2009 Model Practice Application (Public)

Baltimore City Fluoride Varnish Initiative

Baltimore City Health Department

Tooth decay is a chronic disease that affects thousands of Baltimore children. It causes pain, impairs nutrition, and interrupts learning. Yet tooth decay is largely preventable. Fluoride varnish applied regularly between the ages of six months to five years can reduce tooth decay by 46 percent. Because there are not enough pediatric dentists to implement fluoride varnish for all children in Baltimore who could benefit, integrating primary care and oral health is vital to improving the health status of low-income Baltimore City children. Although toddlers are rarely are taken to the dentist, they are regularly seen at pediatric medical practices. To determine the feasibility of incorporating prophylactic applications of fluoride varnish into Medicaid well-child visits throughout Maryland, the Baltimore City Health Department undertook a new pilot program at sites serving this population. To date, more than 2,115 children have received the fluoride varnish treatment, and the treatment has been applied 2,607 times. Approximately 61 percent of eligible children have received the treatment. A comprehensive interim report was completed in May 2008. The report was released publicly and contributed to public understanding of the program. It ultimately led to Maryland Medicaid’s decision to offer this service to all patients’ ages 12 to 36 months in the state of Maryland, beginning July 1, 2009.

In 2001, the Office of Oral Health conducted a survey of the oral health status of nearly 3,500 Maryland school children from Kindergarten through 10th grade. Findings included 42 percent of all children had untreated decay, with rates highest on the Eastern Shore and in Baltimore City. Hispanic children were much more likely than Caucasian children to have untreated decay. Children eligible for free or reduced lunches, or those who came from families with less than a high school education were 50 percent less likely to have dental sealants than children from families in higher socioeconomic brackets. This data correlates well with national evidence that children of low socioeconomic status, low maternal education levels, and poor nutritional habits are up to 32 times more likely to have dental caries by the age of three. Development of poor habits in oral care early in life frequently leads to continuation of these habits into adulthood. In February 2007, twelve-year-old Deamonte Drive, a Maryland resident, died from a brain infection caused by an untreated tooth abscess. Although his mother attempted to seek care for her son she ran into several obstacles, including finding a dentist to treat Deamonte. Few dentists in Maryland see children covered by Medicaid, Deamonte’s insurer, and so he never received basic preventive care or treatment. After Deamonte’s death, local and national media questioned the reason behind his untimely death. The American Dental Association released a statement and called for, “action to prevent the next child’s needless death; to end society’s neglect of the oral health of the most vulnerable among us.” What was quickly learned was that while the federal government requires states to provide oral health services to children through Medicaid programs, “the shortage of dentists who will treat indigent patients remains a major barrier to care.” Data from 2006 indicate that fewer than one in three children in Maryland’s Medicaid program received any dental service at all, with only 19 percent of dentists participating in Medicaid programs. Dr. Lindsey K. Grossmen from the University of Maryland School of Medicine and Dr. Norman Tinanoff from the University of Maryland School of Dentistry teamed with the Baltimore City Health Department to undertake a pilot program implementing the use of fluoride varnish within a variety of pediatric primary care sites. At least 10 states reimburse physicians for applying fluoride varnish to children through Medicaid. By covering the application of fluoride varnish within the primary care setting, Maryland could quickly and significantly improve the health status of low-income children. In a policy statement released in 2003, the American Association of Pediatrics supported integration of oral health into primary care, recommending that all pediatricians be trained to do oral health risk assessments for children over six months of age. Multiple randomized control-based trials have suggested the evidence-based efficacy of using fluoride varnish in a preventative regimen, and the Cochrane review in 2004 found that varnish is equivalent to commercially available fluoride mouth rinses and gels in the reduction of dental caries. With varnish costing less than $1 per application, the treatment also appears cost-effective when targeted to a high-risk population. In 2004, the American Dental Association passed a bill supporting “the use of fluoride varnishes as safe and efficacious within a caries prevention program.” Our program uses licensed nurses, pediatricians, and dental hygienists to expand oral health capacity, and is targeted at high-risk Medicaid-eligible children. Primary care providers in Maryland have not traditionally offered fluoride varnish to patients, yet its use in the primary care setting has the potential to have a major public health effect by reducing the prevalence of cavities in primary teeth. Results from a 2003 study in North Carolina demonstrate

Th+AU1e Baltimore City Health Department and Baltimore Health Care Access partnered with the University of Maryland School of Dentistry, Baltimore Medical Systems, Dr. Ralph Brown, Total Health Care, and the East Baltimore Medical Center to implement the program. The UMD School of Dentistry helped to develop the training program for participating health care providers and helped to develop policies relating to the application of the varnish. UMD School of Dentistry also led the evaluation of the program. Community partners Baltimore Medical Systems, Dr. Ralph Brown, Total Health Care, and the East Baltimore Medical Center implement the program in their clinics. The Baltimore City Health Department has worked closely with the Maryland State Board of Dental Providers, the Maryland Chapter of the Academy of Pediatrics, and other interested groups in the medical community to ensure collaboration from all stakeholders. This partnership has allowed for the permanent expansion of the pilot program.

The Baltimore City Health Department and Baltimore Health care Access raised $263,200, supplemented by in-kind contributions by both organizations of personnel and administrative time.

The Baltimore City Health Department, with funding from private foundations, partnered with the University of Maryland (UMD) Dental School and six pediatric clinics in three different settings: two academic centers, three community health centers, and one private practice. After receiving training by dentists, staff at each pediatric center began applying fluoride varnish to children between ages 12 and 27 months during well-child visits and at sick visits when appropriate. In November 2008, the age of eligible patients was extended to include children up to 36 months. An online registry was developed, based on Baltimore’s immunization registry, to track applications. The registry helps ensure that children receive regular varnish applications at the recommended time, without duplication. It also allows convenient monitoring of fluoride applications by clinicians and health departments to encourage a population-wide effect. Once varnish treatments are entered into the registry, clinics are reimbursed $30 per application. Dental referrals are encouraged and recorded based on evidence of cavities or other serious problems. Goals for the initiative included expanding oral health access to the low-income pediatric population in Baltimore City, and establishing a model practice of primary care-based fluoride varnish application that could be extended to other sites in future years. Objective 1 included identifying pediatric practice pilot sites: academic centers, community health centers, and/or private providers. Action taken: four initial sites, including an academic center, two community health centers, and one private provider were secured. Later two additional sites, an academic center and a community health center, were added to the pilot. Timeframe: Initial sites were secured in September 2007. Two additional sites were secured in November 2008. Objective 2 included completing educational sessions at each of the sites. Pediatricians were trained on the techniques of oral health risk assessment and fluoride varnish application. Action taken: training materials were developed by BHCA, BCHD, and the UMD School of Dentistry. Dental professionals trained staff at each clinic. Timeframe: initial sites were trained in October 2007. Two additional sites were trained in December 2008. Objective 3 included adapting the immunization registry to include fluoride varnish treatment. Action taken: the registry was developed by BCHD. Timeframe: registry was completed in November 2007. It continues to be adapted to best serve the program. Objective 4 included providing oral health screenings and fluoride varnish application biannually to 6,000 low-income children, ages 1–3, in Baltimore City. Action taken: support is provided to participating clinics to ensure application numbers. Timeframe: this service began in November 2007 and continued through June 2009. Objective 5 included tracking numbers of children seen, numbers of children receiving fluoride varnish, and number of children referred to dental homes. Action taken: a part-time research assistant from the UMD School of Nursing was hired to track these indicators. Timeframe: this information is tracked continuously.

There is significant stakeholder commitment to sustain the Pediatric Dental Fluoride Varnish Program both within the city of Baltimore and throughout the state of Maryland. Based on recommendations from Maryland’s Dental Action Committee and on the success of this pilot program, the Maryland Department of Health and Mental Hygiene has planned to rollout the Fluoride Dental Varnish Program statewide starting in July 2009.

Primary providers can easily learn how to apply fluoride varnish and are major proponents of the program. Fluoride varnish application takes an average of four minutes during an office visit. Use of fluoride varnish is feasible and time-efficient in the primary care setting. Standard and convenient training models should be made available to clinicians to ensure appropriate content. Modifications included adding two additional pilot practices to the program design. These clinics were added because the patient load was less than the originally estimated amount as was the target application rate of 85 percent during well child visits.

Information was not provided in 2009