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  1. 1. 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
  2. 2. What’s This Presentation About? <ul><li>PROGRAM EVOLUTION, using ECC individual pilots, programs and opportunities </li></ul><ul><li>How things evolve depending on the latest science, lessons learned, community needs, etc. </li></ul><ul><li>How programs relate to each other </li></ul>
  3. 3. The Beginning Smart Start Regional Meeting December 1996 Morganton desire and willingness to try to do something about “bottle rot” for the children in their centers. BURKE
  4. 4. Meeting Outcomes <ul><li>Selected dental as focus </li></ul><ul><li>Submitted a multiyear grant with DEHNR (summer 1997) </li></ul><ul><li>ARC grant funded </li></ul>
  5. 5. Morganton Meeting 1996
  6. 6. The Need <ul><li>Appalachian Regional Consortium/NC </li></ul><ul><li>Partnership for Children/ Smart Start health </li></ul><ul><li>assessment (fall 1997) </li></ul><ul><li>1/3 kindergarten children in western part of state had untreated decay </li></ul><ul><li>Primary need </li></ul><ul><ul><li>reduce early childhood caries </li></ul></ul><ul><ul><li>improve dental health </li></ul></ul>
  7. 7. Goals <ul><li>Increase access to oral preventive care for low-income children </li></ul><ul><li>Reduce prevalence of ECC in low-income children </li></ul><ul><li>Reduce treatment needs on a dental care system already stretched beyond its capacity to serve young children </li></ul>
  8. 8. Smart Smiles An Appalachian Regional Collaborative Partnership to Improve Dental Health
  10. 10. Partners/Advisory Board <ul><li>Local community leaders </li></ul><ul><li>State and regional Smart Start agencies </li></ul><ul><li>NC Oral Health Section </li></ul><ul><li>UNC School of Public Health </li></ul><ul><li>UNC School of Dentistry </li></ul><ul><li>Local health departments </li></ul><ul><li>Ruth & Billy Graham Health Center </li></ul><ul><li>Physicians </li></ul>
  11. 11. Pilot Rationale <ul><li>Need preventive services as soon as teeth erupt </li></ul><ul><li>Fluoride varnish </li></ul><ul><ul><li>safe, easy to use, effective </li></ul></ul><ul><ul><li>no studies of effectiveness in 1-2-year-olds but supported by a larger body of evidence </li></ul></ul><ul><ul><ul><li>topical fluorides effective </li></ul></ul></ul><ul><ul><ul><ul><li>effective in permanent teeth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>effective in primary teeth of older children </li></ul></ul></ul></ul><ul><li>Hygienists successful with parents, children, community groups </li></ul>
  12. 12. Why Preventive Model in Medical Office? <ul><li>ECC is public health problem - must start early </li></ul><ul><li>Able to reduce disease and need for treatment at young age </li></ul><ul><li>Infants and toddlers already in medical offices – get multiple services at one visit </li></ul><ul><li>Medical community interested and willing </li></ul><ul><li>Most general dentists don’t see young children </li></ul><ul><li>Few pediatric dentists in NC </li></ul><ul><li>Treatment is expensive </li></ul><ul><li>This was the best idea anyone had </li></ul>
  13. 13. Smart Smiles Services <ul><li>Oral health education for caregivers </li></ul><ul><li>Screening and referral </li></ul><ul><li>Fluoride varnish application </li></ul>
  14. 14. Targets <ul><li>Children, 9 - 36 months , high risk for caries </li></ul><ul><ul><li>80% decay in 20% children </li></ul></ul><ul><li>Risk factors & socioeconomic indicators </li></ul><ul><ul><li>families  200% Federal </li></ul></ul><ul><ul><li>Poverty Level </li></ul></ul><ul><ul><li>medically compromised </li></ul></ul><ul><ul><li>children </li></ul></ul><ul><ul><li>older siblings with poor </li></ul></ul><ul><ul><li>oral health </li></ul></ul>
  15. 15. Dental Support <ul><li>NC Academy of Pediatric Dentistry endorsement - fall 1999 </li></ul><ul><li>NC Dental Society resolution of support - spring 2000 </li></ul><ul><li>NC Academy of Pediatric Dentistry reaffirmed support - fall 2001 </li></ul>
  16. 16. Challenges <ul><li>Learning and implementing dental procedures in medical practices </li></ul><ul><li>Securing licensing board support (medical, dental, nursing) </li></ul><ul><li>Evaluating (adoption rates, quality of care, clinical effectiveness, costs and political concerns) </li></ul>
  17. 17. Challenges <ul><li>Administration </li></ul><ul><ul><li>Identifying the “high-risk” children </li></ul></ul><ul><ul><li>Getting them in for service on a “regular schedule” </li></ul></ul><ul><li>Financing </li></ul><ul><ul><li>Grant stipulated service at no cost to patients </li></ul></ul><ul><ul><li>Economics was an issue for medical practices </li></ul></ul>
  18. 18. Morganton Meeting 1996 ARC: Smart Smile 1998
  19. 19. Finances <ul><li>NC IOM Task Force on Dental Care Access (spring, 1999) recommendation #18 </li></ul><ul><li>Medicaid agreed to reimburse </li></ul><ul><ul><li>Medical offices - required training, recognized Smart Smiles trainers </li></ul></ul><ul><ul><li>February 2000, reimburse for: </li></ul></ul><ul><ul><ul><li>dental health education for parent/care-giver </li></ul></ul></ul><ul><ul><ul><li>oral screening and referral for child as needed </li></ul></ul></ul><ul><ul><ul><li>fluoride varnish application for child </li></ul></ul></ul><ul><ul><li>Birth of Into the Mouths of Babes </li></ul></ul>
  20. 20. Morganton Meeting 1996 Medicaid Funding 2000 ARC: Smart Smile 1998
  21. 21. Into The Mouths of Babes (IMB) Statewide Medicaid Oral Preventive Program for Young Children
  22. 22. IMB Statewide Pilot <ul><li>December 1999 </li></ul><ul><li>Pediatricians and family practitioners </li></ul><ul><li>Used Smart Smiles training session and educational materials, modified over time </li></ul><ul><li>Added training on </li></ul><ul><li>billing procedures </li></ul>
  23. 23. Goals (same as Smart Smiles ) <ul><li>Increase access to oral preventive care for low-income children </li></ul><ul><li>Reduce prevalence of ECC in low-income children </li></ul><ul><li>Reduce treatment needs on a dental care system already stretched beyond its capacity to serve young children </li></ul>
  24. 24. Statewide IMB Progression <ul><li>Pilot – volunteer trainer </li></ul><ul><li>June 2000, RFA to Medicaid agencies for innovative ECC program </li></ul><ul><ul><li>Partners: Medicaid, UNC Schools of Public Health and Dentistry, NC Pediatric Society, NC Academy of Family Physicians, Oral Health Section </li></ul></ul><ul><li>NC was funded </li></ul><ul><ul><li>Evaluate level of training required for MDs </li></ul></ul><ul><ul><li>Funds for coordinator position </li></ul></ul>
  25. 25. Oral Preventive Package (children 0-36 mo.) <ul><li>Oral screening and referral for dental care as needed </li></ul><ul><li>Caregiver education </li></ul><ul><li>Fluoride </li></ul><ul><ul><li>Toothpaste </li></ul></ul><ul><ul><li>Topical fluoride </li></ul></ul><ul><ul><li>application (varnish) </li></ul></ul>
  26. 26. Morganton Meeting 1996 Medicaid Funding 2000 ARC: Smart Smile 1998 Into the Mouths of Babes 2000
  27. 27. Results: MD Training Evaluation
  28. 28. Training Required <ul><li>Types of training - three randomly chosen groups: </li></ul><ul><ul><li>Traditional AMA approved CME </li></ul></ul><ul><ul><li>Add telephone learning collaborative </li></ul></ul><ul><ul><li>Add on-site technical assistance </li></ul></ul><ul><li>Study results showed that procedure adoption rates were not influenced by amount of training </li></ul>
  29. 29. Morganton Meeting 1996 Medicaid Funding 2000 ARC: Smart Smile 1998 Medical Provider Training Evaluation 2001 Into the Mouths of Babes 2000
  30. 30. IMB 2007 <ul><li>>100,000 visits for dental preventive package </li></ul><ul><li>~ 425 sites trained and supported </li></ul><ul><li>Increase in eligibility to age 3 ½ (42 mo) </li></ul><ul><li>Decrease in time interval to accommodate well child check up schedule </li></ul><ul><li>26 state Medicaid programs reimbursing medical providers </li></ul>
  31. 32. Number of IMB Preventive Visits in NC Medical Offices and Health Departments
  32. 33. Percent of Health Check Screenings Receiving IMB Services * * Includes 1 and 2 yr olds only.
  33. 34. Emerging Data <ul><li>Dose related response: </li></ul><ul><li>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) </li></ul><ul><li>Similar results found in a UCSF study (Weintraub, 2005) </li></ul>
  34. 35. 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
  35. 36. Early Head Start Activities <ul><li>Focus groups, staff and parent surveys, health coordinator planning meeting (2004-2006) </li></ul><ul><li>Oral Health Initiative Grants (2006-2008) </li></ul><ul><ul><li>Guilford Child Development </li></ul></ul><ul><ul><ul><li>Staff training </li></ul></ul></ul><ul><ul><ul><li>Pilot-testing of draft oral health curriculum </li></ul></ul></ul><ul><ul><li>East Coast Migrant Head Start Program </li></ul></ul><ul><li>Carolina Dental Home meeting with Coastal Community Action to continue piloting curriculum (2008) </li></ul>
  36. 37. Upcoming EHS Activities <ul><li>“ Healthy Teeth Toolkit” </li></ul><ul><li>IMB Information </li></ul><ul><li>Oral Health Basics </li></ul><ul><ul><li>Include pregnancy, baby teeth, cleaning teeth, dental visits, special needs, parent page </li></ul></ul><ul><ul><li>Fluoride and healthy foods will be incorporated into the basic topics </li></ul></ul><ul><li>Communicating with Parents </li></ul><ul><ul><li>Information on listening reflectively, asking open ended questions, expressing empathy </li></ul></ul>
  37. 38. Upcoming EHS Activities <ul><li>Healthy Teeth Toolkit distribution </li></ul><ul><ul><li>Short training session (18 EHS programs) </li></ul></ul><ul><ul><ul><li>1 trainer to ensure standardization </li></ul></ul></ul><ul><ul><li>OHS staff as support </li></ul></ul><ul><ul><ul><li>Resource for staff and parents, e.g. brushing </li></ul></ul></ul><ul><ul><li>Support is NOT </li></ul></ul><ul><ul><ul><li>Classroom screening and education </li></ul></ul></ul><ul><ul><ul><li>Taking on responsibility of securing dental treatment for program </li></ul></ul></ul>
  38. 39. Pediatric News <ul><li>Bright Futures revision </li></ul><ul><ul><li>Supports ADA and AAPD recommendation to refer ALL CHILDREN for dental exam by age one (if feasible) </li></ul></ul><ul><li>Pacifier use </li></ul><ul><ul><li>Protective effect on </li></ul></ul><ul><ul><li>incidence of SIDS </li></ul></ul><ul><li>WIC: juice discontinued </li></ul><ul><ul><li>In 2009 </li></ul></ul>
  39. 40. AAPD/Head Start Project <ul><li>National network of dentists to </li></ul><ul><li>Provide dental homes, </li></ul><ul><li>Train dentists and HS personnel, </li></ul><ul><li>Assist HS programs in obtaining services, </li></ul><ul><li>Provide the latest evidence-based information on how to prevent tooth decay and establish a foundation for a lifetime of oral health. </li></ul>
  40. 41. <ul><li>Regional consultants will assist state leadership teams to develop collaborative networks. </li></ul><ul><li>Networks: local dentists, HS staff and other community leaders. </li></ul><ul><li>Aim: identify strategies to overcome barriers to HS children’s access to dental homes. </li></ul>
  41. 42. Carolina Dental Home Genesis <ul><li>RFA released by RWJ Foundation for “Dental Access Grants” (April 2002) </li></ul><ul><li>Proposal submitted (June 2002) </li></ul><ul><ul><li>“ Carolina Dental Access: a demonstration in eastern NC” </li></ul></ul><ul><li>Proposal selected for RWJ site visit (August 2002) </li></ul>
  42. 43. Carolina Dental Access at a Glance… <ul><li>Expand dental delivery system capacity though dental providers’ training </li></ul><ul><li>Delivery of risk-based services </li></ul><ul><li>Facilitation collaboration among community physicians and dentists </li></ul><ul><li>Rely on case managers and outreach series for coordination and integration </li></ul>
  43. 44. Carolina Dental Access - Nuts and Bolts <ul><li>Move beyond IMB - provide access to care for kids 0-60 months </li></ul><ul><li>Train physicians - risk assessment for kids 0-60 months. </li></ul><ul><ul><li>Refer some </li></ul></ul><ul><ul><li>Provide preventive dental care in medical setting </li></ul></ul><ul><li>Provide seamless dental referral process for IMB practices </li></ul><ul><li>Enlist and train GP dentists to provide more care for kids 0-60 months </li></ul>
  44. 45. Looking Backwards <ul><li>RWJ Site Visit (August 2002) </li></ul><ul><li>Carolina Dental Access unfunded </li></ul><ul><li>Fast forward to HRSA announcement (Summer 2006): Grant to States to Support Oral Health Workforce Activities </li></ul><ul><li>OHS responds with Carolina Dental Home - funded (2006) </li></ul>
  45. 46. Carolina Dental Home (CDH) at a Glance… <ul><li>Enhance effectiveness of risk-based dental referral </li></ul><ul><li>Promote availability and adequacy of dental workforce </li></ul><ul><li>Educate parents about importance of oral health </li></ul>
  46. 47. CDH Site Selection <ul><li>County data mined, deliberated & debated by Operations Committee </li></ul><ul><li>Representatives from 5 possible sites invited to discuss project </li></ul><ul><li>Five pediatric dentists from 4 counties met with committee (January 2007) </li></ul>
  47. 48. CDH Implementation <ul><li>Site determined (February 2007) </li></ul><ul><ul><li>Craven/Pamilco/Jones </li></ul></ul><ul><li>Power broker meeting in New Bern (March 2007) </li></ul><ul><li>GP Dentist recruitment (April 2007) </li></ul><ul><li>Team building and training (summer and fall 2007) </li></ul>
  48. 49. CDH Team <ul><li>1 Pediatric dentist </li></ul><ul><li>7 GPs including one each in Jones and Pamilco Counties </li></ul><ul><li>3 IMB-trained pediatric offices (1 practice with 3 offices + a fantastic Case Manager) </li></ul><ul><li>Craven County Heath Director and Mobile Dental Van Team </li></ul><ul><li>Regional OHS public health dental hygienist </li></ul>
  49. 50. Moving Forward… <ul><li>Games began (April 2008) </li></ul><ul><ul><li>First referral was made </li></ul></ul><ul><li>Where are we now? </li></ul>
  50. 51. Challenges & Lessons Learned?
  51. 52. 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
  52. 53. Infant and Toddler Oral Health Care
  53. 54. 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
  54. 55. What Is PORRT? P riority O ral Health R isk Assessment and R eferral T ool 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.
  55. 56. PORRT at a Glance… <ul><li>Refine Risk Assessment Tool </li></ul><ul><ul><li>Develop guidelines to accompany PORRT </li></ul></ul><ul><li>Develop and implement educational intervention for medical providers. </li></ul><ul><li>Evaluate </li></ul><ul><ul><li>Adoption of tool and guidelines </li></ul></ul><ul><ul><li>Referral quality </li></ul></ul><ul><ul><li>Referral effectiveness </li></ul></ul><ul><li>Refine/revise and expand statewide </li></ul>
  56. 57. What We Know <ul><li>Dental services belong in dental offices </li></ul><ul><ul><li>No substitution of physicians for dental services </li></ul></ul><ul><ul><li>IMB increases overall preventive visits </li></ul></ul><ul><ul><li>IMB increases visits to dentists, particularly those with disease </li></ul></ul><ul><li>Physicians have difficulty referring for dental care </li></ul><ul><ul><li>Workforce shortages </li></ul></ul><ul><ul><li>Lack of confidence in screening </li></ul></ul>
  57. 58. Referral Effectiveness IMB Visit Referred (33%) Not Referred ( 67%) Referred 1% Not Referred 99% Visit 35.6% 12.0% 0.2% 0.1% Diseased 5% Not Diseased (95%) N=24,403
  58. 59. PORRT
  59. 60. Systematic Review Question What are the modifiable risk factors for Early Childhood Caries (ECC) in children 0-5 years of age?
  60. 61. Systematic Review: Flow Diagram of Selection Potentially relevant n=1783 Studies retrieved for evaluation n=303 Relevant studies included N=44 Cohort studies n=29 Case-control studies n=15 Prospective n=10 Retrospective n=19 Citations excluded n=1480 Studies excluded n=259
  61. 62. Summary Results of Systematic Review <ul><li>Evidence supports a number of modifiable factors as risk for caries </li></ul><ul><ul><li>Good evidence for biological factors </li></ul></ul><ul><li>(except visible plaque) </li></ul><ul><ul><li>Good to fair evidence for diet, but particularly good for frequency of sweets </li></ul></ul><ul><ul><li>Poor evidence for oral hygiene </li></ul></ul><ul><ul><li>Poor evidence for caries in family members </li></ul></ul>
  62. 63. Develop Tool Guidelines <ul><li>Define “significant” risk for referral </li></ul><ul><li>Refer to appropriate professionals (“triage”) </li></ul><ul><ul><li>Low risk – receive preventive care in medical home until age 3 </li></ul></ul><ul><ul><li>Moderate risk – have non-cavitated lesions but nothing more severe and are referred to GPs </li></ul></ul><ul><ul><li>High risk – have cavitated lesions and are referred to pediatric dentist </li></ul></ul><ul><li>Present guidelines in short, easily understandable format for busy physicians </li></ul>
  63. 64. What’s Next? <ul><li>Materials on how to use guidelines (pilot in 5 medical practices) </li></ul><ul><li>Evaluate quantity, quality and effectiveness in 75 medical practices </li></ul>X X X 25 IMB practices <ul><li>Implement statewide </li></ul>In-office education Guidelines PORRT X X 25 IMB practices X X 25 Non-IMB practices
  64. 65. PORRT Summary <ul><li>It is practical for physicians to use risk assessment/referral checklists during the well-child visit </li></ul><ul><li>Some modifiable risk factors are highly prevalent </li></ul><ul><li>Referral guidelines will need to define “significant” risk and referral for a child without evidence of ECC </li></ul>
  65. 66. 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
  66. 67. It all started with a phone call and continues to evolve depending on oral health needs of North Carolinians, disease developments , and latest science …
  67. 68. Where Do We Go From Here?
  68. 69. Questions?