Starting a State Pediatric Oral Health Initiative:
Step-by-Step Guide of Lessons Learned
in Four New England States
January 2015
Table of Contents
I. Partners
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II. Financing Model
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III. Provider Recruitment
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IV. Integrating Oral Health Into Existing Pediatric Patient Care:
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Training, Adoption, Sustainability
V. Measurement
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VI. Training the Future Workforce
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VII. Consumer Demand
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VIII. Dental Community Alignment
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IX. Summary and Recommendations
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APPENDICES:
A: Sample Provider Marketing Materials
B: Practice Letter of Commitment
C: Office Questionnaire
D. EHR Screenshots
E: New Hire Training Information
F: 4 Week, 3 and 6 Month Follow-up Surveys
G: MOC Guidelines
H: Training Evaluation Form
SUPPORTING DOCUMENTS:
http://www2.aap.org/oralhealth/practicetools.html
http://www2.aap.org/oralhealth/docs/COHARosterforWeb.pdf
http://www2.aap.org/oralhealth/State.html
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From the First Tooth is a four state initiative that began in 2011 to improve the oral health of children in
Connecticut, Maine, Massachusetts and Rhode Island. The overall premise is that medical providers are the first
line of defense against cavities, seeing children much more often and sooner than a dentist. Medical providers
are used to managing the entire needs of the patients and referring the patient to other specialists, and in this
case to a dentist by age 1.
The program developed by From the First Tooth focuses on training private medical practices, community health
centers, health professional schools (e.g. medical schools and residency programs) to incorporate oral health
assessments, patient education, fluoride varnish application and referrals into pediatric visits. It is a preventive
service that can lead to caries free/disease free good oral health. This document provides comprehensive
information for any state to design and implement a similar program.
I.
Partners
To have success in a large endeavor (statewide or regional) requires support from many organizations that
have influence with the medical and dental community. Not only is their buy-in important, they can be
advocates for the implementation of the oral health training program. These organizations can: (1) promote
the importance of oral health and the availability of the training in their newsletters and online
communications; (2) allow for presentations at their conferences, annual meetings and other venues; and
(3) appoint an oral health advocate who will personally reach out to the membership to promote the
training. The associations to consider include:
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State Oral Health Coalitions/Advocacy Taskforces
State Chapter of the American Academy of Pediatrics (AAP)
State AAP oral health champions (http://www2.aap.org/oralhealth/docs/COHARosterforWeb.pdf)
State Chapter of the American Academy of Family Physicians (AAFP)
Nurse Practitioner Association
Physician Assistant Association
State/County Dental Associations
State/County Medical Associations
Dental Hygienists Association
Primary Care Associations
Area Health Education Centers (AHECs)
State Department of Public Health
In addition, hospital/healthcare organizations and primary care group practices can be leaders in
incorporating oral health into primary care practices. Large healthcare systems and provider groups have
the ability to establish these protocols, modify electronic medical records to incorporate oral health screens
and organize staff for training purposes. As leaders they open the doors for others to move in the same
direction.
The third partner, are the insurers, including self-insured companies. Forty-six state Medicaid programs pay
for oral health assessment and fluoride varnish in children (http://www2.aap.org/oralhealth/State.html) .
Very few private insurers, however do. With the ACA changes, this should improve in 2015 but not all
insurers are aware of the requirements. Contacting the insurers to get them thinking about the benefit and
how it will be addressed is important to the overall ability of oral health services to be adopted by physician
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practices. Physicians find it difficult to manage a benefit for some and not others. Contacting insurers early
in the process and getting them committed to the benefit can help improve the marketing of the program to
physicians.
Finally, for the long-term success of having oral health be a standard practice for primary care providers,
education must occur at the training level. Educational Institutions, such as medical schools, residencies,
midlevel provider schools (PA, NP), nursing schools, and medical assisting schools must incorporate oral
health into their curriculum. In many places, inter-professional programming, that includes dental schools
and dental hygiene schools, is tackling the oral health issue as a way to familiarize all the specialties with
oral health. The learning that happens in school will be carried forward to clinical practice. It will become
an expectation that it is part of primary care practice. In section VI there is more discussion on how to enlist
schools in the process.
II. Financing Models
Payment by Medicaid for oral health assessment and fluoride varnish in a medical setting exists in 46 states.
As of 2014, only four states were not reimbursing for these services through their Medicaid programs
(Tennessee, Delaware, New Hampshire and Indiana)( http://www.pewtrusts.org/en/research-andanalysis/analysis/2011/08/29/reimbursing-physicians-for-fluoride-varnish). Payers beyond Medicaid vary by
state. The US Preventive Services Task Force has recommended that oral health assessment and fluoride
varnish be part of a child’s medical services from birth through age 5. As part of the Affordable Healthcare
Act (ACA), this recommendation will be adopted in 2015, and it is expected that all insurers will add this
benefit by June 2015.
Payers:
i. Medicaid – The American Academy of Pediatrics has an up to date chart on the reimbursement
for each state. Some states have two codes and two reimbursement amounts; one for oral
health assessments and one for fluoride varnish. Other states have only one code for both
activities. Reimbursement ranges from as low as $4 to as high as $85. The most common
amount being between $15 and $25. Go to
http://www2.aap.org/commpeds/dochs/oralhealth/State.html for an up to date chart on
payments and other information about each state.
ii. Self-insured Employers – Some self-insured employers, generally those associated with health
professions (e.g. hospitals, health organizations) have included oral health in their health
insurance benefits. These are relatively rare offerings, but are expected to change with the ACA
requirements in 2015.
iii. Commercial Insurance Companies – Similar to the self-insured, commercial insurers have yet to
offer the benefit, but are expected to by June 2015 when it is required by the ACA.
iv. Self-Pay – Physician offices can offer the service to any patient for a fee that is equivalent or
greater than what they charge their Medicaid patients. Many practices do offer this to their
patients who upon assessment, would benefit from the fluoride varnish. In most cases, if the
charge is reasonable (Less than $25), patients have been wiling to pay out of pocket.
Billing Codes:
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To date, medical providers have had to use dental “D “ codes to bill for oral health services. This is
something medical practices struggle with, as they are not accustomed to these codes. As this
benefit gets rolled as part of the ACA, the AAP has created a medical code that is expected to be
adopted nationwide. Two dental codes are currently in use:
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D1206 – used to bill for fluoride varnish application
D0145 – used to bill for oral health assessment
99188 – Medical code (to be adopted in 2015)
Many states also require ICD-9 codes. The varnish is usually offered as part of a well child exam
using V20.2. If offered during a routine acute visit VO7.31, (prophylactic fluoride) can be used. In
many states, the assessment and fluoride varnish application can only occur during a well child
visit, thus the need for the ICD-9 code. In other states, these services can be provided at any visit,
whether well child or a sick visit.
In a four state DentaQuest funded project to train practices in Connecticut, Maine, Massachusetts
and Rhode Island, the data suggested that the reimbursement amounts and the use of one or two
codes impacted the volume and type of services provided. Though the evaluation did not focus on
the impact of the reimbursement rates and structure, the data suggested that low reimbursement
rates, of $13 for the full service, kept practices from providing the service and that two billing
codes, one for assessment and one for fluoride varnish application, though closely equal in
amount, showed more practices billing for assessment than varnish. The disparity, which could be
explained by the assessment indicating that there was no need for fluoride varnish, appeared too
significant to explain the difference according to clinician review of the data. It is recommended
that Medicaid programs and insurers consider this as they construct and/or review their current
rate structures.
Restrictions and Age Limitations:
Most states restrict coverage to children to a particular age. This varies greatly by state, with 36
and 48 months being the most common age limit. However, a handful of states cover the service
until age 21. See http://www2.aap.org/commpeds/dochs/oralhealth/State.html for the limits set
by each state for Medicaid members. In addition, most states also limit the number of fluoride
applications per year. These also vary considerably from state to state and in some cases are tied
to the number of fluoride varnish applications received from a dentist. The link above provides
information on each state’s limitation.
The ACA, following the US Preventive Task Force recommendations, will expect coverage from
eruption of the first tooth through age 5.
Required Documentation:
States may also require documentation that a provider has been trained before the practice can
be reimbursed. States have recommended or mandatory training programs and some states
require that a certificate or verification form of the training be provided. In addition, some states
require that electronic health records be amended to capture oral health services.
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III. Provider Recruitment
The key to a successful program is the recruitment and training of private primary care practices and their
adoption and sustainability of the practice of oral health assessments and fluoride varnish application.
Initially the focus should be on practices with significant Medicaid populations for two reasons: (1) The
Medicaid population has a greater percentage of children at risk for dental disease; and (2) Private insurance
coverage will not be effective until mid-2015 under the ACA.
Recruitment:
Recruitment of primary practices requires more than one approach. Primary care practices can be difficult
to navigate to reach someone who has the authority to make a decision regarding new procedures/services
and training. The approach taken in the four New England states varied by state and each approach had
varying degrees of success. The approaches used were as follows:
i. Direct Contact: There are several ways to go about contacting practices directly.
• Mailings followed up by phone calls or visits – With the help of pediatric and family medicine
associations, addresses can be obtained for primary care practices. If possible, the mailings
should be addressed to the practices’ medical director, physician leaders or practice manager.
Marketing materials are important and are discussed below. Follow-up phone calls or in
person visits should be made within a week or two of the mailing. Sending information in
advance can help to get past the front desk staff that answer the phone or greet people in
person. Knowing something about the practice, particularly who the physicians and office
manager are, is helpful in starting a conversation with the front desk staff.
• Personal emails or phone calls – Having a physician, who has incorporated oral health into
his/her practice, reaching out to other physicians has been effective in recruiting practices.
Physicians can send personalized emails, make phone calls or chat about the positives of doing
oral health assessments and fluoride varnish at local meetings. With physicians taking the
lead, provider relations/recruitment staff can then follow-up with the physicians who have
been contacted, particularly if emails or phone calls were made. Marketing materials can be
sent out as follow-up and provider relations staff can follow-up in person or with emails to try
to recruit the practice. Utilize local and state resources; each state has an AAP oral health
champion who may be able to co-sign letters or suggest practices or large group practices. See
http://www2.aap.org/oralhealth/docs/COHARosterforWeb.pdf
http://www2.aap.org/oralhealth/State.html
• Academic detailing – Having a project member, who is trained or experienced in office
detailing, visit primary care offices, much like pharmacy representatives do, is one approach
used to recruit practices. In Massachusetts, the Medicaid oral health program is managed by
a third party administrator, DentaQuest, Inc. DentaQuest was contracted to not only manage
Medicaid dental services, but to provide outreach to medical practices. They assigned an
outreach coordinator to visit primary care offices and by being able to introduce herself as
part of the Medicaid program carried significant weight. It exemplified the importance a title
and affiliation have to gaining access to the decision-makers and commitment from the
practice. In other states, an outreach/provider relations staff person with a pharmaceutical
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representative background was hired. These individuals are trained on how to approach
practices and gain commitments from physician staff. The approach was the same as the
Medicaid outreach coordinator, but the success rate was less, again pointing to the
importance of title and affiliation.
ii. Social Media: In today’s world, social media plays an important role and collaborating with
others who have similar causes can help spread the word. Working with local physician
organizations, state AAP and AAFP chapters, gives access to the membership of these
organizations and their communication vehicles. Short email blasts or newsletter articles about
the training program from these organizations creates visibility and acts as an endorsement.
iii. Presentations: Grand rounds (where physicians meet usually on hospital premises for
industry/medical updates) is one way to introduce the program. Having a comprehensive
lecture that provides significant information and rationale for the need and importance of oral
health can help recruit practices. These presentations need to be scheduled far in advance but
they consist of sizeable audiences. Having marketing materials on hand to distribute makes it
easy for physicians to schedule a full office training. Efforts should be made to collect contact
information so that follow-up calls or visits can be made within two weeks of the presentation
as a means for encouraging practices to sign on for the full office training. In addition, there
may be other venues in which to get the word out. For example, local annual AAP and AAFP
meetings, rural health conferences, community health center annual meetings and conferences.
iv. Incentives: Small incentives can go a long way in enticing practitioners and practices to adopt
oral health screening and fluoride varnish application. In order to recruit new practices,
additional fluoride varnish supplies were given to practices that provided a referral to another
practice that then agreed to participate in a training session. The cost of this incentive was
minimal to the overall cost of recruitment.
Marketing Materials:
First and most important, materials need to be professional looking. The program needs to have a name
and a logo that appears on all of the marketing literature. Regardless of how the marketing materials are
delivered (in person, by mail, at a conference, etc.) they need to be comprehensive, addressing all
anticipated questions about the need to incorporate the service into the practice as well as the details of
what the on site training includes.
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Information about oral health assessment and fluoride varnish.
A Q & A piece addressing common questions.
Information about the training and what is included (e.g. CME, CNE, lunch, start up materials,
posters, fluoride varnish samples, pocket guides, etc.)
A letter from a prominent physician who endorses the program
A list of trained practices in the state
Samples of marketing materials can be found in Appendix A.
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Letter of Commitment:
The cost of training a practice is not insignificant and therefore a firm commitment from a practice, to not
only schedule a training, but to agree to implement the program is one approach to saving valuable
resources. When asking a practice to sign such a letter, the practice generally gives thought to what they
are committing to and therefore is more prepared to move forward. Enforcing the commitment in any legal
way is not practical, but referencing the signed commitment does psychologically have an impact. An
example letter of commitment can be found in Appendix B.
IV. Integrating Oral Health into Existing Pediatric Patient Care
Oral health should become a standard part of a pediatric practice to the same degree as giving
immunizations. Both are preventive measures that will ensure the health of the patient. But oral health has
always been seen as the dentists’ purview. Very young children generally see a primary medical provider
more than eight times for well child visits before their first visit to the dentist. Because of the numerous
contacts with a primary care provider, early intervention can easily be provided. Early intervention is pivotal
to identifying oral health problems, providing anticipatory guidance, providing fluoride varnish and referring
the child to a dentist as early as age one. The Health Resources and Services Administration (HRSA) has
developed guidelines for the role of oral health integration into primary care (see
http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/ ). The US Preventive Services Task Force
recommends a physician offer these services through age 5. Much of this recommendation has to do with
the lack of availability and accessibility of dentists who are trained to treat young children. The ACA will be
adopting this recommendation in mid-2015, thus encouraging the primary care providers to adopt this role.
It is recommended that a child establish a dental home by age one and primary care providers are
encouraged to have established relationships with the dental community so that patients can be referred as
soon as possible.
Primary care physicians play essential roles in managing the health of their patients and oral health should
be part of the practice. The Medical Home movement focuses on patient centered, comprehensive,
coordinated, quality care and oral health fits into this growing model of medicine.
Provider & Staff Training:
Initially, many programs used physicians and dentists to provide the training to medical practices. This came
at a great cost and there were few physicians and dentists who had the time to devote to this type of in
office training program. Experience in Massachusetts of using group training sessions after hours at local
venues proved unsuccessful because only physicians would attend and it is generally the medical office staff
who are responsible for implementing the program into the workflow of the office and the staff who
ultimately would be applying the fluoride varnish. Training in individual offices proved more successful
measured by the adoption of the service in the practice. It was also far easier to recruit part time hygienists
to carry out the trainings. Based on evaluations completed by participants in the training, no difference was
found between the performance of the physician trainers and hygienist trainers. This was measured over a
two year period. As long as the hygienists were well prepared to provide the training, their scores on the
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evaluation were excellent. They were well respected for their knowledge and were enthusiastic believers in
what they were presenting.
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Who Should Be Trained: Each state has different workforce practice acts as to who is allowed to do
an oral health assessment and apply fluoride varnish. In most states, the physician, PA or NP is
responsible for the oral health assessment and the determination of the need for fluoride varnish.
In most states these providers as well as nurses (RNs) are allowed to apply fluoride varnish. A
majority of states also allow fluoride varnish to be applied by LPNs, certified medical assistants
(CMAs) and medical assistants (MAs). See http://www2.aap.org/oralhealth/State.html for your
state requirements. It is recommended that all clinical staff and the practice manager participate in
the training. Regardless of who can apply fluoride varnish, how the service fits into the practice’s
workflow can be better determined once all staff understand the importance of oral health and
fluoride varnish.
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Preparation for the Training: Before the training occurs, it is best that the office be prepared to
begin implementation as soon as the day of the training. With the trainer present and willing to
spend time overseeing fluoride varnish application, helping billing staff and working with an office
designated oral health champion (see below), the service can be implemented on the same day as
the training. An office questionnaire helps the office and the trainer prepare. For the trainer, it
provides information on how many posters, varnish kits, and other materials to bring. For the
practice, it prepares the office to address how the service will be integrated into the practice and
who will be responsible, how it be incorporated into the billing system (electronic v. manual needs),
and who will order the fluoride varnish and other supplies. See Appendix C for example office
questionnaire.
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On-line Training Option: Smiles for Life has on-line training that provides CMEs to physicians at
http://www.smilesforlifeoralhealth.org, Course 6. This course is the basis for our in-office training
and therefore covers the same material but lacks the hands-on portion of the training. Nurses, PAs,
NPs, medical assistants can all access this program on line. We recommend this program for new
employees, and as noted below, have suggestions for incorporating the training into new employee
training materials. We also promote this training to anyone who misses the in office training.
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Incentives: The hands-on training is a significant benefit of the in-office training. We do a power
point presentation and have all participants apply varnish on each other for practice. Though it is
not the same as working with a small child, it still gets staff familiar with the fluoride varnish.
Offering a small denomination gift card can also be used to recruit staff to do this. Once staff try
putting on fluoride varnish they generally get comfortable quite quickly with the process and are
more likely to carry through with the program. Most effective is to have the medical office staff
schedule well child visits following the lunch and learn program. In this way the trainer can watch as
staff practice applying fluoride varnish. Small denomination gift cards can be offered to office staff
for scheduling well child visits. If well child visits have not been scheduled, varnish can be offered to
children coming in for acute reasons. This training format makes staff comfortable with applying
fluoride varnish, one of the bigger hurdles to adopting the program.
Practice Champions & Lead Staff:
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Every office should have at least one person, and preferably two, who understand the oral health
procedures and can maintain the service going forward. At a minimum, the oral health champion should be
responsible for:
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Developing workflow procedures - This varies from office to office, but most offices assign MAs or
nurses to do the fluoride application generally at the same time as the immunizations are given.
From the First Tooth provided caddies (similar to venipuncture plastic carrying kits) with all the
supplies needed – fluoride varnish, gloves, gauze, and post-application information for the family.
Some of these caddies are carried into the exam room from a central location and some of them are
locked in the exam room for use when needed.
Adjusting EHRs – Many of the EHR systems have screens for oral health. A few samples are provided
in Appendix D. EHRs should be updated immediately to make the incorporation of oral health and
fluoride varnish application easy to document and bill for. The oral health champion should be
responsible for directing changes to the EHR or assigning them to the person who maintains the
EHR.
Adding billing code(s) – Currently medical offices need to add “D” billing codes to their billing
systems. These codes are currently used in all states and were discussed above. A medical code has
been proposed for this service for 2015. It is expected the code will be adopted during the course of
2015. The oral health champion should be responsible for seeing that the billing codes are added to
the EHR or the billing system in the office.
Ordering fluoride varnish – Making sure supplies are adequate and ordered when needed. The oral
health champion should know how much is needed, who the supplier is and when to order.
Process for Training New Hires
In order to maintain the oral health program, new staff members need to take the training and familiarize
themselves with the office procedures. All office staff can take the online training at
http://www.smilesforlifeoralhealth.org, Course 6 If they are going to be responsible for applying the
fluoride varnish, then a staff member should demonstrate the procedure and have them practice In front of
the staff member until they are comfortable. In order to guarantee that the training takes place,
information about it should be placed in the new employee handbook or other documents/procedures that
are used to train new employees. Appendix E has language that can be incorporated into new employee
materials.
Sustainability
Steps are taken along the way to enable the program to be sustainable. These include: (1) training staff in
their offices and demonstrating hands-on fluoride varnish application, particularly on patients; (2) providing
all start up materials, particularly caddies that can be carried from room-to-room and contain all supplies
needed for varnish applications; (3) assisting offices to determine workflow and billing procedures; and (4)
follow-up calls to offices after the training to assist with any implementation issues. From the First Tooth
instituted calls and surveys at one week, two weeks, 4 weeks, 3 months and 6 months. The purpose of the
call is twofold: (1) to assist the practice should they not be sustaining the program; and (2) to obtain data
that measures the sustainability. The earlier calls to the practices determine if additional assistance is
needed by the practice, such as around workflow, billing or supply ordering. In some cases a practice may
require that the hygienist trainer return to the practice to assist in implementation, which may require more
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hands on training, clarification of billing or different strategies to integrate the service. The later calls are to
confirm that the program has been consistent and that the service is being provided. The survey asks how
many assessments and fluoride applications are being done, whether it is considered easy or hard to
implement and again, whether additional assistance is needed. See Appendix F for tracking forms.
Incentives
One incentive to attract practices to implement the program is for the practice to offer Maintenance of
Certification (MOC) to the physicians. As part of a physician’s license renewal, he/she must complete a
quality improvement project every 7-10 years. The American Academy of Pediatrics has a quality
improvement program around oral health that meets the MOC requirement. It is called EQIPP and it can be
an incentive to practices to provide oral health assessments and fluoride varnish. Appendix G has guidelines
for how to assist a practice with the MOC. Practices that go through the effort of the MOC generally sustain
the oral health assessment and fluoride varnish program. An incentive for doing the MOC is to offer to pay
the cost of EQIPP, at a cost of approximately $100 per physician. EQIPP is not currently accepted by the
Academy of Family Physicians, but it is under review for adoption in 2015/2016. Family Physicians can use
fluoride varnish implementation as an MOC project however they have to apply through the independent
project format and write it up themselves. EQIPP can serve as a guideline.
Practices can also be incentivized to adopt the oral health assessment and fluoride varnish program by
offering extra boxes of varnish if they meet a goal of applying varnish to a percentage of the children in their
practice over a one-month period. Other rewards, such as gift cards can be used in a similar fashion.
V. Measurement
There are several measurements that can be taken to determine the successfulness of the program.
i. Training - All those trained should complete an evaluation of the training. The evaluation
provides feedback on areas that may require modification or improvement. See Appendix H for
an example evaluation form. This form originally was used to compare the results of trainings
performed by physicians v. hygienists. On a scale of 0 – 5.0, physicians averaged 4.9 and
hygienists, 4.8, an insignificant difference and both in the excellent range.
ii. Follow-up Calls – Calls are made to practices using a survey instrument at one month, 3 months
and 6 months. These surveys capture information on whether the program was adopted, how
easy or hard it has been for the practice to incorporate the oral health screen and fluoride
varnish and whether additional assistance is needed to guarantee adoption and sustainability.
Data is requested on how many fluoride varnishes were applied on average. See Appendix F for
the form. As noted above, these calls are used to determine the level of commitment the
practice has to the program and if additional resources are needed to guarantee adoption and
sustainability.
iii. Claims Data – Depending on who is responsible for the training program, data can sometimes be
obtained from state Medicaid agencies to determine the extent to which practices are billing for
the service. From the First Tooth was able to obtain Medicaid data at a provider specific level
and match up those billing against those trained by the From the First Tooth. Practices that were
trained but not billing were contacted. Some needed retraining, some needed assistance with
workflow and billing. There was several that made the decision not to offer the service. It was
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reported in some instances that they felt their patients had established dental homes and the
medical practice was not in need of addressing oral health. Unfortunately, whether the patients
had actually established the dental home was unknown to the medical practice. Medicaid also
collects data on dental services utilization by age that can be compared to the number of
children enrolled in Medicaid. This can provide an overall picture of the percentage of the
children on Medicaid accessing dental care.
iv. EHR Reports – Most of the EHRs provide for report generation. Practices can use EHR reporting
functions to track their overall progress and compliance as well as examine individual providers.
This is also very helpful for those practices that undertake the MOC (see Section IV above).
VI. Training the Future Workforce
Health care is changing more rapidly now than at any other time. Educational programs have had to adapt
to these changes and to presenting new skills. Oral health training should be incorporated into educational
programs as an important knowledge and skill set that is the standard of care. Oral health is now on
national medical board exams for family medicine and pediatrics. Reports by the Institute of Medicine
(https://www.iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-andUnderserved-Populations.aspx and http://www.iom.edu/Reports/2011/Advancing-Oral-Health-inAmerica.aspx) and HRSA’s document on Integration of Oral Health and Primary Care Practice
(http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/) define the roles for primary care
health providers. Presentation of statistics on the impact oral disease has on overall health and health care
costs can engage learners in the importance of oral health. Personal stories, such as the one about the
death of Deamonte Driver in Maryland can drive home the importance of not overlooking oral health in the
examination of a patient.
Recruitment & Engagement of Health Professions Education Program(s)
Training of students in educational programs is not limited to medical students and residents. It should
include MDs/DOs, PAs, NPs, RNs, MAs. It should also include establishing relationships with dental schools
and dental hygiene schools to share knowledge, skills and how services can be integrated. The most
important aspect of a strong oral health curriculum is for it to be worked into the ongoing rotation of other
health topics. Training programs should be encouraged to start with children’s oral health and fluoride
varnish training and add other oral health topics, as they are able.
i. Learning Objectives
Initial training objectives should include teaching oral health across the life span as
appropriate: infant/child, adolescent health, prenatal, adult, and geriatric. Topics should
include: oral-systemic connections, urgent care, oral exam, and fluoride varnish. Emphasis
should be put on practical clinically based lessons with a focus on inter-professional, team
based system approaches.
ii. Instructional Strategies
Smiles for Life (www.smilesforlifeoralhealth.org) has 8 modules and cases that cover the
topics above. In addition From the First Tooth has tools to help with practical clinical
integration of oral health assessment and fluoride varnish into training programs.
iii. Faculty Training
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Ideally an on-site faculty member should be trained to be the faculty champion. Using Smiles
for Life, the presentations come with speaker notes so they are easy to use. Faculty members
can also learn from veteran faculty champions in other programs. The faculty champion
should be able to strategize how to incorporate oral health training in the curriculum on an
annual basis, with focus on particular age groups where appropriate.
iv. Student/Resident Instruction
Learners should be taught either by an interactive presentation (Smiles for Life can be
downloaded with speaker notes) or via an on-line module (Smiles for Life) with follow-up time
for discussion and possible deepening of lessons with case reviews. A dental hygienist is an
excellent co-teacher to help with practical skills for fluoride varnish application.
Students/residents can practice on each other with samples of the varnish. Free clinics and
other rotations can be used as training grounds for applying fluoride varnish on children
patients.
v. Outcomes Assessment
Learners can be asked to complete the Smiles for Life modules online and answer the test
questions at the end of the module(s). These can be printed and submitted for proof of
mastery of the topic. Alternatively the test questions can be downloaded and used by a faculty
member. Learners should be observed applying fluoride varnish and “signed off” as
competent like any other procedure in the clinic.
vi. Inter-professional education
Dental hygienists and dentists can be asked to lecture and teach about a variety of oral health
topics including fluoride varnish. Inviting outside dental professionals is also a good way to
improve communication and collaboration and may also assist in establishing referral patterns
for medical patients to connect with a dental home. Universities that have both medical and
dental schools can learn together and share cases. Inter-professional education can also
include nursing, physician assistant and dental hygiene schools.
VII. Consumer Demand
When consumers know about services that are available to them, there is generally greater demand for such
services or at minimum, acceptance of them when offered by their physician. Materials in the waiting
rooms and in the exam rooms can provide basic information about oral health. Materials can also be
distributed to local community organizations, which reach out to certain population groups, assisting them
with accessing medical care. Many materials, available from the federal or state governments are available
in multiple languages.
Materials
Handouts and Posters:
http://www.mchoralhealth.org/publications.html
http://www.fromthefirsttooth.org/
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Games for Children:
http://www.colgate.com/app/BrightSmilesBrightFutures/US/EN/Program-Materials/KidsGames/Games.cvsp
http://www.learninggamesforkids.com/health_games_dental.html
http://www.lookingfordental.com/games.php
Videos for children:
http://2min2x.org/watch-brush
http://www.mouthhealthykids.org/en/Home-MouthHealthy-Kids/games-and-quizzes/visit-the-dentist-withmarty
http://www.sesamestreet.org/parents/topicsandactivities/toolkits/teeth
VIII. Dental Community Alignment
The effort to provide services in a medical setting does not at all preclude the need for children to be
connected with a dental home. If anything, it is hoped that a connection with a dental home will occur
faster and at a younger age. The American Academy of Pediatrics (AAP) and the American Dental
Association (ADA) both advocate for children having a dental home by age 1.
The role of the physician is to educate, provide some preventive services and assist the patient in
establishing a dental relationship, by referring the patient. Most physicians do not want to be considered
the dental home although they need to incorporate oral health into their screenings and assessments. This
is no different than assessing a patient for a multitude of medical conditions and referring where necessary.
The physician may be supplementing care in the child’s early years, but the goal is to have the patient have
a dental provider. For this to happen easily, there are several things a medical provider can do:
•
•
•
Establish a referral relationship with several local dentists. By reaching out and connecting with
local dentists, the physician will know which dentists are accepting new patients and at what age.
Not all dentists are comfortable treating very young children
Add oral health to the information provided to patients with a list of local dentists that will accept
the patient.
Assist patients in making an appointment with a dentist. Some offices will go the extra step and
call a referral source for the patient to guarantee that the follow-up appointment is made.
Physicians may ask a parent if the child has a dentist. The question may not go far enough to determine if
the child has actually seen the dentist, particularly within the prior six months. Probing the parent on these
types of questions will help in establishing a dental home. The recent US Preventive Task Force
recommendations are for physicians to apply fluoride varnish through age 5. Alternatively if a physician
knows a patient is receiving fluoride varnish regularly from a dentist, the physician does not have to apply
the varnish.
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Although initially many physicians feel they should either not be in the dental business or feel they are
hurting their dental colleagues by providing fluoride varnish, but by promoting the importance of oral
health they are actually doing the opposite. They are getting patients to understand the importance of oral
health and in establishing a dental home.
IX. Summary and Recommendations
In order to have a successful oral health and fluoride varnish program, it must become a standard of
practice for the office, much like vaccinations and flu shots have become. It is a preventive service that
goes a long way to ensuring healthy outcomes. In summary, here are some quick tips that can be
promoted with primary care offices to successfully incorporate oral health into a medical practice.
•
•
•
•
•
•
•
•
•
•
Promote benefits to everyone in the office to get buy-in:
o Reduction of caries/cavities by 30-65%
o Increase in children seeking and obtaining dental care
o Increase revenue in the office – range $6,000-$70,000 depending on volume and
reimbursement
Have an office champion who can answer questions, motivate staff, order varnish, etc
Set up billing and progress note prompts in EHR (See Appendix D)
Plan office flow; most offices offer the varnish with the immunizations; think about who will ask
oral health questions, do exam, make dental referral – divide and conquer
Train all members of the staff so everyone gets it
Have staff practice on each other, then family members to improve confidence, skill
On the day of the training – GO LIVE – start varnish and billing
Have an expert (the trainer, a dental hygienist, the oral health champion) directly work with staff
during the first week to increase confidence
Offer incentives for first week, month to get medical staff to try it (e.g. first person, team to do 30
varnishes gets a gift card, free lunch, etc.)
Add on-line training to new employee training/manual; be sure the new hire gets some practical
observation and hands-on experience
Updates on information contained in this document can be found at: http://www.fromthefirsttooth.org/
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APPENDIX A: SAMPLE MARKETING MATERIALS
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APPENDIX B: LETTER OF COMMITMENT
Letter of
Commitment
From the First Tooth will provide oral health training for your staff, CME/CNE credit, materials to immediately
implement the program and a free lunch for attendees.
___________________________________________________________________________(name of practice)
agrees to participate in this training and commit to providing the oral health services to its Medicaid patients,
starting on the date of the training, and in doing so will:
1. Have MDs, Nurses and MAs attend in full, a one-hour lunch and learn in order to qualify for CME/CNE.
2. Have at least 2 patients (they may be children of a staff person) for the purpose of having an MD, nurse or
MA apply fluoride varnish while the trainer observes.
3. Make accessible a billing staff person for the trainer to explain the billing codes and procedures.
4. Identify an office oral health champion who will be responsible for ordering the fluoride varnish and
establishing a workflow that guarantees that oral health assessment and fluoride varnish are included in
well child visits
5. Participate in the evaluation of the program, by completing and sending an evaluation form to the trainer
and accepting periodic follow-up calls from the trainer or program outreach staff.
Agreed to this ___________________ day of ___________________, 20_____ .
By: ___________________________________________________________________________ (signature)
_________________________________________________________________________(print name)
Confirmed by From the First Tooth Program Staff:
___________________________________________________________________________
ID#_________
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APPENDIX C: OFFICE QUESTIONNAIRE
USED TO PREPARE FOR TRAINING
Practice Name:
Primary Site Address:
Street
Name of Contact Person:
Contact Info:
Billing Staff Contact:
Name:
City
E mail
Contact Info:
Office Billing NPI:
Phone
E mail
State & Zip
Fax
Phone
Practice Type:
☐Private Office
☐Rural Health Center ☐Federally qualified health center
☐Hospital or community clinic
☐Other (describe) _______________
Clinicians who provide majority of well child care visits:
☐Pediatricians ☐Family physicians/Internal Medicine
Number of Employees Across all Offices to be Trained:
☐Other:
_____ Medical Assistants
_____ Registered Nurses (RNs)
_____ Nurse Practitioners/Physician Assistants
_____ MDs and DOs
_____ Residents
_____ Receptionists/Front desk
_____ Other, please list:_________________________________________________
Has your office, or staff, received any oral health training in the past?
☐Yes
☐No
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Estimated number of patients served weekly for well child-care visits:
6 months to 3 years inclusive
4 years to 20 years inclusive (MA only)
Number of the above patients on Medicaid
Number of the above patients on Private Insurance
Number of the above patients without insurance
Clinic Systems:
Practices are most successful when they start implementing oral health and fluoride varnish immediately after the
training. Please answer the following questions so we can help you to be prepared:
Determine when the services will be delivered and how children will be identified:
• Oral health and fluoride varnish can be provided at well child care visits from 6 mths through 3 yrs
• Who will identify eligible children?
• How will the charts be flagged?
• Will a billing/consent form be used for parents desired fluoride varnish who do not have insurance?
☐Yes, who will give the form to parents?
☐No
Who will provide the following services?
• Oral Health Risk Assessment Questions:
• Oral Evaluation and Plan (Primary Care Provider):
• Parent/Caregiver Education:
• Fluoride Varnish Application:
Create a plan for fluoride varnish materials and oral health information:
• Who will order supplies?
• Where will they be stored?
• Where will the patient information be displayed?
• Who will give the information on fluoride to the parent?
• For the patient visit, who will get the supplies ready?
Establish documentation:
• EMR: Who will add dental fields?
• EMR: Who will enter the data during the visit?
• Paper charts: Stickers/stamps (provided) or other prompt?
• Who will add the dental codes to the billing sheets?
How many exam rooms do you have?
For this program to be successful it is important to identify an office member that is willing to be a fluoride varnish
“champion” who helps answer questions, ensures supplies are ordered and encourages staff members to
remember to promote oral health. Please indicate who in your office will fulfill this role:
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Name:
Contact Info:
E mail
Phone
Fax
Training Day
To help staff become comfortable providing oral health services our training staff will stay for the afternoon
patient session. How many ELIGIBLE patients (6 mths- 3.5 yrs) do you have scheduled for this session?
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APPENDIX D: EXAMPLE EHR SCREENSHOTS
Centricity:
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EPIC
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APPENDIX E: NEW HIRE TRAINING INFORMATION FOR EMPLOYEE MANUAL
New Employee Training
Oral Health and Fluoride Varnish
For new employees, on line training for oral health and fluoride varnish application can be found at
www.smilesforlifeoralhealth.org. The sidebar on the home page marked “Quick Course Links, Module 6” will provide
the full training. The training is sell-explanatory and takes the learner through a series of on-line pages and ends with a 10
question test. The information contained with the module is the same as the training materials that have been provided for
offices when a "Smiles for Life" training has been done.
Upon completion of the on line training, it is recommended that a veteran staff person who is comfortable with applying
fluoride varnish provide a hands-on demonstration on how to apply the fluoride varnish with a young child. The new
staff person should then try applying the varnish while the other staff person watches until the new staff person is
comfortable with the procedure.
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APPENDIX F: POST TRAINING FOLLOW-UP QUESTIONNAIRES
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APPENDIX G: MOC GUIDELINES
Pediatric
Maintenance of Certification (MOC) Part IV TIPS
for an Oral Health Quality Improvement Project
All information contained in this document are based upon using the American Academy of Pediatrics (AAP) Education in
Quality Improvement for Pediatric Practice (EQIPP) Course
All physicians need to complete at least 1 MOC Part IV every 7-10 year board cycle. We want to help you make it as
easy as possible for you and your colleagues/practice. This document will take you step by step through the AAP MOC
IV EQIPP course for “Oral Health in Primary Care”.
Step 1:
ENROLL: You can enroll for MOC Part IV as an individual doctor or as a group practice.
You register on the AAP website at: http://eqipp.aap.org
How can I enroll my group or practice for an EQIPP course?
To register for an EQIPP course as a group, you may complete the EQIPP Group Registration form. You will need to
obtain the first and last name, AAP ID #, and a contact email address from all group members in order to complete the
registration form. This will take about 10 minutes.
Be prepared to pay the following fees:
(Note: the AAP offers a discount on a different course each Thursday)
FEES: The fees for registering are:
Individual Registrations:
Individual AAP Member: $99
Individual Non-Member: $129
Group Registrations:
Group AAP Member (2 or more): $79/person
Group Non-Member (2 or more): $119/person
You will obtain the following CME credits:
CME: The breakdown of CME credits is:
AMA PRA Category 1 Credit(s): 28.50
AAP Credit: 28.50
MOC Part 4: 25.00
NAPNAP Credit: 28.50
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Performance Improvement: 20.00
Pharmacology Rx: 0.50
The AAP EQIPP course expects that at the end of the project you will achieve these goals:
•
•
•
•
•
•
•
•
•
Understand the importance of a dental home
Identify the various facets and barriers in facilitating the establishment of a dental home
Understand the dental caries process and impact of Early Childhood Caries (ECC)
Know the process of performing a caries risk assessment
Identify groups that are at high risk for dental caries
Provide age-specific oral health anticipatory guidance
Be familiar with fluoride varnish—who should apply it and how it is applied
Address families’ concerns about fluoride varnish
Understand the process for procuring and billing for fluoride varnish
Step 2:
PROCESS: You will measure and improve oral health care delivery by doing the following:






Collect and analyze baseline data to establish a starting point for improvement.
Identify one or more performance gaps in one or more key activities of oral health care.
Create a PDSA cycle for closing identified performance gap(s) by clarifying the improvement idea to be tested:
Plan: What area will we try to improve? How will we do it?
Do: Carry out the plan
Study: Assess how the change made an improvement?
Act: Make changes to the plan to make it even better and disseminate the plan wider
Test your ideas quickly, on a small scale, so you can determine if the changes lead to improvement.
Collect and analyze follow-up data to measure the results of your test.
Determine how to sustain successful changes and how to systematically integrate them into the culture,
processes, and workflow of your practice.
NEXT “PRACTICAL” STEPS:
There are many ways to complete the EQIPP course. Below are two suggestions to make it easy for you.
You are encouraged to read and review as much of the material on the AAP EQIPP web site as you need. Here, we are
trying to focus your energies.
Strategy 1 for Completing MOC IV
If you have no oral health interventions in your office currently, you can consider stating that your office is at
point “0” and all change will be a positive change from there.
You could complete the optional Practice Survey to gain insight about your practice’s people, processes,
resources, and culture.
Our team can provide the Smiles for Life training working with you to train your entire staff, help set up EHR
oral health prompts, modify your billing procedure to include oral health code(s) and work on office flow to
make oral health assessments and fluoride varnish work as part of well child visits.
For evaluation, we can work with your office manager or billing manager to print up a summary of billing
information. You could also pull 20-30 charts from well child visits to assess how well you and colleagues are
doing on documenting oral health screens, referrals and varnishes. See ‘Resources’ below for an evaluation
spreadsheet. If you have a medical or nursing student or a pediatric resident that works with you – they may be
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able to assist you and get credit for the work with their home institution as well. An alternative idea would be to
hire a summer student.
Strategy 2 for Completing MOC IV
Alternatively you can begin the project with some baseline data by pulling 20-30 charts to evaluate how your
practice is doing around documenting oral health with current patients. See ‘Resources’ below for an evaluation
spreadsheet. Again, consider having a student or resident that needs a research project work with you on this.
After having us help you implement the Smiles for Life training, you can pull 20-30 charts again and re-evaluate.
RESOURCES
On the web site, http://eqipp.aap.org/ - This course is organized by tabs:
The Home tab includes this course introduction.
The My Improvement Project tab "houses" all data collection tools and quality improvement activities:
1. Enter patient data into the form. The first data set creates a baseline, or starting point for improvement.
You could have a student or office staff member do this.
2. Let the sequential “wizard” walk you through the steps of analyzing results to identify gaps.
3. When ready, create a plan to address gap(s) in key clinical activities. (Note: It is recommended that you
review information in the Clinical Guide related to an identified gap before addressing it in an improvement
project.) For example – if currently your office screens for oral health risk or gives advice haphazardly,
create a standardized process. Change your well child form/screen to have prompts or have the nurse/MA
do this for each patient. Offer varnish with vaccines so they do not get missed. This is where we can help
you with our training.
4. Offline, conduct small tests of change through PDSA cycles (using the advice above.) For example you might
find that storing the varnish in the room works better than carrying it into the room each time. That would
be a PDSA cycle to trial and get feedback from nurses and Mas as to how it worked.
5. Return to the My Improvement Project tab and enter follow-up data to measure if the tested changes
actually resulted in improvement. Successful changes can then be implemented on a larger scale or
practice-wide. You could also do this with your own spreadsheets.
6. You can stop here or repeat the steps of collecting data, analyzing results to identify gaps, refining/creating
an improvement project, working offline to complete Plan Do Study Act (PDSA) cycles, and entering followup data until you have achieved your goals of delivering optimal oral health care.
The Clinical Guide tab provides relevant background information for each key clinical activity. Information includes
evidence-based guidelines, scientific recommendations, best practices, related tools and resources, and more.
The Resources tab organizes all course tools and resources in a central location.
Team tools: Developing a quality improvement (QI) team with leadership support is one way to create success in
medical home improvement. The team helps create a shared vision for oral health screening, which is necessary to
obtain practice-wide buy-in for innovations and bring about long-lasting, sustainable change. Find out more about
working with a team on the Teamwork Tips Tab.
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In Summary – keep the project simple. Create a baseline; have us help you implement pediatric oral health screens and
fluoride varnish complete with billing and documenting; re-assess your progress; and submit to the AAP. We at From
the First Tooth, can help you with each step.
For more information about the MOC Part IV process contact Hugh Silk, MD at [email protected]
To book a training:
in Connecticut or Rhode Island contact Jan Ruh at [email protected]
in Maine contact Susan Cote at [email protected]
in Massachusetts contact Megan Mackin at [email protected]
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APPENDIX H: TRAINING EVALUATION FORM
4 Week Follow-up and 4/6 Month Follow-up
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