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. What’s This Presentation About? PROGRAM EVOLUTION, using ECC individual pilots, programs and opportunities How things evolve depending on the latest science, lessons learned, community needs, etc. How programs relate to each other

3. The Beginning BURKE Smart Start Regional Meeting December 1996 Morganton desire and willingness to try to do something about “bottle rot” for the children in their centers.

4. Meeting Outcomes Selected dental as focus Submitted a multiyear grant with DEHNR (summer 1997) ARC grant funded

5. Morganton Meeting 1996

6. The Need Appalachian Regional Consortium/NC Partnership for Children/Smart Start health assessment (fall 1997) 1/3 kindergarten children in western part of state had untreated decay Primary need –reduce early childhood caries –improve dental health

7. Goals Increase access to oral preventive care for low-income children Reduce prevalence of ECC in low-income children Reduce treatment needs on a dental care system already stretched beyond its capacity to serve young children

8. Smart Smiles An Appalachian Regional Collaborative Partnership to Improve Dental Health

9. ARC Counties CHEROKEE SWAIN MACON GRAHAM CLAY JACK- SON HAY- WOOD HENDER- SON TRAN- SYLVANIA POLK RUTHER- FORD BUN- COMBE YAN- CEY MADISON MITCHELL AVERY BURKE STOKES SURRY FORSYTH YADKIN DAVIE ASHE WILKES ALLE- GHANY CALDWELL ALEX- ANDER McDowell WATAUGA Funded Sept 1998 Public Health Dental Hygienist ARC Counties ARC Counties-Special Project March 23, 1998

10. Partners/Advisory Board Local community leaders State and regional Smart Start agencies NC Oral Health Section UNC School of Public Health UNC School of Dentistry Local health departments Ruth & Billy Graham Health Center Physicians

11. Pilot Rationale Need preventive services as soon as teeth erupt Fluoride varnish –safe, easy to use, effective –no studies of effectiveness in 1-2-year-olds but supported by a larger body of evidence topical fluorides effective –effective in permanent teeth –effective in primary teeth of older children Hygienists successful with parents, children, community groups

12. Why Preventive Model in Medical Office? ECC is public health problem - must start early Able to reduce disease and need for treatment at young age Infants and toddlers already in medical offices – get multiple services at one visit Medical community interested and willing Most general dentists don’t see young children Few pediatric dentists in NC Treatment is expensive This was the best idea anyone had

13. Smart Smiles Services Oral health education for caregivers Screening and referral Fluoride varnish application

14. Targets Children, 9 - 36 months, high risk for caries –80% decay in 20% children Risk factors & socioeconomic indicators –families  200% Federal Poverty Level –medically compromised children –older siblings with poor oral health

15. Dental Support NC Academy of Pediatric Dentistry endorsement - fall 1999 NC Dental Society resolution of support - spring 2000 NC Academy of Pediatric Dentistry reaffirmed support - fall 2001

16. Challenges Learning and implementing dental procedures in medical practices Securing licensing board support (medical, dental, nursing) Evaluating (adoption rates, quality of care, clinical effectiveness, costs and political concerns)

17. Challenges Administration –Identifying the “high-risk” children –Getting them in for service on a “regular schedule” Financing –Grant stipulated service at no cost to patients –Economics was an issue for medical practices

18. Morganton Meeting 1996 ARC: Smart Smile 1998

19. Finances NC IOM Task Force on Dental Care Access (spring, 1999) recommendation #18 Medicaid agreed to reimburse –Medical offices - required training, recognized Smart Smiles trainers –February 2000, reimburse for: dental health education for parent/care-giver oral screening and referral for child as needed fluoride varnish application for child –Birth of Into the Mouths of Babes

20. Morganton Meeting 1996 Medicaid Funding 2000 ARC: Smart Smile 1998

21. Into The Mouths of Babes (IMB) Statewide Medicaid Oral Preventive Program for Young Children

22. IMB Statewide Pilot December 1999 Pediatricians and family practitioners Used Smart Smiles training session and educational materials, modified over time Added training on billing procedures

23. Goals (same as Smart Smiles) Increase access to oral preventive care for low-income children Reduce prevalence of ECC in low-income children Reduce treatment needs on a dental care system already stretched beyond its capacity to serve young children

24. Statewide IMB Progression Pilot – volunteer trainer June 2000, RFA to Medicaid agencies for innovative ECC program –Partners: Medicaid, UNC Schools of Public Health and Dentistry, NC Pediatric Society, NC Academy of Family Physicians, Oral Health Section NC was funded –Evaluate level of training required for MDs –Funds for coordinator position

25. Oral Preventive Package (children 0-36 mo.) Oral screening and referral for dental care as needed Caregiver education Fluoride –Toothpaste –Topical fluoride application (varnish)

26. Morganton Meeting 1996 Medicaid Funding 2000 ARC: Smart Smile 1998 Into the Mouths of Babes 2000

27. Results: MD Training Evaluation

28. Training Required Types of training - three randomly chosen groups: –Traditional AMA approved CME –Add telephone learning collaborative –Add on-site technical assistance Study results showed that procedure adoption rates were not influenced by amount of training

29. Morganton Meeting 1996 Medicaid Funding 2000 ARC: Smart Smile 1998 Medical Provider Training Evaluation 2001 Into the Mouths of Babes 2000

30. IMB 2007 >100,000 visits for dental preventive package ~ 425 sites trained and supported Increase in eligibility to age 3 ½ (42 mo) Decrease in time interval to accommodate well child check up schedule 26 state Medicaid programs reimbursing medical providers

32. Number of IMB Preventive Visits in NC Medical Offices and Health Departments

33. Percent of Health Check Screenings Receiving IMB Services * * Includes 1 and 2 yr olds only.

34. Emerging Data Dose related response: 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) Similar results found in a UCSF study (Weintraub, 2005)

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

36. Early Head Start Activities Focus groups, staff and parent surveys, health coordinator planning meeting (2004-2006) Oral Health Initiative Grants (2006-2008) – Guilford Child Development Staff training Pilot-testing of draft oral health curriculum – East Coast Migrant Head Start Program Carolina Dental Home meeting with Coastal Community Action to continue piloting curriculum (2008)

37. Upcoming EHS Activities “Healthy Teeth Toolkit” IMB Information Oral Health Basics –Include pregnancy, baby teeth, cleaning teeth, dental visits, special needs, parent page –Fluoride and healthy foods will be incorporated into the basic topics Communicating with Parents –Information on listening reflectively, asking open ended questions, expressing empathy

38. Upcoming EHS Activities Healthy Teeth Toolkit distribution –Short training session (18 EHS programs) 1 trainer to ensure standardization –OHS staff as support Resource for staff and parents, e.g. brushing –Support is NOT Classroom screening and education Taking on responsibility of securing dental treatment for program

39. Pediatric News Bright Futures revision –Supports ADA and AAPD recommendation to refer ALL CHILDREN for dental exam by age one (if feasible) Pacifier use –Protective effect on incidence of SIDS WIC: juice discontinued In 2009

40. AAPD/Head Start Project National network of dentists to Provide dental homes, Train dentists and HS personnel, Assist HS programs in obtaining services, Provide the latest evidence-based information on how to prevent tooth decay and establish a foundation for a lifetime of oral health.

41. http://www.aapd.org/headstart/ Regional consultants will assist state leadership teams to develop collaborative networks. Networks: local dentists, HS staff and other community leaders. Aim: identify strategies to overcome barriers to HS children’s access to dental homes.

42. Carolina Dental Home Genesis RFA released by RWJ Foundation for “Dental Access Grants” (April 2002) Proposal submitted (June 2002) “Carolina Dental Access: a demonstration in eastern NC” Proposal selected for RWJ site visit (August 2002)

43. Carolina Dental Access at a Glance… Expand dental delivery system capacity though dental providers’ training Delivery of risk-based services Facilitation collaboration among community physicians and dentists Rely on case managers and outreach series for coordination and integration

44. Carolina Dental Access - Nuts and Bolts Move beyond IMB - provide access to care for kids 0-60 months Train physicians - risk assessment for kids 0-60 months. –Refer some –Provide preventive dental care in medical setting Provide seamless dental referral process for IMB practices Enlist and train GP dentists to provide more care for kids 0-60 months

45. Looking Backwards RWJ Site Visit (August 2002) Carolina Dental Access unfunded Fast forward to HRSA announcement (Summer 2006): Grant to States to Support Oral Health Workforce Activities OHS responds with Carolina Dental Home - funded (2006)

46. Carolina Dental Home (CDH) at a Glance… Enhance effectiveness of risk-based dental referral Promote availability and adequacy of dental workforce Educate parents about importance of oral health

47. CDH Site Selection County data mined, deliberated & debated by Operations Committee Representatives from 5 possible sites invited to discuss project Five pediatric dentists from 4 counties met with committee (January 2007)

48. CDH Implementation Site determined (February 2007) Craven/Pamilco/Jones Power broker meeting in New Bern (March 2007) GP Dentist recruitment (April 2007) Team building and training (summer and fall 2007)

49. CDH Team 1 Pediatric dentist 7 GPs including one each in Jones and Pamilco Counties 3 IMB-trained pediatric offices (1 practice with 3 offices + a fantastic Case Manager) Craven County Heath Director and Mobile Dental Van Team Regional OHS public health dental hygienist

50. Moving Forward… Games began (April 2008) First referral was made Where are we now?

51. Challenges & Lessons Learned?

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

53. Infant and Toddler Oral Health Care

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

55. What Is PORRT? Priority Oral Health Risk Assessment and Referral Tool 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.

56. PORRT at a Glance… Refine Risk Assessment Tool –Develop guidelines to accompany PORRT Develop and implement educational intervention for medical providers. Evaluate –Adoption of tool and guidelines –Referral quality –Referral effectiveness Refine/revise and expand statewide

57. What We Know Dental services belong in dental offices –No substitution of physicians for dental services –IMB increases overall preventive visits –IMB increases visits to dentists, particularly those with disease Physicians have difficulty referring for dental care –Workforce shortages –Lack of confidence in screening

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

59. PORRT

60. Systematic Review Question What are the modifiable risk factors for Early Childhood Caries (ECC) in children 0-5 years of age?

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

62. Summary Results of Systematic Review Evidence supports a number of modifiable factors as risk for caries –Good evidence for biological factors (except visible plaque) –Good to fair evidence for diet, but particularly good for frequency of sweets –Poor evidence for oral hygiene –Poor evidence for caries in family members

63. Develop Tool Guidelines Define “significant” risk for referral Refer to appropriate professionals (“triage”) –Low risk – receive preventive care in medical home until age 3 –Moderate risk – have non-cavitated lesions but nothing more severe and are referred to GPs –High risk – have cavitated lesions and are referred to pediatric dentist Present guidelines in short, easily understandable format for busy physicians

64. What’s Next? Materials on how to use guidelines (pilot in 5 medical practices) Evaluate quantity, quality and effectiveness in 75 medical practices XXX 25 IMB practices In-office educationGuidelinesPORRT XX 25 IMB practices XX 25 Non-IMB practices Implement statewideImplement statewide

65. PORRT Summary It is practical for physicians to use risk assessment/referral checklists during the well-child visit Some modifiable risk factors are highly prevalent Referral guidelines will need to define “significant” risk and referral for a child without evidence of ECC

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

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…

68. Where Do We Go From Here?

69. Questions?