Capstone Project Proposal

Developing Educational Oral Health Resources for the

Maternal Infant Health Program

Jennifer Smits, RDH, AAS

University of Michigan Degree Completion Program

HYGDCE 489

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Table of Contents

Project Statement/Description 2

Review of the Literature 3

I. Introduction to MIHP 3

II. Developing Oral Health Resources 4

III. Management/Intervention 5

IV. Prevention/Education 7

V. Conclusion 9

Project Rationale 9

Project Objectives 10

Project Design 10

Project Methods 11

Project Evaluation 12

Project Timeline 14

References 16

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PROJECT TITLE

Developing Educational Oral Health Resources for the Maternal Infant Health Program

PROJECT STATEMENT/DESCRIPTION:

The focus of this Capstone Project is the development of educational oral health

resources. These resources will support increasing awareness about oral health for non-dental

personnel as well as mothers/children who participate in the Michigan Department of

Community Health’s (MDCH) Maternal and Infant Health Program (MIHP). This project will

involve t he development of resources for two audiences that include mothers in the MIHP as

well as the non-dental professionals who make home visits. These resources will serve to

improve oral health knowledge and provide early childhood caries prevention strategies.

Three specific resources are to be developed. One will address infant oral health. It will

be designed at a second/third grade reading level and will be distributed to the participating

mothers of the MIHP. Secondly, a quick reference card will be developed with step-by-step

directions for conducting a knee-to-knee exam. This card will be helpful for professionals to use

with oral screenings in the home MIHP visits. These non-dental professionals may include

nurses, social workers or other healthcare personnel. Lastly, an existing MDCH educational

resource about fluoride varnish will be redesigned from a fifth grade reading level to a

second/third grade reading level in order to best suit the MIHP population being served.

A literature review will be performed to discover information about the MIHP, oral

disparities among those involved in the MIHP, knee-to-knee examinations, infant oral health &

early childhood caries (ECC) information, and health literacy. Professional association websites

may provide already published educational tools and this project can discover ways to adapt

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these for the MIHP. Providing oral health educational resources will benefit non-dental

professionals involved in the health care field, women who are pregnant, and children who are

at high risk for ECC in the MIHP.

Project Advisors include Christine Farrell, RDH, BSDH, MPA, the MDCH Oral Health

Director, and Susan Deming, RDH, BS, also from the MDCH. The Faculty Advisor is Anne

Gwozdek, RDH, BA, MA, University of Michigan Dental Hygiene Degree Completion E-Learning

Program Director. The project advisors support our “on-site” involvement with the capstone

project and shares experience, content, and expertise. The Faculty Advisor helps to refine

topics, define methods to approach these topics, and polish our work along the way. This

project will also be done in collaboration with E-Learning student, Lindsey VandenBerg.

Review of the Literature

Introduction and Overview of MIHP

The Maternal Infant Health Program (MIHP) is part of the Michigan Department of

Community Health ( MDCH). This program offers support for mothers and infants with

Medicaid health insurance by promoting healthy pregnancies, good delivery outcomes, and

healthy infants.1 MIHP’s are scattered throughout the state of Michigan at federally qualified

health centers, private providers offices, and local health departments. It is through this

program that women and infants can receive health assessments by nurses, social workers, or

nutritionists.1 The Michigan Department of Community Health Oral Health Program is

collaborating with the MIHP to increase oral health knowledge among non-dental providers and

mothers in the program.

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Generally, the population enrolled in the MIHP are low income, black non-Hispanics,

have less than high school education, with Medicaid as the primary source of health care.2 A

total of 912,000 Michigan Medicaid enrollee’s are infants and children.3 Children who come

from low-income families are twice as likely to suffer from decay and this is more likely to be

left untreated.4 Along with low socio-economic status, frequency of sugar consumption,

enamel defects, presence of current decay, how often teeth are brushed, level of parental

education, children who live in poverty, and children of color are also relevant determinants in

caries risk.5,6,7 Oral health education for this community can be supported by professional

training so that providers who work at MIHP’s can inform, motivate, and help mother and

infant participants adopt and maintain healthy practices and lifestyles.2,3

Developing Oral Health Resources

Developing educational resources will support Michigan’s Oral Health Plan goal of providing

education opportunities for non-dental health care providers on topics such as the relationship

between oral and maternal health, screening and referral for early signs of decay in

infants/children. The Michigan’s Oral Health Plan is also associated with the goal of partnering

with community organizations to provide resources to support comprehensive and culturally

sensitive oral health education and prevention activities.3 These two examples identify how the

MIHP oral health initiatives fits in with the state’s plan.

Having these resources available for non-dental health care providers provides an

opportunity for them to present anticipatory guidance for parents and caregivers. Anticipatory

guidance is defined as providing recognition (screening) and intervention for those who are at

high risk for dental caries and to provide referrals to a dental home for those in need of further

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dental care.3 These professionals see women and children at their well-child visits on a more

regular basis than visiting dental personnel, therefore offering them the opportunity to offer

oral-health information.4,8 Primary health care providers can be a significant asset when

providing dental caries prevention information, intervention, and diet education to help aid in

reducing preventable ECC.4 In a national survey that included 862 pediatricians, over 90% of

the respondents noted that they play a significant role in early detection of dental decay and

provide anticipatory guidance for oral-health related topics to parents and caregivers.4 With

adequate oral health risk assessment training child healthcare professionals have the ability to

screen children for decay, apply preventive fluoride varnish, and give referrals to dental

professionals for further treatment.4

It will be important for these educational resources to be understood by the general

population. Basic vocabulary at a second to third grade reading level will be most effective.

There is a need to simplify written health education information for patients with limited

literacy, as over one quarter of the U.S. population has a second-grade reading level.9 Those

with restricted health literacy are linked to lower levels of personal health, minimal use of

preventive care and higher risks of hospitilzation.9 Members of minority groups and those of

low socioeconomic status are more likely to have a lower health literacy level.10

Management/Intervention

Dental caries is five times more likely to occur in children than asthma and seven times

more likely than hay fever making it the single most common chronic, preventable disease that

affects 28% of children in the U.S.4,6,9 ECC is a dieto-bacterial disease that results from

interactions between the host (child), cariogenic (decay causing) bacteria (Streptococcus

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mutans, Streptococcus sobrinus), and diets that are high in cariogenic foods.9 This disease,

when left untreated, can have such consequences as: pain, bacteremia, speech disorders, high

treatment cost (emergency room visits), compromised chewing resulting in lack of adequate

nutrition, low self-esteem, and reduced growth development.4 All of these are negative side

effects from a disease that is preventable. One way to check for early signs of disease and

provide prevention education is the knee-to-knee screening.

Knee-to-knee screening technique is technique for health care professionals and

caregivers to thoroughly inspect the oral cavity of infants and determine risk for ECC. The

rationale for performing this screening is to examine the child before potential dental problems

are given the chance to become apparent, which in turn can become more costly and difficult

to treat.6 Most importantly having these screening visits with the caregivers allows time for

the health care professional to provide education and oral health prevention strategies.6 The

knee-to-knee technique for this screening is simple yet effective.

There are guidelines for the provider to use in this screening. First, tooth surfaces,

especially near gum tissues, for smooth, white, dull areas, generally on the facial surface of the

tooth should be checked.4 These are areas of demineralization (tooth mineral loss), commonly

caused from a sticky biofilm (plaque) which supports an acid attack on the teeth whenever

fermentable carbohydrates are consumed.4 These white spot lesions are also commonly

caused when the infant is put to bed with a bottle filled with liquids other than water.

Sweetened liquids such as juice, soda, formula and milk also promote acid attacks on the teeth

and promote ECC.6 Infants who also have an increased frequency of consuming liquids and

snacks during the day have an increased risk for these lesions to appear.9 Another symptom to

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look for is an abscessed tooth. This infection could also be caused by severe ECC.6 Finally, the

gingival tissues, checking for redness, swelling, and bleeding, which are all common signs of

gum disease should be thoroughly evaluated. It is here during this screening that the health

care professional is given the opportunity to dialogue with the parent/caregiver and child,

expressing areas of concern and reinforcing healthy behaviors.4

Prevention & Education

Prevention by ways of early intervention helps to reduce the risk of possible dental diseases

such as decay.6 Fluoride varnish is one example of a cost effective product that can be used for

prevention. Fluoride varnish is a concentrated topical fluoride with a resin or synthetic base,

allowing it to adhere to the tooth surface in the presence of saliva.6 According to the American

Academy of Pediatric Dentistry, studies have shown if infants are provided fluoride varnish four

times a year prior to ever having any dental decay their caries risk is reduced by 40%.8 Not

only can fluoride varnish help prevent decay from forming, it can also remineralize areas where

early lesions have already started.10 Moreover, topical fluoride is more effective than systemic

fluoride when it comes to decay prevention. 4 This results in a strengthened tooth surface that

is more resistant to acid caused by cariogenic bacteria.7

In addition to fluoride varnish, oral health education for both non-dental personnel and

parents/caregivers offers great potential for caries risk prevention. Once health care

professionals are trained and educated they are then able to pass along this wealth of

information to the families they provide services for. By educating caregivers, health care

professionals can help manage factors that contribute to this disease as well as help parents

identify early signs of high risk infants so they can get a referral to a dental home for further

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evaluation.4 Caregivers/parents may also be unaware that they could possibly be contributing

to ECC in their children from the transmission of saliva via sharing utensils such as spoons and

pacifiers.4,6

The work of non-dental health care providers and caregivers can only go so far,

however. It is important to establish a relationship with a pediatric or general dentist by the

time the child is one year of age for regular preventive visits, especially if they are at high risk

for decay.4 It is here that further anticipatory guidance, diet education, prevention strategies,

and risk assessments can be provided. The American Academy of Pediatric Dentistry

recommends bi-yearly visits to the dentist starting from the first year of life to five years of age

to provide risk assessments, diet evaluations, surveys on parental knowledge and dental health,

and behavioral surveys/analysis.6 These visits to the dentist, establishing the dental home(a

place where a patient can continuously count on going to when needed), will help to establish a

relationship with the dentist/dental hygienist and parents as well as building a positive

connection with the infant.6

Conclusion

Non-dental health care professionals are ideal persons’ for providing oral health

education and disease prevention strategies. However, limited knowledge of oral health and

caries risk assessment are barriers that keep them from performing assessment and education

prevention techniques for infants. Becoming educated professionals through training and

obtaining appropriate educational resources will give them oral health prevention strategies to

use to educate caregivers. Non-dental health care providers can serve as advocates for infant

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oral health and can provide screening, share information with parents, and, ultimately may help

to reduce ECC.

Project Rationale

Dental decay is a common, chronic, yet preventable disease. Early childhood caries

(ECC) can cause pain, infection, minimize nutrient intake, and costly emergency room visits.

Caries experience is closely associated with those with low socioeconomic status. Those

involved with the MIHP fall under this category. If education on oral hygiene recommendations,

fluoride information, basic screening techniques, and how to address nutrition are provided at

an appropriate reading level, ECC and its needless pain, costly medical bills, and malnutrition

could be reduced. Educational resources are needed to support this effort.

Three educational resources will be developed. One involves the revision of a fluoride

brochure to a second grade reading level, a level needed for those involved with the MIHP.

Secondly, a quick reference card will be developed for the non-dental professionals for

conducting a knee-to-knee screening. The development of an infant health brochure is the final

resource. These three educational resources will benefit non-dental professionals, the patients

whom are seen, and employees involved with the MIHP.

Developing these educational resources will support increasing awareness about oral

health for non-dental personnel as well as mothers/children who participate in the Michigan

Department of Community Health’s (MDCH) Maternal and Infant Health Program (MIHP).

Developing resources that are culturally appropriate and at a literacy level where information

can be easily understood will help provide oral disease prevention education for years to come.

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Project Objectives

OBJECTIVES EVALUATION METHODS By the end of the project a quick reference card will be developed for the non-dental professionals to use when conducting a knee-to-knee screening.

An evaluation form will be developed and Susan Deming and participating non-dental health care providers will be completing this form.

By the end of the project revisions of a fluoride varnish brochure to an appropriate reading level will be completed.

MDCH education coordinator will fill out an evaluation form for feedback to assess the information (including appropriate reading level, format, etc).

By the end of the program the development of the infant oral health brochure will be provided for caregivers and staff.

The staff/caregivers will be able to discuss factors that contribute to both dental health and disparities such as decay and its’ causes.

Project Design

This project will entail the development of educational oral health resources to support the

Maternal Infant Health Program (MIHP) program. The topics include knee-to-knee screening,

fluoride varnish benefits, and infant oral health. The focus of the project will center around the

development of two educational resources and the revision of one that is existing. The first will

be the development of an index (reference) card for knee-to-knee screening. The second will

be the development of an oral health informational brochures for mothers and children. Some

of the topics of discussion that will be included in this brochure include caries risk, nutrition,

and infant oral health. Finally, a revision of an existing fluoride varnish related brochure from

the Michigan Department of Community Health (MDCH) will be converted from a 5th grade

reading to a 2nd grade reading level.

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Project Methods

Contacting Susan Deming, RDH, BS, Education and Fluoridation Coordinator from the

MDCH, Christine Farrell, RDH, BSDH, MPA, the MDCH Oral Health Director, and Anne Gwozdek

RDH, BA, MA, University of Michigan Dental Hygiene Degree Completion E-Learning Program

Director will be the first necessary step of the project. Contacting these three key persons will

allow detailed conversation to take place to discuss a plan of action. Susan and Chris, the “on-

site” project advisors will educate those developing the project on necessary information to

include and the most effective ways to format the educational resources for index cards and

brochure form.

The three educational resources each have their own purpose and audience. It will be

important to have them all be visually appealing and at an education level where those reading

will have full understanding of the material. Once determined, researching evidence based

information via PubMed, Google Scholar, and peer-reviewed journals will be necessary to gain

information that will be used in these resources. Anne, our faculty advisor, will aid in refining

topics and polish our project along the way. Initial drafts of these resources will be sent to

Susan Deming for preliminary review.

Evaluation forms will be developed to address content, format, and literacy level for

each resource. Project advisor Susan Deming and faculty advisor Anne Gwozdek will review

these forms prior to their distribution. Based on the feedback given, the resources will be

revised.

Project Evaluation

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Evaluation forms for each educational resource will be developed and will be filled out

by the project advisors or other stakeholders identified by Susan Deming, once the final

brochure and reference cards are complete. Their feedback analyzes these resources and gives

the strengths/weaknesses and leaves space to comment. Format, reading level, and visually

appealing resources are priority criteria. All evaluation forms will be reviewed by both Susan

and Anne prior to their use. Upon receiving this feedback, revisions will be made to all three

educational resources prior to dissemination.

The knee-to-knee screening reference cards will be evaluated by non-dental providers in

the MIHP program. A review of these cards will be done during an MIHP presentation given by

Susan Deming on March 24th, 2011. During break, a rough draft of the knee-to-knee screening

index (reference) card will be given to random volunteers along with an evaluation form. Once

filled out, this evaluation form will give feedback on the structure of the index cards.

Information that will be included on this form will include whether or not the card was an

appropriate size and layout, was visually appealing, had comprehensive and sequenced

information, and was easy to follow. Once filled out, Susan will collect the forms at the end of

her presentation and send the results via email to those developing the project.The revised

fluoride related brochure and infant oral health brochure will both be evaluated by Susan and

Chris. After evaluation, any final revisions will be made for the final version.

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PROJECT TIMELINE

Tasks Activities Start Finish Resources Development of Project Idea

Contact Susan Deming, set up meeting

Jan 20 (meeting Jan 29)

Jan 29

Susan Deming, education & fluoridation coordinator of MDCH

Research Phase Develop letter of MOU Jan 29 Jan 29

Indentify Resources

People: 1. Susan Deming 2. Chris Farrell 3. Anne Gwozdek

Reading Materials: PubMed, Google Scholar

Jan 29

Project and Faculty advisors (Anne Gwozdek, Chris Farrell, and Susan Deming)

Define Project Developing educational resources for those involved in the MIHP.

Jan 29 Rough draft (RD) by: March 1st

Design Phase Choose Design Brochure

1. Infant oral health 2. Revised fluoride

varnish related brochure

Jan 29

March 26 Susan Deming, Chris Farrell,

Anne Gwozdek

Reference cards 1. Knee-to-knee

Jan 29

April 8

Obtain EB information for brochure content

Those with low SES affected. Jan 29 Mar 23 PubMed, Google Scholar, Peer-reviewed journals

Develop resources Develop Evaluation forms

1. Index card

a. Knee-to-knee screening

2. Infant oral health

brochure (rough draft)

3. Revised fluoride varnish related brochure (rough draft)

Feb 1st

Jan 29

th

Jan 29th

March 19

Rough draft: March 1

st

for index card April 23

rd

May 1

st

March-index cards May-

Susan Deming, Anne Gwozdek, Chris Farrell Susan Deming, volunteer evaluators from MIHP meeting

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Brochure

Evaluation Phase Administer Evaluation Forms

Disperse Index Card 1. Evaluation form

Mar 24th

meeting

Apr 10th

Random volunteers from March 24

th seminar held by

Susan Deming

Feedback via evaluation forms Mar 24th

Apr 10th

Brochure 1. Infant oral health

a. Evaluation form 2. Revised fluoride

related brochure a. Evaluation form

April 30th

June 1st

Analyze Results May 10th May 15th

Revision Phase Revise all educational resources according to evaluation forms and feedback

Apr 10 May 2011

Implementation Phase

Post-project resources: implemented through MDCH Complete Capstone Project Report

June 1 June 26

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References

1. Michigan.gov [Internet] Michigan Department of Community Health: maternal infant health program. C 2001-2011. [cited 2011 March 20]. Available from: http://www.michigan.gov/mdch/0,1607,7-132-2942_4911_34593---,00.html

2. Michigan Department of Community Health Oral Health Program: Oral Health Plan. 2010;46-7.

3. Kagihara L, Niederhauser V, Stark M. Assessment, management, and prevention of early childhood caries. J Am Acad of Nurse Pract. 2009;21:1-10.

4. Ramos-Gomez F, Jue B, Bonta CY. Implementing an infant oral care program. J Calif Dent Assoc. 2002;30;10:752-61.

5. Center for Disease Control [Internet]. Atlanta: Recommendations for using fluoride to prevent and control dental caries in the United States. c2001. 2001 Aug 11 [cited 2011 Mar 20]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm

6. Palmer CA, Kent R, Loo CY, Hughes CV, Stutius E, Pradhan N, Dahlan et al. Diet and caries-associated bacteria is severe early childhood caries. J Dent Res. 2010;89;11:1224-9.

7. American Academy of Pediatrics: Fluoride varnish [Internet]. Illnois: c2001. [cited 2011 Mar 20]. Available from: http://www.aap.org/commpeds/dochs/oralhealth/cme/page46.htm

8. Deming S. Maternal & Infant health program coordinator meeting. Presented at: Crown Plaza Hotel, MIHP meeting; 2011 Mar 24. Grand Rapids, MI.

9. Roter D. Oral literacy demand of health care communication: challenges and solutions. Nurs outlook. 2011;59:79-84.

10. Jackson R. Parental health literacy and children’s dental health: implications for the future. Pediatr Dent. 2006;28:72-5.