Special Needs Patients: Training Occupational Therapists to Perform Oral Health Risk Assessments

Breanne Reid, DDS

Background
Over 9 million U.S. children and adolescents have a special health care need (CSHCN)

CSHCN, relative to their non-special health care need peers, have: More unmet dental care needs Worse oral health
For low SES and more severe conditions 13 times adjusted odds for unmet dental care needs

Background
Study regarding the unmet dental care needs for CSHCN found: A regular doctor or nurse was significantly protective against unmet dental care needs
Reference: Lewis C, Robertson AS, Phelps S. Unmet dental care needs among children with special health care needs: implications for the medical home. Pediatrics 2005; 116;426-431.

Prevention Is Key
Pediatric primary health care providers can provide oral health promotion and disease prevention activities to their patients and families

The goal is to eliminate or delay dental disease and treatment needs at a young age

Putting It together
CSHCN have more unmet dental needs and limited access to dental care

Early oral health promotion, risk assessment and referral by pediatric primary care providers can eliminate or delay dental disease and decrease dental disparities

Children With Special Health Care Needs

Multi-disciplinary team of health care providers working together to enhance their overall health and development Pediatricians Medical specialists Nurses Social workers Therapists

The Occupational Therapist (OT)

OT services for young children with SHCN are available under the Individuals with Disabilities Education Act OT services are Personal Patient-focused Frequent (weekly or monthly)

Occupational Therapy Services

Support and promote development Help with everyday routines Rest and sleep Daily living activities Social participation

A New Avenue For Prevention

OTs may be a resource to reduce dental disparities among CSHCN Currently, little is known about OTs Knowledge of preventive oral health Frequency of observing dental problems Perception of barriers to access of dental care Value placed on promotion of oral health Willingness to incorporate activities aimed at oral health assessment

My Purpose
To assess whether oral health assessment training Improves the knowledge, attitude and behavior of OTs regarding oral health Results in implementation of oral health assessment for CSHCN in their practice

Methods
11 hospital-based and private OT practices in San Diego County were contacted 5 practices agreed to participate 31 OTs were surveyed before and 3 months after training
Survey assessed oral health Knowledge Attitudes Behavior

Methods
Oral health assessment training 30 minute PowerPoint presentation (20 slides) Topics covered included: Oral health as part of general health Caries process and visual signs of disease Ways to prevent tooth decay Recommendation for 1st dental visit Reference Handouts Oral health risk assessment (AAPD Caries Risk Assessment Guideline) Brochures on oral health for children Local dental providers referral list

Methods
Data analyses were performed Vassarstats and Excel Pre- vs post-training survey responses Paired t-tests Chi-square analysis

RESULTS
Mean age= 39.4y
(range= 24-63y)

Mean years in practice= 12.5y

(range= 0-37y)

Mean pts/week= 33 29% reported previous oral health instruction

RESULTS
At post-training 100% knew: Caries is most common chronic childhood disease (p< .0001) There is mother-child bacterial transmission (p= .003) Brushing begins at first tooth eruption (p<.0001) Post-training, more knew: First dental visit is at 1yr (p<.0001) White spots signify high decay risk (p<.0001)

RESULTS
More positive attitudes on importance of primary teeth (ps .001) More confidence in: Providing oral health assessments (p's .0001) Making dental referrals (ps .0001)

Oral Health Preventive Behaviors Increased

Post-training, OTs were significantly more likely to: Check teeth for decay (p=.0006) See decay in school-age children (p=.04) Ask if sleeping with bottle (p=.02) Counsel on importance of brushing (p=.0006) Ask about fluoride intake (p=.0004) Give caregiver name of pediatric dentist (p=.004)

Post-training, OTs were somewhat more likely to: See decay in children <5yr (p=.06) Refer kids <5yr to pediatric dentist (p=.06) Call dental office to make appt (p=.10) Tell caregiver child needs to see ped. dentist (p=.08)

100 90 80

Pre-training

Post-training

70
60 50 40 30 20 10 0

Recommended Snacks

Pre- vs Post- Recommended Snacks Post-training, OTs recommended Less cariogenic snacks More fruits, cheese, milk Less dried fruit, crackers and juice

Limitations and Strengths

Limitations Relatively small sample size Geographical limitation
No public schools or government agencies

Relatively short follow up period

Would attitudes and behavior changes be sustained for longer periods of time?

Strengths Recent and earlier grads included in sample 100% follow up among all OTs who responded to the pre-training survey Included OTs in differing practice types Used a single, short training session

Conclusions
Training OTs in oral health assessment resulted in improved: Oral health knowledge Attitudes and confidence Oral health preventive behaviors Training OTs in oral health assessment can: Improve primary prevention Reduce dental disparities for CSHCN Oral health assessment training should be included in OT curriculum

Future studies should: Include larger sample size followed for longer period Examine effects of changing OT curriculum to include oral health assessment training

References
1. National Maternal and Child Oral Health Resource Center, Georgetown University. Oral health for children and adolescents with special health care needs: challenges and opportunities. National Maternal and Child Oral Health Resource Center, Georgetown University 2005. 2. Lewis, CW. Dental care and children with special health care needs: a population-based perspective. American Pediatrics 2009; 9:420-6. 3. Lewis C, Robertson AS, Phelps S. Unmet dental care needs among children with special health care needs: implications for the medical home. Pediatrics 2005; 116;426-431.

4. dela Cruz GG, Rozier RG, Slade G. Dental screening and referral of young children by pediatric primary care providers. Pediatrics 2004; 114;642-652.
5. The American Occupational Therapy Association. Occupational therapy for young children birth through 5 years of age. The American Occupational Therapy for young Association, Inc. 2009.

References
6. Garcia, J. Open wide. State of Connecticut Department of Public Health. Commissioner Joxel Garcia, MD, MBA. 7. National Maternal and Child Oral Health Resource Center. Oral Health Services for Children and Adolescents with Special Health Care Needs: Resource Guide. National Maternal and Child Oral Health Resource Center, Georgetown University. 2005. 8. Association of State and Territorial Dental Directors and the National Maternal and Child Oral Health Resource Center. Promoting the Oral Health of Children with Special Health Care Needs- In Support of the National Agenda. Association of State and Territorial Dental Directors and the National Maternal and Child Oral Health Resource Center, Georgetown University. 2006

9. Kagihara LE, Niederhauser VP, Stark M. Assessment, Management, and Prevention of Early Childhood Caries. Journal of the American Academy of Nurse Practitioners 2009; 21;1-10.
10. Lewis CW, Grossman DC, Domoto PK, Deyo RA. The Role of the Pediatrician in the Oral Health of Children: A National Survey. Pediatrics 2000; 106;e84. 11. The American Occupational Therapy Assocation. Role of Occupational Therapy With Infants, Toddlers, and Families in Early Intervention. The American Occupational Therapy Association, Inc. 2009.