SPNS IHIP Oral Health Webinar Series:
Healthy Mouth, Healthy Body
……………….
Presented by CDR Mahyar Mofidi, DMD, PhD and Jane Fox, MPH
December 13, 2013
Agenda
■ Introduction
to SPNS Integrating HIV
Innovative Practices (IHIP) project
■
Sarah Cook-Raymond, Managing Director of
Impact Marketing + Communications
■ Presentations from:
■ Dr. Mahyar Mofidi; Branch Chief of the Division of
Community HIV/AIDS Programs and Chief Dental
Officer, HRSA HIV/AIDS Bureau
■ Jane Fox, MPH; Project Director of SPNS Oral Health
Initiative Evaluation Center for HIV and Oral Health
(ECHO), Boston University School of Public Health
■Q
&A
IHIP Resources on
TARGET Center Website
www.careacttarget.org/ihip
IHIP Oral Health Resources
■Training
Manual
■Curriculum
■Pocket
Guide
■Webinar
■
■
■
Series
Healthy Mouth, Healthy Body
Dental Case Management
Clinical Aspects of Oral Health Care for PLWHA
Recording and slides for all Webinars will be uploaded to
TARGET Center Web site following the live event:
www.careacttarget.org/ihip
Other IHIP Resources
■
Buprenorphine Therapy
■
■
Engaging Hard-to-Reach Populations
■
■
Training Manual, Curriculum, and Webinars on engaging hardto-reach populations
Jail Linkages
■
■
Training Manual, Curriculum, Monograph, and Webinars on
implementing buprenorphine in primary care settings
Training Manual, Curriculum, Pocket Guide, and Webinars on
enhancing linkages to HIV care in jails settings
UPCOMING: Hepatitis C Treatment Expansion
■
In Spring/Summer 2014, look for training materials on increasing
access to and completion of Hepatitis C treatment for PLWHA on
the TARGET Center Web site.
Healthy Mouth, Healthy Body: Oral Health Care's
Vital Role in Overall Well Being for
People Living with HIV/AIDS
CDR Mahyar Mofidi, DMD, PhD
Branch Chief
Chief Dental Officer
HRSA, HIV/AIDS Bureau
December 13, 2013
6
12+ years ago
 You cannot be healthy
without oral health.
 Oral health is essential
to overall health and
quality of life, and all
families need access to
high-quality dental
care.
7
Oral Health for PLWHA
 “While good oral health is important to the well
being of all population groups, it is especially critical
for people living with HIV/AIDS (PLWHA). Inadequate
oral health care can undermine HIV treatment and
diminish quality of life, yet many individuals living
with HIV are not receiving the necessary oral health
care that would optimize their treatment.”
-U.S. Public Health Service Surgeon General Regina
M. Benjamin, MD, MBA
8
Why does
good oral health
matter in HIV care?
9
Oral Disease in HIV Infection
 Oral infections and
neoplasms occur with
immunosuppression
32-46% of PLWHA have at
least one oral disease
condition related to HIV
(bacterial, fungal, viral,
neoplastic, lymphoma,
ulcers)
 High prevalence of dental
caries and periodontal
disease
Some HIV medications have
side effects (xerostomia or
dry mouth) which can lead to
tooth decay and periodontal
disease
10
Prevalence of Dental Caries and Periodontal
Disease in a Ryan White HIV/AIDS ProgramFunded Dental Clinic
Dental caries were present in 66% of patients
54% had gingivitis and 28% had periodontal
disease
Infectious Disease Society of America (IDSA) 47th
Annual Meeting – November 2009 – Poster #1063
11
Oral Manifestations of HIV/AIDS
For those with unknown HIV status, oral
manifestations may suggest HIV infection,
although they are not diagnostic.
Reznik DA. Perspective - Oral Manifestations of HIV Disease.
International AIDS Society–USA Topics in HIV Medicine.
Volume 13 Issue 5 December 2005/January 2006
12
Oral Manifestations of HIV/AIDS
For persons living with HIV disease not
yet on therapy, the presence of certain
oral manifestations may signal
progression of disease.
Reznik DA. Perspective - Oral Manifestations of HIV Disease.
International AIDS Society–USA Topics in HIV Medicine.
Volume 13 Issue 5 December 2005/January 2006
13
Oral Manifestations of HIV/AIDS
For persons living with HIV disease on
antiretroviral therapy, the presence of
certain oral manifestations may signal a
failure in therapy.
Hodgson TA, Greenspan D, Greenspan JS. Oral lesions of HIV
disease and HAART in industrialized countries. Adv Dent Res.
2006 Apr 1;19(1):57-62
14
Oral Disease is Rarely Self-Limiting
Untreated oral disease may
lead to systemic infections,
weight loss, malnutrition
Oral health diseases are linked
to systemic diseases: diabetes,
heart disease, pregnancy issues
Oral diseases impact quality of
life: psycho-social problems,
limited career opportunities
15
How can dental
providers make a
difference?
16
Role of Dental Providers
 Eliminate infection, pain, and discomfort
 Restore oral health functions
 Early detection of HIV and referral: Oral lesions can be the first overt
clinical feature of HIV infection. Early detection can improve prognosis
and reduce transmission/
 A visit to the dentist may be a health care milestone for PLWHA. The
dental professional can address oral health concerns and play a role in
helping engage or re-introduce patients into the health care system and
coordinate their care with other primary care providers.
17
What are the Benefits of Early Linkage to
Oral Health Care After HIV Diagnosis?
 196 HIV-positive individuals:
63 newly diagnosed cases (out of oral care and within 12
months of their HIV diagnoses)
Previously diagnosed controls (66 out of oral care and
diagnosed with HIV between 1985-2007)
Historical controls (67 receiving regular oral care and
diagnosed with HIV between 1985-2007)
IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.
18
Findings
 Persons who were newly diagnosed had significantly more teeth at baseline
compared to the previously diagnosed and historical groups.
 Newly diagnosed individuals had less periodontal disease (attachment loss and
less bleeding on probing).
 Previously diagnosed individuals had poorer gingival health and more broken
teeth.
 The previously diagnosed group had the most dental decay.
 Service usage varied considerably:
 Newly diagnosed: more preventive and maintenance services
 Previously diagnosed: more costly prosthodontic services
IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.
19
Findings
 The higher levels of dental disease in the previously
diagnosed group resulted in higher treatment costs.
 “Early dental intervention in the newly diagnosed
HIV-positive individuals results in significant
functional maintenance, more optimal oral health,
and considerable financial savings.”
IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.
20
What oral health
needs/barriers do
PLWHA face?
21
Unmet Oral Health Needs
 Oral health is one of the top unmet needs for PLWHA
who obtain services through the Ryan White
HIV/AIDS Program nationwide.
 PLWHA have more unmet oral health care needs than
the general population and have more unmet oral
health care needs than medical needs.
 PLWHA most likely to report unmet need for dental
care are African American, uninsured, Medicaid
recipients, and within 100% of federal poverty limits.
22
Barriers to Oral Health Care
 Lack of dental insurance
 Limited financial resources
 Shortage of dentists
 Too many appointments, other aspects of illness seen as
being more important
 Fear, no positive role models, stigma, shame
 Negative patient-provider experiences
 Shrinking adult dental Medicaid benefits
23
State Adult Dental Coverage in Medicaid, 2013
20
18
18
18
Number of states
16
14
15
12
12
14
10
8
10
9
6
6
4
2
0
0
Full benefits Comprehensive
Limited
benefits
Emergency
benefits
No benefits
Source: ADULT DENTAL BENEFITS IN MEDICAID, ADA
24
Oral Health Care is Expensive
Service
National average fees charged by
private practitioner
Comprehensive oral evaluation/
examination
Limited oral evaluation
Intraoral radiograph (first film)
$66.29
Sample reimbursed fees by
Medicaid
$14.89 - $44.61
$57.60
$23.41
$14.00 - $36.76
$3.63 - $14.91
Adult cleaning
Filling (amalgam, one surface)
$77.64
$110.35
$22.10 - $58.00
$15.59 - $64.56
Filling (clear, one surface)
Extraction (simple)
Extraction (surgical)
Endodontic (molar root canal)
$131.30
$138.21
$224.11
$868.00
$25.62 - $65.90
$25.62 - $63.54
$33.43 - $109.23
$157.93 - $409.90
Crown (porcelain)
Complete denture (upper)
$908.00
$1,333.57
$580.00
$584 - $600
25
What are we doing
about oral health?
26
Oral Health: HRSA Strategic Priority
Expand oral health and integrate
it in primary care settings
27
Ryan White HIV/AIDS Program
and Oral Health Services
SPNS OHI
Special Projects of National Significance
Innovations in Oral Health Care Initiative
15 sites across country
Grantees implemented innovative models of
comprehensive oral health care services to
expand dental access
29
Other HIV/AIDS Bureau
Oral Health Investments
 Oral health capacity assessment during site visits
 All Grantee Meeting
 Oral health performance measures
 Oral health a funding priority under Part C Capacity Development
Funding Opportunities
 Program evaluations
 Publications
30
Impact of Ryan White HIV/AIDS
Programs on Oral Health Care
 FY 2011: 135,004 clients received dental services
 FY 2011: 8,480 dental providers (mostly dental students and
residents) provided direct oral health care as part of CBDPP
and DRP
 FY 2011: 8,461 health care professionals (3,451 dental, 5,010
non dental) received oral health care education through
AETCs
31
Impact on Our Clients
“People treat you as if they have known you their whole life.”
“They take care of my fear.”
“They are like a big family…they gave me my smile back.”
“I feel free, secure and welcomed by the staff.”
“I feel comfortable…not treated as a HIV patient but a person who needs dental care.”
“We’re all so fortunate to get what we need.”
“It’s affordable. It’s a one stop shop.”
“This is the only game in town.”
“Quality of care here is 110%.”
32
Acknowledgment
Dr. David Reznik
33
Contact Info
CDR Mahyar Mofidi, DMD, PhD
HRSA/HAB Chief Dental Officer
mmofidi@hrsa.gov
301-443-2075
34
Evaluating the HRSA
SPNS Oral Health
Initiative
Jane Fox, MPH
Boston University
HRSA Oral Health
SPNS Initiative
• September 2006 HRSA funded 15 sites
and one evaluation & TA center
• Five year funding cycle
• Sites were charged with increasing access
to oral health care for PLWHA
SPNS Sites
SPNS Models - Typology
• Three types of host agencies
– ASO/CBO (5), CHC (4), and
hospital/University-based programs (6)
• Three basic models:
– Fixed site
• Expansion of prior dental program/services
• Implementation of new dental program
– Mobile dental units
Evaluation Study Questions
• Do the demonstration programs increase access to
oral health care for the target population?
• What are the main similarities and differences in
strategies and program models to increase access
to oral health care across programs?
• Are the oral health services performed in
accordance with professional practice guidelines?
• Do clients experience improvements in health
outcomes over time?
Evaluation Study Questions
• Are clients’ oral health care needs met?
• Do clients experience improvements in oral health
related quality of life after enrollment in oral
health care?
• What strategies are most effective in furthering
successful program implementation: barriers,
facilitators, key lessons learned?
• What strategies to address the structural, policy
and financing issues can be replicated in other
settings?
Evaluation Study Design
• Study criteria
– HIV+, 18+ years of age, and no oral health care*
for the past 12 months or more
• Quantitative survey at baseline and follow-up
– Demographics, past access, insurance, HIV
status, past oral health symptoms, SF-8, OH
QOL, and presenting problem
• Utilization and ancillary data
– CDT codes of EVERY procedure done, evidence of
tx plan completion and recall
Evaluation Study Design
• Qualitative interviews
– In-depth interviews of 60 patients at 6 sites
• OH experiences and values, OH self care
knowledge and behaviors, patient education, and
impact of HIV on OH
• Dental case manager focus group
– June 2008 with 12 participants
Patient Demographics
• 75% male
• 40.6% Black, 21.2%
Latino
• 33.4 % high school
education, 43.0% beyond
high school
• 30.6% working, 55.7%
monthly income < $850
• Age = 43.6 (18 – 81),
• Yrs positive = 10.07
Last dental visit
Never
3%
21%
29%
12%
35%
< 12
months
1 - 2 yrs
2 - 5 yrs
>5 yrs
Baseline Dental Access
• Usual place for dental care: 38.6% none;
31.0% private dentist
• 48.2% reported needing dental care but
were not able to get it since testing positive
• Of those who did not get dental care, 53.8%
stated affordability as the reason.
Baseline HIV Status
• 97.5% had a regular place for HIV care and
95.0% had seen their HIV provider in the
past 6 months
• 85.2% had an HIV case manager and 77.9%
were taking ARTs
• 57.35 had a CD4 count over 350 and 52.8%
had an undectable viral load
Significant Changes in Outcomes
at 12 Months, N=1391
Outcome
Report unmet need for oral
health care
Report good/excellent health of
teeth and gums
Oral health symptoms: mean
(SD)
Baseline 12 Mos.
48%
17%
38%
67%
3.35 (2.34) 1.78 (1.93)
Significant Changes in Oral Health
Symptoms at 12 Months, N=1391
60%
53%
52%
50%
40%
30%
20%
51%
43%
30%
35%
34%
26%
21%
Intake
17%
10%
0%
Tooth decay Sensitivity Appearance Toothache
Bleeding
gums
12 Months
Significant Changes in Habits at 12
Months, N=1391
Habit
Baseline
12 mos P value
Daily brushing
83%
82%
.407
Daily flossing
19%
25%
<.001
Flossing at all in past 6 months
53%
62%
<.001
Current smoker
50%
45%
<.001
Eating candy or chewing gum with
sugar
61%
52%
<.001
Drinking soda with sugar
64%
31%
<.001
Patient Perspectives - Habits
• Improvements in oral health care practices
– Better brushing & flossing techniques & frequency
• “ Now I buy lots of toothbrushes and use them for a short
time and replace them.”
• “I brush everyday instead of 3 times/week...I floss a lot more”
• “I brush longer”
– Reduce or stop smoking/tobacco use
• “ I still use snuff but I cut back a little and don’t leave it in my
mouth as long...”
• “I cut down from 3 cigarettes/day from 1 pack...”
– Dietary changes
• “I still drink soda but only once in awhile...I try not to buy it”
Standards of Care
• We established a set for the multi-site
evaluation:
–
–
–
–
–
The presence of a comprehensive exam
The presence of any xrays
The presence of any cleaning or periodontal work
Completion of Phase I treatment plan
Patient placed on recall
Service Utilization:
N=2178, 14 sites
Over the course of
the study:
• Patients made over
15,000 clinic visits
• They received over
37,000 services
• 917 (42%)
completed a Phase 1
treatment plan
*Phase 1 Treatment Plan = Prevent
and treat active disease
Services provided in first 12 months of care
#
Pts who
provided
received any
service
n /%
Clinic Visits
Phase 1
Treatment Plans
Completed*
Comprehensive
Exams
11,315
2178
100%
717
717
33%
2077
1944
89%
Access to & Retention in Care
• 43% of patients came in for preventive care
• 64% of patients were retained in care
• Those retained in care were:
– More likely to complete their treatment plan
– More likely to have a recall visit
– Reported less pain, fewer symptoms at follow up
• Factors significantly associated with
retention
– Older age, better physical health, on HIV medications, more recent dental
visit
– Receipt of patient education – 6 times as likely to be retained in
care
“…I very rarely go. I was not a regular client
at the dentist because my parents only
took me to the dentist once in my life and
so I didn’t know the need for follow-up
dental—you know keeping a good hygiene
program until I got older.”
Engagement in Care
“Outreach and retention were two things
we did not anticipate to be problematic
when planning for this grant. As we
began to open our clinic and serve
patients, we realized that this is one of
the most important aspects of operating
a dental clinic for this population.”
Getting Patients in the Door
• Marketing
– Paid & unpaid media
• Community materials
– Literacy level
• Outreach to providers
– Clinicians
– Case managers
– Other CBOs
• Ancillary services
– Transportation
– Other social or
medical services
• Special events
– SPNS days
• Word of mouth
– Peers
Keeping Patients in Care
• Follow-up appointments
− Timely and efficient
• Reminder calls
• Dedicated staffing
− Patient navigators/dental case managers
− Staff skills and relationships with patients
• Patient education and empowerment
− “When both the dentist and the dental case manager reviewed the
treatment plan with the patients, the patients gained a better
understanding of why the proposed treatment was needed.”
•
Incentives
− “thank you gifts”
− transportation
Dental Case Management
•
8 programs included dental case management
–
–
•
758 patients were enrolled into the study from the 8 DCM sites.
–
•
5 in non-urban settings and 3 in urban settings
DCMs were either
• Dental assistants who were given training on case management; or
• HIV case managers who were given training on oral health topics
They had a total of 2715 encounters with a DCM over the course of a year of treatment.
• Appointment reminders/rescheduling
• Arranging or providing transportation
• Provision of food or nutritional information
• Provision of oral health information and support
Outcomes
–
Participants with more DCM encounters were significantly more likely to complete their Phase 1
treatment plan at 12 months, be retained in oral care and experience improvements in overall oral
health and mental health status.
–
Participants with 5+ DCM encounters (23%) were 2.73 times more likely to complete their
treatment plan compared to those with just one DCM encounter. (Lemay, et.al)
“
Patient Perspectives DCMs
She has helped me very much. First and
foremost, she has helped me just with the
comfort level of dealing with a place like this.
I am kind of intimidated by a dentist. I mean,
who is not? But she has been very comforting
and she has been very good at explaining
procedures. If it wasn’t for what she has done for
me as far as helping, scheduling, talking, sitting
with me during the dentist and everything, I may
not have followed through. So it has made a
really big difference. It makes me feel like there
is somebody committed to my dental care, so
my commitment can’t be any less than that.
Patient PerspectivesThe role of the DCM
– Access to oral health care
• “I would not have dental care if it wasn’t for (name of
dental case manager)”
• “He (dental case manager) got me into the program and
it has been good to me”
– Retention in dental care
• “ I feel comfortable with her and it makes me want to
come to appointments”
– Helps with patient/provider communication
– Provides oral health education
Policy Implications
• Successful strategies for outreach, engagement
and retention in dental care
• Increasing access is feasible
• Standards of care
• Patient and community education
• Workforce innovations
• Future financing and sustainability
Contact Information
Jane Fox, MPH
Evaluation Center for HIV and Oral Health
Boston University
617-638-1937
janefox@bu.edu
http://echo.hdwg.org/
Upcoming Oral Health Webinars
Dental Case Management
January 9, 2014 at 1 PM EST
•
Presenters:
•
Dr. Howell Strauss and Mr. Nelson Diaz, AIDS Care Group of
Chester, PA
•
Dr. Carolyn Brown and Ms. Lucy Wright, Native American
Health Center of San Francisco, CA
Clinical Aspects of Oral Health Care for PLWHA
January 22, 2014 at 3 PM EST
•
Presenters:
•
Dr. David Reznik, HIVDent and Grady Health System of Atlanta,
GA
•
Ms. Helene Bednarsh, RDH, MPH, HIVDent and Boston Public
Health Commission of Boston, MA
Q&A
To be informed about Webinars and other upcoming IHIP
resources, sign up for the IHIP listserv by emailing
scook@impactmc.net.
IHIP Web site: www.careacttarget.org/ihip
Connect with Us
Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications
Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300