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Initiative takes aim at early childhood caries

Program emphasizes communication, education and prevention


Family affair: A participating mom and child get a toothbrush as part of the family’s oral health education to help prevent early childhood caries.

Building relationships: An ECC program site professional interacts with a child during a regular visit.
Westborough, Mass
.—Armed with fluorides, disease management tools and a quality improvement plan to help at-risk families with young children manage and prevent dental disease, a collaborative program is working to change the way dentists fight the epidemic of early childhood caries.

The results include better outcomes, happier patients, fewer no-shows and a growing sense of community among the participating clinics.

In 2008, the DentaQuest Institute, along with Boston Children's Hospital and St. Joseph Hospital for Specialty Care in Providence, R.I., developed the Early Childhood Caries Collaborative to reduce the number of young patients treated in the operating room and to reduce cavity recurrence in patients treated at hospitals. The initiative uses an evidence-based method of managing and preventing early childhood tooth decay in patients seeking treatment at hospital-based dental clinics.

The initial phase of the ECC Initiative was so successful, reducing operating room utilization by 55 percent, new cavity development by 69 percent and pain by 50 percent, that the program was expanded to five additional federally qualified health centers. This month, the initiative will enter its third phase and branch out to some 40 total sites—including private dental practices—that will use its evidence-based protocols to help improve the oral health of children in vulnerable populations.

"The philosophy behind the initiative is to help providers feel more comfortable treating young children at high risk because they are so susceptible to caries and it's really important to see them early on," said Dr. Robert Compton, DentaQuest Institute executive director. "Our Phase I pilot showed that following the protocols had a significant impact. The protocols focused on changing behaviors—bringing kids to the dentist early on to catch disease before it takes hold, educating parents, helping families set simple goals and using risk status to determine recall and fluoride varnish frequencies." 

Statistics from the National Institute of Dental and Craniofacial Research say that, though dental caries in the baby teeth of children ages 2-11 declined from the early 1970s to the mid 1990s, the most recent National Health and Nutrition Examination Survey from 1999-2004 has shown that primary decay is on the increase in younger children. Forty-two percent have had dental caries in their primary teeth and children in high-risk categories—minorities and those living in families with lower incomes—have more decay. The survey also showed that nearly a quarter of children in this age group, 23 percent, have untreated dental caries.

The ADA defines early childhood caries as "the presence of one or more decayed, missing or filled tooth surfaces in any primary tooth in a preschool-age child between birth and 71 months of age" and recognizes that early childhood caries is a significant public health problem in selected populations and is also found throughout the general population. ADA policy (Trans. 2000:454) encourages its members "to educate parents (including expectant parents) and caregivers about reducing the risk for early childhood caries" and "recognizing that the science surrounding early childhood caries continues to evolve, encourages research activities to study risk factors and preventive practices and should continue to seek a cure for early childhood caries."

The usual treatment, according to the DentaQuest Institute, has been to treat the damage from tooth decay in the operating room with aggressive treatment that often involves anesthesia, root canals and stainless steel crowns but not address what caused the problem in the first place. As a consequence, many children return within a year with new disease and in need of additional surgery.


Dr. Compton

Dr.Ng
"DentaQuest is a dental benefits administrator for 17 million people nationwide, and through the DentaQuest Institute, we are always looking at how we could improve quality of care and control costs," said Dr. Robert Compton, executive director of the institute. "The DentaQuest Foundation offers grants to groups who are trying to make changes for the better and the institute works with the providers themselves. Our mission is to improve the oral health of all and we are getting good results through the ECC Collaborative."

"The ECC Collaborative allows my team to learn from experts in practice-based oral health improvement, participate in free professional development and related discussion groups and receive support in implementation of effective protocols for the management and prevention of advanced tooth decay in children," said Dr. Man Wei Ng, dentist-in-chief at Children's Hospital Boston and principal investigator for the first two phases of the initiative. "In Phase I, we developed and tested a clinical protocol to prevent and manage ECC in high-risk children using quality improvement methods at two hospital-based practices. We created and tested scripts to better communicate with parents, assess their child's caries risk, explain the causes of the caries process and work collaboratively with them to identify self-management goals that would address disease etiology. Self-management goals typically include diet modification, parental assistance with tooth brushing and using fluorides and other remineralizing agents to help control the disease process."

Clinical staff participating in the program had several face-to-face learning sessions, monthly conference calls and received training and coaching by faculty and collaborative staff on topics including quality improvement theories, methods and activities and disease prevention and management of early childhood caries. 

Patients were asked to return for re-evaluation based on their caries risk, she added. At the follow-up appointment, the providers re-examined them for clinical changes, asked questions to assess behavioral changes in their diet and oral hygiene, applied fluoride varnish and reaffirmed or adjusted the patient's self-management goals. As the project entered the second phase, the protocols and communication tools were refined.


Care: Dr. Linda Nelson of Boston Children’s Hospital spends some time chairside with a young ECC patient.
"Sites have told us that the learning collaboratives are a great way to share knowledge and experiences not only between participants and faculty, but also among the participants and sites as well," Dr. Ng said.  "Some Phase II participants told us that they believed that they became better clinicians as a result of what they learned from the collaborative by communicating more effectively with parents and families and engaging them in the care of the child."

Not only were the learning sessions helpful for clinicians, they helped clinicians build strong working relationships with the patients in the program.

"Parents have told us that they feel the disease management approach was helpful for their child," said Dr. Ng. "Most parents appreciated being given reasons as to why their child may have developed ECC and some believe the disease management approach to be less judgmental and felt less blamed for their child's condition. Some like the collaboration/partnership with providers, believing that they were given a voice in the care of their children."

"The dental team at my former health center, the Center for Family Health in Jackson, Mich., is still very actively involved in the ECC Collaborative," said Dr. Jane Grover, director, ADA Council on Access, Prevention and Interprofessional Relations. Dr. Grover was the dental director at the federally qualified health center before joining the ADA. "From the very beginning, we could see that parent involvement was critical in the project, and setting the self-management goals with them, rather for them was a big motivator. The collaborative not only lowers the caries rates in high-risk kids, but lowers the no-show rate for treatment as well."

As the program expands into the third phase, Phase II site providers are serving as mentors to the new participating sites, said Dr. Compton.

"They feel a sense of community by being connected," he said. "This is helping the new sites get acclimated to the program. The initial seven sites are so excited about it. They're getting really good outcomes and they want to share the success with the Phase III sites."

"I am very excited about ECC Phase III as we have an opportunity to further test and disseminate the ECC chronic disease management approach," said Dr. Ng.  "With further dissemination, I hope to see a paradigm shift toward risk based disease prevention and management of ECC in the near future. DentaQuest has been instrumental in terms of the way we are practicing at Children's Hospital."

"Once we show clinically that we can get better outcomes using these protocols, we can bring the information to policymakers—that we can lower costs, avoid the OR, save $10 in treatment costs for every dollar spent on disease management and prevention and spur benefit design changes," said Dr. Compton. "It's a better way to spend our very limited dollars and it is an empowering way to look at the way we provide care in the U.S."