Massachusetts Department of Public Health

1
Connect Oral Health to Every Childs Medical Care

• Massachusetts Department of Public Health
• Office of Oral Health

2
Objectives

• 1. Understand the child health providers role in
  oral health
• 2. Understand the etiology of oral diseases
• 3. Understand the relationship between systemic
  and oral health
• 4. Gain knowledge and skills to perform oral
  health assessments
• 5. Identify appropriate oral disease prevention
  strategies
• 6. Understand when and how to apply fluoride
  varnish

3
Outline

• 1. Pretest
• 2. Childrens Oral Health/CSHCN
• 3. BLOCK Oral Disease Strategy
• 4. BLOCK Oral Disease Materials
• 5. Oral Health Assessments and Fluoride Varnish
• 6. Closing Discussion
• 7. Post test

Note. Pass out the pretests and give the
participants 5 to 10 minutes max. Stress to
participants that they must remain through the
entire 60 minute presentation and take the
pre/posttests and course evaluation to get the
certificate of completion. Also mention that they
need to write legibly on these forms so we can
read their name/address to send the certificate
to.
4
Training Instructions

• Complete the Pretest via Survey Monkey
• LINK. http//www.surveymonkey.com/s.aspx?sm7546uI
  4J7mSEoDwh49rSvA_3d_3d
• Read the entire PowerPoint
• At the end, you will link to a Survey Monkey
  posttest
• After completing the posttest, you will have an
  opportunity to request the mailing of a BLOCK
  Oral Disease Toolkit
• In order to receive a certificate of completion,
  you MUST complete the entire training, pretest,
  and posttest!!!

5
Why talk about ORAL HEALTH in MEDICINE?
Note. The overall goal of this session is to help
you think of oral health as a component of
overall systemic health. Oral health is not a
separate entity! Just as systemic health and oral
health have influences on each other. Therefore,
it is in the medical communitys interest to talk
about oral health in the context of primary care.
6
The Problem

• Dental caries is the most common chronic disease
  in children. Citation, CDC, 2005.
• Dental caries is transmissible from caregiver to
  child
• The general public lacks knowledge about oral
  health
• Many children lack access to preventive dental
  care
• Certain child populations are at a higher risk
  for oral diseases

Note. Low socioeconomic status and special
health care needs are risk indicators for oral
disease.
7
Oral Disease In Massachusetts Children in 2008

• Dental caries experience.
• 25 of kindergarten children, 52 untreated
• 40 of third graders, 42 untreated
• Overall, lower income and minority children
  experienced a 1.7 times greater prevalence of
  dental caries than non Hispanic White children

Note. These data are from the Catalyst
Institutes report The Oral Health of
Massachusetts Children, January 2008. Many
children who experience dental caries at the
highest rates are children who receive their
medical care at community health centers. This
high risk population of minority and low income
children is a population you see every day at
your medical facility. You might be the only
source of preventive oral health education and
service these high risk children receive.
8
Children with Special Health Care Needs

• High risk for dental caries and periodontal
  infections
• Dental care is the number 1 unmet health care
  need
• Need to increase access to oral disease
  prevention interventions

9
Percent of CSHCN Needing Specific Health Services
Note. These data are from the National Survey of
Children with Special Health Care Needs, 2005 to
2006. It indicates that 81 of CSHCN were in
need of preventive dental care, which includes
cleanings, x rays, fluoride, and exams. 24 of
CSHCN needed other dental care, which could
include fillings, orthodontic, periodontic, and
cosmetic procedures.
10
Percent of CSHCN with Reported Health Services
Needed but Not Received
Source. National Survey of Children with Special
Health Care Needs, 2005 to 2006.
Note. The previous slide showed that 81 of
CSHCN needed preventive dental care. This slide
displays that many CSHCN did not receive
preventive care that was needed. Preventive
dental care is the number 1 unmet healthcare need
for CSHCN.
11
Note. For children at higher risks for oral
disease such as minority, low income, and CSHCN,
you could be an extremely important influence on
promoting oral disease prevention.
12
AAP Oral Health Risk Assessment Timing and
Establishment of the Dental Home Policy
Statement, 2003

• Every child should begin to receive oral health
  risk assessments by 6 months of age from a
  pediatrician or qualified pediatric health care
  professional.
• Infants identified as having significant risk of
  caries should be entered into an aggressive
  anticipatory guidance and intervention program
  provided by a dentist between 6 and 12 months of
  age.
• Pediatricians should support the establishment of
  a dental home for all children between 6 and 12
  months of age.

Source. Hale, K., Weiss, P., Czerepack, C.,
Keels, M., Huw, T. Webb, M. (2003). American
Academy of Pediatrics Policy Statement Oral
Health Risk Assessment Timing and Establishment
of the Dental Home. Pediatrics 111(5) 1113 to
111 AAP Section on Pediatric Dentistry and Oral
Health (2008). Preventive oral health
intervention for pediatricians. Pediatrics
1221387 to 1394 One of the most recent oral
health policy statements published by the AAP,
December 2008 Tell participants that there is a
printed copy of the most recent AAP publication
about oral health in the blue folder they
receive. Contains evidence based recommendations
for pediatricians regarding oral disease
prevention in the medical home The AAP has become
an influential leader for oral health
integration. The AAP has published many articles
about oral health and launched an Oral Health
Initiative, which includes a website that
contains a wealth of oral health information and
resources.
13
BLOCK Oral Disease
There is a lot being done to address the topic of
oral health in primary care, however, there is a
lack of specific information covering the direct
links and associations between oral disease and
systemic disorders/conditions/diseases. This
presentation gives you a basic introduction to
childrens oral health and the specific oral
health needs of CSHCN. The corresponding toolkit
provides detailed information and clinical
reference tools. You will have the opportunity to
request a copy of the toolkit that can be mailed
to you. The BLOCK Oral Disease Strategy is a way
to think of oral health in the context of overall
health. Its an integration strategy.
14
BLOCK Toolkit Components
Note. After you complete the posttest for this
training, you will be able to request your
toolkit.
15
Note. The first part of the BLOCK Oral Disease
strategy includes connecting systemic and oral
health. Oral diseases can effect physical,
mental, and social well being in addition to
being infectious and transmissible. One can not
be healthy without oral health. Furthermore, we
now have an increasing amount of data to support
the relationship and associations between oral
disease and the effects on systemic health. Some
of these include diabetes and blood glucose
control, cardiovascular disease, respiratory
diseases, preterm births, and many others.
16
The Picture of Oral Health

• Primate Spaces
• Shiny, White Enamel
• Gums, Pink and Firm
• No demineralization or cavities
• No plaque or food accumulation

Note. What does oral health look like? Primate
spaces are integral in that they create space for
larger permanent teeth to erupt as the jaw and
maxilla grow and develop. If a child has very
crowded primary teeth, they erupt as the jaw
grows and develops. If a child has a very crowded
primary teeth, they might have serious
malocclusion issues. Malocclusion needs to be
addressed because it can increase dental caries
risk and lead to problems with speaking and
eating. Children with malocclusion might need to
see dental professionals early for orthodontic
assessments and treatments.
17
Enamel Structure

• Enamel is the hardest, most mineralized tissue in
  the human body
• 97 mineral by weight
• Composed of hydroxyapetite mineral and trace
  elements

Source. www.usc.edu/.../Bits/2000fw/Achievement.ht
m www.dent.unc.edu/research/defects/aigenes.cfm

Note. Lets first review some basic dental
anatomy. The tooth is composed of 3 major layers
which are the enamel, dentin, and pulp chamber.
The Enamel is composed of hydroxyapetite with
trace elements of fluoride, chloride, sodium, and
magnesium. Even though enamel is the hardest
mineralized substance in the body, it is still
porous. The second layer of the tooth is dentin.
Dentin is a less mineralized structure compared
to enamel. The innermost part of the tooth is the
pulp chamber. The pulp chamber houses the blood
vessels and nerve that give the tooth life. From
the pulp chamber, the blood vessles and nerves
connect to the circulatory and nervous systems.
Tooth decay begins on the outer enamel surface
and can then continue into the deeper tooth
structures. Unfortunately, pain from tooth decay
is only felt when the infection has destroyed
much of the tooth and has entered the pulp
chamber. It is important to know what the very
early of enamel decay look like so the decay can
be arrested and not left to destroy the tooth.
Source. www.childrenshospital.org/.../Images/tooth
.gif
18
How does this happen?
ITS ALL PREVENTABLE!
No child should experience this severity of oral
disease, especially when we know how to prevent
it. Being proactive and assessing whether medical
conditions or treatments could compromise oral
health can help reduce the incidence and severity
of oral disease.
19
BACTERIA
20
Bacteria and Oral Disease

• Different bacteria are responsible for tooth
  decay and periodontal or gum disease.
• DECAY. streptococcus mutans, gram
• PERIO. gram, anaerobes, facultative anaerobes

Note. If bad bacteria are left in the mouth,
they proliferate and colonize. Once this occurs,
the bacteria are more destructive. They can
destroy tooth structure AND the gum and bone
support.
21
From Health to Disease

• Its a COMPLEX SEQUENCE of events
• Start with that just cleaned smooth, shiny
  feeling.
• Within minutes, glycoproteins in saliva coat
  enamel for protection, but also create a sticky
  coating called the pellicle to which a bacterial
  biofilm, plaque, can adhere.
• Once you eat any carbohydrate, mainly simple
  sugars, amylase enzymes begin breaking down
  sucrose molecules.
• Bacteria sticking close to the enamel via the
  pellicle metabolize sucrose molecules,
  proliferate, and release acid as a byproduct.
• Acid then penetrates the porous mineral structure
  of the enamel and diffuses Calcium and Phosphorus
  out of the tooth, called demineralization.

22
What are plaque and tartar?

• Plaque is SOFT
• Composed of bacteria, food debris, glycoprotein
• Can be brushed away
• Tartar, calculus, is HARD
• Mineralized plaque
• Can not be brushed away, need professional
  cleaning to remove
• Creates a substrate for bacterial growth and
  colonization
• Plaque can mineralize in only 24 hours!

Note. It is very important to brush your teeth
at least twice a day, and floss at least one time
every day. Flossing and brushing remove plaque
when it is soft so that it does not remain on the
tooth to either initiate demineralization or
mineralize into calculus onto the tooth.
23
Enamel Demineralization
Caries

• Saliva
• Buffering Capacity
• Flow Rate pH
• pH Composition

• Note. The very first stages of tooth decay are
  demineralization of the porous enamel surface.
  Demineralization is influenced by three factors.
• Fermentable carbohydrates, substrate
• Cariogenic microorganisms such as Streptococcus
  mutans and Lactobacilli
• Susceptible tooth surface, host
• Can be restored through the natural process of
  remineralization via saliva and the addition of
  topical fluoride
• All three factors must be present for the dental
  caries process to initiate and continue. The
  addition of fluoride to the natural minerals in
  saliva supports reversing demineralization.

24
GERD is a pH of 1
Sippy Cup is a pH of 3
Note. The pH of the oral cavity is a very
important factor in caries development. Medical
conditions such as GERD and Bulimia combined with
poor dietary habits can seriously impact oral PH
and contribute to rapid caries initiation and
progression. Sippy cups filled with anything
other than water should only be used in short
increments of time, and should never be given to
a child as they sleep. GERD causes gastric acids
to enter the oral cavity. These gastric acids
have a very low pH and can cause generalized
enamel erosion and dental caries. Children with
such medical conditions must be placed on a
preventive oral health regimen to include
fluoride therapy and routine dental home
appointments.
Source. http//www.dentaleconomics.com/display_art
icle/284037/55/none/none/Feat/ Treating-Caries-Che
mically-Fact-or-Fiction?hostwww.dentalofficemag.
com
25
Dental Caries
Source. PennWell.com
Note. There is a delicate balance between
pathological and protective factors. The goal is
to have more protective factors than pathologic.
Unfortunately, CSHCN have an increased risk for
more pathological factors and therefore need
additional protective factors such as fluoride
varnish at regular intervals.
26
Enamel Remineralization

• Four conditions or events must occur at the same
  time.
• Sufficient minerals must be present in the
  saliva
• A molecule of carbonic acid must be produced in
  proximity to a mineral molecule, which then
  dissolves into its ionic components
• Proximity to a clean and accessible
  demineralized spot in the hydroxyapetite
  requiring the exact mineral ion
• Convertion of carbonic acid to carbon dioxide
  and water and precipitation of a mineral ion out
  of solution into the structure of the enamel

Source. An Update on Demineralization/Remineraliza
tion, ME Jensen, http//www.dentalcare.com/soap/co
nteduc/index.htm
Note. Remineralization is the process of
restoring mineral ions to the tooth structure,
like replacing the missing links in a chain.
Remineralization with fluoride actually replaces
the hydroxyapetite with fluorapetite.
Fluorapetite is stronger and more resistant to
demineralization compared to the original
hydroxyapetite mineral. Minerals also come from
food and saliva.
27
Incipient Carious Lesions Demineralization
Caries disease process initiated, but CAN BE
REMINERALIZED
Note. Demineralization has occurred. The caries
disease process has been initiated, but this is
not a cavity yet. The tooth can be restored
naturally with fluoride therapy until the point
of cavitations. Once the tooth is fully
cavitated, a hole in the tooth, it must be
restored by a dentist.
28
Remineralizing Effects of Fluoride Varnish

• Arrows indicate areas of enamel
  demineralization.

Evidence of remineralization 3 months after
fluoride varnish application.
Source www.uiowa.edu/c090247/fluoride_varnish.ht
m
29
Cavitations
Needs Immediate Restorative Treatment!
Note. This is severe dental caries, however, in
primary teeth it often does not take long for the
caries disease to progress to this severity.
Primary teeth are more susceptible to caries
because the enamel is much thinner than the
enamel of permanent teeth. Adding an additional
pathologic factor such as medication that
contains sucrose or has the side effect of
xerostomia can significantly expedite the disease
progression.
30
What Chronic Conditions Could Increase Dental
Caries Risk?

• Physical challenge or disability
• Immunsuppression
• Defect in enamel development
• Xerostomia, either condition or medication
  induced
• Gastrointestinal disorders or GERD
• Frequent snacking and drinking beverages
  containing simple sugars and low pH

Note. A physical challenge or disability could
inhibit a childs manual dexterity enough to
impede effective oral hygiene behaviors, such as
flossing and brushing. Some physical disabilities
also make it difficult for dental staff to
provide services.
31
Xerostomia

• Abnormal reduction of saliva
• Salivas functions. Lubrication, protection
  against mucosal drying, digestion,
  neutralization, taste, irrigation of debris and
  microbes
• Can result as a symptom of disease or as a side
  effect of over 500 medications
• Can be chronic as a result of damage to salivary
  glands during chemotherapy and head/neck
  radiation
• Significantly increases the risk for dental
  caries and periodontal infections

Note. Xerostomia is the most common adverse drug
related effect in the oral cavity. The absence of
saliva increases the risk for oral diseases for
several reasons. Saliva is the mouths natural
cleansing mechanism. It helps to protect the soft
and hard tissues in the mouth by delivering
immune components and lubrication for soft
tissues, and a it provides a constant delivery of
minerals to hard tissues. Many people with
xerostomia experience rampant dental caries and
other oral infections like fungal candidiasis.
32
Prevention Strategies Anticipatory Guidance

• Proactive developmentally based counseling
  technique that focuses on the needs of a child at
  particular stages of life
• CD ROM 2 in the Toolkit can provide you with
  great educational materials to discuss oral
  health anticipatory guidance with caregivers.
• You can also find these on the Office of Oral
  Health Webpage under Resources and Fact Sheets

Note. Anticipatory guidance is about arming
caregivers with knowledge of their childs growth
and development so they know what to expect and
they can prepare to decrease disease risk by
promoting healthy behaviors. CD ROM 2 has many
multi lingual anticipatory guidance materials for
various childrens oral health topics. These can
be useful educational tools for caregivers.
33
Prevention Strategies Plaque Control
Smear

• Brush twice daily
• WITH CAREGIVER SUPERVISION
• Children 2 years and under use a smear of
  fluoride toothpaste
• Children over 2 years and use a pea sized amount
  of fluoride toothpaste
• Floss at least once daily
• Children over age 6 can rinse with fluoride or
  antimicrobial

Pea sized
Note. Children should always be supervised when
brushing, flossing, and rinsing up to age 8.
First, it is important to make sure they child is
not only using the appropriate amount of fluoride
toothpaste and he/she is not swallowing excess
amounts of it. Fluorosis of the teeth often
occurs because of too much fluoride ingested via
toothpaste. Second, children might need help with
brushing and flossing their teeth to make sure
they are being effective and cleaning all of the
plaque off. Young children do not have the manual
dexterity to brush all teeth surfaces effectively
with a toothbrush.
34
Prevention Strategies Dietary Counseling

• Children of all ages with poor dietary habits are
  at a high risk for developing early childhood
  caries. It is not just children drinking from
  bottles or sippy cups
• Limit the frequency of consuming any liquid or
  food containing sugar and/or simple carbohydrates
• Even healthy foods and drinks can be
  cariogenic.
• Animal crackers/cookies/cheerios
• Gummy and chewable vitamins
• Raisins
• Citrus juices
• Diet Sodas

Note. A healthy diet is not only good for the
teeth and oral health. It is also vital for a
childs overall growth and development. After
consuming foods that are cariogenic, it is good
to wash the mouth with plenty of water and brush
the teeth if possible. This action buffers the
oral pH and inhibits plaque bacteria from forming.
35
Prevention Strategies Fluoride

• Assess for adequate fluoride exposure.
• Topical sources
• Toothpaste
• Community water fluoridation
• Fluoride varnish
• OTC fluoride rinses
• Professional fluoride treatments at dental
  offices
• School based fluoride mouth rinse programs
• Systemic sources
• Community water fluoridation
• Foods and drinks produced using fluoridated water
• Fluoride supplements

Note. Assess fluoride exposure from all possible
sources, and decipher whether the source is
systemic or topical. Fluorosis only occurs if too
much SYSTEMIC fluoride is ingested. Usually, this
occurs because a child is consuming fluoride
toothpaste instead of rinsing thoroughly and
spitting it all out. It is important to ask
whether a child lives in a community that has
fluoridated water. It is also important to find
out if the child is actually drinking the water.
If the child only drinks bottled water, they
might not be getting the public health benefit of
fluoridated community drinking water. The most
updated list of Massachusetts communities that
fluoridate their water supply is located in your
blue folder. Some communities only partially
fluoridate their water, so make sure to look
closely at what areas within one community have
fluoridated water
36
Fluoride Supplementation Schedule
Massachusetts has 140 fluoridated communities!
Note. This is also available on CD ROM 1 in the
toolkit.
37
Prevention Strategies Access to a Dental Home

• Frequent dental examinations
• Routine dental radiographs
• Oral hygiene education
• Prophylaxis, cleaning, and fluoride treatments
• Dental sealants on permanent molars

Note. Many parents do not think baby teeth are
important, and they do not see the need to take
their children to the dentist. Your opinion on
this issue might influence them to change these
misperceptions about oral health. Oral disease in
childhood is indicative of oral disease in
adulthood. Preventing oral disease in childhood
is equally as important as preventing it in
adulthood. The AAP recommends that child health
providers encourage caregivers to establish a
dental home for their child by age 1. This might
be even sooner if a child is at moderate to high
risk for developing oral diseases.
38
Prevention Strategies Dental Sealants

• Plastic material placed into the deep groves and
  fissures of posterior permanent teeth
• Painless procedure for children, no tooth
  structure is removed
• Recommended when first molars fully erupt,
  usually by age 6, and when second molars erupt
  around age 12

Source. http//www.dentalcarekids.com/new_techniqu
es.htm
Note. Dental sealants protect back teeth from
dental caries because the think plastic fills up
the deep grooves, pits, and fissures in the
teeth. This prevents food and plaque from
remaining stuck in these areas. Dental sealants
differ from fluoride varnish. Sealants are a
plastic material that is placed in pits and
fissures of the posterior teeth to block plaque
from getting stuck there. Fluoride varnish is a
topical fluoride that can remineralize enamel to
prevent caries.
39
Lets talk about the GUMS

• Healthy teeth are not good unless they have
  healthy SUPPORT
• Gums and alveolar bone SUPPORT the teeth.
  Periodontal health is the foundation for COMPLETE
  oral health and function.

40
Gingival/Soft Tissue Anatomy
Source. http//medical-dictionary.thefreedictionar
y.com/Gum(anatomy)
41
Periodontal Infections

• Bacterial, plaque induced
• Gingivitis .
• Localized and reversible
• Periodontal Disease
• Progressive and irreversible
• ANUG
• Acute Necrotizing Ulcerative Gingivitis
• treatable, but damage not always reversible

Source. www.rideaudental.ca/tips.html
Source. www.drrafia.com/ServicesWeOffer/Periodonta
l.aspx
Note. ANUG is sometimes associated with stress or
immunosuppression. The gingiva can become very
red and tender. The gum that fills the space
between teeth is punched out or cratered in
appearance. ANUG needs to be treated by both
medical and dental professionals since it is
often associated with something systemic.
Sometimes the gingiva do not return to the
natural contour around the tooth even after the
infection is treated and the infection is gone.
42
Diseased vs. Healthy Gingiva

• Source. OraPharma, Inc.,www.arestin.com

Source. www.rideaudental.ca/tips.html
Note. In periodontal disease, destruction of the
clinical attachment includes both that of the
gingival connective tissue and the alveolar bone.
Dental professionals measure this destruction
with a periodontal probe.
43
Conditioned Gingival Enlargement

• Medication Induced
• Anticonvulsants
• Calcium Channel Blockers
• Immunosuppressants
• Hormonal Changes
• Vitamin C and B deficiencies
• Immunosuppression
• Leukemia
• Lymphoma
• Aplastic Anemia
• Conditions associated with systemic inflammation
• Diabetes

Note. The key to reducing the risk of
conditioned gingival enlargement is to maintain
very meticulous plaque control. Studies have
suggested that the risk of conditioned gingival
enlargement can be reduced with strict oral
hygiene routines beginning at least 10 days prior
to when the medication therapy begins. If the
enlargement is severe, it might need to be
treated by a dental professional such as a gum
specialist, or periodontist.
44
Viral Oral Infection

• Herpes Simplex
• Keratinized epithelium. Hard palate, lip,
  attached gingiva
• Multiple vesicles that coalesce
• Highly contagious
• Virus remains on trigeminal nerve
• Often induced during immunosuppression, trauma,
  or stress

Note. Caregivers should know that cold sores
are very contagious and can spread on different
locations on a childs body as well as between
family members and other children. This is a
virus that remains with the child for life, and
many people are not aware of this.
45
Aphthous Ulcers

• Often misdiagnosed as herpetic lesions
• Occur on nonkeratinized tissue including the soft
  palate, buccal and labial mucosa, vestibules, and
  non attached gingiva.
• Painful, clearly defined, shallow round or oval 1
  to 3 millimeter ulcers
• Often reoccurring, called Recurrent Aphthous
  Stomatitis
• Predisposing factors include
• Oral trauma
• Emotional disturbances or stress
• Family history
• Hypersensitivity to foods
• Drug therapy
• Immunosuppression/deficiency

Note. Aphthous ulcers are often called canker
sores, and usually have a prodromal period of
approximately 24 to 48 hours in which symptoms of
localized burning or pain can occur. Shortly
after, clinical manifestations include an ulcer
with a shallow necrotic center covered with a
yellow gray pseudomembrane surrounded by
minimally raised margins and an erythematous
halo. They are often painful, and usually subside
in 3 to 4 days. O. TC topical anesthetics can be
used to relieve pain.
46
Fungal Oral Infection

• Oral Candidiasis
• Usually indicates immunosuppression
• Can occur as complication of xerostomia
• White, curd like lesions
• Treat with anti fungal, either topical or
  systemic.

47
Gingival Infection Prevention

• Identify risk and reinforce meticulous oral
  hygiene and care under a dental professional
• Implement strict oral hygiene at least 10 days
  before induction of pharmaceutical treatment with
  known gingival side effects
• Assess for adequate saliva flow
• Consider consulting with a dentist about
  prescription antimicrobial mouthrinse, such as a
  0.12 solution of chlorhexidine gluconate or low
  dose doxycycline to control gingival infection
  and inflammation

Note. Healthy children do not usually have
periodontal problems, but CSHCN might experience
problems because they have more risk factors for
developing gingival infections. Chlorhexidine
gluconate is often used to treat adult
periodontal infections, but has not extensively
been studied in the pediatric population.
48
Review

• To Bridge Systemic Health with Oral Disease
  Risk, Ask Three Questions.

• Does the child have any conditions, diseases, or
  special health care needs today that may increase
  his or her risk for oral disease/injury in the
  future?
• 2. Will any recommended or prescribed treatment
  increase the risk for oral disease/injury? If so,
  what can be done to prevent it?
• 3. If oral disease occurs, how could it affect
  the childs overall health and normal growth and
  development?

49

• History of access to dental care
• Current access to dental care
• Caregiver/family history of oral disease
• Current caregiver oral health status
• Oral Health Knowledge, Attitudes, and Behaviors

Note. The next important step in the BLOCK Oral
Disease Strategy is to Learn about families
access to dental care and dental health history.
Caregivers and families oral health histories
are predictive of the childs oral health status.
50

• LOOK For
• Fillings
• Plaque on teeth
• Red puffy gums
• White spots on teeth demineralization
• Soft tissue lesions
• Oral trauma
• Severe decay/abscess
• Adequate saliva flow

Note. The next BLOCK Oral Disease Strategy step
is to do a quick and simple oral health
assessment. Once you complete the posttest and
request a copy of the Toolkit, you will have
access to many more resources. In the Toolkit, CD
ROM 1 provides oral health assessment forms and
tips. The printed clinical reference tools in
your folder today also have pictures of oral
disease indicators and the Caries Risk Assessment
Tool or CAT. You will need the CAT to establish
caries risk when considering the application of
fluoride varnish.
51
Assessing Caries History
Decay
Prepped
Restored
Source. www.dentalcarekids.com/new_techniques.htm
Note. Its important to ask caregivers about
caries history. Dont just rely on visual
examination! As you can see, its difficult to
detect tooth colored fillings!
52
Note. The next step in the BLOCK Oral Disease
Strategy is to calculate the information you
gathered from your assessment to determine the
childs oral disease risk.
53

• What do you see?
• What does the caregiver need to know and
  understand?
• What is the next step for the caregiver to take
  in regards to his/her childs oral health?
• Refer to www.mass.gov/dph/oralhealth for
  anticipatory guidance materials
• Document all oral health services rendered and
  when to follow up

Note. Use the anticipatory guidance materials on
CD ROM 2 to communicate with parents about their
childs oral health. You can also find resources
on the Office of Oral Healths webpage. These
resources will give parents something to take
home, which will reinforce what you discussed
about oral health at the medical visit. CLICK ON
LINK TO BRING UP ORAL HEALTH ASSESSMENT LABELS
FOR DOCUMENTATION
54
Note. Know how to apply the oral health
assessment data that you gather, and follow up
with the children and their caregivers at
subsequent appointments.
55
Fluoride Varnish

• Delivers remineralization benefits like other
  topical fluoride sources
• Can slow, arrest, and reverse the caries disease
  process by 30
• Intended for children who are at moderate to high
  risk for dental caries

Note. CSHCN might benefit greatly from receiving
fluoride varnish in the medical setting. This is
something any medical provider should consider
when treating a child with any risk for dental
caries, especially since it is a sustainable
service. MassHealth now reimburses 24.00 per
application. Dollar amount subject to change.
56
Source. AAP Oral Health Initiative,
www.aap.org/commpeds/dochs/oralhealth/reimbursemen
t.cfm
Note. Massachusetts is now included among 24
other U.S. states with Medicaid coverage for
fluoride varnish application in the medical
setting!
57
Why Consider Fluoride Varnish in the Medical
Setting?

• A dental cleaning is not needed prior to
  application
• No special dental equipment is needed
• It is quick and easy to apply, and dries
  immediately upon contact with saliva
• Little training and skill is needed to apply
  fluoride varnish
• It is safe and well tolerated by infants,
  children, and children with special health care
  needs
• It is a sustainable service

Note. Fluoride varnish should take less than 2
minutes to apply. Many health professionals can
potentially qualify to apply fluoride varnish if
they complete a MassHealth approved training.
Contact MassHealth directly about other available
training opportunities.
58
Who Can Apply Fluoride Varnish?

• After completing a MassHealth approved training,
  the following health care professionals are
  eligible to apply fluoride varnish.
• Physicians
• Physician assistants
• Nurse practitioners
• Registered nurses
• Licensed practical nurses

Note. You MUST complete a MassHealth approved
training before you can apply fluoride varnish on
patients teeth. This training is approved by
MassHeatlh, however, you must remember to
complete the posttest and provide your contact
information so the Office of Oral Health can send
you a certificate of completion.
59
MassHealth Coverage Eligibility

• Limitations and Restrictions
• Not recommended to exceed one application every
  180 days per provider type from first tooth
  eruption, usually 6 months, to the third birthday
• Recommended during a well child visit and will be
  delivered along with oral health anticipatory
  guidance and a dental referral if necessary
• Intended for children ages 3 and younger, but
  will be considered for members who are
• Under age 21
• Eligible for dental services
• At high risk as determined by a Caries Risk
  Assessment Tool, CAT

Note. Contact MassHeatlh directly for specific
coverage eligibility questions.
60
Preparation

• Perform an Oral Health Assessment, and the CAT
• Assess coverage eligibility
• Assess for contraindications such as pine nut
  and/or colophony allergy
• Informed consent and educate caregiver
• Have caregiver assist with managing a young child
  during application

Note. Examples of informed consent and caregiver
education for fluoride varnish application are on
CD ROM 1 and 2 in the toolkit.
61
Fluoride Varnish Supplies

• Gloves
• 2x2 gauze or cotton rolls
• Varnish and applicator
• Mirror or tongue depressor

Source. www.aap.org/oralhealth/cme/page46.htm
Source. www.uiowa.edu/c090247/fluoride_varnish.ht
m
Note. As you can see, very few supplies are
needed to apply fluoride varnish.
62
Application

• For young children, sit knee to knee with
  caregiver
• For older children, stand in front and tilt his
  or her head back
• Provider drys teeth with gauze and paints
  varnish onto childs teeth on all accessible
  surfaces

Source. North Carolina Department of Public
Health, http//www.communityhealth.dhhs.state.nc.u
s/dental/Into_the_Mouths_of_Babes.htm
Note. The entire process should take no more
than 2 minutes. Fluoride varnish doesnt have to
be painted perfectly onto the teeth. Just get
it onto the most teeth surfaces that you can and
dont worry about painting in the lines. The
varnish will not harm the soft tissues and
gingiva if it comes into contact. Before applying
it on children, practice applying fluoride
varnish onto one of your colleagues teeth.
Source. www.mohealthysmiles.com/2008/02/index.htm
l
63
Caregiver Instructions

• Teeth will look dull, but will be back to normal
  once varnish is removed
• Brush the varnish off the next day
• Child can eat and drink normally for the rest of
  the day
• Varnish is applied every 3 to 6 months depending
  on moderate to high risk status
• Reinforce the dental home

Note. It is important that informed consent is
given by the parent before fluoride varnish is
applied to the childs teeth.
64
Billing for Fluoride Varnish

• Community Health Centers or CHC, must bill
  MassHealth with CDT code D1206 on the MassHealth
  Claim form number 9, or transmitted through the
  837P electronic transaction
• CHCs may bill for fluoride varnish provided by a
  physician or qualified staff member under the
  supervision of a physician for the same member,
  the same date, and the same location as a visit,
  a treatment, or a procedure
• CHCs may not bill for a visit in addition to
  billing for the application of fluoride varnish,
  if the sole purpose of the visit was to apply the
  fluoride varnish. In this instance, CHCs may bill
  for the fluoride varnish code only.

Note. Keep up to date by communicating with
MassHealth about any policy changes that might
affect coverage and reimbursement for fluoride
varnish in the medical setting.
65
Making an Action Plan

• Questions to ask in preparing for implementation.
• Whom do you need to talk to and educate about
  oral health? Do you need to educate your
  administrators to gain their support? Support
  staff? Medical billing personnel? Use the BLOCK
  materials to educate others.
• What staff members will be involved? Do you want
  to involve other health professionals such as
  physician assistants and nurses? They will need
  to take approved training before they can apply
  fluoride varnish. Again, use the BLOCK Materials
  to educate other health professionals who might
  be involved.
• How will supplies be purchased and paid for?
  Identify who will need to budget for the cost of
  fluoride varnish supplies.
• Who will do oral health assessment/fluoride
  varnish application? The BLOCK Oral Disease
  Toolkit contains information about various
  companies that can supply fluoride varnish. It
  is generally very inexpensive, but you will need
  to designate a staff member to be responsible for
  ordering and supplying the fluoride varnish.
• How will this be documented and followed up?
  Every facility has different documentation
  standards and procedures. If you use paper
  charts, you might use the printable oral health
  assessment labels. They are quick and easy to
  fill out and document oral health assessments,
  education, and fluoride varnish application.
• How and to whom will dental referrals be made?
  Try establishing and building relationships with
  dental providers in your CHC. They are great
  resources for you.
• How will billing for fluoride varnish be
  completed? Identify who needs to be educated
  about the billing procedures, as well as what the
  CHC will do for children who need fluoride
  varnish are covered under a private health
  insurance that does not reimburse for fluoride
  varnish.

66

• Check out the Massachusetts Department of Public
  Health Office of Oral Health Website for fact
  sheets, publications, and reports!
• www.mass.gov/dph/oralhealth
• For any additional questions or comments about
  the BLOCK Oral Disease training and materials,
  please contact
• Lynn Bethel, RDH, BSDH, MPH
• Director, Office of Oral Health
• Lynn.Bethel_at_state.ma.us
• 617-624-6074

67
Please Complete Your Posttest!

• Please Remember to do the following.
• Go to this link to complete the posttest
  http//www.surveymonkey.com/s.aspx?smjPbZLjXgNF4S
  U9Q76Pj9iQ_3d_3d
• Request a toolkit at the end of your posttest
• If you want a certificate mailed to you, provide
  your name and mailing address when prompted on
  the post test