Early Childhood Cavities Prevention (ECCP) in Klamath County

Klamath County's pilot project, "Klamath Mothers and Infants Cavity Prevention Initiative — A Rural Health Department Model," spent the first six months building partnerships, preparing protocols, developing and accumulating educational materials. Through this collaboration, a model system or blueprint was developed for providing a dental home, education, and oral health toolkits for all Oregon Health Plan eligible pregnant women and their children. The Community Health Partnership's Sub-Committee for the Early Childhood Cavity Prevention Program decided that the Health Department's WIC program was the logical hub or cornerstone of a successful program to engage the client population. All eligible pregnant women seen by health and human services providers were referred to the WIC program where they were recruited into one of two care models. It was found necessary to provide two models of service. Model A is for those women who are less than 32 weeks gestation. These women will receive a complete assessment, assigned to a dental home to receive any needed dental work before their baby is born, their child will be assigned to the same dentist for preventative care until the age of two, and receive age appropriate oral health toolkits. Those women who are greater than 32 weeks gestation fall into model B. They receive oral health toolkits and education, since they are getting too close to delivery.

The Community Health Partnership includes all organizations that work with pregnant women and children under two years of age. Primary participants are local dental and medical managed care organizations, the dentists and primary providers who contract with the managed health organizations, and the Oregon Institute of Technology's Dental Hygiene school.

Referrals of eligible pregnant women are sent on a daily basis from WIC or another collaborating agency to a central clearinghouse staffed by pilot project staff. After eligibility is confirmed, project staff contact the woman and schedule a home visit. At the same time the women are assigned to an ECCP dental provider. Home visits are done by a Dental Hygiene student from the Oregon Institute of Technology together with one of the pilot project personnel. During the visit, educational material is given in either English or Spanish by the appropriate project personnel. The clients are offered support and advice on how best to get the most out of a dental visit by eliminating barriers to care and providing age appropriate oral health toolkits and education. They are then scheduled for two visits to be assessed at the dental hygiene school at OIT or at Klamath Open Door Dental Clinic. There they will receive prophylaxis, radiographs, oral hygiene instruction, and a chlorhexidine regimen. (Northwest Dental Service the Dental Care Organization, pays OIT a flat rate for seeing those patients). A Medical Clearance form is sent by the OIT student to the OB/GYN and follow-up done to ensure it is returned before the scheduled appointment. When the OIT screening is completed, project staff pick up charts and deliver them to the assigned dental office. Follow-up contacts with the mother and the dental office are maintained to ensure a successful completion. [A full program protocol will be sent separately]. When the mother delivers, the child will be assigned to the same dental home to receive fluoride varnish every six months after the first tooth erupts.

Since February 2004 through to the end of May, 135 pregnant women were referred to the dental screening program. Of these 24 were ineligible either because they did not have OHP coverage, because they were referred past 32 weeks of gestation or because they opted out of the program. A further 32 were pending enrolment either because they could not be contacted or because they were currently applying to enroll in OHP. Of the remaining 79 pregnant women, 13 have not yet scheduled a home visit but 66 have received home visits. So far 24 people have completed their dental office visit, a further 31 have been seen at the dental hygiene school. The total number of home visits, OIT and dental office appointments scheduled is, at the time of reporting, now at 117. No show rate after scheduling appointments is around 12.8%.

Klamath's underlying premise is that if pregnant women's oral health and knowledge about best oral health practices are the focus then it will also lead to an improvement in the oral health of infants through decreasing transmission of bacteria from mother to child, from increasing her involvement in oral health behaviors and from providing a successful series of interactions with dental care professionals. The project's ambitious goal is to see all children whose mothers have participated in the program to be caries free at two years of age.

In establishing the groundwork for the Klamath program, trainings were offered with the partnership of the local hospital and the Managed Care Organizations to all medical and dental providers in the Klamath area. Three trainings with accompanying breakfast, lunch or dinner were given by Dr Peter Milgrom, Professor of Dental Public Health Sciences and Director of the Northwest/Alaska Center to Reduce Oral Health Disparities, University of Washington. Dr. Milgrom is the co-author of Early Childhood Caries: A Team Approach to Prevention and Treatment. The training took place two days in January during the worst winter snow and ice storm experienced in the state over the last few years. In spite of the weather 25 out of 39 Obstetricians, Family Providers and come in for an appointment and who are given some oral health information have been reporting that their prenatal care provider told them to use fluoride toothpaste at night and to spit without rinsing; exactly as the trainings has advised.

In Collaboration with the local Dental Care Organization, (Northwest Dental Services), a distribution program for xylitol gum to enrolled women has been designed with the recommendation to chew two chiclets four times a day for six months after delivery of the child. Monthly distribution will occur through Klamath County WIC staff and project personnel beginning July 2004.

The leadership of the Klamath County Health Department and Klamath Tribal Health have conferred on how best to include Native American women and children into the ECCP program. Options currently under discussion include:

1. Klamath Tribal Health would refer Medicaid eligible pregnant women to the WIC program to receive oral health care education either on-site or by a home visit. Participants would be referred back to the Tribal Dental Clinic to receive necessary radiographs, prophylaxis, fluoride treatment chlorhexidine therapy and necessary dental treatment to reduce Strep mutans levels.
   
2. Same as (1) except, KCHD will provide the education and oral health toolkits through classes instead of home visits.
   
3. Klamath County Health Department will train Tribal Health staff or a tribal member to educate Medicaid eligible pregnant moms and their children through a facilitated peer education system centered on establishing a dental home at the Tribal Dental Clinic. KCHD would supply oral health toolkits and education materials to Klamath Tribal Health.

Migrant Head Start has seen an increase in the number of dentists in Klamath Falls who are now seeing younger children. This rarely happened before this project began.

The Klamath ECCP project has been responsible for further opportunities that have been brought to the county. A proposal from Dr Peter Milgrom, University of Washington has been submitted to the Klamath County Head Start. The proposal is to have gummy bears made with xylitol, given to Head Start children after snacks two times a day. If accepted, Klamath County will be the first and only site in the continental United States to be involved in this project. Currently, the Milgrom research is offered in Head Start Centers in Guam and Hawaii.

Also, Klamath County Commissioner, John Elliott (an active member of the ECCP Advisory Committee) and Dr. Peter Milgrom have submitted several letters of invitation to commercial fluoride toothpaste manufacturers requesting their support of a countywide oral health improvement campaign. The campaign will promote improvement in the number of low income adults who brush regularly with fluoride toothpaste, provided for one year by the toothpaste manufactures. The impact of the use of toothpaste will be measured after the year's use.

MOVING TO SUSTAINABILITY. The Klamath County project has attempted to design a delivery model with sustainability in mind. They have expressed the goal of developing a program that can carry on long after grant support has ceased. With sustainability in mind, they:

1. folded a large part of the enrollment and education into a pre-existing and established agency, i.e., WIC;
   
2. involved over 20 different agencies on subcommittees and the advisory committee;
   
3. distributed sample toolkits and the ECCP Coalition literature to other agencies that work with the target population and encouraged those agencies to use and replicate the materials;
   
4. partnered with local medical and dental professionals to deliver oral health messages and services; continuing education credits have been provided for training. (training has been attended by a majority of medical physicians, nurses, dentists, dental staff and dental hygiene students in Klamath);
   
5. persuaded physicians and dentists through the trainings to tell their patients about the importance of using fluoride toothpaste and other oral health messages
   
6. involved dental providers at Northwest Dental Services, Klamath Open Door, and Oregon Institute of Technology in training in the new ECCP messages (this included all but one of the Medicaid Managed Care dental providers in the community);
   
7. are developing a fundraising campaign to assure that the program will continue after the RWJ funding ends and have received training in the use of federal Administrative Match dollars to assist in funding the outreach and linkage portion of the program.

Word of this program has spread throughout the state of Oregon and interest in replicating the program has been expressed from several areas in Oregon including, the Tri-County Health Coalition, which includes south Deschutes County, east Lake County, and north Klamath County, along with Harney County, east of Klamath County, and several counties in central Oregon.

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