ASTDD Best Practices Project



A Best Practice Approach Report describes a public health strategy, assesses the strength of evidence on the effectiveness of the strategy, and uses practice examples to illustrate successful/innovative implementation.

Date of Report: _____________

Best Practice Approach

Perinatal Oral Health

I. Description (page 1)

II. Guidelines and Recommendations (page 13)

III. Research Evidence (page 14)

IV. Best Practice Criteria (page 15)

V. State Practice Examples (page 16)

VI. Acknowledgement (page 20)

VII. Attachments (page 21)

VIII. References (page 27)

I. Description

A. Oral Health and Its Significance for Pregnant Women

(this whole section needs expansion)

1. Same as any other individual

2. Relief from pain and acute infection- PRAMS & MIHA data

3. Treatment & management of the most common chronic oral diseases: dental caries and periodontal disease; other oral pathologies (including tobacco)

4. Improved Quality of Life

B. Significance of Mother’s Oral Health on Baby

(#1-2 needs expansion and #3 needs more references for transmissibility)

1. Developmental Issues (folic acid intake-cleft lip & palate)

2. Association with adverse birth outcomes (include tobacco use and periodontal disease)

3. Transmissibility of caries-causing bacteria

Tooth decay is caused by bacteria. Infants are first infected with cariogenic (tooth decay causing) bacteria transmitted through saliva, typically from the mother or primary caregiver. (refs) The bacteria ingest dietary sugar and produce acid that dissolves tooth structure, resulting in tooth decay. If the disease process is left unchecked (e.g., the tooth is not restored with a filling), the bacteria will advance into the nerve and blood vessels of the tooth causing inflammation and infection.

Early childhood caries (ECC) is a term used for tooth decay in infants, toddlers and preschoolers. According to the American Academy of Pediatric Dentistry (AAPD), ECC is defined as the presence of one or more tooth surfaces that are decayed (breakdown in tooth structure), missing (lost or extracted due to tooth decay) or filled (with dental filling materials) in any primary tooth of a child 71 months of age or younger (age 0-5).4

In the United States, tooth decay is the most prevalent chronic disease of childhood, five times more common than asthma.11 For the period of 1999-2004, 28 percent of 2-5 year-olds have experienced tooth decay. Children under age 6 receive less than half the dental care services as children ages 6-12 (25 percent vs. 59 percent).21 Tooth decay is not distributed equally among U.S. children. Approximately 80 percent of tooth decay is found in 25 percent of children, primarily children from low-income families.14

Dental disease can have consequences that hinder a child’s physical growth and quality of life. Dental caries, untreated for an extended period of time, can progressively lead to pain, infection and dental abscess. Pain and swelling can limit a child’s ability to eat and speak, and distract a child from learning and playing. Studies have found that severe ECC may keep toddlers from reaching normal height and weight and may compromise their general health and ability to thrive.5-10 Furthermore, dental infection is a risk for medical complications, especially for children who are the least able to afford or access professional care. In rare cases, untreated dental caries has led to life-threatening infection and death. (cite Deamonte Driver & Alex Callendar article)

ECC places a burden on children, families, communities, and the health care system. Therefore initiating primary prevention through clinical prevention and treatment as well as self-management of disease risk factors with pregnant women is a logical and necessary strategy to improve children’s oral health.

4. Self-care and lifestyle habits that will increase/decrease caries risk for baby

Inappropriate bottle-feeding and habits such as dipping a pacifier in honey, sugar or syrup lead to frequent sugar intake and increase the risk for ECC. Giving an infant or toddler a bottle for prolonged time periods with milk or other sugary drinks (having a bottle continuously throughout the day or sleeping with a bottle) can lead to rampant tooth decay. High, frequent intake of simple sugars is associated with tooth decay. Simple sugars, also called simple carbohydrates, are found in refined sugars (“table sugar”). Sweets like cookies, cakes, candy, and soda are high in simple sugars. Sweets that stay in the mouth for long periods of time are particularly damaging to the teeth.

Discuss protective factors (FL exposure, tap water etc) here

C. Barriers to Achieving Optimal Perinatal Oral Heath

Barriers related to attaining oral health during pregnancy:

● Poor dietary habits leading to frequent and high intake of sugar.

● Inadequate exposure to topical fluorides to prevent tooth decay.

● Cultural, social and economic influences on oral health such as dietary practices, home care and beliefs about the teeth

● Beliefs and attitudes about oral health during pregnancy (lose a tooth for every child)

● Beliefs and attitudes about receiving oral health care during pregnancy (fear/concern about dental procedures)

Barriers related to accessing and utilizing professional dental care:

● Cost or lack of dental insurance.28-31

● Lack of dentist participation in Medicaid.32

● Limited dental safety net services, capacity and infrastructure.

● Insufficient number of dentists willing to provide routine dental care to pregnant women.33

● Beliefs and attitudes by dentists about providing dental care to pregnant women (fear of litigation, insufficient experience, lack of guidelines/knowledge)

• Lack of evidence-based, widely accepted protocols for dental care of pregnant women

● Lack of knowledge & training by perinatal medical professionals about the importance of perinatal oral health

D. An Overview of a Strategic Framework to Promote Perinatal Oral Health

For preventing and controlling the disease process, strategies should:

● Establish dental homes for pregnant women

● Treat tooth decay and periodontal disease in pregnant women. Professional care is needed to arrest the disease and if needed, restore damaged teeth to proper form, function and esthetics.

● Prevent relapse and new tooth decay by addressing the risk factors for tooth decay prevents relapse.

For promoting systems of care, strategies should:

● Provide an adequate trained workforce that is willing to deliver comprehensive oral health care to pregnant women

● Integrate oral health and coordinate dental care services into systems supporting perinatal health. Healthcare providers can help facilitate establishment of the dental home for preventive/restorative dental care.

For developing public health practices, strategies should:

● Utilize a population-based approach. The Institute of Medicine proposed that public health “is what we, as a society, do collectively to assure the conditions for people to be healthy.”40 Public health focuses on the health of the population,41 including obtaining a high level of oral health throughout society. A population-based approach uses a community perspective, population data and evidence-based practice, with emphasis on prevention and effective outcomes.42 Community water fluoridation (a population-based strategy to prevent tooth decay) is recognized as one of ten great public health achievements. Population-based interventions complement individual interventions.

● Promote public and private partnership. Many governmental agencies are involved with health (e.g., agencies concerned with health and child welfare)41 as are many non-governmental institutions (e.g., managed care organizations, community-based groups, and academic institutions). The National Call to Action to Promote Oral Health acknowledges the need for public-private partnerships at all levels of society.43

● Respond to emerging issues. Public health practice needs to be responsive to emerging issues that impact perinatal oral health, while using the best evidence and practice as guides.

E. Components of the Strategic Framework to Promote Perinatal Oral Health

Figure 2 provides strategic framework to promote perinatal oral health. The framework guides efforts to promote perinatal oral health and supports the development of best practices. The strategic framework has four focus areas: (1) Prevention, (2) Disease Management, (3) Access to Dental Care Services, and (4) Systems of Integration and Coordination. The four focus areas are tied to the individual woman, family and community levels of influences on perinatal oral health.

E. Components of the Strategic Framework to Promote Perinatal Oral Health

1. Prevention

Action can be taken by families, dental and health care providers, communities, and policymakers to optimize perinatal oral health

Fluoride

Fluoride prevents and slows the progression of tooth decay and even reverses very early tooth decay. A small, consistent and prolonged level of fluoride in saliva and dental plaque brings fluoride in contact with tooth surfaces. This topical fluoride prevents tooth decay by: (a) improving tooth surface strength to resist acid attacks that break down tooth structure, (b) re-hardening tooth dental enamel following acid attack, and (c) reducing the ability of tooth decay causing bacteria to grow, metabolize sugar and produce acid.44 Sources of topical fluoride delivery include drinking water with optimal levels of fluoride and use of products such as fluoride toothpaste, mouthrinse, gel and varnish:

● Water fluoridation is an effective, safe, and low-cost way to prevent tooth decay. Low levels of fluoride in drinking water allow for frequent topical exposure. Fluoridated community drinking water is adjusted to the optimal level of 0.7 parts per million (ppm), for preventing tooth decay.45 Approximately 69 percent of the U.S. population is served by community water systems with optimally fluoridated water; the national Healthy People 2010 objective is to reach 75 percent.46 The Association of State & Territorial Dental Directors (ASTDD) fully supports and endorses community water fluoridation.

● Fluoride varnish has increasingly become a common method to deliver topical fluoride for prevention. An increasing body of evidence indicates that fluoride varnish is effective in caries prevention, a practice endorsed by the ADA, ASTDD, and American Association of Public Health Dentistry (AAPHD).53-59 Fluoride varnish (with 22,600 ppm fluoride) is easily applied with a small brush on tooth surfaces, does not require special preparation of the teeth, and quickly sets and sticks to the tooth surface until removed by repeated toothbrushing. In addition, fluoride varnish can also reverse early tooth decay.53

● Fluoride gel applications are mostly delivered in dental offices by dental professionals, generally at intervals of 3 to 12 months. The professionally applied products have 9,040-12,300 ppm fluoride.

● Toothpastes sold in the U.S. contain 1,000-1,500 ppm fluoride. Children under age two years should not use fluoride toothpaste unless instructed by a dentist or health professional. Children starting at age two should use fluoride toothpaste. Parents need to place only a small smear or pea-size amount on the toothbrush, as young children may like the taste of the paste and tend to swallow it.

● Fluoride mouthrinses (over-the-counter solutions have 230 ppm fluoride) are not appropriate for very young children who have not matured enough developmentally to be able to swish and spit without swallowing the rinse.

A woman’s caries risk (low, moderate or high) should be considered in determining the use of fluoride supplements and professionally applied topical fluoride treatment. Recent recommendations describe regimes for adults. (ADA clinical recommendations).58

Education and Anticipatory Guidance

Education is recommended for pregnant women to increase awareness about the importance of maintaining good oral health by imparting knowledge, discussing questions or concerns, and developing realistic prevention strategies.

Education and counseling should be provided to maintain oral health and prevent recurrence of dental caries or periodontal disease in the pregnant woman. Anticipatory guidance is the process of providing pregnant women with practical, developmentally-appropriate information about their own health related to significant physical, emotional, and psychological milestones.55

Pregnancy is also an opportune time to educate/counsel expecting mothers about preventing ECC. Topics include bottle feeding, oral hygiene, fluoride use, dietary and oral habits, speech/language development, injury prevention, and the first dental visit. AAPD guidelines and recommendations are found in Attachment B).4,55

Health literacy and cultural considerations are important when communicating with pregnant women. Recent estimates indicate that over 90 million Americans are unable to comprehend basic health information. Persons with low health literacy levels often have poor knowledge of health-related information, show little ability to control chronic diseases, and rarely maximize benefits from available preventive health services.63 Resources exist that provide guidance on developing culturally competent messages using plain language when communicating with families (e.g., from Centers for Disease Control and Prevention, National Maternal and Child Oral Health Resource Center, American Medical Association, Harvard School of Public Health, and National Network of Libraries of Medicine).

Interventions for pregnant women need effective approaches in delivering health education and in modifying health behaviors. More input from behavioral scientists, social workers, and educators will be needed to maximize effective and culturally competent communication with families to promote healthy behaviors. It should be a public health and clinical goal to develop effective methods to inform the public at large and on an individual level about the importance perinatal oral health on both the woman and her family.

Tobacco Cessasion

(need a whole section on this)

2. Disease Management

Risk Assessment for Dental Disease

Numerous risk factors lead to tooth decay. Early risk assessment identifying factors within the context of the child, family, community, and culture can assist in achieving and maintaining oral health. Both dental and other health professionals are encouraged to utilize a caries-risk assessment tool in their practices.55,57 Such a tool determines the risk level for an individual and guides the selection of appropriate interventions. Risk assessments for tooth decay should:

● identify risk factors including social, biological, behavioral, and nutritional factors;

● clinically assess the disease process such as bacteria levels, dental plaque appearance, and frequency of simple carbohydrate (sugar) ingestion;

● be simple, inexpensive, and have high predictive values (sensitivity/specificity).

Caries risk assessment tools for individuals include:

(check if these 3 tools are applicable for pregnant women, i.e. age 12 & up)

● the Caries-Risk Assessment Tool (CAT)65 developed by the AAPD, which is based on a set of clinical, environmental and general health factors;

● the Caries Management By Risk Assessment (CAMBRA)66 developed to assess the child’s risk for tooth decay and determine appropriate preventive and therapeutic interventions; and

● the ADA Caries Risk Assessment Form (Ages 0-6)67 developed as a practice tool for the dentists and a communication tool with the parent/guardian.

(need paragraphs here about periodontal disease risk and tobacco risk)

Monitoring health status to identify and solve community problems is an essential public health service, which 68 involves the identification of tooth decay risks and determination of dental service needs. For public health, risk assessment of tooth decay focuses on the population, rather than the individual. Risk factors of tooth decay for a population include social and environmental factors, such as non-fluoridated community water systems and dental health provider shortage areas. The pubic health practice of assessment identifies the extent of the problem in a community and unmet needs, as well as underutilized resources or shortcomings of the service delivery system.69

Spectrum of Dental Treatment

Dental decay that has progressed to the cavitation stage and beyond, and periodontal disease should be treated in the standard manner during pregnancy, following established guidelines. (ref ADA and/or AAP guidelines on treatment of perio & caries here). Relating to treatment of the pregnant patient follow guidelines regarding medical consult, medications and postural concerns (ref CA & NY guidelines here).

Since tooth decay and periodontal disease are both bacterial diseases, the potential use of antimicrobial agents to reduce the bacteria associated with the disease mirrors the approach used with other infectious diseases, but with some limitations as the mouth is also an external structure exposed to outside elements. An emerging area of clinical practice is the use of chemotherapeutic agents for caries prevention and as an adjunct to traditional dental treatment.70 Treating tooth decay chemically is part of a paradigm shift in dental disease management. Chemotherapeutic agents interfere with the colonization, growth and metabolism of decay causing bacteria and should not decrease the ability of other agents to prevent caries.

Fluoride can be considered a chemotherapeutic agent. There has been some research on preventing tooth decay with other agents such as chlorhexidine varnish, xylitol, povidone iodine, and silver diamine fluoride.71-78 It is possible that in the future some chemotherapeutic agents will become a routine part of the management of tooth decay.

3. Access to Dental Care Services

Pregnancy is an important times to access dental services because the consequences of poor oral health at these times can have a major impact throughout the lifespan. However, pregnant women are less likely to access dental care while pregnant regardless of income or insurance status. (Flesh this out more with specific data about pregnant women accessing dental care.) Lack of access to dental care disproportionately affects low-income women. Access is also dependent on a dental workforce with capacity and diversity, and an effective system to pay for professional dental care services.

Dental Home

To achieve optimal oral health, pregnant women need professional dental care, which should start in the pre-conception period and extent throughout the life-cycle beyond.55,65 A dental home delivers oral health care in a comprehensive, continuously accessible, coordinated, and family-centered way.65 A dental home should emphasize disease prevention and management, as well as tailor care to meet individual needs for better health outcomes at lower costs. A dental home should also provide education and counseling including anticipatory guidance, and make necessary referrals to dental specialists (see Appendix B).55,59,65

Medical and dental homes have led to the concept of a “health home” to coordinate all health care needs. At the 2009 Institute of Medicine workshop Sufficiency of the U.S. Oral Health Workforce in the Coming Decade, presenters spoke about moving toward better integration of dental care within the medical home model by creating a health home. A health home will further integrate oral health into the health care system.

Dental Workforce and Professional Development

To assure optimal perinatal oral health, a sufficient, trained dental workforce is needed with professionals in diverse settings. an adequate and effective workforce to achieve optimal oral health for all children:71

● Integrate established science on prevention and disease management for the perinatal patient into educational and training programs. Professionals should be appropriately trained and experienced on all aspects of treating dental disease in pregnant women; disease management that includes family-centered and risk-based interventions; and education to minimize disease transmission and establish lifelong healthy behaviors.

● Create an equitable dental workforce to meet the needs of all families. Strategies are needed to assure an adequate supply of dental professionals, equitable distribution of dental professional, and improved capacity and efficiency of the dental workforce.

● Expand the diversity of the dental workforce to meet current and future demands. The Institute of Medicine has recommended increasing the number of minority health professionals as a key strategy to eliminating health disparities. Nearly 25 percent of the U.S. population is African American, Hispanic American, and American Indian.72 Only five percent of dentists are from these racial/ethnic groups.72 More than 91 percent of dental hygienists are non-Hispanic White.73

Traditionally, dental care teams deliver services through the combined expertise, knowledge and/or skills of dentists, dental hygienists and dental assistants. To address access to care problems, workforce development also needs to focus on enhancing the dental team. Issues requiring more effective and efficient dental teams to meet workforce demands include:

● Efforts are needed to increase general dentists’ willingness to treat pregnant women with confidence

• Low-income inner city and rural/frontier communities have the greatest dental disease burden and experience greater dental workforce shortages. Can ref HPSA data here to show maldistribution of existing dental providers

● More than 150,000 dental hygienists are licensed to practice in the U.S.73 Practice laws in 30 states have increased direct access for dental hygienists to initiate treatment based on assessment of a patient’s needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and can maintain a provider-patient relationship.76

4. Systems of Integration and Coordination

Integrating and coordinating perinatal oral health into health systems that support the perinatal patient is essential. Interaction with perinatal providers and programs, and other public and private community agencies is needed to ensure awareness of perinatal oral health issues.65 The collective efforts of provider groups, state/community program administrators, advocates for mothers/children/families, and policymakers will be needed to implement effective strategies and organized programs and services at the state and local levels.

Partnership with Perinatal Providers

Since physicians, nurses, and allied health professionals are far more likely to see perinatal patients than are dentists, they must be engaged as partners to advocate and support perinatal oral health.

Partnership with health and perinatal providers can advance perinatal oral health by assuring that:

● curricula of medical, nursing, and allied health professional programs include training on perinatal oral health

● primary health care professionals who serve mothers ask about & access oral health

● pregnant women receive oral health counseling and referral for a comprehensive oral examination and treatment;

● Pregnant women have concerns regarding dental treatment answered & safety of dental care is reinforced

● Medical clearance for dental treatment is provided as needed

Federal, State and Local Programs for Early Childhood Oral Health

Organized efforts to promote perinatal oral health through state and local dental public health programs can: (a) mobilize partners to integrate systems, avoid duplicating services, and leverage resources, (b) provide statewide and/or local assessment of the burden of disease, and (c) support a state and/or local strategic plan developed and implemented by stakeholders and constituents.

State MCH programs (administered by state health agencies or statewide initiatives) should have a focus on population-based and infrastructure-building strategies. These strategies are necessary to understand and ensure that specific oral health needs of perinatal patients are met.

● Devlop a state perinatal, infant, early childhood oral health taskforce;

● Implement a state needs assessment of perinatal and infant oral health access and utilization;

● Educate partners, stakeholders, funders, legislature, and the public on early childhood oral health issues and needs;

● Develop a strategic plan based on state findings and needs that establishes specific goals, objectives, and activities with expected outcomes to improve the oral health status and access to care for pregnant women and children;

● Develop policies, coordination of care, quality assurance, and standards of care;

● Promote public-private partnerships, and system integration and coordination;

● Integrate perinatal oral health into existing state improvement plans and infrastructure;

● Develop guidelines and practice models for use by other maternal and child health partners;

● Evaluate the effectiveness of state and local perinatal oral health programs.

Local programs for perinatal oral health (such as community-based programs implemented by county/city health departments, health centers, community organizations, faith-based organizations, and hospital systems) can provide a range of services to mothers, children, families and communities. Dental preventive and restorative services may be delivered through community-based clinics, portable dental equipment, mobile dental vans, or contractual arrangements with dental service providers. Oral health care services can be added to existing community-based health care programs and centers.78 Local programs for perinatal oral health may include these activities:

● Educate or counsel pregnant women

● Train perinatal health providers;

● Provide case management/care coordination, establish dental homes, or develop health homes;

● Deliver preventive dental services (caries risk assessment, anticipatory guidance, fluoride varnish applications, and saliva testing for levels of bacteria);

● Deliver restorative dental treatment services for pregnant women;

● Provide enabling services that include transportation, translation, and assistance with enrollment in Medicaid;

● Support dental team enhancements and utilize technology (e.g., teledentistry) to reduce barriers and increase access to care in underserved areas; and

● Provide quality assurance of services and evaluate service programs.

Outcomes for state or local perinatal oral health programs should be tracked and routinely assessed for improvement in knowledge, attitudes, behaviors, practices, systems, and health status.

Short-Term Program Outcomes:

● Decision makers in the public and private sectors will make more informed decisions on matters affecting the oral health and care of pregnant women, new mothers, infants, toddlers, and preschoolers.

● Health and childcare providers, and parents and primary caregivers, have gained knowledege of the importance of perinatal oral health.

● Broader interaction and collaboration will occur among multi-disciplinary maternal and child health stakeholders to promote oral health.

Intermediate Program Outcomes:

● Policies will be developed and programs will be expanded based on a greater understanding of maternal and early childhood oral health and access to care issues.

● State and community public health officials will develop new and improved programs (population-based and individual approaches) to delivering perinatal, infant and early childhood oral health preventive and restorative services.

Long-Term Program Outcomes:

● Improved state and local perinatal programs, infrastructure and care systems.

● Improved capacity in the delivery of oral health care services for perinatal women and young children.

● Improve oral health status of pregnant women, infants, toddlers and preschoolers.

Policy Development

Oral health policy is needed to provide clear direction that will guide oral health practices and actions. Oral health policy is comprised of the decisions that determine how issues are addressed either by those elected or appointed to represent communal interests (“public policy”) or those involved in the delivery of health services (“clinical policy”):79

● Public policy deals with issues related to allocation of shared resources (people, programs and dollars) and the conditions under which those resources are distributed and utilized. For example, public policies govern what benefits are covered under various health programs; what types of health promotion, disease prevention and treatment programs are available to a population; and what actions should be taken to address access to care where service shortages exist.

● Clinical policy deals with issues of clinical care delivery. Typical issues include what and when clinical services are to be provided under a benefit program and how those services are delivered.

A wide range of policy-related issues impact perinatal oral health:79

● oral health and disease management (e.g., population-based interventions and oral health disparities);

● dental care services (e.g., unmet needs, primary care, health care delivery system, and public health programs);

● dental care organization and financing (e.g., Medicaid, dental managed care, and integrated service delivery);

● workforce (e.g., dental/public health workforce capacity and mid-level providers);

● case management and beneficiary services (e.g., care coordination and coverage);

● family-centered care (e.g., cultural determinants of health and maternal oral health).

Opportunities exist to promote policies to improve perinatal oral health on federal, state, and local levels. Initiatives could advocate increasing access to community water fluoridation, establishing and/or expanding state surveillance for perinatal oral health, and expanding community-based perinatal/early childhood preventive programs. The 2009 Children’s Health Insurance Program Reauthorization Act (CHIPRA) illustrates the potential impact of policy. The new federal law reauthorizing CHIP seeks to improve access to dental care and expands efforts to prevent dental disease through major provisions such as a required program to educate new parents on ECC.

Legislators, policymakers, and third party payors should be educated about the benefits of perinatal intervention in order to support efforts to improve oral health and access to care for mothers and their children.59

F. Initiatives and Coordinated Efforts

(review if appropriate to perinatal oral health & if other initiatives/efforts exist)

1. Targeted Oral Health Services Systems (TOHSS) Grant Program

(would this include perinatal oral health?)

Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau’s TOHSS grant program supports states in expanding preventive and restorative oral health service programs for Medicaid and CHIP eligible children, and other underserved children and their families. Grantees are asked to develop state strategies to make improvement within three program areas, which include increasing the number of children receiving age one dental visits.

2. Oral Health Disparities Collaborative (OHDC) Pilot

HRSA, Bureau of Primary Health Care initiated the OHDC pilot to develop “comprehensive primary oral health care system change interventions” (based on the Chronic Care Model and evidence-based concepts) to improve ECC prevention and treatment, and perinatal oral health in Health Centers. The Oral Health Disparities Collaborative Implementation Manual was developed from the pilot to guide future efforts.

3. The Children’s Dental Health Project Perinatal Initiative

(need a description of their perinatal initiative)

4. HRSA Maternal and Child Health Bureau

Consensus Conference on Perinatal Oral Health (2007) and follow-up (2008)

(describe these meetings and the outcomes)

II. Guidelines & Recommendations from Authoritative Sources

(general review to see if other guidelines/recommendations exist)

A. New York State Department of Health – Oral Health During Pregnancy and Early Childhood Practice Guidelines (August 2006)

In 2006, the New York State Department of Health convened an expert panel of health care professionals to develop recommendations (published as the Guidelines) to bring about changes in the health care delivery system and to improve the overall standard of care.

B. California Dental Association Foundation – Oral Health During Pregnancy and Early Childhood:  Evidence-Based Guidelines for Health Professionals (February 2010)

In 2009, California Dental Association Foundation convened an expert panel of medical and dental professionals to provide practice guidelines, based on evidence and professional consensus, on the importance of dental care to pregnant women and their young children.

C. Office of Surgeon General

Oral Health in America: A Report of the Surgeon General

The Surgeon General’s Report on Oral Health in America reported the following:

● Effective disease prevention measures exist for use by individuals, practitioners and communities (most focus on dental caries prevention such as fluorides).

● Many community-based programs required a combined effort among social service, health care, and education services at the state or local level.

● Primary prevention of dental disease is possible with appropriate diet, nutrition, oral hygiene, and health-promoting behaviors, including the use of professional services.

National Call to Action to Promote Oral Health

The National Call to Action to Promote Oral Health calls for these actions to achieve the goals of the Surgeon General and Healthy People 2010, include early childhood oral health:

● Change perceptions of oral health.

● Overcome barriers by replicating effective programs and proven efforts.

● Build the science base and accelerate science transfer.

● Increase oral health workforce diversity, capacity, and flexibility.

● Increase collaborations.

D. Healthy People 2010 – Oral Health

Healthy People 2010 Objectives promoting perinatal oral health include:

21-9. Increase the proportion of the U.S. population served by community water systems with optimally fluoridated water.

21-10. Increase the proportion of children and adults who use the oral health care system.

E. Association of State & Territorial Dental Directors (ASTDD)

ASTDD promotes a governmental oral health presence in each state and territory, to formulate and promote sound oral health policy, to increase awareness of oral health issues, and to assist in the development of initiatives for prevention and control of oral diseases.

● Community Water Fluoridation Policy Statement – ASTDD fully supports and endorses community water fluoridation in all public water systems throughout the U.S.

● ASTDD is in the process of adopting a policy statement supporting the use of fluoride varnish for individuals at moderate to high risk for tooth decay as an effective adjunct in programs designed to reduce lifetime dental caries experience.

F. American Association of Public Health Dentistry (AAPHD)

AAPHD policies related to promoting perinatal oral health include:

● Policy Statement on Primary Care

● Policy on Access to Care

● Resolution on Fluoride Varnish for Caries Prevention

G. American Public Health Association (APHA)

APHA policy statements in support of perinatal oral health include:

● Community Water Fluoridation in the United States

I. American Academy of Pediatrics (AAP)

The AAP policy statement on Oral Health Risk Assessment Timing and Establishment of the Dental Home recommends:

● Health care professionals who serve mothers and infants should integrate parent and caregiver education into their practices that instruct methods to prevent ECC.

J. American Dental Association (ADA)

ADA positions and statements include:

● ADA Supports Fluoridation

● ADA Statement on Water Fluoridation Efficacy and Safety

● ADA Statement on the Effectiveness of Community Water Fluoridation

K. American Academy of Family Physicians (AAFP)

AAFP has published anticipatory guidance for perinatal oral health:

● Oral Health During Pregnancy

L. American Academy of Periodontology (AAP)

The AAP Statement Regarding Periodontal Management of the Pregnant Women encourages all women to attain good oral health prior to and throughout their pregnancies, and encourages necessary treatment beginning early in and throughout the pregnancy.

III. Research Evidence

(review if existing reviews appropriate to perinatal oral health & if other newer reviews exist)

The following major sources of evidence-based reviews contribute to the body of evidence on perinatal oral health:

1. The Agency for Healthcare Research and Quality (AHRQ)

● (need to do a search)

2. The National Institutes of Health convened the Consensus Development Conference on Diagnosis and Management of Dental Caries Throughout Life in 2001. The Consensus Development Conference Statement, resulting from the meeting reviews, provided guidance on the best methods for detecting caries in early and advanced stages, indicators for elevated risk, best methods for primary prevention of caries, the best treatments for arresting or reversing early caries progression, and identified new directions for future research.81

3. U.S. Preventive Services Task Force (USPSTF)

● (need to do a search)

4. The Cochrane Reviews explore the evidence for and against the effectiveness and appropriateness of treatments to facilitate the choices that doctors, patients, policymakers and others face in health care (published in The Cochrane Library).83 A selection of Cochrane Oral Health Group Reviews relevant to perinatal oral health are highlighted below:

● (need to do a search)

5. The ADA Center for Evidence-Based Dentistry provides systematically assessed evidence as tools and resources to support clinical decisions to integrate evidence into patient care:

● An expert panel established by the ADA Council on Scientific Affairs evaluated the collective body of scientific evidence and provided evidence-based clinical recommendations on the use of professionally applied topical fluoride (published in May 2006).52

IV. Best Practice Criteria

The ASTDD Best Practices Project has selected five best practice criteria to guide state and community oral health programs in developing their best practices. For these criteria, initial review standards, are provided to help evaluate the strengths of a program or practice to promote perinatal oral health.

1. Impact / Effectiveness

● A practice or program enhances the processes to improve oral health status and/or improve access to dental care for pregnant women.

Example: Increased number of programs to train physicians, nurses, and dentists to provide screening and preventive services for pregnant women or increased number of providers being trained.

● A practice or program produces outcomes that improve oral health status and/or improve access to dental care for pregnant women.

Example: Reduced dental caries experience and untreated decay among pregnant women, fewer emergency visits to the dentist, or fewer hospital emergency room services for dental problems.

2. Efficiency

● A practice or program shows cost savings in preventing oral disease and reducing the extent of treatment needs for pregnant women.

Example: Increased savings based on the comparison of the cost for delivering in-office dental treatment compared to utilization of hospital emergency rooms for dental related conditions.

● A practice or program shows leveraging of federal, state, and/or community resources to improve the oral health of pregnant women.

Example: Expanded partnership between the public and private sectors to support an oral health program for outreach, case management, preventive services, and dental care for pregnant women.

3. Demonstrated Sustainability

● A practice or program that has demonstrated sustainability or has a plan to maintain sustainability.

Example: A program that has served pregnant women for many years and receives agency line-item funding and reimbursement from public and private insurers.

4. Collaboration / Integration

● A practice or program establishes partnerships or collaborations that integrate oral health efforts with other disciplines to improve the general health of pregnant women.

Example: The state oral health and MCH programs working collaboratively to improve systems of care (such as improving coordination between medical and dental homes) and financing for oral health.

5. Objectives / Rationale

● A practice or program aligns its objectives with the national or state agenda to improve the oral health and general health of pregnant women.

Example: Program objectives target Healthy People 2010 objectives to reduce caries experience, untreated decay, and use of the oral health care delivery system.

V. State Practice Examples

(have retained 2 examples from the ECC paper which also targeted pregnant women so we already have 2 prelim submissions…but will need to solicit more)

The following practice examples illustrate various elements or dimensions of the best practice approach. These reported success stories should be viewed in the context of the states and program’s environment, infrastructure and resources. End-users are encouraged to review the practice descriptions (click on the links of the practice names) and adapt ideas for a better fit to their states and programs.

A. Summary Listing of Practice Examples

Table 1 provides a listing of programs and activities submitted by states. Each practice name is linked to a detailed description.

|Table 1. State Practice Examples Promoting Perinatal Oral Health |

|# |Practice Name |State |Practice |

|Oral Health Training for Health Professionals |

|1 | | | |

|2 | | | |

|3 | | | |

|4 | | | |

|5 | | | |

|Primary Prevention |

|6 |The Mother and Youth Access (MAYA) Project |CA |06003 |

|7 |Oral Health Disparities Collaborative |CO & MT |99001 |

|8 | | | |

|9 | | | |

|10 | | | |

|3. Care Coordination and Systems Integration |

|11 | | | |

|12 | | | |

|13 | | | |

|14 | | | |

|15 | | | |

B. Highlights of Practice Examples

Highlights of state practice examples are listed below.

1. Oral Health Training for Health Professionals

2. Primary Prevention

CA The Mother and Youth Access (MAYA) Project / Practice #06003

The MAYA Project, a randomized clinical trial, was designed to compare different interventions to prevent dental caries: chlorhexidine rinses to reduce the number of tooth decay causing bacteria, a fluoride varnish applications to increase enamel remineralization, and parental oral health counseling to promote behavioral change.

CO & MT Oral Health Disparities Collaborative / Practice #99001

The Oral Health Disparities Collaborative was launched in order to improve access to oral health services for low-income children ages 0 to 5 and pregnant women. The Collaborative used the Chronic Care Model as the framework for system redesign.

3. Care Coordination and Systems Integration

VI. Acknowledgements

This report is the result of efforts by the ASTDD Best Practices Committee to identify and provide information on developing and successful practices that address the oral health care needs of infants, toddlers and preschool children.

The ASTDD Best Practices Committee extends a special thank you to the ASTDD Perinatal and Early Childhood Committee for their partnership in the preparation of this report.

This publication was supported by Cooperative Agreement U58DP001695 from CDC, Division of Oral Health and by Cooperative Agreement U44MC00177 from HRSA, Maternal and Child Health Bureau.

VII. Attachments

ATTACHMENT B

Anticipatory Guidance

AAPD provides the following anticipatory guidance for mothers ():

General anticipatory guidance for the mother (or other intimate caregiver) includes the following:

● Oral hygiene: Tooth-brushing and flossing by the mother on a daily basis are important to help dislodge food and reduce bacterial plaque levels.

● Diet: Important components of dietary education for the parents include the cariogenicity of certain foods and beverages, role of frequency of consumption of these substances, and the demineralization/remineralization process.

● Fluoride: Using a fluoridated toothpaste approved by the American Dental Association and rinsing every night with an alcohol-free, over-the-counter mouth rinse containing 0.05% sodium fluoride have been suggested to help reduce plaque levels and help enamel remineralization.

● Caries removal: Routine professional dental care for the mothers can help keep their oral health in optimal condition. Removal of active caries with subsequent restoration is important to suppress maternal MS reservoirs and has the potential to minimize the transfer of MS to the infant, thereby decreasing the infant's risk of developing early childhood caries (ECC).

● Delay of colonization: Education of the parents, especially mothers, on avoiding saliva-sharing behaviors (e.g., sharing spoons and other utensils, sharing cups, cleaning a dropped pacifier or toy with their mouth) can help prevent early colonization of MS in their infants.

● Xylitol chewing gums: Evidence demonstrates that mothers' use of xylitol chewing gum can prevent dental caries in their children by prohibiting the transmission of MS.

Dental Home

An AAPD policy recognizes that a dental home should provide ():

● comprehensive oral health care including acute care and preventive services in accordance with AAPD periodicity schedules;

● comprehensive assessment for oral diseases and conditions;

● individualized preventive dental health program based upon a caries-risk assessment (and a periodontal disease risk assessment for older children);

● anticipatory guidance about growth and development issues (i.e., teething, digit or pacifier habits);

● plan for acute dental trauma;

● information about proper care of the child’s teeth and gingivae (include the prevention, diagnosis, and treatment of disease of the supporting and surrounding tissues and the maintenance of health, function, and esthetics of those structures and tissues);

● dietary counseling;

● referrals to dental specialists when care cannot directly be provided within the dental home;

● education regarding future referral to a dentist knowledgeable and comfortable with adult oral health issues for continuing oral health care; referral at an age determined by patient, parent, and pediatric dentist.

ATTACHMENT C

Barriers to Reducing Disease and Achieving Optimal Perinatal Oral Health

(I did not change this since we may not need this as the CDA Guidelines has an accompanying policy paper which goes into the barriers in detail!)

Young children experience barriers in attaining optimal oral health and barriers to accessing and utilizing professional dental care. Developing solutions for young children to achieve optimal oral health (particularly infants, toddlers and preschoolers at high risk to dental disease) will need to address the following barriers.

Barriers to Attaining Oral Health During Early Childhood:

a. Failure to prevent, limit or delay the transmission of tooth decay causing bacteria as the first primary teeth erupt.

As the first primary teeth erupt, the risk for early childhood caries (ECC) can be reduced by preventing, limiting, or delaying the infection of tooth decay causing (cariogenic) bacteria. Transmission, typically from mothers or primary caregivers to young children, has three components which can be controlled: the bacteria in the mouth of the parent or caregiver, the ways through which saliva carrying the bacteria are transmitted, and the child’s ability to retain these bacteria in the mouth. Families with high caries experience (as observed with the mother or older siblings), efforts to address transmission of the bacteria may have the greatest value.

Barriers to implementing the preventive strategy include:

● lack of public (and sometimes professional) knowledge of transmission as a risk factor;

● lack of well developed family-level risk assessment tools to identify and target at-risk families;

● lack of evidence-based protocols of limiting bacterial transmission.

b. Poor dietary habits leading to frequent and high intake of sugar.

A young child’s risk for ECC increases with a high sugar diet and the frequent intake of sugar throughout the day and night. The sugar feeds the tooth decay causing bacteria and high sugar intake will stimulate and exacerbate the caries process (bacteria will multiply and more acid are produced to damage the teeth).

Barriers to implementing the preventive strategy include:

● lack of public (and sometimes professional) knowledge about the impact of frequency of sugar exposure to caries development;

● public acceptance of frequent use of sugar-containing foods and liquids to pacify a child (e.g., dry snacks and sugar-laden liquids in bottles and sippy cups);

● some culture related feeding, eating and diet habits and practices;

● sleep-time offering of bottle containing liquids other than water during the day or night.

c. Inadequate exposure to topical fluorides, especially for high-risk children and young children with aggressive tooth decay.

The presence of frequent low-levels of topical fluorides will reduce acid production by the tooth decay causing bacteria, disrupt dental plaque integrity (which allows the bacteria to colonize on the teeth), stabilize the crystal structure of the tooth surface (the enamel), and promote remineralization to re-harden the tooth surface damaged by acid.

Barriers to implementing the preventive strategy include:

● concern about potential fluorosis of the permanent teeth (a problem caused by excessive or protracted ingestion of fluorine causing a mottled appearance of the teeth and in extreme cases, pitting in the teeth);

● lack of public awareness and understanding about the proper use of fluoridated toothpaste in young children;

● lack of low-dose fluoride toothpaste products in the United States appropriate for young children.

d. Common failure to detect tooth decay early in a child’s life and before the disease process progress and lead to cavities in the teeth.

For toddlers and preschoolers, dental pain and infection often follow quickly after the appearance of cavities in the teeth. These signs and symptoms require a dental visit that typically results in extensive treatment for the young child (e.g., fillings, pulp therapy for the nerve of the tooth, crowns, extractions and/or antibiotic treatment). However, early signs of tooth decay could be used by informed parents, caregivers, day-care staff, and medical providers who are in regular contact with young children. “White spots” or streaks, particularly along the gumline of the upper front teeth, are signs of the damage by acid produced by bacteria (decalcification of the tooth surface). Another early sign include children having thick and soft dental plaque along the gumline of the upper front teeth. When a toothpick is touched to this plaque and lifted from the surface, it produces a glutinous strand which has high level of tooth decay causing bacteria and is diagnostic for ECC. Assessment of he level of tooth decay causing bacteria can be made by collecting saliva on a sterile tongue blade by pressing it onto the child’s tongue and transferring the saliva to a culturing media.

Barriers to implementing the preventive strategy include:

● lack of knowledge by the public and people who come in contact with young children about the early signs of this disease;

● lack of access to oral health professionals who can work with families to suppress caries activity once identified.

● families may be unaware of the need for early and regular oral health care.

e. Cultural, social and economic influences on oral health such as dietary practices, home care and beliefs about the primary teeth.

The importance placed on oral health can vary due to cultural, social, and economic factors. Dietary practices specific to certain cultures may post a risk to early onset of tooth decay, while other social and economic factors may discourage certain populations from seeking regular professional dental care. Families who do not place value on the first set of primary teeth may not be as concerned about tooth decay in those teeth.

Barriers Related to Access and Utilization of Professional Dental Care:

a. Lack of dental insurance.

At least 23 million children in the United States lack dental insurance coverage. Children who lacked dental insurance are less likely to have received preventive care and more likely to have unmet need for care.28 In 2006, one in five children had no dental coverage during the year.29

Medicaid and Children’s Health Insurance Program (CHIP), the nation’s safety-net health insurance programs, are a major source of coverage for children in the United States. In 2006, among low income children in the U.S., more than two-thirds (69 percent) received dental coverage through Medicaid and CHIP during at least part of the past year, 16 percent had private dental insurance, and 15 percent had no dental insurance coverage.29 In the absence of Medicaid and CHIP, most children covered by these programs would be uninsured. Children enrolled in Medicaid and CHIP have better access to dental care than uninsured children. In 2006, 73 percent of children age 2-17 with public coverage had a dental visit in the past year, compared with 48 percent of uninsured children.30 The one-quarter of publicly insured children who had no dental visit in the past year indicates a substantial gap in dental access.

In the majority of cases, the people who are enrolled in Medicaid programs can locate and utilize the services that they need. This is not true with for dental services. Even though states are required to provide dental care to Medicaid-enrolled children, only one in three of these children utilized dental services in 2006.31

b. Lack of dentist participation in Medicaid.

Dentists’ participation in Medicaid is limited. In a 1999 survey of Medicaid directors, 23 of 39 states that responded revealed that less than half of dentists in their state saw at least one Medicaid patient that year, and only five reported 25 percent or more saw a minimum of 100 Medicaid patients (which represented roughly 10 percent of the typical dentist’s patient load in a year).32 Dentists cited reimbursement rates, cumbersome administrative procedures and a high proportion of “no shows” for appointments as the primary reasons for not participating in the Medicaid program.32

c. An insufficient number of pediatric dentists to care for young children with severe needs.

There is also an insufficient number of pediatric dentists available to care for the young children in the United States. In 2008, there are 233,104 dentists in the United States and only 6,087 are pediatric dentists.33 The majority of practicing dentists are general dentists; however, with minimal training in the care of young children, the lack of general dentists treating young children also contributes to the shortage of dental providers willing to treat infants, toddlers and preschoolers.

d. Need to enhance the dental care team with new types of dental professionals.

Traditional dental care teams are form to deliver services through the combined expertise, knowledge and/or skills of dentists, dental hygienists and dental assistants. In creating solution to address access to care problems, enhancing the dental care team has become a focus. Current efforts to develop new types of dental professionals in the United States include:34-36 (a) the Alaska Native Tribal Health Consortium, in partnership with the University of Washington School of Medicine's MEDEX program, trains dental therapists to deliver community level dental disease prevention for the underserved Alaska Native populations; (b) the American Dental Association is developing a new member of the oral health team called the Community Dental Health Coordinator (CDHC) who will be responsible for promoting oral health through organized and dentally coordinated community-based promotion and prevention programs; and (c) the American Dental Hygienists Association has been working to develop a mid-level professional with a much broader range of duties than a dental therapist called the Advanced Dental Hygiene Practitioner (ADHP).

e. Limited dental safety net services, capacity and infrastructure.

Low-income families who cannot find and/or afford a private practice dentist to treat their children often turn to safety net providers. Dental care traditionally has not been a core focus of general safety net providers (e.g., public and not-for-profit hospitals, community health centers, free clinics and local health departments). The availability of safety net dental services is typically far less extensive than the safety net medical services. States and communities often report that dental safety capacity is limited and does not meet demand for dental care.

Efforts are invested to build and expand the public dental health infrastructure (consists of systems, people, relationships and resources) to promote the oral health of young children. This includes increasing the capacity to deliver dental safety net capacity services for vulnerable communities, families and children. However, such infrastructure remains inadequate in some states and communities.

There is a continued need to strengthen the infrastructure to support community-based efforts to prevent and manage dental disease (e.g., expanding school-based/school-linked sealant and fluoride varnish/rinse programs); increase safety-net services for young children (e.g., Community Health Centers and local health departments); and assure state oral health leadership. State oral health leadership for a range of services including assessment and surveillance of the dental workforce, developing a state oral health plan to establish goals and strategies to reduce the burden of dental disease and improve access to care, and mobilizing stakeholders and partners through a state oral health coalition to take action.

f. Lack of evidence-based widely-accepted protocols for dental care of young children.

While the American Academy of Pediatric Dentistry has provided leadership in establishing guidelines for early childhood oral health care, research is needed to build the evidence needed to provide well-tested protocols for risk assessment, disease management protocols and criteria for follow up care.

g. Lack of financing that supports disease management.

Dental spending in the United States typically pays for preventive and restorative dental care. In 2009, dental spending will exceed $100 billion. The projected 2 percent increase in the nation’s Dental Services Expenditures from $99.9 billion in 2008 to $101.9 billion would be the lowest annual increase in dental spending since 1960.37 For 2009, the National Health Expenditure will be $2.5 trillion, consuming 17.6% of the nation’s Gross Domestic Product; Dental Services Expenditures represent only four percent of the National Health expenditure.38

For 2009 Dental Services Expenditures, Out of Pocket Payments will total $44.0 billion, Private Insurance Payments $50.2 billion, and Public Insurance Payments $7.7 billion. Public Insurance Payments include Federal $4.6 billion, State & Local $3.0 billion, Medicare $0.2 billion, and Medicaid $6.5 billion.38 Average 2009 Dental Services Expenses Per Capita is $331, which includes Out of Pocket Payments $141, Private Insurance Payments $163, and Public Insurance Payments $25.

Finance is needed to support dental disease management that include additional protocols (e.g., motivational counseling, risk assessment, etc.) to prevent and control ECC. Insurance coverage for the adult parent/caregiver is also critical in the disease management of ECC (to limit transmitting tooth decay causing bacteria to the child).

h. Low value/priority placed on regular dental visits for preventive care.

Even if a child has dental insurance, if there is low priority attached to regular preventive dental care, the child may only see a dentist if there is an obvious dental problem.

VIII. References

Top of Form

-----------------------

Disease Management

( Risk assessment for dental disease

▪ Spectrum of dental treatment

Prevention

( Fluoride

( Education and anticipatory guidance

( Tobacco cessation

Figure 2. A Strategic Framework to Promote Perinatal Oral Health

Four Focus Areas and Their Components

Prevention

( Fluoride

( Education and anticipatory guidance

( Tobacco cessation

DRAFT 1/31/11

Best Practice Approaches

for State and Community Oral Health Programs

[pic]

Summary of Evidence Supporting

Strategies to Promote

Early Childhood Oral Health

Research ++

Expert Opinion +++

Field Lessons ++

Theoretical Rationale +++

See Attachment A for details.

Disease Management

( Risk assessment for dental disease

▪ Spectrum of dental treatment

Systems of Integration and Coordination

( Partnership with perinatal providers

( State and local programs for maternal oral health

▪ Policy development

Suggested citation: Association of State and Territorial Dental Directors (ASTDD) Best Practices Committee. Best practice approach: perinatal oral health [monograph on the Internet]. Sparks, NV: Association of State and Territorial Dental Directors; 2012 Feb 1. ___ p. Available from: .

Access to Dental Care Services

( Dental home

( Dental workforce and professional development

Access to

Dental Care Services

( Dental home

( Dental workforce and professional development

Systems of Integration and Coordination

( Partnership with perinatal providers

( State and local programs for perinatal oral health

▪ Policy development

ATTACHMENT A

Strength of Evidence Supporting Best Practice Approaches

The ASTDD Best Practices Committee takes a broad view of evidence to support best practice approaches for building effective state and community oral health programs. The Committee evaluated evidence in four categories: research, expert opinion, field lessons and theoretical rationale. Although all best practice approaches reported have a strong theoretical rationale, the strength of evidence from research, expert opinion and field lessons fall within a spectrum. On one end of the spectrum are promising best practice approaches, which may be supported by little research, a beginning of agreement in expert opinion, and very few field lessons evaluating effectiveness. On the other end of the spectrum are proven best practice approaches, ones that are supported by strong research, extensive expert opinion from multiple authoritative sources, and solid field lessons evaluating effectiveness.

Promising Proven

Best Practice Approaches Best Practice Approaches

Research + Research +++

Expert Opinion + Expert Opinion +++

Field Lessons + Field Lessons +++

Theoretical Rationale +++ Theoretical Rationale +++

Research

+ A few studies in dental public health or other disciplines reporting effectiveness.

++ Descriptive review of scientific literature supporting effectiveness.

+++ Systematic review of scientific literature supporting effectiveness.

Expert Opinion

+ An expert group or general professional opinion supporting the practice.

++ One authoritative source (such as a national organization or agency) supporting the practice.

+++ Multiple authoritative sources (including national organizations, agencies or initiatives) supporting the practice.

Field Lessons

+ Successes in state practices reported without evaluation documenting effectiveness.

++ Evaluation by a few states separately documenting effectiveness.

+++ Cluster evaluation of several states (group evaluation) documenting effectiveness.

Theoretical Rationale

+++ Only practices which are linked by strong causal reasoning to the desired outcome of improving oral health and total well-being of priority populations will be reported on this website.

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