Cavity Free at Three/Practicum Rebecca McGruder, RDH, MPH, Intern for CDPHE Cavity Free at Three

Literature Review Perinatal Guidelines Infant Oral Health Guidelines Professional Organizations Database searches- PubMed, CINAHL, Academic Search Premier White Papers Sister Organizations; Smiles for Life, Out of the Mouth of Babes, From the 1st Tooth, ABCD, CA Health Foundation Infant Oral Health Guidelines Professional Organizations Database searches- PubMed and Academic Search Premier White Papers Sister Organizations; Smiles for Life, Out of the Mouth of Babes, From the 1st tooth, and ABCD

Perinatal- Standard of Care Prevention, diagnosis and treatment of oral diseases, including needed dental radiographs and use of local anesthesia, are highly beneficial and can be undertaken during pregnancy with no additional fetal or maternal risk when compared to the risk of not providing care. Good oral health and control of oral disease protects a woman’s health and quality of life and has the potential to reduce the transmission of pathogenic bacteria from mothers to their children.1 1.Perinatal Oral Health Practice Guidelines. (2010). Oral health during pregnancy and early childhood: Evidence based guidelines for health professionals. California Dental Association. Retrieved from http://www.cdafoundation.org/education/perinatal- oral-health

Perinatal-Standard of Care Past guidelines have suggested that treatment should only be given between the gestation weeks of 14 and 20, and providers should weigh the benefits of any treatment before 14 weeks. This may lead to some confusion since the guidelines have changed to recommend treatment at any point during pregnancy.2 2. Lansler, I. (2016). Provision of dental treatment during pregnancy. Colgate Oral Care Report, Vol 26, No. 1. Retrieved from http://www.colgateoralhealthnetwork.com/

Treatment Guidelines Include: Comprehensive oral examination Radiographs as clinically indicated, including the use of a protective apron and thyroid collar Risk Assessment for dental caries and periodontal disease Comprehensive treatment plan, including preventative, treatment, and maintenance options

Treatment Guidelines Include Counseling on oral hygiene instructions Standard restorative care Endodontic treatment Periodontal treatment Antimicrobial rinses, as long as they are alcohol free, fluoride, and xylitol products 3, 4 3. Oral Health Care during Pregnancy Expert Workgroup. (2012). Oral health care during pregnancy: A national consensus. Washington D.C.: National Maternal and Child Oral Health Resource Center. 4. Perinatal Oral Health Practice Guidelines. (2010). Oral health during pregnancy and early childhood: Evidence based guidelines for health professionals. California Dental Association. Retrieved from http://www.cdafoundation.org/education/perinatal-oral-health

There are specific guidelines for anesthetic, sedatives, analgesics, and antibiotics. Below are listed the guidelines from the National Consensus Statement on Oral Care during Pregnancy.3 Local Anesthetics LAs containing epinephrine may be used—for example, bupivacaine, lidocaine, or mepivacaine. Nitrous Oxide Consult with a prenatal medical healthcare professional. 30% nitrous oxide may be used during pregnancy when topical or local anesthetics are inadequate. IV Sedation Before using, first consult with a prenatal care health professional. Analgesics May use acetaminophen, acetaminophen with codeine, hydrocodone, codeine, oxycodone, meperidine, or morphine. May use aspirin, ibuprofen, or naproxen during the 2nd trimester, and then only for 48–72 hours. Do not use aspirin, ibuprofen, or naproxen during the 1st and 3rd trimesters. Antibiotics May use amoxicillin, cephalosporin, clindamycin, metronidazole, or penicillin. Avoid ciprofloxacin, clarithromycin, levofloxacin, moxifloxacin 3. Oral Health Care during Pregnancy Expert Workgroup. (2012). Oral health care during pregnancy: A national consensus. Washington D.C.: National Maternal and Child Oral Health Resource Center.

Recommendations for Curriculum Increase in information on the connection between periodontal disease and preterm birth Increase in information on the benefits to treatment while pregnant Increase information on safety of treatments Increase in information on the maternal-child link regarding disease transmission Emphasis on the consequences of disease transmission Inclusion of Motivational Interviewing

Infant Oral Health-Standard of Care The United States Preventative Task Force, the American Academy of Family Physicians, the American Dental Association, the American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Public Health Association all agree on examination and fluoride recommendations.5,6,7,8,9,10 5. Moyer, VA.  Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement. Pediatrics 2014; 133: 1-10. 6. American Academy of Family Physicians. (2014). Clinical preventive service recommendation dental caries. American Academy of Family Physicians. Retrieved from http://www.aafp.org/patient-care/clinical-recommendations/all/dental-caries.html 7. American Dental Association. (2013). Topical fluoride for caries prevention. American Dental Association Center for Evidence Based Dentistry. Retrieved from http://ebd.ada.org/en/evidence/guidelines/topical-fluoride 8. American Academy of Pediatric Dentistry. (2013). Guideline on periodicity of examination preventative dental services, anticipatory guidance/counseling, and oral treatments for infants, children, and adolescents. American Academy of Pediatric Dentistry clinical practice guidelines V37 No 6 9. American Academy of Pediatrics. (2014). AAP recommends fluoride to prevent dental caries. American Academy of Pediatrics. Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Recommends-Fluoride-to-Prevent-Dental-Caries.aspx 10. American Public Health Association. (2008). Fluoride varnish for caries prevention. American Public Health Association. Retrieved from https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/09/07/51/fluoride-varnish-for-caries-prevention

Examinations The first examination should occur at eruption of 1st tooth and no later than 12 months of age Children should be monitored throughout eruption at regular clinical examinations (every 3-6 months) These examinations should include fluoride treatments

Fluoride Recommendations11 11. Clark, M. and Slayton, R. (2014). Fluoride use in caries prevention in the primary care setting. Pediatrics 2014; 134:626-633

Xylitol Recommendations Xylitol may reduce S. Mutan transmission from mother to child and be effective on erupting teeth The recommended dosage is 3 to 8 grams a day with a minimum of two doses a day 12 This is considered expert opinion and is not evidence based recommendations 12. American Academy of Pediatric Dentistry. (2011). Guideline on xylitol use in caries prevention. American Academy of Pediatric Dentistry. Reference Manual V36/NO6 14/15

Recommendations for Curriculum Inclusion of insurance reimbursement/codes Discussion of Motivational Interviewing techniques Discussion of fluoride recommendations Discussion of fluoride modalities

Motivational Interviewing Patient Education - process where health professionals provide information to patients to change behavior and improve health status Anticipatory Guidance -proactive developmentally based counseling technique that focuses on the needs of child at each stage of life Motivational Interviewing -method that works on facilitating and engaging intrinsic motivation within the person in order to change behavior

Motivational Interviewing Motivational Interviewing is a patient centered guiding method for enhancing motivation to change It addresses the natural inclination to be ambivalent towards change. This ambivalence needs to be addressed before real behavior change can occur 13 13. Schwartz, R. (n.d.). Motivational Interviewing. Performing Preventative Services: A Bright Futures Handbook. Pg. 175-178

Motivational Interviewing Motivational interviewing has been shown to yield significant improvements in health behavior, including oral health. 14 Though there is a need for further research there is evidence that shows motivational interviewing is more effective than traditional education models in improving knowledge and awareness of oral health.15, 16 There has also been evidence that motivational interviewing may be more effective than traditional educational programs in preventing caries and decreasing bacterial plaque. 17 14. Borrelli, B., Tooley, E., and Scott-Sheldon, L. (2015). Motivational interviewing for parent-child health interventions: A systematic review and meta-analysis. Pediatric Dentistry 2015; 37(3):254-65 15. Mohammadi T., Hajizamani A, Bozorgmehr E. (2015). Improving oral health status of preschool children using motivational interviewing method. Dent Res J 2015; 12:476-81. 16. Naidu, R., Nunn, J., Irwin, J. (2015). The effect of motivational interviewing on oral healthcare knowledge, attitudes and behavior of parents and caregivers of preschool children: an exploratory cluster randomized controlled study. Naidu et al. BMC Oral Health (2015) 15:101 DOI 10.1186/s12903-015-0068-9 17. González-Del-Castillo-McGrath, M., Guizar-Mendoza,J., Madrigal-Orozco,C., Anguiano-Flores,L., and Amador-Licona, N. (2014). A parent motivational interviewing program for dental care in children of a rural population. J Clin Exp Dent. 2014; 6(5):e524-9. doi:10.4317/jced.51662 http://dx.doi.org/10.4317/jced.51662

Motivational Interviewing and Anticipatory Guidance Physicians and Dentists have been trained to provide information but not in how to change behavior This is why it is important to use both Anticipatory Guidance and Motivational Interviewing 13 Together Anticipatory Guidance and Motivational Interviewing are the best strategies for improved health 18 13. Schwartz, R. (n.d.). Motivational Interviewing. Performing Preventative Services: A Bright Futures Handbook. Pg. 175-178 18. Ramos-Gomez, F., Crystal, Y., Ng, M., Crall, J. and Featherstone, J. (2010). Pediatric dental care: prevention and management protocols based on caries risk assessment. J Calif Dent Assoc. 2010 October ; 38(10): 746–761

Motivational Interviewing Techniques OARES- Key Components FRAMES- Adaption of MI Provide Feedback on the risks and consequences of the behavior. Emphasize the patient’s personal Responsibility to change or not to change. “It’s up to you.” Provide Advice—your professional opinion and recommendation. Offer Menus. You provide a menu of strategies, not a single solution. The patient selects the approach that seems best for him or her. Show Empathy. A positive, caring manner will foster rapport. Encourage Self-efficacy,encourage positive “change talk” and support your patient in believing that he or she can change the behavior. Ask Open-ended questions. Affirm what your patient says. Use Reflective listening. Elicit self-motivational statements or “change talk.” Summarize. 13. Schwartz, R. (n.d.). Motivational Interviewing. Performing Preventative Services: A Bright Futures Handbook. Pg. 175-178