© richard niederman 2008-2012 cariedaway in co, hi, ks, me, nh september 2012 supported by nimhd...

© 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