Arizona nurses tackle cavity prevention in kids

May 1, 2011

CHW nurses provide dental screenings and fluoride treatments

Kathleen Dowler could see the trouble in their little smiles.

Dowler, a nurse at Chandler Regional Medical Center near Phoenix, saw many children with serious dental needs as she visited schools, Women, Infants and Children (WIC) centers and other stops on the hospital's traveling health clinic's circuit. Many of the children had never been to a dentist. Some didn't have toothbrushes.

What they had were cavities, lots of them. "The need was greater than I had imagined," said Dowler, director of community integration for Chandler Regional and Mercy Gilbert Medical Center. "We'd have kids with eight, nine cavities and abscesses. Some of their mouths were a mess."

Dowler and others expanded their health outreach to include basic dental screenings, applications of fluoride varnish and, when necessary, referrals of children to dentists. Chandler petitioned the Arizona State Board of Nursing to confirm that trained nurses may perform those checks upon children. The fluoride treatment involves using a brush or swab to coat a child's teeth with the varnish.

In January, the board approved. That makes Arizona part of a growing trend of having nurses perform these initial checkups, although few other states have clarified the issue by declaring it within the scope of practice.

Public-private partnership
The concept in Arizona dates to 2008, when representatives of Chandler, a Catholic Healthcare West hospital, met with leaders of the city of Chandler to consider the unmet dental care needs of children. The hospital obtained a three-year state grant for the work in August 2009, and began serving children in February 2010 under the supervision of a medical director. The first year's grant was for $493,836.

Chandler and its sister hospital, Mercy Gilbert, formally sought the nursing board nod in August 2010 at the request of First Things First, a state program adopted by voters that supports early childhood development and health. Both hospitals serve the East Valley region of the greater Phoenix area.

The state grant covers reimbursement for the costs of serving children up to age five. Another dental program sponsored by the hospitals, the CHW Children's Dental Clinic, also serves children up to 18 at clinics based in two elementary schools.

Megan Miks, manager of the CHW Oral Health Program at Chandler, said many of the children it serves are from families without dental insurance. Of the 2,800 children screened since February 2010, nurses found evidence of tooth decay in 617 mouths — a ratio of almost one in four children. The nurses referred 18 of them for immediate treatment by participating dentists because of evidence of pain, infection or swelling.

They also have explained basic dental hygiene for children to about 4,000 parents. 

Medical-dental collaboration
Dowler said there aren't enough dentists who accept Medicaid patients to screen all of Arizona's low-income children. And she said children who are eligible for Medicaid are three times more likely to have cavities than children who are seen by dentists regularly through private insurance or family payments.

"Because dental professionals cannot do all of this, the collaboration between medical and dental is definitely growing," said Miks. "The medical and dental communities can more effectively meet the needs of the community by working together."

Kevin Earle, executive director of the Arizona Dental Association, said his group supports the CHW program for children. "It's an innovative use of medical professionals to promote oral health," Earle said. "A lot of these kids aren't covered by Medicaid, and their rate of tooth decay is hugely high. This program can get to the children at a young age and educate their parents."

Miks said the program reflects CHW's mission in Catholic health care. "Resources are dedicated to delivering compassionate, high-quality, affordable health services, serving and advocating for our sisters and brothers who are poor and disenfranchised." 

Preventing problems
The CHW program in the East Valley employs three nurses who received training from the Arizona Department of Health Services. Miks said the training only takes a few hours. It enables registered nurses to conduct dental screenings and apply fluoride varnish, and licensed practical nurses to apply fluoride varnish under the supervision of an RN.

"We do a basic visual screening, looking for white spots and other signs of decay," said Miks. "An advantage to fluoride varnish is that you don't need a full dental cleaning before applying it."

Miks said the nurses visit schools, day care centers, health fairs and other places to offer the screenings. They go to area WIC centers twice monthly. WIC is a federally funded nutrition supplement program for low-income pregnant, postpartum and breast-feeding women and children up to age five who are at risk for nutritional deficiencies.

Educating mom and dad
Miks said the nurses speak with parents whenever they can to explain the need for daily dental care. She said many parents don't give much thought to baby teeth, figuring they're all going to fall out anyway.

"But tooth decay at any age causes problems," she said. "Kids have trouble eating and sleeping. If their baby teeth fall out before they should, it affects how their adult teeth come in."

For many uninsured families, it's the old story — given a choice between buying food or toothbrushes, food will win every time. The nurses give children gift bags with toothpaste, brushes and floss.

"One little girl was so excited to get her first tube of toothpaste," Miks said.


Copyright © 2011 by the Catholic Health Association of the United States
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