Team Approach

Achieving and maintaining optimal oral health is challenging for children with special health care needs. These children, who experience physical, behavioral, or emotional problems necessitating professional health care services, are often at great risk of oral disease, yet they face many barriers to accessing dental care, including accessibility, financial, psychosocial, physical, communication, and medical problems.^1,2 In order to address the feeding and nutritional issues affecting this patient population, pediatric feeding teams are often used. These teams contain a variety of health care professionals who are dedicated to ensuring their patients receive adequate nourishment. Dental hygienists—with their expertise in oral health—would be significant assets to these teams and would further encourage an interdisciplinary approach to care.

INTERDISCIPLINARY APPROACH TO CARE

Interdisciplinary care involves professionals from various disciplines working as a team, with each professional contributing an expertise to create a “creative synergy.”³ Through collaboration, the interdisciplinary team increases opportunities for improved health outcomes, including oral health.^4,5 In Washington State, community feeding teams (CFTs) serve children with special health care needs through an interdisciplinary approach.⁶ The Washington State Collaborative Action Plan on Oral Health Access for Special Populations provides basic training in oral health to nondental professionals who care for children with special health care needs including physicians, nurses, physician assistants, and dietitians.⁷ New research conducted in Washington shows that dental hygienists would be effective feeding team members in this dynamic interdisciplinary approach to provide preventive oral health education and services in collaborative, sustainable models of care.⁸

THE PEDIATRIC FEEDING TEAM

Feeding teams are composed of interdisciplinary health care professionals who address feeding/nutrition concerns for children with special health care needs.⁹ The teams evaluate oral motor skills, dental health, feeding practices, dietary intake, and caregiver expectations. Assessment and intervention may include evaluation of swallowing ability, implementing therapeutic feeding techniques and proper positioning, recommending appropriate quantities of food and adequate dietary intake to meet nutritional needs, and implementing the correct use of feeding tubes.⁹ 

Currently, there are 16 feeding teams in Washington State, spanning 13 counties. Each is composed of a registered dietitian, speech language pathologist, occupational therapist, registered nurse, and advanced registered nurse practitioner who work in developmental centers (most common), hospitals, public health and home health settings, and schools.⁹

Children with special health care needs are at increased risk of developing oral disease, but unfortunately, dental care is their number one unmet health care need.^1,3 A 2005-2006 national survey found that 81.1% of children with special health care needs require preventive dental care while 24.2% also needed additional oral care services. In addition, the survey found that 6.3% were not able to access preventive dental care and 2.6% were not able to obtain additional oral care services.¹⁰ As licensed oral health professionals skilled in providing oral health promotion and prevention services, dental hygienists are in a unique position to provide community feeding teams with the knowledge needed to support parents and caregivers in anticipatory guidance, administer preventive dental care, and provide referrals to improve their children’s oral health.

ORAL CARE CONSIDERATIONS

Children with special health care needs face a myriad of complex medical problems, in addition to oral health challenges. The most common oral conditions seen in children who are served by feeding teams include: gastroesophageal reflux disease (GERD); oral, pharyngeal, and esophageal motor and sensory disorders; sialorrhea (excessive saliva); sensory disorders (including hypo- and hypersensitivities); oral effects of long-term medication use; and failure to thrive.^11–14 These children often require gastrointestinal feeding tubes to insure proper nutrition, which can create additional oral health problems, such as malocclusion and increased risk of caries and periodontal diseases.

COORDINATION OF CARE

Care coordination is a process involving assessment, planning, implementation, evaluation, education, monitoring, support, and advocacy (Figure 1).¹⁵ The goals of care coordination when serving children with special health care needs are to encourage access to services, increase continuity of care, and support the overall well-being of both children and their parents.¹⁵ The patient process of care is the cornerstone of dental hygiene practice.^15–17

THE ROLE OF THE DENTAL HYGIENIST

Washington State CFT members developed an educational pilot program to examine the role of the dental hygienist as a member of the pediatric feeding team.^14,15 The team presented a program at a meeting of pediatric feeding team members that focused on the following oral health topics: oral health problems associated with tube feeding, medications and sugar content, early childhood caries and transmission of bacteria, preventive measures for the special needs child, adaptations and oral hygiene self-care, healthy snacks, and resources for access to dental care. Following the program, 86% of pediatric feeding team members strongly agreed that the dental hygienist can play an important role in the multidisciplinary, collaborative approach. Additional research is needed to identify the role of dental hygienists on the feeding team, as well as to develop a model for integrating them into this multidisciplinary team.

Dental hygienists are well-suited to educate and help problem-solve with families who have children experiencing feeding issues that require medical intervention. Families may not be aware of the importance of maximizing oral health, even when their children are receiving nutrition through feeding tubes. Topics that dental hygienists could address include: timing of first dental visit, eruption patterns, nutritional issues, sugar in medications, gastro-esophageal reflux disease and acid oral environment, oral health information for caregivers, oral health risk factors, preventive measures, and referral to oral health providers who understand this population’s unique needs. Table 1 lists five oral health prevention and promotion services prioritized by a small focus group of Washington pediatric feeding team therapists that could be delivered by dental hygienists as members of the pediatric feeding team.

Dental hygienists can also play an important role in assessment, diagnosis, planning, implementation, evaluation, advocacy, and oral health education and health promotion as part of the pediatric feeding team. Table 2 provides a detailed list of possible functions for dental hygienists within these categories. Additional research and work must be done to integrate dental hygienists into the pediatric feeding team, including educating other team members about dental hygienists’ skill sets and securing funding to support their participation.

SUMMARY

Children with special health care needs face a greater risk of oral disease. By including dental hygienists on the pediatric feeding team, they can help these patients and their caregivers improve and maintain their oral health. Interdisciplinary care may be the most effective in treating this patient population and dental hygienists can serve as a key component of this model. As licensed health professionals skilled in providing oral health promotion and prevention services, dental hygienists are in a unique position to work with other members of the pediatric feeding team and improve the oral health of children with special health care needs.

Table 1. Oral health prevention and promotion services that could be provided by dental hygienists as prioritized by pediatric feeding team therapists.

1. Provide dental care and referral for dental services.
2. Educate team members about oral hygiene care for patients with oral hypo- and hypersensitivities.
3. Present in-service oral health programs to team members and deliver on-site oral health intervention presentations to children, parents, and caregivers.
4. Provide oral health assessment and monitor oral health needs.
5. Create printed oral health-related materials/ resources for both team members and families and explain how to use special oral hygiene devices.

Table 2. Possible responsibilities of the dental hygienist on the pediatric feeding team.

Assess

• Oral hygiene (plaque biofilm removal)
• Fluoride exposure
• Risk factors for dental caries
• Risk factors for periodontal diseases
• Oral effects of gastroesophageal reflux disease
• Need for a dental home
Diagnose
• Existing or potential oral health problems related to the teeth
• Existing or potential oral health problems related to periodontal diseases
• Existing or potential oral health problems related to oral lesions
• Existing or potential oral health problems related to sensory disorders
Plan
• Oral health promotion and anticipatory guidance for disease prevention
• Dental cleaning intervals
• Dental sealant application
• Fluoride application intervals
Implement
• Oral health promotion and anticipatory guidance for disease prevention
• Provision of dental cleanings
• Application of fluoride
• Health promotion education to caregivers and/or feeding team members
• Coordination of referral with dental provider to establish a dental home
Evaluate
• Oral health outcomes
Delivery of care
• Monitoring of follow-through of referral for restorative care with dental home
Advocate
• Engage in the legislative process on behalf of children with special health care needs
Educate and promote
• In-service oral health education/promotion presentations to feeding team members
• Oral health education/promotion presentations to parents/caregivers/patients served by the feeding teams
• Oral health resource materials for professionals
• Oral health resource materials for parents/caregivers
• Family-centered patient education
• Oral health education and health promotion interventions to improve oral health literacy

REFERENCES

1. McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needs. Pediatrics. 1998;102:137–140.
2. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Available at: www.surgeongeneral.gov/libray/oralhealth.Accessed June 13, 2012.
3. Casamassimo PS. Pediatric oral health interfaces background paper: Children with special health care needs; patient, professional and systems issues. Washington, DC: American Academy of Pediatric Dentistry, Children’s Dental Health Project. Available at: www.astdd.org/docs/BPResLinkInterfaceMedicineDentistry.pdf. Accessed June 13, 2012.
4. Yeager S: Interdisciplinary collaboration: the heart and soul of health care. Crit Care Nurs Clin N Am. 2005;17:143–148.
5. Swanson Jaecks K: Current perceptions of the role of dental hygienists in interdisciplinary collaboration. J Dent Hyg. 2009;83:84–91.
6. Washington State Department of Health. Children with Special Needs Program. Available at: www.doh.wa.gov/cfh/mch/cshcn_current_projects.htm#WISE. Accessed June 13, 2012.
7. Washington State Department of Health. Washington state collaborative action plan on oral health access for special populations. Olympia, WA: Washington State Department of Health, Maternal and Child Health, Oral Health Program. Available at: www.astdd.org/docs/WAStateDOHActionPlanonOHCSHCNrevised.pdf.Accessed June 13, 2012.
8. Washington State Department of Health. Washington state community feeding teams. Available at: www.depts.washington.edu/cshcnnut. Accessed June 13, 2012.
9. Washington State Department of Health and Children with Special Health Care Needs Program. Guidelines for the Development and Training of Community-Based Feeding Teams in Washington State. Available at: www.doh.wa.gov/ cfh/cshcn/docs/ftguidelines.pdf.Accessed June 13, 2012.
10. US Department of Health and Human Services, Health Resources and Services Administration, and Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook 2005-2006. Available at: www.mchb.hrsa.gov/cshcn05. Accessed June 13, 2012.
11. Linnett V, Seow WK. Dental erosion in children: A literature review. Pediatr Dent. 2001;23:37–43.
12. Blasco P. Oral–motor dysfunction. In: Promoting Oral Health Of Children with Neurodevelopmental Disabilities and Other Special Health Needs: Develop Training andResearch Agenda. Seattle: University of Washington; 2001.
13. McGhee B, Katyal N. Avoid unnecessary drug–related carbohydrates for patients consuming the ketogenic diet. J Am Diet Assoc. 2001;101:87–101.
14. Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003;68:879–884.
15. Lindeke L, Leonard B, Presler B, Garwick A. Family-centered care coordination for children with special health needs across multiple settings. J Pediatr Health Care. 2002;16:290–297.
16. American Dental Hygienists’ Association. American Dental Hygienists’ Association standards for dental hygiene practice. Access. 2008;20:1–16.
17. Vingilis E, Paquette-Warren J, Kates N, Crustolo AM, Greenslade J, Newman S. Descriptive and process evaluation of a shared primary care program. Internet Journal ofAllied Health Sciences and Practice. 2007;5:1–10. Available at: www.ijahsp.nova.edu/articles/vol5num4/vingilis.htm. Accessed June 13, 2012.

From Dimensions of Dental Hygiene. July 2012; 10(7): 60-63.