1. Oral Health Partnership Core Group Meeting April 21, 2017
Seven Hills Foundation and Tufts University School of Medicine

2. Agenda – April 21, 2017 Introductions Communication plan update
Peter Demko
Research question identification
John Morgan
Tier II – Tier III transition and next steps
Paula Minihan

3. Research Question Overview
National PCORI goal
Determine which of the options available to patients (and health professionals who care for them) work best
Individual PCORI project goals
Identify gaps in knowledge about best ways to prevent or treat an important health problem
Propose a research question (evidence-based) to fill information gap
PICOTS framework
Population
Intervention
Comparisons
Outcomes
Time period
Setting

4. Research Questions from March 17th Meeting (PICOTS)
Group A
Intervention: Monitor toothbrushing at home
Outcome: Reduction in caries
Comparison: Compare adults with and without toothbrushing monitoring at home
Group B
Intervention: Reduce behavioral barriers to dental visits through patient-focused interventions (e.g., systematic desensitization)
Outcome: Increase % patients with at least 1 dental cleaning/year
Comparison: Compare adults with and without intervention
Group C
Dental varnish applications at least 2 times/year
Outcome: Decrease in caries over time
Comparison: Compare adults with at least 2 varnish applications/year with those without

5. Tooth Decay (Dental Caries)
U.S. general population of dentate adults aged 20 or older (U.S. CDC)
Approximately 91% had caries experience (at least one cavity)
23% had untreated caries
Adults with intellectual and developmental disabilities in Massachusetts aged 20 or older with access to dental care* (Morgan et al 2012)
87.8% of dentate adults had caries experience
32.2% of dentate adults had untreated caries
*4.6 preventive dental visits during study year

6. Cause of Tooth Decay
For tooth decay to occur, bacteria (plaque) use sugars in your diet to produce acids which dissolve the tooth surface.

7. What Factors Can Modify Tooth Decay Process
Saliva
Frequency of sugar intake (diet, beverages, nutritional supplements, medications)
Fluoride use
Drinking fluoridated water
Brushing with fluoridated toothpaste
Having dental professionals apply fluoride

8. Caries - Adults with IDD
What Can We Influence ?
Community
Access to dental care; Public policies, laws; regulations; Fluoridation
Family/caregivers Competing demands; Oral health roles; Adaptive tools ,
Patients Level of disability; Anatomical considerations; Medications; Diet (sugar); Ability to cooperate with dental visits; Oral home care
Caries - Adults with IDD

9. Scientific Evidence for Prevention of Tooth Decay/Caries
PCORI requires we use evidence-based information to develop our research question
Summary
No studies to show effective prevention of caries in those with intellectual and developmental disabilities (IDD)
Should we consider the evidence for prevention of caries in those without IDD ?
What evidence do we have?

10. Studies – Evidence about Preventing Decay
Children
Fluorides prevent decay in children
Toothpaste, rinses used at home are effective
Gels and varnishes applied by dental professionals are effective
Chronic disease management strategies - working with parents and caregivers – prevent early childhood caries
Few studies for effective use of fluorides in adults
Recent fluoride studies/medically compromised Veterans
Self applied or professionally applied fluoride reduced caries
No studies for fluoride use in those with disabilities
No studies for chronic disease management in adults with disabilities

11. Chronic Disease Management (CDM) Interventions
Package of strategies that – combined together - might help prevent or manage a disease
Focus on health conditions in which patient’s/caregiver’s personal behaviors have major influence on disease process
Preventive home care key
Examples: Diabetes, Childhood asthma, Early childhood caries
Approach is multi-disciplinary
Involves community resources and supports
Can involve clinical interventions like fluoride varnish application

12. CDM of Dental Caries: Prevents Early Childhood Caries
CDM strategies reduced new cavities, dental pain, and referrals to OR in children compared to baseline (i.e., experiences before enrolling in research study).
Relies on patient-specific prevention and focused management of the disease (diet, brushing, flossing, plus motivational interviewing and other caregiver supports) in addition to repairing/restoring teeth
Individual Risk Assessment
Examples:
MySmileBuddy: IPad-based behavioral, family-based intervention to eradicate ECC
ECC Collaborative

13. CDM of Dental Caries ECC Collaborative
Pediatric hospital dental clinic-based (up to age 5)
Caries risk assessment
Effective communication with parents/hygienist
Self-management goal setting/hygienist
Caries charting
Fluorides/remineralization strategies
Restorative treatment
Risk-based recare intervals
MySmile Buddy
Pediatric dental clinic-based (ages 2-6)
Standard of care at clinic
Technology-assisted ECC risk assessment & behavioral intervention tool (iPads) with families
Diet, feeding practices, attitudes, fluoride, family hx
Lay health worker and family create self-defined plan to reduce ECC risk
Lay health worker provides community-based family support and monitoring using iPad interactive programming

14. Other Evidence
Four studies have demonstrated that training caregivers in oral hygiene practices for adults with IDD was effective in improving daily oral hygiene practices
Not known if improved daily oral hygiene translated into improved oral health outcomes

15. What is Best Way Forward
Use the scientific evidence that is available and apply and tailor it to address the needs and circumstances of adults with IDD

16. Tier II – Tier III Transition and Next Steps
Tier II Final Report and related documents due May 31
Communication Plan
State, Regional, National Stakeholder document
CER Question
Governance document
Tier III Proposal and Workplan due May 31
Tier III awardees announced mid-July
Tier III begins August 1