norman tinanoff university of maryland august 3, 2011 norman tinanoff university of maryland august...
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Norman TinanoffUniversity of Maryland
August 3, 2011
Norman TinanoffUniversity of Maryland
August 3, 2011
Caries Risk Assessment Caries Risk Assessment and Clinical Care Pathsand Clinical Care Paths
History of Access to Care in MarylandHistory of Access to Care in Maryland
Year Medicaid Population Preventive Visits %
Restorative Visits %
1997 88,000 18 7
2005 483,000 28 26
2006 491,000 28 27
2007 493,000 31 29
2008 505,000 35 30
2009 540,000 43 33
Dental Action Committee RecommendationsDental Action Committee Recommendations Sept. 2007 (6 months after D. Driver died)Sept. 2007 (6 months after D. Driver died)
Develop a Develop a unified and unified and culturally and linguistically culturally and linguistically appropriate oral health appropriate oral health messagesmessages to educate parents to educate parents and caregivers of young and caregivers of young childrenchildren
Incorporate Incorporate dental screeningsdental screenings with with vision and hearing screenings vision and hearing screenings for for public school children or require public school children or require dental exams prior to school dental exams prior to school entryentry. .
Provide Provide trainingtraining to dental and to dental and medical providers to provide medical providers to provide oral health risk assessmentsoral health risk assessments, , educate parents/caregivers educate parents/caregivers about oral health, and to assist about oral health, and to assist families in establishing a dental families in establishing a dental home for all children. home for all children.
Initiate statewide single vendor dental Administrative Services Only provider
Increase dental reimbursement rates to the 50th percentile
Maintain and enhance the dental public health infrastructure by ensuring that local jurisdiction has a local health department dental clinic and a community oral health safety net clinic and by providing funding
Establish a public health level dental hygienist to provide screenings, prophylaxis, fluoride varnish, sealants, and x-rays in public health settings.
Dental Action Committee7 Recommendations
Increase dental reimbursement rates (indexed by inflation) to median fee charged by area dentists (ADA 50th percentile) – began July 1, 2008– First of 3 annual increments – most diagnostic and all preventive
rates increased
Single payer dental Medicaid program – carve out from Medicaid program – Implemented – July 2009– Insurance company has to have a provider identified for every
child
Increase the dental public health infrastructure - $2M/yr. – Funding to Office of Oral Health in July 2008– Funding for local health department, federally qualified health
center (FQHC) and private, & non-profit dental programs– New dental clinical programs in 6 Maryland counties previously
without public health dental services
Dental Action Committee7 Recommendations
Expand the role of dental hygienists in public health practice– Legislation (HB 1280/SB 818) unanimously passed --October
2008
Pediatric dental training of physicians and general dentists– Fluoride varnish initiatives - Medicaid reimbursement to
physicians in July 2009– 400 physicians trained at the University of Maryland Dental
School– 20,000 fluoride varnish claims ($.5M)
Oral health screenings required for school entrance – Demonstration project funded for one county in 2011– Legislation pending for next state legislative session
Develop a unified educational/social marketing program– Federal Earmark of $1.3M from Senator Mikulsky – Deamonte Driver Program of Oral Health Access - $1.1M
History of Access to Care in MarylandHistory of Access to Care in Maryland
Year Medicaid Population
Preventive Visits %
Restorative Visits %
1997 88,000 18 7
2005 483,000 28 26
2006 491,000 28 27
2007 493,000 31 29
2008 505,000 35 30
2009 540,000 43 33
Because of the tremendous increase in the population 9X more preventive services and 8X more restorative services were delivered in 12 years.
However, the costs have increased from 2.7M in 1997 to 71.4 M in 2008 (26X).
Caries Risk Assessment Caries Risk Assessment
Dental Caries Protocols (Care Paths) Dental Caries Protocols (Care Paths)
As Bob Russell said last night, “Is this tremendous increase in effort and cost actually
reducing dental disease?”
Perhaps the system is inefficient without --
JAMA 285: 2486, 2001
Physicians Use of Risk Assessment (e.g. Heart Disease) Physicians Use of Risk Assessment (e.g. Heart Disease)
Early Studies of Risk Assessment in DentistryEarly Studies of Risk Assessment in Dentistry
Bohannan et al. A summary of the results of the National Preventive Dentistry Bohannan et al. A summary of the results of the National Preventive Dentistry Demonstration Program. Demonstration Program. Can Dent Assoc JCan Dent Assoc J 6: 435, 1985 6: 435, 1985
Demers et al. A multivariate model to predict caries increment in Montreal children age 5 Demers et al. A multivariate model to predict caries increment in Montreal children age 5 years. years. Comm Dent Health Comm Dent Health 9:373, 19929:373, 1992
Disney et al. The University of North Carolina caries risk assessment study. Disney et al. The University of North Carolina caries risk assessment study. Comm Dent Comm Dent Oral EpidemiolOral Epidemiol 20:64, 1992 20:64, 1992
Thibodeau and O’Sullivan. Mutans streptococci and caries prevalence in preschool Thibodeau and O’Sullivan. Mutans streptococci and caries prevalence in preschool children. children. Comm Dent Oral Epidemiol Comm Dent Oral Epidemiol 21:288, 199321:288, 1993
Litt MD et al. Multidimensional Causal Model of Dental Caries Development in Low-Litt MD et al. Multidimensional Causal Model of Dental Caries Development in Low-Income Preschool Children. Income Preschool Children. Public Health ReportsPublic Health Reports 110: 607, 1995 110: 607, 1995
Caries diagnosis and risk assessment. A review of preventive and strategies and Caries diagnosis and risk assessment. A review of preventive and strategies and management. management. JADAJADA 126:1S, 1995 126:1S, 1995
Recent Emphasis on Recent Emphasis on Risk Assessment in Dentistry Risk Assessment in Dentistry
• Gives understanding of the disease factors for a patientGives understanding of the disease factors for a patient
• Individualizes and selects preventive recommendationsIndividualizes and selects preventive recommendations
• Individualizes treatment Individualizes treatment
• Less treatment for low risk; more for those at high riskLess treatment for low risk; more for those at high risk
History and Evidence History and Evidence History and Evidence History and Evidence previous cariesprevious caries
mutans streptococcimutans streptococci
income and educationincome and education
visible plaquevisible plaque
dietdiet
fatalismfatalism
mother’s taste perceptionmother’s taste perception
multiple risk factorsmultiple risk factors
previous cariesprevious caries
mutans streptococcimutans streptococci
income and educationincome and education
visible plaquevisible plaque
dietdiet
fatalismfatalism
mother’s taste perceptionmother’s taste perception
multiple risk factorsmultiple risk factors
caries freecaries free
pit and fissurepit and fissure
maxillary anteriormaxillary anterior
caries freecaries free
pit and fissurepit and fissure
maxillary anteriormaxillary anterior
initial caries patternsinitial caries patternsinitial caries patternsinitial caries patterns Baseline dmfsBaseline dmfs year 2 dmfsyear 2 dmfsBaseline dmfsBaseline dmfs year 2 dmfsyear 2 dmfs
0.00.0 1.4 1.4
3.03.0 5.9 5.9
5.05.0 10.1 10.1
0.00.0 1.4 1.4
3.03.0 5.9 5.9
5.05.0 10.1 10.1
Relationship of initial caries pattern to caries incidenceRelationship of initial caries pattern to caries incidence
in 142, 3- to 4-year-old (at baseline) inner city childrenin 142, 3- to 4-year-old (at baseline) inner city children
Relationship of initial caries pattern to caries incidenceRelationship of initial caries pattern to caries incidence
in 142, 3- to 4-year-old (at baseline) inner city childrenin 142, 3- to 4-year-old (at baseline) inner city children
Thibodeau and O’Sullivan. Comm Dent Oral Epidemiol 21:288, 1993
All dmfs is Not the SameAll dmfs is Not the Same
Probably arrested lesionsProbably arrested lesions
Probably active lesionsProbably active lesions
All White Spot Lesions are Not the SameAll White Spot Lesions are Not the Same
Probably arrested lesionsProbably arrested lesions
Probably active lesionsProbably active lesions
Mutans StreptococciMutans Streptococci
Evidence for mothers as the source of MS Evidence for mothers as the source of MS in their childrenin their children
Paper Country Mother-Child pairs
Children with at least 1 identical
strain
Berkowitz et al , 1975 US 4 100%
Li et al, 1995 US 34 71%
De Soet et al, 1998 Netherlands 21 38%
Kohler et al, 2003 Sweden 16 85%
Klein et al 2004 Brazil 16 81%
Li et al, 2004 US 37 89%
Hames-Kocabas et al, 2006 Turkey 25 24%
There are 17 studies in this area between 1975 and 2006, with the mean of 70.4% of children with at least one identical strain.
MS rangeMS range baseline dmfs baseline dmfs year 2 dmfs year 2 dmfs
lowlow 0.2 0.2 1.2 1.2
moderatemoderate 1.4 1.4 3.1 3.1
highhigh 3.4 3.4 7.9 7.9
MS rangeMS range baseline dmfs baseline dmfs year 2 dmfs year 2 dmfs
lowlow 0.2 0.2 1.2 1.2
moderatemoderate 1.4 1.4 3.1 3.1
highhigh 3.4 3.4 7.9 7.9
Relationship of mutans streptococci levels to caries incidenceRelationship of mutans streptococci levels to caries incidence
in 148, 3- to 4-year-old (at baseline) inner city childrenin 148, 3- to 4-year-old (at baseline) inner city children
Relationship of mutans streptococci levels to caries incidenceRelationship of mutans streptococci levels to caries incidence
in 148, 3- to 4-year-old (at baseline) inner city childrenin 148, 3- to 4-year-old (at baseline) inner city children
Thibodeau and O’Sullivan. Comm Dent Oral Epidemiol 21:288, 1993
Counts/ml salivaCounts/ml saliva Caries was Caries was presentpresent
Caries was not Caries was not presentpresent
Odds RatioOdds Ratio Fisher Exact Fisher Exact test (P)test (P)
Selective MediaSelective Media
Mutans streptococci (MS) ≥ 10Mutans streptococci (MS) ≥ 1044 3131 44 6464 0.0010.001
MS < 10MS < 1044 55 4141
Lactobacilli (LB) ≥ 10Lactobacilli (LB) ≥ 1033 1414 22 1414 0.0010.001
LB < 10LB < 1033 2121 4343
Veillonella (VL) ≥ 106 24 14 5 0.001
VL < 106 11 31
Microbial Indicators of Dental Caries in Children Under Three Years of Age Microbial Indicators of Dental Caries in Children Under Three Years of Age
Park et al. Caries Res 40:277, 2006Park et al. Caries Res 40:277, 2006
Caries Experience by Economic SituationCaries Experience by Economic Situation
in U.S. 2-5-Year-Old Children in U.S. 2-5-Year-Old Children NHANES III, 1988-1994NHANES III, 1988-1994
Caries Experience by Economic SituationCaries Experience by Economic Situation
in U.S. 2-5-Year-Old Children in U.S. 2-5-Year-Old Children NHANES III, 1988-1994NHANES III, 1988-1994
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0Education
Income
<$10K $10K-20K $20K-30K >$30K
No HighSchool
Some HighSchool
CompletedHigh School
College
Correlation of caries prevalence to SES indicators Correlation of caries prevalence to SES indicators
in 1,539 4-year-old Arizona childrenin 1,539 4-year-old Arizona children
Correlation of caries prevalence to SES indicators Correlation of caries prevalence to SES indicators
in 1,539 4-year-old Arizona childrenin 1,539 4-year-old Arizona children
Tang et al. Public Health Reports 112: 319, 1997.Tang et al. Public Health Reports 112: 319, 1997.
Correlation of Plaque on Primary Teeth and Caries RiskCorrelation of Plaque on Primary Teeth and Caries Risk
Aluluusua, S. et al. Comm Dent Oral Epi. 22: 273-276, 1994 Sensitivity 83%, Specificity 92%
Lee CL, et al. J. Pub Hlth Dentistry 68:57-60, 2008 Correlation between % MS and plaque regrowth, R = 0.34; p <.05
Dietary FactorsDietary Factors
Eats breakfast every dayEats breakfast every daynono 34.6% 34.6%yesyes 22.5% 22.5% 0.0010.001
Stopped bottle by 12 monthsStopped bottle by 12 months no 26.5%no 26.5% yesyes 20.5% 0.02 20.5% 0.02
% with ECC Sig% with ECC Sig
Nunn et al., J Dent Res 88:361-366-275, 2009Nunn et al., J Dent Res 88:361-366-275, 2009
Dental Fatalism Dental Fatalism
“ “Most children eventually develop dental cavities” Most children eventually develop dental cavities” yesyes 76.7% 76.7%
nono 23.3% 23.3% 0.02 0.02
Ismail, et al. J Dent Res 88:270-275, 2009Ismail, et al. J Dent Res 88:270-275, 2009
% with ECC Sig% with ECC Sig
Mothers’ Taste Perception as a Risk Factor for their Children's Dental Caries
Mothers’ Taste Perception as a Risk Factor for their Children's Dental Caries
Figure 12. Mean dmfs of children related to mothers’ PROP type and the presence of grandparents in the household (F=9.251, p=0.005)
Presence of grandparents in the household
Yes
No
Non-taster Super taster PROP type
Mothers’ Taste Perception as a Risk Factor for their Children's Dental Caries
Multiple Risk FactorsMultiple Risk Factors
HISTORICAL PRESENT FUTURE
psychological factors
baby bottle usage sucrose consumption
race/ethnicity
parent’s dental knowledge mutans strep. levels
CARIES
CARIES (86% of caries predicted)
HISTORICAL PRESENT FUTURE
psychological factors
baby bottle usage sucrose consumption
race/ethnicity
parent’s dental knowledge mutans strep. levels
CARIES
CARIES (86% of caries predicted)
Litt et al. Public Health Reports 110: 607, 1995
Multidimensional Causal Model of Dental Caries Development in Low-Income Preschool Children
High Risk
Moderate Risk
Protective Factors
Biological Factors
Mother/primary caregiver has active caries Yes
Parent/caregiver has low SES Yes
Child has >3 between meal sugar snacks Yes
Put to bed with a bottle containing sweets Yes
Child has special health care needs Yes
Child is a recent immigrant Yes
Protective Factors
Child exposed to fluoridated drinking water Yes
Child has teeth brushed daily with F toothpaste
Yes
Child receives professional topical fluoride Yes
Additional home measures Yes
Child has dental home/regular dental care Yes
Clinical Findings
Child has white spot lesions or enamel defects Yes
Child has visible caries Yes
Child has elevated mutans streptococcus Yes
Child has plaque on teeth Yes
Caries Risk Assessment for 0-5 Year Olds Caries Risk Assessment for 0-5 Year Olds (CCA, 2010(CCA, 2010))
High Risk
Moderate Risk
Protective Factors
Biological Factors
Patient has >3 between meal sugar snacks Yes
Patient is of low SES Yes
Patient has special health care needs Yes
Patient is a recent immigrant Yes
Protective Factors
Patient exposed to fluoridated drinking water Yes
Patient brushes teeth daily with F toothpaste Yes
Child receives professional topical fluoride Yes
Additional home measures Yes
Patient has dental home/regular dental care Yes
Clinical Findings
Patient has one or more interproximal lesions Yes
Patient low salivary flow Yes
Patient has defective restorations Yes
Patient wearing an intraoral appliance Yes
Caries Risk Assessment for >6 Year Olds Caries Risk Assessment for >6 Year Olds (CCA, 2010)(CCA, 2010)
Evidence for Caries Risk Assessment Evidence for Caries Risk Assessment
Dental Caries Protocols (Care Paths) Dental Caries Protocols (Care Paths)
Newsweek, March 2, 2009Newsweek, March 2, 2009
$1 Billion for Comparative-Effective Research $1 Billion for Comparative-Effective Research – research on best practices and measures – research on best practices and measures which ones are most cost-effective. which ones are most cost-effective.
Health care in the US is a marvel of Health care in the US is a marvel of technology, consumes 1/6 of nations wealth, technology, consumes 1/6 of nations wealth, without making us comparatively healthy. without making us comparatively healthy.
Newsweek, March 9, 2009Newsweek, March 9, 2009
Coronary by-pass surgery in Texas is 5X those Coronary by-pass surgery in Texas is 5X those in Colorado; Back surgery in Wyoming is 6X in Colorado; Back surgery in Wyoming is 6X those in Hawaiithose in Hawaii
The difference in how conditions are treated The difference in how conditions are treated are due to medical culture not to medical are due to medical culture not to medical sciencescience
Conclusion – need to allow for individual Conclusion – need to allow for individual differences; but also need standardsdifferences; but also need standards. .
Rate of Orthopedic Procedures in Medicare Population, 2003Rate of Orthopedic Procedures in Medicare Population, 2003
Each point represents 1 of 300 health regionsEach point represents 1 of 300 health regions
mean
mean
Congressional Budget Office, Research on the Comparative Effectiveness of Medical Treatments, Dec. 2007
Wyoming
Hawaii
Newsweek, March 23, 2009Newsweek, March 23, 2009
……....decision to pursue one treatment over decision to pursue one treatment over another is based more on professional bias and another is based more on professional bias and patient’s misperceptions than it is on sound patient’s misperceptions than it is on sound sciencescience …… treatments each come with their …… treatments each come with their own cadre of devotees, and members of one own cadre of devotees, and members of one camp often don’t communicate with members of camp often don’t communicate with members of another. another.
April 29, 2009April 29, 2009
The Affordable Care Act contains $1.1 billion for The Affordable Care Act contains $1.1 billion for Comparative Effectiveness Research.Comparative Effectiveness Research.
The aim is to compare the clinical outcomes, The aim is to compare the clinical outcomes, effectiveness, and appropriateness of services, effectiveness, and appropriateness of services, that are used to prevent, diagnose, or treat that are used to prevent, diagnose, or treat diseases. diseases.
Example of a Caries Protocol for a 0-2 Year-OldExample of a Caries Protocol for a 0-2 Year-Old
Diagnostic Fluoride Sealants Diet Counseling
Restorative
Low Risk --Recall every year--Baseline MS
--Twice daily brushing with F toothpaste
NA Yes Surveillance
Moderate Risk parent engaged
--Recall every six mo. -- Baseline MS
--Twice daily brushing with F toothpaste
--Fluoride supplements*-- Prof. topical F every 6 mo.
NA YesActive surveillance **
Moderate Risk parent not engaged
--Recall every six mo.--Baseline MS
--Twice daily brushing with F toothpaste
--Prof. topical F every 6 mo.
NA Limit expectationsActive surveillance
High Risk parent engaged
--Recall every three mo.-- Baseline & followup MS
--Twice daily brushing with F toothpaste
--Fluoride supplements*--Prof. topical F every 3 mo.
NA Yes--Active surveillance -- Restore cavitated lesions in posterior
with ITR
High Risk parent not engaged
--Recall every three mo.--Baseline & followup MS
--Twice daily brushing with F toothpaste
--Prof. topical F every 3 mo.
NA Limit expectations --Active surveillance -- Restore cavitated lesions in posterior
with ITR
* Need to consider fluoride levels in drinking water
Tests Caries Risk Analysis
Clinical ExamRadiographic Exam
Compliance
Low Caries Risk
Moderate Caries Risk
High Caries Risk
Toothbrush with F, .1%
Toothbrush with F, .1%Professional F, 6 mo.
Diet counseling
Toothbrush with F, .1%Professional F, 3 mo.
Diet counselingMotivational Interview
Recall
Active Surveillance Active Surveillance (0-2 yr old)(0-2 yr old)(prevention and careful monitoring for signs of progression)(prevention and careful monitoring for signs of progression)
Example of a Caries Protocol for a 3-5 Year-OldExample of a Caries Protocol for a 3-5 Year-Old
Diagnostic Fluoride Sealants Diet Counseling
Restorative
Low Risk --Recall every year--Radiographs every two
years --Baseline MS
--Twice daily brushing with F No No Surveillance
Moderate Risk parent engaged
--Recall every six mo.--Radiographs yearly-- Baseline MS
--Twice daily brushing with F --Fluoride supplements*
--Prof. topical F every 6 mo.
Yes Yes Active surveillance of incipient lesions
Moderate Risk parent not engaged
--Recall every six mo.--Radiographs yearly--Baseline MS
--Twice daily brushing with F--Prof. topical F every 6 mo.
Yes Limit expectations
--Active surveillance --restore cavitated or
enlarging lesions
High Risk parent engaged
--Recall every three mo.--Radiographs , six mo.--Baseline & followup MS
--Brushing with high potency F gel (with caution)
--Fluoride supplements*--Prof. topical F every 3 mo.
Yes Yes --Active surveillance --restore cavitated or
enlarging lesions
High Risk parent not engaged
--Recall every three mo.--Radiographs, six mo.--Baseline & followup MS
--Brushing with high potency F gel (with caution)
--Prof. topical F every 3 mo.
Yes Limit expectations
Restore, incipient, cavitated or enlarging
lesions
* Need to consider fluoride levels in drinking water
Radiographic CriteriaRadiographic Criteria
Risk Category Only Primary Dentition
Transitional Dentition
Permanent Dentition
New Patient May not be required
Bitewings and panorex
Bitewings and panorex or FMS
Low Risk Recall Posterior bitewings at 12-24
months
Posterior bitewing at 12-24
months
Posterior bitewings at 24-26 months
Increased Risk Recall
Posterior bitewings at 6-12
months
Posterior bitewings at 6-12
months
Posterior bitewings at 6-18 months
ADA & US Dept of Health and Human Services, 2004.
Topical FluorideTopical Fluoride
Risk Category <6 6-18 18+
Low None None None
Moderate Varnish or foam at 6 month intervals
Varnish or gel at 6 month intervals
Varnish or gel at 6 month intervals
High Varnish or foam at 3 or 6 month
intervals
Varnish or gel at 3 or 6 month intervals
Varnish or gel at 3 or 6 month intervals
Hunter et al. Professionally Applied Topical Fluoride: Evidence-Based Clinical Recommendations. JADA 2006;137:1151-1159.
Example of a Caries Protocol for a >6 Year-OldExample of a Caries Protocol for a >6 Year-Old
Diagnostic Fluoride Sealants Diet Counseling
Restorative
Low Risk --Recall every year--Radiographs every two
years
--Twice daily brushing with F No No Surveillance
Moderate Risk child engaged
--Recall every six mo.--Radiographs yearly
--Twice daily brushing with F--Fluoride supplements*--Prof. topical F every 6 mo.
Yes --Yes--xylitol
--Active surveillance --restore cavitated or
enlarging lesions
Moderate Risk child not engaged
--Recall every six mo.--Radiographs yearly
--Twice daily brushing with F--Prof. topical F every 6 mo.
Yes --Limit expectations
--xylitol
--Active surveillance --restore cavitated or
enlarging lesions
High Risk child engaged
--Recall every three mo.--Radiographs , six mo.
--Brushing with high potency F gel--Fluoride supplements*--Prof. topical F every 3 mo.
Yes --Yes--xylitol
--Active surveillance --restore cavitated or
enlarging lesions
High Risk child not engaged
--Recall every three mo.--Radiographs, six mo.
--Brushing with high potency F gel--Prof. topical F every 3 mo.
Yes --Limit expectations
--xylitol
Restore, incipient, cavitated and enlarging
lesions
* Need to consider fluoride levels in drinking water
Tests Caries Risk Analysis
Clinical ExamRadiographic Exam
Compliance
Low Caries Risk
Moderate Caries Risk
High Caries Risk
Toothbrush with F, .1%
Toothbrush with F, .1%Professional F, 6 mo.
SealantsXylitol
Diet counseling
Toothbrush with F, .5%Professional F, 3 mo.
SealantsXylitol
Diet counselingMotivational Interview
Recall
Active Surveillance Active Surveillance (>6 years old)(>6 years old)
June 14, 2011 MeetingJune 14, 2011 Meeting
17 experts from dental insurance, education and practice recommended guiding principles for the Pediatric Dental benefit of the Affordable Care Act to the Secretary of HHS:
Treatment should be based on individualized-care according to their level of diseaseTreatment should be based on evidence-based guidelines