A Best Practice Approach is defined as a public health strategy that is supported by evidence for its impact and effectiveness. This Best Practice Approach Report describes a public health strategy, summarizes the strength of evidence of the effectiveness of the strategy, and uses current practice examples to illustrate successful and/or innovative implementation of the strategy. The report serves as a resource to share ideas and promote best practices for state and community oral health programs.

Table of Contents:I. Best Practice Approach (page 1)

II. Description (page 1)III. Guidelines and Recommendations from Authoritative Sources (page 15)

IV. Research Evidence (page 19)

V. Best Practice Criteria (page 19)

VI. State Practice Examples (page 20)References (page 23)Attachments (page 24)

I. Best Practice Approach

Early Childhood (Infant, Toddler andPreschooler) Oral Health

II. Description

A. Oral Health and Its Significance for Infants, Toddlers and Preschoolers

What does oral health mean for infants, toddlers and preschoolers? Why is oral health important for infants, toddlers and preschoolers?

Early childhood is the time in which significant physical growth and development occurs and functional capacity develops. This is as true for the mouth as other parts of body. Efforts to enhance oral health during this period help to build the cornerstone for lifelong health and well-being.

A child’s first set of teeth are called primary teeth, and usually erupt from age 6 months to 3 years. The first set of 20 primary teeth is replaced with successional teeth, and an additional 12 new teeth emerge, called accessional teeth, that erupt between ages 6-20. A child develops 32 permanent teeth between ages 6 to 14 (1). A child's primary teeth are as important as the permanent adult teeth because they:

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Summary of Evidence SupportingPerinatal, Infant, Toddler and Early Childhood Oral Health Programs

Research ++Expert Opinion +++Field Lessons ++Theoretical Rationale +++

See Attachment A for details.

Best Practice Approaches for State and Community Oral Health Programs

DRAFT 9/15/08

• Are needed to bite and chew food; • Are critical to speech development;• aid in the normal development of the jaw bones and facial muscles;• reserve space for the permanent teeth and help guide them into position; and• assist in the development of self-esteem.

B. Dental Disease and Early Childhood Caries

Dental caries, the disease that causes cavities, is an infectious, transmissible but preventable and manageable chronic condition. According to American Academy of Pediatric Dentistry, Early Childhood Caries (ECC), is defined as the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger (2).

The Disease Process and Rationale for Prevention/Treatment

What is the disease process of dental caries?

Dental disease can be consequential to growth, function, learning, self-image and employability. The most frequent symptom of dental caries is pain that can distract children from learning and playing, and limit their ability to eat and speak. Extensive early childhood caries has been correlated to inhibit attainment of normal weight and height in toddlers and is increasingly understood to compromise general health and function (3, 4, 5, 6, 7).

Dental caries is initiated by bacteria transmitted through saliva from the mother or a primary caregiver to the child. If this transmission is supported by a high-frequency sugar diet, an efficient system of tooth decalcification results. The acid produced by the interaction between cariogenic bacteria and sugar in the diet first dissolves the enamel. After the enamel is decalcified it appears as a “white spot.” Further acid dissolution of the tooth surface results in greater breakdown and is evidenced by a cavity. If the disease process is left unchecked its progression leads to loss of the inner tooth tissue, dentin, and ultimately affects the pulp of the tooth with its blood vessels and nerves. If left unchecked, the pulp becomes inflamed and painful, ultimately dies, and leads to a dental abscess. When transmission of the bacteria happens, the disease is present without visual signs, but is still causing damage to the enamel of the teeth (the outer structure of the tooth crown) before it is noticed by caregivers or health professionals.

Fluoride mitigates this caries process in a number of ways: by making the enamel less susceptible to acid dissolution, by inhibiting the cariogenic bacteria, and by facilitating remineralization of the tooth. Therefore the ongoing balance between sugar intake frequency and fluoride intake frequency determines the progression and severity of the disease and its effect on the tooth. The earlier in a child’s life that the caries process is initiated, typically the more sever and rapidly progressing it will be. It is for this reason that children who manifest tooth decay early in life remain at high-risk for ongoing caries progression throughout their primary and permanent dentitions.

Because not all children have equivalent exposure to dietary and bacterial risk factors, children vary in their caries susceptibility. Needed are valid and reliable risk assessment measures that can identify children at greatest risk, and in greatest need for earliest and most intensive intervention. The need for such risk assessment tools is widely recognized and a variety of efforts are underway, most notable the AAPD Caries-risk Assessment Tool

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(CAT) which employs social, behavioral, and biological factors (8). The importance of including mutans testing in a caries risk assessment tool is currently under investigation. Risk-based clinical assessment of all infants no later than twelve months of age is important in prevention and management of dental caries. In addition to risk assessment, the earliest possible identification of caries activity is important in targeting interventions. While the presence of a small cavity is a definitive sign of disease activity, so too are the presence of decalcifications (white spots), and the presence of visible plaque along the gumline of the upper front teeth (9). Once risk has been determined and disease is identified, treatment can focus on factors that can help to control the disease, including changes in diet, intensive fluoride control, and follow-up visits to monitor progress.

Tooth decay in the primary teeth is the most reliable predictor of caries in permanent teeth. An eight-year study of children ages 3-5 found that children having tooth decay in their primary teeth were three times more likely to develop decay in their permanent teeth (10). Ideally, caries control measures are instituted to obtain caries arrest (disease inactivation) prior to dental repair. Then, depending on the extent of tooth destruction, various treatments can be employed to restore teeth to proper form, function, and esthetics.

Disease prevention and management approaches including anticipatory guidance, primary prevention, and disease suppression have distinct, dynamic applications to addressing caries before cariogenic conditions are established, as well as after caries activity is underway.

The Burden of Disease

How extensive is the problem of tooth decay among infants/toddlers/preschoolers? What is the burden and cost of dental caries?

Dental caries is the most prevalent chronic disease of childhood, five times more common than asthma (11). CDC reports that for the period of 1999-2004, 28% of 2-5 year olds had visible caries experience. This represents a 15 percent increase among U.S. toddlers and preschoolers over the period 1988-1994, indicating that more than one in four pre-school age children have experienced the disease. An estimated 1.12 million preschoolers have visible signs of ECC experience. The study also found that 74 percent of young children – an estimated 840,000 children- who have experienced tooth decay are in need of dental repair (12). Data from the National Health and Nutrition Examination Survey reveals the progression of caries experience by age, as 1-in-10 two year olds are reported to have cavities, growing to 2-in-5 among children of age five (13).

Tooth decay is not distributed equitably across child populations in the U.S. According to the 2000 Surgeon General’s Report on Oral Health, individuals living below the poverty level experience more dental decay than those who are more affluent (11). In fact, 80 percent of pediatric dental decay is found in 25 percent of children – primarily those from low-income families (14). Preschoolers in poverty have twice the odds of experiencing decay, the severity and twice the pain experience compared to preschoolers from families living above the federal poverty level (15). Therefore, the greatest need for dental services remains among children in low-income families. However, there are also marked disparities in access to and utilization of care among these children. Overall, children under age 6 receive less than half (25 %) the rate of dental services as children ages 6-12 (59%) (16). Just as dental disease is concentrated in children from families characterized by low-income, minority, and

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lesser caregiver education, so too, these children receive the least dental care (16). In sum, young children with the greatest need obtain the least services.

Parental assessment of children’s oral health appears to be more favorable than epidemiologic assessments, as 68.5 percent of parents in the National Survey of Children’s Health conducted in 2003 reported their children’s oral health as excellent/very good. Even with such overestimation of oral health status, parents themselves report disparities. Parents reported that approximately 3/4 of white, and multiracial children’s teeth were in excellent or very good condition compared with less than 2/3 of African American children and about 1/2 of Hispanic children (17).

Failure to prevent early childhood caries has long-term consequences that can be costly in terms of disease progression and function, as described. It can also be costly in terms of dollars. The cost of preventive dental care is low compared to treatment once the disease is established. Cost estimation modeling applied to ECC prevention has shown net positive results i.e. actual cost-savings (18, 19, 20). Simultaneously, research confirms the high cost of treatment that results in emergency care. A three year comparison of Medicaid reimbursement for inpatient emergency department treatment ($6,498) versus preventive treatment ($660) revealed that on average, the cost to manage symptoms related to dental caries on an inpatient basis is approximately 10 times more than to provide dental care for these same patients in a dental office (21).

The greater cost of treatment relative to prevention can be attributed to the high cost of early childhood care, with attendant medical costs of hospitalization and general anesthesia. But even this treatment results in high disease recurrence rates because of common failure to arrest the underlying caries process. In Berkowitz’ study, 40% of ECC patients relapsed within the first year after dental surgery (22).

Low-income children who have their first preventive dental visit by age one are not only less likely to have subsequent restorative or emergency room visits, but their average dentally related costs are almost 40% lower ($263 compared to $447) over a five year period than children who receive their first preventive visit after age one (23). While this study could not control for confounding factors of parent motivation for the dental visit, its finding is consistent with the cost estimation modeling.

Barriers to Reducing Disease and Achieving Optimal Oral Health

What contributes to the problem? What are the barriers?

Two types of barriers limit young children’s achievement of optimal oral health: (I) barriers that relate to oral health attainment and (II) barriers that relate more narrowly to access and utilization of early dental care.

(I) Barriers to attaining oral health during early childhood

a. Failure to prevent, limit, or delay the acquisition of cariogenic flora as the first primary teeth erupt.

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Risk for ECC can be reduced by preventing, limiting, or delaying acquisition of cariogenic flora as the first teeth erupt. Transmission, typically from mothers or primary caregivers to young children has three components, each of which can be addressed: the caregiver’s oral flora, the vectors through which saliva-borne bacteria are transmitted, and the recipient child’s ability to retain these bacteria in the mouth. Efforts to address this transmission hold greatest value in families where caries experience is high as evidenced by the mother’s/caregiver’s prior caries experience or the caries experience of older siblings (who may be viewed as surrogates for the instant child).

Barriers to implementing the primary preventive strategy of curtailing transmission of cariogenic bacteria to young children 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 for reducing caries initiation by curtailing transmission through suppression of maternal reservoirs, elimination of vectors, and/or enhancing the resistance to implantation.

b. High frequency exposure to cariogenic dietary substrates.

Risk for ECC increases with the frequency of sugar-containing diet exposures that a young child experiences throughout the day and night. The caries process, once initiated after acquisition of cariogenic bacteria, is stimulated and exacerbated by the frequency of sugar exposure.

Barriers to implementing the secondary preventive strategy of curtailing the frequency of cariogenic episodes during the day 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 offered for pacification typically as dry snacks and sugar-laden liquids in bottles and sippy cups;

• some culture-bound feeding, eating, and diet habits and practices;• night-time offering of pacification bottle containing liquids other than water.

c. Inadequate exposure to topical fluorides, especially in high risk children and young children with aggressive caries activity.

As with other forms of caries, ECC is modulated by the presence of frequent low-levels of topical fluorides which reduce mutans acid production, secondarily disrupt plaque integrity, stabilize enamel crystals, and promote remineralization of caries-damaged enamel.

Barriers to implementing the preventive strategy of assuring sufficient topical fluoride exposure in at-risk children include:

• concern about potential fluorosis of the permanent teeth;• lack of public awareness and understanding about the proper use of

fluoridated toothpaste in young children;

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• lack of low-dose fluoride toothpaste products in the US.

d. Common failure to detect caries activity early in a child’s life and before cavitations occur.

Pain and infection often follow quickly after the first appearance of cavities in toddlers and preschoolers and often elicit the first dental visit in children who suffer from ECC. However, there are clear signs of caries activity prior to cavitation that could be used by informed parents, caregivers, day-care staff, and medical providers who are in contact with young children. Prior to cavitation, clear visual evidence of decalcification occurs as “white spots” or streaks, particularly along the gumline of the upper front teeth. Prior to development of these decalcifications, children with early caries activity typically demonstrate a thick, white, soft plaque along the gumline of the upper front teeth. When a toothpick is touched to this plaque and lifted from the surface, it typically produces a glutinous strand which is pathognomonic for mutans-rich plaque associated with ECC. High levels of mutans can also be identified through bacterial assessment of toddlers’ oral flora by collecting saliva on a sterile tongue blade depressed onto the dorsum of the child’s tongue and impressed on selective media for culturing.

Barriers to early detection of cariogenic activity 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.

In addition, families may be unaware of the need for early and regular oral health care. The importance placed on oral health can also vary due to cultural, social, and economic factors. In addition, dietary practices specific to certain cultures may encourage the onset or development of caries, while other factors may discourage certain populations from seeking care. Unless appropriate dental care referrals are given by other health professionals, families not seeking or prioritizing dental care may remain unaware of its importance in offsetting and managing dental caries.

(II) Barriers related to access and utilization of care

Existing barriers to promoting oral health in young children include dental coverage/financing of dental care, dental training and workforce limitations, and dental public health infrastructure inadequacies.

At least 23 million US children lack dental coverage. Children with private or public dental coverage are 30 percentage points more likely than low-income uninsured children to have had a preventive dental visit in the previous year. And even of children with Medicaid dental coverage, only 1-in-3 sees a dentist annually (24).

a. Lack of dentist participation in Medicaid

Dentists’ participation in Medicaid is limited. In a survey of Medicaid directors in 1999, 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 would represent roughly

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10% of the typical dentist’s patient load in a year) (24). Dentists cite 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 (25).

b. Paucity of pediatric dentists to care for children with severe needs.

Although payment and financing of dental care are barriers, to date there is also an insufficient number of pediatric dentists available to see children. Currently only approximately 4,500 of the 150,000 dentists in the country are pediatric dentists. Given that the majority of practicing dentists are general dentists, their minimal training in the care of young children has also contributed to the shortage of dentists willing to see this population.

c. Limited dental safety net capacity.

The public dental health infrastructure for the oral health of young children is growing; however it remains inadequate in some states and communities. The need to strengthen the infrastructure to support community-based efforts to prevent and manage dental disease includes school-based programs (including, but not limited to school-based/school-linked sealant and fluoride varnish/rinse programs); safety-net settings that can see young children (including, but not limited to Community Health Centers and local health departments); and state leadership.

d. Lack of evidence-based widely-accepted protocols for care of young children.

While the American Academy of Pediatric Dentistry has led the way in establishing guidelines for early childhood care, the field remains unsupported by well-tested protocols for risk assessment, triage into various intensities of disease management, disease management protocols, and criteria for follow up.

e. Lack of financing that supports disease management.

Dental care financing typically supports reparative care but provides little support for risk-based disease management beyond the “one-size-fits-all” semiannual prophylaxis (which has been shown to be of minimal caries prevention benefit) and topical fluoride application.

C. Strategic Framework for Promoting Early Childhood Oral Health

What is the “big picture” to understanding how to promote oral health of infants, toddlers and preschoolers?

What can be done for early prevention and control of early childhood caries?

In the development of a strategic framework for addressing the oral health of young children, a distinction is made from efforts to address the oral health of older children and adults. This distinction reflects an emphasis on the ability to delay the onset of dental caries, and to initiate early efforts in managing the chronic disease upon onset. Additionally, because young children encounter numerous systems – medical, developmental, and educational -- before entering school, there are numerous opportunities for coordination and integration of oral health with overall health and development. _____________________________________________________________________________________________Early Childhood (Infant, Toddler and Preschoolers) Oral Health 7

The following strategic framework is specific to the prevention and management of early childhood caries within family, professional, community, and policy levels of influence.

Preventing Early Childhood Caries

Dental caries is a chronic disease that is infectious and transmissible. Due to the nature of dental caries transmission – primarily from mother to child (due to biological and behavioral factors) primary prevention can be achieved through eliminating or reducing the dental caries infection in new mothers. There are three primary strategies for doing so: reduction of bacteria in caregivers’ mouths (through use of prescription mouthwash, high frequency fluoride rinse prescriptions, and other mechanisms), minimizing transmission itself (through avoidance of sharing food, utensils, sugary drinks, discouraging baby from putting fist in parent’s mouth, etc.), and addressing the receptor (baby), as it is ideal to delay acquisition of bacteria for as long as possible.

A dental visit before the age of one is also an opportunity for assessing and addressing the dental caries risk of a child. Proactive strategies can be taken by families, communities, and policymakers to prevent and/or delay the onset of dental caries.

Perinatal Oral Health: Improving the oral health of expectant and new mothers through clinical treatment, oral health counseling, and general oral health education can contribute to the health and well-being of the mother and child. Evidence suggests that most young children acquire caries-causing bacteria from mothers, and efforts taken to reduce the transmission of such bacteria from mothers to children improves the likelihood of better oral health for the child.

Pregnancy is also an opportune time to educate women about preventing dental caries in young children, one of the most common childhood problems. Pregnancy and early childhood are particularly important times to access oral health care because the consequences of poor oral health can have a lifelong impact.

Age One Dental Visit and Establishing a Dental Home: The American Academy of Pediatric Dentistry (AAPD), American Dental Association( ADA), and the American Academy of Pediatrics (AAP) all recommend that infants receive an oral evaluation within six months of the eruption of the first primary tooth, but by no later than 12 months of age. Similar to the concept of a medical "well baby checkup" the exam is intended to assess risk, check for problems, and educate parents/caregivers. The age-one visit can be the first step to establishing a dental home for a child. Similar to the original concept of “medical home” a dental home refers to an ongoing relationship between the dentist and the patient, in a comprehensive, continuously accessible, coordinated and family-centered manner.

Disease Management

Although primary prevention is preferred, most individuals will eventually acquire dental caries. However, the older the child is at onset of caries, the greater the likelihood that a child will not suffer significant decay. Given the numerous factors that influence a child’s risk of having significant decay, an early risk assessment in the context of a child’s family, community, and culture can help to achieve better oral health – even for those at greatest risk. Managing dental caries requires differential treatment for children at high-risk compared to children at low-risk. Therefore, professionals and caretakers, with enough information, can partner to understand and manage dental disease. Decades of scientific

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research provide tools for the management of dental caries, including but not limited to: fluoride varnish, dental sealants, and nutrition education.

Risk Assessment: The use of a caries-risk assessment tool (CAT) to determine the risk level for an individual child allows for an appropriate intervention to be determined, taking into account the diverse factors that impede and contribute to oral health. Several tools are available and targeted for use by different providers. The AAPD encourages both dental and non-dental professionals to utilize a caries-risk assessment tool in caring for infants and children (2). Their CAT is available at http://www.aapd.org/media/Policies_Guidelines/P_CariesRiskAssess.pdf. The AAP has developed the Oral Health Risk Assessment: Training for Pediatricians and Other Child Health Professionals module utilizing the AAPD’s CAT. Other caries-risk assessment measures include those developed by The Center to Address Disparities in Children’s Oral Health at the University of California, San Francisco and the Center for Research to Evaluate and Eliminate Dental Disparities at Boston University, among other efforts underway.

Key aspects of these risk assessments include:

1. risk factors include social, biological, behavioral, and nutritional factors at the level of child, family, and community;

2. the need for a simplified, clinically relevant risk assessment tool for individual children will likely result in a risk factor approach that features primarily biological (mutans levels and associated plaque appearance) and dietary (frequency of simple carbohydrate ingestion) factors;

3. ultimately a satisfactory clinical assessment tool must be simple, inexpensive, and have high predictive values associated with high sensitivity and specificity.

Caries-rise assessment tools are an active and dynamic method of assessment and should be used frequently to account for changes in a child’s level of risk, as they provide insight into a specific time in the child’s life.

Fluoride: Water fluoridation is an effective, safe, and low-cost way to prevent and protect against the occurrence of tooth decay. Using topical fluoride applications, such as fluoride toothpastes, fluoride varnishes, or fluoride rinses can aid in the remineralization or “rebuilding” of a tooth that has begun to decay. Many communities have instituted fluoride varnish/rinse programs in schools for children at highest risk for caries. The most universal form of fluoride is community water fluoridation. Water fluoridation is monitored and controlled in individual communities to provide an optimal level of fluoride in the public water source in order to reduce the rate of dental decay in children and adults.

Parent Education on Nutrition and Fluoride Compliance: Educating caregivers on the transmissible nature of caries, and promoting the avoidance of saliva-sharing behaviors to delay colonization are key factors in preventing ECC, as is providing information to parents on incorporating fluoride into the child’s daily routine. The importance of appropriate health literacy and cultural competency cannot be underestimated in communication efforts with both parents and children. Recent estimates indicate that over 90 million Americans are unable to comprehend basic health information, and according to the ADA, patients with low health literacy levels often “demonstrate poor knowledge of health-related information, show little ability to control the chronic diseases afflicting them, rarely maximize benefits from available preventive health services, and are more likely to have higher age-adjusted of both morbidity and mortality” than those with higher healthy literacy levels (26). Many resources

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exist, through the National Maternal and Child Oral Health Resource Center and other initiatives, that provide guidance on utilizing appropriate health literacy levels and culturally competent messages when communicating with parents and families.

Increasingly recognized in ECC interventions, as in obesity, asthma, and diabetes interventions, is the need for effective health education and health behavior modification approaches. As in medical care, there is an overall growing awareness for health promotional services rather than exclusive care of illness. Future improvements in prevention and management approaches will require more input from behavioral scientists, social workers, and educators in maximizing effective and culturally competent communication to families and promoting preventive behaviors in the home.

Access to Care

A key factor in the successful management of ECC is access to preventive services as well as treatment and restorative care. Access to dental services is dependent on both an effective method for paying for services and the participation of dentists, as well as on systems coordination and integration on state and community levels. While children with dental coverage (public or private) are 30 percent more likely than uninsured low-income children to have a preventative dental visit in a year – coverage alone does not assure access (27). The creation of the Medicaid Early Periodic, Screening, Diagnostic and Treatment (EPSDT) program in the 1960s provided medical and dental coverage to low-income children. Today Medicaid covers a quarter of all children in this country, but only 1/3 of enrolled children see a dentist annually. Therefore, access to dental care disproportionately affects low-income children.

Systems Coordination and Integration

The collective efforts of provider groups, state and community programs, and policymakers can provide a solid foundation for advancing the oral health of young children. Integration of oral health into medical care, early education, and other systems that families with young children regularly encounter can provide the necessary information and reinforcement needed for preventing early dental decay. Policies and programs at the local, state, and national level that emphasize the mouth as part of the body can also significantly play a role in advancing the oral health of young children.

A coordinated effort at the state and local levels is key to implementing effective strategies to promote early childhood oral health and provide early prevention and management of tooth decay among infants, toddlers and preschoolers. There are several key roles state programs and local programs can play. State programs can (a) mobilize partners to integrate systems, avoid duplicating services, and leverage resources, (b) provide a statewide assessment of the burden of disease, and (c) support a state strategic plan that will be owned and implemented by stakeholders and constituents.

State Programs for Early Childhood Oral Health: State infant and early childhood oral health programs focus on population-based and infrastructure-building services. They include a variety of strategies necessary to understand and ensure that the specific oral health needs of infants, toddlers, and pre-school aged children are met. Many programs incorporate a perinatal component, as primary prevention of dental caries in infants includes reducing the maternal dental disease and transmission to child. The overarching goal of these programs is to assure optimum oral health for maternal, infant and early-childhood groups.

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Local Programs for Early Childhood Oral Health: Pre-school and community-based infant, toddler, and early childhood oral health programs focus on education and direct access to comprehensive oral health care services for pregnant women, infants, toddlers, and pre-school aged children. They incorporate an education and training component for daycare providers, perinatal and child health/development providers, and parents and other caretakers. These programs may also include a clinical component focusing on individual and early risk assessment, anticipatory guidance, and referral to a dental home. Some programs offer dental care services on-site through the use of portable dental equipment or mobile dental vans. In such programs where dental care services are provided in the pre-school or community-based setting, program administrators develop formal agreements with the dental services provider establishing a dental home and responsibility for care of the children enrolled in the day-care or pre-school setting. Other community and pre-school programs link the clinical services to a neighboring community health center dental clinic or local dental provider. In either case, informed parental consent is required before any services are administered.

III. Guidelines & Recommendations from Authoritative Sources

A. Surgeon General

Oral Health in America: A Report of the Surgeon Generalhttp://www.surgeongeneral.gov/library/oralhealth/The Surgeon General’s Report on Oral Health in America reported the following findings on community and other approaches to promote oral health and prevent oral disease:

• Effective disease prevention measures exist for use by individuals, practitioners and communities. Most of these focus on dental caries prevention, such as fluorides and daily oral hygiene practices.

• Many community-based programs required a combined effort among social service, health care, and education services at the local or state level.

• Primary prevention of dental disease and conditions is possible with appropriate diet, nutrition, oral hygiene, and health-promoting behaviors, including the appropriate use of professional services.

National Call to Action to Promote Oral Healthhttp://www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.htmThe National Call To Action To Promote Oral Health builds on the Surgeon General’s Oral Health in America report by creating action items to achieve the goals of the Surgeon General and Healthy People 2010. Each action reflects the need to address early childhood oral health.

Action 1: Change Perceptions of Oral HealthAction 2: Overcome Barriers by Replicating Effective Programs and Proven EffortsAction 3: Build the Science Base and Accelerate Science TransferAction 4: Increase Oral Health Workforce Diversity, Capacity, and FlexibilityAction 5: Increase Collaborations

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http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Conference/ConferenceChildrenOralHealth/During the Conference on Children and Oral Health held in 2000, experts in the field developed an action-oriented agenda intended to eliminate disparities in children’s oral health and their access to care. Recommendations stemming from the Conference include:

1. Start early, emphasize prevention, involve parents2. Assure a sufficient workforce and public health capacity3. Revamp health professional education4. Integrate and innovate in science and all service delivery systems5. Expand the knowledge base and transfer science6. Develop strategic communication plans7. Align policy with knowledge and children’s needs

B. Healthy People 2010http://www.healthypeople.gov/Document/HTML/Volume2/21Oral.htm The Healthy People 2010 Objectives promoting early childhood oral health include:

21-1a. Reduce the proportion of young children with dental caries experience in their primary teeth. (Target: 11 percent)

21-1b. Reduce the proportion of children with dental caries experience in their primary and permanent teeth. (Target: 42 percent)

21-2a. Reduce the proportion of young children with untreated dental decay in their primary teeth. (Target: 9 percent)

21-2b. Reduce the proportion of children with untreated dental decay in primary and permanent teeth. (Target: 21 percent)

21-8 Increase the proportion of children who have received dental sealants on their molar teeth. (Target: 50 percent)

21-9 Increase the proportion of the U.S. population served by community water systems with optimally fluoridated water. (Target: 75 percent)

21-10 Increase the proportion of children and adults who use the oral health care system each year (Target: 56 percent)

21-12 Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year (Target: 57 percent)

21-13 Increase the proportion of school-based health centers with an oral health component. (Target: developmental)

21-15 Increase the number of States and the District of Columbia that have a system for recording and referring infants and children with cleft lips, cleft palates, and other craniofacial anomalies to craniofacial anomaly rehabilitative teams. (Target: All States and the District of Columbia.)

C. American Academy of Pediatric Dentistry (AAPD)http://www.aapd.org/media/policies.aspThe vision of the AAPD is optimal health and care for infants, children, adolescents and persons with special health care needs. The AAPD is the leader in representing the oral health interests of children. AAPD’s mission is to advocate policies, guidelines and programs that promote optimal oral health and oral health care for children. AAPD has the following oral health policy statements and guidelines, among others.

• Oral Health Care Programs for Infants, Children, and Adolescents • Dental Home • Use of a Caries-risk Assessment Tool (CAT) for Infants, Children, and Adolescents

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• Use of Fluoride • Early Childhood Caries (ECC): Classifications, Consequences, and Preventive

Strategies• Infant Oral Health Care

D. American Academy of Pediatrics (AAP)http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1113 The AAP policy statement on Oral Health Risk Assessment Timing and Establishment of the Dental Home:• Recognizes that early childhood dental caries emerges within all cultural and

economic pediatric populations; however, it approaches near epidemic proportions in populations of low socioeconomic status.

• States pediatricians and pediatric health care professionals should develop the knowledge base to perform oral health risk assessments on all patients beginning at 6 months of age.

• Endorses that the ideal deterrence to early childhood caries is the establishment of the dental home when indicated by the unique needs of the child.

E. American Dental Association (ADA)http://www.ada.org The Association recognizes that early childhood caries is a significant public health problem in selected populations and is also found throughout the general population. ADA positions and statements include:

• ADA Statement on Early Childhood Caries (http://www.ada.org/prof/resources/positions/statements/caries.asp)

• ADA Supports Fluoridation (http://www.ada.org/prof/resources/positions/statements/fluoride3.asp )

• ADA Statement on Water Fluoridation Efficacy and Safety (http://www.ada.org/prof/resources/positions/statements/fluoride_community_effective.asp)

F. American Academy of Family Physicians (AAFP)http://www.aafp.orgAAFP has published anticipatory guidance for perinatal and infant oral health:

• A Practical Guide to Infant Oral Health (http://www.aafp.org/afp/20041201/2113.html)

• Anticipatory Guidance in Infant Oral Health: Rationale and Recommendations (http://www.aafp.org/afp/20000101/115.html)

• Oral Health During Pregnancy(Am Fam Physician. 2008; 77(8):1139-1144)

G. American Academy of Periodontology (AAP)http://www.perio.org/resources-products/pdf/44-pregnancy.pdfAAP has published a statement on the management of periodontal disease for pregnant women, encouraging all women to attain good oral health prior to and throughout their

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pregnancies, as well as encouraging necessary treatment throughout pregnancy, but as early in the pregnancy as possible.

H. Maternal and Child Health Bureau, Health Resources and Services Administration

Bright Futures http://brightfutures.aap.org/index.htmlBright Futures is a resource containing principles, strategies, and tools that are theory-based, evidence-driven, and systems-oriented that can be used to improve the health and well-being of all children. A partnership between HRSA’s Maternal and Child Health Bureau and AAP, Bright Futures uses a developmentally based approach that addresses children's health needs in the context of family and community. The guidelines are designed to present a single standard of care and a common language based on a model of health promotion and disease prevention. Bright Futures provides anticipatory guidance for oral health from infancy through 21 years of age.

I. Office of Head Start , Administration for Children and Familieshttp://eclkc.ohs.acf.hhs.gov/hslc/Program%20Design%20and%20Management/Head%20Start%20Requirements/PIs/2006/resour_pri_00109_122006.html;1166801446188%20

The Office of Head Start has established policies that govern compliance with identified oral health requirements. The program instructions outline requirements for such areas as oral health hygiene, establishment of a dental home, dental screenings, and Medicaid EPSDT Periodicity Schedule.

J. New York State Department of Health http://www.health.state.ny.us/prevention/dental/oral_health_care_pregnancy_early_childhood.htmOral Health During Pregnancy and Early Childhood Practice GuidelinesIn 2006, the New York State Department of Health convened an expert panel of health care professionals to review literature, identify existing interventions, practices and guidelines, assess issues of concern, and develop recommendations, published as the Oral Health Care During Pregnancy and Early Childhood Practice Guidelines. The panel developed separate recommendations for prenatal, oral health, and child health professionals. The recommendations are intended to bring about changes in the health care delivery system and to improve the overall standard of care.

K. US Preventive Services Task Forcehttp://www.ahrq.gov/clinic/USpstf/uspsdnch.htmPrevention of Dental Caries in Preschool Children: Recommendations and RationaleThe US Preventive Services Task Force provides results of an examination of evidence related to young children’s dental disease and gives recommendations and clinical considerations regarding primary care physicians’ role in efforts to prevent dental disease in children of preschool-age.

L. Centers for Medicare & Medicaid Services, Department of Health & Human Services http://www.cms.hhs.gov/medicaiddentalcoverage/downloads/dentalguide.pdf

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Guide to Children’s Dental Care in MedicaidThe Guide to Children’s Dental Care in Medicaid includes the Emphasis on Early Initiation of Oral Health Care, highlighting the infectious and transmissible nature of tooth decay, and recommending that prevention efforts begin in the first to second year of life, while also targeting pregnant women and new mothers. The Guide also provides information on Infant Oral Health Care and the First Dental Visit.

IV. Research Evidence

Scientific evidence exists in support of bio-behavioral interventions for the management of caries, but there is not evidence yet as to the efficacy and efficiency of such interventions. The science of cariology is now well established to support clinical interventions; however as of this report, demonstrations of effectiveness are incomplete.

The Agency for Healthcare Research and Quality (AHRQ) conducted an assessment of existing methods for diagnosis and treatment of caries in 2001. The research report Diagnosis and Management of Dental Caries provides the results of this comprehensive review. AHRQ found that evidence is poor to support any diagnostic method for cavitated lesions, lesions involving dentin, enamel lesions, and any lesions. AHRQ also found that evidence was incomplete in support of methods for the management of noncavitated carious lesions. Of nine identified management methods for caries-active individuals, evidence for all techniques was rated as incomplete, except for fluoride varnish which was rated as fair. AHRQ determined that further research is needed to assess the performance of existing diagnostic methods, as well as to determine the performance of management strategies for caries-active individuals (28).

In addition, the US Preventive Services Task Force found that “there are several gaps in evidence on the prevention of dental disease in young children.” The Task Force found no relevant studies assessing primary care providers’ efficacy in promoting parental compliance for fluoride supplementation, and no studies to determine primary care providers’ accuracy when identifying children at higher risk levels for dental caries or in their effectiveness for providing referrals to dentists. The Task Force also describes little evidence for health education efforts to improve oral hygiene and prevent acquisition of caries and limited evidence for the efficacy of parental education efforts by primary care providers in the prevention of dental disease (29).

The National Institutes of Health convened the Consensus Development Conference on Diagnosis and Management of Dental Caries Throughout Life in 2001, in order to synthesize existing caries diagnosis, treatment, and prevention strategies, to assess the quality of existing data, and to provide recommendations for future research. The Consensus Development Conference Statement resulting from the meeting reviews and provides guidance on the best methods for detecting caries in early and advanced stages, indicators for elevated risk, best methods for primary prevention of caries acquisition, the best treatments for arresting or reversing early caries progression, and identifies new directions for future research (30).

Further research and demonstration studies are needed to provide additional evidence of the efficacy of preventive and management methods targeted to infants and young children.

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V. Best Practice Criteria The ASTDD Best Practices Project has selected 5 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 improve the oral health of infants, toddlers, and children and to identify areas of the practice for improvement.

1. Impact / Effectiveness • A practice or program enhances the processes to improve oral health status

and/or improve access to dental care for infants and toddlers. Example: Increased number of programs to train physicians, nurses, and

dentists to provide screening and preventive services for infants and toddlers 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 infants and toddlers.

Example: Reduced caries experience and untreated decay among children, fewer emergency visits to the dentist, or fewer hospital operating 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 infants and toddlers. Example: Increased savings based on the comparison of the cost for

delivering early prevention services to the projected cost of dental treatment for averted tooth decay and having treatment in the OR.

• A practice or program shows leveraging of federal, state, and/or community resources to improve the oral health of infants and toddlers.

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 high-risk infants, toddlers, and preschoolers.

3. Demonstrated Sustainability• A practice or program that has demonstrated sustainability or has a plan to

maintain sustainability. Example: A program that has served infants and toddlers for many years

and receives agency line-item funding in addition to 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 infants and toddlers.

Example: The state oral health and MCH programs working collaboratively to improve systems of care (such as improved collaboration between medical and dental homes) and financing for oral health.

5. Objectives / Rationale

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• A practice or program aligns its objectives with the national or state agenda to improve the oral health and general health of infants and toddlers.

Example: Program objectives target Healthy People 2010 objectives to reduce caries experience, untreated decay, and use of the oral health care delivery system.

VI. State Practice Examples

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.

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 report.

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TABLE 1.State and Community Practice Examples of

State, Pre-school and Community-based Infant, Toddler and Early Childhood Oral Health Programs

Item Practice Name State Practice #

A. Pediatric Oral Health Training Programs for Health Professionals

1American Academy of Pediatrics Collaborative Care Program (PedsCare)

2 Bright Futures in Oral Health

3 Access to Baby and Child Dentistry Program (ABCD) WA

4 Into the Mouths of Babes NC

5 California First Five Oral Health Initiative CA

6Healthy Smile - Happy Child Program (Early Childhood Caries Prevention) <Updated March 2003)

NV 31001

B. Screening, Education and Prevention Programs

1Kids Smile: Kentucky’s Screening and Fluoride Program for Children Ages 0-5

KY

2 More Smiling Faces in Beautiful Places SC

3 Open Wide CT

4 Mother and Youth Access Program CA

5 Iowa Access to Baby and Child Dentistry (ABCD) Program IA 18003

C. Head Start Programs

1Cavity Free Kids: Oral Health Education for Pre-school Children and their Families

WA

2Kansas Head Start Association Early Head Start Oral Health Initiative

KS

3 Tufts University Dental School Community Outreach Program MA

4 Iowa Healthy Smiles Parent Education Program IA

D. WIC Programs

1 Klamath Falls Early Childhood Cavity Prevention Program OR

2 Fluoride Varnish Application Program (Updated March 2006) IA 18002

E. CHC, Portable and Mobile Dental Programs

1 Commonwealth Mobile Oral Health Programs MA

2 Massachusetts Dental Society Care Van MA

3 HRSA, Oral Health Disparities Pilot Program CO/MO

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B. Highlights of Practice Examples

Highlights of state practice examples are listed below.

<Will write highlights once practice example descriptions are collected.>

Date of Report: DRAFT September 15, 2008

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ATTACHMENT A

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Strength of Evidence Supporting Best Practice Approaches

The ASTDD Best Practices Committee took a broader 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 ProvenBest Practice Approaches Best Practice Approaches

Research + Research +++Expert Opinion + Expert Opinion +++Field Lessons + Field Lessons +++Theoretical Rationale +++ Theoretical Rationale +++

Research+ 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.

Expert Opinion+ 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.

Field Lessons+ 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.

1. Baby’s first teeth. Journal of the American Dental Association 2002; 133: 255.2. American Academy of Pediatric Dentistry. Definitions, Oral Health Policies, and Clinical

Guidelines. Available at: http://www.aapd.org/media/Policies_Guidelines/D_ECC.pdf3. Sheiham, A. Dental caries affects body weight, growth and quality of life in pre-school children.

British Dental Journal 2006; 201(10): 625-6.4. Acs G, Shulman R, Ng, MW, Chussid S. The effect of dental rehabilitation on the body weight of

children with early childhood caries. Pediatric Dentistry 1999; 21(2): 109-13. 5. Acs, G, Lodolini G, Shulman R, Chussid S. The effect of dental rehabilitation on the body weight

of children with failure to thrive: Case reports. The Compendium of Continuing Education in Dentistry 1998; 19(2): 164-8, 170-1.

6. Ayhan H, Suskan E, Yildirim S. The effect of nursing or rampant caries on height, body weight and head circumference. The Journal of Clinical Pediatric Dentistry 1996; 20(3): 209-12.

7. Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatric Dentistry 1992; 14(5): 302-5.

8. American Academy of Pediatric Dentistry. Policy on use of a Caries-risk Assessment Tool (CAT) for infants, children, and adolescents. Reference Manual 2008; 29(7): 29-33.

9. Berkowitz, RJ. Causes, treatment, and prevention of ECC: A microbiologic perspective. Journal of the Canadian Dental Association 2003; 69: 304-7.

10. Li Y, Wang W. Predicting caries in permanent teeth from caries in primary teeth: An eight year cohort study. Journal of Dental Research 2002; 81: 561-6.

11. United State Public Health Service, Office of the Surgeon General. Oral health in America: A report of the surgeon general. Rockville, MD: Department of Health and Human Services, U.S. Public Health Service, 2000.

12. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Dental examiners procedure manual. Accessed 9/15/08 at: http://www.cdc.gov/ nchs/data/nhanes/oh-e.pdf

13. Hiroko L, Auinger P, Billings R, Witzman M. Association between infant breastfeeding and early childhood caries in the United States. Pediatrics 2007; 120(4): 944-952.

14. Edelstein B, Crall J. Pediatric dental care in CHIP and Medicaid: Paying for what kids need, getting value for state payments. The Reforming State Group and the Milbank Memorial Fund. July 1999.

15. Edelstein, B. Dental care considerations for young children. Special Care Dentistry 2002; 22(3): 11S-25S.

16. Manski, RJ, Brown E. Dental use, expenses, private dental coverage, and changes, 1996 and 2004. Rockville, MD: Agency for Healthcare Research and Quality; 2007. MEPS Chartbook No. 17

17. Child and Adolescent Health Measurement Initiative. 2003 National Survey of Children’s Health, Data Resource Center for Child and Adolescent Health website. Retrieved 9/15/08 from www.nschdata.org

18. Zavras T, Edelstein BL, Vamvakidis T. Health care savings from microbiologic caries risk screening of toddlers: A cost estimation model. Journal of Public Health Dentistry 2000; 60: 182-8.

19. Ramos-Gomez FJ, Shephard DS. Cost-effectiveness model for prevention of early childhood caries. Journal of the California Dental Association 1999; 27(7): 539-44.

20. Kowash MB, Toumba KJ, Curzon ME. Cost-effectiveness of a long-term dental health education program for the prevention for the prevention of early childhood caries. European Archives of Paediatric Dentistry 2006; 7(3): 130-5.

21. Pettinato E, Webb M, Seale S. A comparison of Medicaid reimbursement for non-definitive pediatric dental treatment in the emergency room versus periodic preventive care. Pediatric Dentistry 2000; 22(6): 463-468.

22. Berkowitz RJ. Causes, treatment and prevention of early childhood caries: A microbiologic perspective. Journal of the Canadian Dental Association 2003; 69(5): 304-7.

23. Savage MF, Lee JY, Kotch JB, Vann WF. Early preventive dental visits: Effects on subsequent utilization and costs. Pediatrics 2004; 114(4): 418-423.

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24. Borchgrevink A, Snyder A, Gehshan S. The effects of Medicaid reimbursement rates on access to care. National Academy for State Health Policy March 2008

25. American Dental Association. State and community models for improving access to dental care for the underserved- a white paper. Chicago: American Dental Association: 2004.

26. Glick M. The tower of Babel and health outcomes. Journal of the American Dental Association 2006; 137: 1356-1358.

27. Kenney GM, McFeeters JR, Yee JY. Preventive dental care and unmet dental needs among low-income children. American Journal of Public Health 2005; 95(8): 1360-1366.

28. Agency for Healthcare Research and Quality. Rockville, MD. Diagnosis and management of dental caries. Summary, evidence report/technology assessment: Number 36. AHRQ Publication No. 01-E055, February 2001. http://www.ahrq.gov/clinic/epcsums/dentsumm.htm

29. Prevention of Dental Caries in Preschool Children, Topic Page. April 2004. U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf/uspsdnch.htm

30. Diagnosis and management of dental caries throughout life. NIH Consensus Statement 2001 March 26-28; 18(1): 1-24.

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