Download The AAP policy statement on Oral Health Risk Assessment

DRAFT 1/31/11
Best Practice Approaches
for State and Community Oral Health Programs
A Best Practice Approach Report describes a public health strategy, assesses the strength of evidence on the
effectiveness of the strategy, and uses practice examples to illustrate successful/innovative implementation.
Date of Report: _____________
Best Practice Approach
Perinatal Oral Health
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Description (page 1)
Guidelines and Recommendations (page 13)
Research Evidence (page 14)
Best Practice Criteria (page 15)
State Practice Examples (page 16)
Acknowledgement (page 20)
Attachments (page 21)
References (page 27)
Summary of Evidence Supporting
Strategies to Promote
Early Childhood Oral Health
Research
Expert Opinion
Field Lessons
Theoretical Rationale
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See Attachment A for details.
I. Description
A. Oral Health and Its Significance for Pregnant Women
(this whole section needs expansion)
1. Same as any other individual
2. Relief from pain and acute infection- PRAMS & MIHA data
3. Treatment & management of the most common chronic oral diseases: dental caries and
periodontal disease; other oral pathologies (including tobacco)
4. Improved Quality of Life
B. Significance of Mother’s Oral Health on Baby
(#1-2 needs expansion and #3 needs more references for transmissibility)
1. Developmental Issues (folic acid intake-cleft lip & palate)
2. Association with adverse birth outcomes (include tobacco use and periodontal disease)
3. Transmissibility of caries-causing bacteria
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Tooth decay is caused by bacteria. Infants are first infected with cariogenic (tooth
decay causing) bacteria transmitted through saliva, typically from the mother or
primary caregiver. (refs) The bacteria ingest dietary sugar and produce acid that
dissolves tooth structure, resulting in tooth decay. If the disease process is left
unchecked (e.g., the tooth is not restored with a filling), the bacteria will advance into the
nerve and blood vessels of the tooth causing inflammation and infection.
Early childhood caries (ECC) is a term used for tooth decay in infants, toddlers and
preschoolers. According to the American Academy of Pediatric Dentistry (AAPD), ECC
is defined as the presence of one or more tooth surfaces that are decayed (breakdown
in tooth structure), missing (lost or extracted due to tooth decay) or filled (with dental
filling materials) in any primary tooth of a child 71 months of age or younger (age 0-5).4
In the United States, tooth decay is the most prevalent chronic disease of childhood, five
times more common than asthma.11 For the period of 1999-2004, 28 percent of 2-5 yearolds have experienced tooth decay. Children under age 6 receive less than half the
dental care services as children ages 6-12 (25 percent vs. 59 percent).21 Tooth decay is
not distributed equally among U.S. children. Approximately 80 percent of tooth decay is
found in 25 percent of children, primarily children from low-income families.14
Dental disease can have consequences that hinder a child’s physical growth and quality
of life. Dental caries, untreated for an extended period of time, can progressively lead to
pain, infection and dental abscess. Pain and swelling can limit a child’s ability to eat and
speak, and distract a child from learning and playing. Studies have found that severe
ECC may keep toddlers from reaching normal height and weight and may compromise
their general health and ability to thrive.5-10 Furthermore, dental infection is a risk for
medical complications, especially for children who are the least able to afford or access
professional care. In rare cases, untreated dental caries has led to life-threatening
infection and death. (cite Deamonte Driver & Alex Callendar article)
ECC places a burden on children, families, communities, and the health care system.
Therefore initiating primary prevention through clinical prevention and treatment as well
as self-management of disease risk factors with pregnant women is a logical and
necessary strategy to improve children’s oral health.
4. Self-care and lifestyle habits that will increase/decrease caries risk for baby
Inappropriate bottle-feeding and habits such as dipping a pacifier in honey, sugar or
syrup lead to frequent sugar intake and increase the risk for ECC. Giving an infant or
toddler a bottle for prolonged time periods with milk or other sugary drinks (having a
bottle continuously throughout the day or sleeping with a bottle) can lead to rampant
tooth decay. High, frequent intake of simple sugars is associated with tooth decay.
Simple sugars, also called simple carbohydrates, are found in refined sugars (“table
sugar”). Sweets like cookies, cakes, candy, and soda are high in simple sugars. Sweets
that stay in the mouth for long periods of time are particularly damaging to the teeth.
Discuss protective factors (FL exposure, tap water etc) here
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C. Barriers to Achieving Optimal Perinatal Oral Heath
Barriers related to attaining oral health during pregnancy:
● Poor dietary habits leading to frequent and high intake of sugar.
● Inadequate exposure to topical fluorides to prevent tooth decay.
● Cultural, social and economic influences on oral health such as dietary practices,
home care and beliefs about the teeth
● Beliefs and attitudes about oral health during pregnancy (lose a tooth for every
child)
● Beliefs and attitudes about receiving oral health care during pregnancy
(fear/concern about dental procedures)
Barriers related to accessing and utilizing professional dental care:
● Cost or lack of dental insurance.28-31
● Lack of dentist participation in Medicaid.32
● Limited dental safety net services, capacity and infrastructure.
● Insufficient number of dentists willing to provide routine dental care to pregnant
women.33
● Beliefs and attitudes by dentists about providing dental care to pregnant women
(fear of litigation, insufficient experience, lack of guidelines/knowledge)

Lack of evidence-based, widely accepted protocols for dental care of pregnant
women
● Lack of knowledge & training by perinatal medical professionals about the
importance of perinatal oral health
D. An Overview of a Strategic Framework to Promote Perinatal Oral Health
For preventing and controlling the disease process, strategies should:
● Establish dental homes for pregnant women
● Treat tooth decay and periodontal disease in pregnant women. Professional care
is needed to arrest the disease and if needed, restore damaged teeth to proper
form, function and esthetics.
● Prevent relapse and new tooth decay by addressing the risk factors for tooth decay
prevents relapse.
For promoting systems of care, strategies should:
● Provide an adequate trained workforce that is willing to deliver comprehensive oral
health care to pregnant women
● Integrate oral health and coordinate dental care services into systems supporting
perinatal health. Healthcare providers can help facilitate establishment of the
dental home for preventive/restorative dental care.
For developing public health practices, strategies should:
● Utilize a population-based approach. The Institute of Medicine proposed that public
health “is what we, as a society, do collectively to assure the conditions for people
to be healthy.”40 Public health focuses on the health of the population,41 including
obtaining a high level of oral health throughout society. A population-based
approach uses a community perspective, population data and evidence-based
practice, with emphasis on prevention and effective outcomes.42 Community water
fluoridation (a population-based strategy to prevent tooth decay) is recognized as
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one of ten great public health achievements. Population-based interventions
complement individual interventions.
● Promote public and private partnership. Many governmental agencies are involved
with health (e.g., agencies concerned with health and child welfare)41 as are many
non-governmental institutions (e.g., managed care organizations, communitybased groups, and academic institutions). The National Call to Action to Promote
Oral Health acknowledges the need for public-private partnerships at all levels of
society.43
● Respond to emerging issues. Public health practice needs to be responsive to
emerging issues that impact perinatal oral health, while using the best evidence
and practice as guides.
E. Components of the Strategic Framework to Promote Perinatal Oral Health
Figure 2 provides strategic framework to promote perinatal oral health. The framework
guides efforts to promote perinatal oral health and supports the development of best
practices. The strategic framework has four focus areas: (1) Prevention, (2) Disease
Management, (3) Access to Dental Care Services, and (4) Systems of Integration and
Coordination. The four focus areas are tied to the individual woman, family and
community levels of influences on perinatal oral health.
Figure 2.
A Strategic Framework to Promote Perinatal Oral Health
Four Focus Areas and Their Components
Systems of Integration and Coordination
 Partnership with
perinatal providers
Access to Dental Care Services
Disease Management
 Risk assessment for
dental disease
Prevention
 Fluoride
 Dental home
 Dental workforce
and professional
development
 State and local
programs for
maternal oral health
 Policy development
 Spectrum of dental
treatment
 Education and
anticipatory guidance
 Tobacco cessation
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E. Components of the Strategic Framework to Promote Perinatal Oral Health
1. Prevention
Action can be taken by families, dental and health care
providers, communities, and policymakers to optimize
perinatal oral health
 Fluoride
Fluoride
 Education and
anticipatory guidance
Prevention
 Tobacco cessation
Fluoride prevents and slows the progression of tooth decay
and even reverses very early tooth decay. A small,
consistent and prolonged level of fluoride in saliva and dental plaque brings fluoride in
contact with tooth surfaces. This topical fluoride prevents tooth decay by: (a) improving
tooth surface strength to resist acid attacks that break down tooth structure, (b) rehardening tooth dental enamel following acid attack, and (c) reducing the ability of tooth
decay causing bacteria to grow, metabolize sugar and produce acid.44 Sources of topical
fluoride delivery include drinking water with optimal levels of fluoride and use of products
such as fluoride toothpaste, mouthrinse, gel and varnish:
● Water fluoridation is an effective, safe, and low-cost way to prevent tooth decay.
Low levels of fluoride in drinking water allow for frequent topical exposure.
Fluoridated community drinking water is adjusted to the optimal level of 0.7 parts
per million (ppm), for preventing tooth decay.45 Approximately 69 percent of the
U.S. population is served by community water systems with optimally fluoridated
water; the national Healthy People 2010 objective is to reach 75 percent.46 The
Association of State & Territorial Dental Directors (ASTDD) fully supports and
endorses community water fluoridation.
● Fluoride varnish has increasingly become a common method to deliver topical
fluoride for prevention. An increasing body of evidence indicates that fluoride
varnish is effective in caries prevention, a practice endorsed by the ADA, ASTDD,
and American Association of Public Health Dentistry (AAPHD).53-59 Fluoride varnish
(with 22,600 ppm fluoride) is easily applied with a small brush on tooth surfaces,
does not require special preparation of the teeth, and quickly sets and sticks to the
tooth surface until removed by repeated toothbrushing. In addition, fluoride varnish
can also reverse early tooth decay.53
● Fluoride gel applications are mostly delivered in dental offices by dental
professionals, generally at intervals of 3 to 12 months. The professionally applied
products have 9,040-12,300 ppm fluoride.
● Toothpastes sold in the U.S. contain 1,000-1,500 ppm fluoride. Children under
age two years should not use fluoride toothpaste unless instructed by a dentist or
health professional. Children starting at age two should use fluoride toothpaste.
Parents need to place only a small smear or pea-size amount on the toothbrush,
as young children may like the taste of the paste and tend to swallow it.
● Fluoride mouthrinses (over-the-counter solutions have 230 ppm fluoride) are not
appropriate for very young children who have not matured enough developmentally
to be able to swish and spit without swallowing the rinse.
A woman’s caries risk (low, moderate or high) should be considered in determining the
use of fluoride supplements and professionally applied topical fluoride treatment. Recent
recommendations describe regimes for adults. (ADA clinical recommendations).58
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Education and Anticipatory Guidance
Education is recommended for pregnant women to increase awareness about the
importance of maintaining good oral health by imparting knowledge, discussing
questions or concerns, and developing realistic prevention strategies.
Education and counseling should be provided to maintain oral health and prevent
recurrence of dental caries or periodontal disease in the pregnant woman. Anticipatory
guidance is the process of providing pregnant women with practical, developmentallyappropriate information about their own health related to significant physical, emotional,
and psychological milestones.55
Pregnancy is also an opportune time to educate/counsel expecting mothers about
preventing ECC. Topics include bottle feeding, oral hygiene, fluoride use, dietary and
oral habits, speech/language development, injury prevention, and the first dental visit.
AAPD guidelines and recommendations are found in Attachment B).4,55
Health literacy and cultural considerations are important when communicating with
pregnant women. Recent estimates indicate that over 90 million Americans are unable to
comprehend basic health information. Persons with low health literacy levels often have
poor knowledge of health-related information, show little ability to control chronic
diseases, and rarely maximize benefits from available preventive health services.63
Resources exist that provide guidance on developing culturally competent messages
using plain language when communicating with families (e.g., from Centers for Disease
Control and Prevention, National Maternal and Child Oral Health Resource Center,
American Medical Association, Harvard School of Public Health, and National Network
of Libraries of Medicine).
Interventions for pregnant women need effective approaches in delivering health
education and in modifying health behaviors. More input from behavioral scientists,
social workers, and educators will be needed to maximize effective and culturally
competent communication with families to promote healthy behaviors. It should be a
public health and clinical goal to develop effective methods to inform the public at large
and on an individual level about the importance perinatal oral health on both the woman
and her family.
Tobacco Cessasion
(need a whole section on this)
2. Disease Management
Risk Assessment for Dental Disease
Disease Management
 Risk assessment for
dental disease
Numerous risk factors lead to tooth decay. Early risk
 Spectrum of dental
assessment identifying factors within the context of the
treatment
child, family, community, and culture can assist in
achieving and maintaining oral health. Both dental and other health professionals are
encouraged to utilize a caries-risk assessment tool in their practices.55,57 Such a tool
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determines the risk level for an individual and guides the selection of appropriate
interventions. Risk assessments for tooth decay should:
● identify risk factors including social, biological, behavioral, and nutritional factors;
● clinically assess the disease process such as bacteria levels, dental plaque
appearance, and frequency of simple carbohydrate (sugar) ingestion;
● be simple, inexpensive, and have high predictive values (sensitivity/specificity).
Caries risk assessment tools for individuals include:
(check if these 3 tools are applicable for pregnant women, i.e. age 12 & up)
●
●
●
the Caries-Risk Assessment Tool (CAT)65 developed by the AAPD, which is based
on a set of clinical, environmental and general health factors;
the Caries Management By Risk Assessment (CAMBRA)66 developed to assess
the child’s risk for tooth decay and determine appropriate preventive and
therapeutic interventions; and
the ADA Caries Risk Assessment Form (Ages 0-6)67 developed as a practice tool
for the dentists and a communication tool with the parent/guardian.
(need paragraphs here about periodontal disease risk and tobacco risk)
Monitoring health status to identify and solve community problems is an essential public
health service, which 68 involves the identification of tooth decay risks and determination
of dental service needs. For public health, risk assessment of tooth decay focuses on
the population, rather than the individual. Risk factors of tooth decay for a population
include social and environmental factors, such as non-fluoridated community water
systems and dental health provider shortage areas. The pubic health practice of
assessment identifies the extent of the problem in a community and unmet needs, as
well as underutilized resources or shortcomings of the service delivery system.69
Spectrum of Dental Treatment
Dental decay that has progressed to the cavitation stage and beyond, and periodontal
disease should be treated in the standard manner during pregnancy, following
established guidelines. (ref ADA and/or AAP guidelines on treatment of perio & caries
here). Relating to treatment of the pregnant patient follow guidelines regarding medical
consult, medications and postural concerns (ref CA & NY guidelines here).
Since tooth decay and periodontal disease are both bacterial diseases, the potential use
of antimicrobial agents to reduce the bacteria associated with the disease mirrors the
approach used with other infectious diseases, but with some limitations as the mouth is
also an external structure exposed to outside elements. An emerging area of clinical
practice is the use of chemotherapeutic agents for caries prevention and as an adjunct
to traditional dental treatment.70 Treating tooth decay chemically is part of a paradigm
shift in dental disease management. Chemotherapeutic agents interfere with the
colonization, growth and metabolism of decay causing bacteria and should not decrease
the ability of other agents to prevent caries.
Fluoride can be considered a chemotherapeutic agent. There has been some research
on preventing tooth decay with other agents such as chlorhexidine varnish, xylitol,
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Best Practice Approach: Perinatal Oral Health
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povidone iodine, and silver diamine fluoride.71-78 It is possible that in the future some
chemotherapeutic agents will become a routine part of the management of tooth decay.
3. Access to Dental Care Services
Access to
Pregnancy is an important times to access dental
Dental Care Services
services because the consequences of poor oral health
at these times can have a major impact throughout the
 Dental home
lifespan. However, pregnant women are less likely to
 Dental workforce and
professional development
access dental care while pregnant regardless of income
or insurance status. (Flesh this out more with specific
data about pregnant women accessing dental care.)
Lack of access to dental care disproportionately affects low-income women. Access is
also dependent on a dental workforce with capacity and diversity, and an effective
system to pay for professional dental care services.
Dental Home
To achieve optimal oral health, pregnant women need professional dental care, which
should start in the pre-conception period and extent throughout the life-cycle beyond.55,65
A dental home delivers oral health care in a comprehensive, continuously accessible,
coordinated, and family-centered way.65 A dental home should emphasize disease
prevention and management, as well as tailor care to meet individual needs for better
health outcomes at lower costs. A dental home should also provide education and
counseling including anticipatory guidance, and make necessary referrals to dental
specialists (see Appendix B).55,59,65
Medical and dental homes have led to the concept of a “health home” to coordinate all
health care needs. At the 2009 Institute of Medicine workshop Sufficiency of the U.S.
Oral Health Workforce in the Coming Decade, presenters spoke about moving toward
better integration of dental care within the medical home model by creating a health
home. A health home will further integrate oral health into the health care system.
Dental Workforce and Professional Development
To assure optimal perinatal oral health, a sufficient, trained dental workforce is needed
with professionals in diverse settings. an adequate and effective workforce to achieve
optimal oral health for all children:71
● Integrate established science on prevention and disease management for the
perinatal patient into educational and training programs. Professionals should
be appropriately trained and experienced on all aspects of treating dental disease
in pregnant women; disease management that includes family-centered and riskbased interventions; and education to minimize disease transmission and establish
lifelong healthy behaviors.
● Create an equitable dental workforce to meet the needs of all families.
Strategies are needed to assure an adequate supply of dental professionals,
equitable distribution of dental professional, and improved capacity and efficiency
of the dental workforce.
● Expand the diversity of the dental workforce to meet current and future
demands. The Institute of Medicine has recommended increasing the number of
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Best Practice Approach: Perinatal Oral Health
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minority health professionals as a key strategy to eliminating health disparities.
Nearly 25 percent of the U.S. population is African American, Hispanic American,
and American Indian.72 Only five percent of dentists are from these racial/ethnic
groups.72 More than 91 percent of dental hygienists are non-Hispanic White.73
Traditionally, dental care teams deliver services through the combined expertise,
knowledge and/or skills of dentists, dental hygienists and dental assistants. To address
access to care problems, workforce development also needs to focus on enhancing the
dental team. Issues requiring more effective and efficient dental teams to meet
workforce demands include:
● Efforts are needed to increase general dentists’ willingness to treat pregnant
women with confidence
 Low-income inner city and rural/frontier communities have the greatest dental
disease burden and experience greater dental workforce shortages. Can ref HPSA
data here to show maldistribution of existing dental providers
● More than 150,000 dental hygienists are licensed to practice in the U.S.73 Practice
laws in 30 states have increased direct access for dental hygienists to initiate
treatment based on assessment of a patient’s needs without the specific
authorization of a dentist, treat the patient without the presence of a dentist, and
can maintain a provider-patient relationship.76
4. Systems of Integration and Coordination
Integrating and coordinating perinatal oral health into
health systems that support the perinatal patient is
essential. Interaction with perinatal providers and
programs, and other public and private community
agencies is needed to ensure awareness of perinatal oral
health issues.65 The collective efforts of provider groups,
state/community program administrators, advocates for
mothers/children/families, and policymakers will be needed
to implement effective strategies and organized programs
and services at the state and local levels.
Systems of Integration
and Coordination
 Partnership with
perinatal providers
 State and local programs
for perinatal oral health
 Policy development
Partnership with Perinatal Providers
Since physicians, nurses, and allied health professionals are far more likely to see
perinatal patients than are dentists, they must be engaged as partners to advocate and
support perinatal oral health.
Partnership with health and perinatal providers can advance perinatal oral health by
assuring that:
● curricula of medical, nursing, and allied health professional programs include
training on perinatal oral health
● primary health care professionals who serve mothers ask about & access oral
health
● pregnant women receive oral health counseling and referral for a comprehensive
oral examination and treatment;
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●
●
Pregnant women have concerns regarding dental treatment answered & safety of
dental care is reinforced
Medical clearance for dental treatment is provided as needed
Federal, State and Local Programs for Early Childhood Oral Health
Organized efforts to promote perinatal oral health through state and local dental public
health programs can: (a) mobilize partners to integrate systems, avoid duplicating
services, and leverage resources, (b) provide statewide and/or local assessment of the
burden of disease, and (c) support a state and/or local strategic plan developed and
implemented by stakeholders and constituents.
State MCH programs (administered by state health agencies or statewide initiatives)
should have a focus on population-based and infrastructure-building strategies. These
strategies are necessary to understand and ensure that specific oral health needs of
perinatal patients are met.
● Devlop a state perinatal, infant, early childhood oral health taskforce;
● Implement a state needs assessment of perinatal and infant oral health access and
utilization;
● Educate partners, stakeholders, funders, legislature, and the public on early
childhood oral health issues and needs;
● Develop a strategic plan based on state findings and needs that establishes
specific goals, objectives, and activities with expected outcomes to improve the
oral health status and access to care for pregnant women and children;
● Develop policies, coordination of care, quality assurance, and standards of care;
● Promote public-private partnerships, and system integration and coordination;
● Integrate perinatal oral health into existing state improvement plans and
infrastructure;
● Develop guidelines and practice models for use by other maternal and child health
partners;
● Evaluate the effectiveness of state and local perinatal oral health programs.
Local programs for perinatal oral health (such as community-based programs
implemented by county/city health departments, health centers, community
organizations, faith-based organizations, and hospital systems) can provide a range of
services to mothers, children, families and communities. Dental preventive and
restorative services may be delivered through community-based clinics, portable dental
equipment, mobile dental vans, or contractual arrangements with dental service
providers. Oral health care services can be added to existing community-based health
care programs and centers.78 Local programs for perinatal oral health may include these
activities:
● Educate or counsel pregnant women
● Train perinatal health providers;
● Provide case management/care coordination, establish dental homes, or develop
health homes;
● Deliver preventive dental services (caries risk assessment, anticipatory guidance,
fluoride varnish applications, and saliva testing for levels of bacteria);
● Deliver restorative dental treatment services for pregnant women;
● Provide enabling services that include transportation, translation, and assistance
with enrollment in Medicaid;
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●
●
Support dental team enhancements and utilize technology (e.g., teledentistry) to
reduce barriers and increase access to care in underserved areas; and
Provide quality assurance of services and evaluate service programs.
Outcomes for state or local perinatal oral health programs should be tracked and
routinely assessed for improvement in knowledge, attitudes, behaviors, practices,
systems, and health status.
Short-Term Program Outcomes:
● Decision makers in the public and private sectors will make more informed
decisions on matters affecting the oral health and care of pregnant women,
new mothers, infants, toddlers, and preschoolers.
● Health and childcare providers, and parents and primary caregivers, have
gained knowledege of the importance of perinatal oral health.
● Broader interaction and collaboration will occur among multi-disciplinary
maternal and child health stakeholders to promote oral health.
Intermediate Program Outcomes:
● Policies will be developed and programs will be expanded based on a greater
understanding of maternal and early childhood oral health and access to care
issues.
● State and community public health officials will develop new and improved
programs (population-based and individual approaches) to delivering perinatal,
infant and early childhood oral health preventive and restorative services.
Long-Term Program Outcomes:
● Improved state and local perinatal programs, infrastructure and care systems.
● Improved capacity in the delivery of oral health care services for perinatal
women and young children.
● Improve oral health status of pregnant women, infants, toddlers and
preschoolers.
Policy Development
Oral health policy is needed to provide clear direction that will guide oral health practices
and actions. Oral health policy is comprised of the decisions that determine how issues
are addressed either by those elected or appointed to represent communal interests
(“public policy”) or those involved in the delivery of health services (“clinical policy”):79
● Public policy deals with issues related to allocation of shared resources (people,
programs and dollars) and the conditions under which those resources are
distributed and utilized. For example, public policies govern what benefits are
covered under various health programs; what types of health promotion, disease
prevention and treatment programs are available to a population; and what actions
should be taken to address access to care where service shortages exist.
● Clinical policy deals with issues of clinical care delivery. Typical issues include
what and when clinical services are to be provided under a benefit program and
how those services are delivered.
A wide range of policy-related issues impact perinatal oral health:79
● oral health and disease management (e.g., population-based interventions and oral
health disparities);
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●
●
●
●
●
dental care services (e.g., unmet needs, primary care, health care delivery system,
and public health programs);
dental care organization and financing (e.g., Medicaid, dental managed care, and
integrated service delivery);
workforce (e.g., dental/public health workforce capacity and mid-level providers);
case management and beneficiary services (e.g., care coordination and coverage);
family-centered care (e.g., cultural determinants of health and maternal oral health).
Opportunities exist to promote policies to improve perinatal oral health on federal, state,
and local levels. Initiatives could advocate increasing access to community water
fluoridation, establishing and/or expanding state surveillance for perinatal oral health,
and expanding community-based perinatal/early childhood preventive programs. The
2009 Children’s Health Insurance Program Reauthorization Act (CHIPRA) illustrates the
potential impact of policy. The new federal law reauthorizing CHIP seeks to improve
access to dental care and expands efforts to prevent dental disease through major
provisions such as a required program to educate new parents on ECC.
Legislators, policymakers, and third party payors should be educated about the benefits
of perinatal intervention in order to support efforts to improve oral health and access to
care for mothers and their children.59
F. Initiatives and Coordinated Efforts
(review if appropriate to perinatal oral health & if other initiatives/efforts exist)
1. Targeted Oral Health Services Systems (TOHSS) Grant Program
(would this include perinatal oral health?)
Health Resources and Services Administration (HRSA), Maternal and Child Health
Bureau’s TOHSS grant program supports states in expanding preventive and restorative
oral health service programs for Medicaid and CHIP eligible children, and other
underserved children and their families. Grantees are asked to develop state strategies
to make improvement within three program areas, which include increasing the number
of children receiving age one dental visits.
2. Oral Health Disparities Collaborative (OHDC) Pilot
HRSA, Bureau of Primary Health Care initiated the OHDC pilot to develop
“comprehensive primary oral health care system change interventions” (based on the
Chronic Care Model and evidence-based concepts) to improve ECC prevention and
treatment, and perinatal oral health in Health Centers. The Oral Health Disparities
Collaborative Implementation Manual was developed from the pilot to guide future
efforts.
3. The Children’s Dental Health Project Perinatal Initiative
(need a description of their perinatal initiative)
4. HRSA Maternal and Child Health Bureau
Consensus Conference on Perinatal Oral Health (2007) and follow-up (2008)
(describe these meetings and the outcomes)
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II. Guidelines & Recommendations from Authoritative Sources
(general review to see if other guidelines/recommendations exist)
A. New York State Department of Health – Oral Health During Pregnancy and Early
Childhood Practice Guidelines (August 2006)
In 2006, the New York State Department of Health convened an expert panel of health care
professionals to develop recommendations (published as the Guidelines) to bring about
changes in the health care delivery system and to improve the overall standard of care.
B. California Dental Association Foundation – Oral Health During Pregnancy and Early
Childhood: Evidence-Based Guidelines for Health Professionals (February 2010)
In 2009, California Dental Association Foundation convened an expert panel of medical and
dental professionals to provide practice guidelines, based on evidence and professional
consensus, on the importance of dental care to pregnant women and their young children.
C. Office of Surgeon General
Oral Health in America: A Report of the Surgeon General
The Surgeon General’s Report on Oral Health in America reported the following:
● Effective disease prevention measures exist for use by individuals, practitioners and
communities (most focus on dental caries prevention such as fluorides).
● Many community-based programs required a combined effort among social service,
health care, and education services at the state or local level.
● Primary prevention of dental disease is possible with appropriate diet, nutrition, oral
hygiene, and health-promoting behaviors, including the use of professional services.
National Call to Action to Promote Oral Health
The National Call to Action to Promote Oral Health calls for these actions to achieve the
goals of the Surgeon General and Healthy People 2010, include early childhood oral health:
● Change perceptions of oral health.
● Overcome barriers by replicating effective programs and proven efforts.
● Build the science base and accelerate science transfer.
● Increase oral health workforce diversity, capacity, and flexibility.
● Increase collaborations.
D. Healthy People 2010 – Oral Health
Healthy People 2010 Objectives promoting perinatal oral health include:
21-9. Increase the proportion of the U.S. population served by community water systems
with optimally fluoridated water.
21-10. Increase the proportion of children and adults who use the oral health care system.
E. Association of State & Territorial Dental Directors (ASTDD)
ASTDD promotes a governmental oral health presence in each state and territory, to
formulate and promote sound oral health policy, to increase awareness of oral health issues,
and to assist in the development of initiatives for prevention and control of oral diseases.
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Best Practice Approach: Perinatal Oral Health
13
●
●
Community Water Fluoridation Policy Statement – ASTDD fully supports and endorses
community water fluoridation in all public water systems throughout the U.S.
ASTDD is in the process of adopting a policy statement supporting the use of fluoride
varnish for individuals at moderate to high risk for tooth decay as an effective adjunct
in programs designed to reduce lifetime dental caries experience.
F. American Association of Public Health Dentistry (AAPHD)
AAPHD policies related to promoting perinatal oral health include:
● Policy Statement on Primary Care
● Policy on Access to Care
● Resolution on Fluoride Varnish for Caries Prevention
G. American Public Health Association (APHA)
APHA policy statements in support of perinatal oral health include:
● Community Water Fluoridation in the United States
I.
American Academy of Pediatrics (AAP)
The AAP policy statement on Oral Health Risk Assessment Timing and Establishment of the
Dental Home recommends:
● Health care professionals who serve mothers and infants should integrate parent and
caregiver education into their practices that instruct methods to prevent ECC.
J. American Dental Association (ADA)
ADA positions and statements include:
● ADA Supports Fluoridation
● ADA Statement on Water Fluoridation Efficacy and Safety
● ADA Statement on the Effectiveness of Community Water Fluoridation
K. American Academy of Family Physicians (AAFP)
AAFP has published anticipatory guidance for perinatal oral health:
● Oral Health During Pregnancy
L. American Academy of Periodontology (AAP)
The AAP Statement Regarding Periodontal Management of the Pregnant Women
encourages all women to attain good oral health prior to and throughout their pregnancies,
and encourages necessary treatment beginning early in and throughout the pregnancy.
III. Research Evidence
(review if existing reviews appropriate to perinatal oral health & if other newer reviews
exist)
The following major sources of evidence-based reviews contribute to the body of evidence on
perinatal oral health:
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Best Practice Approach: Perinatal Oral Health
14
1. The Agency for Healthcare Research and Quality (AHRQ)
● (need to do a search)
2. The National Institutes of Health convened the Consensus Development Conference on
Diagnosis and Management of Dental Caries Throughout Life in 2001. The Consensus
Development Conference Statement, resulting from the meeting reviews, provided guidance
on the best methods for detecting caries in early and advanced stages, indicators for
elevated risk, best methods for primary prevention of caries, the best treatments for
arresting or reversing early caries progression, and identified new directions for future
research.81
3. U.S. Preventive Services Task Force (USPSTF)
● (need to do a search)
4. The Cochrane Reviews explore the evidence for and against the effectiveness and
appropriateness of treatments to facilitate the choices that doctors, patients, policymakers
and others face in health care (published in The Cochrane Library).83 A selection of
Cochrane Oral Health Group Reviews relevant to perinatal oral health are highlighted below:
● (need to do a search)
5. The ADA Center for Evidence-Based Dentistry provides systematically assessed evidence
as tools and resources to support clinical decisions to integrate evidence into patient care:
● An expert panel established by the ADA Council on Scientific Affairs evaluated the
collective body of scientific evidence and provided evidence-based clinical
recommendations on the use of professionally applied topical fluoride (published in
May 2006).52
IV. Best Practice Criteria
The ASTDD Best Practices Project has selected five best practice criteria to guide state and
community oral health programs in developing their best practices. For these criteria, initial
review standards, are provided to help evaluate the strengths of a program or practice to
promote perinatal oral health.
1. Impact / Effectiveness
● A practice or program enhances the processes to improve oral health status and/or
improve access to dental care for pregnant women.
Example: Increased number of programs to train physicians, nurses, and
dentists to provide screening and preventive services for pregnant
women or increased number of providers being trained.
● A practice or program produces outcomes that improve oral health status and/or
improve access to dental care for pregnant women.
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Best Practice Approach: Perinatal Oral Health
15
Example: Reduced dental caries experience and untreated decay among
pregnant women, fewer emergency visits to the dentist, or fewer
hospital emergency room services for dental problems.
2. Efficiency
● A practice or program shows cost savings in preventing oral disease and reducing
the extent of treatment needs for pregnant women.
Example: Increased savings based on the comparison of the cost for delivering
in-office dental treatment compared to utilization of hospital
emergency rooms for dental related conditions.
● A practice or program shows leveraging of federal, state, and/or community
resources to improve the oral health of pregnant women.
Example: Expanded partnership between the public and private sectors to
support an oral health program for outreach, case management,
preventive services, and dental care for pregnant women.
3. Demonstrated Sustainability
● A practice or program that has demonstrated sustainability or has a plan to
maintain sustainability.
Example: A program that has served pregnant women for many years and
receives agency line-item funding and reimbursement from public and
private insurers.
4. Collaboration / Integration
● A practice or program establishes partnerships or collaborations that integrate oral
health efforts with other disciplines to improve the general health of pregnant
women.
Example: The state oral health and MCH programs working collaboratively to
improve systems of care (such as improving coordination between
medical and dental homes) and financing for oral health.
5. Objectives / Rationale
● A practice or program aligns its objectives with the national or state agenda to
improve the oral health and general health of pregnant women.
Example: Program objectives target Healthy People 2010 objectives to reduce
caries experience, untreated decay, and use of the oral health care
delivery system.
V. State Practice Examples
(have retained 2 examples from the ECC paper which also targeted pregnant women so
we already have 2 prelim submissions…but will need to solicit more)
The following practice examples illustrate various elements or dimensions of the best practice
approach. These reported success stories should be viewed in the context of the states and
program’s environment, infrastructure and resources. End-users are encouraged to review the
practice descriptions (click on the links of the practice names) and adapt ideas for a better fit to
their states and programs.
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Best Practice Approach: Perinatal Oral Health
16
A. Summary Listing of Practice Examples
Table 1 provides a listing of programs and activities submitted by states. Each practice name is
linked to a detailed description.
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Best Practice Approach: Perinatal Oral Health
17
Table 1.
State Practice Examples Promoting Perinatal Oral Health
#
Practice Name
State
Practice
CA
06003
CO & MT
99001
Oral Health Training for Health Professionals
1
<Need to search, identify and invite states to submit
descriptions of their successful perinatal OH practices.>
2
3
4
5
Primary Prevention
6
The Mother and Youth Access (MAYA) Project
7
Oral Health Disparities Collaborative
8
9
10
3. Care Coordination and Systems Integration
11
12
13
14
15
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Best Practice Approach: Perinatal Oral Health
18
B. Highlights of Practice Examples
Highlights of state practice examples are listed below.
<Need to search, identify and invite states to submit descriptions of their successful perinatal
OH practices.>
1. Oral Health Training for Health Professionals
<Add highlights from new submissions.>
2. Primary Prevention
<Add highlights from new submissions.>
CA
The Mother and Youth Access (MAYA) Project / Practice #06003
The MAYA Project, a randomized clinical trial, was designed to compare different
interventions to prevent dental caries: chlorhexidine rinses to reduce the number of
tooth decay causing bacteria, a fluoride varnish applications to increase enamel
remineralization, and parental oral health counseling to promote behavioral change.
CO & MT
Oral Health Disparities Collaborative / Practice #99001
The Oral Health Disparities Collaborative was launched in order to improve access to
oral health services for low-income children ages 0 to 5 and pregnant women. The
Collaborative used the Chronic Care Model as the framework for system redesign.
3. Care Coordination and Systems Integration
<Add highlights from new submissions.>
_____________________________________________________________________________________________
Best Practice Approach: Perinatal Oral Health
19
VI. Acknowledgements
This report is the result of efforts by the ASTDD Best Practices Committee to identify and
provide information on developing and successful practices that address the oral health care
needs of infants, toddlers and preschool children.
The ASTDD Best Practices Committee extends a special thank you to the ASTDD Perinatal and
Early Childhood Committee for their partnership in the preparation of this report.
This publication was supported by Cooperative Agreement U58DP001695 from CDC, Division
of Oral Health and by Cooperative Agreement U44MC00177 from HRSA, Maternal and Child
Health Bureau.
Suggested citation: Association of State and Territorial Dental Directors (ASTDD) Best Practices
Committee. Best practice approach: perinatal oral health [monograph on the Internet]. Sparks, NV:
Association of State and Territorial Dental Directors; 2012 Feb 1. ___ p. Available from:
http://www.astdd.org.
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Best Practice Approach: Perinatal Oral Health
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VII. Attachments
ATTACHMENT A
Strength of Evidence Supporting Best Practice Approaches
The ASTDD Best Practices Committee takes a broad view of evidence to support best practice
approaches for building effective state and community oral health programs. The Committee
evaluated evidence in four categories: research, expert opinion, field lessons and theoretical
rationale. Although all best practice approaches reported have a strong theoretical rationale, the
strength of evidence from research, expert opinion and field lessons fall within a spectrum. On
one end of the spectrum are promising best practice approaches, which may be supported by
little research, a beginning of agreement in expert opinion, and very few field lessons evaluating
effectiveness. On the other end of the spectrum are proven best practice approaches, ones that
are supported by strong research, extensive expert opinion from multiple authoritative sources,
and solid field lessons evaluating effectiveness.
Promising
Best Practice Approaches
Proven
Best Practice Approaches
Research
Expert Opinion
Field Lessons
Theoretical Rationale
Research
Expert Opinion
Field Lessons
Theoretical Rationale
+
+
+
+++
+++
+++
+++
+++
Research
+
++
+++
Expert Opinion
+
++
+++
Field Lessons
+
++
+++
A few studies in dental public health or other disciplines reporting effectiveness.
Descriptive review of scientific literature supporting effectiveness.
Systematic review of scientific literature supporting effectiveness.
An expert group or general professional opinion supporting the practice.
One authoritative source (such as a national organization or agency) supporting
the practice.
Multiple authoritative sources (including national organizations, agencies or
initiatives) supporting the practice.
Successes in state practices reported without evaluation documenting
effectiveness.
Evaluation by a few states separately documenting effectiveness.
Cluster evaluation of several states (group evaluation) documenting
effectiveness.
Theoretical Rationale
+++ Only practices which are linked by strong causal reasoning to the desired
outcome of improving oral health and total well-being of priority populations will
be reported on this website.
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Best Practice Approach: Perinatal Oral Health
21
ATTACHMENT B
Anticipatory Guidance
AAPD provides the following anticipatory guidance for mothers
(http://www.aapd.org/media/Policies_Guidelines/G_InfantOralHealthCare.pdf):
General anticipatory guidance for the mother (or other intimate caregiver) includes the following:
●
Oral hygiene: Tooth-brushing and flossing by the mother on a daily basis are important to help
dislodge food and reduce bacterial plaque levels.
●
Diet: Important components of dietary education for the parents include the cariogenicity of
certain foods and beverages, role of frequency of consumption of these substances, and the
demineralization/remineralization process.
●
Fluoride: Using a fluoridated toothpaste approved by the American Dental Association and rinsing
every night with an alcohol-free, over-the-counter mouth rinse containing 0.05% sodium fluoride
have been suggested to help reduce plaque levels and help enamel remineralization.
●
Caries removal: Routine professional dental care for the mothers can help keep their oral health
in optimal condition. Removal of active caries with subsequent restoration is important to
suppress maternal MS reservoirs and has the potential to minimize the transfer of MS to the
infant, thereby decreasing the infant's risk of developing early childhood caries (ECC).
●
Delay of colonization: Education of the parents, especially mothers, on avoiding saliva-sharing
behaviors (e.g., sharing spoons and other utensils, sharing cups, cleaning a dropped pacifier or
toy with their mouth) can help prevent early colonization of MS in their infants.
●
Xylitol chewing gums: Evidence demonstrates that mothers' use of xylitol chewing gum can
prevent dental caries in their children by prohibiting the transmission of MS.
Dental Home
An AAPD policy recognizes that a dental home should provide
(http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf):
● comprehensive oral health care including acute care and preventive services in accordance with
AAPD periodicity schedules;
● comprehensive assessment for oral diseases and conditions;
● individualized preventive dental health program based upon a caries-risk assessment (and a
periodontal disease risk assessment for older children);
● anticipatory guidance about growth and development issues (i.e., teething, digit or pacifier
habits);
● plan for acute dental trauma;
● information about proper care of the child’s teeth and gingivae (include the prevention, diagnosis,
and treatment of disease of the supporting and surrounding tissues and the maintenance of
health, function, and esthetics of those structures and tissues);
● dietary counseling;
● referrals to dental specialists when care cannot directly be provided within the dental home;
● education regarding future referral to a dentist knowledgeable and comfortable with adult oral
health issues for continuing oral health care; referral at an age determined by patient, parent, and
pediatric dentist.
_____________________________________________________________________________________________
Best Practice Approach: Perinatal Oral Health
22
ATTACHMENT C
Barriers to Reducing Disease and Achieving Optimal Perinatal Oral Health
(I did not change this since we may not need this as the CDA Guidelines has an
accompanying policy paper which goes into the barriers in detail!)
Young children experience barriers in attaining optimal oral health and barriers to accessing and utilizing
professional dental care. Developing solutions for young children to achieve optimal oral health
(particularly infants, toddlers and preschoolers at high risk to dental disease) will need to address the
following barriers.
Barriers to Attaining Oral Health During Early Childhood:
a. Failure to prevent, limit or delay the transmission of tooth decay causing bacteria as the first
primary teeth erupt.
As the first primary teeth erupt, the risk for early childhood caries (ECC) can be reduced by
preventing, limiting, or delaying the infection of tooth decay causing (cariogenic) bacteria.
Transmission, typically from mothers or primary caregivers to young children, has three
components which can be controlled: the bacteria in the mouth of the parent or caregiver, the
ways through which saliva carrying the bacteria are transmitted, and the child’s ability to retain
these bacteria in the mouth. Families with high caries experience (as observed with the mother or
older siblings), efforts to address transmission of the bacteria may have the greatest value.
Barriers to implementing the preventive strategy include:
● lack of public (and sometimes professional) knowledge of transmission as a risk factor;
● lack of well developed family-level risk assessment tools to identify and target at-risk
families;
● lack of evidence-based protocols of limiting bacterial transmission.
b. Poor dietary habits leading to frequent and high intake of sugar.
A young child’s risk for ECC increases with a high sugar diet and the frequent intake of sugar
throughout the day and night. The sugar feeds the tooth decay causing bacteria and high sugar
intake will stimulate and exacerbate the caries process (bacteria will multiply and more acid are
produced to damage the teeth).
Barriers to implementing the preventive strategy include:
● lack of public (and sometimes professional) knowledge about the impact of frequency of
sugar exposure to caries development;
● public acceptance of frequent use of sugar-containing foods and liquids to pacify a child
(e.g., dry snacks and sugar-laden liquids in bottles and sippy cups);
● some culture related feeding, eating and diet habits and practices;
● sleep-time offering of bottle containing liquids other than water during the day or night.
c.
Inadequate exposure to topical fluorides, especially for high-risk children and young children with
aggressive tooth decay.
The presence of frequent low-levels of topical fluorides will reduce acid production by the tooth
decay causing bacteria, disrupt dental plaque integrity (which allows the bacteria to colonize on
the teeth), stabilize the crystal structure of the tooth surface (the enamel), and promote
remineralization to re-harden the tooth surface damaged by acid.
Barriers to implementing the preventive strategy include:
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Best Practice Approach: Perinatal Oral Health
23
●
●
●
concern about potential fluorosis of the permanent teeth (a problem caused by excessive
or protracted ingestion of fluorine causing a mottled appearance of the teeth and in
extreme cases, pitting in the teeth);
lack of public awareness and understanding about the proper use of fluoridated
toothpaste in young children;
lack of low-dose fluoride toothpaste products in the United States appropriate for young
children.
d. Common failure to detect tooth decay early in a child’s life and before the disease process
progress and lead to cavities in the teeth.
For toddlers and preschoolers, dental pain and infection often follow quickly after the appearance
of cavities in the teeth. These signs and symptoms require a dental visit that typically results in
extensive treatment for the young child (e.g., fillings, pulp therapy for the nerve of the tooth,
crowns, extractions and/or antibiotic treatment). However, early signs of tooth decay could be
used by informed parents, caregivers, day-care staff, and medical providers who are in regular
contact with young children. “White spots” or streaks, particularly along the gumline of the upper
front teeth, are signs of the damage by acid produced by bacteria (decalcification of the tooth
surface). Another early sign include children having thick and soft dental plaque along the
gumline of the upper front teeth. When a toothpick is touched to this plaque and lifted from the
surface, it produces a glutinous strand which has high level of tooth decay causing bacteria and is
diagnostic for ECC. Assessment of he level of tooth decay causing bacteria can be made by
collecting saliva on a sterile tongue blade by pressing it onto the child’s tongue and transferring
the saliva to a culturing media.
Barriers to implementing the preventive strategy include:
● lack of knowledge by the public and people who come in contact with young children
about the early signs of this disease;
● lack of access to oral health professionals who can work with families to suppress caries
activity once identified.
● families may be unaware of the need for early and regular oral health care.
e. Cultural, social and economic influences on oral health such as dietary practices, home care and
beliefs about the primary teeth.
The importance placed on oral health can vary due to cultural, social, and economic factors.
Dietary practices specific to certain cultures may post a risk to early onset of tooth decay, while
other social and economic factors may discourage certain populations from seeking regular
professional dental care. Families who do not place value on the first set of primary teeth may not
be as concerned about tooth decay in those teeth.
Barriers Related to Access and Utilization of Professional Dental Care:
a. Lack of dental insurance.
At least 23 million children in the United States lack dental insurance coverage. Children who
lacked dental insurance are less likely to have received preventive care and more likely to have
unmet need for care.28 In 2006, one in five children had no dental coverage during the year.29
Medicaid and Children’s Health Insurance Program (CHIP), the nation’s safety-net health
insurance programs, are a major source of coverage for children in the United States. In 2006,
among low income children in the U.S., more than two-thirds (69 percent) received dental
coverage through Medicaid and CHIP during at least part of the past year, 16 percent had private
dental insurance, and 15 percent had no dental insurance coverage.29 In the absence of Medicaid
and CHIP, most children covered by these programs would be uninsured. Children enrolled in
Medicaid and CHIP have better access to dental care than uninsured children. In 2006, 73
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Best Practice Approach: Perinatal Oral Health
24
percent of children age 2-17 with public coverage had a dental visit in the past year, compared
with 48 percent of uninsured children.30 The one-quarter of publicly insured children who had no
dental visit in the past year indicates a substantial gap in dental access.
In the majority of cases, the people who are enrolled in Medicaid programs can locate and utilize
the services that they need. This is not true with for dental services. Even though states are
required to provide dental care to Medicaid-enrolled children, only one in three of these children
utilized dental services in 2006.31
b. Lack of dentist participation in Medicaid.
Dentists’ participation in Medicaid is limited. In a 1999 survey of Medicaid directors, 23 of 39
states that responded revealed that less than half of dentists in their state saw at least one
Medicaid patient that year, and only five reported 25 percent or more saw a minimum of 100
Medicaid patients (which represented roughly 10 percent of the typical dentist’s patient load in a
year).32 Dentists cited reimbursement rates, cumbersome administrative procedures and a high
proportion of “no shows” for appointments as the primary reasons for not participating in the
Medicaid program.32
c.
An insufficient number of pediatric dentists to care for young children with severe needs.
There is also an insufficient number of pediatric dentists available to care for the young children in
the United States. In 2008, there are 233,104 dentists in the United States and only 6,087 are
pediatric dentists.33 The majority of practicing dentists are general dentists; however, with minimal
training in the care of young children, the lack of general dentists treating young children also
contributes to the shortage of dental providers willing to treat infants, toddlers and preschoolers.
d. Need to enhance the dental care team with new types of dental professionals.
Traditional dental care teams are form to deliver services through the combined expertise,
knowledge and/or skills of dentists, dental hygienists and dental assistants. In creating solution to
address access to care problems, enhancing the dental care team has become a focus. Current
efforts to develop new types of dental professionals in the United States include:34-36 (a) the
Alaska Native Tribal Health Consortium, in partnership with the University of Washington School
of Medicine's MEDEX program, trains dental therapists to deliver community level dental disease
prevention for the underserved Alaska Native populations; (b) the American Dental Association is
developing a new member of the oral health team called the Community Dental Health
Coordinator (CDHC) who will be responsible for promoting oral health through organized and
dentally coordinated community-based promotion and prevention programs; and (c) the American
Dental Hygienists Association has been working to develop a mid-level professional with a much
broader range of duties than a dental therapist called the Advanced Dental Hygiene Practitioner
(ADHP).
e. Limited dental safety net services, capacity and infrastructure.
Low-income families who cannot find and/or afford a private practice dentist to treat their children
often turn to safety net providers. Dental care traditionally has not been a core focus of general
safety net providers (e.g., public and not-for-profit hospitals, community health centers, free
clinics and local health departments). The availability of safety net dental services is typically far
less extensive than the safety net medical services. States and communities often report that
dental safety capacity is limited and does not meet demand for dental care.
Efforts are invested to build and expand the public dental health infrastructure (consists of
systems, people, relationships and resources) to promote the oral health of young children. This
includes increasing the capacity to deliver dental safety net capacity services for vulnerable
communities, families and children. However, such infrastructure remains inadequate in some
states and communities.
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Best Practice Approach: Perinatal Oral Health
25
There is a continued need to strengthen the infrastructure to support community-based efforts to
prevent and manage dental disease (e.g., expanding school-based/school-linked sealant and
fluoride varnish/rinse programs); increase safety-net services for young children (e.g., Community
Health Centers and local health departments); and assure state oral health leadership. State oral
health leadership for a range of services including assessment and surveillance of the dental
workforce, developing a state oral health plan to establish goals and strategies to reduce the
burden of dental disease and improve access to care, and mobilizing stakeholders and partners
through a state oral health coalition to take action.
f.
Lack of evidence-based widely-accepted protocols for dental care of young children.
While the American Academy of Pediatric Dentistry has provided leadership in establishing
guidelines for early childhood oral health care, research is needed to build the evidence needed
to provide well-tested protocols for risk assessment, disease management protocols and criteria
for follow up care.
g. Lack of financing that supports disease management.
Dental spending in the United States typically pays for preventive and restorative dental care. In
2009, dental spending will exceed $100 billion. The projected 2 percent increase in the nation’s
Dental Services Expenditures from $99.9 billion in 2008 to $101.9 billion would be the lowest
annual increase in dental spending since 1960.37 For 2009, the National Health Expenditure will
be $2.5 trillion, consuming 17.6% of the nation’s Gross Domestic Product; Dental Services
Expenditures represent only four percent of the National Health expenditure.38
For 2009 Dental Services Expenditures, Out of Pocket Payments will total $44.0 billion, Private
Insurance Payments $50.2 billion, and Public Insurance Payments $7.7 billion. Public Insurance
Payments include Federal $4.6 billion, State & Local $3.0 billion, Medicare $0.2 billion, and
Medicaid $6.5 billion.38 Average 2009 Dental Services Expenses Per Capita is $331, which
includes Out of Pocket Payments $141, Private Insurance Payments $163, and Public Insurance
Payments $25.
Finance is needed to support dental disease management that include additional protocols (e.g.,
motivational counseling, risk assessment, etc.) to prevent and control ECC. Insurance coverage
for the adult parent/caregiver is also critical in the disease management of ECC (to limit
transmitting tooth decay causing bacteria to the child).
h. Low value/priority placed on regular dental visits for preventive care.
Even if a child has dental insurance, if there is low priority attached to regular preventive dental
care, the child may only see a dentist if there is an obvious dental problem.
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Best Practice Approach: Perinatal Oral Health
26
VIII. References
<Have the full list of citations. Did not include the list for now just to keep the work file
shorter.>
_____________________________________________________________________________________________
Best Practice Approach: Perinatal Oral Health
27