Introduction by Christopher E. Carroll, D.M.D.
This issue is Northwest Dentistry’s first opportunity to introduce its readers to one of the Minnesota Dental Association’s newest committees, and, in a way, to its fraternal twin. The former is the Children’s Health Care Committee. This committee had long been planned for before its birth. The chair and members knew well in advance of its inaugural meeting. Much groundwork had been done: A mission, objectives, and even an agenda were in place when we first came together as a group on January 11, 2010.
The delivery of the second twin, a mere eight days later on January 19, was considerably more complicated. Even the name is more difficult: Dentists and Physicians Working Together to Address Oral Health. It was brought together, in part, to deal with a brushfire that the Minnesota State Senate was trying to start over on the physicians’ side of the health professions.
After introductions, the Children’s Health Care Committee got right down to business. Plans were made for Children’s Dental Health Month, and other pieces of business were dealt with as well, but our major new initiative was introduced by our Chair, Teresa Fong, a pediatric dentist from Saint Paul. She was determined that our committee should be promoting to our membership the infant dental exam.
That children be seen for their first dental examination within six months of the eruption of the first tooth or within the first year of life is something that the American Right from the Start: A New Initiative for Children’s Oral Health Dental Association, American Academy of Pediatric Dentistry, Academy of General Dentistry, and many other organizations have long recommended. With more than 60,000 live births in Minnesota each year and only 50 pediatric dentists, higher math is not required to determine that if these infant examinations are to be accomplished, general practice dentists will be needed to assume the significant portion of the load. Dr. Fong wants the MDA to encourage general practicing dentists to start seeing infants in their practices, and she wants us to teach them how to do it and how to make it rewarding for the families and practices alike.
Several states already have comprehensive infant dental programs in place. Washington State’s “ABCD” program has been going strong for more than 15 years. Western Michigan’s “Points of Light” program is very successful and still growing. South Dakota is up and running, and Wisconsin and Kentucky are getting underway. Even “Dr. Bicuspid” and “Inside Dentistry” have gotten ahead of us on this, so Minnesota has some catching up to do.
Oh, the brushfire part of the story. The American Academy of Pediatrics endorses similar recommendations for infants’ oral health. A review of their website shows the subject covered quite well. It includes an excellent, on-line CE course for their members that includes caries risk assessment, screening exams, oral health care instructions for the parents, and a protocol for referral to dentists.
The Minnesota Medical Association is also on board with the concept. In 2009 their House of Delegates had resolutions that promoted oral exams, caries risk assessment, oral health care guidance and education, and fluoride varnish. They also resolved to work with the Minnesota Dental Association on pediatric dental access issues. Not unlike their dental colleagues, the physicians have yet, enmasse, to implement these recommendations. In steps the Minnesota State Senate. They were forwarding a bill requiring that “At the time of the child... care visit, the primary care health care provider [physician] MUST [our emphasis] perform primary caries preventive services.” These went on to include oral exam, caries risk assessment, topical fluoride, oral hygiene instructions, and so on.
An unfunded mandate sits just as well with our medical colleagues as it does with us. They quite naturally bristled at this and also quite naturally wanted to know where the dentists were. They asked to meet with us, and thus the “Dentists and Physicians Working Together to Address Oral Health Committee” was gathered.
Hit the ground running we did with an enthusiastic and productive meeting. More than a dozen of us met - members, trustees, vice-presidents, presidents, and Executive Directors of the MMA, MDA, Minnesota Academy of Pediatrics, Minnesota Academy of Pediatric Dentistry, and the Minnesota Academy of Family Physicians. What resulted from this first meeting was a plan to start two
pilot projects. One will be in the metro area, and the other will be outstate. These projects intend to bring, onto the same page, all that area’s stakeholders in infant oral health care. Each primary care physician and dentist is to be taught how to conduct the screenings and exams, how to best promote the oral health of the child, and how to collaborate most effectively with the colleagues in the other profession.
This article is the first of two. Part One discusses the what and the why of the initiative. Part Two will introduce our readers to the infant dental exam, and will expand the discussion of the why, when, and how as our efforts evolve.
Of course, it won’t do any good for the physicians to attempt to collaborate with the dentists on infant oral health care if we dentists are not in the game. We must do better. The purpose of the second half of the article is to introduce our membership to the infant dental exam, attempt to take some of the mystery and trepidation out of the process, and have everyone looking forward to a fuller participation in this critical and, honestly, delightful aspect of health care.
The knee-to-knee is the most commonly recommended method for examining infants. The parent is comfortable with it, and the little one is well controlled. It also gives the family a method to safely control the child in case they ever need to assess the extent of an injury (boo boo), administer medications, or even brush the teeth until Junior gets accustomed to having it done.
This three-year-old boy was seen recently for his first dental exam. This is his second dental appointment. One of the authors crunched the numbers for a year’s worth of their OR cases. The patients’ ages ranged from two years two months to five years four months, with an average just over three years of age. For the care rendered, it ranged from a low of six teeth for one child to 19 teeth for two other children, for an average of more than 11 teeth per child. If the one-year dental exam were to be embraced by all, the professions and the public alike, then scenes like this would become rare instead of commonplace.
On Friday, March 5, 2010, Northwest Dentistry sat down with MDA Children’s Health Care Committee chair Dr. Teresa Fong and Winona pediatric dentist and MDA Southeastern District trustee Dr.Chris Carroll to discuss the initiative to create the “first-year exam”. Their enthusiasm for the project is a match for their understanding of its implications for the future oral health of the public. Northwest Dentistry will follow the activities supporting their initiative over several issues.
NWD: Now that Dr. Carroll has introduced our readers to the context for this new initiative, let’s ground it in all the reasons why the profession should embrace it.
Dr. Fong: I’d begin with the necessity of breaking old paradigms, focusing on and discussing what is going on in the world right now, what’s going on with baby and children’s teeth today, and why all dentists should be interested. That has a lot of layers, from financial and political through to the professional responsibilities and ethics of care for the oral health of the entire population. In our meetings with the pediatricians, one of them told us that she does the Well Child early exams all the time, and when she sees something that needs a dentist’s attention, she advises the parents to get the child to a dentist right away. [pauses] And then the parent will call back and say, “I can’t find a dentist.” We want our initiative to speak to that general practice dentist. The need to start doing this first-year exam is an idea that is supported by all these institutions: American Academy of Pediatric Dentistry, American Dental Association, American Academy of Public Health Dentistry, American Academy of Pediatrics, Academy of General Dentistry.
NWD: Mandate, initiative ... how do we characterize this right now?
Dr. Carroll: In Minnesota, the credit goes to Teresa (Dr. Fong). She is the chair of the MDA’s Children’s Health Committee, this initiative was her idea, and she is advancing it with great enthusiasm.
Dr. Fong: Our committee believes that if we as dentists don’t do something about this, it could become a mandate, because right now the legislature is looking to mandate physicians to apply fluoride varnish.
NWD: How did this concern first reach you?
Dr. Fong: Gosh, it’s from every group I belong to! Through the MDA, however, this is an initiative, a member initiative, from the Children’s Health Care Committee. It also stems from a collaboration among the MDA, the Minnesota Academy of Family Physicians, and the Minnesota Academy of Pediatricians.
Dr. Carroll: People are surprised to learn that dentists have not been seeing babies. It has been recommended for decades - the American Academy of Pediatric Dentistry for 30 years; the ADA soon after that — but for some reason it has not been embraced by the profession.
Dr. Fong: The idea is supported nationally. Momentum is growing.
Dr. Carroll: We’re in the midst of a paradigm shift. Another of those “reasons why” it is important is that prevention is the best medicine. We have good statistics to prove it works. A study out of North Carolina in Pediatrics* said that if you see children at one year of age for their first dental visit, you subsequently end up paying less to keep them healthy. Seeing them early actually saves money.
NWD: What is the lie of the land among pediatricians, dentists, and physicians regarding this right now?
Dr. Fong: It really depends on the individual.
Dr. Carroll: Pediatricians have their hands full. We found out they have about 20 minutes per appointment to do what they have to do, and here we are asking them to add another 10-15
minutes to do really what dentists ought to be doing. So naturally they’re asking, “Where are the dentists?” While they are more than happy to be attuned to dental needs, asking them to be the primary oral health care giver and educator isn’t reasonable. They have enough to do already. Even so, some of them have really embraced it.
NWD: Current “common wisdom” is take children to the first exam when they are three, so part of this initiative has to be to educate the public.
Dr. Fong: Yes. Many dentists were trained in an era, prior to the late 90s, let’s say, when the concept wasn’t really taught in school, so they think “I really wouldn’t know what to do.” In actuality, every dentist practicing in our state has the tools already! Our committee isn’t trying to get every dentist in our state to treat every cavity, but to be able to recognize it, educate parents, and refer the child if he or she doesn’t wish to treat the decay. Being able to refer, for those dentists who think “If I see the decay, I’ll have to do something about it,” is doing something about it.
Dr. Carroll: This is an access-to-care issue too, where pediatric dentists aren’t available to a community. Pediatricians and primary care physicians look for dentists to see these patients, to see them before three, and currently they cannot find them. Even by the age of two, for so many of our cases we have already missed the boat.
Not all cases need to the operating room. Early or incipient lesions may not require any treatment at all other than changing habits at home and treating with dietary modifications, a toothbrush,
and a little fluoride from time to time. For very mild lesions, the dentist could treat with the IRT (Interim Restorative Treatment), where, just with hand instruments, you excavate an amount of decay and place a glass ionomer, a fluoride-releasing restorative that will stabilize things. There’s treatment, and there’s treatment; each person has to decide what he or she is comfortable with. Once you get rolling, who knows what you’ll get comfortable with eventually.
Dr. Fong: There are not enough pediatric dentists in our state, in our nation, to see every child one year old and under, so we need help, and we appreciate general dentists seeing children this age, referring if needed.
Dr. Carroll: I’d see all of ‘em if I could. We can’t see them all, but we want them seen. I’m tired of going to the hospital to see three-year-olds who just had their first dental visit and all 20 teeth need to be restored. We as a profession have failed that child. And what a way to get started with dental care! That has to stop.
Dr. Fong: An informal survey of eight of my metropolitan area pediatric dental colleagues found that each saw, on average, more than 60 baby bottle cases per year. With the hospital and anesthesia and dental costs all combined, the billing for these cases came to, conservatively, $6,000 per child. If one could extrapolate these numbers to include all 50 of Minnesota’s pediatric dentists, that would come to $18,000,000 per year. We asked the Department of Human Services to help us pin down more complete figures for the state, but it proved to be more difficult a problem for them than we thought it would be. We will continue to work on refining these figures, but nonetheless, it will still end up being a staggering sum of money spent each year for something which, conceivably, could have been prevented at close to 100%, and of course, let’s not ever lose sight of the terrible human cost of all of this.
An extremely damaged dentition, left, compared to a healthy mouth.
Grabbing the whole head and using two fingers to retract the lip is a safe and secure way to gain access to the upper anterior teeth. Cradling the lower jaw with the fingers and retracting the lip with the thumb will reveal the lower anterior teeth.
NWD: What do you anticipate for CE as the initiative grows?
Dr. Carroll: The state of Wisconsin and the AAPD collaborated on a 33-minute DVD that goes over the rationale for the baby exam, how to do it, how to bill for it, and everything. We are planning to take it around the state one society or study club at a time and try to educate everybody. Then we have these pilot projects. Dean Lloyd has signed on and is very enthusiastic, and is offering the School’s outreach clinics. We’ll bring together the infant oral health care stakeholders - pediatricians, county nurses, dentists, primary care physicians, possibly Head Start — get us all on the same page, teach everyone how to conduct these exams, get us all speaking the same language, and get these babies seen at one year of age in the dental office before they are seen at three
in the OR.
Dr. Fong: I do feel that general dentists recognize the need for this. Many may just feel, “Oh, I don’t know exactly what to do.” A goal of our committee is to provide the education, to help people know how to do this exam, because they possess all the tools already.
Dr. Carroll: I think they’re just scared of babies! [laughter]
Dr. Fong: When someone screams, it’s scary!
NWD: So how do you handle that?
Dr. Fong: They need the mindset, the knowledge and understanding of what needs to get done.
Dr. Carroll: The first thing they teach in pediatric dentistry is “You treat the child, and manage the parent.” The hardest thing about the baby exam probably is how to manage the parents so they don’t get exercised when Junior gets upset about having his teeth looked at. You can get an emotional feedback loop between parent and child that can spiral out of control. Start by looking at what you can do to keep things calm while baby’s fussing. What do you tell the parent to make him or her accepting of what is about to happen?
Dr. Fong: You don’t just plop a baby down and start.
NWD: So what is the mindset that will allow you to succeed?
Dr. Carroll: I try to set the parent’s mind at ease. I look at the child and try to anticipate how he or she is going to react; then tell the parent how the kid is going to behave before it happens. If you put the kid in the chair and then explain why he or she is fussing, it is too late. However, if you explain that every time that child goes to a new clinic he or she gets an inoculation, naturally they are going to be wary. They are going to “complain a bit,” but “this is only natural and to be expected.” It can make all the difference. So prepare them for the worst. Then if it all goes well and the child is laughing, the parent thinks you’re a miracle worker.
Dr. Fong: By the time I come to the chair, the assistant or hygienist has already done the caries risk assessment, and I can see the answers. I begin a conversation as the parent holds the child, and that’s when I can size up the patient and the parent. That determines the course of what I tell the parents about what is going to happen, and I can reassure them that a given behavior happens often during these exams.
Dr. Carroll: Then you wink at the parent and say, “And if they do fuss, we get a real good look at things.” [laughter] But one-year-olds don’t fuss like three-year-olds! While most general practice dentists seem to want to wait until three, I cannot conceive of a more difficult age for an initial dental exam. Three-year-olds are smart, but egocentric. The whole world is seen only through their eyes. They are not capable of abstract thinking; for example, that someone else might have an agenda too. They’re willful. It’s a fun age because they’re adventuresome — it’s the time we discover where our boundaries are by pushing everybody and everything as hard as we possibly can. That’s not when I first want to see the kid!
Dr. Fong: I agree. One-year-olds are great for an exam, especially with the parent holding them; the child’s head is in your lap or in the chair, the parent is right there.
Dr. Carroll: A one-year-old might grouse and complain, but he or she won’t be struggling and kicking. If three-year-olds weighed 300 pounds, our species would not have evolved. They’d have killed us all. [laughter] From two-and-a-half to three-and-a-half, it’s the nature of the child to be disagreeable. It’s the best they can do. Thank goodness they turn four; it’s the nature of a four-year-old to be cooperative. Four is delightful most of the time.
Dr. Fong: Other than that, I think what scares general practitioners is just not knowing what needs to be incorporated in that first exam. What if I leave something out; what if I overdo it? Because dentists are perfectionists.
NWD: We’ve heard that somewhere.
Dr. Carroll: But the mindset of seeing them at three is entrenched. In society, and unfortunately in the profession. But think about it: We’re not “family dentistry” or “all family dental” if we don’t see all the family. And again, prevention is the best medicine; the sooner we start, the greater our chances for success become.
Dr. Fong: Our committee is working on a template for the “how to” of that first exam. It is being developed, and will be available to all MDA member dentists. Right now we need to get the word out about the “reasons why”. You asked about our pilot projects. The Children’s Health Care Committee is focused on working with our member dentists on increasing the accessibility and the knowledge of the first-year exam. The MDA also has a collaboration with the Minnesota Academy of Family Physicians and Minnesota Academy of Pediatrics to debunk any myths the dentists and physicians have about each other and dental care for kids, and to bring about a way for dentists and physicians in communities to communicate in order to best provide a first-year exam or dental screening to start a process to get these kids seen and taken care of. This pilot project will begin in one rural area and one within the Twin Cities. This is in everyone’s best interest, and everyone will be considered a stakeholder as it develops. The goal will be to make sure there is a unified message about the first-year dental exam for children, to be sure children are being screened, examined, that fluoride varnish is applied appropriately, that caries risk assessment is done, and to find a way to bring dentists and physicians together in communities to discuss how best to achieve these things with a consistent message. We want to reach that dentist who isn’t doing this now.
Dr. Carroll: What I don’t want to get lost in this message is this: It’s just - fun. I love babies. When one is in the waiting room, I have to go out there and pick ‘em up, hold them or play with them. Here’s the secret: If I pick a baby up and it fusses, I don’t take it personally, I just hand it right back. They are just acting their age, so I’m not embarrassed and my feelings aren’t hurt. This takes the fear out of seeing babies, and since I’m not scared of them, they tend not to fuss. Often parents are agog, saying things like, “They won’t even let their grandmother hold them!” Remember,you have not embarrassed yourself if one of them fusses, and don’t take it personally. They’re just acting their age - which is what we should do: “cowboy up” and take care of these children. It’s our responsibility.
Dr. Fong: I see this as a great opportunity for all dentists in our state. We are rich in family practices where we have full-family patient relationships built in already, so there is a history already in place when a baby is added. In my practice, I often meet the parent for the first time with the neonate patient. Adding the first-year exam is a great opportunity to build your practice, help stem
the flood of dollars going to early childhood caries treatment, and to add another service you can provide. You don’t have to buy a thing - you as a dentist possess all the tools already.
Dr. Carroll: And if you don’t, someone else will. Demand is increasing. The one-year dental exam is the standard now being promoted in the popular press for parents. If your practice isn’t on board, you are not going to get that whole family. As for the exam, it’s easy to do. There are no special tricks, and what tricks there are, you will learn with experience. And how rewarding it is to look back on a mature patient of yours and to see them in great shape and know they have been under your care since they got their first tooth. How can you have more pride in what you do than that? It’s time for dentists to get in the game