Integrating Oral Health into Pediatric Primary Care

1. Integrating Oral Health into Pediatric Primary Care Alison Days, MD, MPH TxOHC Oral Health Summit Dec. 2, 2011

2. Objectives • Observe a pediatrician’s view of oral health • Learn how to incorporate dental education into a quick childhood visit • Learn how dental decay and/or dental abnormalities impact pediatric care

3. Why I decided to enter the world of oral health • Left NY and moved to El Paso, TX. Saw more children with teeth, gum or mouth problems in first few months than ever before. • Why so many in El Paso? Why so many in Horizon City? • Began a pilot project with a pediatric colleague working in Tornillo, TX and with the EPCC Dental Assisting Program (Sharon Dickinson)

4. What the studies showed about kids • Fewer than 1 in 5 Medicaid-covered children received at least one preventive dental service within the previous year (CDC, 2004). • Only 7% of general dentists report treating patients with Medicaid coverage (Seale NS et. al., 2003). • NHANES data from 1988-1994 and 1999-2004 report that Mexican-American children had higher prevalence of caries of their primary (2-11 years of age) and permanent teeth (6-19 years of age) (54.9% and 48.8%, respectively) than African-American (43.3% and 39.9%) and non-Hispanic white children (37.9% and 38.8%). Beltrán-Aguilar, ED. Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis --- United States, 1988--1994 and 1999—2002; CDC MMWR Surveillance Summaries, Aug. 2005.

5. What the studies showed about the El Paso area • Of Hispanics surveyed in a national study, only 45% of those living in Texas vs. 66.1% living in NY State had visited a dentist in the previous year (CDC, 1999 data). • El Paso County data for 2001 showed the ratio of population per dentists to be 5,784 vs. a ratio of only 2,820 for the state of Texas (Texas Department of Health, 2001). • Of 147 practicing El Paso dentists only 30 accepted Medicaid in 2006 (unpublished communications).

6. Results of our study done in 2006 • Of 300 children surveyed, 281 met full criteria • The average age of a subject was 22.18 months • 254 (88%) of patients surveyed had Medicaid as primary form of insurance • 269 (94%) described themselves as being of Hispanic (primarily Mexican) origin • 270 (94%) were born in the United States (the other 5% born in Mexico) • 175 (61%) of patients drink primarily bottled water vs. only 27% tap water.

7. Results of our study (cont’d) • The number of subjects with affected teeth was 58 (20%). The number of affected teeth ranged from 1-20. • The number of subjects who were still using pacifier at time of study was 105 (40%). • Number of children who still drink from bottle or cup at night was 84.3 (30%). • Other dental conditions such as trauma, gingivitis, and malocclusion were seen in 7 children.

8. Preliminary Conclusions • In this sample group the prevalence of caries was only 20%as compared tothe NHANES data reporting that prevalence of caries in primary teeth of Hispanic-American children was 54.9%. • However, the NHANES surveyed children 2-11 years, while we surveyed 6 months to 5 years. • Additionally, in those children with decay, many had more than half the number of teeth affected. • This suggests that, the overall prevalence is significant for this age group and the morbidity for a small group of children is noteworthy. • Moreover, risk factors such as pacifier use and using a bottle at night are still prevalent in this population despite education about these practices.

9. Personal Effects of study results • I wanted to know more about dental care and how to prevent/treat some of these problems • Have incorporated oral health into new curriculum for second year medical students at Texas Tech • I have learned and taught how to apply fluoride varnish to children’s teeth • I have referred patients to local dentists for both routine care and for dental emergencies

10. A need to change our way of thinking

11. Pediatric Oral Health Issues

12. Practical Considerations akaComments you might hear • I only give her a bottle at night when she wants to sleep (15 month old) • She wakes up every night and cries so I give her a bottle (9 month old) • He still sucks his fingers all the time (4 year old) • He won’t let me brush his teeth (2 year old) • He wants clearance to play football this year (15 year old)

13. How to incorporate into Well Child Visit • Have CMAs/nurses ask when child was seen last by dentist and/or if family has a dentist • If child is less than 4 months, talk about what type of water is used for formula and about cleaning baby’s gums. Also mention infectious nature of caries • At 6 months, talk about beginning to wean bottle (esp. falling asleep with bottle). No pre-chewing food. • At 9-12 months, begin discussing dental home and brushing/wiping teeth American Academy of Pediatrics. A Pediatric Guide to Children’s Oral Health. Elk Grove Village, IL: AAP 2009

14. How to incorporate into Well Child Visit • Discourage bottle use, encourage cups/sippy cups at meal times. • Teach injury prevention • For older kids, begin conversation about child’s growth and development by talking about food choices—what and when the child eats—discourage sticky or acidy choice and encourage limitation of snacking behavior. • Reinforce brushing and flossing • Assure dental visits are regular • Address any abnormalities seen in mouth immediately. American Academy of Pediatrics. A Pediatric Guide to Children’s Oral Health. Elk Grove Village, IL: AAP 2009

15. How to examine a child’s mouth • Have child open mouth wide: • Look at throat • Look at buccal mucosa • Look at biting surfaces of teeth • Have child bite down and smile: • Check tooth enamel • Check occlusion of teeth • Check gums/gingiva

16. Case #1 • CC: Richard is crying in pain and can’t seem to eat or sleep well. • HPI: Richard has a long history of chronic diseases which are stable. For the past two days he has been more clingy and fussy, throwing tantrums and crying out in pain stating that his “mouth hurts.” Mother says he has had low grade fever off and on also and she thinks maybe it is a throat infection because his sister was sick a week ago with similar symptoms. • PMH: Patient born full-term but with spina bifida, kidney failure. Birth weight 2.8kg. Patient has had a repaired myelomenigocele and a VP shunt since 3 weeks of age. • ROS: Mother reports decreased appetite in patient and maybe some “swollen gums”. All rest of ROS negative. • PE: weight-11.97kg ht-92cm Temp-98.7 Pulse-80 Resp. 24 • Appearance: patient awake and alert, mild distress sitting upright in Mom’s lap. • HEENT: tympanic membranes intact and normal b/l; EOMI, PERRLA; dry lips and reddened tongue; patient mouth-breathing; ulceration of second molar on left lower gum. Inflammation and pus with surrounding erythema and tenderness to palp of nearby cheek. • Rest of Physical Exam WNL for this patient

17. Case #1 • Why isn’t this child eating? • What is the diagnosis? • How should it be treated? • What should be the pediatrician’s next step? • What advice should be given to the mother?

18. Case #2 • CC: Dwight is a healthy 1 year old boy who presents with persistent skin rash/dryness.  • HPI: Dwight has a history of dry skin since age 2 months, allergies since age 6 months. His mother is convinced that he is allergic to rice, eggs, peas, pears, wheat, strawberries, soy products, and granola and has been severely limiting his food choices. When asked if she has any other concerns, the mother reports that she is worried about his teeth because they look “sort of weird.” She says she brushes his teeth every day at least twice a day, although she just started that recently. His first tooth erupted at age 10 months and he currently has four teeth.   • General allergies, eczema and episodes of mild wheezing • Drug allergies: none documented, but mother claims he is allergic to PCN • Meds: Zyrtec • FH: mother with history of PCN allergy and egg allergy, dad with history of childhood asthma, sister with mild eczema as infant, PGF with hypertension, PGM with diabetes, distant relatives on both sides with history of cancer • SH: Lives at home with mother, father and older sister aged 6 years. Does not attend daycare • Physical Exam: vitals stable • Appearance—well appearing 1 year old boy with no apparent distress. He is currently sucking on his bottle. • HEENT—mild runny nose with boggy turbinates, pt with 4 teeth (2 upper, 2 lower incisors). Upper front teeth have small white spots near gumline. All else within normal limits • Skin-- very dry skin all over body with large, dry reddened and excoriated patches in several locations on arms and legs.

19. Case #2 • What diagnosis would you give? • What should the mother be told? • What can his pediatrician do in the office to help prevent further progression of cavities?

20. Case #3 • CC: Jacob is a 10 year old boy who presents for mouth pain and swelling.  • HPI: Jacob is in good health in general but today was running at school during recess and was tripped by a classmate. He fell headlong onto the pavement, hitting his mouth and chin. He reports instantly seeing and feeling blood from his mouth and nose and pain at his gums/lips. A nearby teacher put pressure on the wound immediately to stop the bleeding. The school nurse evaluated patient and noted a cut on bottom lip, a cut on top lip and gums and a loose tooth. Patient was sent to physician’s office for further evaluation. Patient complains of mouth pain and some numbness/swelling of lower lips, but denies headache, nausea/vomiting, dizziness, neck pain, ear pain or trouble hearing, trouble breathing or visual changes. • Physical Exam: wt-33.5 kg Temp- 99.0 Pulse- 67 Resp-24 • Appearance- age-appropriate child sitting quietly with hand holding tissue pressed over his mouth. Appears in no significant distress • HEENT— Head, ear, eyes, all WNL. Dried blood seen at bilateral nares, but no active bleeding and no deviation of septum. Upper lip swollen with tear at frenulum, no loose maxillary teeth or lacerations at upper gum. Lower lip swollen with small laceration at inner surface. No active bleeding. The two lower central incisors appear crooked and are loose when palpated. Patient reports pain with movement of these teeth and some active bleeding occurs with evaluation. Tenderness with palpation of the lower jaw, especially inferior to the central incisors and slight movement felt with evaluation of jaw. Patient exhibits a malocclusion of teeth when attempting to hold a tongue blade in place with teeth.. • Neck—WNL. Patient able to move neck fully without pain or stiffness. • All else normal on this patient during physical exam except minor abrasions at hands, elbows and knees.

21. Case #3 • Of all his injuries, which is most worrisome? • What needs to happen emergently?

22. Thanks!! • Questions?

23. References • CDC Surveillance summaries. Dental Caries and Periodontal Disease Among Mexican-American Children from Five Southwestern States, 1982-1983. MMWR. July 1, 1988; 37 (SS-3): 33-45 • CDC. Dental Health of School Children—Oregon, 1991-92. MMWR. November 26, 1993: 42(46): 887-891 • Barnes GP et al. Ethnicity, Location, Age and Fluoridation Factors in Baby Bottle Tooth Decay and Caries Prevalence of Head Start Children. Public Health Reports. 1992; 107: 167-73 • Weinstein P et al. Mexican-American parents with children at risk for baby bottle tooth decay: Pilot Study at a migrant farmworkers clinic. J. of Dentistry for Children. Sept-Oct. 1992: 376-83 • Blen M et al. Dental caries in children under age three attending a university clinic. Pediatric Dentistry. 1999; 21(4): 261-64

24. References • American Academy of Pediatrics policy Statement. Section on Pediatric Dentistry. Oral Health Risk Assessment Training and Establishment of the Dental Home. Pediatrics. 2003, 111(5):1113-1116. • CDC Chronic Disease Prevention statistics. Preventing Daily Caries Fact Sheet. National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, 2004 • Georgia G. dela Cruz, R. Gary Rozier and Gary Slade. Dental Screening and Referral of Young Children by Pediatric Primary Care Providers. Pediatrics. 2004; 114(5): e642-52. • Keels MA. Pediatric Dental Pearls: what you need to know for excellent patient care. American Academy of Pediatrics Presentation, Washington, DC: October 2005. • National Oral Health Surveillance System. Texas Oral Health Profile. CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, 1999 • National Oral Health Surveillance System. Tracking of Dental Visits Texas vs. New York. CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, 1999 • Oral Health in America: A Report of the Surgeon General. US Department of Health and Human Services, NIH, National Institute of Dental and Craniofacial Research. Rockville, MD, 2000:2 • American Academy of Pediatrics. A Pediatric Guide to Children’s Oral Health. Elk Grove Village, IL: AAP 2009

25. Internet References • http://www.drashouri.com • http://www.farrarendo.com/pages/treatment_traumatic_injuries.html • http://www.pulsetoday.co.uk/story.asp?storycode=4127161 • http://www.aap.org/ORALHEALTH/AboutUs.html • http://www.cdc.gov/OralHealth/