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Preventing Tooth Decay in Children Through Quality Improvement

As tooth decay rates in young children have soared, Dr. Man Wai Ng has made it her mission to integrate oral care into pediatrics

June 17th, 2014
By Kristina Grifantini

Dr. Man Wai Ng
Dr. Man Wai Ng

With an increase in sugary drink options, the practice of offering juice at bedtime, less fluoride exposure and other changes, tooth decay rates in children under the age of 5 have jumped in recent years. To help remedy this problem, quality improvement initiatives are underway to make sure young children get screened—and referred—for preventive oral health care.

Man Wai Ng, DDS, MPH, chief of the Department of Dentistry at Boston Children’s Hospital, has spearheaded many of these efforts, most recently as Faculty Chair of a quality improvement project run by the DentaQuest Institute in coordination with NICHQ (the National Institute for Children’s Health Quality). She spearheaded a Health Resources and Services Administration (HRSA)-funded oral health initiative at Boston Children’s Hospital Primary Care Center (CHPCC). Ng also serves as an advisor to the oral health program for the Children’s Hospital team as it undergoes a major primary care redesign initiative, funded by such supporters as NICHQ (via the CHIPRA Massachusetts Medical Home Initiative) and the Harvard Medical School Center for Primary Care. She recently chatted with NICHQ about the improvements she’s been seeing—and leading—in improving oral health practices throughout pediatric offices.

Why is dental care in children so important to address now?
Oral health has been improving for all populations in the United States, except in our youngest children. Tooth decay rates in children aged 2-5 have been on the rise. At least one cavity is found in 28 percent of kids in this age group (pdf).

We know that children who have dental disease are more likely to have general health issues. But they’re also at a greater risk for eating and sleeping difficulties, as well as difficulty learning in school. By addressing oral health issues, we have an opportunity to improve children’s overall health.

Why is it important to discuss dental care in primary care environments, rather than wait until the child sees a dentist?
Pediatricians are at the front line of children’s overall health and they see children frequently for well visits during the first couple years of life. As trusted advisors to their patients and families, the messages that they give are usually well received.

Dentists used to believe the first dental visit should be at an age when children can accept dental care easily without resistance; typically that would be at age 3. But now children are seen with tooth decay at a much younger age, at age 1 or 2. As a result, in 2008, the American Academy of Pediatrics released a policy statement on preventive oral health intervention for pediatricians, stating that an oral health risk assessment should be administered periodically to all children, and every child should have a dental home by 1 year of age (pdf). The recommendations also called for oral health risk assessment training to medical providers who provide care for children, integration of dietary counseling, fluoride exposure and anticipatory guidance for oral health into comprehensive patient education, as well as the establishment of collaborative relationships between pediatricians and dentists to optimize the availability of dental homes. 

How did you first become involved in improvement efforts around dental care?
Boston Children’s Hospital Primary Care Clinic (CHPCC), the primary care pediatric practice and ambulatory training site for the pediatric residency program, and the Department of Dentistry share a patient population of high-risk, low-income, underserved children. Prior to 2005, oral health was not on the radar of our primary care practitioners at CHPCC. Knowing that tooth decay affects high-risk children disproportionately, can start very early and is a preventable disease, I felt that if we can identify risk factors early in infancy and focus on prevention, we will start to see improvements in children’s oral health. I felt that our pediatricians would recognize that their patients would benefit from early oral health assessment and preventive interventions.

Over time, CHPCC and the Department of Dentistry developed a collaborative relationship that supported pediatricians and staff in incorporating oral healthcare components into their visit routines, most particularly around three areas: performing caries (cavity) risk assessment, fluoride varnish and dental referrals when needed. We trained pediatricians to perform an assessment of risk by asking a few questions, for example, if children are going to bed with a bottle of juice or milk or if they are brushing teeth with a fluoride toothpaste, and to refer children with early signs of problems—such as the presence of tooth decay, enamel defects, or a family history of tooth decay. As a result, we have seen a significant increase in the referrals of children from CHPCC to the Department of Dentistry for their first preventive dental visit, and at a much younger age. The dental disease rate and severity have also been reduced in children seen during their first visit. 

A second initiative exposed me to improvement work in our own dental care delivery setting at the dental clinic at Boston Children’s Hospital. Many children are referred to Dentistry to receive dental treatment under general anesthesia. At one time, children who required operating room (OR) treatment faced very long wait times. While on the waitlist, they commonly developed pain and infection. At the same time, rates of new decay and recurrent decay after OR care were very high. It has been known that tooth decay is a largely preventable disease, and repairing decayed teeth alone does not address the etiology of the disease process. Without improvements in diet and oral hygiene, new and recurrent decay would likely occur.

We thought there had to be a better way to take care of children with early childhood caries (ECC). That was the impetus for embarking on a demonstration project, dubbed the Early Childhood Caries (ECC) Collaborative, in 2008 with the DentaQuest Institute, and later in coordination with NICHQ in ECC Collaborative Phase 3.

How does improving dental care relate to the medical home initiative?
The medical home initiative has actually enveloped oral health as one of its goals. Aside from improving young children’s oral health from performing risk assessments and applying fluoride varnish, another benefit we found through the medical home effort is the connection to healthy weight. Our primary care providers at CHPCC have found that they are able to more easily address healthy eating from the perspective of healthy teeth rather than healthy weight. Interestingly, they have found that parents are more willing to change behavior for their kids to have nice-looking teeth.

How have quality improvement (QI) practices helped with this effort?
The use of QI methods has been valuable to help transform the CHPCC practice to include oral healthcare during well child visits of young children. For example, a nursing caries risk assessment tool (N-CAT) and fluoride varnish application for high-risk children were introduced and tested among a small group of providers first at CHPCC and found to be successful. Over time, its use was spread to more providers and later to the entire practice. 

In 2008, the dental profession understood very little about QI. Although we already knew how to prevent the disease, no one in the dental care community had a systematic clinical protocol in place. That year, DentaQuest funded the ECC Collaborative to test the feasibility of a disease management protocol in clinical practice. We found that the disease management protocol was not only able to be implemented into practice, but results also showed lower rates of new cavities, pain from untreated decay, and referrals to the OR for dental treatment under anesthesia. DentaQuest funded a larger Phase 2 program in 2011 and saw similar outcomes. Last year we began a Phase 3, spreading the change to 33 practices.

What results have you seen, specifically?
With regard to the DentaQuest ECC disease management protocol, consistent with quality improvement practices, we tested and implemented the workflow first in two hospital-based dental practices, then continued with testing and spread to five additional practices, and now to 33 practices.

Pertaining to oral healthcare in the primary care setting, we have spread the CHPCC protocol to Martha Eliot Health Center, a Boston Children’s Hospital operated health center in Jamaica Plain, Boston. We have also disseminated this program to the Children’s primary care network of more than 70 pediatric practices around Massachusetts in the past year. The new quality improvement program has been very well received, and many of those groups have incorporated oral health practices such as caries risk assessment, reinforcing messaging, applying fluoride varnish, recommending fluoride toothpaste and referring patients onto dental care when needed. The practices have assessed their patients’ needs to determine how oral health fits into their practice, and have adapted the protocol to their workflow.


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