Improving Access and Provision of Preventive Oral Health Care for Very Young, Poor, and Low-Income Children Through a New Interdisciplinary Partnership

Abstract

Objectives. We provided oral health care services at 2 sites using a nurse practitioner–dietitian team to increase dental workforce capacity and improve access to care for low-income preschool children.

Methods. Our team provided oral health assessments and education, fluoride varnish application, and dentist referrals. The primary endpoint was participants’ access to oral health care. Secondary endpoints included increasing the practice scope of registered dietitians through training programs for oral health assessment and the application of fluoride varnishes for children. The oral health and hygiene and dietary habits of the participants were also determined.

Results. From 2010 to 2013, 4360 children received fluoride varnishes in 7195 total visits. Although the proportion of children with dental caries at the first visit was greater at the urban site, both sites were similar by visits 2 and 3. The number of caries declined with increased program visits, which coincided with an increase in the proportion of participants visiting a dentist.

Conclusions. Progress toward eliminating dental health disparities requires addressing barriers to dental care access. We showed that expanding access to oral health services through nurse practitioner–dietitian cooperation improved access to preventive fluoride varnishing use in low-income children.

In 2000, the surgeon general’s report, Oral Health in America,¹ described the profound disparities that exist in the oral health of vulnerable populations, especially in children and the elderly. The “silent epidemic” of oral diseases was subsequently highlighted in Healthy People 2010 and Healthy People 2020, which both included objectives to decrease the proportion of children and adults who experience dental caries and tooth decay, as well as increase access to preventive services and delivery of oral health interventions.^2,3 Specifically, the prevalence of dental caries is 2.4-fold higher for children aged 3 to 5 years living 100% below the federal poverty level compared with those living 100% above the federal poverty level.⁴

Of the vulnerable populations described in the surgeon general’s report,¹ poor children younger than 5 years are at particular risk because they are vulnerable to dental caries because of unhealthy drinking and eating habits.⁵ The prevalence of untreated dental caries in low-income preschool children is more than 2-fold higher than their higher income counterparts (26% vs 12%, respectively).⁶ Moreover, 25% of poor children have not seen a dentist before entering kindergarten.¹ Even when Medicaid provides dental services, only 33% to 57% of eligible children receive preventive or restorative dental service, partly because of a shortage of dentists who accept Medicaid and who are willing to treat children.^7–9

Untreated dental conditions contribute to poor health, dysfunctional speech, compromised growth, and poor educational performance.^10–14 Children with poor oral health combined with poor general health are 2.3 times more likely to experience poor school performance, compared with children with either poor health or poor general health, who are only 1.4 times more likely to have poor school performance.¹⁵ In addition, it is estimated that 52 million school hours are lost annually as a result of dental problems.¹³

The declining dentist-to-population ratio represents a significant barrier to access for vulnerable children. A 2010 report by the Ohio Department of Health indicated that Ohio, the state in which we undertook this study, had 56 federally designated dental health professional shortage areas.¹⁶ Moreover, the shortage of dentists is compounded by the low proportion of dentists that treat children covered by public insurance. For example, only 27% of dentists in Ohio submitted at least 1 claim to Medicaid in 2008.¹⁶

To meet the demands for greater access to dental care, models that increase the dental workforce capacity have been implemented, such as dental aid therapists and dental coordinators working now in Alaska, Minnesota, and on American Indian reservations.^17,18 Into the Mouths of Babes, a state-wide program in North Carolina that provides medical office-based preventive oral health services (i.e., screening and referrals to dentists for existing disease, parental education, and fluoride treatment) for Medicaid preschool-aged children, reported a reduction in caries-related treatments for those participants with 4 or more visits.¹⁹ Similar reductions in the number of decayed, missing, and filled surfaces were reported for American Indian children who received fluoride varnishes in conjunction with their well-child visits.²⁰

To increase access to oral health care in vulnerable children from birth to 5 years, we examined the feasibility of linking children’s oral health care services with care at 2 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program sites (1 rural and 1 urban site). There were several advantages for choosing WIC sites. First, WIC programs see more than half of all children born in the United States. Second, WIC requires regular 3- to 6-month appointments for the vulnerable populations they serve before vouchers are provided. Mothers are usually accompanied by their small children (up to 5 years), who are likely to have unmet oral health care needs. Most of the participants in our study had not seen a dentist in the past 6 months before enrolling in our study, and for many children, our services were their first introduction to dental services. Third, the WIC appointment system itself provides a physical means of tracking appointments and children. We simply arranged a method of flagging appointees’ WIC charts and checked the charts before clients came to their appointments. In our experience, we were easily able to intervene with the children, often while they and their mothers were waiting to see the WIC dietitian. Finally, WIC sites already link clients with health care providers, including dentists.²¹ For example, WIC participation increased the probability of having a dental visit and use of preventive services in North Carolina.²² Thus, WIC sites represented a potentially untapped pool of preschool-aged children with unmet oral health care needs.

Our demonstration model was novel because a dietitian was trained under the aegis of a nurse practitioner’s collaborative agreement with her physician and within the scope of practice of both the dietitian and the nurse practitioner. In the new model, a registered dietitian, as well as nursing and dietetic students, were trained by a pediatric nurse practitioner (S. T. and M. D.) with oral health expertise to both perform oral health assessments and apply dental varnish to children, outside of the typical clinical sites for varnish application. After enrollment, oral health assessments were conducted by either of the 2 clinicians hired for the project (i.e., a registered dietitian (S. T.) and a pediatric nurse practitioner), and dental fluoride varnish was applied to these WIC at-risk children. The practice of teeth brushing, frequency of dental visits, dietary practices, and oral health were tracked longitudinally. We focused on the methods and relevant results from the demonstration project at 2 WIC sites for increasing access to oral health care through oral health assessments and fluoride varnishing of teeth in children younger than 5 years.

METHODS

We included 4360 children who were younger than 5 years whose parents or guardians were enrolled in the WIC program. Participants were recruited at 2 Ohio WIC sites—1 urban (population 208 000) and 1 rural (population 11 422)—which were separated by approximately 40 miles.

Each oral health visit coincided with the parent or guardian’s 6-month visit to the WIC program. The primary endpoint for our project was the oral health (i.e., tooth and gum status) of the participants. Secondary endpoints included oral hygiene habits, dental visits, dietary habits, and type of water consumed (e.g., well water, fluoridated water, etc.). Informed consent was obtained from the parent or guardian of each participant before enrollment using our custom-designed consent form, which was at the fourth-grade reading level.

Workforce Capacity Enhancement

In our demonstration project, a nurse practitioner with a PhD (M. D.) adapted a variety of best practice educational materials from WIC, the Ohio Department of Health, and the dental community to train the dietitians and nursing and dietetic undergraduate and graduate students in conducting oral health assessments and fluoride varnishing. Before this project, this nurse practitioner was a member of the Ohio Department of Health committee that taught providers about administering fluoride varnishes and oral health assessments, and supplied supporting educational materials; these were part of the source materials we later provided to our own students and clinicians.

We provided several written descriptions and photographs of various states of oral health from a variety of best practice sources, including white spots, caries, types of decay (such as that related to bottles and sippy cups), and gingivitis, in the educational materials used in our project. We adapted the research data gathering tools and dental records from the Caries Management by Risk Assessment oral health risk assessment tool. Each person who performed the oral health screening or fluoride varnishing first demonstrated competency before practicing at a WIC site. Training for competency was accomplished in 2 phases. First, a pediatric nurse practitioner (M. D.), who was previously taught and practiced this technique, trained our hired clinicians, a registered dietitian, and a pediatric nurse practitioner, under the use of the standard practice agreement she had with her physician, who signed the agreement knowing its planned use in oral health care. Delegation was undertaken by the nurse practitioner and her collaborating physician within the laws of the state of Ohio to ensure that the practice scope of the dietitians, which was enlarged before our demonstration project, was legitimately expanded. In addition, our research associate nurse practitioner taught incoming classes of dietetic and nursing students the principles and techniques of oral health assessment and fluoride varnish application. Our 2 clinicians, who were responsible for most of the varnishing at each site, supervised nursing and dietetics students in their performance of oral health screening and fluoride varnish application of the WIC children. All students received a training manual that was based upon previously published best practices of oral health assessment and fluoride application, and a certificate of recognition upon successful completion of their training.^23–25

In addition to evaluation through pre- and posttests, competency was confirmed by observing that the clinicians and students correctly performed the following steps of the procedure: (1) hand washing, (2) equipment preparation, (3) delivery of instructions to parent or guardian and children, (4) positioning the child, (5) food debris removal, (6) tooth and gum assessment, (7) varnish application, and (8) postvarnish instruction delivery.

Varnish Application and Parent or Guardian Education

When applying the varnish, the provider and the parent or guardian typically sat knee-to-knee, with the child in a supine position with their head in the provider’s lap. Children were then asked to open their mouths. After the provider removed food debris and dried the child’s teeth with cotton gauze, a layer of fluoride varnish was applied on all surfaces of each erupted tooth. The procedure was completed with oral and written instructions to the parent or guardian regarding the varnish application and subsequent oral mouth care.

At each oral health visit, the following topics were discussed with the parent or guardian, and written educations materials were provided: appropriate brushing and use of fluoride for the child’s age (range = 100%–96.6%); frequency and type of carbohydrate-rich snacks or beverages consumed (range = 68.2%–31.1%); appropriate use of the bottle or sippy cup (range = 54.2%–26.7%); fluoride concerns (range = 15.2%–1.7%); and the importance of dental visits (range = 51.1%–23.0%). The ranges indicated the proportion of visits at which this particular topic was discussed with the parents.

Oral Health Assessment

The oral health of each participant was recorded in a dental screening record by the clinicians. Using this record (instrument), the status of the child’s teeth (number of missing, broken, decayed or discolored, filled, and silver capped teeth) and gums (normal, teething, inflamed, and lesions) were recorded at each visit using a dental mirror and artificial light. In addition, follow-up recommendations were made by the clinician at every visit, which included recommendations to see a dentist, initiate daily teeth cleaning, changes in dietary practices, and any other needed oral health counseling. Compared with the teaching nurse practitioner, the clinicians demonstrated reliability for teeth and gum oral health assessments. Reliability was ensured by working together until the clinicians and the teaching nurse practitioner reached 100% agreement, followed by periodic assessments to confirm continued reliability.

In addition to the dental screening record, a parent or guardian oral health survey was completed by the parent or guardian at each visit. In this survey, preventive oral health care, dietary habits, and dental visits of the child were recorded. In addition, the reasons for not seeing a dentist were collected at each oral health visit. The most frequently cited reason for not going to a dentist was that the parent assumed the child was too young (52% urban, 74% rural). The next most frequently cited reasons were not knowing a dentist (9% urban, 8% rural), cost factors (6% urban and 0.6% rural), lack of transportation (2% urban, 1% rural), or fear of dentists by parent or guardian or child (1% urban, 3% rural).

Parents or guardians were also given a list of pediatric dentists who accepted public, insurance, and the children received a bag containing a toothbrush, toothpaste, and age-appropriate oral health education materials, including a dental coloring book and crayons. Finally, a 98% parent satisfaction rate with the services was obtained, and several parents requested whether the services could be provided for their older children as well. This suggested that using a WIC site for the delivery of oral health services for children of all ages could be an innovation that increases access for many more vulnerable low-income children.

RESULTS

Continuous variables, such as the comparison of means between 2 continuous variables, were compared using an independent samples t-test; categorical variables such as the urban and rural comparison groups were compared using the Pearson χ² test. A P value of less than .05 was considered statistically significant. All statistical analysis was performed using the SPSS computer software.

From July 2010 to September 2013, 4360 children received fluoride varnishes in 7195 visits at 2 WIC sites, with 2493 (57.2%) children visiting the rural site and 1867 (42.8%) visiting the urban site (Table 1). Children’s visits were spaced either 3 or 6 months apart, according to WIC procedures. The mean age of the children at the first visit was 2.31 years (2.30 years at the rural site and 2.32 year at the urban site), which increased to 3.15 and 3.76 years by the third and fifth visits, respectively. Males comprised 51% of participants and females 49% (Table 1). No significant differences in age or gender of the program participants were observed between the urban and rural sites. Of the 4360 children who received at least 1 fluoride varnish, 1832 children returned for a second visit, and 728 (236 urban and 492 rural) received 3 or more fluoride varnishes within the project period (Table 1). Because the number of children with 4 or 5 visits was much lower, we subsequently chose to focus in this study on those children with at least 3 visits. We had no data to account for the drop in numbers in subsequent visits, but speculated that children aged into other preschool programs and were not then followed at WIC.

TABLE 1—

Program Participation and Characteristics of Participants: Ohio, 2010–2013

Characteristics	Visit 1	Visit 2	Visit 3	Visit 4	Visit 5
No. of children
Total	4360	1832	728	230	45
Urban	1867	705	236	46	7
Rural	2493	1127	492	184	38
Average age, y
Total	2.31	2.79	3.15	3.60	3.76
Urban	2.32	2.80	3.10	3.49	3.39
Rural	2.30	2.79	3.17	3.63	3.82
Males, %
Total	51	52	53	57	58
Urban	51	51	52	61	71
Rural	52	52	54	56	55
Females, %
Total	49	48	47	43	42
Urban	49	49	48	39	29
Rural	48	48	46	44	45

Oral Health Status

The oral health of each participant was recorded in a dental screening record at each visit. As shown in Table 2, the proportion of children who had dental caries (decayed, discolored, or filled teeth) at the first visit was 17.1%, with a significantly greater proportion found in the urban site compared with the rural site (21.4% vs 13.9%, respectively; P < .05). By visits 2 and 3, no differences in the proportion of children presenting with dental caries were observed between the urban and rural sites (Table 2). Analysis of the number of caries by total number of program visits for each child revealed that, although the proportion of children with at least 1 decayed, discolored, or filled tooth increased with each successive program visit, the mean number of caries for the study population actually dropped between the first and second program visits, and thereafter leveled off and remained relatively unchanged across the second and third visits.

TABLE 2—

Presence of Dental Caries and Gum Status of Participants With at Least 3 Visits: Ohio, 2010–2013

Characteristic	Visit 1	Visit 2	Visit 3
Dental caries
No. (%)
Total	745 (17.1)	366 (20.0)	159 (21.8)
Urban	399 (21.4)	148 (21.0)	53 (22.5)
Rural	346a (13.9)	218 (19.3)	106 (21.5)
Mean no.
Total	3.59	3.33	3.26
Urban	3.91	3.32	3.45
Rural	3.22	3.33	3.17
Gum status
Normal, %
Total	98.1	97.7	98.9
Urban	97.1	97.4	97.5
Rural	98.9	97.9	99.6
Teething, %
Total	22.6	13.4	8.5
Urban	12.4	4.8	1.3
Rural	30.2a	18.7a	12.0a
Inflamed gums, %
Total	0.8	0.4	0.4
Urban	1.3	0.9	1.3
Rural	0.3	0.1	0.0
Lesions, %
Total	0.1	0.2	0.0
Urban	0.1	0.1	0.0
Rural	0.0	0.2	0.0
Tongue and buccal mucosa pink, moist, and without lesions, %
Total	96.8	97.5	98.4
Urban	96.7	97.6	97.0
Rural	97.0	97.4	99.0

Note. Caries were defined as decayed, brown, discolored, or filled teeth.

^aIndicates a significant difference from the urban group (P < .05).

Gum status was also examined in the dental screening record. As shown in Table 2, most children (≥ 97.7%) had normal gums at all visits. Although a greater proportion of children were teething at the rural site compared with the urban site (P < .05), the proportion of children classified as teething decreased with each visit as the children grew older.

Dietary Practices and Oral Health Habits

Table 3 shows a significantly greater proportion of urban participants drank more than 1 sweet drink per day and used a bottle throughout the study (P < .05). Sippy cup use decreased throughout the study period in both groups. Furthermore, a greater proportion of children in the urban group consumed fruits and vegetables daily (P < .05). Finally, although a significantly greater proportion of urban children consumed high sugar foods more than once a day at the first and second visits (P < .05), both groups had similar consumption habits by the third visit.

TABLE 3—

Dietary Practices of Participants With at Least 3 Visits: Ohio, 2010–2013

Dietary Practices	Visit 1 (n = 2844), %	Visit 2 (n = 1740), %	Visit 3 (n = 721), %
Child drinks >1 cup of a sweet drink per d
Total	35.3	36.5	34.3
Urban	46.9	53.1	52.4
Rural	27.9a	26.6a	25.6a
Child uses a bottle for milk or other drinks
Total	33.9	10.9	5.0
Urban	36.5	13.1	8.3
Rural	32.2a	9.6a	3.5a
Child uses a sippy cup for milk or other drinks
Total	61.5	55.6	44.4
Urban	52.8	50.2	43.5
Rural	66.9a	58.7a	44.8
Child eats fruits or vegetables at least 1 time per d
Total	92.4	90.5	90.6
Urban	97.0	97.2	97.0
Rural	89.6a	86.5a	87.5a
Child snacks on high sugar foods more than 1 time per d
Total	15.9	22.2	23.7
Urban	21.3	25.6	23.2
Rural	12.5a	20.2a	24.0a

^aIndicates a significant difference from the urban group (P < .05).

The oral health habits of the participants were also evaluated using the parent or guardian oral health survey. Although only 18.4% of rural participants visited the dentist within the past 6 months at the first visit, this proportion nearly doubled by the third visit for both groups (Table 4). A significantly greater proportion of urban participants reported visiting the dentist within the past 6 months at each visit (P < .05). Reported daily tooth brushing or cleaning also increased in both groups from visit 1 to visit 3; however, no differences between the rural and urban participants were reported.

TABLE 4—

Oral Health Habits of Participants With at Least 3 Visits: Ohio, 2010–2013

Characteristics	Visit 1, %	Visit 2, %	Visit 3, %
Dentist visit in past 6 mo
Total	21.8	30.6	37.3
Urban	26.2	40.3	45.9
Rural	18.4a	24.5a	33.2a
Daily tooth cleaning or brushing
Total	90.3	95.8	96.0
Urban	89.2	96.8	97.9
Rural	91.1	95.3	95.1

^aIndicates a significant difference from the urban group (P < .05).

DISCUSSION

The shortage of dentists and the relatively low proportion of those who treat children covered by public insurance represent considerable barriers to access for children to receive oral health care. At the time our demonstration project was initiated, only 2 pediatric dentists and 8 to 10 dentists accepted Medicaid clients in the 2 counties in which we were located, and most dentists preferred to treat children older than age 3 years. Our demonstration project was undertaken to examine the feasibility of linking preventive oral health care services with services at 2 WIC program sites; we used a workforce expansion model that consisted of oral health care services provided by a registered dietitian compared with services offered by a pediatric nurse practitioner. The chief goal of our project was to improve access to oral health care for vulnerable children younger than 5 years. In addition, we hoped to increase oral health care worker collaboration and the scope of practice of registered dietitians through training programs for oral health assessment and the application of fluoride varnish.

To meet the oral health care needs of underserved populations and to recognize the challenges regarding the current state of the oral health workforce, new practitioner models (e.g., dental therapists, community dental health coordinators, and oral health practitioners) have been recommended.^26,27 These programs differ greatly in the training, scope of practice, level of supervision, and practice setting.¹⁹ Our demonstration project took advantage of the oral health expertise of our co-investigator, who is a PhD pediatric nurse practitioner. In Ohio, nurse practitioners must have an agreement arranged with a collaborating physician to practice, which permits them to delegate portions of their clinical work to other personnel whom they deem competent to the tasks assigned. Thus, the main premise of our model lay in the approved scope of practice of nurse practitioners, who, under the aegis of their agreement with a collaborating physician, trained and directed a registered dietitian in the practice of pediatric oral health assessment and the application of fluoride varnish to young children in the care of a guardian. In this model, the dietitians also arranged for an enlarged scope of practice, and then undertook the necessary education, including learning a child’s comfort positioning and attending to the social or psychological needs of a child undergoing such examination and varnish application.

WIC Sites as Potential Educational Clinical Sites

WIC sites have already extended the work of their staff to some procedures that are related to their clients, such as assessment of blood lead levels in children. However, the particular state department overseeing the WIC sites would have to approve any change in WIC dietitian work duties to accommodate oral health assessments and fluoride varnishing. In Ohio, budget cuts required a reduction in staff for some WIC sites; hence, a redistribution of duties at any site would have to consider the associated cost–benefit ratio. Thus, to transfer this model, there must be a clear understanding of the scope of practice permitted in a given area for the nurse practitioner and dietitian, as well as the experience or education in oral health care of both individuals, but particularly of the nurse practitioner. Although not every nurse practitioner might have the expertise of our study’s pediatric nurse practitioner, most are or can be taught pediatric oral health practices. Although nurse practitioners are available to some WIC sites, typically through public health venues, it is more likely that, for this model, a nurse practitioner would have to be hired specifically for a WIC site. Nurse practitioners need not be full-time employees to teach dietitians how to assess oral health or apply varnish, but they must be available as needed under the aegis of the collaborative practice agreement.

Our 2 WIC sites processed approximately 225 children per year per site (mean = 450 per year), whereas our 2 clinicians completed approximately 7200 visits (mean = 1750 visits per year), illustrating both the need and the purely voluntary nature of these vulnerable populations’ access to oral health preventive care. Several parents inquired about bringing their older children to the site for similar examinations. These data, coupled with the client requests for more preventive care, reinforced the literature that indicated the tremendous impact that WIC sites and their networks could have on access to care for vulnerable populations.

In addition to provision of preventive services, referrals to appropriate health personnel could also follow, as was the case for our demonstration project. However, the issue of referrals to dental homes could not be easily managed without available dental homes, which was our experience. Toward that end, we enlisted the aid of a practicing public health dentist who had access to federally qualified health centers, to which we were given permission to refer clients to appointments on an as needed basis.

The Efficacy of Fluoride Varnish Application

Subsequent to its approval by the US Food and Drug Administration in 1994, the use of fluoride varnish has become a routine tool for caries prevention, especially in young children, because of its efficacy, ease of application, and safety.²⁸ The efficacy of fluoride varnish application in the prevention of caries in both primary and permanent teeth was recently highlighted in a meta-analysis that included 22 trials and 12 455 participants.²⁹ Moreover, it remains a well-documented method of decreasing the incidence of early childhood dental caries in high-risk children,³⁰ which was consistent with the results of our project. Varnish packets and informational flyers for the children and parents were available from the Ohio State Department, as well as from our sponsored funds.

Cost Benefits of Preventive Oral Health Care

In addition to reducing oral health disease in disadvantaged children, the cost benefits of providing preventive oral health services were reported. Specifically, children who received early preventive dental care had 40% lower dental costs over their lifetime than those who did not receive this care.³¹ Similar cost-effectiveness was reported for the Into the Mouths of Babes program, which targeted preschool-aged Medicaid enrollees.^32,33 Moreover, reimbursement of physician application of fluoride varnish to Indiana Medicaid recipients starting at 9 months of age was shown to be cost saving over 3 years.³⁴ In addition, participation in WIC was associated with increased use of preventive and restorative oral health services and less use of emergency services.²³

Although the cost benefits of preventive oral health care have been recognized, the sustainability of these programs is dependent upon expansion of Medicaid services, or in some cases, increasing the reimbursement rates in recognition of the future cost savings. For example, a Medicaid policy change in Wisconsin to allow reimbursement for fluoride varnish application by medical care providers greatly increased the number of claims, with the greatest increase of claims observed in children aged 1 to 2 years, 83.5% of which were from medical care providers.³⁵ In addition, studies by Agency for Healthcare Research Quality researchers demonstrated a correlation between reimbursement rates and access or quality of care.³⁶ In Connecticut’s HUSKY health insurance program, which increased provider reimbursements and streamlined the process by which dental benefits were administered and reimbursed, access to oral health care in 2011 was nearly triple that of 2008, when the program was first implemented.³⁷ Because the lack of dentists accepting individuals covered by public insurance represents a significant barrier to access, it is anticipated that increasing reimbursement rates will increase access to care.

Limitations

Our project was limited in its lack of an untreated control group to assess the impact of the project on oral health. Thus, further studies are necessary to confirm our findings. In addition, we experienced a drop in the number of children over time. We did not assess the reason for this attrition; however, because the mean age of the participants was 3.15 years by the third visit, many of the children might have simply started preschool and no longer attended the WIC visits with their mothers.

Conclusions

Barriers to access remain a significant impediment toward eliminating dental health disparities in low-income children. Our project demonstrated that a nurse practitioner-dietitian delegated work model at WIC sites increased dental workforce capacity by providing access for preventive oral health services, including topical fluoride application, to low-income children, and oral health education and dietary counseling to their parents or guardians. It also suggested that WIC sites could become excellent clinical training sites for nursing, dietetic, dental, and medical education in selected oral health care services.