1. © Richard Niederman 2008-2012 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

2. © Richard Niederman 2008-2012 This is not “the” truth This is how I see it You need to decide for yourself Disclaimers

3. © Richard Niederman 2008-2012 Plan 1.Background 2.ForsythKids 3.Materials and Methods a. Glass ionomer b. Diagnosis 4.CariedAway

4. © Richard Niederman 2008-2012 Background: US Healthy People Goals 10 year goal

5. © Richard Niederman 2008-2012 ForsythKids School-Based Comprehensive Caries Prevention

6. © 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 regulations 7.Meet triple bottom line

7. © Richard Niederman 2008-2012 Evidence Level *from Niederman et al JADA 2011

8. © Richard Niederman 2008-2012 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

9. © 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

10. © 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

11. © Richard Niederman 2008-2012 e Records evolution: Paper, PC pad, Kindle Fire, Android phone

12. © Richard Niederman 2008-2012 Patient Chart

13. © Richard Niederman 2008-2012 Start 2003 21% Each circle = 1 school N = 6 Schools N/school = ~200 Mean of 6 schools 67% End 2010

14. © Richard Niederman 2008-2012 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 %

15. © Richard Niederman 2008-2012 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

16. © Richard Niederman 2008-2012 Glass Ionomer

17. © Richard Niederman 2008-2012 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

18. © Richard Niederman 2008-2012 Diagnosis

19. © Richard Niederman 2008-2012 Perceived Diagnosis True Caries True No Caries Diagnosed Caries + Diagnosed No Caries -

20. © Richard Niederman 2008-2012 Actual Diagnosis True Caries True No Caries Diagnosed Caries 25% (+ +) 25% (- +) Diagnosed No Caries 25% (+ -) 25% (- -) Total Wrong 50% Total Right 50%

21. © Richard Niederman 2008-2012 Perceived Diagnosis, Treatment, & Predicted Outcome True Caries True No Caries Predicted Outcome Diagnosed Caries IRT Abscess Diagnosed No Caries SealantPrevent Decay

22. © Richard Niederman 2008-2012 Perceived Diagnosis, Treatment, & Actual Outcome True Caries True No Caries Actual Outcome Diagnosed Caries Diagnosed No Caries Sealant Prevent Decay

23. © Richard Niederman 2008-2012 Perceived Diagnosis, Treatment, & Actual Outcome True Caries True No Caries Actual Outcome Diagnosed Caries IRT Prevent Abscess Diagnosed No Caries Sealant Prevent Decay

24. © Richard Niederman 2008-2012 Evidence-Based Guidelines Sealants Beauchamp et al JADA 2008 Gooch et al JADA 2009 IRT AAPD 2001 Medicaid 2004

25. © Richard Niederman 2008-2012 CariedAway: Goal: Assessment and improvement of school-based caries prevention programs

26. © Richard Niederman 2008-2012 Definitions of Quality IOM Safe, Effective Efficient, Timely, Patient Centered, Equitable Industrial Reduce variability Reduce waste

27. © Richard Niederman 2008-2012 Participating Program Variability* StateCareNumber /YrGradeScreenF- Rinse F- Varnish SealIRTMaterialStudentSchoolsCounty CO2K-8RDH-+All-Glass1,000104 KS1K-8DDS-+All-Resin4,000162 ME12-4RDH++6-Resin3,500342 NH1K-5DDS-+6,7-Resin1,50072 9,8576710 HI--------25,0001251 * Similarities: All start with paper, not electronic records None start with longitudinal or outcome data

28. © Richard Niederman 2008-2012 Quality of Programs IOM + Safe ? Effective -? Efficient, Timely, Patient Centered, Equitable Industrial (and IHI.org) - Reduce variability - Reduce waste

29. © Richard Niederman 2008-2012 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

30. © Richard Niederman 2008-2012 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

31. © Richard Niederman 2008-2012 Start with After-School Programs Categorization of Individuals *Rogers, 2003

32. © Richard Niederman 2008-2012 Social Network Analysis Hawaii School Principals

33. © Richard Niederman 2008-2012 Connectivity LowestLowHighHighest Oral Health Attitude Lowest 214 129, 153130, 142, 146149, 163 Low 132, 135, 145, 148, 205 134208189, 204 High 139 131, 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

34. © 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

35. © Richard Niederman 2008-2012

36. Thank you