1. TRUMAN MEDICAL CENTERS Effects of oral care training on a mobile dental population Lakewood John Dane, DDS, FAAHD, DABSCD Dental Director Elks Mobile Dental Program TMC Lakewood Presentation to SCDA April 28, 2012

2. Presentation Objectives Background of the problem Patient management Oral Care before training Video and testing Results of the Oral Care Changes Keys of Success/Ideas for the future

3. Hypotheisis 1. When individuals brush daily or receive assistance from caregivers in cleaning their teeth and mouth routinely, potential decay of teeth and disease of gums will be reduced. 2. When individuals become accustomed to someone cleaning their teeth and mouth daily, they become less anxious when they have the opportunity to access care from dental professionals, resulting in better cooperation and reduced need for stabilization procedures

4. Project Participants Department of Mental Health Division of Developmental Disabilities – Training needs – Oral Care needs identified for clients/customers – Patient care issues on mobile unit Elks Mobile Dental Program – Sedation limitations by the Dental Board – Overwhelming number of patients needing care

5. Program Objectives Objective1: Develop and implement an oral health training curriculum for caregivers of people with developmental disabilities, and train registered nurse staff at DMRDD Regional Offices as trainers of the curriculum Objective 2: Describe the Oral Health and Cooperation of Elks patients to dental treament. Objective 3: Implement oral health care training with Emmaus Homes, Inc.(St. Charles, MO), and Arc of the Ozarks (Springfield, MO)

6. Program Objectives Cont’d. Objective 3: Implement oral health care training with additional community providers, and with natural family caregivers Objective 4: Describe the Oral Health and the Cooperation of Elks Patients to treatment after implementation of the training.

7. Elks Mobile Dental Currently in it’s 50 th year providing dental services The DHSS contract ranged from it’s highest $428,000.00 in 2003 to $270,000 in September 2009. Our relationship with the DHSS ended September 2009. Elks provide $250,000 per year in support Down from a high of 42 locations in the state we now provide services in only 14 counties in the state of Missouri

8. Elks Mobile Dental Program Partnerships Training for community based dentists in management of developmentally delayed patients State-wide referral network of dentists who provide care Partner with SB40 Boards and other agencies

9. The Problem

10. People with IDDD have significantly higher need for oral care and periodontal treatments Dependence on caregivers for oral care Minimal instruction for caregivers and what is given is not standardized need to improve education for all persons involved in the oral health of adults with intellectual disabilities. 1

11. Is the Operating room the answer?

12. Background “Little attention has been given to the oral health needs of middle generation of disabled Adults whose numbers are growing.” 4 Estimated 30,000 IDDD persons in Missouri. Missouri Survey 2007 revealed that: – 24% of the DD individuals could not find dental care – 37% cited cost of care a barrier – 44% responded that they had unmet dental needs 76% did not have access to routine basic care 37% did not have access to emergency dental care

13. Money?! Adults with IDDD are overwhelmingly poor. 4 Missouri Medicaid dropped almost all of the Adults with developmental disabilities in 2005 – Must qualify at 26% of US Poverty guidelines – Only those in institutional settings might qualify – They won’t pay for hospital charges if the patient is seen in the operating room.

14. Implementation

15. Behavioral Assessment Staff was instructed in the definitions of patients in-chair behaviors based on the methods needed to manage the patient for the appointment. Pre operative assessment was kept from the staff. The same staff did the Pre training and the post training assessment several months apart. Procedures accomplished on the patient were not necessarily identical In both appointments.

16. Cooperation Assessment Scores 1.Cooperative patient treat as easily as a non- disabled patient 2.Patient has difficulty cooperating but can be treated with training, education or verbal coaching 3.Patient requires stabilization, handholding, or immobilization. 4.Sedation or Anxiolytics may be required. 5.Unable to treat effectively in outpatient setting, referred for general anesthesia. 6.Wheelchair bound, cooperative patient

17. Oral Health Assessment Staff was instructed in the definitions of patients oral care status during screening visits in the facility Pre-training assessment was kept from the staff. The same staff did the Pre training and the post training assessment several months apart. Screening assessments were similar.

18. ARC Oral Health Index Aug-09Aug-10 ScoreDescription of Oral Health CareBaseline Totals%Follow-Up Totals%Results% 1Excellent00%12%11% 2Very Good00%812%810% 3Very Good/Good00%69%67% 4Good/Very Good00%711%79% 5Good69%35%-34% 6Good/Fair914%46%-56% 7Fair/Good00%58%56% 8Fair2844%69%-2228% 9Fair/Poor58%69%11% 10Poor/Fair00%35%34% 11Poor914%12%-810% 12Poor/Very Poor00%23%22% 13Very Poor23%00%-22% 14Non-Existent00%0 0 15Edentulous12%23%11% 16Did Not Participate/No Data46%1116%79% Totals64100%65100%

21. Emmaus Home-St. Charles Oral Health Index Nov-09Jul-10 ScoreDescription of Oral Health CareBaseline Totals% Follow-Up Totals%Results% 1Excellent00%0 0 2Very Good23%57%35% 3Very Good/Good00%11%12% 4Good/Very Good00%0 0 5Good811%8 00% 6Good/Fair00%11%12% 7Fair/Good00%46%47% 8Fair912%1014%12% 9Fair/Poor00%710%712% 10Poor/Fair00%0 0 11Poor2230%1116%-1118% 12Poor/Very Poor00%23%2 13Very Poor1926%11%-1829% 14Non-Existent00%0 0 15Edentulous1014%811%-23% 16Did Not Participate/No Data34%1319%1017% Totals73100%71100% ** Note--Edentulous patients will have two descriptions. ** 63 total Emmaus Patients.

24. Development of Training Video A 38 minute video presentation was developed with the Mo D MH Division of Developmental Disabilities “To be effective a preventive dental program must be modified and tailored to the needs and functional abilities of the individual” 4

25. Cooperation for Dental Care In a 1998 survey done by Gordon, they found 27.9% of respondents expressed fear and anxiety to dental visits Half of this group reported being nervous or terrified Extreme fear was inversely related to frequency of dental visits and perceived oral health status.

26. Program Plan “Physicians, nurses, counselors, therapists, must gain and awareness of the importance of oral health to total health” 4 “Direct attendant personnel must know fundamental of oral health and disease” 4 Evidence based training curriculum developed

27. Access to Training Elks dental staff were assigned training sessions for nurse trainers in the DMDD system. Materials we installed on the Statewide Department of Secondary Education Website and You Tube.

28. Emmaus/St Charles cooperation index Nov-09Jul-10 ScoreDescription of CooporationBaseline Totals%Follow-Up Totals%Results% 1No Stabilization33%1921%1627% 2Needs Prompting/Handholding3335%1517%-1831% 3Head Restraint/Resistant2223%1517%-712% 4Needs Sedation44%22%-23% 5Papoose/Potective Stabilization00%0 0 6Patient in Wheelchair3234%2730%-58% 7Did Not Participate/No Data11%1213%1119% Totals95100%90100% ** Note patients in wheelchairs will have two descriptions. ** 63 total Emmaus patients.

30. ARC Springfield Cooporation Index Aug-09Aug-10 ScoreDescription of CooporationBaseline Totals%Follow-Up Totals%Results% 1Normal00%2333%2336% 2Needs Prompting/Handholding3954%2231%-1727% 3Head Restraint/Resistant1723%710%-1016% 4Needs Sedation11%00%2% 5Patient in Wheelchair1014%710%-35% 6Papoose/Potective Stabilization23%00%-23% 7Did Not Participate/No Data45%1116%711% Totals73100%70100% ** Note patients in wheelchairs will have two descriptions. ** 63 total ARC Patients.

32. Keys to success/Plans for the future Support and involvement of the nurse trainers of the Department of Mental Health Division of Developmental Disabilities Plan a more controlled study

33. References 1.Simon, Mary-Anne, Cullen Erickson, Margaret, Lloyd, Chris and Carlson, Glenys, (2004). The Experiences and Perceptions of Unit Managers in Facilitating Oral Health in Adults with Intellectual Disability. International Journal of Disability, Community and Rehabilitation,Vol 3, 2.Oral Health in America: A Report of the Surgeon General, 2000 3.Wolfe, Adam J. D.D.S., Waldman, H. Barry, D.D.S.,M.P.H., Ph.D., Milano, Michael, D.M.D., and Perlman, D.D.S., M.Sc.D, (2004) Dental student’s experiences with and attitudes toward people with mental retardation. Journal of the American Dental Association, Vol 135, No. 3, 353-357

34. References Cont’d 4.Stiefel DJ, Dental Care Considerations for Disabled Adults, Special Care Dentist 22(3)26S-39S, 2002 5.Charles JM, Dental Care in Children with Developmental Disabilities, Attention Deficit Disorder, Intellectual Disabilities and Autism., Journal Dent Child 77:2, 84-91. 2010