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SPNS IHIP Oral Health Webinar Series: Healthy Mouth, Healthy Body ………………. Presented by CDR Mahyar Mofidi, DMD, PhD and Jane Fox, MPH December 13, 2013.

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Presentation on theme: "SPNS IHIP Oral Health Webinar Series: Healthy Mouth, Healthy Body ………………. Presented by CDR Mahyar Mofidi, DMD, PhD and Jane Fox, MPH December 13, 2013."— Presentation transcript:

1 SPNS IHIP Oral Health Webinar Series: Healthy Mouth, Healthy Body ………………. Presented by CDR Mahyar Mofidi, DMD, PhD and Jane Fox, MPH December 13, 2013

2 Agenda ■ Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project ■ Sarah Cook-Raymond, Managing Director of Impact Marketing + Communications ■ Presentations from: ■ Dr. Mahyar Mofidi; Branch Chief of the Division of Community HIV/AIDS Programs and Chief Dental Officer, HRSA HIV/AIDS Bureau ■ Jane Fox, MPH; Project Director of SPNS Oral Health Initiative Evaluation Center for HIV and Oral Health (ECHO), Boston University School of Public Health ■ Q & A

3 IHIP Resources on TARGET Center Website

4 IHIP Oral Health Resources ■ Training Manual ■ Curriculum ■ Pocket Guide ■ Webinar Series ■ Healthy Mouth, Healthy Body ■ Dental Case Management ■ Clinical Aspects of Oral Health Care for PLWHA Recording and slides for all Webinars will be uploaded to TARGET Center Web site following the live event:

5 Other IHIP Resources ■ Buprenorphine Therapy ■ Training Manual, Curriculum, Monograph, and Webinars on implementing buprenorphine in primary care settings ■ Engaging Hard-to-Reach Populations ■ Training Manual, Curriculum, and Webinars on engaging hard- to-reach populations ■ Jail Linkages ■ Training Manual, Curriculum, Pocket Guide, and Webinars on enhancing linkages to HIV care in jails settings ■ UPCOMING: Hepatitis C Treatment Expansion ■ In Spring/Summer 2014, look for training materials on increasing access to and completion of Hepatitis C treatment for PLWHA on the TARGET Center Web site.

6 Healthy Mouth, Healthy Body: Oral Health Care's Vital Role in Overall Well Being for People Living with HIV/AIDS CDR Mahyar Mofidi, DMD, PhD Branch Chief Chief Dental Officer HRSA, HIV/AIDS Bureau December 13, 2013 6

7 12+ years ago You cannot be healthy without oral health. Oral health is essential to overall health and quality of life, and all families need access to high-quality dental care. 7

8 Oral Health for PLWHA “While good oral health is important to the well being of all population groups, it is especially critical for people living with HIV/AIDS (PLWHA). Inadequate oral health care can undermine HIV treatment and diminish quality of life, yet many individuals living with HIV are not receiving the necessary oral health care that would optimize their treatment.” -U.S. Public Health Service Surgeon General Regina M. Benjamin, MD, MBA 8

9 Why does good oral health matter in HIV care? 9

10 Oral Disease in HIV Infection Oral infections and neoplasms occur with immunosuppression  (bacterial, fungal, viral, neoplastic, lymphoma, ulcers) High prevalence of dental caries and periodontal disease 10 32-46% of PLWHA have at least one oral disease condition related to HIV Some HIV medications have side effects (xerostomia or dry mouth) which can lead to tooth decay and periodontal disease

11 Prevalence of Dental Caries and Periodontal Disease in a Ryan White HIV/AIDS Program- Funded Dental Clinic Dental caries were present in 66% of patients 54% had gingivitis and 28% had periodontal disease  Infectious Disease Society of America (IDSA) 47 th Annual Meeting – November 2009 – Poster #1063 11

12 Oral Manifestations of HIV/AIDS For those with unknown HIV status, oral manifestations may suggest HIV infection, although they are not diagnostic. Reznik DA. Perspective - Oral Manifestations of HIV Disease. International AIDS Society–USA Topics in HIV Medicine. Volume 13 Issue 5 December 2005/January 2006 12

13 Oral Manifestations of HIV/AIDS For persons living with HIV disease not yet on therapy, the presence of certain oral manifestations may signal progression of disease. Reznik DA. Perspective - Oral Manifestations of HIV Disease. International AIDS Society–USA Topics in HIV Medicine. Volume 13 Issue 5 December 2005/January 2006 13

14 Oral Manifestations of HIV/AIDS For persons living with HIV disease on antiretroviral therapy, the presence of certain oral manifestations may signal a failure in therapy. Hodgson TA, Greenspan D, Greenspan JS. Oral lesions of HIV disease and HAART in industrialized countries. Adv Dent Res. 2006 Apr 1;19(1):57-62 14

15 Oral Disease is Rarely Self-Limiting 15 Untreated oral disease may lead to systemic infections, weight loss, malnutrition Oral health diseases are linked to systemic diseases: diabetes, heart disease, pregnancy issues Oral diseases impact quality of life: psycho-social problems, limited career opportunities

16 How can dental providers make a difference? 16

17 Role of Dental Providers Eliminate infection, pain, and discomfort Restore oral health functions Early detection of HIV and referral: Oral lesions can be the first overt clinical feature of HIV infection. Early detection can improve prognosis and reduce transmission/ A visit to the dentist may be a health care milestone for PLWHA. The dental professional can address oral health concerns and play a role in helping engage or re-introduce patients into the health care system and coordinate their care with other primary care providers. 17

18 What are the Benefits of Early Linkage to Oral Health Care After HIV Diagnosis? 196 HIV-positive individuals:  63 newly diagnosed cases (out of oral care and within 12 months of their HIV diagnoses)  Previously diagnosed controls (66 out of oral care and diagnosed with HIV between 1985-2007)  Historical controls (67 receiving regular oral care and diagnosed with HIV between 1985-2007) IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry. 18

19 Findings Persons who were newly diagnosed had significantly more teeth at baseline compared to the previously diagnosed and historical groups. Newly diagnosed individuals had less periodontal disease (attachment loss and less bleeding on probing). Previously diagnosed individuals had poorer gingival health and more broken teeth. The previously diagnosed group had the most dental decay. Service usage varied considerably:  Newly diagnosed: more preventive and maintenance services  Previously diagnosed: more costly prosthodontic services IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry. 19

20 Findings The higher levels of dental disease in the previously diagnosed group resulted in higher treatment costs. “Early dental intervention in the newly diagnosed HIV-positive individuals results in significant functional maintenance, more optimal oral health, and considerable financial savings.” IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry. 20

21 What oral health needs/barriers do PLWHA face? 21

22 Unmet Oral Health Needs Oral health is one of the top unmet needs for PLWHA who obtain services through the Ryan White HIV/AIDS Program nationwide. PLWHA have more unmet oral health care needs than the general population and have more unmet oral health care needs than medical needs. PLWHA most likely to report unmet need for dental care are African American, uninsured, Medicaid recipients, and within 100% of federal poverty limits. 22

23 Barriers to Oral Health Care Lack of dental insurance Limited financial resources Shortage of dentists Too many appointments, other aspects of illness seen as being more important Fear, no positive role models, stigma, shame Negative patient-provider experiences Shrinking adult dental Medicaid benefits 23

24 State Adult Dental Coverage in Medicaid, 2013 Source: ADULT DENTAL BENEFITS IN MEDICAID, ADA Number of states 9 18 14 10 24

25 Oral Health Care is Expensive Service National average fees charged by private practitioner Sample reimbursed fees by Medicaid Comprehensive oral evaluation/ examination $66.29$14.89 - $44.61 Limited oral evaluation$57.60$14.00 - $36.76 Intraoral radiograph (first film)$23.41$3.63 - $14.91 Adult cleaning$77.64$22.10 - $58.00 Filling (amalgam, one surface)$110.35$15.59 - $64.56 Filling (clear, one surface)$131.30$25.62 - $65.90 Extraction (simple)$138.21$25.62 - $63.54 Extraction (surgical)$224.11 $33.43 - $109.23 Endodontic (molar root canal)$868.00$157.93 - $409.90 Crown (porcelain)$908.00$580.00 Complete denture (upper)$1,333.57$584 - $600 25

26 What are we doing about oral health? 26

27 Oral Health: HRSA Strategic Priority Expand oral health and integrate it in primary care settings 27

28 Ryan White HIV/AIDS Program and Oral Health Services

29 SPNS OHI Special Projects of National Significance Innovations in Oral Health Care Initiative 15 sites across country Grantees implemented innovative models of comprehensive oral health care services to expand dental access 29

30 Other HIV/AIDS Bureau Oral Health Investments Oral health capacity assessment during site visits All Grantee Meeting Oral health performance measures Oral health a funding priority under Part C Capacity Development Funding Opportunities Program evaluations Publications 30

31 Impact of Ryan White HIV/AIDS Programs on Oral Health Care FY 2011: 135,004 clients received dental services FY 2011: 8,480 dental providers (mostly dental students and residents) provided direct oral health care as part of CBDPP and DRP FY 2011: 8,461 health care professionals (3,451 dental, 5,010 non dental) received oral health care education through AETCs 31

32 32 Impact on Our Clients “People treat you as if they have known you their whole life.” “They take care of my fear.” “They are like a big family…they gave me my smile back.” “I feel free, secure and welcomed by the staff.” “I feel comfortable…not treated as a HIV patient but a person who needs dental care.” “We’re all so fortunate to get what we need.” “It’s affordable. It’s a one stop shop.” “This is the only game in town.” “Quality of care here is 110%.”

33 Acknowledgment Dr. David Reznik 33

34 Contact Info CDR Mahyar Mofidi, DMD, PhD HRSA/HAB Chief Dental Officer 301-443-2075 34

35 Evaluating the HRSA SPNS Oral Health Initiative Jane Fox, MPH Boston University

36 HRSA Oral Health SPNS Initiative September 2006 HRSA funded 15 sites and one evaluation & TA center Five year funding cycle Sites were charged with increasing access to oral health care for PLWHA

37 SPNS Sites

38 SPNS Models - Typology Three types of host agencies – ASO/CBO (5), CHC (4), and hospital/University-based programs (6) Three basic models: – Fixed site Expansion of prior dental program/services Implementation of new dental program – Mobile dental units

39 Evaluation Study Questions Do the demonstration programs increase access to oral health care for the target population? What are the main similarities and differences in strategies and program models to increase access to oral health care across programs? Are the oral health services performed in accordance with professional practice guidelines? Do clients experience improvements in health outcomes over time?

40 Evaluation Study Questions Are clients’ oral health care needs met? Do clients experience improvements in oral health related quality of life after enrollment in oral health care? What strategies are most effective in furthering successful program implementation: barriers, facilitators, key lessons learned? What strategies to address the structural, policy and financing issues can be replicated in other settings?

41 Evaluation Study Design Study criteria – HIV+, 18+ years of age, and no oral health care* for the past 12 months or more Quantitative survey at baseline and follow-up – Demographics, past access, insurance, HIV status, past oral health symptoms, SF-8, OH QOL, and presenting problem Utilization and ancillary data – CDT codes of EVERY procedure done, evidence of tx plan completion and recall

42 Evaluation Study Design Qualitative interviews – In-depth interviews of 60 patients at 6 sites OH experiences and values, OH self care knowledge and behaviors, patient education, and impact of HIV on OH Dental case manager focus group – June 2008 with 12 participants

43 Patient Demographics 75% male 40.6% Black, 21.2% Latino 33.4 % high school education, 43.0% beyond high school 30.6% working, 55.7% monthly income < $850 Age = 43.6 (18 – 81), Yrs positive = 10.07

44 Baseline Dental Access Usual place for dental care: 38.6% none; 31.0% private dentist 48.2% reported needing dental care but were not able to get it since testing positive Of those who did not get dental care, 53.8% stated affordability as the reason.

45 Baseline HIV Status 97.5% had a regular place for HIV care and 95.0% had seen their HIV provider in the past 6 months 85.2% had an HIV case manager and 77.9% were taking ARTs 57.35 had a CD4 count over 350 and 52.8% had an undectable viral load

46 Significant Changes in Outcomes at 12 Months, N=1391 OutcomeBaseline12 Mos. Report unmet need for oral health care 48%17% Report good/excellent health of teeth and gums 38%67% Oral health symptoms: mean (SD) 3.35 (2.34)1.78 (1.93)

47 Significant Changes in Oral Health Symptoms at 12 Months, N=1391

48 Significant Changes in Habits at 12 Months, N=1391

49 Patient Perspectives - Habits Improvements in oral health care practices – Better brushing & flossing techniques & frequency “ Now I buy lots of toothbrushes and use them for a short time and replace them.” “I brush everyday instead of 3 times/week...I floss a lot more” “I brush longer” – Reduce or stop smoking/tobacco use “ I still use snuff but I cut back a little and don’t leave it in my mouth as long...” “I cut down from 3 cigarettes/day from 1 pack...” – Dietary changes “I still drink soda but only once in awhile...I try not to buy it”

50 Standards of Care We established a set for the multi-site evaluation: – The presence of a comprehensive exam – The presence of any xrays – The presence of any cleaning or periodontal work – Completion of Phase I treatment plan – Patient placed on recall

51 Service Utilization: N=2178, 14 sites Over the course of the study: Patients made over 15,000 clinic visits They received over 37,000 services 917 (42%) completed a Phase 1 treatment plan # provided Pts who received any service n /% Clinic Visits11,3152178100% Phase 1 Treatment Plans Completed* 717 33% Comprehensive Exams 2077194489% Services provided in first 12 months of care *Phase 1 Treatment Plan = Prevent and treat active disease

52 Access to & Retention in Care 43% of patients came in for preventive care 64% of patients were retained in care Those retained in care were: – More likely to complete their treatment plan – More likely to have a recall visit – Reported less pain, fewer symptoms at follow up Factors significantly associated with retention – Older age, better physical health, on HIV medications, more recent dental visit – Receipt of patient education – 6 times as likely to be retained in care

53 “…I very rarely go. I was not a regular client at the dentist because my parents only took me to the dentist once in my life and so I didn’t know the need for follow-up dental—you know keeping a good hygiene program until I got older.”


55 Engagement in Care “Outreach and retention were two things we did not anticipate to be problematic when planning for this grant. As we began to open our clinic and serve patients, we realized that this is one of the most important aspects of operating a dental clinic for this population.”

56 Getting Patients in the Door Marketing – Paid & unpaid media Community materials – Literacy level Outreach to providers – Clinicians – Case managers – Other CBOs Ancillary services – Transportation – Other social or medical services Special events – SPNS days Word of mouth – Peers

57 Keeping Patients in Care Follow-up appointments −Timely and efficient Reminder calls Dedicated staffing −Patient navigators/dental case managers −Staff skills and relationships with patients Patient education and empowerment −“When both the dentist and the dental case manager reviewed the treatment plan with the patients, the patients gained a better understanding of why the proposed treatment was needed.” Incentives −“thank you gifts” − transportation

58 Dental Case Management 8 programs included dental case management – 5 in non-urban settings and 3 in urban settings – DCMs were either Dental assistants who were given training on case management; or HIV case managers who were given training on oral health topics 758 patients were enrolled into the study from the 8 DCM sites. – They had a total of 2715 encounters with a DCM over the course of a year of treatment. Appointment reminders/rescheduling Arranging or providing transportation Provision of food or nutritional information Provision of oral health information and support Outcomes – Participants with more DCM encounters were significantly more likely to complete their Phase 1 treatment plan at 12 months, be retained in oral care and experience improvements in overall oral health and mental health status. – Participants with 5+ DCM encounters (23%) were 2.73 times more likely to complete their treatment plan compared to those with just one DCM encounter. (Lemay,

59 She has helped me very much. First and foremost, she has helped me just with the comfort level of dealing with a place like this. I am kind of intimidated by a dentist. I mean, who is not? But she has been very comforting and she has been very good at explaining procedures. If it wasn’t for what she has done for me as far as helping, scheduling, talking, sitting with me during the dentist and everything, I may not have followed through. So it has made a really big difference. It makes me feel like there is somebody committed to my dental care, so my commitment can’t be any less than that. Patient Perspectives DCMs “ ”

60 Patient Perspectives- The role of the DCM – Access to oral health care “I would not have dental care if it wasn’t for (name of dental case manager)” “He (dental case manager) got me into the program and it has been good to me” – Retention in dental care “ I feel comfortable with her and it makes me want to come to appointments” – Helps with patient/provider communication – Provides oral health education

61 Policy Implications Successful strategies for outreach, engagement and retention in dental care Increasing access is feasible Standards of care Patient and community education Workforce innovations Future financing and sustainability

62 Contact Information Jane Fox, MPH Evaluation Center for HIV and Oral Health Boston University 617-638-1937

63 Upcoming Oral Health Webinars Dental Case Management January 9, 2014 at 1 PM EST Presenters: Dr. Howell Strauss and Mr. Nelson Diaz, AIDS Care Group of Chester, PA Dr. Carolyn Brown and Ms. Lucy Wright, Native American Health Center of San Francisco, CA Clinical Aspects of Oral Health Care for PLWHA January 22, 2014 at 3 PM EST Presenters: Dr. David Reznik, HIVDent and Grady Health System of Atlanta, GA Ms. Helene Bednarsh, RDH, MPH, HIVDent and Boston Public Health Commission of Boston, MA

64 Q & A Twitter: @impactmc1| Facebook: ImpactMarCom | | Connect with Us Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications To be informed about Webinars and other upcoming IHIP resources, sign up for the IHIP listserv by emailing IHIP Web site:

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