This online manual provides an overview of the WIC: Early Entry into Dental Care Program, developed by the Center for Oral Health in California, and lessons learned, guidance, and tools for groups interested in implementing the program in their own locales. This program uses effective strategies, integrated on-site with other WIC services, to prevent dental disease in infants and young children of low-income families. It uses WIC (the Special Supplemental Nutrition Program for Women, Infants and Children) as the entry point for oral health assessment, preventive services, and referral for regular follow-up care. The specific goals of the program are:
Increase the number of infants and toddlers who receive preventive dental services and early dental care.
Provide dental services in non-traditional settings.
Increase caregiver knowledge of oral health and preventive oral health strategies.
Develop and implement systems that will enable WIC to serve as an early entry point for oral health services for caregivers and children.
Create dental homes through referrals from WIC sites.
Create a model that is integrated with WIC services and sustainable.
Planning and implementing this program is not easy. It will require dedicated professionals who are committed to communication and coordination, as well as state medical and dental practice acts and a Medicaid reimbursement system to make the programs professionally and financially viable. Groups who have experience working in public health settings with diverse populations of low-income families and a variety of community-based partners will probably have the greatest success. Dental professionals working in community health centers or in private practice may require guidance in adapting to this unique venue, while WIC or public health staff may require additional oral health care training. This handbook attempts to address some of the knowledge and skills that will be needed, as well as some tips regarding planning, implementation, and evaluation. In addition to reading this manual, The Center for Oral Health strongly recommends asking for consultation in selecting and implementing a model.
Contact information for The Center for Oral Health:
A successful WIC-based preventive dental services program is based on a solid, trusting, motivated relationship between a dental provider and a WIC center. The two partners play very different roles so they must be organized, committed to the success of the program, and able to effectively communicate and work together.
The dental provider offers oral health education and counseling to participants and performs simple preventive oral health services, like fluoride varnish applications, on participants’ young children and infants. The dental provider may also train WIC personnel on key oral health messages to share with participants. The provider could be from a private practice, a community clinic, a state or county health program, or a Federally Qualified Health Center (FQHC).
The WIC center provides space in which the program can operate (generally one or two half-days per week, but sometimes less), encourages its participants to utilize the dental services, and may assist in educating participants, setting appointments, and collecting participant billing data (usually Medicaid). The WIC center could be operated privately, publically at the state or county level, or as part of an FQHC.
One of the many factors that makes WIC such an ideal portal for preventive dental services is its access to low-income, underserved, Medicaid-eligible children. Medicaid dental benefits cover some preventive services, so in theory the vast majority of dental services provided could be billed to Medicaid. This would be a win-win situation; underserved children could receive much-needed preventive care and dental providers could acquire new patients through a sustainable outreach program. Unfortunately, this ideal is not always realized.
The greatest barrier for the dental provider is funding. In low-volume WIC centers, there may not be enough participants to cover costs. Medicaid managed care plans may not allow fee-for-service billing by the provider. Participants may forget to bring their insurance cards or be hesitant to provide their information out of fear that they may lose other benefits or be charged for services. Other barriers are noted in Section 3, Information for Dental and Medical Professionals, and Section 5, Program Models in California. The dental provider needs to cover personnel and materials costs and may not have access to much—if any—external grant funding, so one of the key components of a successful program is an organized, cooperative system for obtaining participant billing information.
For the WIC center, the two most significant barriers are space availability and the preservation of WIC’s core mission. WIC centers are rarely large and sometimes very busy, so the space necessary for oral health education and services may not be available often, if at all. Furthermore, especially in light of the lack of space and other issues, a WIC center may be hesitant to host and allocate resources for a program that does not clearly relate to nutrition. Dental providers know that preventive oral health care and proper nutrition extensively overlap, but this is not necessarily obvious to those outside the oral health community, so this point should be clearly articulated.
Despite the difficulties, however, developing a successful and sustainable program based on Medicaid reimbursement is possible. Sustainability and Medicaid reimbursement are discussed in more detail in Sections 3 and 4, as well as in the program models highlighted in Section 5. It is also highly recommended that prospective program developers ask the Center for Oral Health for consultation on these topics.
In California, more than 40% of children have already experienced dental decay by the time they enter kindergarten; by third grade, this number has risen to 70%. Dental decay can lead to serious consequences if left untreated; 5.5% of low-income children attending school need immediate care due to severe dental decay and abscesses. Other consequences include pain, chewing difficulty, malnutrition, and low self-esteem. Early dental decay in the primary (baby) teeth can also lead to decay in the permanent teeth. This is almost entirely preventable if families begin to receive counseling during pregnancy and if they themselves have good oral health, a regular source of care, and value and practice health-promoting behaviors.
Unfortunately, infants and toddlers from low-income families in California rarely receive early oral health assessments or care unless they are offered these opportunities through community-based programs. Locating dental professionals who both participate in the Medicaid program and are comfortable caring for infants and toddlers is difficult in many areas, and seeking oral health care (which is already not among the highest priorities of most low-income families) at private practices or community clinics can be impractical and expensive.
An important component of WIC is referring children to health and social services, and it is often the first point of contact between low-income families and the health care system. WIC is an ideal location for preventive oral health services to be provided; it is an efficient, natural, community-based venue where there are significant incentives for attendance. Families already visiting WIC to receive food vouchers and education can also receive preventive oral health services for their children with little to no extra effort, which is important when transportation and other costs are a significant burden.
Nationally, WIC is one of the largest providers of service to low-income young children who may be at high risk for developing dental decay. More than 60% of all children born in California are served by WIC. To receive WIC benefits like food vouchers and education, caregivers are required to go to a WIC site with their infants and young children.
The WIC: Early Entry into Dental Care Program builds partnerships between WIC sites, public health clinics, community health clinics, and private dental practitioners and provides onsite oral health services as well as ongoing care. By offering oral health services at WIC sites, providers can reach caregivers and children early enough to prevent dental decay. Collaboration with WIC staff helps ensure that oral health education and services are delivered in a culturally-relevant and language-appropriate way. This collaboration also builds the shared goal of promoting nutrition and feeding practices that contribute to both oral and overall health.
Oral health services are typically offered on days when participants are already scheduled to pick up food vouchers or attend classes. Infants and older siblings are given an oral health assessment and preventive services such as fluoride varnish applications. Caregivers receive individual counseling and/or group educational sessions on healthy feeding practices, nutrition, and oral hygiene. Families are referred to dental practices or clinics for follow-up care beyond the preventive services delivered at WIC sites. Since most children enrolled in WIC are Medicaid eligible, dental and medical providers may be able to bill for this service according to their state Medicaid regulations and state practice acts.
The WIC target population is low-income, nutritionally at risk:
Pregnant women (through pregnancy and up to 6 weeks after birth or after pregnancy ends).
Breastfeeding women (up to infant’s 1st birthday)
Non-breastfeeding postpartum women (up to 6 months after the birth of an infant or after pregnancy ends)
Infants (up to 1st birthday)
Children up to their 5th birthday
At the end of FY 2009, 9.3 million women, infants and children received monthly WIC benefits. One-half of infants born in the U.S. are enrolled in the WIC program.
The following benefits are provided to WIC participants:
Supplemental nutritious foods via food vouchers (some are now electronic cards) redeemable for specific items at a local grocery stores or farmers markets; WIC guidelines were recently changed to better align with U.S. Dietary Guidelines for Americans and with AAP infant/toddler feeding guidelines
Nutrition education and counseling, including breastfeeding promotion and support at WIC clinics
Screening and referrals to other health, public assistance, and social services such as prenatal/well-child care services, Healthy Families (CHIP), and child support services
WIC is not an entitlement program; Congress does not set aside funds to allow every eligible individual to participate in the program. Rather, it is a Federal grant program for which Congress authorizes specific funds each year. WIC is:
Administered at the Federal level by Food & Nutritional Service;
Administered by 90 WIC state agencies, through approximately 47,000 authorized retailers;
Operated through 1,900 local agencies in 10,000 clinic sites, in 50 State health departments, 34 Indian Tribal Organizations, the District of Columbia, and five territories (Northern Mariana, American Samoa, Guam, Puerto Rico, and the Virgin Islands).
While risk assessment for dental decay, referred to as “caries risk assessment,” is not yet precise, the American Dental Association (ADA), Centers for Disease Control and Prevention (CDC), and American Academy of Pediatric Dentistry (AAPD) agree that the single greatest risk factor for future dental decay is having had tooth decay as a young child.
Anticipatory guidance, as used in pediatric health care, is the process of providing practical, developmentally-appropriate health information about children to their caregivers in anticipation of significant physical, emotional, and psychological milestones. This information guides caregivers by alerting them to upcoming changes, teaching them their role in maximizing children's developmental potential, and identifying children's special needs. Pediatricians have been using anticipatory guidance for years in clinical practice. Each well-child-care visit, for example, involves physical examination, immunization, and anticipatory guidance keyed to the child's developmental stage.
Oral health anticipatory guidance is now widely promoted as part of Bright Futures; a national health promotion and disease prevention initiative that addresses children's health needs in the context of family and community. In addition to their use in pediatric practice, many states implement Bright Futures principles, guidelines, and tools to strengthen the connections between state and local programs, pediatric primary care, families, and local communities.
Lower Treatment Costs
Children who have severe dental decay are difficult to manage and treat under normal clinical conditions without the aid of conscious sedation or general anesthesia. These factors make this disease expensive to treat, and many caregivers cannot afford to follow the dentist’s recommendations. Early preventive oral care results in lower treatment costs later in life; it is estimated that for every dollar spent on prevention services, $8 to $50 are saved in treatment. Dental costs for children enrolled in Medicaid for five continuous years who have their first preventive dental visit by age one are nearly 40% less ($263 compared to $447) than for children who receive their first dental visit after age one.
This fast-drying resin is a safe and effective preventive agent painted onto tooth surfaces to prevent tooth decay. It is particularly effective for high-risk children under 5 years of age. It can be applied quickly and is available in several flavors.
Numerous studies have documented the effectiveness of fluoride varnish to prevent decay. Reductions in dental disease depend on children’s risk for tooth decay and the number of fluoride methods used. Most studies indicate four applications over two years as the interval that demonstrates overall reductions in tooth decay of approximately 30 percent (0-69%) in at-risk populations. For those with active dental decay, three to four applications annually may be more effective; however, the strength of evidence is limited to a few studies and the recommendation is based largely on opinion or information extrapolated from related studies.
These core dental services are the minimum services recommended to be provided at WIC sites. Some programs may need to work up to this level over time. Providing these services typically takes between 15 and 20 minutes per child for an initial visit and less for repeat visits, depending on paperwork and other issues.
Dental / health professionals should provide all core dental services unless arrangements have been made for WIC staff to provide the caregiver education. Education can be provided either through individual counseling sessions or group classes.
Core preventive services that must be provided by dental / health professionals include:
Interviewing the caregiver about health and dental history, identifying risk factors for oral health problems, reviewing current home dental care practices, and having the caregiver sign consent and other forms
Brushing the child’s teeth to remove plaque or food debris and serve as a skill-building opportunity for caregivers
Inspecting the child’s mouth to check for normal growth and development and any signs of tooth decay
Painting a small amount of fluoride varnish on the teeth to protect them from dental decay
Discussing the child’s risk factors for dental problems and setting realistic goals and activities for home care to promote oral health and healthy feeding practices
Helping families arrange for ongoing care and a dental home, as well as treatment for decay and other conditions if necessary
Children will need regular oral health care beyond the initial preventive services provided at the WIC site. Further collaboration with public health organizations, Federally Qualified Health Centers (FQHCs), community dental clinics, and/or private dental practices is needed to assure that children have dental homes, that a recall system for diagnostic and preventive services is established, and that any treatment for dental problems is completed. Some programs will decide to use case manager models to arrange for dental follow-up.
Target Age Group
To prevent Early Childhood Caries (ECC), the target age group for preventive oral health services should be 9-24 months old. Some programs may extend this to provide fluoride for older children, especially siblings who are likely to be present with the caregiver. Extension of the age group will largely depend on the resources available to providers. WIC can identify children in specific age groups.
Billing for Services
Most children enrolled in WIC are either eligible for, or already enrolled in Medicaid. As a result, dental and medical providers in California and many other states who work in private or public health practice, including Federally Qualified Health Centers (FQHCs), can bill Medicaid for some of the oral health services provided at WIC (please check your state laws on billing restrictions). In some circumstances, WIC staff may be able help assess a participant’s current Medicaid status and other insurance coverage (with the consent of the participant, and according to HIPAA restrictions), but this may not be feasible. If billing Medicaid is not possible, then another reliable source of funding will be needed to develop a sustainable program. See Section 3 for more on this topic.
A HRSA MCHB Targeted Oral Health Services Systems grant in 2007 allowed the Center for Oral Health (COH) to develop the program and pilot it at two WIC sites; one in Alameda County, the other in Humboldt County. (Alameda has since expanded the program to two sites, and Humboldt to three.) The HRSA grant also provided for expansion into six more partnerships. These have included public health departments, Registered Dental Hygienists in Advance Practice (RDHAP) serving rural WIC programs, consolidated tribal health services and private dental clinics. Local First 5 commissions assisted by providing additional funding for case management.
In 2009, Kaiser Southern California Foundation funded a one-year project to expand the program to serve six communities in Southern California. This model relies on a partnership between public health departments, RDHAPs, tribal health clinics, and Federally Qualified Health Centers (FQHCs). Also in 2009, the COH received a grant from the First 5 Los Angeles County Commission to develop partnerships between seven FQHCs and WIC sites throughout Southern California for 3+ years.
In 2010, First 5 San Bernardino funded a program that was originally intended to provide services to children and pregnant women at WIC. Because of changes in the WIC providers, the same services were successfully initiated in medical clinics by dental providers.
In addition, COH staff has provided consultation to programs in a number of other states.
See Section 5 for details on five different models in California.