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© Richard Niederman 2008-2012
CariedAway in
CO, HI, KS, ME, NH
September 2012Supported by NIMHD and NIDCR
Richard Niederman
Center for Evidence-Based Dentistry
Forsyth Institute, Boston, MA
© Richard Niederman 2008-2012
• This is not “the” truth• This is how I see it• You need to decide for yourself
Disclaimers
© Richard Niederman 2008-2012
Plan
1. Background
2. ForsythKids
3. Materials and Methodsa. Glass ionomer
b. Diagnosis
4. CariedAway
© Richard Niederman 2008-2012
Background: US Healthy People Goals
10 year goal
10 year goal
10 year goal
© Richard Niederman 2008-2012
ForsythKids School-Based Comprehensive Caries Prevention
© Richard Niederman 2008-2012
ForsythKids Basic Precepts
1. Address U.S. oral health needs identified in Surgeon General’s 2000 report
2. Meet/exceed goals of Healthy People 2010
3. Highest quality, defined by Institute of Medicine
4. Focus on comprehensive prevention (not incremental prevention) 5. Implement current best evidence (defined by Centre for EBM, Oxford)
6. Comply with US and MA regulations7. Meet triple bottom line
© Richard Niederman 2008-2012
Evidence Level
*from Niederman et al JADA 2011
© Richard Niederman 2008-2012
DDS/CHCRecruitment
SchoolRecruitment
DataAnalysis
Billing
MedicaidEnrollment
EBComprehensive
Prevention
ExaminationInformedConsent
Implementation Know HowCommunity Participation + Care +
Analysis
Disparities Equality
© Richard Niederman 2008-2012
Know How Process
1. What are we trying to accomplish?2. What changes can we make? 3. How will we measure
improvement?
Time
© Richard Niederman 2008-2012
Clinical Method: School-based prevention 2x per year
Fluoride Varnish
Glass Ionomer: 1. Pit Fissure Sealants + 2. Seal Caries / IRT / ART / Temporary Filling
Tooth cleaning + Rx Toothbrush + Rx F Toothpaste +Hygiene instruction
School-based Care
© Richard Niederman 2008-2012
e Records evolution:Paper, PC pad, Kindle Fire, Android phone
© Richard Niederman 2008-2012
Patient Chart
© Richard Niederman 2008-2012
Reduction of Untreated CariesElementary School-Based Comprehensive Prevention
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13
Visit Number
%C
hild
ren
Un
tre
ae
d D
ec
ay
Start 2003
21%
Each circle = 1 schoolN = 6 SchoolsN/school = ~200
Mean of 6 schools67%
End 2010
© Richard Niederman 2008-2012
Acute Infection Reduction Following Prevention
0
5
10
15
20
25
Visit 1 Visit 2
Visit Number
% o
f C
hil
dre
n w
ith
Acu
te I
nfe
ctio
n
Grade:6
1
2, 5, 4
K, 3Each symbol = average of ~2,000 students
Mean Visit 1 = 17.5 %
Mean Visit 2 = 4.5 %
© Richard Niederman 2008-2012
ForsythKidsOutcomes
Increase access: >50% children on Medicaid
Improve health, reduce: Untreated caries from >65% to <25% Acute infections from >15% to <5%
Reduce cost: $58/patient/visit
Meet national goals: Exceed Healthy People 2020 before 2010
© Richard Niederman 2008-2012
Glass Ionomer
© Richard Niederman 2008-2012
Composite / Glass IonomerMetric Composite Glass
Easy “visible retention” Yes No
Actual retention Yes Yes
Caries prevention Yes Yes
Need Etch Yes No
Curing Light Chemical
Application time/tooth Slow Fast
Bonding to tooth Mechanical Chemical
Release of fluoride No Yes
Kill subjacent bacteria ? Yes
Stimulate secondary dentin ? Yes
Cost per tooth ~= ~=
Saliva sensitive Yes No
Technique sensitive Yes No
© Richard Niederman 2008-2012
Diagnosis
© Richard Niederman 2008-2012
Perceived Diagnosis
True Caries
TrueNo Caries
DiagnosedCaries
+ +
Diagnosed No Caries
- -
© Richard Niederman 2008-2012
Actual Diagnosis
True Caries
TrueNo Caries
DiagnosedCaries
25%(+ +)
25%(- +)
Diagnosed No Caries
25%(+ -)
25%(- -)
Total Wrong50%
Total Right50%
© Richard Niederman 2008-2012
Perceived Diagnosis, Treatment, & Predicted Outcome
True Caries
TrueNo Caries
Predicted Outcome
DiagnosedCaries
IRTAbscess
Diagnosed No Caries
Sealant Prevent Decay
© Richard Niederman 2008-2012
Perceived Diagnosis, Treatment, & Actual Outcome
True Caries
TrueNo Caries
ActualOutcome
DiagnosedCaries
Diagnosed No Caries
Sealant SealantPrevent Decay
© Richard Niederman 2008-2012
Perceived Diagnosis, Treatment, & Actual Outcome
True Caries
TrueNo Caries
ActualOutcome
DiagnosedCaries
IRT IRTPreventAbscess
Diagnosed No Caries
Sealant SealantPrevent Decay
© Richard Niederman 2008-2012
Evidence-Based Guidelines
Sealants
Beauchamp et al JADA 2008
Gooch et al JADA 2009
IRT
AAPD 2001
Medicaid 2004
© Richard Niederman 2008-2012
CariedAway:
Goal: Assessment and improvement of
school-based caries prevention programs
© Richard Niederman 2008-2012
Definitions of Quality
IOMSafe, Effective
Efficient, Timely, Patient Centered, Equitable
IndustrialReduce variability
Reduce waste
© Richard Niederman 2008-2012
Participating Program Variability*
State Care Number /Yr Grade Screen F-
RinseF- Varnish
Seal IRT Material Student Schools County
CO 2 K-8 RDH - + All - Glass 1,000 10 4
KS 1 K-8 DDS - + All - Resin 4,000 16 2
ME 1 2-4 RDH + + 6 - Resin 3,500 34 2NH 1 K-5 DDS - + 6,7 - Resin 1,500 7 2 9,857 67 10
HI - - - - - - - - 25,000 125 1
* Similarities: All start with paper, not electronic records None start with longitudinal or outcome data
© Richard Niederman 2008-2012
Quality of Programs
IOM+ Safe
? Effective
-? Efficient, Timely, Patient Centered, Equitable
Industrial (and IHI.org)- Reduce variability
- Reduce waste
© Richard Niederman 2008-2012
PhasesME, NH, CO, KS
1. Articulate current protocols
2. Initiate electronic records – on paper
3. Determine baseline / subsequent untreated decay
4. Compare baseline / subsequent untreated decay
5. Offer change package of any/all
a. Glass ionomer
b. KindleFire electronic record
c. Seal some / seal all
d. IRT
6. Determine follow-on untreated decay
© Richard Niederman 2008-2012
CariedAway HawaiiNo school-based health
**Adopt from E. Rogers, 2003
B. Implementation
3. Application
EvidenceAdvantage
2. Acceptance Simplicity Compatibility Trust
1. Awareness Choice
A. Stakeholder
Government
Organization
Clinician
Patients
© Richard Niederman 2008-2012
Start with After-School ProgramsCategorization of Individuals
*Rogers, 2003
© Richard Niederman 2008-2012
Social Network Analysis Hawaii School Principals
1
14
3
1920
23
64
72
5
4
6
10
12
789
2
11
15
13
17
16
24
26
27
28
30
3241 51
29
48
9133
36
3739
40
53
54
31
4635
38
42
43
45
95
52
34
88
4447
50
49
55
57
58
59
56
6061
62
6380
89
65
77
118
© Richard Niederman 2008-2012
Connectivity
Lowest Low High Highest
Oral HealthAttitude
Lowest214 129, 153 130, 142, 146 149, 163
Low
132, 135, 145, 148, 205
134 208 189, 204
High
139131, 133, 138, 140, 141, 161, 164
Highest
150, 151, 203, 924
136, 143, 147, 157
137, 144, 154, 156, 158, 159, 160 152, 155, 162
Social Network Analysis Hawaii School Principals
© Richard Niederman 2008-2012
Know How
1. What are we trying to accomplish?2. What changes can we make? 3. How will we measure
improvement?
Time
© Richard Niederman 2008-2012
© Richard Niederman 2008-2012
Thank you