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