The Affordable Care Act (ACA) mandates risk assessments, preventive care, and evaluations based on outcomes. ACA compliance will require easily accessible, cost-effective care models that are flexible and simple to establish. UCLA has developed an Infant Oral Care Program (IOCP) in partnership with community-based organizations that is an intervention model providing culturally competent perinatal and infant oral care for underserved, low-income, and/or minority children aged 0–5 and their caregivers. In collaboration with the Venice Family Clinic's Simms/Mann Health and Wellness Center, UCLA Pediatrics, Women, Infants, and Children (WIC), and Early Head Start and Head Start programs, the IOCP increases family-centered care access and promotes early utilization of dental services in nontraditional, primary care settings. Emphasizing disease prevention, management, and care that is sensitive to cultural, language, and oral health literacy challenges, IOCP patients achieve better oral health maintenance “in health” not in “disease modality”. IOCP uses interprofessional education to promote pediatric oral health across multiple disciplines and highlights the necessity for the “age-one visit”. This innovative clinical model facilitates early intervention and disease management. It sets a new standard of minimally invasive dental care that is widely available and prevention focused, with high retention rates due to strong collaborations with the community-based organizations serving these vulnerable, high-risk children.
The US Surgeon General has identified early childhood caries (ECC) as the most common chronic childhood disease; it is five times more prevalent than asthma [
About 80% of dental disease, including ECC, is concentrated in 20%–25% of children, primarily those from low-income and/or minority backgrounds [
Although ECC is exceedingly prevalent among young children, it is also highly preventable with early intervention. Early identification of oral diseases like ECC can reduce the risk of, arrest, or even reverse disease. The American Academy of Pediatric Dentistry [
As such, strategies are necessary to ensure and promote early recurring dental care, particularly for populations suffering the greatest burden of disease. To that end, for instance, the American Academy of Pediatric Dentists has funded grants to improve access to high quality dental care for children in need. From 2010 to 2012, eighteen grant recipients received assistance to support community-based programs that expanded dental care to children in need; another 15 received grants in 2013 [
The Commission Dental Accreditation (CODA) has also recently recognized the value of community-based learning for dental students by updating their standards to include broader clinical experiences [
IOCP launched in 2010 through UCLA’s School of Dentistry’s Section of Pediatric Dentistry in partnership with the Venice Family Clinic’s Simms/Mann Health and Wellness Center (VFC) and nearby WIC and EHS/HS sites. IOCP functions on the assumption that at-risk children and their parents/caregivers visit venues like community clinics and HS/EHS and WIC sites earlier and with more regularity than dental clinics. Therefore, these program sites offered significant promise as partners for outreach, education, and referrals to increase compliance with the age-one visit [
IOCP was established with the goal of offering early and ongoing dental care to low-income and/or minority children aged 0–5 years old. VFC and WIC donated office space and medical exam rooms for IOCP operations. The IOCP provided trainings to all community partners, for example, WIC and HS/EHS staff, VFC pediatricians and nurse practitioners, and other allied health workers, on the effect of oral health on overall health over the life course. These trainings were key in obtaining patient recruitment and referrals as well as to initiate a cultural and perception change on when to seek dental care. Pediatric residents, supervised by faculty and assisted by 3rd and 4th year predoctoral dental students, conducted exams for IOCP patients. Exam protocols emphasized early, ongoing care provided in a culturally appropriate manner. The IOCP remained the child’s dental home until he/she “graduated” at age 3–5 years to a full service dental clinic. In addition, patients of the IOCP who required restorations or other more invasive procedures were seamlessly referred to the VFC’s dental clinic, while referrals for tertiary care, such as full mouth rehabilitation under general anesthesia, were made to university clinics or comparable hospital programs. Whenever possible, the IOCP designed its operational procedures to be as simple and as streamlined as possible, to make access entry and continuation effortless for its patients and their families.
IOCP has limited overhead and start-up costs. The provision of basic dental services only requires a “pod”—a private room with two chairs and a portable light as well as educational materials, intake forms, and disposable dental equipment and supplies such as mirrors, gloves, fluoride varnish, and gauze. For UCLA’s IOCP, VFC and WIC provided space within their existing facilities for a minimum of four hours per week. With an already established pool of low-income and/or minority patients and clients at these facilities, the IOCP had immediate access to its target population; for example, VFC had a well-established Well Baby clinic. All IOCP patients were required to register as a patient of VFC to facilitate tracking, record keeping, and care coordination. Initially, IOCP clinicians did not have access to an electronic medical record system (EHR). Data and communications with caregivers and other providers were manually captured and tracked. However, the recent installation of new software at VFC has enabled the IOCP clinicians to more efficiently document and track a child’s oral health status over time through electronic medical records (EHR), which have incorporated forms for caries management by risk assessment (CAMBRA) and self-management goals.
IOCP is also a required three-month rotation for UCLA pediatric dentistry residents to provide more in-depth exposure to working within a community health setting with children at high risk for disease due to socioeconomic circumstances. In addition, their IOCP rotation is supplemented by didactic experiences that enhance their understanding of oral health from a public health perspective, rather than merely clinical one. IOCP is also an elective offered to third and fourth year predoctoral dental students interested in increasing their experience in pediatric dentistry. Candidates in UCLA’s Advanced Education in General Dentistry program and foreign-trained dentists participating in UCLA’s Preceptorship program may also elect for a rotation through IOCP. Even further, practicing dentists of any type as well as pediatricians and nurse practitioners may participate in IOCP; in fact, many have taken part to increase their comfort level in working with children and their understanding of access disparities for high-risk populations.
All partner staff involved in IOCP received trainings led by UCLA pediatric dentistry residents on the oral disease process and commitment to oral health. To more deliberately encourage these diverse team members to work collaboratively, structured discussions are also held to gain consensus on how each profession can contribute to a child’s optimal oral health and on how to better coordinate care across disciplines to improve their health through IOCP. Due to the cultural diversity of the patients served, IOCP practitioners also received specific training to sensitize them to the language, culture, and oral health literacy challenges they would face in order to effectively treat these patients. Further, a focus on interprofessional collaboration among medical and dental professionals and with community-based organizations required taking a multifaceted approach to “health”, including a focus on holistic and comprehensive care that factor in things that include but are not limited to diet and physical activity.
The IOCP provides early and culturally competent perinatal and infant oral care for mothers/caregivers and children aged 0–5 years old based on a simple standard of care infant oral protocol [
At each scheduled visit, providers conduct an Infant Well Baby Oral Exam, similar to a Well Baby visit with a pediatrician. This exam includes six steps: (1) caries risk assessment, (2) proper positioning of the child for a knee-to-knee exam, (3) age-appropriate tooth-brushing prophylaxis, (4) a clinical exam, (5) fluoride varnish treatment, and (6) anticipatory guidance, counseling, and self-management goals [
Step 1: CAMBRA interview.
At VFC, IOCP clinicians use the caries management By risk assessment (CAMBRA) caries risk assessment tool to rate a child as having high, moderate, or low caries risk (Figure
The CAMBRA interview is followed by the oral exam. First and foremost is proper positioning of the child to ensure that he/she is comfortable, safe, and secure. In young children or those with special needs, a knee-to-knee position is best (Figure
Step 2: knee-to-knee exam.
During each exam, the provider performs a toothbrush prophylaxis to remove any plaque or debris from the teeth prior to the clinical exam (Figure
Step 3: toothbrush prophylaxis.
The examiner will then conduct a clinical exam that includes counting the child’s teeth aloud, using the toothbrush handle as a mouth prop, if necessary (Figure
Step 4: clinical exam.
Step 5: fluoride varnish.
Step 6: self-management goals.
CAMBRA form.
Self-management goals.
Although the program provides care only four hours per week at each site (VFC and WIC), IOCP has been able to reach a significant portion of its target population earlier than planned and with higher retention levels than have been seen in dental clinics. In fact, IOCP has attended to 672 unique patients across over 1,500 visits since its inception in 2010. Slightly more than 42% of the children in IOCP have had two or more visits, and the numbers continue to increase.
As of July 2013, among those patients who have not graduated to the VFC dental clinical, IOCP maintained 138 patients as caries-free and prevented precavitated lesions from progressing in 51 patients. These successes are attributed to capturing underserved populations through proactive referrals from our community partners and case management and triage based on individual risk and by interdisciplinary clinic staff. Part of the success may also be due to positive shifts in parental and caregiver knowledge and attitudes regarding oral health.
The quality improvement measures tracked include, but are not limited to, the following: Percent of ECC patients presenting with new cavitation; Percent of ECC patients presenting with pain from untreated decay; Percent of ECC patients with documented caries (high, medium, and low); Percent of ECC patients who had disease management visiting within the recommended interval based on risk; Percent of ECC patients with self-management goals reviewed at most recent disease management visit; Percent of ECC patients whose risk status has improved.
The above measures have helped isolate areas for improvement in IOCP and develop disease management and prevention strategies that can be implemented on a much wider scale. We believe that long-term analysis will provide evidence showing the efficacy of IOCP in reducing the burden of oral disease, developing a strong case for expanding similar oral health disease prevention and management programs elsewhere.
The integration of oral health into primary medical care can improve the continuity of care between dental and medical homes and could foster better health behaviors that could achieve and preserve good oral health, resulting in a lower disease risk [
Coordinated community outreach is also important. More must be done to achieve consensus and acceptance within the dental community on enforcing the age-1 visit recommendation. Medical personnel, especially pediatric and obstetric professionals and allied health workers, must understand the correlation between a mother’s oral health status and its impact on her child(ren), and they must also endorse and promote the age-1 visit to their patients. Community-based organizations, such as Head Start/Early Head Start (HS/EHS), Women, Infants, and Children (WIC), day care centers, and schools need to be actively engaged in educating their parent and caregiver participants on the need for regular dental checkups beginning at the age of 1. Finally, cost-effective, easily accessible, family-centered, culturally sensitive models of care are needed. The success of an Infant Oral Care Program depends on overcoming such challenges.
The IOCP is also built upon the principle that prevention of oral disease is preferable to surgical treatment. The IOCP emphasizes the need for risk assessments so that care can be tailored to the individual child’s need as opposed to a one-size-fits-all approach to recall visits, fluoride varnish applications, and other preventive care. This concept, while not new, is often difficult to promote since, in many states, more traditional dental treatments generate income, while the cost effectiveness of prevention is harder to enumerate. In addition, Medicaid reimbursement rates may not cover all the activities recommended by the IOCP. Sites with existing dental clinics may see the IOCP as a program that could decrease revenue. However, the IOCP is intended to maximize resource utilization by increasing the number of patients overall for the clinic with only the more acute cases necessitating more expensive clinical chair time and where net dental home patients also increase. Therefore, mandates to change to reimbursement rates are also needed to incent dental providers to increase their acceptance of Medicaid patients and shift emphasis to preventing disease.
Dental programs need to act now to update their curriculum to provide future dentists with a skill set that can address the growing community need and provide their doctoral candidates with the opportunity to gain proficiency through community practice. Cultural sensitivity will become more critical and dental schools also need to incorporate risk assessment and preventive care programs with an emphasis equal to cavitation treatment options.
The IOCP is an easily replicable program with low start-up and maintenance costs. However, success is contingent upon establishing strong community-based partnerships in order to overcome the many biological, behavioral, and environmental differences among vulnerable populations that influence health outcomes. IOCP community partnerships were selected based on each program’s close proximity to the IOCP operational site. WIC and EHS/HS were chosen because their program dynamics had a retention element already established, for example, appointments to pick up vouchers, attendance of their children, and so forth. In fact, any site can establish an IOCP and since most families accept a periodicity schedule for infant and toddler health care exams and procedures, such as immunizations, dental home visits, for example, can be offered on the same day and at the same venue as nondental appointments like Well-Baby visits. This strategy, combined with outreach and services provided by organizations similar to Early Head Start, Head Start, and WIC, can facilitate and has facilitated access to culturally sensitive oral health care screening, education and services for low-income and vulnerable populations by simplifying the entry process and linking it to other services that they are already utilizing with regularity.
IOCP effectively coalesces a multidisciplinary care team to establish a model for a new generation of healthcare providers and social service staff, all of whom will have the capacity to address the oral health needs for patients of all ages and backgrounds. Subsequently, this could reduce current disparities in oral health care access and disease among vulnerable populations that include children and low-income and/or minority families. Programs similar to the IOCP are important to the future of dental care to increase entry points for accessing care and to provide appropriate training for general dentists and other pediatric providers. Designed to complement existing medical and dental primary clinical settings, the IOCP provides a low-cost alternative to providing a dental home to a young population of children prior to the onset of dental disease which may require intervention in a full clinical environment. There is evidence based results on the success of utilizing community-based, social service partnerships in close proximity to the proposed operational site to increase patient early age recruitment and retention in a disease prevention management model such as the IOCP. The IOCP also importantly functions as a training opportunity for both dental and nondental professionals to increase experience, training, proficiency, and acceptance in treating very young children, aged 0–5 years, and keep their healthy teeth healthier.
However, multidisciplinary collaboration is not enough; as noted, care must also be culturally sensitive as critical factor in care. Professionals, both dental and nondental, need to begin to understand the importance of achieving and maintaining good oral health as an integral part of total health in order to address the emerging oral health crisis. To prepare for these changes, dentists and the providers with whom they collaborate will need to know how to best serve their patients using an individualized, age-appropriate, and risk-based approach to care and practice applying their knowledge in the community.
The author declares that there is no conflict of interests regarding the publication of this paper.
This study was funded by the HRSA Grant no. D88HP20129. The author wishes to recognize and thank Rebecca L. Pizzitola, MPH.; Debra L. Tom, BA; and Eric Lan, BS, for their research and editorial assistance.