paul glassman dds, ma, mba professor and director of ... · teeth treated with complete caries...

Paul Glassman DDS, MA, MBAProfessor and Director of Community Oral HealthUniversity of the Pacific School of Dentistry San Francisco, [email protected]

Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry

Virtual Dental HomesContext and Rationale

• The evolving U.S. health care system• Trends in the U.S. oral health industry• Recognition that the major oral diseases are chronic diseases

• Scientific basis for sealing caries• Use of telehealth‐connected teams and Virtual Dental Homes

• Financing dental care in the Era of Accountability• Conclusions


Health Care Spending 1980‐2013

http://www.commonwealthfund.org/publications/issue‐briefs/2015/oct/us‐health‐care‐from‐a‐global‐perspective. Data: OECD Health Data 2015.

Percent of GDP


Health Care and Social Spending as a Percent of GDP 2013

The Commonwealth FundU.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countrieshttp://www.commonwealthfund.org/publications/issue‐briefs/2015/oct/us‐health‐care‐from‐a‐global‐perspective.


A Framework for Educating HealthProfessionals to Address the Social Determinants of Health


National Oral Health Expenses

Source: CMS National Health Expenditure NHE Historical and projections, http://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Statistics‐Trends‐and‐Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.htmlhttp://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Statistics‐Trends‐and‐Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html

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U.S. National Dental Expenditures 2000 ‐ 2025 ($ Billions)

Dental Services (DS)

DS % of 2000 Level (321%)


Health Spending by Condition

General Health: MEPS: Expenditures by Medical Condition 2013, Table 3http://meps.ahrq.gov/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2013&Table=HCFY2013%5FCNDXP%5FC&_Debug=Dental Health: MEPS: Expenditures per Person by Health Care Service 2012, Table 3http://meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2013&Table=HCFY2013%5FPLEXP%5FB&VAR1=AGE&VAR2=SEX&VAR3=RACETH5C&VAR4=INSURCOV&VAR5=POVCAT13&VAR6=REGION&VAR7=HEALTH&VARO1=4+17+44+64&VARO2=1&VARO3=1&VARO4=1&VARO5=1&VARO6=1&VARO7=1&_Debug=

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(Millions)

Medical Expenditure Panel Survey ‐ Top 25, 2013


Oral Health Expenses

Source: Bureau of Labor Statistics: Consumer Price Indexhttp://www.bls.gov/cpi/cpi_dr.htm

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140%

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Consumer Price Index (CPI) and CPI for Dental Services (% of 1990 dollars)

CPI % of 1990 Level (177%)

CPI‐DS % of 1990 Level (285%)


Out‐of‐Pocket Health Expenses

In‐patient care (8.8%)

Outpatient/ emergency room care (6.4%)

Physicians'services (15.9%)

Dental services$30.7 billion (22.2.0%)Other professional

services (8.1%)

Prescriptiondrugs (31.0%)

Medical supplies (7.6%)

Out‐of‐pocket health care total$138.5 billion

Source: Bureau of Labor Statistics. Consumer out‐of‐pocket health care expenditures in 2008. http://www.bls.gov/opub/ted/2010/ted_20100325.htm

Consumer out‐of‐pocket health care expenditures in 2008


Health Centers and Underserved Populations ‐ 2015

Percent Number

Total individuals served by health centers 24,295,946

Total individuals receiving dental care 21.4% = 5,199,332

U.S. population 320,000,000

U.S. population not receiving dental care 65% = 208,000,000

Percent (%) of population served in health centers = 2.5%


The future of dental practice: DemographicsApril 10, 2015 By Eric Solomon, DDS, MA

Solomon S. The future of dental practice: Demographics. April 15, 2015. http://www.dentaleconomics.com/articles/print/volume‐105/issue‐4/macroeconomics/the‐future‐of‐dental‐practice‐demographics‐patients‐professionals‐and‐procedures.html


Care for Chronic Oral Diseases

Acute Care/Surgical

Intervention

Chronic Disease

Management


Total Health: How Long and How Well We Live

McGinnis JM & Foege WH. Actual Causes of Death in the United States. JAMA 1993; 270(18):2207-12 (Nov 10). McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93 (Mar).

Behaviors(alcohol, tobacco,diet, exercise,preventive dentalprocedures?)

40%10%

20%

30%

Genetics

Environment,Public Health

Health Care Delivery(procedures)


• Expert panel convened by ADA Council on Scientific Affairs• Sealants are effective in reducing occlusal caries incidence in

permanent first molars of children, with caries reductions of 76.3 percent at four years, when sealants were reapplied as needed. Caries reduction was 65 percent at nine years from initial treatment, with no reapplication during the last five years

• The use of explorers is not necessary for the detection of early lesions. Forceful use of a sharp explorer can damage tooth surfaces

• The clinician should use recent radiographs, if available, in the decision‐making process but should not obtain radiographs for the sole purpose of placing sealants


• The evidence supports the placement of sealants over non‐cavitated caries lesions in the pits and fissures of permanent teeth in children, adolescents, and young adults.

• This finding does not support reported concerns about poorer outcomes associated with the inadvertent sealing of caries and should lessen the reluctance of practitioners to provide sealants—an intervention proven to be highly effective in preventing caries.


Qvist V, Borum MK, Moller KD, et. al. Sealing Occlusal Dentin Caries in Permanent Molars: 7‐Year Results of a RandomizedControlled Trial. JDR Clinical & Translational Research. January 2017:2(1):73‐86


Incomplete Caries Removal

• This 10‐year study evaluated bonded and sealed composite restorations placed directly over frank cavitated lesions extending into dentin vs. sealed conservative amalgam restorations and conventional unsealed amalgam restorations.

• The results indicate that both types of sealed restorations exhibited superior clinical performance and longevity compared with unsealed amalgam restorations.

• Also, the bonded and sealed composite restorations placed over the frank cavitated lesions arrested the clinical progress of these lesions for 10 years.



• Increasing numbers of clinical trials have demonstrated the benefits of incomplete caries removal, in particular in the treatment of deep caries.

• Teeth treated with incomplete caries removal showed risk reduction for both pulpal exposure and pulpal symptoms.



• Teeth treated with incomplete caries removal had half to two‐thirds fewer pulp exposures compared to teeth treated with complete caries removal

• Partial caries removal and sealing into the tooth leads to the systematic and progressive arrest of the carious lesion.

Operative caries management in adults and children (Review)Ricketts D, Lamont T, Innes NPT, Kidd E, Clarkson JEThe Cochrane Library. 2013, Issue 3


Interim Therapeutic Restoration (ITR)

AAPD Policy on Interim Therapeutic Restorations (ITR)


EHR: Radiographs


EHR: Photographs


Space and Equipment


Radiographs


Photographs


Community‐based Prevention and Early Intervention Procedures


The Virtual Dental Home Sites


Pacific Center for Special Care at the University of the Pacific School of Dentistry. Report of the Virtual Dental Home Demonstrationhttp://dental.pacific.edu/departments‐and‐groups/pacific‐center‐for‐special‐care/publications


Oral Health Systemsfor Underserved Populations


• Reach people, emphasize prevention, and lower costs• Majority of people kept and verified healthy on‐site

– About 2/3 of children had all needed services completed by dental hygienist

• Continuous presence• Community organization integration• Dentist integration


Hub and Spoke System


AB 1174


The ADA House of Delegates passed Resolution 45H‐2015, Comprehensive ADA Policy Statement on Teledentistry, in November at ADA 2015 – America’s Dental Meeting.


Denti‐Cal Teledentistry Billing

Denti‐Cal Bulletin. March, 2016, V32, #4http://www.denti‐cal.ca.gov/provsrvcs/bulletins/Volume_32_Number_04.pdf


CPCA GuideIntermittent ClinicsDental Hygiene BillingTelehealth BillingDentist Contracting


Proof of Concept

Legislation/Regulation

Expansion/Research

2009 2015 2016 +

OR, CO, HI,MN, AZ, MO...

OR, CO, HI

Virtual Dental Home Timeline


The Era of Accountability


The Triple Aim

• improving the experience of care• improving the health of populations• reducing per capita costs of health care


The Quadruple Aim


Dental Care in the Future• Dental Practice =

– Geographically distributed– Telehealth enabled– Oral health teams

• Chronic disease management– using biological, medical, behavioral, and social tools

• Integrated with general health, educational, and social service systems

• Interacting with the majority of the population• Focused on oral health outcomes in the Era of Accountability

Paul Glassman DDS, MA, MBAProfessor and Director of Community Oral HealthUniversity of the Pacific School of Dentistry San Francisco, [email protected]

paul glassman dds, ma, mba professor and director of ... · teeth treated with complete caries...

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