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 treating dental caries • Shift prevention and treatment of caries from mechanical problem to manageable medical condition • Focus on managing caries lesions early before cavitation develops • No drilling • Non-invasive and minimally-invasive treatment 2
Clinical Potentials • Identify caries risk level of individual patients by evaluating: • Disease indicators • Risk factors • Preventive factors • Categorize patients into: • Low, medium, and high/extreme risk • Measuring for Improvement • Set treatment plan according to individual risk level 3
Policy Potentials • Improve efficiency: • Identify those at moderate and high risk • Justify reallocation of resources from low risk (reduce the redundancy of services) • Assist in strategic planning: • Identify and target high risk population • Use in decision-making process and comparative cost-effectiveness studies • Better allocate available resources 4
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 5
Research Questions: • Can current CRA tools inform oral health policies? • Using current CRA tools, what is the projected 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)? 6
Methods: • Selected a sample of 9 CRA tools • National Health and Nutrition Examination Survey (NHANES) 2013-2014 • Developed 10 caries risk assessment models • Modified of the 9 tools & DFMT • Individuals aged 1-20 enrolled in Medicaid or CHIP • 1,520 observations representing a weighted nationally representative population of 24,026,343 people 7
National Health and Nutrition Sample of CRA Tools Examination Survey 2013-2014 CRA tool CRA modification models AAPD assessment that more than one decayed/missing/filled M1. DMFT/dmft_all tooth surface is considered a high-risk case T1. CAMBRA risk assessment tool for children 0 to 5 years of M2. CAMBRA-C age T2. American Academy of Pediatric Dentistry risk assessment M3. AAPD-nondental-I tool for nondental providers T3. American Academy of Pediatric Dentistry risk assessment M4. AAPD-C tool for children 0 to 5 years of age T4. American Dental Association risk assessment index for M5. ADA-C children 0 to 6 years of age T5. Boston Children’s Hospital risk assessment tool for children M6. BCH-C ages 0 to 5 years T6. CAMBRA risk assessment tool for individuals age 6 years M7. CAMBRA-A and above M8. CARIOGRAM-all T7. CARIOGRAM risk assessment tool all ages T8. American Academy of Pediatric Dentistry risk assessment M9. AAPD-A tool for individuals 6 years of age and above T9. American Dental Association risk assessment tool for M10. ADA-A 8 individuals 7 years of age and above
Costing Methodology: • Estimated the cost of care by risk level using a disease management protocol • Estimated the cost of dental care for this population by multiplying: % at risk level*utilization rate at risk level*cost of recommended care at risk level • Estimated the cost per user by adding the estimate cost of care at all levels • Estimated the aggregate cost by multiplying the cost per enrollee by the number of enrollees 9
RESULTS 10
Risk Factors Included in Selected CRA Tools: Disease Indicators and Biological Factors AAPD non- Risk factors CAMBRA CAMBRA Cariogram 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 Disease Indicators and Biological Factors 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 11
Risk Factors Included in Selected CRA Tools: Disease Indicators and Protective Factors AAPD non- Risk factors CAMBRA CAMBRA Cariogram 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 Socioeconomic factors 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 X X X X X X dental care/regular dental care) Recent immigrant X X X Eligibility for government programs X Risk factors Caregiver/sibling has active caries X X X X X X Diet (>3 between meal sugar-containing snacks or beverages X X X X X X X X X per day) Presence of saliva-reducing factors (medication, medical or X X X X genetic factors) Bottle use (contains fluids other than water; sleeps with a X X X X bottle); continual bottle use; or nurses on demand Recreational drug use/alcohol abuse X X Protective factors Fluoride exposure (drinking water, fluoride supplement, X X X X X X X X X toothpaste, or topical fluoride from health professional) Additional home measures (e.g. Xylitol) X X X X Caregiver decay free last 3-years X 12
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 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, Use fluoride toothpaste; given Tooth decay or previous experience with dental concentrating, walking, dressing or bathing, or doing prescription fluoride drops or CAMRA-C diseases, and presence of plaque errands alone; did not see dentist for more than a year fluoride tablets; brush teeth twice a (irregular dental care); visited dentist due to being day bothered, hurt, or problem; consume more than the recommended daily sugar intake; use prescription drugs Presence of plaque; consume more than the Use fluoride toothpaste; given recommended daily sugar intake; use prescription Tooth decay or previous experience with dental prescription fluoride drops or CAMRA-A drugs; used marijuana every month for a year; ever used diseases, and presence of plaque fluoride tablets; brush teeth twice a cocaine/heroin/methamphetamine; ever had 4/5 drinks day every day Presence of plaque; consume more than the Use fluoride toothpaste; given Tooth decay or previous experience with dental recommended daily sugar intake; serious difficulty in prescription fluoride drops or CARIOGRAM diseases, and presence of plaque any of the following: hearing, seeing, concentrating, fluoride tablets; brush teeth twice a walking, dressing or bathing, or doing errands alone day From household at or below federal poverty line; HH reference education level is high school graduate or less; presence of plaque ; consume Use fluoride toothpaste; given more than the recommended daily sugar intake; prescription fluoride drops or AAPD nondental-I serious difficulty in any of the following: NA fluoride tablets; brush teeth twice a hearing, seeing, concentrating, walking, day dressing or bathing, or doing errands alone; tooth decay or previous experience with dental diseases; reside in the US for less than 5 years 13
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