1. From The First Tooth An early childhood caries prevention program
to improve the oral health of Maine children
Funded by the Sadie and Harry Davis Foundation
A partnership of MaineHealth, MaineGeneral and Eastern Maine Health Services
Northeast Center for Research to Evaluate and Eliminate Dental Disparities

2. The purpose is to improve the oral health of Maine’s children by:
From The First Tooth
The purpose is to improve the oral health of Maine’s children by:
Increasing children’s access to preventive oral health services
Integrating early oral health as the standard of care for children
in medical practices through:
Oral health screening
Fluoride varnish
Parent/caregiver education and counseling
Referral to a dentist

3. Chronic Infectious Disease
From The First Tooth
Dental Caries is a
Chronic Infectious Disease
Transmissible
Bacterial by-products (acids)
dissolve the enamel of teeth
Loss of tooth structure, pain,
tooth loss, systemic infections

4. From The First Tooth
Dental caries is the single most common chronic disease of childhood
Approximately one third or more of Maine children has dental caries
Early childhood caries is the best predictor of lifelong dental caries
Source: National Health and Nutrition Examination Survey,
National Center for Health Statistics, CDC

5. Source: National Health and Nutrition Examination Survey, 1999–2002
Source: National Health and Nutrition Examination Survey, 1999–2002. National Center for Health Statistics, CDC.
Source: National Health and Nutrition Examination Survey, 1999–2002. National Center for Health Statistics, CDC. 5

6. What are the Consequences?
Pain & infection
Hospitalization,
surgical intervention, death
Missed work/school
Distraction from normal activities
Speech and eating dysfunction
Growth delay

7. Prevention Reduces Disease and Saves Money
From The First Tooth
Prevention Reduces Disease and Saves Money
Low-income children who have their first preventive dental visit by age one:
Less likely to have subsequent restorative or emergency room visits
Average dental related costs are almost 40% lower ($263 compared to $447) over a five year period than children who receive their first preventive visit after age one.

8. Dental/Medical Home By Age One
Recommended by:
American Academy of Pediatrics
American Dental Association
American Academy of Pediatric Dentistry
Endorsed by:
Maine Chapter of the American Academy of Pediatrics
Maine Dental Association
Maine Medical Association
Maine Academy of Family Physicians
Maine Osteopathic Association
Maine Primary Care Association

9. Preventive Dental Care is linked to
Role of the Primary Care Physicians
Oral health is part of overall health!
Patients are seen more regularly at the medical offices
Part of oral health prevention strategies
Screen for disease and risk
Monitor oral-systemic health interactions
Initially manage oral emergencies
Referral for dental care
Provide anticipatory guidance
Apply fluoride varnish
Preventive Dental Care is linked to
Good Overall Health!

13. Factors Necessary for Dental Caries
Tooth
Age
Fluoride
Nutrition
Pit & Fissures
Dental
Caries
Tooth
Substrates
Oral Flora
Flora
Strep. Mutans
Oral Hygiene
Fluoride in Plaque
Substrates
Oral hygiene
Saliva
Carbohydrates
Frequency of eating 13

14. Streptococci Mutans Transmission
Bacteria are transmitted mainly from mother or primary caregiver to infant.
Window of infectivity is first 2 years of life.
The earlier a child is colonized, the higher the risk of caries.

15. You Are What You Eat
Caries development is promoted by carbohydrates
which act as substrate for bacteria to produce acid
Acid causes demineralization of enamel
Beware “hidden carbohydrates”

16. Frequency vs. Quantity
Acids produced by bacteria after carbohydrate intake
persist for minutes lowering pH

17. Examples of Sugar Content of Food and Drinks

18. Sucrose Content of Some Medicines
Amoxicillin %
Ceclor %
Erythromycin %
Penicillin %
Bactrim 50%
Benadryl %

19. Oral Health Assessment of Child
Position child in caregiver’s lap facing the caregiver
Sit with knees touching the knees of the caregiver
Lower the child’s head onto your lap

20. What to Look For:
Lift the lip, retract the cheeks and inspect the soft tissues and teeth to assess for:
Presence of plaque
Presence of white spot lesions or dental caries
Presence of tooth defects
Presence of dental abscess

21. Dental Plaque
A biofilm that attaches to the tooth surfaces. It is composed of primarily streptococci mutans and other bacteria. Nourished by food and beverages high in sugar, they produce an acid that initiates the demineralization of the teeth.

22. Healthy Teeth

23. White Spot Lesions

24. Cavitated Lesions

25. Urgent Dental Care

26. Urgent Dental Care Dental Abscess

27. Caries Risk Assessment
Higher Risk: One of the below
Low income - (i.e. MaineCare)
Special healthcare needs
Parents/siblings have decay
Existing decay/fillings
Limited/no dental care
Frequent sugar intake
No access to fluoridated water or tablets
Lower Risk:
None of the above

28. Fluoride Demineralization <------------ > Remineralization
Frequent carbohydrate intake
Frequent exposure to acids
Plaque presence
Decreased salivary flow
Exposure to fluoride
Removal of plaque
Balanced diet
Limited exposure to carbohydrates

29. System and Topical Fluoride Delivery
Toothpaste
Anti-Cavity Rinses
Fluoride Applications
Varnish, gel or foam
SYSTEMIC
Water
Tablets
Drops
In Vitamins 29

30. Fluoride Varnish Inhibits the growth of cariogenic
5% sodium or 22,600 PPM fluoride resin
Inhibits the growth of cariogenic
organisms thus decreasing acid metabolism
Reduces enamel solubility
Promotes remineralization of enamel
and may arrest or reverse early caries

31. Efficacy of Fluoride Varnish in Preschool Children
Study
Country
% Caries Decrease
Holm 1979
Sweden 44
Grodzha et al. 1982
Poland 10
Clark et al. 1985
Canada 9
Petersson et al. 1998 7
Frostell et al. 1991 37
Twetman et al. 1996 30
Weintraub et al. 2006 US 50

32. Application of Fluoride Varnish
Using gentle finger pressure, open the child’s mouth.
Gently remove excess saliva or plaque with a gauze sponge.
Use your fingers and sponges to isolate the dry teeth and keep them dry.
Isolate a quadrant of teeth at a time, or a few teeth at a time.
Apply a thin layer of the varnish to all surfaces of the teeth.
Once the varnish is applied, you need not worry about moisture (saliva) contamination. The varnish sets quickly.

33. Post Application Instructions
Soft diet for the rest of the day.
Do not brush or floss the child's teeth
until the next morning.
It is normal for the teeth to appear dull
and yellow until they are brushed.
Tell the parent that the teeth will not be white
and shiny until the next day

34. Efficacy on the Number of Fluoride Varnish of Applications
Children stratified by number of actual fluoride-containing varnish applications received
N= 280
Weinstraub et al. J Dent Res 2006

35. Age Distribution of Children Receiving Fluoride

36. From The First Tooth
MaineCare is reimbursing medical providers for the therapeutic application of fluoride varnish for members with moderate to high caries risk. MC will cover 2 applications per calendar year. For members with high caries rates and new decay within 18 months as documented, MC will cover 3 times per year.
In Maine, commercial insurers and self insured companies and beginning to pay for the varnish procedure.
All three health systems (MaineHealth, Eastern Maine Health Systems, and MaineGeneral Health) now pay for the procedure for their age-eligible dependents who are covered by their health plans.

37. Infant and Toddler Oral Health Anticipatory Guidance
Advise to parents and caregivers
The importance of healthy teeth
How to take care of their child’s teeth
The importance of healthy food choices

38. Infant and Toddler Oral Health Anticipatory Guidance Schedule
6 Months
Bottles are for nutrition. They should
only be used to feed babies who are
not breast feeding.
Discuss and demonstrate brushing of
infant teeth as soon as they erupt.
Instruct the parent to conduct
"Lift the Lip" procedures.
9 Months
Monitor progress in weaning
infant from bottle to cup.
Offer appropriate guidance
in limiting juice in sippy cup.

39. Infant and Toddler Oral Health Anticipatory Guidance Schedule
12 Months
Infants are weaned from the bottle.
Infants should see the dentist by year one.
Review healthy eating habits and snacking.
Sippy cups at mealtimes only. Water between meals
Parents continue to brush and check their teeth
24 Months
Monitor healthy behaviors and snacking
Discuss and evaluate the toddler’s ability
to begin to use fluoridated toothpaste.
Parents should continue to monitor the child’s
brushing and checking their teeth

40. Posters, ed materials in waiting room
Parent/Child Arrives
for Well Child Visit
(or other visit)
Posters, ed materials in waiting room
Vitals Signs Taken
Medical Assistant tells parent of the FTFT
(Parent Counseling)
Well Child Exam
Medical Provider - Oral Screening,
Orders for fluoride based on risk
(Parent counseling)
No Access to a Dental Home
Referral to a Dental Home
Immunization
Medical Assistant Applies Fluoride
Dental Home

41. Documentation Caries Risk Assessment – (LOWER) (HIGHER) Guidelines
Higher Risk: One of the below
Low income - (i.e. MaineCare)
Special healthcare needs
Parents/siblings have decay
Existing decay/fillings
Limited/no dental care
Frequent sugar intake
No access to fluoridated water or tablets
Lower Risk:
None of the above
Dental Caries – Y or N
Oral health education – Y or N
Fluoride varnish applied (Code D1206) – Y or N
In Chart Notes, document urgent dental needs, such as abscesses
and other clinical findings and referral to dentist

43. From The First Tooth We are committed to ensure every child within
our organizations and affiliates has access
to early childhood caries prevention program.

44. Questions? 44

45. Contact Information:
Susan Cote, RDH, MS
Program Manager
MaineHealth
110 Free Street
Portland, ME 04101
(207)
(207)