SPNS IHIP Oral Health Webinar Series: Healthy Mouth, Healthy Body……………….Presented by CDR Mahyar Mofidi, DMD, PhD and Jane Fox, MPHDecember 13, 2013

Agenda

■Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project■Sarah Cook-Raymond, Managing Director of

Impact Marketing + Communications

■Presentations from:■Dr. Mahyar Mofidi; Branch Chief of the Division

of Community HIV/AIDS Programs and Chief Dental Officer, HRSA HIV/AIDS Bureau

■Jane Fox, MPH; Project Director of SPNS Oral Health Initiative Evaluation Center for HIV and Oral Health (ECHO), Boston University School of Public Health

■Q & A

IHIP Resources onTARGET Center Website www.careacttarget.org/ihip

IHIP Oral Health Resources■ Training Manual

■ Curriculum

■ Pocket Guide

■ Webinar Series■ Healthy Mouth, Healthy Body■ Dental Case Management■ Clinical Aspects of Oral Health Care for

PLWHA

Recording and slides for all Webinars will be uploaded to TARGET Center Web site following the

live event: www.careacttarget.org/ihip

Other IHIP Resources■ Buprenorphine Therapy

■ Training Manual, Curriculum, Monograph, and Webinars on implementing buprenorphine in primary care settings

■ Engaging Hard-to-Reach Populations■ Training Manual, Curriculum, and Webinars on engaging

hard-to-reach populations

■ Jail Linkages■ Training Manual, Curriculum, Pocket Guide, and Webinars on

enhancing linkages to HIV care in jails settings

■UPCOMING: Hepatitis C Treatment Expansion■ In Spring/Summer 2014, look for training materials on

increasing access to and completion of Hepatitis C treatment for PLWHA on the TARGET Center Web site.

Healthy Mouth, Healthy Body: Oral Health Care's Vital Role in Overall Well Being for

People Living with HIV/AIDS

CDR Mahyar Mofidi, DMD, PhD Branch Chief

Chief Dental Officer HRSA, HIV/AIDS Bureau

December 13, 2013

6

12+ years ago

You cannot be healthy without oral health.

Oral health is essential to overall health and quality of life, and all families need access to high-quality dental care.

7

Oral Health for PLWHA

“While good oral health is important to the well being of all population groups, it is especially critical for people living with HIV/AIDS (PLWHA). Inadequate oral health care can undermine HIV treatment and diminish quality of life, yet many individuals living with HIV are not receiving the necessary oral health care that would optimize their treatment.” -U.S. Public Health Service Surgeon General Regina M. Benjamin, MD, MBA

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Why does good oral health

matter in HIV care?

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Oral Disease in HIV Infection

Oral infections and neoplasms occur with immunosuppression (bacterial, fungal, viral,

neoplastic, lymphoma, ulcers)

High prevalence of dental caries and periodontal disease

10

32-46% of PLWHA have at least one oral disease

condition related to HIV

Some HIV medications have side effects (xerostomia or

dry mouth) which can lead to tooth decay and periodontal

disease

Prevalence of Dental Caries and Periodontal Disease in a Ryan White HIV/AIDS Program-

Funded Dental Clinic

Dental caries were present in 66% of patients

54% had gingivitis and 28% had periodontal disease

Infectious Disease Society of America (IDSA) 47th Annual Meeting – November 2009 – Poster #1063

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Oral Manifestations of HIV/AIDS

For those with unknown HIV status, oral

manifestations may suggest HIV infection,

although they are not diagnostic.

Reznik DA. Perspective - Oral Manifestations of HIV Disease. International AIDS Society–USA Topics in HIV Medicine. Volume 13 Issue 5 December 2005/January 2006

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Oral Manifestations of HIV/AIDS

For persons living with HIV disease not

yet on therapy, the presence of certain

oral manifestations may signal

progression of disease.

Reznik DA. Perspective - Oral Manifestations of HIV Disease. International AIDS Society–USA Topics in HIV Medicine. Volume 13 Issue 5 December 2005/January 2006

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Oral Manifestations of HIV/AIDS

For persons living with HIV disease on

antiretroviral therapy, the presence of

certain oral manifestations may signal a

failure in therapy.

Hodgson TA, Greenspan D, Greenspan JS. Oral lesions of HIV disease and HAART in industrialized countries. Adv Dent Res. 2006 Apr 1;19(1):57-62

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Oral Disease is Rarely Self-Limiting

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Untreated oral disease may lead to systemic infections, weight loss, malnutrition

Oral health diseases are linked to systemic diseases: diabetes, heart disease, pregnancy issues

Oral diseases impact quality of life: psycho-social problems, limited career opportunities

How can dental providers make a

difference?

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Role of Dental Providers

Eliminate infection, pain, and discomfort

Restore oral health functions

Early detection of HIV and referral: Oral lesions can be the first overt clinical feature of HIV infection. Early detection can improve prognosis and reduce transmission/

A visit to the dentist may be a health care milestone for PLWHA. The dental professional can address oral health concerns and play a role in helping engage or re-introduce patients into the health care system and coordinate their care with other primary care providers.

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What are the Benefits of Early Linkage to Oral Health Care After HIV Diagnosis?

196 HIV-positive individuals:63 newly diagnosed cases (out of oral care and within 12

months of their HIV diagnoses)Previously diagnosed controls (66 out of oral care and

diagnosed with HIV between 1985-2007)Historical controls (67 receiving regular oral care and

diagnosed with HIV between 1985-2007)

IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.18

Findings Persons who were newly diagnosed had significantly more teeth at baseline

compared to the previously diagnosed and historical groups.

Newly diagnosed individuals had less periodontal disease (attachment loss and less bleeding on probing).

Previously diagnosed individuals had poorer gingival health and more broken teeth.

The previously diagnosed group had the most dental decay.

Service usage varied considerably:

Newly diagnosed: more preventive and maintenance services Previously diagnosed: more costly prosthodontic services

IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.

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Findings

The higher levels of dental disease in the previously diagnosed group resulted in higher treatment costs.

“Early dental intervention in the newly diagnosed HIV-positive individuals results in significant functional maintenance, more optimal oral health, and considerable financial savings.”

IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.

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What oral health needs/barriers do

PLWHA face?

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Unmet Oral Health Needs

Oral health is one of the top unmet needs for PLWHA who obtain services through the Ryan White HIV/AIDS Program nationwide.

PLWHA have more unmet oral health care needs than the general population and have more unmet oral health care needs than medical needs.

PLWHA most likely to report unmet need for dental care are African American, uninsured, Medicaid recipients, and within 100% of federal poverty limits.

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Barriers to Oral Health Care Lack of dental insurance

Limited financial resources

Shortage of dentists

Too many appointments, other aspects of illness seen as being more important

Fear, no positive role models, stigma, shame

Negative patient-provider experiences

Shrinking adult dental Medicaid benefits

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State Adult Dental Coverage in Medicaid, 2013

Source: ADULT DENTAL BENEFITS IN MEDICAID, ADA

Num

ber

of s

tate

s

9

18

14

10

0

12

15

18

6

0

2

4

6

8

10

12

14

16

18

20

Full benefits Comprehensive Limitedbenefits

Emergencybenefits

No benefits

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Oral Health Care is ExpensiveService National average fees charged by

private practitioner Sample reimbursed fees by

Medicaid Comprehensive oral evaluation/

examination$66.29 $14.89 - $44.61

Limited oral evaluation $57.60 $14.00 - $36.76Intraoral radiograph (first film) $23.41 $3.63 - $14.91

Adult cleaning $77.64 $22.10 - $58.00Filling (amalgam, one surface) $110.35 $15.59 - $64.56

Filling (clear, one surface) $131.30 $25.62 - $65.90Extraction (simple) $138.21 $25.62 - $63.54Extraction (surgical) $224.11 $33.43 - $109.23

Endodontic (molar root canal) $868.00 $157.93 - $409.90

Crown (porcelain) $908.00 $580.00Complete denture (upper) $1,333.57 $584 - $600

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What are we doing about oral health?

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Oral Health: HRSA Strategic Priority

Expand oral health and integrate it in primary care settings

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Ryan White HIV/AIDS Programand Oral Health Services

SPNS OHI

Special Projects of National Significance Innovations in Oral Health Care Initiative

15 sites across country

Grantees implemented innovative models of comprehensive oral health care services to expand dental access

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Other HIV/AIDS Bureau Oral Health Investments

Oral health capacity assessment during site visits

All Grantee Meeting

Oral health performance measures

Oral health a funding priority under Part C Capacity Development Funding Opportunities

Program evaluations

Publications

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Impact of Ryan White HIV/AIDS Programs on Oral Health Care

FY 2011: 135,004 clients received dental services

FY 2011: 8,480 dental providers (mostly dental students and residents) provided direct oral health care as part of CBDPP and DRP

FY 2011: 8,461 health care professionals (3,451 dental, 5,010 non dental) received oral health care education through AETCs

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Impact on Our Clients “People treat you as if they have known you their whole life.”

“They take care of my fear.”

“They are like a big family…they gave me my smile back.”

“I feel free, secure and welcomed by the staff.”

“I feel comfortable…not treated as a HIV patient but a person who needs dental care.”

“We’re all so fortunate to get what we need.”

“It’s affordable. It’s a one stop shop.”

“This is the only game in town.”

“Quality of care here is 110%.”

Acknowledgment

Dr. David Reznik

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Contact Info

CDR Mahyar Mofidi, DMD, PhD

HRSA/HAB Chief Dental Officer

mmofidi@hrsa.gov

301-443-2075

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Evaluating the HRSA SPNS Oral Health

Initiative

Jane Fox, MPHBoston University

HRSA Oral Health SPNS Initiative

• September 2006 HRSA funded 15 sites and one evaluation & TA center

• Five year funding cycle

• Sites were charged with increasing access to oral health care for PLWHA

SPNS Sites

SPNS Models - Typology• Three types of host agencies

– ASO/CBO (5), CHC (4), and hospital/University-based programs (6)

• Three basic models:– Fixed site

• Expansion of prior dental program/services• Implementation of new dental program

– Mobile dental units

Evaluation Study Questions

• Do the demonstration programs increase access to oral health care for the target population?

• What are the main similarities and differences in strategies and program models to increase access to oral health care across programs?

• Are the oral health services performed in accordance with professional practice guidelines?

• Do clients experience improvements in health outcomes over time?

Evaluation Study Questions

• Are clients’ oral health care needs met? • Do clients experience improvements in oral

health related quality of life after enrollment in oral health care?

• What strategies are most effective in furthering successful program implementation: barriers, facilitators, key lessons learned?

• What strategies to address the structural, policy and financing issues can be replicated in other settings?

Evaluation Study Design• Study criteria

– HIV+, 18+ years of age, and no oral health care* for the past 12 months or more

• Quantitative survey at baseline and follow-up– Demographics, past access, insurance, HIV

status, past oral health symptoms, SF-8, OH QOL, and presenting problem

• Utilization and ancillary data– CDT codes of EVERY procedure done, evidence

of tx plan completion and recall

Evaluation Study Design• Qualitative interviews

– In-depth interviews of 60 patients at 6 sites

• OH experiences and values, OH self care knowledge and behaviors, patient education, and impact of HIV on OH

• Dental case manager focus group– June 2008 with 12 participants

Patient Demographics• 75% male• 40.6% Black, 21.2%

Latino• 33.4 % high school

education, 43.0% beyond high school

• 30.6% working, 55.7% monthly income < $850

• Age = 43.6 (18 – 81), • Yrs positive = 10.07

3%12%

35%29%

21%

Last dental visit

Never< 12 months1 - 2 yrs2 - 5 yrs>5 yrs

Baseline Dental Access

• Usual place for dental care: 38.6% none; 31.0% private dentist

• 48.2% reported needing dental care but were not able to get it since testing positive

• Of those who did not get dental care, 53.8% stated affordability as the reason.

Baseline HIV Status

• 97.5% had a regular place for HIV care and 95.0% had seen their HIV provider in the past 6 months

• 85.2% had an HIV case manager and 77.9% were taking ARTs

• 57.35 had a CD4 count over 350 and 52.8% had an undectable viral load

Significant Changes in Outcomes

at 12 Months, N=1391 Outcome Baseline 12

Mos.Report unmet need for oral health care

48% 17%

Report good/excellent health of teeth and gums

38% 67%

Oral health symptoms: mean (SD)

3.35 (2.34)

1.78 (1.93)

Significant Changes in Oral Health Symptoms at 12 Months, N=1391

Tooth decay

Sensitivity Appearance Toothache Bleeding gums

0%

10%

20%

30%

40%

50%

60%53% 52% 51%

43%

35%30%

34%

26%21% 17%

Intake12 Months

Significant Changes in Habits at 12 Months, N=1391

Habit Baseline 12 mos P value

Daily brushing 83% 82% .407

Daily flossing 19% 25% <.001

Flossing at all in past 6 months 53% 62% <.001

Current smoker 50% 45% <.001

Eating candy or chewing gum with sugar 61% 52% <.001

Drinking soda with sugar 64% 31% <.001

Patient Perspectives - Habits

• Improvements in oral health care practices– Better brushing & flossing techniques & frequency

• “ Now I buy lots of toothbrushes and use them for a short time and replace them.”

• “I brush everyday instead of 3 times/week...I floss a lot more”

• “I brush longer”

– Reduce or stop smoking/tobacco use• “ I still use snuff but I cut back a little and don’t leave it in

my mouth as long...”• “I cut down from 3 cigarettes/day from 1 pack...”

– Dietary changes• “I still drink soda but only once in awhile...I try not to buy it”

Standards of Care• We established a set for the multi-

site evaluation:– The presence of a comprehensive exam– The presence of any xrays – The presence of any cleaning or periodontal work – Completion of Phase I treatment plan– Patient placed on recall

Service Utilization: N=2178, 14 sites

Over the course of the study:• Patients made over

15,000 clinic visits• They received over

37,000 services• 917 (42%)

completed a Phase 1 treatment plan

# provided

Pts who received any

service n /%

Clinic Visits 11,315 2178

100%

Phase 1 Treatment Plans Completed*

717 717 33%

Comprehensive Exams

2077 1944

89%

Services provided in first 12 months of care

*Phase 1 Treatment Plan = Prevent and treat active disease

Access to & Retention in Care

• 43% of patients came in for preventive care• 64% of patients were retained in care• Those retained in care were:

– More likely to complete their treatment plan– More likely to have a recall visit– Reported less pain, fewer symptoms at follow up

• Factors significantly associated with retention– Older age, better physical health, on HIV medications, more recent dental

visit– Receipt of patient education – 6 times as likely to be retained in

care

“…I very rarely go. I was not a regular client at the dentist because my parents only took me to the dentist once in my life and so I didn’t know the need for follow-up dental—you know keeping a good hygiene program until I got older.”

Engagement in Care

“Outreach and retention were two things we did not anticipate to be problematic when planning for this grant. As we began to open our clinic and serve patients, we realized that this is one of the most important aspects of operating a dental clinic for this population.”

Getting Patients in the Door

• Marketing– Paid & unpaid media

• Community materials– Literacy level

• Outreach to providers– Clinicians– Case managers– Other CBOs

• Ancillary services– Transportation– Other social or

medical services• Special events

– SPNS days• Word of mouth

– Peers

Keeping Patients in Care

• Follow-up appointments− Timely and efficient

• Reminder calls• Dedicated staffing

− Patient navigators/dental case managers

− Staff skills and relationships with patients

• Patient education and empowerment− “When both the dentist and the dental case manager reviewed the

treatment plan with the patients, the patients gained a better understanding of why the proposed treatment was needed.”

• Incentives− “thank you gifts”− transportation

Dental Case Management• 8 programs included dental case management

– 5 in non-urban settings and 3 in urban settings– DCMs were either

• Dental assistants who were given training on case management; or• HIV case managers who were given training on oral health topics

• 758 patients were enrolled into the study from the 8 DCM sites.– They had a total of 2715 encounters with a DCM over the course of a year of treatment.

• Appointment reminders/rescheduling• Arranging or providing transportation• Provision of food or nutritional information• Provision of oral health information and support

• Outcomes– Participants with more DCM encounters were significantly more likely to complete their Phase

1 treatment plan at 12 months, be retained in oral care and experience improvements in overall oral health and mental health status.

– Participants with 5+ DCM encounters (23%) were 2.73 times more likely to complete their treatment plan compared to those with just one DCM encounter. (Lemay, et.al)

She has helped me very much. First and foremost, she has helped me just with the comfort level of dealing with a place like this. I am kind of intimidated by a dentist. I mean, who is not? But she has been very comforting and she has been very good at explaining procedures. If it wasn’t for what she has done for me as far as helping, scheduling, talking, sitting with me during the dentist and everything, I may not have followed through. So it has made a really big difference. It makes me feel like there is somebody committed to my dental care, so my commitment can’t be any less than that.

Patient Perspectives DCMs

“

”

Patient Perspectives- The role of the DCM

– Access to oral health care• “I would not have dental care if it wasn’t for

(name of dental case manager)”• “He (dental case manager) got me into the

program and it has been good to me”– Retention in dental care

• “ I feel comfortable with her and it makes me want to come to appointments”

– Helps with patient/provider communication– Provides oral health education

Policy Implications• Successful strategies for outreach,

engagement and retention in dental care• Increasing access is feasible• Standards of care• Patient and community education• Workforce innovations• Future financing and sustainability

Contact Information

Jane Fox, MPHEvaluation Center for HIV and Oral Health

Boston University617-638-1937

janefox@bu.edu

http://echo.hdwg.org/

Upcoming Oral Health Webinars

Dental Case ManagementJanuary 9, 2014 at 1 PM EST • Presenters:

• Dr. Howell Strauss and Mr. Nelson Diaz, AIDS Care Group of Chester, PA

• Dr. Carolyn Brown and Ms. Lucy Wright, Native American Health Center of San Francisco, CA

Clinical Aspects of Oral Health Care for PLWHA

January 22, 2014 at 3 PM EST• Presenters:

• Dr. David Reznik, HIVDent and Grady Health System of Atlanta, GA

• Ms. Helene Bednarsh, RDH, MPH, HIVDent and Boston Public Health Commission of Boston, MA

Q & A

Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300

Connect with UsSarah Cook-Raymond, Managing Director |Impact Marketing +

Communications

To be informed about Webinars and other upcoming IHIP resources, sign up for the IHIP listserv by emailing

scook@impactmc.net.

IHIP Web site: www.careacttarget.org/ihip