OralHealthPartnershipCoreGroupMeetingNovember10,2017SevenHillsFoundationandTuftsUniversitySchoolofDentalMedicine
Agenda• TierIIIoverview(fundingends7-31-18)• Deliverables• NationalPCORIAwardeesMeeting
• RevisitTierIIresearchproposaldraft:Chronicdiseasemanagementinterventiontoreducecavities(toothdecay)• ConsiderreframingTierIIproposalfrom‘research’toaninitiativetosupportgoodoralhealthforadultswithIDDasahumanright• PCORIEngagementAwardoption
• Brainstormingexercise• PlanforTierIIIactivities
TierIIIDeliverables• QuarterlyReports– Nov.,Feb.,May• FinalReport – Aug.• ProposalOpportunityPlan:Potentialfunderslist• Draft– Nov.• Updated– May,Aug.
• Dissemination&CommunicationPlan• Draft– Feb.• Final– Aug.• Reporttocommunityaboutproposal– Aug.
• LetterofIntent(LOI)forPCORIfunding• MajorsectionsofaproposaltoPCORIoralternativefunder– Aug.
ReviewofTierIICERproposaldraft:“Chronicdiseasemanagementinterventiontoreducecavities”
•Whatweproposedandwhy• Informationaboutanewnon-research-orientedPCORIfundingoption– EngagementAwards(LOIdue2/1/2018)
TierIICER*ProposalDraft• Weproposed:testingaChronicdiseasemanagementinterventiontoseeifitreducedcaries(toothdecay)inadultswithIDD• PCORIproposalrequirements:• Mustcomparetheoutcomesof2ormoreinterventionsthatareevidence-based
• Ourproblem:• NOinterventionshavebeenproveneffectiveinimprovingoralhealthforadultswithIDD• Weneededto‘borrow’interventionsproveneffectivewithotherdentalpt.groups
• *CER– ComparativeEffectivenessResearch
Proposal:Why‘ToothDecay’Outcome• Toothdecaycausespain,poornutrition,seriousinfections,andmayaffectbehaviorsathome&work.Alsoleadstodentalofficeinterventionsassociatedwithstress/anxiety/fear.• LimiteddatasuggestadultswithIDDinCentralMA(GlavinClinic)have>untreatedcaries(40.1%)thantotalTDFclinicpatients(32.2%)• Manyfactorscanmodifytoothdecayprocessanditmaybepossibletoinfluencethem• Saliva• Frequencyofsugarintake(diet,beverages,meds,supplements)• Fluorideuse• Drinkingfluoridatedwater• Brushingwithfluoridatedtoothpaste• Havingdentalprofessionalsapplyfluorideinoffice
Proposal:WhyCDMIntervention• ChronicDiseaseManagement(CDM)strategies:• Packageofstrategiesthat– combinedtogether– helppreventormanageadisease
• Mostusefulwithhealthconditionswhere:• At-homebehavioralchangesareneededtoprevent/treatdisease• e.g.,childhoodobesity,childhoodasthma,diabetes
• CDMstrategieshavebeeneffectiveinmanagingEarlyChildhoodCaries(ECC):Reducednewcavities,dentalpain,ORreferrals• Reliedon:• IndividualRiskAssessment• Familysupport/coachinglinkeddirectlytoindividual/child’sneedsre:diet,
brushing,flossing,arrangingdentalvisits• Dentalofficeinterventionstorepair/restoreteeth
TierIIResearchProposal#1• WhichofthefollowingvariationsofachronicdiseasemanagementinterventionfordentalcariesinadultswithIDDismosteffectiveatreducingtheonsetandrecurrenceofdentalcaries:
• FollowingcompletionofanIndividualRiskAssessment:• InterventionGroupA:Implementationofapatient-specificmanagementplanincludingtailoredpreventivedentalservicesandsupportsforboththeadultwithIDDANDacaregiver
• InterventionGroupB:implementationofapatient-specificmanagementplanincludingtailoredpreventivedentalservicesandsupportsfortheadultwithIDDonly
• ControlGroup:Participantsfollowtheirusualandcustomaryoralhealthpractices,includingpreventivedentalvisitsandoralhomecareservices.
TierIIResearchProposal#2• WhichtopicalfluorideapplicationprotocolismosteffectiveatreducingdentalcariesinadultswithIDD?
• Comparisonsunderconsideration:• Comparingdifferentformsofapplication (professionallyappliedcomparedtoself/caregiverapplied)
• Comparingdifferentfrequenciesofprofessionalapplications• fourtimes/yearascurrentlyallowedbyMassHealth/MedicaidforadultswithIDDvs.otherfrequencies(e.g.):• FrequencyallowedbyprivatedentalbenefitprovidersinMassachusetts• FrequencyrecommendedbydentistsfollowingCAMBRA(caries
managementbyriskassessment)protocol.
ReframingnextstageofTierIIIfromCERresearchproposaltoaninitiativefocusedoncreatingaframeworktosupportgoodoralhealthforadults
asahumanright
PCORIEngagementAwardInitiative(‘research- supportnotresearch’)
PCORIEngagementAward-FranciscanChildren’sHospital• Thisprojectaimstodevelopanetworktoconnectparentsofchildrenwithmedicalcomplexity(CMC)toeachotherandtotheirkeyhealthcareproviderstoidentifythemostcommonchallengesforCMCinthehealthcarecontinuum.• Fourparent-generatedonlinesurveysconductedtoidentifytheobstaclesparentsencounterwhenobtainingmedicalcarefortheirchildwithcomplexmedicalneeds
• Ameetingofprojectcollaboratorstoidentifyrootcausesandpotentialsolutionstoparent-identifiedproblems
• Asurveyadministeredtoobtainadditionalparentinputregardingthesepotentialsolutions
• Finalcollaboratorsmeetingtoformalizeprojectrecommendationsforfutureresearchefforts.
FramingoralhealthforadultswithIDDasahumanright
•Dr.Morgan
FramingoralhealthforadultswithIDDasahumanright• Goal:• Definebasicpackageofservices&supportstoensuregoodoralhealthforadultswithIDDinMassachusetts• Fromavailabilityoftoothpastetoaccesstodentalspecialists
• Spelloutpolicychangesthatwouldberequiredtogetthere
• Elementswouldbesame(ifnotmore)asthoseinTierIICERresearchproposal• Activitieswouldfocusondevelopingworkablepolicyandpracticesolutionsinsteadofdevelopingarigorousscientificresearchstudybut
AttributesofanIdealOralHealthCareSystem*• Integrationwiththerestofthehealthcaresystem• Emphasisonhealthpromotionanddiseaseprevention• Monitoringofpopulationoralhealthstatusandneeds• Evidence-based• Effective• Cost-effective• Sustainable• Equitable• Universal• Ethical• Includescontinuousqualityassessmentandassurance• Culturallycompetent• Empowerscommunitiesandindividualstocreateconditionsconducivetohealth
• (*Tomar &Cohen,2010)
CanweuseanEngagementAwardtodefinethebasicpackageofservices&supportsneededtopromoteoralhealth/reducenewandrecurrentcavitiesinadultswithIDDwholiveincommunitysettings?
Recall...
CauseofToothDecay• Fortoothdecaytooccur,bacteria(plaque)usesugarsinyourdiettoproduceacidswhichdissolvethetoothsurface.
ManyFactorsCanModifyToothDecayProcess• Saliva• Frequencyofsugarintake• Sugar-sweetenedfoodandbeverages• Medication• NutritionalSupplements
• FluorideUse• Drinkingfluoridatedwater• Brushingwithfluoridatedtoothpaste• Havingdentalprofessionalsapplyfluorideindentaloffice(orsometimesinothercommunity-basedsettings)
•Otherfactors?
SpheresofInfluenceOralHealthofAdultswithDisabilities
CommunityLevelResidenceType,Availabilityof
AffordableDentalCare,Policies,LawsandRegulations
InterpersonalLevelFamily/PaidCaregiverRole– Diet,OralHomeCareSupport,FacilitateAccesstoDentalCare
,advocacygroupsIndividualLevel
Diet,Medications,OralHomeCare,
LevelofDisability,AbilitytoCooperate,ReceiptofDentalCare
Services
OralHealthStatusof
AdultswithIDD
YourListofTopOralHealthInfluences(2016)• Individual&caregiverinfluences• Geneticfactors/medsthatincreaserisk• Highsugardiet• Unhealthybehaviors• Brushingteethatleast2x/day• Flossingteethatleast1x/day• Uncooperativebehaviors
• Dentalcareinfluences• Scared/anxiousaboutvisitingdentist• Financialbarriersre:visitingdentist• Barrierstovisitingdentalspecialists
• Others?
ASPiRE Participants:Howmanytimes/daydoyoubrushyourteeth?(2015)#Times/day 0 1 2 3 4 >4
%Participants(#)(n=84)
10.7%(9) 22.6%(19) 46.4%(39) 16.7%(14) 1.2%(1) 2.4%(2)
ASPiRE Participants:Howmanytimes/daydoyouflossyourteeth?(2015)#Times/day 0 1 2 3 4 >4
%Participants(#)(n=84)
64.3%(54) 19.0%(16) 9.5%(8) 4.8%(4) 2.4%(2) 0
ASPiRE Participants(cont.)
#Times/day 0 1 2 3 4 >4%Participants(#)(n=84)
10.7%(9) 22.6%(19) 46.4%(39) 16.7%(14) 1.2%(1) 2.4%(2)#Times/day 0 1 2 3 4 >4%Participants(#)(n=84)
64.3%(54) 19.0%(16) 9.5%(8) 4.8%(4) 2.4%(2) 0
%(n)YesResponses %(n)NoResponses
Doyourteetheverhurt?(n=84) 34.5%(29) 65.5%(55)
Whenyoubrushyourteethdoessomeonehelp/instructyou?(n=84)
19.0%(16) 80.9%(68)
Whenyouflossyourteethdoessomeonehelp/instructyou?(n=84)
16.7%(14) 83.3%(70)
Doyouhaveallthetoolsyouneedtocareforyourteeth(n=84)
Toothbrush 100%(84) 0
Toothpaste 97.6%(82) 2.4%(2)
Floss 51.2%(43) 48.8%(41)
Mouthwash 64.3%(54) 35.7%(30)
Whatadditionalinformationdoyouneed?(2016)• DoesDDSrequireindividualstoincorporateoralhealthintotheirISP?Ifnot,couldthatbesuggested?• DoesSHFrequireandtrainstafftoensureparticipantsingroupandsharedlivinghomesbrushproperlyandregularly?Ifnot,shouldstafftrainingbesuggested?• Otherinformation?
BrainstormingExercise
Whatcouldbedone– thinkingcreatively–toinfluencethesefactorsandreducetheriskoftoothdecay?•Caregiverperspective•Administratorperspective•Participantperspective
Resources• Justtohaveonhand
PrevalenceofDentalDiseaseamongGlavin ClinicPatients(2009/10)
DentalDisease Glavin ClinicPatients*(dentateonly=469)
TotalTDFClinicPatients(Dentateonly=4218)
Cariesexperience
436(93.0%ofGlavin pts.)
3705(87.8%of totalTDFpts.)
Untreatedcaries 188(40.1%ofGlavin pts.)
1359(32.2%oftotalTDFpts.
Periodontitis 418(89.1%ofGlavin pts.)
3369(80.3%oftotalTDFpts.)
PatientCharacteristics– atGlavin andatallTDFClinicsCombinedPatientCharacteristics
Glavin ClinicPatients
TotalTDFClinicPatients
GenderMaleFemale
310(58.9%)216(41.1%)
2714(57.4%)2018(42.6%)
Age20-3940-5960andolder
119(22.6%)296 (56.3%)111 (21.1%)
1174 (24.8%)2471 (52.2%)1087(23.0%)
ResidenceTypeHome w/familyMADDScommunityHomeindependentlyMADSSfacilityNursinghomeOther
49 (9.3%)406 (77.2%)5(1.0%)41(7.8%)7(1.3%)13(2.5%)
625 (13.2%)3208(67.8%)97(2.0%)583 (12.3%)57 (1.2%)117(2.5%)
Characteristics(continued)PatientCharacteristics Glavin
ClinicPatients(n=526)
TotalTDFClinicPatients(n=4732)
CooperationLevels0 – Doesn’tenterclinicand/ordentalchair1- Sitsindentalchaironly2-Allowsbrushing,visualexamorboth3– Allowsdentalexam&dentalinstrumentplacementwithbehavioralassistance4– Allowsdentalprocedures;requiresbehavioralassistance>50%oftime5– Allowsdentalprocedures;requiresbehavioralassistance<50oftime6– Allowsdentalprocedureswithoutassistance
1(0.2%)1(0.2%)46(9.1%)92(18.1%)
147(29.0%)
110(21.7%)
110(21.7%)
10(0.2%)41(0.9%)396(8.7%)690(15.1%)
1013(22.2%)
828(18.1%)
1592(34.8%)
Fluoridatedwater- MA