© Richard Niederman CariedAway in CO, HI, KS, ME, NH September 2012 Supported by NIMHD and NIDCR Richard Niederman Center for Evidence-Based Dentistry Forsyth Institute, Boston, MA

© Richard Niederman This is not “the” truth This is how I see it You need to decide for yourself Disclaimers

© Richard Niederman Plan 1.Background 2.ForsythKids 3.Materials and Methods a. Glass ionomer b. Diagnosis 4.CariedAway

© Richard Niederman Background: US Healthy People Goals 10 year goal

© Richard Niederman ForsythKids School-Based Comprehensive Caries Prevention

© Richard Niederman ForsythKids Basic Precepts 1. Address U.S. oral health needs identified in Surgeon General’s 2000 report 2. Meet/exceed goals of Healthy People 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 regulations 7.Meet triple bottom line

© Richard Niederman Evidence Level *from Niederman et al JADA 2011

© Richard Niederman DDS/CHC Recruitment School Recruitment Data Analysis Billing Medicaid Enrollment EB Comprehensive Prevention Examination Informed Consent Implementation Know How Community Participation + Care + Analysis Disparities Equality

© Richard Niederman 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 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 e Records evolution: Paper, PC pad, Kindle Fire, Android phone

© Richard Niederman Patient Chart

© Richard Niederman Start % Each circle = 1 school N = 6 Schools N/school = ~200 Mean of 6 schools 67% End 2010

© Richard Niederman Grade : 6 1 2, 5, 4 K, 3 Each symbol = average of ~2,000 students Mean Visit 1 = 17.5 % Mean Visit 2 = 4.5 %

© Richard Niederman ForsythKids Outcomes 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 Glass Ionomer

© Richard Niederman Composite / Glass Ionomer MetricCompositeGlass Easy “visible retention”YesNo Actual retentionYes Caries preventionYes Need EtchYesNo CuringLightChemical Application time/toothSlowFast Bonding to toothMechanicalChemical Release of fluorideNoYes Kill subjacent bacteria?Yes Stimulate secondary dentin?Yes Cost per tooth~= Saliva sensitiveYesNo Technique sensitiveYesNo

© Richard Niederman Diagnosis

© Richard Niederman Perceived Diagnosis True Caries True No Caries Diagnosed Caries + Diagnosed No Caries -

© Richard Niederman Actual Diagnosis True Caries True No Caries Diagnosed Caries 25% (+ +) 25% (- +) Diagnosed No Caries 25% (+ -) 25% (- -) Total Wrong 50% Total Right 50%

© Richard Niederman Perceived Diagnosis, Treatment, & Predicted Outcome True Caries True No Caries Predicted Outcome Diagnosed Caries IRT Abscess Diagnosed No Caries SealantPrevent Decay

© Richard Niederman Perceived Diagnosis, Treatment, & Actual Outcome True Caries True No Caries Actual Outcome Diagnosed Caries Diagnosed No Caries Sealant Prevent Decay

© Richard Niederman Perceived Diagnosis, Treatment, & Actual Outcome True Caries True No Caries Actual Outcome Diagnosed Caries IRT Prevent Abscess Diagnosed No Caries Sealant Prevent Decay

© Richard Niederman Evidence-Based Guidelines Sealants Beauchamp et al JADA 2008 Gooch et al JADA 2009 IRT AAPD 2001 Medicaid 2004

© Richard Niederman CariedAway: Goal: Assessment and improvement of school-based caries prevention programs

© Richard Niederman Definitions of Quality IOM Safe, Effective Efficient, Timely, Patient Centered, Equitable Industrial Reduce variability Reduce waste

© Richard Niederman Participating Program Variability* StateCareNumber /YrGradeScreenF- Rinse F- Varnish SealIRTMaterialStudentSchoolsCounty CO2K-8RDH-+All-Glass1, KS1K-8DDS-+All-Resin4, ME12-4RDH++6-Resin3, NH1K-5DDS-+6,7-Resin1, , HI , * Similarities: All start with paper, not electronic records None start with longitudinal or outcome data

© Richard Niederman Quality of Programs IOM + Safe ? Effective -? Efficient, Timely, Patient Centered, Equitable Industrial (and IHI.org) - Reduce variability - Reduce waste

© Richard Niederman Phases ME, 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 CariedAway Hawaii No school-based health **Adopt from E. Rogers, 2003 B. Implementation 3. Application Evidence Advantage 2. AcceptanceSimplicity Compatibility Trust 1. AwarenessChoice A. Stakeholder Government Organization Clinician Patients

© Richard Niederman Start with After-School Programs Categorization of Individuals *Rogers, 2003

© Richard Niederman Social Network Analysis Hawaii School Principals

© Richard Niederman Connectivity LowestLowHighHighest Oral Health Attitude Lowest , , 142, , 163 Low 132, 135, 145, 148, , 204 High , 133, 138, 140, 141, 161, 164 Highest 150, 151, 203, , 143, 147, , 144, 154, 156, 158, 159, , 155, 162 Social Network Analysis Hawaii School Principals

© Richard Niederman Know How 1.What are we trying to accomplish? 2.What changes can we make? 3.How will we measure improvement? Time

© Richard Niederman

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