In 2002, the Clinton County Health Department's MOMS program (Medicaid Obstetrical Maternal Services) had limited dental resources available to which to refer Medicaid-eligible prenatal clients. Annual reports had indicated that more than 50 percent of the MOMS clients had some specific dental concern or poor oral hygiene habits. Very few dental practices were accepting Medicaid-eligible clients, and the local dental clinic had a waiting list of several months. Poor oral hygiene in pregnancy is associated with an increase risk of low birth weight, pre-term infants.
The Clinton County Health Department realized that it could play a role in preventing poor outcomes in pregnancy related to oral hygiene. The health department could not dramatically change the number of dental practices/clinics in the area or increase the number of Medicaid clients served. Prevention could be done through education and by offering the MOMS clients a "dental kit" (toothbrush, toothpaste, dental floss, mouthwash, and a brochure on prenatal oral hygiene). The goal or outcome would be to improve the individual oral hygiene practices of the prenatal woman. Although this project would not capture the desired outcome for the women, it is possible that this preventive measure could reduce the number of low birth weight, pre-term infants born to this population. This program has been well received and results have been positive.
The public health need that this practice addresses is the need for improved prenatal dental hygiene that could improve prenatal outcomes by decreasing the risk of low birthweight, pre-term infants. Initial dental screenings of MOMS participants identify almost 57 percent in need of professional dental services. The most common concerns include cavities, gum disease, dental infection, and pain. Although the Medicaid benefits pregnant women receive via the MOMS program provide dental coverage, there is a serious shortage of participating providers. The CVPH Medical Center Dental Clinic is the primary provider for adult Medicaid clients but has a waiting list of several months. There are no practical alternatives for these prenatal women to obtain dental care and thus they are at risk for complications leading to pre-term, low birthweight babies.
Dr. Roy Williams at the American Dental Association conference indicated that the danger of untreated serious dental problems puts women at seven times the risk for low birth weight/pre-term babies. Few providers and extended waiting times are compounded by the loss of Medicaid benefits following the postpartum period, which may preclude women from beginning or completing dental care. Although the MOMS program could not significantly change the number of dental providers in the area, the program could influence the prenatal woman's oral hygiene and her understanding of the relationship between increased prenatal risk and poor oral hygiene.
A consultant dental hygienist provided training to the MOMS nursing staff on current standards for oral hygiene relating to pregnancy As each patient completes her enrollment in MOMS and completes the nursing assessment (which includes a dental assessment/screening), the nurse will give her a dental hygiene kit. The kit comprises a manual toothbrush, fluoride toothpaste, dental floss, mouthwash, and an informational folder in a small tote bag. The MOMS nurse provides instruction on the importance of dental care and makes a referral to the Medicaid dental clinic or to an alternative dental practice that may provide services. Sometime during their pregnancy, or at the postpartum visit, the MOMS clients are given a replacement toothbrush to reinforce a key concept of regular replacement of the toothbrush to reduce potential bacterial exposure and to promote effective cleaning.
The Clinton County Health Department's MOMS program could not realistically increase the number of dental providers serving the Medicaid-eligible population, but the MOMS program could help to improve the outcome of the pregnancy and the infant involved. In discussion with prenatal women, it was clear that this concern was being addressed minimally addressed or not at all. The dental kits and education provided to prenatal women on the connection between poor oral hygiene and the risk for complications leading to pre-term, low birthweight babies was a new concept in the county and local area. The prenatal practice would hopefully continue into the prenatal woman's family, promoting good oral hygiene habits for the infant and growing family. This program has been used a role model within the state and has been funded for a second year.
Agency Community RolesThe Clinton County Health Department was awarded a grant for Prenatal Oral Hygiene in 2002. The health department's efforts were brought to the attention of the State, and since then the New York State Department of Health Dental Bureau has supported and helps fund the practice. Clinton County staff participate in the Regional Oral Health Prevention and Education Network and also in the New York State Oral Health Plan Steering Committee.
Costs and ExpendituresThe cost to sustain the Prenatal Oral Hygiene/prenatal dental kits is minimal. The goal of the practice is to improve oral hygiene habits in the prenatal population. This would help to eliminate costly pre-term and low birth weight medical care. The preventive plan would hopefully reduce the cost for the woman’s individual dental care.
To serve Clinton County’s Health Department’s MOMS program a total of 400 dental kits were assembled. Each kit costs approximately $6.50. Costs for supplies are approximately $2600.00 to $3000.00 annually. Initially, the staff was trained by a registered dental hygienist who ensured that proper instruction was given to the prenatal women. (Updates may be built into the system as needed.) Upon enrollment, the MOMS staff nurses spend approximately 5-10 minutes explaining the program and providing education on oral hygiene. Assembling a two-week supply of dental kits takes approximately 20 minutes and is done by clerical, volunteer, or nursing staff (if necessary). Collecting the individual assessment surveys and compiling the data takes approximately 30 minutes per week.
Initially this practice was funded for a year through a grant. Due to the positive results received from this program the New York Department of Health Dental Bureau has funded the program for another year. At this point the practice is just entering its second year. Evaluation on the effectiveness of the first year was overwhelmingly positive. The health departments hopes that funding will continue as a result of 1) record keeping that indicates the positive changes in oral hygiene habits within the MOMS population and 2) promoting this practice to other programs within New York State. Until dental services become available to this population the Clinton County Health Department’s MOMS program will strive to continue this practice as implemented using present funding.
ImplementationThe steps taken to put this plan into action were fairly basic:
Dental hygienist instructs MOMS staff on current standards for oral hygiene and pregnancy and explains how the standards are applied to the dental kit.
Provide dental kit with instructions to prenatal women upon MOMS enrollment. Assess the prenatal woman’s present oral hygiene habits.
Relate oral hygiene habits to nutrition, child development and infection risks, and potential pregnancy outcomes.
Replace toothbrush during pregnancy or at the postpartum visit.
Make dental referrals as needed.
At 28 weeks gestation or at the postpartum visit, assess any changes in oral hygiene habits and record results. Compile results on a regular basis and evaluate the changes in oral hygiene habits in the MOMS program population.
Collaborate with agencies to spread the Prenatal Oral Hygiene message.
The timeline for carrying out these tasks revolves around the prenatal and postpartum period, which is approximately nine months, depending on the trimester in which the woman was enrolled into the program. This practice could be adapted for use in many other settings, such as OB-GYN offices, clinics, and dental offices/clinics.
The assessment survey, conducted with each prenatal woman who received a dental kit and education, is completed at the 28 weeks gestation visit or at the postpartum visit. Results from the first year of implementation indicated that a majority of the women improved their brushing, flossing and rinsing habits. The survey results have helped to determine whether implementation and outcomes goals were met. This practice had very few challenges. Developing a system to insure that assessment surveys from the prenatal women were getting to the appropriate Health Department staff member was worked through. This was important to compile the data and maintain accurate results. The acceptance of the initial grant and the ordering of the supplies took more time than expected but since then this process has been timely. As mentioned earlier, if this program continues, it would be helpful to have periodic updates from a dental hygienist or dentist on prenatal oral hygiene. There is minimal time involved in putting the dental kits together. The department uses volunteers, if available, rather than using staff time, but the volunteers are not always available when needed or not available at all, so staff sometime assemble dental kits.
Upon the initial enrollment to the MOMS program the prenatal woman is assessed for her present oral hygiene habits. (See enclosed sample) The MOMS nurse then gives instruction on proper oral hygiene habits. At 28 weeks gestation and/or at the postpartum visit the woman is again assessed for her present oral hygiene habits. The simple assessment form allows the Health Department staff to easily see any increase or decrease in brushing, flossing, or rinsing with mouthwash. Results have been very positive. Of 131 women enrolled from January through June 2003, 46 improved in brushing, 68 improved in flossing, and 45 improved in rinsing. As this was a new program there was no baseline data.
Annual reports and data collected from MOMS enrollment has indicated that greater than 50% of the women had expressed specific dental concerns or poor oral hygiene habits. Since the number of dental practices in the area has not increased and the dental clinic still maintains a waiting list, it is likely that most of these women changed their oral hygiene habits from the instruction and education given by the MOMS nurse. Some of the women may have seen their dentists during this timeframe but the overall increase in brushing, flossing, and rinsing were seen across the board when the data was compiled. With very few alternatives for these women, the program has been more than worth the investment. There is very little time involved in carrying out this project. The overall cost is minimal when the result may be a healthier mother and newborn and possibly reduced medical costs. There are no unintended consequences. The program has more than achieved the goals and objectives.