, sociodemographics and ECC risk factors; p < .004. (unadjusted follow up rates of ECC: 17.7% vs. 31.7%) </li></ul>
  4. 4. Minah, et al. Early Childhood Caries Prevention at an Urban Pediatric Clinic. Pediatric Dentistry 30:211-216, 2008 . Objectives: To evaluate an early childhood caries (ECC) prevention program for infants and toddlers using microbial screening as a primary caries risk assessment (CRA) tool. Methods : Prevention group: 109 dentate children aged 6-15 mos. at the initial visit, who presented at an inner-city well-child clinic in Baltimore, MD for medical check-ups. They received F varnish at counseling at least every 6 months. Comparison group:110 children 12 months older than the prevention group (18-27 mos.) at the same clinic. After 26 mos. the prevention group was compared to the comparison group (initial visit). Results: Prevention group: MS counts 1.8x104 (±7.0 x104), dmfs 0.09(±0.07), 2/109 with clinical caries. Comparison group: MS counts 15.6x104 (±640x104), dmfs 1.13(±3.75), 19/110 with clinical caries . Caries and MS data both were significantly different p<0.02. Evaluation of MS counts to predict caries or no caries longitudinally showed 64% sensitivity and 98% specificity. Conclusions: This program design appears promising for ECC prevention of high risk inner-city populations at well-child or similar facilities
  5. 5. MEAN CARIOUS SURFACES 1.0 0.50 Carious dental surfaces in prevention and comparison group subjects. Comparison group at initial visit. Mean age 22.5 mos. Prevention group at last recall. Mean age 24.3 mos.
  6. 6. 15 MEAN MS x 10 4 7.5 MS levels in prevention and comparison group subjects. Comparison group at initial visit. Mean age 22.5 mos. Prevention group at last recall. Mean age 24.3 mos.
  7. 7. Primary Project Aim <ul><li>To decrease the incidence and prevalence of ECC among children most at risk </li></ul><ul><li>To enhance pediatricians’ and nurses’ skills at advising and counseling parents and caregivers about their practice of ECC risk factors. </li></ul><ul><li>To reduce parents’/caregivers’ practice of ECC risk factors. </li></ul><ul><li>To evaluate whether PCC alone, vs. PCC + Fluoride Varnish, will make more of a differences on ECC incidence and mutans streptococci levels </li></ul>
  8. 8. Project methods <ul><li>Arm 1 </li></ul><ul><ul><li>Attending Physicians and nurses receive training in patient centered counseling to reduce risk factors for ECC, and office support system to remind them to do the training </li></ul></ul><ul><ul><li>FV </li></ul></ul><ul><li>Arm 2 </li></ul><ul><ul><li>FV only </li></ul></ul>
  9. 9. Year 2 Study Design Baseline Year 1 24 month olds 36 month olds Caries Exam Mutans test Caries Exam Mutans test FV+PCC FV FV+PCC FV Caries Exam Mutans test Mutans test 12 month olds Caries Exam Mutans test Caries Exam Mutans test FV FV in in in in
  10. 10. Summary of Provider Training ‘algorithm’ <ul><ul><li>Three domains of risk factors to address: </li></ul></ul><ul><ul><ul><li>Toothbrushing/keeping teeth clean </li></ul></ul></ul><ul><ul><ul><li>Consuming foods and drinks that strengthen teeth and limit sugars </li></ul></ul></ul><ul><ul><ul><li>Monitoring teeth (parent, doctor and dentist) </li></ul></ul></ul><ul><ul><li>Assess </li></ul></ul><ul><ul><ul><li>Risk factors being addressed </li></ul></ul></ul><ul><ul><ul><li>Risk factors that still need to be addressed </li></ul></ul></ul><ul><ul><li>Assist </li></ul></ul><ul><ul><ul><li>Help parents identify barriers and problem solve ways to make changes </li></ul></ul></ul><ul><ul><li>Advise/Educate </li></ul></ul><ul><ul><ul><li>What cavities are, how they’re caused, how to prevent </li></ul></ul></ul><ul><ul><li>Arrange follow-up </li></ul></ul>
  11. 11. Methods, continued <ul><li>At the time of a well child office visit in peds clinic: </li></ul><ul><li>Hygienist/research assistant </li></ul><ul><ul><li>Identifies all children between 1 and 3 presenting for visits </li></ul></ul><ul><ul><li>Obtains informed consent </li></ul></ul><ul><ul><li>Provides ‘gift’/incentive </li></ul></ul><ul><ul><li>Conducts clinical exam </li></ul></ul><ul><ul><li>Administers questionnaire </li></ul></ul>
  12. 12. Clinical Exam <ul><li>Record the presence, number, and location (by tooth number and surface) </li></ul><ul><ul><li>cavitated carious (“d2”) lesions as well as </li></ul></ul><ul><ul><li>white or opaque patches (“d1” ) lesions on tooth surfaces </li></ul></ul>
  13. 13. Questionnaire <ul><li>“ Patient Exit Interview” – assesses parent’s view of content of interactions with clinicians </li></ul><ul><li>Child’s dietary habits </li></ul><ul><li>Child’s hygiene habits </li></ul><ul><li>Parent’s oral health history and hygiene habits </li></ul><ul><li>Sociodemographics </li></ul>
  14. 14. Challenges faced <ul><li>‘ Buy in’ from pediatrics </li></ul><ul><li>Pediatric collaborator turnover </li></ul><ul><li>Getting into the clinic </li></ul><ul><li>Training all clinicians </li></ul><ul><li>Health literacy </li></ul><ul><li>Patient compensation </li></ul><ul><li>Respondent burden </li></ul><ul><li>How to assess caries </li></ul>
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