Download Stuck on me, stuck on you - New Mexico Health Resources

Karen L Carson MD, FAAP
 Dental varnish application as a covered benefit
first presented by Dr. Ben Hoffman and Albert
Bourbon, PA November, 2007 at the NM Pediatric
Society Council Meeting
Who is the Pediatric Council?
NM Pediatric Society Pediatric Council
 Composed of:
 New Mexico Pediatric Society Members from across the
state in various practice roles. (Rural Medicine,
Inpatient Medicine, Specialty Practice)
 Medical Chief Officers from all 4 Saluds and United
Healthcare
 State Health Representatives
 Meet 3 times per year
Goal: Liason between Pediatricians, Health Plan
Officials and State Officials
Pediatric Council Meeting
- November 2007
 Medical Chief Officers of Saluds, other state officials
present.
 NM Pediatric Society Council requested Dental
Varnish application by non-dental provider be covered
by NM Medicaid (D1206).
 Payment per procedure by Medicaid fee schedule:
Approximately $15.00
STATES with MEDICAID Funding for
Physician Oral Health Screening and Fluoride Varnish
MD: July 09
GA: Jan 09
= Medicaid coverage approved
AL: Jan 09
= In certain circumstances
= Considering
= Coming Soon
http://www.mchoralhealth.org/feedback/reimbursementchart6_08.pdf
Version: 11/08
NM Pediatric Council Chair
+
Keith Gardner(R)
+
Britt Catron
=
Chaves County Dental
Varnish Project
BCA Medical Associates:
 8 Pediatricians
 About 18,000 Pediatric patients
 Serves Chaves County and
surrounding areas
 2 Clinic sites
 90% Medicaid insured
 Low Socioeconomic
populace
 “Fluid”
BCA Medical
 Training on Dental Varnish application and oral health
by local dentists:
 Dr. Michelle Luikens, DMD
 Dr. Max Kerr, DMD
 Dr. Michelle Carter, DMD
 Additional training by completing online dental varnish
application module.
June 2009: BCA Medical
Prevalence of Dental Caries
 5 times more common than asthma
 7 times more common than
hay fever
Caries Rate
 18% aged 2 to 4 years
 52% aged 6 to 8 years
 67% aged 12 to 17 years
Early Childhood Caries (ECC)
 A severe, rapidly progressing form of tooth decay in infants
and young children
 Affects teeth that erupt first, and are least protected by
saliva
 Initial lesions—white decalcification with beginning
enamel breakdown
 Late stage lesions—moderate to severe enamel and dentin
destruction
Cariogenic bacteria are transmitted from
mother (or primary caregiver) who harbors
these bacteria to the infant at or before the
eruption of the first tooth. Because bacteria
are transmitted through the saliva, pretasting, pre-chewing, and sharing of utensils
should be avoided.
When a mother/primary caregiver puts the
baby’s feeding spoon into his or her mouth,
or cleans a pacifier in his or her mouth, the
bacteria from the mother/caregiver are
transmitted to the baby’s mouth, and the
risk of caries is increased.
Caries are promoted by carbohydrates,
which break down to acid.
Acid causes demineralization of enamel.
Foods with complex carbohydrates (breads,
cereals, pastas) are major sources of
“hidden” sugars.
High sugar content in sodas is a source of
these substrates.
Tooth Decay
 Plaque + sugars + microorganisms (primarily
streptococcus mutans)  acid that etches the
enamel of the teeth which results in the beginning
of caries (the process), leading to a cavity (the hole).
Caries develops when there is a susceptible
tooth exposed to pathogenic flora (bacteria)
in the presence of substrate. Under these
conditions, the bacteria metabolize
substrate to form acid that decalcifies teeth.
Fluoride's Influence on Oral Flora
Promotes remineralization of enamel, and
may arrest or reverse early caries
Decreases enamel solubility, inhibits the
growth of cariogenic organisms, thus
decreasing acid production.
Primarily topical even when given
systemically
Socioeconomic Factors
 The rate of early childhood dental caries is near
epidemic proportions in populations with low
socioeconomic status.
 No health insurance and/or dental insurance
 Parental education level less than high school or GED
 Families lacking usual source of dental care
 Families living in rural areas
Percent of Children with Decayed and
Filled Primary Teeth by Household
Income Level
(% of Federal Poverty Level)
50
40
0-100%
101-200%
30
201-300%
20
301%+
10
0
Decayed
2-5
year
olds
Decayed
6-12
year
olds
Filled 2-5
year
olds
Filled
6-12
year
olds
Vargas, Crall, Schneider. Analysis of NHANES III data. JADA, 1998.
‘Minority children’ are more likely to have
untreated tooth decay
(regardless of family income)
Percent of children
`
White
Ethnic groups
African American
Mexican American
50
40
30
20
10
0
Fed. Poverty level
2-5 years
6-12 years
Primary dentition
6-14 years
15-18 years
Permanent dentition
Vargas, Crall, Schneider: JADA 1998;129:1229-1238.
 The AAP policy statement “Oral Health Risk
Assessment Timing and Establishment of the
Dental Home” identifies that the following groups
are at risk for early childhood dental caries:
 Children with special health care needs
 Children of mothers with a high caries rate
 Children with demonstrable caries, plaque, demineralization, and/or staining
 Children who sleep with a bottle or breastfeed throughout the night
 Children in families of low socioeconomic status
 If an infant is assessed to be within 1 of these risk groups, it is
recommended that he or she be referred to a dentist as early as 6 months
of age and no later than 6 months after the first tooth erupts or 12
months of age (whichever comes first).
Sad Reality:
 50% of tooth decay in low income children goes
untreated
 1 in 8 children never see the dentist (while more
than half of children with private insurance
received dental care in the preceding year
(Government Accountability Office)).
 GAO estimated that in 2005, 724,000 2-18 year
olds could not get needed dental care.
Change in Paradigm for Dealing with
Dental Caries
 Old Paradigm --> Surgical / ‘Drill and Fill’
(deal with the consequences of the disease)

 Later Paradigm: Prevention!!!
(but generally “one size fits all”)

 “Current” Paradigm: Early Intervention, Risk Assessment,
Anticipatory Guidance, Individualized Prevention and
Disease Management
PREVENTION IS KEY!
 Early, consistent dental health screenings
 Prevention education
Mom/Parent Questions
(The Caregiver Oral Assessment)
 How are your teeth?
 Have you had a lot of cavities?
 Do you have a regular dentist?
 When was your last visit to the dentist?
 Have you ever had a tooth filled?
 Have you had a lot of dental work done?
 Mothers/primary caregivers should be referred to a dental home if oral health
problems are identified, because active dental disease significantly increases
the transmission and early colonization of cariogenic bacteria in the child.
Ethnocultural Factors
 Increased rate of dental caries in certain ethnic groups
 Diet/feeding practices and child-rearing techniques
influenced by culture
 Yes, my daughter still drinks from a bottle. Deal
with it.
Vivian Manning-Schaffel: My daughter is almost two and still drinks
milk from a bottle to go to sleep. And you know what? I've got better
things to do than care. Of course, for a few weeks there, I really cared.
With my oldest, I strictly adhered to most milestone transitions because
I had the time to know what they were.
But now, as a working parent with two kids in the picture, the path of
least resistance is often the path that seduces.
(MomLogic.com)
Not Just What You Eat,
But How Often
 Increased acidity produced by bacteria after sugar
intake persists for 20 to 40 minutes
 With each ingestion of sugar, another wave of
increased acidity lasting for 20-40 minutes
 Frequency of sugar ingestion is more important
than quantity
 Better to drink 16 oz. of Cola in one long gulp than
continually over 8 hours.
Sugar in 12 ounce can of pop
Soda Pop:
 Orange Slice
 Minute Maid Orange
 Mountain Dew
 Barq’s Root Beer
 Pepsi
 Dr. Pepper
 Coca-Cola
 Sprite
Sugar: (in teaspoons)
11.9
11.2
11.0
10.7
9.8
9.5
9.3
9.0
Sugars in beverages
Beverage:
 Powerade (32 oz.)
 Sunny Delight
 Gatorade
 Capri Sun
 Apple Juice (12 oz.)
Sugar (in teaspoons):
15
9
8
6
10
High Risk Eating Patterns
Eating Pattern
Frequent snacking –
Two or more times between
meals
Sticky, retentive snacks, slow
dissolving carbohydrates
Sequence of eating & time
xamples
Candy, sippy cup of juice or soft
drink, graham crackers, cookies
Raisins, dried fruit, fruit rolls,
bananas, caramels, jelly beans,
peanut butter/jelly sandwich
Chewable vitamins at end of meal,
food or drink after brushing and
before bed
Not Just What You Eat, But
How Often
Acids produced by bacteria after sugar
intake persist for 20 to 40 minutes.
Frequency of sugar ingestion is more
important than quantity.
 Anticipatory Guidance:
 Do not put the infant to sleep with a bottle or sippy cup or allow
frequent and prolonged bottle feedings or use of sippy cups containing
beverages high in sugar (e.g., fruit drinks, soda, fruit juice), milk, or
formula during the day or at night to prevent sugary fluids from
pooling around the teeth, which can increase the infant’s risk for tooth
decay.
Child’s Oral Risk Assessment (beginning at age 2 weeks)
 Preexisting risk factors
 Early tooth eruption (<6 months)
 Overlapping/crowded incisors
 White spots (none; 1; >1)
 Plaque (none; present on







anterior front teeth)
Gingivitis (absent; present)
Past caries experience of child
Past caries experience of primary caregiver
Past caries experience of older siblings
Bottle to bed (nap; night) containing sugared
liquids
Frequent/continual access to bottle/sippy cup
containing sugared liquids during day when
awake
Snacking (none; 1-2 times between meals; >2
times between meals)
Oral Screening
 Identify abnormalities and refer children with
suspicious findings (false positives are OK)
 No different from other screenings done as part of
well-child care
 Oral health screening/risk assessment checklist
(handout)
 Risk assessment questions can guide caregiver
education
How to Position the Child
Place the child in knee-to-knee position
or whatever works best
Screaming Child/ Tired Clinician
“Recommendation”
 Position the child in the
caregiver's lap facing the
caregiver.
 Sit with knees touching the
knees of caregiver.
 Lower the child's head onto
your lap.
 Lift the lip to inspect the
teeth and soft tissue.
“Reality”
What to Look For
 Presence of plaque
 Presence of white spots or
dental decay
 Presence of tooth defects
(enamel)
 Presence of dental crowding
 Provide education on
brushing and diet during
examination.
Lift the Lip!!!!
 Look for presence of
plaque on maxillary
central and lateral
incisors
 Run gloved fingernail
along gum line
of child’s incisors
Dental Plaque
 Dental Plaque contains:




Bacteria
Food debris
Dead mucosal cells
Salivary components
 White spots (first visual evidence of
demineralization) where tooth
meets gums of maxillary central
and lateral incisors (buccal and
lingual aspects)
Decay process advances
Brown Spots - Advancing
decay process
Decay process advances
Check for Advanced/Severe Decay
(continuous dissolution of the outer enamel surface)
Prevention:
Xylitol for Mothers
Xylitol gum or mints used 4 times a day may prevent
transmission of cariogenic bacteria to infants.





Helps reduce the development of dental caries.
A “sugar” that bacteria can’t use easily.
Resists fermentation by mouth bacteria.
Reduces plaque formation.
Increases salivary flow to aid in the repair of damaged
tooth enamel.
Toothpaste and Children
 Children ingest substantial
amounts of toothpaste
because of immature
swallowing reflex.
 Early use of fluoride
toothpaste may be
associated with increased
risk of fluorosis.
 Once permanent teeth have
mineralized (around 6-8
years of age), dental
fluorosis is no longer a
concern.
Toothbrushing Recommendations
 < 1 year
Clean teeth with soft toothbrush
 1–2 years
Parent performs brushing
 2–6 years
Pea-sized amount of fluoride-containing toothpaste
2x/day
Parent performs or supervises. Floss close-spaced teeth.
 > 6 years
Brush with fluoridated toothpaste 2x/day. Floss closespaced teeth.
Sources of Fluoride
Systemic
 Water fluoridation
 Fluoride supplements
Topical
 Fluoride toothpastes
 Gels, foams, mouthwashes
 Fluoride varnish
Education
 Offer anticipatory guidance to caregivers of all
children (fluoridated water; proper feeding
practices; risk for dental decay; oral hygiene
instructions; dental home by age 1)
 Discuss behavior modifications with caregivers of
children identified as high-risk
 Apply fluoride varnish according to risk status (low
– not needed; mid – 2 times/year; high – 4
times/year)
Fluoride: Who is in need?
 Fluoride supplements should be considered
if the water supply does not have adequate
fluoridation (naturally (wells); lack of
public fluoridation; home reverse osmosis
filter; bottled), consider, however, other
sources of fluoride
 Infants younger than six months do not
require fluoride supplements
 Infants six months and older who are
breast-fed may have the greatest need for
dietary fluoride supplements
 Failure to clean the child’s teeth 1-2 times/day
 Inadequate exposure to fluoridated water (reverse








osmosis filter); fear of water (dysentery)
Nonuse of fluoridated toothpaste (ADA seal of approval)
 Fluoride supplements
Inability to maintain good oral hygiene (dental or
orthodontic appliances)
Continual exposure to sugar-containing medications
(chronic illnesses)
Xerostomia (Dry Mouth) (drugs for chronic illness)
Pacifier use (caregiver wets with own saliva)
Pretasting/prechewing of food (caregiver saliva)
Bottle sharing (saliva)
Infrequent or no regular dental care
Complete AAPD Policy Statement with Caries Risk Assessment Tool available at:
http://www.aapd.org/pdf/policycariesriskassessmenttool.pdf
Fluoride Supplement Schedule
Fluoride Concentration in Community Drinking Water
Age
<0.3 ppm
0.3–0.6 ppm
>0.6 ppm
0–6 months
None
None
None
6 mo–3 yrs
0.25 mg/day
None
None
3 yrs–6 yrs
0.50 mg/day
0.25 mg/day
None
6 yrs–16 yrs
1.0 mg/day
0.50 mg/day
None
MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the US
(2001): http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.
Fluoride Varnish
 5% sodium fluoride or 2.26% fluoride in a viscous
resinous base in an alcoholic suspension with flavoring
agent (eg, bubble gum)
 Has not been associated with fluorosis
 Application does not replace the dental home nor is it
equivalent to comprehensive dental care
Facts about Fluoride Varnish
 Easy to apply protective coating that is painted on the
surfaces of teeth. It adheres to the enamel and slowly
releases the fluoride in high concentration. Its presence
prevents new cavities from forming and helps stop the caries
process that may have started (white spots).
 Because it adheres, there is no concern of child swallowing
the product. Can be used on babies' teeth. Minimal chance
of ingestion.
 Protective effect will continue to work for several months.
Facts about Fluoride Varnish
 Fluoride varnish will have a yellow color to it when
it sets up (Vanish Varnish (Omni) is white)
 Parent can be involved by assisting in holding the
child in the knee-to-knee position
 Children may cry because they do not like to be
held down and to have foreign objects in their
mouth (however, makes application easier)
 To prevent being bitten, tongue blades taped
together
 Used “off label” but so is aspirin and many drugs
given to children
Indications
• Moderate and high risk
children without caries
• Children with “white spots”
• Children with caries
• Generally applied twice per year
beginning when teeth erupt
• Varnish is not a replacement for
appropriate diet, regular
brushing, indicated systemic
fluoride supplements, or
routine dental care!
Benefits
 Can be quickly and easily applied
 Application does not have to be
done by a physician
 Dry tooth surface facilitates fluoride
uptake
 Sets on contact with moisture
 Taste is tolerable
 Can reverse early decay (“white
spots”) and slow enamel destruction
in active ECC
28
Supplies




Microbrush applicators
2 x 2 gauze squares
Gloves
Disposable mirror (not
critical since all surfaces
will be painted)
 Direct light source
 Toothbrush (optional)
Enamel Pro Varnish
Available Preparations
CavityShield
0.25ml
unidose 5% NaF (2.26% F)
Primier
$1.60 per dose
OMNII
$1.00 per dose
Duraflor
Medicom
$1.00 per dose
All Solutions
Dentsply
$1.60 per dose
31
Applying Fluoride Varnish
 Step One: Drop of varnish in small dish or on gloved
hand (multidose tube) or from unit dose container
Applying Fluoride Varnish
Visually inspect all the child’s
teeth and document any white
spots and/or cavities for future
follow-up
Hints


Use the knee-to-knee
exam
Show the toothbrush to
prompt opening of the
mouth
37
Applying Fluoride Varnish
 Use gentle downward finger pressure against the
labial sulcus on lower incisors to open the child’s
mouth
 If child has a lot of plaque present, brush or wipe
with gauze
38
Applying Fluoride Varnish
Apply a thin layer of varnish to all tooth surfaces in
dried quadrant. Do not wipe again.
Repeat procedure until all quadrants have been
varnished
Applying Fluoride Varnish
Apply varnish to all the
surfaces of the dry teeth
Note: The varnish will not adhere
if it is applied to wet teeth, but
saliva contamination after the
application is fine
Applying Fluoride Varnish
 Once the varnish is applied:

It sets quickly

You need NOT worry about moisture contamination
Applying Fluoride Varnish
Tell the caregiver:
 The child’s teeth will be
discolored for 24-48 hours
 Do not brush the child’s
teeth for 12-24 hours
 Avoid giving the child hot,
sticky or hard foods for 24
hours
Post Application
Information/Instructions
 The applied fluoride varnish will leave a yellow film on
teeth (Vanish Varnish is white); it will gradually disappear
over several days
 The child may drink immediately after the application but
should not eat for 2 hours after the application (soft diet
only for the day)
 Do NOT brush the child’s teeth until the next morning
 Have varnish applied based on risk assessment at 3-6
month intervals
Product Safety
 Following application of varnish on the teeth of
four children ages 4, 5, 12, and 14, peak plasma
fluoride concentrations of 3.2-6.3 micromoles were
found within two hours after application.
 These levels were comparable with those found
after brushing with a fluoridated toothpaste or
after ingesting a 1 mg fluoride tablet and were
considerably lower than from use of fluoridated
gels (Catalanotto, 2002)
The BCA Experience
 All physicians quickly certified to apply dental varnish
by online program
 Program started July 2009
 All children age 6 months and older or at first tooth
eruption administered varnish application at well child
checks every 6 months up to age 3. (6mo,12mo, 18mo,
24 mo, 30 mo, 36mo)
 Total varnish application: 1,811 applicatons in 9 months
 Approx. $25,000 paid to provider from Medicaids
The Bottom Line
Early Childhood Caries Can Lead to ...
 Extreme pain
 Spread of infection
 Difficulty chewing, poor weight gain
 Falling off the growth curve
 Extensive and costly dental treatment
 Risk of dental decay in adult teeth
 Crooked bite (malocclusion)
The Bottom,Bottom Line
 BCA Medical Associates performed approximately 45
“Dental Pre-op” physicals in the past 12 months.
 Typically patient travels to Las Cruces or Albuquerque
with an overnight stay. ($150.00 approx with travel
stipend and hotel stipend).
 Parent off work for 2-3 days.
 Inpatient anesthesia and dental surgery costs ranging
from $5000-$6000 per patient. (Covered by Medicaid)

Total: $237,150.00
 Continued dental follow-up and outpatient
procedures.
Resources

POLICY STATEMENTSAbstractFull TextPDFSection on Pediatric Dentistry
and Oral HealthPreventive Oral Health Intervention for PediatriciansPediatrics 2008 122: 13871394.

POLICY STATEMENTSAbstractFull TextPDFSection on Pediatric DentistryOral Health Risk
Assessment Timing and Establishment of the Dental HomePediatrics 2003 111: 1113-1116.

National Center for Chronic Disease Prevention and Health Promotion 2008 Synopses of
State and Territorial Dental
Public Health Programs

New Mexico Dental Association
The New Mexico Dental Association Web site has been developed with both the member dentist and
dental consumer in mind. Complete with dental facts, links, a listing of New Mexico Dentists,
Medicaid information, and much more.

The Oral Health of Children: A Portrait of States and the Nation-2005
Portraits are based on data from the National Survey of Children's Health; US Department of Health
and Human Services, Health Resources and Services Administration, Maternal and Child Health
Bureau

Centers for Disease Control and Prevention
Division of Oral Healthhttp://www.cdc.gov/OralHealth/index.htm