Dental Public Health Activities: Descriptive Summaries
Infant Oral Care Program (IOCP)
Early childhood caries (ECC) is a highly infectious disease caused by bacteria easily transmitted from subject to subject. ECC disproportionately affects the impoverished but studies have shown that preventing the onset of early childhood caries is more cost effective compared to treating advanced caries. However, access to care whether primary, secondary or tertiary, remains an issue for lower socio-economic populations. Dental service utilization rates for children on the country’s largest safety net program, Medicaid, is only 38%, underscoring issues in accessing care. In Los Angeles, ECC disproportionally affects children who are also most likely to be enrolled in Medi-Cal. Over 70 % of children under five are non-White Hispanic or African American, and over 86 % live at or below poverty level. Furthermore, the Los Angeles County Denti-Cal report and a USC caries experience profile study indicate that there are less than 3 dentists per 10,000 Medi-Cal beneficiaries with a 20% utilization rate for dental service.
These facts highlight widespread difficulties in accessing dental care for many children. However, early identification of risk indicators and implementation of oral health preventive practices can reduce or avoid caries progression. This supports the need for early establishment of dental homes and simple, effective infant oral care preventive programs for all children as part of a medical disease prevention management model. Pediatric primary healthcare is best delivered where comprehensive, continuously-accessible, family-centered, coordinated, compassionate, and culturally effective care is available and delivered or supervised by qualified child health specialists.
In 2010, UCLA launched an Infant Oral Care Program (IOCP) at the Venice Family Clinic (VFC) Simms/Mann Health and Wellness Center. The IOCP provides care coordination that is culturally competent, sensitive to language and oral health literacy challenges and increases access to care and improves oral health outcomes through a disease prevention and management model with appropriate and cost-effective dental services targeted at typically underserved, low-income, minority children ages 0-5 and their mothers/caregivers in a non-traditional setting. This innovative and unparalleled clinical model represents the future of oral health, early intervention and dental disease management, and sets a new standard of comprehensive, integrated, widely accessible and evidence-based dental care. The specific aim of the program is to simultaneously increase entry points of access and enlarge the number of trained on-dental providers to integrate perinatal and pediatric health care with oral health services to improve overall health outcomes. To strengthen the infrastructure of the dental delivery system, we have partnered with WIC, HS/EHS, and a Federally Qualified Health Center (FQHC) to provide basic dental services in a non-clinical setting. FQHC dental clinics in close proximity would provide secondary (acute) dental care, and university or similar programs, supply specialized tertiary care treatment.
The program recruits its patients from co-located Women, Infant and Children (WIC) and Early HeadStart/HeadStart programs as well as through pediatrician referrals at VFC. The IOCP also provides a unique training opportunity for pediatric and pediatric dentistry residents, general dentists, pre-doctoral dental students, and nurse practitioner students. In compliance with the “age one visit” recommendations by several national dental professional organizations, this strategic collaboration provides facilitated, early enrollment in a dental home. At each visit, the child receives a caries risk assessment, a toothbrush prophylaxis, a dental screening, and a fluoride varnish. The periodicity of visits is based on a child’s individual level of risk level. Caregivers receive basic oral health instruction via a brief motivational interviewing approach as well as anticipatory guidance to establish self-management goals to improve the oral health outcomes of their families. Each child receives appropriate triage and comprehensive care specific to their individual needs. Children will receive the IOCV in addition to, but not in lieu, of other services. Children who require acute or specialized care such as restorative treatment, receive a seamless referral to the linked FQHC’s dental clinic or network of community dental providers. When specialized tertiary care is necessary due to advanced disease or special health concerns, patients will receive a referral to UCLA or similar institutions for IV Sedation or General Anesthesia. The advantage of this scalable operation is its limited overhead and start-up costs, which can lower overall per patient preventive care costs compared to the cost of future dental restorations which on the high end can be as much as $10,000-$12,000. The only requirements for the IOCP model’s “pod” located at a WIC, HS/EHS, CHC/FQHC or when in tandem to a clinical site, is a private room, two chairs, a portable light, educational materials, and disposal dental equipment and supplies such as mirrors, gloves, fluoride varnish and gauze.
 Centers for Medicare & Medicaid Services (CMS). Medicaid/CHIP Oral Health Services. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Downloads/2010-Dental-Factsheet.pdf
 American Academy of Pediatrics, Early Childhood Cares (ECC). http://www.aapd.org/media/ECCstats.pdf. Accessed Sept. 29, 2011.
 2000 Census. "Los Angeles Almanac" Retrieved September 29, 2011, from http://www.laalmanac.com/.
 Maiuro LS, Health Management Associaties, Jen Associates Inc. Denti-Cal Facts and Figures. California Health Care Foundation, California Health Care Almanac; 2010.
Since its inception in 2010, the IOCP has reached over 500 patients. This success is attributed to the case management and triage based on individual overall risk level, dental care need, and the collaboration with the community health center staff. Over the past two years, its weekly four hour clinic has increased the number of patients as well as the recall appointments kept. In addition to wrap-around services provided to children and families, the IOCP serves as a community learning environment which gives students, residents general dentists, nurse practitioners and doctors experience providing preventive oral health care in locations where mothers and their children also receive their Well-Baby visits as well as dietary education and counseling. Active participants in this program gain clinical, knowledge and experience in individual caries management by risk assessment (CAMBRA), motivational interviewing, behavior management, disease management, fluoride varnish applications and the unique dental care needs of young patients. In addition, they also acquire a more in-depth understanding of cultural competencies in the community clinic setting as they learn first-hand how to navigate through cultural and language barriers, and patients/caregivers’ socioeconomic limitations. Upon completion of the IOCP rotation, dental and health providers are not only better equipped with a greater awareness of the value of good oral health in maintaining children’s overall health, but are also adequately trained, both clinically and culturally, to effectively early diagnose, prevent and treat very young and underserved young children.
Integrating oral health into primary medical care by pediatricians and nurse practitioners at general Well-Baby visits has improved the continuity of care between dental and medical homes, and has increase positive patient behavior resulting in lowering ECC disease risk. This strategy, combined with outreach and services provided by HS and WIC, has facilitated access to oral health care services for low-income and vulnerable populations by simplifying the entry process and linking it to other services that they are already utilizing with regularity. Furthermore, a streamlined referral process makes it easier for families to get appointments and improves the likelihood that they will comply with follow-up appointments. The IOCP also allows limited dental resources to focus on the more technically clinical treatments.
Contact Person(s) for Inquiries:
Francisco Ramos-Gomez, DDS, MS, MPH,
Lauren Friedman Russell, MPA,