Early Childhood Cavity Prevention Program in Klamath County

State: OR Type: Model Practice Year: 2007

The Early Childhood Cavity (ECC) Prevention Program in Klamath County targets Medicaid women enrolled in the WIC program and their children from birth and up to the age of 5 years. Dental caries in infants and children are a preventable, highly contagious, communicable disease that is spread from mothers to their infants. The goal of the program is to decrease incidence of cavities in two-year-olds. The program's objectives include: To educate pregnant women regarding dental health during pregnancy and its effect on the baby after birth. To establish a dental home for pregnant women and their soon-to-be-born infants, from birth. To provide oral health education and assistance to pregnant women, mothers / caregivers that result in infants receiving dental care by their first birthday. Continue to provide reinforcement of good oral hygiene and dental practices in children up to the age of three years. Outcomes of the program include: Women regularly informed of their eligibility to the program and the benefits to mother and baby; 80% of enrollees followed through on one-on-one education. 69% of women received dental care during pregnancy however continued care was unlikely as they had no insurance after the pregnancy. Very satisfactory paradigm shift with routine dental care being provided to pregnant women at their dental home without incurring problems in finding dental care providers. Access to dental care to infants on the eruption of the infant’s first tooth or at the first birthday and thereafter, becoming norm practice for mother’s in the program and participating dental care providers. All infants who completed the program were cavity free at two years old. Data are still being collected on infants as they complete the program (2 years of age) and thereafter, through state records until three years old.
Data have shown that lack of access to dental care and poor oral health results in an increase in contagious oral health disease. The ECC Program in Klamath County addresses the problem of cavities developing in first teeth with only between 0.64 (2001) – 1.2% (2003) of OHP children under 2 years old receiving dental care. Between 19 – 28% (2001 – 2003) of pregnant women on Medicaid received dental care. Familiarizing women with accessing dental care for themselves and their child in a non-threatening place such as the WIC clinic, resulted in increased knowledge of dental treatment during pregnancy, practical skills in oral health care for both the mother and child and support to access dental care which will decrease the incidence of cavities in women, and intimately in infants being infected by contagious oral disease from the mothers. Surveys conducted locally by the Oregon Institute of Technology School of Nursing and United Way, and through a survey conducted in 2001 in the local farming community after the water crisis, indicated that dental health care was an important unmet health care need. The ECC Program approached a common public health disease in a non-traditional way by addressing the disconnect between medical and dental providers and worked towards a paradigm shift that encouraged dental care as a primary, rather than a tertiary prevention treatment, for pregnant women and their infants. By minimizing the contractibility of the disease in the infant’s first teeth, the growing child is less likely to develop cavities. This population is at risk for less than optimal medical /dental care and according to poor children have nearly 12 times more restricted-activity days because of dental-related illness than children from higher income families. Pain and suffering due to untreated tooth decay can lead to problems eating, speaking, and attending to learn. When the program was instituted as a research project, women at 185% of the poverty level were not receiving dental care routinely however this population was accessible through the WIC program where they obtained their food vouchers and were required to receive health education on a regular basis. Dovetailing the ECC program with the WIC program resulted in compliance with the treatment plan and successful outcomes. The key preventive messages received by women through the program and from dental and medical health care providers, the convenience of appointments and the trusted service provided by WIC staff, were and are an important aspect to the continued success of the project, as was recognized at the Oral Health Readiness for School Convention held in Washington DC, fall 2006. This practice addresses women who are at high risk and without the skills to access dental care during their pregnancy. Women who already have a dental home receive treatment prior to pregnancy and are therefore less at risk and not eligible to participate in the ECC program. The simple preventive message was repeated by medical, dental and WIC staff, resulting in women’s compliance at a critical time in their life (pregnancy) and in their infants' earliest years.
Agency Community RolesThe LHD initiated the project by obtaining funding from the Robert Wood Johnson Foundation and hiring a Coordinator who was a dental hygienist. The program evolved to where WIC provides the site and the instruction and the LHD and North-west Dental Care Organization pays the Coordinator’s salary. The Coordinator is the program resource for the WIC staff, the dental care providers and the clients. The partners in the planning and implementation of the practice were, and remain on the ECCP Community Coalition Committee which meets every 3 months to maintain the program and avert problems. Representation for the dental practitioners is made through the Dental Managed Care Director. The LHD facilitates the ECCP Community Coalition Committee, the key to maintaining the goals of the program, in association with the Coordinator. The LHD prioritizes preventive medicine which describes the message of the ECC program. Costs and ExpendituresFunding sources for the ECC program include: Robert Wood Johnson Foundation for duration of the study. WIC program funding as ECC Program has been successfully integrated into the WIC program. In-kind support: Dental Managed Care Director. Funding was provided initially by a Robert Wood Johnson Foundation grant. The program has developed so that initial funding would be needed for: P/T Program Coordinator who may be a dental hygienist, Public Health Nurse, “Babies First” RN, Case Manager RN for program development, coordination and case management, referred to as “Coordinator” in this document. One-on-one instruction by Dental Hygienist employed by Public Health General Fund, NW Dental Practice and Private/Public matched dollars. Tool kits provided to women to infants at 6 wks, 6 months and 1 year containing: toothbrushes, toothpaste and other items. Nutrition instruction provided by WIC staff. (Optional) Dental Hygiene students providing dental care to women in the program. ImplementationProgram implementation included: The ECCP Community Coalition planning committee consisted minimally of the Dental and Medical Managed Care Directors, the Coordinator, WIC Manager and participating WIC staff, a Representative from Public Health, Oregon Institute of Technology Department of Dental Hygiene; Headstart representative and community dental and medical partners. Estimated time frame (ETF): monthly for up to 6 months planning, decreasing to meet every three to six months after the successful implementation. The Internal ECCP Team consisted of in-house participating persons to deal with day-to-day problems. ETF: Initially meeting weekly after the start of the program, gradually reducing frequency to monthly and thereafter quarterly. Education of obstetricians and dental care providers, dental office staff. ETF: One week preparation for evening start-up presentation for medical and dental providers. WIC staff: three one-hour training sessions given during the work day by the Coordinator regarding education given to women at the distribution of Tool Kits. ETF: three hours. The patient population was already in the system so that no time was invested in accessing clients for the program. ETF: no extra time. From first committee meeting to first client: ETF: approximately 6 months. Staff included: 1.) Dental Managed Care Director or other Dental Professional with drive to initiate, promote and then support the program within the dental and medical community and educate providers unaware of the need to provide dental care to pregnant women and young mothers attending WIC and to work with the Dental Hygiene school if this option was available. 2.) Coordinator: oversees program at client level, good organizational, case management and social skills essential.3.) WIC Manager and staff supporting the program and willing to collaborate with the Coordinator to make the program fit the individual location. The ECCP educational component is part of the required classes provided by the WIC staff in order for the women to receive WIC vouchers. Instruction is provided to the women every two weeks, or once a month, depending on the size of the WIC population. Supplies: The Dental Kits are distributed at 6 weeks, 6 months and 12 month appointment at the WIC clinic. These are an essential component of a successful program. The kits contain: Educational Brochures: Healthy Mouth for your Baby; Prevention of Baby Bottle Tooth Decay; Kick the Bottle Habit, and educational inserts; Dental Supplies for mother and baby: Infant/toddler safety toothbrushes, children’s and adult toothbrushes, dental floss, adult tooth paste and child’s with fluoride toothpaste; Useful / Fun gifts: Sippy cup, teddy bear, stickers etc. Data Collection: Data were obtained by the Coordinator and from Oregon State Medicaid data of dental care provided to pregnant women and infants up to the age of 3 years.  
Objective 1: To educate pregnant women regarding dental health during pregnancy and its effect on the baby after birth.  Performance Measures: 1) Program dynamics presented to all eligible women at WIC clinic; 2) participating pregnant women receive prenatal, one-on-one dental education for mother and baby when baby is 6wks, 6 months and 1 year of age. Outcome: 80% of enrollees received prenatal anticipatory guidance; Data indicates that women are regularly receiving dental education at WIC which contain the same message as that being promoted by medical and dental care providers; the improved dental health is expected to have long term effects. Objective 2: To establish a dental home for pregnant women before 32 weeks gestation, and for their soon-to-be-born infants, from birth.  Performance Measures: 1)Community collaboration to ensure agreement between dental and medical providers on proposed model practices; 2) Liaison services for dental providers for pregnant women with Medicaid coverage; 3) Case management to a) Access a dental home; b) Obtain appropriate, timely, dental treatment (extractions, fillings etc.) to reduce / eliminate dental disease and cleaning to reduce gum disease, up to time of delivery; c) ensure patient compliance at dental office. Outcome: 69% participating women received dental care however continued dental care is unlikely as many women have no insurance after their pregnancy; huge paradigm shift as dental care during pregnancy was previously not encouraged; emergency dental care only was given; recognition of dental care message in medical / dental community produced a paradigm shift resulting in pregnant women being able to access dental care during pregnancy, much easier. Objective 3:To provide oral health education and assistance to pregnant women, mothers / caregivers that result in infants receiving dental care by their first birthday. Performance Measures: In the first year of life: 1) Education provided at 6wk, 6 mo and 1 yr of age and to include the application of fluoride toothpaste to infants’ gums, prior to and during eruption of teeth, “spit but don’t rinse”; at bedtime. 2) Case management services: a) assistance with scheduling baby’s 1st dental appointment; b) Every 6 months thereafter for appointments which include screening and treatment upon evidence of dental lesions.  Outcome: With the education of dental and medical health care providers, dental care for infants by the age of one year is much easier to access. All infants reaching their 2nd birthdays and completing the study were found to be 100% cavity free; data continues to be collected.
SustainabilityThe dental care providers are committed to the ECCP because it provides education and dental treatment to children in infancy and early childhood so that dentists can provide basic, preventative dental care to infants and young children that obviate the referral of young clients to pediatric dentists for expensive dental procedures that would otherwise use Medicaid dental dollars. The project lays the foundation for more, less expensive dental care owing to clients’ better dental health which results in funds for more clients to use in basic dental care. Without having to fund expensive dental procedures, the profit margins for the providers are increased.Funding through WIC is constant and provides education to the women but the outlay on the Tool Kits, although not hugely significant, will be an on-going cost that may be funded through grants, or donations from participating dental practices or manufacturers / retailers of dental products. Lessons LearnedLessons learned include: Population mobility made maintaining contact difficult. Modifications: With ECCP incorporated into WIC, contact improved as women were required to come every 3 months for supplemental food vouchers. Participants feared seeking dental treatment; Modifications: education by familiar WIC staff and support provided by the Coordinator assisted women in dealing with their anxieties; familiarity with dental care decreased fears. Participants had difficult time understanding preventative dentistry and the need for dental treatment; Modifications: 1) grand rounds provided to community physicians helped them embrace new ideas and encouraged pregnant women to seek dental care; 2) increasing education on preventative dental care through case management.