An institutional review of cardiac procedure cancellations, within a paediatric cardiology clinic, found that lack of pre-procedural oral screening was an avoidable cause of these cancellations. The implementation of routine oral screening, in the paediatric cardiology setting, with referral to paediatric dentistry for positive screens, has been recommended as a strategy to prevent cardiac procedure cancellations. ^{Reference Coutinho, Maia and Castro1–Reference Yasney and White10}

Oral health is important to the systemic health of all children but is of greater importance for children with congenital heart disease (CHD), who are at increased risk for infective endocarditis. ^{Reference Knirsch and Nadal11–Reference Wilson, Taubert and Gewitz13} Invasive procedures and surgical correction of congenital malformations further increase the risk for infective endocarditis in children with CHD. ^{Reference Knirsch and Nadal11,Reference Sun, Lai and Wang12} Infective endocarditis, though rare, has a 30% mortality rate, and an average associated cost in excess of $120,000 per patient. ^{Reference Cahill, Baddour and Habib14}

No standardised oral screening tool for paediatric cardiologist use was found within the literature. This result was surprising with current recommendations and guidelines for oral health in CHD children emphasising regular oral health preventive treatment. ^{Reference Yasney and White10,Reference Wilson, Taubert and Gewitz13,Reference Stokes, Richey and Wray15}

Poor oral health directly correlates to an increased risk of infective endocarditis. Oral mucosal surfaces, dentition, and gingiva are densely populated by endogenous microflora and are therefore a significant source of transient bacteremia. ^{Reference Wilson, Taubert and Gewitz13} Trauma to periodontal structures can occur during dental extractions or with routine daily activities such as toothbrushing and flossing creating a portal of ingress. ^{Reference Lockhart, Brennan and Thornhill16}

Multiple studies have shown a correlation between children with CHD and increased incidence of poor oral health. These studies have used standardised measurements such as the decayed missing and filled teeth indices, simplified oral hygiene index, modified gingival index, and modified plaque index. ^{Reference Garrocho-Rangel, Echavarria-Garcia, Rosales-Berber, Florez-Velazquez and Pozos-Guillen2,Reference Nosrati, Eckert, Kowolik, Ho, Schamberger and Kowolik5,Reference Oliver, Cheung, Hallett and Manton6,Reference Balmer and Bu’Lock17–Reference Hayes and Fasules21} Parental and child factors impacting poor oral health in children with CHD include lack of knowledge regarding the link between infective endocarditis and oral health status, and lax oral health routines due to avoidance of power struggles between parent and child. ^{Reference Balmer and Bu’Lock17,Reference Da Silva, Souza and Cunha22} Paediatric cardiologists’ factors influencing oral health include a lack of knowledge regarding oral health screening ^{Reference Coutinho, Maia and Castro1,Reference Olderog-Hermiston, Nowak and Kanellis23,Reference Oliver, Casas, Judd and Russell24} and the deleterious effects of medications and dietary requirements, for managing CHD, on oral health. ^{Reference Stecksen-Blicks, Rydberg, Nyman, Asplund and Svanberg25} These linked factors are external causes that lead to poor oral health.

Despite numerous studies showing a link between poor oral health in CHD patients and an increased risk for infective endocarditis, few studies have described redesigning oral health screening as a standard of practice in the paediatric cardiology setting. The objective of this quality improvement project was the implementation of a provider-driven, standardised, evidence-based, oral screening tool for CHD invasive treatment candidates aged ≥6 months to <18 years old. Positive screens were referred to dental providers for confirmation. The intervention was intended to reduce risk of infection and preempt case cancellations due to failure to perform clinical evaluation of oral status. Addressing early, the need for treatment management has been shown to decrease cancellations rates. This article outlines the steps of an oral screening program with the goal of dissemination of the implementation process for more paediatric cardiology clinics to adopt similar work redesigns.

Implementation framework

The quality implementation framework was used for this project. ^{Reference Meyers, Durlak and Wandersman26} A microsystem assessment of the cardiology and dental clinic environment revealed that no linked process existed, to refer children to the dental clinic from the cardiology clinic. Additionally, there was no goal regarding the transfer of knowledge concerning the patient’s oral health within any clinical microsystem including the pre-operative clinic.

Initially, a 12-item questionnaire was used to obtain data on cardiologists’ self-reported beliefs and knowledge toward oral screening. The survey employed binary, Likert, and multiple-choice scales, consistent with the literature (Appendix 1). The goal was to understand how cardiologists think about oral screening with CHD patients. Conversational interviewing after the survey allowed cardiologists to add pertinent narrative on the survey topics. The chances for success in building education material on a topic is improved through navigation of stakeholder beliefs and knowledge. However, education is rarely sufficient in solving multi-dimensional problems.

Theoretical framework of change

Change needs to be managed to be successful. Structures and processes believed to give momentum to the adoption of the oral screening guideline were identified in an effort to anticipate concerns and plan ahead. A comprehensive diagram of the various inputs, activities, outputs, and goals of the study, are included in Figure 1.

Figure 1. Change diagram.

Method

The oral screening tool for this project was created by paediatric cardiology and dental providers experts, using best-practice guidelines. ^{Reference Wilson, Taubert and Gewitz13,27} The oral screening guideline was developed with collaboration among paediatric cardiologists and dental providers. The Guideline Implementability Appraisal tool, ^{Reference Shiffman, Dixon and Brandt28} was used in the creation of the oral screening guideline:

A positive finding of any of the following constitutes a positive oral screen: obvious dental caries, heavy plaque, gingival inflammation, parulis (gingival boil), abscessed teeth, intra-oral pain, or last dental visit >12 months prior. Any positive screen should be referred to a paediatric dental clinic for immediate follow-up.

Provider behavior change

A 30-minute in-service for participating cardiologists, was presented by dental clinic providers. The five photographic objective examples for the oral screening guideline were obvious caries, gingival inflammation, parulis (gingival boils), heavy plaque, and abscessed teeth. From the patient point of view, the two subjective symptoms were intraoral pain and last dental visit >12 months prior. Printed copies of the guideline were provided. Cardiologists were instructed on the redesigned workflow process: electronic health record oral screening documentation, future appointment dental clinic referral process, and real-time immediate referral process to the dental clinic. Providers were given a flyer from the “Lift the Lip” campaign, a quick oral-examination tool. ^{Reference Arrow, Raheb and Miller29}

A supportive environment is needed for lasting behaviour change. ^{Reference Francke, Smit, De Veer and Mistiaen30} Electronic health record redesign and support within the physical environment were leveraged to promote the behaviour change of oral screening for all CHD patients. Electronic health record changes included a “hard stop”, for the completion of the oral screening (Fig 2) within the referral order forms for cardiac catheterisation and surgery. An oral screening “dotphrase” template was given to providers for use in their encounter documentation (Fig 2). Visual cues were placed in the physical environment as a reminder to perform the oral screening behaviour. The bi-lingual American Dental Association oral health campaign posters provided a memory-aid. Placards with screening guidelines and dental provider contact information were a trigger at each computer. Basic oral hygiene kits were distributed to each eligible child. The kits contained an informational postcard asking parents to talk to their cardiologist “about the importance of oral hygiene for kids with CHD”.

Dental providers committed to providing ongoing education and support to cardiologists in completing oral screenings. Dental providers were available via pager during cardiology clinic hours and responded, as requested. Clinic medical assistants interviewed patients, regarding last dental visit, as part of the patient intake form and distributed the oral hygiene kits.

Figure 2. Electronic medical record oral screening questions and dotphrase.

Audit and feedback

Process assessment strategies included audit and feedback of provider adherence to oral screening. Project leadership summarised frequency and completion data for each provider during the 14-week implementation period. In the 7th week, participating cardiologists received an e-mail reporting the percent of total referrals for cardiac surgery or cardiac catheterisation, in which an oral screening had been completed. Providers with poor compliance were given the opportunity for further education and clarification in order to improve provider adherence. Providers with excellent adherence were also notified and thanked for their outstanding support of the project. All participating providers were encouraged to reach out to project leaders with any questions or suggestions.