Norman Tinanoff University of Maryland August 3, 2011 Norman Tinanoff University of Maryland August 3, 2011 Caries Risk Assessment and Clinical Care Paths

Norman TinanoffUniversity of Maryland

August 3, 2011

Norman TinanoffUniversity of Maryland

August 3, 2011

Caries Risk Assessment Caries Risk Assessment and Clinical Care Pathsand Clinical Care Paths

History of Access to Care in MarylandHistory of Access to Care in Maryland

Year Medicaid Population Preventive Visits %

Restorative Visits %

1997 88,000 18 7

2005 483,000 28 26

2006 491,000 28 27

2007 493,000 31 29

2008 505,000 35 30

2009 540,000 43 33

Dental Action Committee RecommendationsDental Action Committee Recommendations Sept. 2007 (6 months after D. Driver died)Sept. 2007 (6 months after D. Driver died)

Develop a Develop a unified and unified and culturally and linguistically culturally and linguistically appropriate oral health appropriate oral health messagesmessages to educate parents to educate parents and caregivers of young and caregivers of young childrenchildren

Incorporate Incorporate dental screeningsdental screenings with with vision and hearing screenings vision and hearing screenings for for public school children or require public school children or require dental exams prior to school dental exams prior to school entryentry. .

Provide Provide trainingtraining to dental and to dental and medical providers to provide medical providers to provide oral health risk assessmentsoral health risk assessments, , educate parents/caregivers educate parents/caregivers about oral health, and to assist about oral health, and to assist families in establishing a dental families in establishing a dental home for all children. home for all children.

Initiate statewide single vendor dental Administrative Services Only provider

Increase dental reimbursement rates to the 50th percentile

Maintain and enhance the dental public health infrastructure by ensuring that local jurisdiction has a local health department dental clinic and a community oral health safety net clinic and by providing funding

Establish a public health level dental hygienist to provide screenings, prophylaxis, fluoride varnish, sealants, and x-rays in public health settings.

Dental Action Committee7 Recommendations

Increase dental reimbursement rates (indexed by inflation) to median fee charged by area dentists (ADA 50th percentile) – began July 1, 2008– First of 3 annual increments – most diagnostic and all preventive

rates increased

Single payer dental Medicaid program – carve out from Medicaid program – Implemented – July 2009– Insurance company has to have a provider identified for every

child

Increase the dental public health infrastructure - $2M/yr. – Funding to Office of Oral Health in July 2008– Funding for local health department, federally qualified health

center (FQHC) and private, & non-profit dental programs– New dental clinical programs in 6 Maryland counties previously

without public health dental services

Dental Action Committee7 Recommendations

Expand the role of dental hygienists in public health practice– Legislation (HB 1280/SB 818) unanimously passed --October

2008

Pediatric dental training of physicians and general dentists– Fluoride varnish initiatives - Medicaid reimbursement to

physicians in July 2009– 400 physicians trained at the University of Maryland Dental

School– 20,000 fluoride varnish claims ($.5M)

Oral health screenings required for school entrance – Demonstration project funded for one county in 2011– Legislation pending for next state legislative session

Develop a unified educational/social marketing program– Federal Earmark of $1.3M from Senator Mikulsky – Deamonte Driver Program of Oral Health Access - $1.1M

History of Access to Care in MarylandHistory of Access to Care in Maryland

Year Medicaid Population

Preventive Visits %

Restorative Visits %

1997 88,000 18 7

2005 483,000 28 26

2006 491,000 28 27

2007 493,000 31 29

2008 505,000 35 30

2009 540,000 43 33

Because of the tremendous increase in the population 9X more preventive services and 8X more restorative services were delivered in 12 years.

However, the costs have increased from 2.7M in 1997 to 71.4 M in 2008 (26X).

Caries Risk Assessment Caries Risk Assessment

Dental Caries Protocols (Care Paths) Dental Caries Protocols (Care Paths)

As Bob Russell said last night, “Is this tremendous increase in effort and cost actually

reducing dental disease?”

Perhaps the system is inefficient without --

JAMA 285: 2486, 2001

Physicians Use of Risk Assessment (e.g. Heart Disease) Physicians Use of Risk Assessment (e.g. Heart Disease)

Early Studies of Risk Assessment in DentistryEarly Studies of Risk Assessment in Dentistry

Bohannan et al. A summary of the results of the National Preventive Dentistry Bohannan et al. A summary of the results of the National Preventive Dentistry Demonstration Program. Demonstration Program. Can Dent Assoc JCan Dent Assoc J 6: 435, 1985 6: 435, 1985

Demers et al. A multivariate model to predict caries increment in Montreal children age 5 Demers et al. A multivariate model to predict caries increment in Montreal children age 5 years. years. Comm Dent Health Comm Dent Health 9:373, 19929:373, 1992

Disney et al. The University of North Carolina caries risk assessment study. Disney et al. The University of North Carolina caries risk assessment study. Comm Dent Comm Dent Oral EpidemiolOral Epidemiol 20:64, 1992 20:64, 1992

Thibodeau and O’Sullivan. Mutans streptococci and caries prevalence in preschool Thibodeau and O’Sullivan. Mutans streptococci and caries prevalence in preschool children. children. Comm Dent Oral Epidemiol Comm Dent Oral Epidemiol 21:288, 199321:288, 1993

Litt MD et al. Multidimensional Causal Model of Dental Caries Development in Low-Litt MD et al. Multidimensional Causal Model of Dental Caries Development in Low-Income Preschool Children. Income Preschool Children. Public Health ReportsPublic Health Reports 110: 607, 1995 110: 607, 1995

Caries diagnosis and risk assessment. A review of preventive and strategies and Caries diagnosis and risk assessment. A review of preventive and strategies and management. management. JADAJADA 126:1S, 1995 126:1S, 1995

Recent Emphasis on Recent Emphasis on Risk Assessment in Dentistry Risk Assessment in Dentistry

• Gives understanding of the disease factors for a patientGives understanding of the disease factors for a patient

• Individualizes and selects preventive recommendationsIndividualizes and selects preventive recommendations

• Individualizes treatment Individualizes treatment

• Less treatment for low risk; more for those at high riskLess treatment for low risk; more for those at high risk

History and Evidence History and Evidence History and Evidence History and Evidence previous cariesprevious caries

mutans streptococcimutans streptococci

income and educationincome and education

visible plaquevisible plaque

dietdiet

fatalismfatalism

mother’s taste perceptionmother’s taste perception

multiple risk factorsmultiple risk factors

previous cariesprevious caries

mutans streptococcimutans streptococci

income and educationincome and education

visible plaquevisible plaque

dietdiet

fatalismfatalism

mother’s taste perceptionmother’s taste perception

multiple risk factorsmultiple risk factors

caries freecaries free

pit and fissurepit and fissure

maxillary anteriormaxillary anterior

caries freecaries free

pit and fissurepit and fissure

maxillary anteriormaxillary anterior

initial caries patternsinitial caries patternsinitial caries patternsinitial caries patterns Baseline dmfsBaseline dmfs year 2 dmfsyear 2 dmfsBaseline dmfsBaseline dmfs year 2 dmfsyear 2 dmfs

0.00.0 1.4 1.4

3.03.0 5.9 5.9

5.05.0 10.1 10.1

0.00.0 1.4 1.4

3.03.0 5.9 5.9

5.05.0 10.1 10.1

Relationship of initial caries pattern to caries incidenceRelationship of initial caries pattern to caries incidence

in 142, 3- to 4-year-old (at baseline) inner city childrenin 142, 3- to 4-year-old (at baseline) inner city children

Relationship of initial caries pattern to caries incidenceRelationship of initial caries pattern to caries incidence


Thibodeau and O’Sullivan. Comm Dent Oral Epidemiol 21:288, 1993

All dmfs is Not the SameAll dmfs is Not the Same

Probably arrested lesionsProbably arrested lesions

Probably active lesionsProbably active lesions

All White Spot Lesions are Not the SameAll White Spot Lesions are Not the Same

Probably arrested lesionsProbably arrested lesions

Probably active lesionsProbably active lesions

Mutans StreptococciMutans Streptococci

Evidence for mothers as the source of MS Evidence for mothers as the source of MS in their childrenin their children

Paper Country Mother-Child pairs

Children with at least 1 identical

strain

Berkowitz et al , 1975 US 4 100%

Li et al, 1995 US 34 71%

De Soet et al, 1998 Netherlands 21 38%

Kohler et al, 2003 Sweden 16 85%

Klein et al 2004 Brazil 16 81%

Li et al, 2004 US 37 89%

Hames-Kocabas et al, 2006 Turkey 25 24%

There are 17 studies in this area between 1975 and 2006, with the mean of 70.4% of children with at least one identical strain.

MS rangeMS range baseline dmfs baseline dmfs year 2 dmfs year 2 dmfs

lowlow 0.2 0.2 1.2 1.2

moderatemoderate 1.4 1.4 3.1 3.1

highhigh 3.4 3.4 7.9 7.9

MS rangeMS range baseline dmfs baseline dmfs year 2 dmfs year 2 dmfs

lowlow 0.2 0.2 1.2 1.2

moderatemoderate 1.4 1.4 3.1 3.1

highhigh 3.4 3.4 7.9 7.9

Relationship of mutans streptococci levels to caries incidenceRelationship of mutans streptococci levels to caries incidence


Relationship of mutans streptococci levels to caries incidenceRelationship of mutans streptococci levels to caries incidence


Thibodeau and O’Sullivan. Comm Dent Oral Epidemiol 21:288, 1993

Counts/ml salivaCounts/ml saliva Caries was Caries was presentpresent

Caries was not Caries was not presentpresent

Odds RatioOdds Ratio Fisher Exact Fisher Exact test (P)test (P)

Selective MediaSelective Media

Mutans streptococci (MS) ≥ 10Mutans streptococci (MS) ≥ 1044 3131 44 6464 0.0010.001

MS < 10MS < 1044 55 4141

Lactobacilli (LB) ≥ 10Lactobacilli (LB) ≥ 1033 1414 22 1414 0.0010.001

LB < 10LB < 1033 2121 4343

Veillonella (VL) ≥ 106 24 14 5 0.001

VL < 106 11 31

Microbial Indicators of Dental Caries in Children Under Three Years of Age Microbial Indicators of Dental Caries in Children Under Three Years of Age

Park et al. Caries Res 40:277, 2006Park et al. Caries Res 40:277, 2006

Caries Experience by Economic SituationCaries Experience by Economic Situation

in U.S. 2-5-Year-Old Children in U.S. 2-5-Year-Old Children NHANES III, 1988-1994NHANES III, 1988-1994

Caries Experience by Economic SituationCaries Experience by Economic Situation

in U.S. 2-5-Year-Old Children in U.S. 2-5-Year-Old Children NHANES III, 1988-1994NHANES III, 1988-1994

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0Education

Income

<$10K $10K-20K $20K-30K >$30K

No HighSchool

Some HighSchool

CompletedHigh School

College

Correlation of caries prevalence to SES indicators Correlation of caries prevalence to SES indicators

in 1,539 4-year-old Arizona childrenin 1,539 4-year-old Arizona children

Correlation of caries prevalence to SES indicators Correlation of caries prevalence to SES indicators

in 1,539 4-year-old Arizona childrenin 1,539 4-year-old Arizona children

Tang et al. Public Health Reports 112: 319, 1997.Tang et al. Public Health Reports 112: 319, 1997.

Correlation of Plaque on Primary Teeth and Caries RiskCorrelation of Plaque on Primary Teeth and Caries Risk

Aluluusua, S. et al. Comm Dent Oral Epi. 22: 273-276, 1994 Sensitivity 83%, Specificity 92%

Lee CL, et al. J. Pub Hlth Dentistry 68:57-60, 2008 Correlation between % MS and plaque regrowth, R = 0.34; p <.05

Dietary FactorsDietary Factors

Eats breakfast every dayEats breakfast every daynono 34.6% 34.6%yesyes 22.5% 22.5% 0.0010.001

Stopped bottle by 12 monthsStopped bottle by 12 months no 26.5%no 26.5% yesyes 20.5% 0.02 20.5% 0.02

% with ECC Sig% with ECC Sig

Nunn et al., J Dent Res 88:361-366-275, 2009Nunn et al., J Dent Res 88:361-366-275, 2009

Dental Fatalism Dental Fatalism

“ “Most children eventually develop dental cavities” Most children eventually develop dental cavities” yesyes 76.7% 76.7%

nono 23.3% 23.3% 0.02 0.02

Ismail, et al. J Dent Res 88:270-275, 2009Ismail, et al. J Dent Res 88:270-275, 2009

% with ECC Sig% with ECC Sig

Mothers’ Taste Perception as a Risk Factor for their Children's Dental Caries


Figure 12. Mean dmfs of children related to mothers’ PROP type and the presence of grandparents in the household (F=9.251, p=0.005)

Presence of grandparents in the household

Yes

No

Non-taster Super taster PROP type


Multiple Risk FactorsMultiple Risk Factors

HISTORICAL PRESENT FUTURE

psychological factors

baby bottle usage sucrose consumption

race/ethnicity

parent’s dental knowledge mutans strep. levels

CARIES

CARIES (86% of caries predicted)

HISTORICAL PRESENT FUTURE

psychological factors

baby bottle usage sucrose consumption

race/ethnicity

parent’s dental knowledge mutans strep. levels

CARIES

CARIES (86% of caries predicted)

Litt et al. Public Health Reports 110: 607, 1995

Multidimensional Causal Model of Dental Caries Development in Low-Income Preschool Children

High Risk

Moderate Risk

Protective Factors

Biological Factors

Mother/primary caregiver has active caries Yes

Parent/caregiver has low SES Yes

Child has >3 between meal sugar snacks Yes

Put to bed with a bottle containing sweets Yes

Child has special health care needs Yes

Child is a recent immigrant Yes

Protective Factors

Child exposed to fluoridated drinking water Yes

Child has teeth brushed daily with F toothpaste

Yes

Child receives professional topical fluoride Yes

Additional home measures Yes

Child has dental home/regular dental care Yes

Clinical Findings

Child has white spot lesions or enamel defects Yes

Child has visible caries Yes

Child has elevated mutans streptococcus Yes

Child has plaque on teeth Yes

Caries Risk Assessment for 0-5 Year Olds Caries Risk Assessment for 0-5 Year Olds (CCA, 2010(CCA, 2010))

High Risk

Moderate Risk

Protective Factors

Biological Factors

Patient has >3 between meal sugar snacks Yes

Patient is of low SES Yes

Patient has special health care needs Yes

Patient is a recent immigrant Yes

Protective Factors

Patient exposed to fluoridated drinking water Yes

Patient brushes teeth daily with F toothpaste Yes

Child receives professional topical fluoride Yes

Additional home measures Yes

Patient has dental home/regular dental care Yes

Clinical Findings

Patient has one or more interproximal lesions Yes

Patient low salivary flow Yes

Patient has defective restorations Yes

Patient wearing an intraoral appliance Yes

Caries Risk Assessment for >6 Year Olds Caries Risk Assessment for >6 Year Olds (CCA, 2010)(CCA, 2010)

Evidence for Caries Risk Assessment Evidence for Caries Risk Assessment

Dental Caries Protocols (Care Paths) Dental Caries Protocols (Care Paths)

Newsweek, March 2, 2009Newsweek, March 2, 2009

$1 Billion for Comparative-Effective Research $1 Billion for Comparative-Effective Research – research on best practices and measures – research on best practices and measures which ones are most cost-effective. which ones are most cost-effective.

Health care in the US is a marvel of Health care in the US is a marvel of technology, consumes 1/6 of nations wealth, technology, consumes 1/6 of nations wealth, without making us comparatively healthy. without making us comparatively healthy.


Coronary by-pass surgery in Texas is 5X those Coronary by-pass surgery in Texas is 5X those in Colorado; Back surgery in Wyoming is 6X in Colorado; Back surgery in Wyoming is 6X those in Hawaiithose in Hawaii

The difference in how conditions are treated The difference in how conditions are treated are due to medical culture not to medical are due to medical culture not to medical sciencescience

Conclusion – need to allow for individual Conclusion – need to allow for individual differences; but also need standardsdifferences; but also need standards. .

Rate of Orthopedic Procedures in Medicare Population, 2003Rate of Orthopedic Procedures in Medicare Population, 2003

Each point represents 1 of 300 health regionsEach point represents 1 of 300 health regions

mean

mean

Congressional Budget Office, Research on the Comparative Effectiveness of Medical Treatments, Dec. 2007

Wyoming

Hawaii


……....decision to pursue one treatment over decision to pursue one treatment over another is based more on professional bias and another is based more on professional bias and patient’s misperceptions than it is on sound patient’s misperceptions than it is on sound sciencescience …… treatments each come with their …… treatments each come with their own cadre of devotees, and members of one own cadre of devotees, and members of one camp often don’t communicate with members of camp often don’t communicate with members of another. another.

April 29, 2009April 29, 2009

The Affordable Care Act contains $1.1 billion for The Affordable Care Act contains $1.1 billion for Comparative Effectiveness Research.Comparative Effectiveness Research.

The aim is to compare the clinical outcomes, The aim is to compare the clinical outcomes, effectiveness, and appropriateness of services, effectiveness, and appropriateness of services, that are used to prevent, diagnose, or treat that are used to prevent, diagnose, or treat diseases. diseases.

Example of a Caries Protocol for a 0-2 Year-OldExample of a Caries Protocol for a 0-2 Year-Old

Diagnostic Fluoride Sealants Diet Counseling

Restorative

Low Risk --Recall every year--Baseline MS

--Twice daily brushing with F toothpaste

NA Yes Surveillance

Moderate Risk parent engaged

--Recall every six mo. -- Baseline MS


--Fluoride supplements*-- Prof. topical F every 6 mo.

NA YesActive surveillance **

Moderate Risk parent not engaged

--Recall every six mo.--Baseline MS


--Prof. topical F every 6 mo.

NA Limit expectationsActive surveillance

High Risk parent engaged

--Recall every three mo.-- Baseline & followup MS


--Fluoride supplements*--Prof. topical F every 3 mo.

NA Yes--Active surveillance -- Restore cavitated lesions in posterior

with ITR

High Risk parent not engaged

--Recall every three mo.--Baseline & followup MS



NA Limit expectations --Active surveillance -- Restore cavitated lesions in posterior

with ITR

* Need to consider fluoride levels in drinking water

Tests Caries Risk Analysis

Clinical ExamRadiographic Exam

Compliance

Low Caries Risk

Moderate Caries Risk

High Caries Risk

Toothbrush with F, .1%

Toothbrush with F, .1%Professional F, 6 mo.

Diet counseling


Diet counselingMotivational Interview

Recall

Active Surveillance Active Surveillance (0-2 yr old)(0-2 yr old)(prevention and careful monitoring for signs of progression)(prevention and careful monitoring for signs of progression)

Example of a Caries Protocol for a 3-5 Year-OldExample of a Caries Protocol for a 3-5 Year-Old


Restorative

Low Risk --Recall every year--Radiographs every two

years --Baseline MS

--Twice daily brushing with F No No Surveillance

Moderate Risk parent engaged

--Recall every six mo.--Radiographs yearly-- Baseline MS

--Twice daily brushing with F --Fluoride supplements*


Yes Yes Active surveillance of incipient lesions

Moderate Risk parent not engaged

--Recall every six mo.--Radiographs yearly--Baseline MS

--Twice daily brushing with F--Prof. topical F every 6 mo.

Yes Limit expectations

--Active surveillance --restore cavitated or

enlarging lesions

High Risk parent engaged

--Recall every three mo.--Radiographs , six mo.--Baseline & followup MS

--Brushing with high potency F gel (with caution)

--Fluoride supplements*--Prof. topical F every 3 mo.

Yes Yes --Active surveillance --restore cavitated or

enlarging lesions

High Risk parent not engaged

--Recall every three mo.--Radiographs, six mo.--Baseline & followup MS

--Brushing with high potency F gel (with caution)


Yes Limit expectations

Restore, incipient, cavitated or enlarging

lesions


Radiographic CriteriaRadiographic Criteria

Risk Category Only Primary Dentition

Transitional Dentition

Permanent Dentition

New Patient May not be required

Bitewings and panorex

Bitewings and panorex or FMS

Low Risk Recall Posterior bitewings at 12-24

months

Posterior bitewing at 12-24

months

Posterior bitewings at 24-26 months

Increased Risk Recall

Posterior bitewings at 6-12

months

Posterior bitewings at 6-12

months

Posterior bitewings at 6-18 months

ADA & US Dept of Health and Human Services, 2004.

Topical FluorideTopical Fluoride

Risk Category <6 6-18 18+

Low None None None

Moderate Varnish or foam at 6 month intervals

Varnish or gel at 6 month intervals

Varnish or gel at 6 month intervals

High Varnish or foam at 3 or 6 month

intervals

Varnish or gel at 3 or 6 month intervals

Varnish or gel at 3 or 6 month intervals

Hunter et al. Professionally Applied Topical Fluoride: Evidence-Based Clinical Recommendations. JADA 2006;137:1151-1159.

Example of a Caries Protocol for a >6 Year-OldExample of a Caries Protocol for a >6 Year-Old


Restorative

Low Risk --Recall every year--Radiographs every two

years

--Twice daily brushing with F No No Surveillance

Moderate Risk child engaged

--Recall every six mo.--Radiographs yearly

--Twice daily brushing with F--Fluoride supplements*--Prof. topical F every 6 mo.

Yes --Yes--xylitol


enlarging lesions

Moderate Risk child not engaged

--Recall every six mo.--Radiographs yearly

--Twice daily brushing with F--Prof. topical F every 6 mo.

Yes --Limit expectations

--xylitol


enlarging lesions

High Risk child engaged

--Recall every three mo.--Radiographs , six mo.

--Brushing with high potency F gel--Fluoride supplements*--Prof. topical F every 3 mo.

Yes --Yes--xylitol


enlarging lesions

High Risk child not engaged

--Recall every three mo.--Radiographs, six mo.

--Brushing with high potency F gel--Prof. topical F every 3 mo.

Yes --Limit expectations

--xylitol

Restore, incipient, cavitated and enlarging

lesions


Tests Caries Risk Analysis

Clinical ExamRadiographic Exam

Compliance

Low Caries Risk

Moderate Caries Risk

High Caries Risk

Toothbrush with F, .1%


SealantsXylitol

Diet counseling


SealantsXylitol

Diet counselingMotivational Interview

Recall

Active Surveillance Active Surveillance (>6 years old)(>6 years old)

June 14, 2011 MeetingJune 14, 2011 Meeting

17 experts from dental insurance, education and practice recommended guiding principles for the Pediatric Dental benefit of the Affordable Care Act to the Secretary of HHS:

Treatment should be based on individualized-care according to their level of diseaseTreatment should be based on evidence-based guidelines

Documents

Norman Tinanoff University of Maryland August 3, 2011 Norman Tinanoff University of Maryland August 3, 2011 Caries Risk Assessment and Clinical Care Paths