Maternal health and dentistry: A collaborative approach

Abstract

Cabarrus Health Alliance (CHA), the only public health provider in Cabarrus County, North Carolina, has a long history of cooperative programming within the community and private sectors. This has resulted in a safety net that offers both diverse and innovative approaches to delivery of comprehensive maternity, pediatric, and dental services for high risk, low income residents. With greater competition for resources, the CHA is focusing intervention strategies at the earliest opportunity. Vertical transmission of cariogenic oral bacteria from high risk mothers to their newborns is well documented and puts the child at risk for very aggressive tooth decay. Additionally, chronic infections such as periodontal disease have recently been proposed to play a role in premature birth .To address this, the CHA has added strategies to identify and provide care for high risk women during pregnancy to offer the earliest possible prevention of early childhood caries and provide a therapeutic protocol which may decrease risk for premature birth and low birth weight.

A network of screening and surveillance has been in place to access high risk children for comprehensive dental care. Over the past 10 years, this has generated enormous community support for expansion of the CHA Dental Program. We have now identified several access points within both the community and CHA at which to target high risk pregnant women for dental care. North Carolina Medicaid for pregnant women provides coverage for routine as well as emergency dental care, thus providing access to dental services during this critical period.

Background

Cabarrus Health Alliance (CHA) the only public health provider in Cabarrus County, North Carolina, has a long history of cooperative programming with both the community and private sectors. This has resulted in a safety net formed from progressive and innovative approaches for the provision of comprehensive maternity, pediatric, and dental services for high risk, low income residents.

The CHA Dental Program consists of three major components: a community network of screening, surveillance, referral and education; a 12 chair fixed clinic providing comprehensive dentistry to children and adults; and a 2-chair mobile unit that travels to Head Start programs, high-risk schools and daycare centers. The Dental Program has grown from a 2 chair mobile unit ten years ago to its current status as a result of successful collaboration with community partners. A network of screening and surveillance has been established at several levels, resulting in referral of high risk children for comprehensive dental care. The outcome has been a reduction in the dental decay rate of kindergartners from 26% in 1999 to 13% in 2006. Currently, the CHA is adding a preventive strategy of targeting women during pregnancy to offer the earliest possible intervention for early childhood caries and to reduce the role periodontal disease may play as a risk factor for premature birth.

Research demonstrates that mothers with high concentrations of salivary bacteria, which contribute to dental caries, can pass this infection to the baby. This vertical transmission of cariogenic oral bacterial from high risk mothers to their newborns puts the child at risk for a very aggressive form of tooth decay at a young age. Early childhood caries have been documented as one of the most common diseases in the pediatric population, causing pain, infection and absenteeism in school-age children. Additionally, in recent years chronic infections such as periodontal disease have been proposed as a risk factor in premature birth and low birth weight infants. We have established a pilot project which will not only improve the health of low income pregnant women, but also the oral health status of their children.

The Maternal Health Program at the Cabarrus Health Alliance has always targeted high risk pregnant women. Designed to help decrease infant mortality and assure early and consistent prenatal care, program services consist of not only prenatal and delivery care, but also case management, intensive home visiting, Lamaze classes, and other parenting and safety classes in collaboration with community partners. This extensive network provides numerous points of access for evaluation and referral of maternity patients for dental assessment and care. In North Carolina, Medicaid coverage for pregnant women provides for dental care for routine as well as emergency services. This makes dental care during the prenatal period attainable, a critical point since this may be the only opportunity our clients have to access dental care.

The Maternal Health Program already has a history of referring high risk women to the Dental Program for emergency dental treatment. This year, we started referring women meeting our criteria for preventive and restorative dental treatment. In preparation for beginning to treat pregnant women, the CHA dental and medical directors commenced a review of current literature regarding dental treatment of maternity patients at various stages in pregnancy. A protocol for dental treatment was developed and reviewed with CHA dental providers as well as referring providers from the Maternal Health Program. Medicaid documentation and prior approval requirements were also reviewed to maximize potential for compensation for services rendered.

A liaison to the dental clinic was identified, and is primarily responsible for appointing the patient, and follow up to assure appointments have been kept. Once appointed in the Dental Program, culturally competent dental staff assists in assessment of each patient, and provides a comprehensive dental exam (both clinical and radiographic), periodontal therapy, restorative treatment and education. Approximately 70% of the women are Latino and require interpreter services. We estimate that the average treatment plan requires 5-7 appointments to complete, with most treatment targeted for the second trimester. Education is provided primarily by dental hygienists and assistants.

After delivery, the children are followed in the Cabarrus Health Alliance Pediatric Clinic. With a goal of establishing the medical home by age one, Pediatric services provided by the CHA include comprehensive well and primary care, case management for high risk conditions, intensive home visiting, and neurobehavioral intervention. Dental screenings and fluoride varnishes have been an integral part of well child visits for more than two years. Pediatric providers have had training in oral health screening and prevention protocols. Consequently, a similar goal is now practiced to establish a Dental Home by age 1 year.

As stated previously, low income children in Cabarrus County have access to a variety of early childhood health and intervention programs through the CHA as well as community agencies. Expanded collaboration between Maternal and Dental Health Programs at the CHA will allow us to provide high risk maternity patients with prenatal dental care and establish a dental home for their children, improving the oral health status of the next generation of high risk children.