Spotlight on Child Health Issues:
Oral Health & Medical Home
Oral health care can no longer be separated from the rest of body. Having good oral health is key to optimal general health. Primary care pediatricians who provide a medical home to their patients are in a unique position to influence the overall health of their patients by providing preventive oral health care. This care may include an oral health risk assessment; anticipatory guidance and counseling about oral hygiene and nutrition; fluoride varnish application for children at high risk of developing caries; and a referral to a dental home.
Why is this important?
- Early childhood caries (cavities) is the number 1 chronic disease affecting young children.
- Early childhood caries is 5 times more common than asthma and 7 times more common than hay fever.
- Tooth pain keeps many children home from school or distracted from learning.
- Children are recommended to have their first dental visit by age 1 by the American Academy of Pediatric Dentistry and the American Academy of Pediatrics.
An effective medical home does not stand alone but functions in collaboration with a child's dental home. This requires that pediatricians and dentists know each other and work together to address the oral health and overall health of their child patients. Incorporation of an oral health risk assessment into well-child visits takes a few extra minutes and gives pediatricians the information they need to discuss dietary and behavioral factors that contribute to caries risk.—Rebecca L Slayton, DDS, PhD, AAP Section on Oral Health Executive Committee member.
Pediatricians can provide preventive oral health care within the medical home for patients who have trouble accessing oral health care. Coordinating care with the dental home will ensure that patients receive optimal preventive oral health care and, when needed, treatment services.
Medical home involvement in patient oral health care is especially important for those with special health care needs.
Oral health is a frequently unmet need in children who have special health care needs. These children are at increased risk for oral health problems including dental caries and oral infections. For some children with special health care needs, their oral health problems contribute to the social exclusion that they already experience. In other children, the consequences of poor oral health can be as serious as feeding problems and malnutrition. An effective medical home should recognize the importance of oral health in children with special health care needs, and partner with the child's dental home to insure their optimal oral health.—Kenneth W Norwood Jr, MD, FAAP, AAP Council on Children with Disabilities Executive Committee member.
Attention to the comprehensive oral health care is an important aspect of overall health across the lifespan.
Note: Drs Norwood and Slayton are currently developing a clinical report that will address oral health needs of children with disabilities in the pediatric practice. The report is scheduled for publication in late 2012.
(Back to Top)
Alabama Oral Health Initiatives
The Alabama Chapter of the American Academy of Pediatrics (AAP) has several providers trained to provide oral health services in the pediatric setting. This includes oral health risk assessment, an oral exam, anticipatory guidance, and fluoride varnish application when needed. Large areas of the state have been identified as underserved for oral health, as well as general pediatric care. To address this problem, the Alabama Chapter is utilizing oral health data about services provided by the community to address health profession shortage areas. Counties with no oral health services have been identified by the Alabama Chapter, which is working to improve the level of care in the areas identified through provider messaging and training about oral health risk assessment, fluoride varnish, and payment from state Medicaid and SCHIP. Additionally, the Alabama Chapter Pediatric Council is working on advocacy with private payers to pay for oral health risk assessment and fluoride varnish in the pediatric setting.
Through these ongoing efforts, the Alabama Chapter has been raising awareness about the importance of good oral health and access to a medical home for all children and youth in the state. For additional information about these initiatives, click here.
Colorado Cavity Free at Three Program
The Cavity Free at Three Program is an effort to prevent early childhood caries in young children. The effort aims to engage medical and dental providers and early childhood educators in the prevention and early detection of oral disease in pregnant women, infants and toddlers. One of the program’s main strategies includes the provision of basic preventive dental care by medical providers, such as oral health instruction and fluoride varnish application, in the medical home.home. This strategy takes advantage of the many visits that children have with their pediatric provider by age three. The program has trained over 1,400 providers on the prevention of ECC and has developed many useful tools, including oral health educational materials in nine languages, a Caries Risk Assessment Tool, and a Caregiver Goal Setting Tool. For more information, visit www.cavityfreeatthree.org/ or contact Patricia.braun@dhha.org.
Early childhood caries (ECC), commonly known as tooth decay, is defined as dental caries in the primary teeth of children. Although largely preventable, dental caries remains the single most common chronic disease of childhood and large disparities exist. Poor children have more than twice the rate of dental caries as non-poor children. The AAP and American Academy of Pediatric Dentistry (AAPD) both recommend that a child receive primary preventive dental care through an Age One Dental Visit; however, very few children < 3 years of age have ever seen a dental provider.
The Cavity Free at Three Program receives support from multiple foundations including the Caring for Colorado Foundation, Colorado Health Foundation, Colorado Trust, Colorado Delta Dental Foundation, Kaiser Foundation and Rose Foundation.
Illinois Bright Smiles from Birth: Intergrading Oral Health into Medical Homes
Bright Smiles from Birth (BSFB) aims to educate primary care providers on oral health in young children including application of fluoride varnish. Developed by the Illinois Chapter, American Academy of Pediatrics (ICAAP), the Illinois Society of Pediatric Dentists and the University of Illinois at Chicago School of Dentistry, BSFB teaches pediatricians about the pathogenesis of early childhood caries and provides information on prevention through application of fluoride varnish and anticipatory guidance. Local dentists are trained to present the program in pediatric primary care offices throughout Illinois.
In 2009, BSFB expanded its focus to include oral health of children with special healthcare needs (CSHCN). With funding from the Illinois Children’s Healthcare Foundation, the Illinois Department of Healthcare and Family Services and the Illinois Department of Public Health, BSFB enhanced its curriculum to include additional information on the oral health of CSHCN and target trainings to providers who treat CSHCN. These clinics received additional materials such as mouth rests that assist with opening a child’s mouth for treatment. Currently ICAAP is updating its website to include links to additional resources for CSHCN and developing policy recommendations on improving the oral healthcare of CSHCN. For resources and training visit www.illinoisaap.org/projects/bright-smiles.
Kansas Cavity Free Kids Program
Cavity Free Kids (CFK) is a free educational program for physicians and nurses on the importance of oral health and the application of fluoride varnish for children ages 0-3 years. The program provides education and training during the lunch hour, free toolkits including tooth brushes and fluoride varnish, AAP oral health flip chart, Medicaid reimbursement information, and offers Continuing Education Credit for physicians and nurses. Participants have found that it is easy to incorporate fluoride varnish into the well child checkup.
In practice, Sara Nelson, MD, FAAP, Program Director of CFK and AAP Chapter Oral Health Advocate (COHA) for Kansas, discusses oral health and fluoride varnish while examining children's teeth. If the parents are interested in having the varnish applied, Dr Nelson either conducts the process at the end of the visit or has a nurse apply it when they are giving vaccinations. Dr Nelson has found that parents are always grateful that we are interested in preserving their child's beautiful smile!
If you see Kansas Medicaid children in your office and would like to learn how to define early childhood carries (ECC), risks of ECC, recognize ECC in its various stages, implement prevention of ECC, perform knee-to-knee oral screenings, and discuss the use of fluoride varnish in pediatric patients,. For additional information, visit www.kansasaap.org or contact Leslie Sherman at leslie.sherman@kansasaap.org or Dr Nelson at saranelsonmd@gmail.com.
Pennsylvania Oral Health Initiatives
The state of Pennsylvania (PA) has trained two AAP Chapter Oral Health Advocates (COHA). Once trained, COHA are asked to deliver at least 4 trainings annually on how to incorporate oral health into the medical home, advocate for children’s oral health issues at the state and local levels, serve as an access point for others working in their community on improving children’s oral health through pediatric involvement, and build relationships with dental colleagues in their communities and dental societies to improve access to oral health care.
Additionally, the Pennsylvania Chapter of the American Academy of Pediatrics (PAAAP) has received funding from the US National Oral Health Alliance Oral Health 2014 Initiative for a planning year for a project—Healthy Teeth, Healthy Children, Pennsylvania: A Medical/Dental Collaborative. The project will work in collaboration with the PA Medical Home Project, PA Association of Pediatric Dentists, PA Dental Association, PA Medicaid medical director, PA Medicaid dental director, Head Start, Early Childhood Education (ECELS), PA Collaborative for Oral HealthHealth, Lehigh Valley Oral Health Collaborative, the Medical and Dental Schools and residency programs in the state, and others.
The overarching goal of the project is to increase access to dental care for young children and adolescents and improve oral health literacy for families across the state. This will be accomplished through:
- Using the Educating Physicians in Their Community (EPIC) model to create a curriculum.
- Training trainers to teach practices, medical school students, pediatric and family practice residents the importance of oral health to physical health, examination of the teeth, oral health risk assessment, family education, fluoride varnish application, and referral to and collaboration with local dentists.
- Working with Head Start, Early Childhood Educators, and WIC programs to find family friendly educational materials for physicians and other professionals serving children birth to 5 years old in PA.
- Developing creative ways to help families access oral health care for their children.
- Incorporating oral health principles into medical homes across the state.
For additional information about the oral health initiatives in Pennsylvania, contact Eve J. Kimball, MD, FAAP at ekimball@aacpp.com. Information on these efforts will be posted on the PA AAP Web site by mid-2012.
Utah Clinic Finds Small Efforts Go a Long Way in the Oral Health of Patients
The physicians and staff at the Intermountain Sandy Clinic in Utah meet as a team on a monthly basis to discuss and implement practices and procedures that benefit their pediatric patients and their families. Projects that have been addressed by the clinic include ADHD, asthma, childhood obesity, and oral health assessment. Oral health has received recent attention as all of the clinic’s practitioners have been trained in taking an oral health history and applying fluoride varnish. Despite practicing in an area that has many pediatric dentists that care for children who receive services through Medicaid, Utah state statistics show that children in the state with Medicaid have twice as much dental disease as the general population.
The clinic has been able to treat patients who have public insurance within the clinic with fluoride varnish during well checks. Medicaid reimburses this procedure—for children under 4—so both the patients’ parents and the clinic staff are happy to have these services provided by the child’s primary care provider. The clinic has found that a simple step that has helped to facilitate this process is having the fluoride varnish material prepared and placed in the exam room for the physician prior to a visit. This extra step has ensured that it takes additional time to apply the varnish to the patient’s teeth at the conclusion of a physical exam, making it a routine part of the care provided within a patient’s medical home. For additional information about the oral health efforts at the Intermountain Sandy Clinic, contact Mark Valentine, MD, FAAP, at mark.valentine@imail.org.
(Back to Top)
Through the medical home model, a pediatrician and the entire practice team provide patient- and family-centered care through a trusting, collaborative, working partnership with families, respecting their diversity, and recognizing that they are the constant in a child’s life. The following resources are examples of ways to communicate the value of good oral health and the importance of every child and youth having access to a medical home.
HealthyChildren.org
HealthyChildren.org is the official Web site for parents from the AAP. It is the only parenting Web site backed by 60,000 pediatricians committed to the attainment of optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.
Bright Futures Theme Sheet—Oral Health 
This informative 1-pager for families on oral health provides a description of oral health, how oral health relates to the child and family, how oral health relates to different ages and stages, and what families can do to promote healthy development as part of oral health; it also includes additional resources.
Medical Home Fact Sheets in English and Spanish
National Center for Medical Home Implementation (NCMHI)
These fact sheets are for providers, parents, and children/youth to communicate the importance of every child and youth having a medical home. These resources are designed to be used by providers with patients to facilitate discussion around the development of ongoing partnerships within the medical home for all patients and their families. The fact sheets for parents and children/youth are also available in Spanish.
(Back to Top)
The American Academy of Pediatrics (AAP) and other organizations have developed tools and resources focused on integration of oral health in the medical home and to enhance communication between primary care providers and dental professionals.
AAP Resources
Pediatric Oral Health and Health IT Toolbox
Health Resources & Services Administration
Information, tools, and resources that illustrate the importance of pediatric oral health, how stakeholders can impact oral health, and how health IT can facilitate the delivery of high quality oral health care.
New Brief on Opportunities for Collaboration between State Oral Health and MCH Programs to Improve Early Childhood Oral Health
Association of Maternal and Child Health Programs (AMCHP) and the Association of State and Territorial Dental Directors
This issue brief describes strategies to improve oral health within maternal and child health (MCH) populations by better integrating oral health activities and information into state early childhood MCH programs. Successful state examples are included.
Oral Health Program Fact Sheets
University of Washington School of Dentistry and Washington State Department of Health
These oral health fact sheets are available for parents, caregivers, and providers to facilitate dental treatment to children with special health needs that impact delivery of care.
The State of Children’s Dental Health: Making Coverage Matter
Pew Center on the States
This report reviews progress since 2010 on policy benchmarks to meet the dental care needs of children.
Opportunities in Health Care Reform: Addressing the Oral Health of Children with Special Health Care Needs
National Maternal and Child Oral Health Policy Center and the Association of State and Territorial Dental Directors
This issue brief looks at provisions in the Patient Protection and Affordable Care Act as opportunities to address the oral health of children with special health care needs. Specific topics included in the brief are: barriers to care; coverage and benefits; and new or additional points of access including school-based health centers, home visiting programs, professional training, access to diagnostic equipment, and public-health-education campaigns.
Oral Health for Infants, Children, Adolescents, and Pregnant Women—MCH Knowledge Path
The Maternal & Child Health Library at Georgetown University
This site includes current, high quality resources that analyze data, describe effective programs, and report on policy and research intended to improve access to oral health care and quality of oral health for infants, children, adolescent, and pregnant women.
TRENDNOTES—Children’s Oral Health in the Health Home
National Maternal and Child Oral Health Policy Center
This publication discusses the overall importance of a patient-centered health home that includes medical, dental and mental health care to improving children’s health and explores key considerations related to integrating dental care with medical care. Additionally, it discusses federal opportunities, particularly those under the Accountable Care Act (ACA), to promoting a health home for children and their families.
(Back to Top)
