In July 2008, the Minnesota Department of Health began a two-year project aimed at addressing the rising oral healthcare crisis among at-risk children in the state. Funded by the Health Resources and Services Administration, or HRSA, and the Centers for Disease Control and Prevention, the Oral Health Zone, or OHZ, project is a subproject of the state’s overall commitment to HRSA and CDC to develop for Minnesota a public oral health infrastructure.
The overarching goal of the OHZ project was to assist the participating counties in addressing the dental caries crisis affecting Minnesota’s high-risk children. Caries — the disease process, the end result of which is the cavity, or “hole” — has reached silent epidemic proportions among the nation’s high-risk children. Among these high-risk children, it is estimated that as many as 20% of 2-year-olds and 50% to 60% of 5-year-olds have caries. Caries is the most common chronic disease of childhood, five times more prevalent than asthma and seven times more prevalent than hay fever. Though mortality from caries is rare, in 2007, a 12-year-old boy in Maryland and a 6-year-old boy in Mississippi each died — one from a brain abscess, the other from a generalized infection. In both cases, the underlying pathology was an abscessed tooth for which the child’s caregiver could not find a dentist to provide care.
Morbidity from badly decayed teeth is common. It can range from simple cosmetic effects, which may have an impact on self-esteem, to more significant health problems, including, pain, abscess, difficulty eating secondary to pain, delay in growth and development, speech problems, and poor facial and jaw development. Left untreated, such systemic, long-term effects as increased risk for cardiovascular disease and difficulty controlling diabetes mellitus can occur.
Children in pain experience poor school performance and miss school days. In 1999, an estimated 51 million hours of school time were lost due to children experiencing severe pain. For each child who misses school, a parent has to stay home with the child; if the parent works, this often leads to lost wages and potentially loss of employment.
But because caries is an infectious disease, it is theoretically preventable through early intervention and application of fluoride varnish and caregiver education.
The basis for the Minnesota OHZ project was originally established with a generous founding grant from the 3M Foundation and support from the National Children’s Oral Health Foundation, or NCOHF. The project’s initial objective required training primary care medical providers in Minnesota to integrate caries prevention intervention, or CPI, into the well-child examination. The training included instruction on how to do a gross oral examination; perform a paper-and-pencil caries risk assessment; offer anticipatory guidance to caregivers about caries etiology and the caregiver’s role in prevention; apply fluoride varnish on a quarterly basis to the teeth of a high-risk child starting at age 1; and how to instruct caregivers that fluoride varnish is neither a sealant nor is it a substitute for a dental home for comprehensive care, and that it is critical to establish the dental home by the child’s first birthday.
From late 2008 to September 2010, CPI training was implemented in 130 practices in a variety of medical settings, including, small groups, small networks, large networks and health systems, located in large and small cities throughout Minnesota. More than 80% of clinics that received the training have since integrated CPI into their examination of high-risk children.
The second objective of the project was to begin to establish OHZs in communities throughout Minnesota in a collaborative effort to improve the oral health of high-risk children in those areas.
The basic approach of the OHZ project is to convene a meeting involving all community stakeholders, including, but not limited to, primary care physicians (i.e., pediatrics, family medicine and obstetrics); nurse practitioners and physician assistants; dentists (general and pediatric) and dental hygienists; pharmacists; social workers; public health nurses and school representatives. Communities were also encouraged to identify and add additional stakeholders that made sense to partner in the project.
Once community stakeholder groups have been convened, OHZ project staff performs a review of the community’s caries statistics, and provide assistance and support to help community stakeholders take ownership of, and begin to solve, the problems in their areas. Several possible strategies for addressing the caries problem have been identified, including:
Early childhood primary care providers and dental hygienists counsel caregivers about caries etiology and prevention and, on a quarterly basis, apply fluoride varnish to the teeth of high-risk children;
Caregiver education during the third trimester of prenatal care;
Dentists better prepared to provide necessary restorative work for young children; and
Educators, dental hygienists, and public health nurses work to improve oral health literacy of community residents.
Amos S. Deinard, M.D., holds a masters degree in public health and is an associate professor at the University of Minnesota Department of Pediatrics/School of Public Health.