ASSESSMENT POTENTIALS AND REALITIES Yara A. Halasa-Rappel, DMD, - - PowerPoint PPT Presentation
CARIES RISK ASSESSMENT POTENTIALS AND REALITIES Yara A. Halasa-Rappel, DMD, PhD AcademyHealth Annual Research Meeting Sunday June 2, 2019 Washington, DC Caries Risk Assessment: Background Major transformation in conceptualizing and
Yara A. Halasa-Rappel, DMD, PhD AcademyHealth Annual Research Meeting Sunday June 2, 2019 Washington, DC
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Caries Risk Assessment: Background
dental caries
mechanical problem to manageable medical condition
cavitation develops
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Clinical Potentials
evaluating:
level
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Policy Potentials
(reduce the redundancy of services)
cost-effectiveness studies
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Source: Halasa-Rappel, Ng, Gaumer, and Banks. 2019. How useful are current risk assessment models in informing the oral health decision making process? The Journal of the American Dental Association, 150(2): 91-102, https://doi.org/10.1016/j.adaj.2018.11.011
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Research Questions:
policies?
cost to state and the federal government, for providing dental care services to those aged 1- 20 enrolled in Medicaid or the Children’s Health Insurance Plan (CHIP)?
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Methods:
Survey (NHANES) 2013-2014
CHIP
nationally representative population of 24,026,343 people
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Sample of CRA Tools
CRA modification models
CRA tool
AAPD assessment that more than one decayed/missing/filled tooth surface is considered a high-risk case
age
tool for nondental providers
tool for children 0 to 5 years of age
children 0 to 6 years of age
ages 0 to 5 years
and above
tool for individuals 6 years of age and above
individuals 7 years of age and above
National Health and Nutrition Examination Survey 2013-2014
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Costing Methodology:
disease management protocol
population by multiplying: % at risk level*utilization rate at risk level*cost of recommended care at risk level
estimate cost of care at all levels
cost per enrollee by the number of enrollees
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Risk Factors Included in Selected CRA Tools: Disease Indicators and Biological Factors
Risk factors CAMBRA CAMBRA Cariogram AAPD non- dental AAPD AAPD ADA ADA BCH DMFT Targeted age 0-5 6+ 21+ 0-3 0-5 6+ 0-6 7+ 0-5 1-110 Obvious white spots, decalcification, or obvious decay X X X X X X X X X X Plaque X X X X X X X X Inadequate salivary flow X X X X X X X Radiographic proximal enamel lesions X X Patient wearing an intraoral appliance X X X X X Recent dental restoration (past caries experience) X X X X X X Missing teeth due to caries X X X X Microflora (Mutans streptococci) X X New demineralization since last exam X MS and LB both medium or high (by culture) X Deep pits and fissures X X Exposed roots X X Saliva buffer X Non-cavitated carious lesions X X Defective restorations X X Unusual tooth morphology X Disease Indicators and Biological Factors
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Risk Factors Included in Selected CRA Tools: Disease Indicators and Protective Factors
Risk factors CAMBRA CAMBRA Cariogram AAPD non- dental AAPD AAPD ADA ADA BCH DMFT Targeted age 0-5 6+ 21+ 0-3 0-5 6+ 0-6 7+ 0-5 1-110 Socio-demographics X X X X X Special healthcare needs/ general health conditions X X X X X X X X Child has a dental home and regular dental care (access to dental care/regular dental care) X X X X X X Recent immigrant X X X Eligibility for government programs X Caregiver/sibling has active caries X X X X X X Diet (>3 between meal sugar-containing snacks or beverages per day) X X X X X X X X X Presence of saliva-reducing factors (medication, medical or genetic factors) X X X X Bottle use (contains fluids other than water; sleeps with a bottle); continual bottle use; or nurses on demand X X X X Recreational drug use/alcohol abuse X X Fluoride exposure (drinking water, fluoride supplement, toothpaste, or topical fluoride from health professional) X X X X X X X X X Additional home measures (e.g. Xylitol) X X X X Caregiver decay free last 3-years X Socioeconomic factors Risk factors Protective factors
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Assignment of Risk Factors by Caries Risk Model
Risk model High risk Moderate risk Low risk DMFT/dmft_all More than 2 decayed, filled, or missing teeth One decayed, filled, or missing tooth No decayed, filled, or missing teeth CAMRA-C Tooth decay or previous experience with dental diseases, and presence of plaque At or below federal poverty line; HH reference education level is high school graduate or less; serious difficulty in any of the following: hearing, seeing, concentrating, walking, dressing or bathing, or doing errands alone; did not see dentist for more than a year (irregular dental care); visited dentist due to being bothered, hurt, or problem; consume more than the recommended daily sugar intake; use prescription drugs Use fluoride toothpaste; given prescription fluoride drops or fluoride tablets; brush teeth twice a day CAMRA-A Tooth decay or previous experience with dental diseases, and presence of plaque Presence of plaque; consume more than the recommended daily sugar intake; use prescription drugs; used marijuana every month for a year; ever used cocaine/heroin/methamphetamine; ever had 4/5 drinks every day Use fluoride toothpaste; given prescription fluoride drops or fluoride tablets; brush teeth twice a day CARIOGRAM Tooth decay or previous experience with dental diseases, and presence of plaque Presence of plaque; consume more than the recommended daily sugar intake; serious difficulty in any of the following: hearing, seeing, concentrating, walking, dressing or bathing, or doing errands alone Use fluoride toothpaste; given prescription fluoride drops or fluoride tablets; brush teeth twice a day AAPD nondental-I From household at or below federal poverty line; HH reference education level is high school graduate or less; presence of plaque; consume more than the recommended daily sugar intake; serious difficulty in any of the following: hearing, seeing, concentrating, walking, dressing or bathing, or doing errands alone; tooth decay or previous experience with dental diseases; reside in the US for less than 5 years NA Use fluoride toothpaste; given prescription fluoride drops or fluoride tablets; brush teeth twice a day
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Risk model High risk Moderate risk Low risk AAPD-C From household at or below federal poverty line; HH reference education level is high school graduate or less; consume more than the recommended daily sugar intake; tooth decay or previous experience with dental diseases Serious difficulty in any of the following: hearing, seeing, concentrating, walking, dressing or bathing, or doing errands alone; reside in the US for less than 5 years; presence of plaque Use fluoride toothpaste; given prescription fluoride drops; or fluoride tablets; brush teeth twice a day; and on average use a pea-sized amount of toothpaste when brushing teeth AAPD-A From household at or below federal poverty line; HH reference education level is high school graduate or less; consume more than the recommended daily sugar intake; tooth decay or previous experience with dental diseases; use prescription drugs (patient has slow salivary flow) Serious difficulty in any of the following: hearing, seeing, concentrating, walking, dressing or bathing, or doing errands alone; reside in the US for less than 5 years Use fluoride toothpaste; given prescription fluoride drops or fluoride tablets; brush teeth twice a day; and have regular dental care (visited a dentist in the last 6 months for routine check-up) ADA-C Eligible for government programs (Medicaid/ SCHIP insurance); consume more than the recommended daily sugar intake; serious difficulty in any of the following: hearing, seeing, concentrating, walking, dressing or bathing, or doing errands alone; use prescription drugs (patient has slow salivary flow) Presence of plaque; no regular dental care (did not visit a dentist in the last 6 months for routine check-up); no fluoride exposure Use fluoride toothpaste; given prescription fluoride drops or fluoride tablets; brush teeth twice a day; and have regular dental care (visited a dentist in the last 6 months for routine check-up) ADA-A Consume more than the recommended daily sugar intake; serious difficulty in any of the following: hearing, seeing, concentrating, walking, dressing or bathing, or doing errands alone; tooth decay or previous experience with dental diseases; use prescription drugs (patient has slow salivary flow) Presence of plaque; no regular dental care (did not visited a dentist in the last 6 months for routine check- up); no fluoride exposure; serious difficulty in any of the following: hearing, seeing, concentrating, walking, dressing or bathing, or doing errands alone (age over 14 years); use prescription drugs (patient has slow salivary flow); used marijuana every month for a year; ever used cocaine/heroin/methamphetamine; ever had 4/5 drinks every day Use fluoride toothpaste; given prescription fluoride drops or fluoride tablets; brush teeth twice a day; and have regular dental care (visited a dentist in the last 6 months for routine check-up) BCH-C Tooth decay or previous experience with dental diseases, and presence of plaque Consume more than the recommended daily sugar intake; use prescription drugs (patient has slow salivary flow); serious difficulty in any of the following: hearing, seeing, concentrating, walking, dressing or bathing, or doing errands alone Use fluoride toothpaste; given prescription fluoride drops or fluoride tablets; brush teeth twice a day; and on average use a pea-sized amount of toothpaste when brushing teeth
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Individuals Enrolled in Medicaid/CHIP: Ages 1-20
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Individuals Enrolled in Medicaid/CHIP: Age 1-3
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Individuals enrolled in Medicaid/SCHIP: Age 4 -6
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Individuals enrolled in Medicaid/SCHIP: Age 7-20
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Projected Annual Cost: Low Risk
Dental service Frequency Unit cost Cost Disease management (DM) protocol 1.5 $45 $68 Fluoride varnish application 1.5 $35 $53 Diagnostic and prevention (excluding DM) $88 $0 Interim therapeutic restoration (ITR) $135 $0 Conventional restorative $193 $0 Surgery $8,026 $0 Total cost $120 Low Risk
Source: Ng MW. Quality improvement efforts in pediatric oral health. J Calif Dent Assoc. 2016;44(4):223-32
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Projected Annual Cost: Moderate Risk
Dental service Frequency Unit cost Cost
Source: Ng MW. Quality improvement efforts in pediatric oral health. J Calif Dent Assoc. 2016;44(4):223-32
Total cost $120 Disease management (DM) protocol 3.5 $45 $158 Fluoride varnish application 3.5 $35 $123 Diagnostic and prevention (excluding DM) 1 $88 $88 Interim therapeutic restoration (ITR) 1 $135 $135 Conventional restorative 1 $193 $193 Surgery $8,026 $0 Total cost $696 Moderate Risk
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Projected Annual Cost: High Risk
Total cost $696 Disease management (DM) protocol 8 $45 $360 Fluoride varnish application 8 $35 $280 Diagnostic and prevention (excluding DM) 1 $88 $88 Interim therapeutic restoration (ITR) 1 $135 $135 Conventional restorative 1 $193 $193 Surgery 1 $8,026 $8,026 Total cost $9,082 High Risk
Source: Ng MW. Quality improvement efforts in pediatric oral health. J Calif Dent Assoc. 2016;44(4):223-32
Dental service Frequency Unit cost Cost
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Projected Cost of Dental Services by Risk Level for Individuals Enrolled in Medicaid or SCHIP: Age 1-20
CRA Models Low Moder- ate High Low Moder- ate High Low Moder- ate High Low Moder- ate High DMFT/dmft- all 46% 8% 47% 69% 85% 83% $120 $696 $9,082 $37 $46 $3,492 CAMBRA-C 5% 40% 55% 100% 64% 83% $120 $696 $9,082 $5 $181 $4,135 CAMBRA-A 33% 5% 62% 79% 67% 83% $120 $696 $9,082 $31 $26 $4,650 CARIOGRAM- all 32% 5% 62% 81% 72% 83% $120 $696 $9,082 $31 $27 $4,687 AAPD non- dental-I 12% 0% 88% 83% 0% 77% $120 $696 $9,082 $12 $0 $6,130 AAPD-C 12% 5% 83% 81% 75% 77% $120 $696 $9,082 $12 $27 $5,805 AAPD-A 12% 3% 85% 88% 68% 77% $120 $696 $9,082 $13 $13 $5,946 ADA-C 0% 0% 100% 0% 0% 76% $120 $696 $9,082 $0 $0 $6,930 ADA-A 30% 50% 19% 100% 60% 81% $120 $696 $9,082 $36 $210 $1,429 BCH-C 66% 23% 11% 100% 70% 78% $120 $696 $9,082 $79 $112 $800 Risk level Utilization by risk level Cost per risk level Cost of care by risk level
Cost per risk level=Risk level*Utilization by risk level*Cost of care by risk level
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Projected cost of dental services (per user, per enrollee and aggregate) for individuals enrolled in Medicaid or SCHIP: Age 1-20
Cost of covering the same population (24 million) varies from $18 billion to $127 billion depending on the model used
Models Annual cost per user Annual cost per enrollee Annual aggregate cost, in billion US$ DMFT/dmft-all $3,576 $2,729 $65.60 CAMBRA-C $4,322 $3,287 $79.00 CAMBRA-A $4,707 $3,801 $91.33 CARIOGRAM-all $4,745 $3,870 $92.99 AAPD non-dental-I $6,143 $4,780 $114.84 AAPD-C $5,844 $4,549 $109.28 AAPD-A $5,972 $4,663 $112.02 ADA-C $6,930 $5,287 $127.03 ADA-A $1,675 $1,279 $30.72 BCH-C $991 $745 $17.90
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Conclusions:
important concept for both strategic planning or policy formulation
need to share and use big data
system
Institute of Medicine (2001)
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Acknowledgements:
Medicine, Boston, MA
Analysis, Cedar Park, TX
Fellowship at Harvard School of Dental Medicine
Institute of Medicine (2001)
Yara Halasa-Rappel, DMD, PhD Yara.HalasaRappel@dentaquest.com (781) 860-0680