CONTRA COSTA REGIONAL MEDICAL CENTER NOON CONFERENCE SERIES DISCLOSURE OF CONFLICT OF INTEREST

1. CONTRA COSTA REGIONAL MEDICAL CENTER • NOON CONFERENCE SERIES • DISCLOSURE OF CONFLICT OF INTEREST • Speaker has nothing to disclose

2. Fluoride Varnish Training for Physicians & Nurses

3. Educational Goals Part 1: Understand Caries (Tooth Decay) and Fluoride Varnish • Early Childhood Caries • The importance of fluoride • Fluoride varnish (FV) • Applying FV

4. Oral Health in Primary Care • Coordinated services in a family-centered setting • Most children see a doctor 1x/ year • Primary Care provides regularly scheduled visits • Early screening • Early intervention • Health promotion

5. Early Childhood Caries (ECC) • Chronic, infectious disease among children aged 0-5 • Most common disease of childhood • 5x more common disease than asthma • Transmitted through saliva-sharing behaviors • California • 33% of preschool aged children • ~70% in Kindergarten through grade 3

6. How does Early Childhood Caries develop? • Bacteria (strep mutans)in the mouth • Bacteria feed on dietarysugars to make acid • Acid demineralizesteeth Bacteria Teeth Caries Sugars + Bacteria = Acid

7. Impact of Frequent Sugary Snacks and Drinks on Children’s Teeth Acid Levels Time ____ = No F ____ = w/ F

8. Consequences of ECC Abscess • Pain/ infection • Poor self-esteem • School absences • Impaired chewing/ nutrition • Below average weight gain • Increases risk of caries in permanent teeth • Higher costs for ER & hospital-based treatment Caries Pathologic tooth loss

9. ECC Risk Indicators • Low socioeconomic status • Caries history with family/ caregivers • Frequent carbohydrate drinks or snacks • Frequent use of bottle/ nighttime bottle/ sippy cup • Inadequate fluoride • Reduced saliva (xerostomia) • Chronic medical conditions • Visible plaque* or decay*

10. A Child’s Healthy Mouth • Normal primary (baby) teeth Normal primary (baby) teeth

11. White Lines: Mild ECC white lines • First evidence of ECC • Frosty, white lines along gums • Requires dental referral white lines

12. Cavitated Caries • Eroded enamel • Appearance: • Yellow, brown, black holes or spots • Can rapidly progress to other teeth

13. Urgent Dental Referrals Severe Caries Trauma or Dental Abscess

14. Fluoride Recommended for Young Children • CDC, American Academy of Family Physicians & Pediatrics, American Dental Association • Frequent exposure to small amounts of fluoride in all age groups reduces tooth decay • Brushing twice daily • Drinking fluoridated tap water • High-risk groups → additional fluoride may be needed Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States, 2001. CDC Web site at: http://www.cdc.gov/mmwr/PDF/RR/RR5014.pdf.

15. Where do we get fluoride? • Toothpaste • Fluoridated tap water -- Fluoride Varnish Parents at home Dentist’s or Physician’s office

16. Tooth Brushing with Fluoride Toothpaste is Important • Use small amount on brush • Smear: 12 mo→ toddler • Pea-sized: 2+ yrs • Brush all teeth, front, sides and back • Brush twice daily • Assist brushing child’s teeth until age 6.

17. What is Fluoride Varnish? A topical fluoride agent painted on children’s teeth → reduces the risk of tooth decay.

18. FV is an Effective & Accepted Treatment for Children FV is shown to be safe and prevent ECC with one or more applications/ year. • Weintraub JA et al. J Dent Res. 2006 35 states reimburse (Medi-caid) for FV in US.

19. CAN DO 1 Efficacy of FV for ECC Prevention % Children with Caries Incidence at Last Follow-Up Exam by Treatment Arm (n=280) Weintraub, et al. JDR, 2006

20. Benefits of Fluoride Varnish • Safe for children • Strengthens teeth to prevent cavities • Doesn’t hurt child when being applied • Easy and fast to apply with single application • Temporary: stays on teeth for 4-6 hours • Does not replace brushing with toothpaste, drinking tap water, or taking supplements!

21. Safety of FV • No documented incidents of acute or chronic fluoride toxicity • FV’s rapid drying characteristics prevents ingestion and minimizes risk of toxicity • takes several days to break down so ingestion occurs slowly reducing risk of acute fluoride toxicity • Release of fluoride peaks early and drops dramatically • Plasma levels of fluoride after application are similar to fluoride toothpaste usage Assoc of State and Territorial Dental Directors Fluorides Committee. FV: an Evidence-based approach 2007.

22. Fluoride Varnish ProgramUCSF Collaboration – CCRMC Health Centers Part 2: • CCRMC Commitment to ECC Prevention • Knee to Knee Positioning/FV application • Provider and Nurse Responsibilities • ECC Prevention Educational Brochures • Dental Referral – Urgent Care/Dental Home • Return FV Visits

23. Contra Costa Regional Medical Center FV Policy • Adopted February 2010 – Policy 4085 • Purpose: provide guidelines for FV application to prevent dental caries and other oral health problems • Children from 12 months through 5 years of age will receive FV in the clinic at well child visits.

24. How to Discuss Fluoride Varnish with Parents 1. Say: “To reduce the risk of tooth decay, we are going to apply FV to your child’s teeth today.” 2. Ask: “Do you have any questions?”

25. Cooperative Child: Knee to Knee and FV application

26. Infant FV application video

27. After Application Reminders DO DON’T Avoid food for 20 minutes Don’t give foods that are hot, hard, crunchy, chewy, or spicy for the rest of the day Stop fluoride supplements for 3-5 days after application • OK to drink water • Soft foods only • Resume brushing teeth and flossing next morning • Remember that yellowish/ whitish coating will go away

28. Provider Responsibilities • Educate parents • baby teeth are important and children need to see a dentist by age 1 • Conduct Oral Exam • Screen for ECC and dental emergencies • Document findings or problems • Recommend FV to parents • Order FV application • Well child form

29. Well Child Visit Forms • PLANS/ORDERS: • Fluoride varnish/info • 12,15,18 months, 2,3,4,5 years

30. CCFA Form • Patient Billing Form • Prophylactic Fluoride Admin (line 44) • Well Child (line 49)

31. Treatment Nurse Responsibilities • Dispense FV Educational Brochure with after- care insert • Position parent and child (knee to knee) 3. Apply FV • Lift the lip • Remove plaque • Gauze or toothbrush • Dry teeth with gauze • Apply FV • Discuss FV After-care instruction 4. Document • FV application • Educational Brochure

32. Well Child Visit Forms • Documentation: • Plans/Orders Section: • Highlight and initial “Fluoride varnish/info” or • Outpatient Notes Section: • Write “FV application/brochure info”

33. CCFA Form • Patient Billing Form • Fluoride varnish application (line 50) • Dental nutritional counseling (line 49)

34. FV Orders/ Dental Codes Provider • FV order 2. FV application 3. Educational Brochure with FV after-care instructions • Well Child Visit Form (Plans/Orders Section): “Fluoride varnish/info” Billing Form (back): FV Application (50) Billing Form (back): Dental Nutritional Counseling (49) Nurse Nurse

35. Documentation Significance • Patient Billing (CCFA) Form • Tracking of FV applications • Tracking of ECC Prevention Brochure distribution “Dental Nutritional Counseling” • CCRMC Quality Improvement Project • Without claims/billing – Under-represents care provided

36. Pass-out the Educational Brochure Who When Treatment Nurses During: • Well Child Visits when FV applied

37. Brochure + After Care Insert (Post FV Application Instructions)

38. Brochure Messages • Baby Teeth are important • Tooth decay is caused by germs. • Brush your child’s teeth with a small amount fluoride toothpaste twice daily • Smear or pea-sized amount • The last thing to touch child’s teeth before bedtime is toothbrush and toothpaste • Child shouldn’t fall asleep with bottle/ sippy cup in mouth

39. Brochure Messages • Parent: promote oral health and prevent caries transmission to child • Brush & floss daily • regular dental visits • Child’s 1st dental visit by 1st birthday • Reduce risk of tooth decay with 1-3 FV applications/ yr

40. Brochure Dietary Messages • Avoid sugary starchy snacks • Avoid sugary drinks • No more than 4 oz of juice/ day • No sugary starchy snacks and drinks or limit to less than 3x/ day • Choose healthier snacks

41. Return FV Visits • Child returns for well-child visits/ vaccines: • 15, 18 months, and 2, 3, 4, and 5 years • Follow-up steps: • Oral exam & FV application • Educational Brochure • Document in medical record • Billing for FV & Educational Brochure

42. Refer Child to Dentist • First dental visit by 1st birthday to establish a dental home (see brochure and “Dental referral “ Plans/orders Toddler 12 months) Contra Costa County Dental Clinics: • Bay Point Dental Clinic (925-427-8302) • Pittsburg Dental Clinic (925-431-2501) • Martinez Dental Clinic (925-370-5300) • Richmond Dental Clinic (510-231-1240)

43. Refer Child to Dentist Five years of age and older • provide “Dental Clinics in Contra Costa County” information sheet) CCHS Dental Clinics: Community Clinics: • Brookside Community Health Center • La Clinica de la Raza - Monument • La Clinica de la Raza - Pittsburg Denti-Cal and Children’s Oral Health #s

44. Improved Dental Access for Children Clinic staff may schedule children for “Pediatric Dental Consult Appointments” directly into Epic (effective January 2011) • Consult slots 1 AM and 1 PM • 15 minute appointments • All Dental Clinics participating • Medi-Cal or pending insurance status eligible

45. FV Program Support • First contact your Oral Health Champion: • Nikki Moultrie, RDHAP (925-300-6579) • Email: nikki.moultrie@ gmail.com • Additional FV program questions, comments, or concerns: • UCSF Jana Murray (502-8739) or Catherine Kavanagh (476-4438) • Email: jana.murray@ucsf.edu catherine.kavanagh@ucsf.edu

46. Thank YouAny Questions? Funding Source: NIH/NIDCR U54 DEO19285