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Integrating Oral Health into Primary

CareFrancis E Rushton, MD, FAAPMedical DirectorSC QTIP

Introduction and Acknowledgements

• This oral health integration training was developed for MORE Care. It was

adapted from the following sources:

• Connecting Smiles Initiative, a collaborative project with the U of SC’s

South Carolina Rural Health Research Center and the Department of

Health and Human Services.

• The training was adapted from the American Academy of Pediatrics A

Pediatric Guide to Oral Health Flip Chart and Reference Guide, 2011.

Copyright 2012

• Smiles for Life Oral Health Curriculum, Module 6.Access at:

http://www.smilesforlifeoralhealth.org

• Christine Veschusio, DrPH, MUSC, Oral Health Policy Consultant• Raymond F. Lala, DDS, Director DHEC Division of Oral Health• Mary Kenyon Jones, Med, DHEC Education and Outreach• Lynn Martin LLSW, Project Director, QTIP

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What primary care physicians need

to convey about pathogenic oral

health disease

Early Childhood Cavities

• A transmissible, infectious, chronicdisease that affects can begin in infancy• Can lead to inability to chew food,

and to pain and infection.• Some feeding habits are strongly

implicated in ECC• Progresses Fast• Starts in upper front teeth

• moves to posterior as teeth erupt

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Mother to baby?

• YES, cariogenic bacteria can be transferred fromthe mother or primary caregiver to baby through saliva contact.

• The more untreated cavities in the mouth of the mother, the more likely the child will be have higher levels of bacteria, increasing the child’s risk for tooth decay.

Key Message: To reduce the risk of passing bacteria to their children, mothers can:

• Receive regular dental care

• Limit frequency of sugar in the diet

• brush with fluoridated tooth paste

• Limit activities in which saliva can be shared

Tip: reinforce message by giving parent handout as part of their visit pack

+Cavity Causing Germs + Sugar

Key Message: your teeth need breaks between meals and snacks to prevent cavities – limit constant eating & drinking of sweets and complex carbs

• Cavity causing bacteria or germs breaks down sugar (formula, fruit juice, cookies, sweet tea, etc ) into acid

• Acid stays for 20-40 minutes after Sugar eaten

• Acid demineralizes or breaks down the tooth surface

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What is the one factor for getting a cavity?

if SUGARS are consumed INFREQUENTLY, REMINERALIZATION can take place as the acid is buffered by the saliva, halting the decay process.

if CYCLE of ACID production & DEMINERALIZATION occurs frequently over TIME

Enamel weakens & breaks down into a CAVITY

Understand how to assess a child’s risk for tooth decay

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• The child is at an absolute high risk for caries if any risk factors or clinical findings, marked with a , are documented yes. In the absence of a risk factors or clinical findings, the clinician may determine the child is at high risk of caries based on one or more positive responses to other risk factors or clinical findings.

• Answering yes to protective factors should be taken into account with risk factors/clinical findings in determining low versus high risk.

Using the AAP Oral Health Risk Assessment Tool

High Risk

• One or more of the following: • Presence of white spots

and/or cavities

• History of cavities and/or fillings in last 3 years

• Presence of plaque/tartar

• Family members have cavities

• particularly mother

• No dental visit in last year

• Child with Special Health Care Needs

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Low Risk

No history of fillings

No what spots or cavities present

No plaque or tartar present

No family history of untreated cavities

– particularly mother

Had dental visit in past year

Describe key Anticipatory Guidance/Oral Health Counseling messages for the prevention of tooth decay in children

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+ The Importance of Early Oral Health Care

• Begins with infants…

• After feeding, an infant's teeth and gums should be wiped with a moist cloth or gum cleaner to remove any remaining liquid that coats the teeth and gums

• Tip: reinforce message by giving parent handout as part of their visit pack & gum cleaner

+Toothbrushing

• Infants and Toddlers

• should be soft with a small head and large handle.

• Supervision: until the child has proper coordination and can reliably rinse and spit out excess toothpaste which usually occurs at about 6 years of age.

• Tip: reinforce message by giving parent handout as part of their visit pack

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Toothbrushing and Toothpaste As soon as teeth appear, parents & caregivers need to begin brushing children’s teeth with fluoride toothpaste 2 minutes 2 times a day.

Under 3 years, use smear

Over 3 years, use pea sized amount

American Dental Association Council on Scientific Affairs (2014) Fluoride toothpaste use for young children. Journal of the American Dental Association. 145(2): 190-191.

Oral Health Counseling: Feeding Habits and Nutrition Impact Oral Health

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+ Information on Breastfeeding & Bottle Feeding

Bottle Feeding: Associated with a higher risk of dental caries.

• Only breast milk, formula, or water in a bottle.

• Babies should be held when bottle-fed

Bottle & Breast Feeding:

• Limit constant feeding

• Wipe their infant’s mouth and teeth clean after feeding.

Tip: reinforce message by giving parent handout as part of their visit pack

+Sippy Cups

Potential Misuse:

• Used continuously throughout the day.

• Filled with juice and other sugary beverages.

• Used a as “pacifier” to calm and appease.

Tip: determine current use & reinforce positive message by giving parent handout as part of their visit pack

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+Dietary Counseling

• Food guidance for dental health often mirrors food guidance for obesity prevention. • Encourage: healthy foods such

as fruits and vegetables or whole grain snacks.

• Encourage: regular meal times for breakfast, lunch and dinner

• Discourage: sticky foods such as raisins, fruit leather, and hard candies.

• Discourage: grazing behavior where the child is eating and drinking very frequently throughout the day.

Tip: reinforce message by giving parent handout as part of their visit pack

Fluoride Assessment: Component of the Risk Assessment:

Describe how to implement the fluoride assessment in a primary care practice

Demonstrate the appropriate application of fluoride varnish

Determine if fluoride supplements are needed

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+Fluoride Assessment

• Determine source of child’s main source of drinking water.

Questions for parents:

• What is the source of your family’s drinking water?

• Where do you live?

• Where does your child stay most of the time?

• Does your child drink well water?

• Does your child drink bottled water?

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+Community Water Fluoridation

Topical – Main Effect: Fluoride can strengthen the tooth surface and protect teeth from decay. Also works systemically, for children as their teeth are forming.

• 70 years of scientific research confirms that Community Water Fluoridation is proven to be the most Safe, Effective and Cost Effective way to prevent tooth decay.

+ American Dental Association Dietary Fluoride Supplement Schedule for Children at High Caries Risk

• Child’s Source of Drinking Water is not fluoridated

• Public Water System – not fluoridated

or

• Private Well – does not contain natural fluoride at a level to prevent tooth decay

Age of

Child

<0.3 ppm 0.3-0.6 ppm >0.6 ppm

Birth to 6

Months

None None None

6 months to

3 years

0.25 mg/d None None

3 to 6 years 0.5 mg/d 0.25 mg/d None

6 to 16 years 1.0 mg/d 0.5 mg/d None

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+Primary Source: Well Water

• If the child’s primary source of drinking water is well-water, determine the level of fluoride in the water by having a water sample tested by DHEC

• Contact SC DHEC for well-water testing program for the presence of fluoride. Access at: https://www.scdhec.gov/environment/water/dwor/dwtesting.htm.

Care Pathway –Primary & Secondary Prevention: Integrating Fluoride Varnish into the PracticeThinking through the process

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+ Rationale - Standard of Care: Fluoride Varnish in Primary Care

• Apply Fluoride Varnish to the teeth of all infants and children starting at the eruption of the first tooth

• At least every 6 months in the primary care office

• Higher risk children should receive every 3-4 months

Topical Effect of Fluoride

2014

Evidence-based Dental Prevention

• Safe and effective way to prevent tooth decay by strengthening enamel

• Recent studies report fluoride varnish application in baby teeth resulted in a 30-35% reduction in tooth decay

• Can reverse early decay – white spots, and slow enamel destruction in active decay

White Spots Varnish applied to teeth Remineralized Enamel

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The why fluoride varnish?for parents

Tip: handout can be given to the parent/caregiver in the waiting room or at any time during visit in order to help them understand why fluoride varnish is applied to children’s teeth.

Reimbursement from SCDHHS Medicaid Reimbursement for Fluoride Varnish in Primary Care as of 7/1/2015

• Former Fluoride Varnish policy – SCDHHS Medicaid 2007 to June 30, 2015• only delivered at EPSDT visit• 0 to 36 months of age only

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Develop a Process for Identifying Opportunities for Delivery of Fluoride Varnish Can be delivered at any visit

Be mindful that the interval must be greater than 180 days since the child’s last fluoride varnish service in the medical setting

EPSDT Oral Exam FluorideVarnish

Other Visits

6 months X

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9 months X

12 months X

15 months X

18 months X

24 months X

36 months X

4 years X

5 years X

6 years X

7 years X

8 years X

9 years X

10 years

11 years

12 years

X

X

X

Thinking through the process of delivering fluoride varnishStep by Step

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Step 1 Set up for Fluoride Varnish

Set up on paper towel:

Fluoride Varnish – single dose with applicator brush

Gauze Square

Gloves

Step 3Position the child

• Knee to knew work well for babies and young children

• Can also use the exam table

• Older children can stand in front of you

Provider – behind child’s head in knee to knee and on exam table

Parent – holds hands

Older child – can apply with child standing or sitting

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Step 4 Applying Fluoride Varnish

• Use gauze to dry the teeth off

• Apply varnish to dried teeth starting in posterior

• Apply a thin layer to all teeth

• Apply to front teeth last

• Saliva contamination after application is fine since varnish sets in contact with saliva

5. Fluoride Varnish After Care Instructions for Parents

• Do not brush the child’s teeth until the next morning

• The child’s teeth may be slightly yellow until they are brushed.

• The child can eat and drink right away but should

• avoid hot liquids.

• sticky or hard foods

SC DHEC will have the Spanish version of their instructions soon.

AAP has instructions available in multiple languages: https://www2.aap.org/oralhealth/docs/varnish-instructions-ALL.pdf

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How do I develop a plan to integrate fluoride varnish into the practice?What changes will be needed to deliver fluoride varnish in our practice?

Health Records/Billing: Determine a procedure for documenting and billing fluoride varnish

• SCDHHS Medicaid Reimbursement for Fluoride Varnish in Primary Care – 2015• Use Procedure Code: 99188

for billing fluoride varnish every 6 months up to 13th

birthday month• Interval between Fluoride

Varnish Services: greater than180 days

• Complete approved Training – (e.g. Smiles for Life)

• Private Insurance: one pedshas reported 99188 billing for private insurance is going well. Only payer not reimbursing is federal BCBS

• Representatives identified from to develop a plan to include fluoride varnish and other oral health documentation into

• Health Records

• Billing

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+ Determine a Protocol for the Delivery of Fluoride VarnishEvery Office is Different! What works best for your office!

1. Assemble fluoride varnish, gauze, gloves on paper towel

2. Position: place child in knee to knee position or other position that works for you

3. Check child’s mouth for

White spots or cavities

Oral hygiene status

Other clinical findings

If child does not open, slide finger into buccal sulcus and open mouth gently

4. Apply Fluoride Varnish & give after care instructions.

5. Record findings & document delivery of fluoride varnish

How do we engage South Carolina pediatric offices in promoting optimal oral health?What changes will be needed to deliver fluoride varnish and expanded oral health prevention in our practices?

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How IP Worked with Practices and Stakeholders

Pediatric Practices Learning Collaborative

• Semi-annual sessions attended by QI team

• Quality measures presented, expert speakers, PCMH and behavioral health concepts, information sharing, etc.

Site Visits• QTIP team technical assistance

site visits

• Peer reviewer participation

• Academic detailing

• Mental Health education and community resource meetings

• Quality Improvement coaching

• 18 practices selected• Each practice identified a QI

team lead: practitioner, nurse and office manager

• 4 year commitment

Plan-Do-Study-Act cycles• Practices document quality

improvement work

Maintenance of Certification • Physicians can earn Part IV

MOC credit on QI work

Regular Contact• Monthly conference calls• Blog (where data and QI

minutes are also posted

2011

July 1, 2015 QTIP practicesmain and satellite offices

2011satellite

2015

2015satellite

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43

55

93

70

219

84

58

14

167

4 1 3

189

0

125

3

238

1

4231

58

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169

2

53

0

50

100

150

200

250

PDSA Jan 2011 - Dec 31, 2014 N= 1,545

Jan ‘11 July ‘11 Jan ‘12 July ‘12 Jan ‘13 July ‘13 Jan ‘14 July ‘14

Documentation of work on core measures

Introduced:

Oral HealthRESULTS• 167 PDSA Cycles have been documented

a. Performing and documenting an oral health risk assessment (20%)

b. Referral of the patient to a dental home (20%)

c. Application of fluoride varnish (47%)

d. Fluoride in the family’s drinking water (6%)

e. Other interventions/focus 18%

(some PDSAs had more than 1 focus)

• All original QTIP practices have documented PDSA Preventive Oral Health

• Preventative Oral Health is the 4th most frequently documented QI project. (11% of all PDSA cycles)

• QTIP trained 369 staff in fluoride varnishing (from 21 practices)

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MOC (Maintenance of Certification) Part IV Credit for American Board of Pediatrics

• On at least 2 of the 5 following criteria. New and/or existing patients seen in the office over the previous 30 days can be included in each 10-chart sample. • Chart documentation of an oral health home or referral to such

in practice well child visit notes.• Documentation of an Oral Exam at each well child visit• Risk Assessment documented for each child at the time of the

well child visit to include: Presence of Medicaid insurance, family oral health status, prematurity and special health care need.

• Provision of Fluoride varnish every 6 months between ages 6 months and 3 years of age in high risk children in the pediatrician’s office

• Documentation of anticipatory guidance around oral health issues including exposure to fluoride in the diet.

July 2011 Learning Collaborative National and State Topic Experts

Oral Health and Primary Care

“Lessons from the Tooth Fairy” Suzanne Boulter, MD

• Overview of Early Childhood Caries: Prevalence and Significance

• Pathophysiology of Caries

• Demographics of Caries Risk

• Oral Health Risk Assessment

• Anticipatory Guidance

• Recommendations and Referral

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National and State ExpertsPaul Hlecko, MD

Georgetown Pediatrics

• Understand the biologic mechanism of fluoridation

• Understand the benefits, possible adverse effects and fluoride dosing

• Understand the community and well water fluoride content issues in SC

• Examples of PDSA cycles

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Oral Health

Results:

• 220 + QTIP practice staff trained to administer fluoride varnish; 14/18 QTIP practices are now eligible to provide fluoride varnish.

• A 507% increase in fluoride varnish application in the pediatric office(D1206) (as of June 2012 and compared with 2015)

• Patients at QTIP practices statistically more likely to go to a dentist than patients at non QTIP practices

• Increased collaborative with DHEC on oral heath toolkits and water testing.

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PDSA cycle – dental home

• P: Develop a list of Dentists in Anderson

• D: Contacted all dentist in area and asked: if they accepted Medicaid? seeing new patients? what age did they start preventive care?

• S: List collated. Lots of local dentists accept Medicaid: 6 start preventive dental care at age 1, 1 starts with first tooth

• A: Give the list to all patients at well child visits and encourage dental home engagement

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PDSA cycles – Risk Assessments

• P: Want an oral health screening tool to use with our EMR to identify children high risk for dental disease and track oral health advice

• D:Used AAP oral health screening instrument, incorporated it in to our well child templates, educated MDs

• S: Baseline data shows 0 screened for oral health risk as we just started initiative

• A: Further tracking of oral health risk assessment, make tool more visible in EMR, train doctors

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Practice reports –new procedures implemented • Distributing a list of local

dentists.

• A practice held a "dental summit" with area dentists and hygienists to discuss oral health issues and increasing efficacy in promoting oral health.

• Posted DHEC oral health posters in every exam room

• Investigated fluoride status of local wells.

• Changing from candy to stickers

• Fluoride, Oral Health Risk Computer Templates (including notations with well child checks)

• Expand patient education packets to include oral health material

• Distributing infant toothbrushes

•Oral Health Goody Bags containing toothbrushes, toothpaste and educational material

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Blog headlines

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Christine Veschusio, DrPHMUSC, CDMOral Health Policy Consultant

Christine Veschusio, DrPHMUSC, CDMOral Health Policy Consultant

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0

2000

4000

6000

8000

10000

12000

14000

16000

2011 2012 2013 2014 2015 2016(10 mos)

Fluoride Varnish in Non-Dental Settings for Medicaid children

QTIP ALL

Preventative Oral Health702%

Improvements in Pediatric Office Dental Varnish Application

0

1000

2000

3000

4000

5000

6000

7000

FY 2010 FY 2011 FY 2012 FY 2013 FY 2014

d1206 all non dental (excluding FQHC)

qtip non qtip total

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Preventative Oral Health

Data source: Medicaid Claims data SFY16

• 10 of 10 (99.4%) eligible

children visited a Physician

• Only 4 out of 10 (43%) eligible

children visited the dental

provider

• Only 5% eligible Medicaid

children (0 – 5) received fluoride

Varnish by a Physician

• Only 41% of Medicaid

children (0-5) received

fluoride varnish from a dental

provider

• Only 8% of Medicaid

children seen by a physician

received fluoride varnish

more than 1 application in a

calendar year

Impact:

• DHHS reviewing policy about

Fluoride varnishing

frequency

• Physician intervention

important and where children

are first and most frequently

seen

• Continued education is

needed with physician and

dental community

Challenges

• Reimbursement for Dental Varnish: MCO, FQHC, private insurance… amount not sufficient for some

• Dental Homes – various dentist accept at patient’s at various ages not in congruence with national recommendations

• Push back from many pediatricians and their office in not wanting to provide dental varnish… some sense this is not their area of expertise.

• Requirement by SC Medicaid that each practitioner complete a DHHS approved oral health course before being allowed to bill for fluoride varnish.

• A long way to go before we are adequately meeting the need 56