1. The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation, and Research Team Division of Oral Health Centers for Disease Control and Prevention (CDC) Atlanta, Georgia Texas Oral Health Summit: Advocacy, Equity & Access Austin, Texas September 9-10, 2004

2. Systematic Reviews and Evidence-Based Recommendations Promoting Oral Health

3. The Community Guide Is: A set of recommendations for action based on the scientific evidence Evidence comes from systematic reviews Reviews coordinated by CDC staff Recommendations determined by independent Task Force

4. What Will Be Reviewed in the Community Guide? Sociocultural Issues Specific ConditionsRisk Behaviors The Environment Vaccine Preventable Disease Pregnancy Outcomes Violence Motor Vehicle Injuries Depression Cancer Diabetes Oral Health Tobacco Use Alcohol Abuse/Misuse Other Substance Abuse Poor Nutrition Inadequate Physical Activity Unhealthy Sexual Behaviors

5. Healthy People 2010 Guide to Clinical Preventive Services Priorities for Prevention Put Prevention into Practice The Community Guide is Part of a Family of Federal Initiatives

6. Promoting Oral Health Recommendations from the Guide to Community Preventive Services

7. Oral Health Chapter Community Guide Interventions for Preventing: Dental Caries Oral and Pharyngeal Cancers Sports-related Craniofacial Injuries

8. Methods for Conducting Systematic Reviews: Five Steps Develop conceptual approach Search for and retrieve evidence Rate quality of evidence Summarize evidence Translate strength of evidence into recommendation

9. Key Findings

10. Oral Health Chapter Community Guide Strong evidence for: Community water fluoridation School sealant programs

11. Translate strength of evidence into recommendations Preventing dental caries Community water fluoridation (strongly recommended) School-based sealant programs (strongly recommended)

12. Oral Health Chapter Community Guide Insufficient evidence for: Community-wide sealant promotion programs Oral cancer awareness and screening programs Promoting use of dental and craniofacial protectors in contact sports

13. Insufficient evidence should not be confused with evidence of ineffectiveness

14. Benefits of the Community Guide Stronger foundation for advocacy, research, and programs –proof of effectiveness may be better (semi-quantitative vs. narrative summary) –recommendations issued by independent, objective Task Force

16. www.thecommunityguide.org

17. ASTDD Best Practices Project Putting science into practice www.astdd.org

18. Purpose of the Project (1)Provide guidance for programs (2)Meet the Surgeon General’s Call to Action (3)Help achieve Healthy People 2010 objectives

19. Best Practice Approaches Dental public health strategies supported by evidence of effectiveness.

20. Best Practice Approaches Strength of Evidence PromisingProven Approaches....................….….…….....….…Approaches Strength of Evidence Research+Research+++ Expert Opinion+Expert Opinion+++ Field Lessons+Field Lessons+++ Theoretical Rationale+++Theoretical Rationale+++

21. Strong Evidence Research Evidence +++ Systematic review Expert Opinion +++Multiple authoritative sources Field Lessons +++Cluster evaluation of several states

22. Best Practice Approaches Strength of Evidence Best Practice ResearchExpert FieldTheoretical ApproachesOpinionLessons Rationale Surveillance Systems +++++++++ State Coalitions +++++++++ State Plans +++++++++ State Mandate for Program +++++++++ Community Water Fluoridation +++++++++++ School Sealant Programs +++++++++++ School Fluoride Programs +++++++++ Workforce Development +++++++++

23. Community Water Program Evidence Supporting Effectiveness Summary of Evidence Supporting Community Water Fluoridation Research+++ Expert Opinion+++ Field Lessons ++ Theoretical Rationale+++

24. School-based Sealant Programs Evidence Supporting Effectiveness Summary of Evidence Supporting School-based Dental Sealant Programs Research+++ Expert Opinion+++ Field Lessons ++ Theoretical Rationale+++

25. Best Practice Criteria Effectiveness Efficiency Collaboration & Integration Sustainability Rationale & Objectives “Best Practice”

26. ASTDD Best Practices Project Community Water Fluoridation

27. Description of a Community Water Fluoridation Program Legislation & policies Advocacy & promotion Supporting communities starting fluoridation Training, monitoring, surveillance, reporting and inspection

28. Description of a Community Water Fluoridation Program Collaborate with water quality and other partners Develop human resources to support community water fluoridation efforts Secure financial resources to support community water fluoridation efforts

29. Best Practice Criteria (1) Effectiveness Review Standard: Compare % population served by water systems with optimally fluoridated water to HP 2010 target (75%). State population with optimally fluoridated water Illinois99% Indiana95% Texas66% Arkansas 60% Mississippi39% California29%

30. Best Practice Criteria (1) Effectiveness Review Standard: Document number of communities or public water systems with optimally fluoridated water. In 2002: 44 of the 50 largest cities in the U.S. fluoridated Illinois: 860 of the 1800 community water systems adjust their fluoride levels Indiana: 482 water systems adjust their fluoride levels

31. Best Practice Criteria (2) Efficiency Estimating costs  Initial cost of capital equipment  Replacement cost of capital equipment  Annual operational costs (chemicals, human resources, maintenance & repairs) Review Standard: Compare average state cost for fluoridation (cost per per person year) to national estimates.

32. Best Practice Criteria (3) Sustainability State Community Water Fluoridation Programs Indiana since 1950 ’ s Oklahomasince 1950 ’ s Missouri since 1960 ’ s Virginia since 1980 ’ s Review Standard: Demonstrate sustainability through the number of years that identifiable water fluoridation program at state level has operated.

33. Best Practice Criteria (4) Collaboration & Integration Fluoridation Partners Professional association Grant makers Health departments Water authorities Universities (dental, medical and public health schools) Dental hygiene programs Local community leaders Review Standard: Demonstrate partnerships & coalitions with stakeholders and organizations to provide political, financial and scientific expertise to local constituents.

34. Best Practice Criteria (5) Rationale & Objectives Healthy People 2010 Objective 21-9 Increase proportion of U.S. population served by community water systems with optimally fluoridated water 2010 target: 75% Review Standard: Program is linked to state &/or national goals and objectives.

35. ASTDD Best Practices Project School-based Dental Sealant Programs

36. Description of School-based Sealant Programs Program conducted within the school setting Provide education to increase awareness of the benefit of sealants Obtain parental consent for screening/sealants Program provider teams include dentists, dental hygienists and dental assistants Utilize portable dental equipment or a fixed dental facility within the school setting

37. Description of School-based Sealant Programs Usual practice: Dentists examine the children and prescribe the sealants; dental hygienists apply the sealants For quality assurance, children re-examined within 1 year after sealant placement to check on retention and need for repair The program should address unmet dental care needs of children

38. State Practice Examples Illinois Dental Sealant Grant Program Ohio Dept. of Health School-based Dental Sealant Program Arizona Dental Sealant Program New Mexico School- based Dental Sealant Program

39. Best Practice Criteria (1) Effectiveness Review Standard: Program delivers to a large number of high risk children. Sealant Programs Ohio 28,000 children Illinois 21,000 children Target Schools 50-65% students in free & reduced lunch programs

40. Best Practice Criteria (1) Effectiveness Review Standard: Program maintains a quality assurance system. Sealant retention Arizona 1-week assessment 1-year assessment New Mexico 1-year assessment

41. Best Practice Criteria (1) Effectiveness Sealant Prevalence Ohio children aged 8: 11% in 1988 30% in 1999 New Mexico 3rd graders: 47-52% in health district with program 19% in health district without program Review Standard: Documentation of program benefits or outcomes.

42. Best Practice Criteria (2) Efficiency New Mexico Dentists screen children Dental hygienists apply sealants Dental assistants also apply sealants Review Standard: Program uses the least expensive personnel permitted by state law.

43. Best Practice Criteria (3) Sustainability Sealant Programs New Mexico26 yrs. Ohio20 yrs. Illinois19 yrs. Arizona17 yrs. Funding Ohio…MCH/Tobacco $ Arizona………Medicaid Review Standard: Program with a track record or a plan for covering program expenses.

44. Best Practice Criteria (4) Collaboration & Integration Sealant Partners Local health departments Community agencies School health services Medicaid Primary Care Office Foundations Private dentists & dental hygienists Review Standard: Partnerships are established to administer & sustain the program.

45. Best Practice Criteria (5) Rationale & Objectives Healthy People 2010 Objective 21-8: Increase of children who have received sealants on their molar teeth Aged 8 years50% Aged 14 years50% Review Standard: Program is linked to state &/or national goals and objectives.

46. ASTDD Best Practices Project Putting science into practice

47. www.astdd.org Best Practice Approach Reports ASTDD Web Site

48. www.astdd.org

52. Building a System: Ongoing and Dynamic Development Identify Best Practices Cultivate Best Practices Promote Best Practices Collaborate & Integrate Science & Art Supportive Environment