Description

In Colorado, 31% of children have experienced dental decay by the time they reach kindergarten. This rate increases for children from low-income communities.

Cavity Free at Three (CF3) is Colorado's statewide initiative to improve oral health outcomes in expectant mothers, infants, and toddlers. The interprofessional oral health promotion program was established in 2007 and is led by the Colorado Department of Public Health and Environment (CDPHE).

Through its training opportunities, CF3 trains medical and dental healthcare providers on how to talk to their patients about cavity prevention. It works through communities to increase preventive oral health services, align oral health messaging, and improve oral health outcomes.

Targeted communities are those with limited access to dental care, including people in rural areas with low socioeconomic status and oral health Medicaid utilization rates. Eighty-seven percent of the program's target counties are considered rural or frontier.

CF3 is funded through a Perinatal and Infant Oral Health Quality Improvement Initiative, funded in part by the Health Resources and Services Administration (HRSA) and allocated to CDPHE's Oral Health Unit.

The state oral health coalition, Oral Health Colorado, provided state lawmakers with compelling data and research to inform their 2018 legislative session. As a result, a long bill was passed, appropriating $500,000 annual state funds to the Oral Health Unit at CDPHE to continue CF3, among other oral health programs.

Other foundations that support the program include:

• Caring for Colorado Foundation
• The Colorado Health Foundation
• The Colorado Trust
• Delta Dental of Colorado Foundation
• Kaiser Permanente
• Rose Community Foundation

This video goes into more detail about the program:

Services offered

Because so many rural and frontier counties in Colorado lack dental providers, primary care providers in rural areas are trained to deliver oral health education, screenings, and apply fluoride varnish through CF3.

CF3 offers an approved certification program for primary care providers to deliver these services so they can get reimbursed by Medicaid.

In addition, CF3 offers free in-person or online training for Colorado providers, resources, and support to help medical and dental providers deliver preventive dental health services in their practices. Forums create an opportunity for providers to learn in a peer-to-peer setting. Components of CF3 training include:

• Information about preventing dental disease in pregnant women and young children
• Key oral health messages using motivational interviewing
• Performing oral examinations
• Dental caries risk assessment
• Hands-on clinical skills training in oral health screening and fluoride varnish application
• Anticipatory guidance in how to recognize forming cavities
• Help with coding and billing preventive oral health services
• Setting dental goals with patients
• Dental referrals
• Continued technical assistance support after training
• Regular updates on the latest research about children's oral health
• Provider resources supporting patient education
• Medical provider certification required by Medicaid

Results

The Centers for Disease Control and Prevention (CDC) funded a screening survey of Colorado children conducted by CDPHE. Results were published in the Tooth Be Told...Colorado's Basic Screening Survey, Children's Oral Health Screenings: 2016-2017. Key results are linked to programs like CF3 and include the following:

• Fewer Colorado children have cavities now than they did 10 years ago. CF3 and other programs of the Department's Oral Health Unit have contributed to the decrease. From 2007-2017, the rate of kindergarteners diagnosed with tooth decay decreased from 45% to 31%.
• Kindergartners who have had at least one cavity has decreased 14%.
• Third graders who have had at least one cavity has decreased 10%.

CDC also funded an evaluation of CF3. Results published in the Cavity Free at Three CDC Evaluation 2013-2018 report:

• From January 2008-June 2018, 5,026 medical and dental providers, health professional students, other health professionals, and individuals have completed a CF3 training. Health professionals who have participated in CF3 training report high satisfaction levels with the program and training.
• Nearly 85% of trainees reported implementing the CF3 model in their practice to some degree after attending a training (56% fully implementing, 27% partially implementing).
• The percentage of children with Colorado Medicaid who received any dental service from a medical or dental provider before the age of 2 has progressively increased, from 23% in 2010 to 33% in 2017.

The effect of the Cavity Free at Three program at Denver Health Federally Qualified Health Centers was also evaluated through this study:

Braun et al. (2017). Effectiveness on Early Childhood Caries of an Oral Health Promotion Program for Medical Providers. American Journal of Public Health, 107(Suppl 1), S97-S103.

Challenges

According to Colorado Health Institute's Family Matters in Oral Health report, there are certain challenges when providing oral healthcare to rural and frontier areas of Colorado. Through CF3, CDPHE has taken the following steps to address those challenges:

• Of Colorado's 64 counties, 57 are designated a Dental Health Professional Shortage Area by the U.S. Health Resources & Services Administration.
  • The largest audience to receive CF3 trainings since the trainings launched in 2008 were students, at 1,719.
• High-risk populations include children covered by Medicaid. While the number of dental providers who treated Medicaid patients grew by 78% from 2013 to 2016, children on Medicaid are less likely to see a dentist than those with commercial or private insurance.
  • Colorado's Medicaid managed care program includes dental visits as a key performance indicator for primary care services. Applying fluoride varnishes qualifies as a preventive service, providing more incentive for primary care providers to participate in oral preventive care for their patients.
• Many areas of Colorado are geographically isolated by mountains or distance, prohibiting access to training opportunities.
  • Through a HRSA Workforce Grant, CDPHE Oral Health Unit contracts with four local public health agencies in rural communities to prioritize oral health. These agencies have each hired a dental hygienist who serves as a Regional Oral Health Specialist (ROHS). Work priorities include that the ROHS become certified CF3 Master Trainers and deliver trainings.

• Medical providers reported inadequate time to provide oral health services during well child visits.
  • CF3 created a guide on ways to efficiently and effectively implement oral health services into clinical practices. The guide includes how to develop process charts for optimizing clinic flow and allocate time for oral health services. The training also provides hand-on skill building to improve clinician competency.

Replication

Cavity Free at Three's website outlines ways to implement a similar program. These include:

• Creating buy-in by assessing your community's needs and involving a multidisciplinary group of stakeholders
• Making yourself known to the professional community
• Seeking multiple sources of funding
• Showing providers the monetary value of providing oral health services

CF3 provides a variety of free tools, including:

• Requests for a free training for Colorado providers.
• Registration for upcoming training opportunities
• Resources provide by CF3:
  • Start-up kits including fluoride varnish and printed resources
  • Tooth decay risk assessment
  • Goal setting sheets (in English and Spanish)
  • Instructional videos on incorporating oral health into primary care
  • Infant oral care kit ordering information
• Patient education pamphlets in 9 languages on oral health for pregnant women and young children are available free for downloading, printing, and distributing
• Many more resources and tools relating to children's oral health

Contact Information

Reid Bryan, MPH, CF3 Education Coordinator
Cavity Free at Three
303.692.2470
support@cavityfreeatthree.freshdesk.com