Evidence-Based DentistryFrederick Eichmiller, DDSVP & Dental Directorfeichmiller@deltadentalwi.com

EBD and Health Care Plans

Definition

• Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences.

“Patient-centered definition”

•Evidence based dentistry is a set of principles and methods intended to insure to the greatest extent possible, clinical decisions, guidelines and other types of policies are based on and consistent with good evidence of effectiveness and benefit.

Adapted from David M EddyHealth Affairs 2005

Business-Centered Definition

Why do we need it?

•Dental treatment decisions have been largely based on observations of historical response of a disease or condition to an intuitive treatment.

• Methods of treatment were based upon a good understanding of underlying disease and physiology.

• G.V. Black’s “extension for prevention”• Caries control via plaque removal

• The observations of outcomes, however, have often rarely been validated or tested scientifically to see if they are valid.

•Un-validated results often reinforce less than optimal treatments.

Example of broken teeth with amalgam fillings

• Most tooth fractures occur in amalgam filled teeth

Conclusion: Amalgam leads to tooth fracture and bonding teeth with posterior composite restorations strengthens them, resulting in fewer tooth fractures.

Fractured teeth

Problems with that conclusion• The oldest and largest fillings are mostly amalgam• There are far more amalgam filled posterior teeth to

observe

The scientific evidence:• The primary reason for failure of a filling is recurrent

decay and there is no difference in the incidence of recurrent decay between different filling materials.

• There is no difference in tooth fracture incidence or prevalence between any of the different types of filling materials.

Information Overload

“Are topical fluoride treatments effective in reducing caries in children?”

MedLine Search “children, topical fluoride, caries”• 1031 articles

No single dentist can possibly keep up with the literature an any single topic, much less all aspects of practice!

“For every PhD there exists an equal, but opposite PhD”

“integration of systematic assessments of clinically relevant scientific evidence”

“Systematic Review”1. Collect all published evidence on a question2. Rank on value-based score card

• Human > animal>laboratory• Prospective>observational>retrospective>case report• Double blind>cohort comparisons• Controlled>non controlled• Randomized > non randomized• Replicated>non replicated

“Gold Standard” – double blind, randomized, controlled clinical trials

“integration of systematic assessments of clinically relevant scientific evidence”

“Meta analysis”1. Compile results and analysis from all available

studies ignoring individual study conclusions2. Re-analyze pooled results based upon common

“meta” statistics3. Develop an overall conclusion based upon the

overall grouped “meta analysis”

Possible Outcomes

1. The evidence supports a particular treatment as being effective.

2. The evidence does not support a particular treatment as being effective.

3. The evidence appears to support, but is not completely definitive for a particular treatment.

4. There is inadequate evidence to support or refute a particular treatment at this time.

Unfortunately, most dental systematic reviews result in either 3 or 4.

“with the dentist's clinical expertise and the patient's treatment needs and preferences”

•Most times in dentistry historical and observational experience is all we have!

•Not all dentists are created equal

•Patients make the final health care decisions

The Nation’s Health Care Dollar

Physician & Clinical Services 22%Physician & Clinical Services 22%

31¢Hospital Care

29¢Physician Services Prescription

Drugs

14¢Admin14¢

Other Professional

Services

9¢ Durable Medical Products

1¢

Source: Adapted from Centers for Medicare and Medicaid Services, 2006

Nursing Home and

Home Health

2¢

Health Costs Represent Largest Sectorof GDP

Source: Bureau of Economic Analysis Q3 2006

16.5% = $2.2 Trillion

3.4% 4.6%

10.5% 9.6%

16.5%

0%2%4%6%8%

10%12%14%16%18%

Auto NationalDefense

Housing Food Health

Perc

ent o

f GD

P

*Projected by Centers for Medicare and Medicaid Services 2006

Private vs. Government Spending

45%

75%

55%46%

25%

38%43% 41%

45%

54%55%59%57%

62%

20%

30%

40%

50%

60%

70%

80%

1965 1970 1980 1990 2000 2002 2003*

GovernmentPrivate

Source: Centers for Medicare and Medicaid Services, Office of the Actuary, 2004

Consumer Mindset

• The nation’s health care costs are rising

• Personal health care costs are rising

• Health care costs are a hot political topic

• Lots of people are uninsured

• What if I became one of them?

• Health care costs hurt profitability

• Employee cost-share must rise• Ancillary benefits (dental) easily

sacrificed • Changes must demonstrate a

return on investment

Employer Mindset

Changes in the workplace

•New emphasis on prevention

•Employee wellness programs

•Incentives for healthy behavior

•New emphasis and total health

•Analysis of health outcomes

ALL OTHERSBRING DATA

Oral-Systemic Connections

The growing body of science showing that oral health is associated with systemic health:

• Periodontal Disease and ...

• Pregnancy outcomes

• Diabetes

• Heart Disease

• Pneumonia

• Osteoporosis

• Arthritis

• Cancer

• Renal Disease

http://www.dentalcare.com/soap/products/pdfs/owbh.pdf

Insurance Industry Response

•Pilot project looking at outcomes from dental treatments with combined medical/dental data.

•Scientific panel to review and advise on emerging oral-systemic literature

•Changes in benefits in response to oral-systemic risk factors

Delta - Evidence Based Integrated Care Plan

Aetna - Medical/Dental Integration

CIGNA – Dental/Oral-Health Integration Program

MetDental – Oral-Health Disease Management Pilot Program

United Concordia – Smile for Health

Insurance Industry Response

Evidence-Based Integrated Care Plan

• Improve overall health by improving oral health and increasing awareness of both oral and systemic health

• Provide more a individualized, risk-based approach to health care benefits

• Promote personal and professional care decisions that are based upon good evidence of effectiveness and benefit

Periodontal Disease and Birth Outcomes

Current evidence exists demonstrating an association• Women with active PD have greater incidence of PT-LBW

babies (risk factor of 2.8 - 7)• National LBW rate 2004 was 8.1%• Preterm rate in US was 12.5% in 2004• Medical costs estimated at >$50,000 each

Some beginning evidence of possible causation• Studies suggest treating PD in pregnant women may result in

fewer PT-LBW babies.

Provides one extra preventive visit during pregnancy

EBICP

Periodontal Disease and Diabetes

Evidence clearly demonstrates association:• Diabetics have higher incidence and severity of PD• Diabetics with PD have poorer diabetic control

Limited evidence of causation:• Treating PD may result in better glucose control.

Meta analysis indicated a statistically non significant drop of 0.38 % HbA1c with the largest drop for Type 2 diabetes of 0.71%.

Medical savings are estimated to be about $1000/yr for each 1% drop in HbA1c.

Provides four preventive-maintenance visits per year

EBICP

Periodontal Disease and Increased Maintenance

• PD is found in 50% of U.S. adults• Treatment costs are $5-$6 billion/year • Strong evidence that more frequent maintenance visits result in better PD health • Fewer than 1/3rd of PD patients continue proper maintenance recalls• Proper maintenance saves:

• Additional surgical procedures• Tooth replacement costs

Provides four maintenance visits per yearand fluoride varnish tx

EBICP

Awareness as part of the EBICP

CheckEligibility

Dentist’s enrollment

check

Awareness

Increasing Health Awareness

Messages on Oral Health and Pregnancy:• Hormonal effects on gums and periodontal

health• Pregnancy tumors• Diet and effects on oral health• Morning sickness and tooth erosion• Nutrition and baby’s tooth developmental

health• Oral health maintenance during pregnancy• Periodontal disease and preterm, low birth-

weight babies• Dental visits and dental x-rays• Folic acid and cleft lip/palate

Increasing Health Awareness

Messages on Oral Health in Infants• Baby bottle tooth decay• Transmission of oral bacteria from mother to child• Fluoride in infant formulas• Baby’s first teeth• Dental injuries in infants and toddlers• Fluoride supplements for infants• Baby’s first dental visit• In-home dental care for infants

PREVENTION OF INFECTIVE ENDOCARDITIS --GUIDELINES FROM THE AMERICAN HEART ASSOCIATION

•A Guideline from the American Heart Association Rheumatic Fever,Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on

Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group

Professionally Applied Topical FluorideEvidence-based clinical recommendations

American Dental Association Council on Scientific Affairs

JADA, Vol. 137 http://jada.ada.org August 2006

Evidence-Based Guidelines

•Current program of increasing benefits for preventive care will hopefully result in better oral health. •Benefit to birth outcomes is difficult to measure, but still a good precautionary measure.•Recent study showed better oral health and no adverse outcomes from extra preventive services (No down side).•Hopefully increased awareness will carry forward to mother and newborn in the future to result in better oral health and lower costs!

Where’s the payoff?

Pregnancy Outcomes

New Evidence-Based Resources

http://www.ada.org/prof/resources/ebd/index.asp

Where is this all going?

•Dentists, consumers and payers will be depending more upon evidence-based decision making•Consumers are becoming better educated and are beginning to ask the right questions•Emerging areas for expansion:

• Cardiovascular disease and strokes• Pulmonary diseases• Osteoporosis

•Day-to-day treatment decisions• Root canal retreatment vs. implants• Material choices• Root caries prevention and treatment

NIDCR - Sponsored Practice-Based Research Networks (PBRN)

Designed to gather “real-world” evidence for the prevention and treatment of oral diseases

Dental Practice-Based Research Networks - Purpose

Answer questions facing general dental practitioners in the routine care of their patients

Strengthen knowledge base for making clinical decisions

• Observational studies

• Clinical trials

• Establish/use a flexible, adaptable electronic network/platform for connectivity, data sharing, & communication within and between dental and medical networks

Dental Practice-Based Research Networks

Ideas to be generated by practicing dentists and dental hygienists (i.e., practitioner-investigators)

Primary objectives: • Conduct 16-22 short-term clinical studies over 7 years

• Emphasis on effectiveness of oral health treatment & disease prevention

• Clear & clinically meaningful outcomes

Secondary objective: Provide data on disease and treatment trends and obtain estimates of the prevalence of less common conditions

Dental Practice-Based Research Networks

At least 100 dental practices per Dental PBRN have been recruited to participate during the first year of operations.

Each PBRN involves large numbers of practitioner-investigators in at least two population centers.

Pennsylvania

Rhode Island

Utah

Virginia

Vermont

Washington

Washington DC

ScandinaviaSweden DenmarkNorway

Participating PBRN Dentists (n ≈ 400) by U.S. State (24) & Countries (3) after First Year

Alabama

Connecticut

Delaware

Florida

Georgia

Idaho

Maryland

Massachusetts

Minnesota

Michigan

Mississippi

Montana

New Hampshire

New Jersey

New York

Ohio

Oregon

MedicalPBRN

Representative

PEARLPRECEDENT

DPBRNNIDCR

NativeAmericanDentists

Representative

AmericanAssociation

Public Health DentistryAmerican

Dental Association

BiomedicalInformatics

Input

NIDCR

HispanicDental

Association

National Dental

Association

OphthalmologyPBRN

Representative

American Dental

EducationAssociation

American Dental

HygienistsAssociation

AmericanAssociation of

Dental Research

Patient Advocate

Representative

PBRN Study Ideas

6.8%0.2%66.3%16.3%10.4%

5463713628957Total

2.0%11001010Other

3.3%1841067Epidemiology & Patient characteristics

6.2%34280321Admin & Practice Characteristics

6.2%34003040Implants

1.3%720131Special Needs Patients

3.3%18101412Pediatric Dentistry

4.2%230011102Orthodontics

2.9%16001231Oral Surgery

7.5%410019202Oral Medicine / pathology

7.7%420024126Periodontics

7.9%43003571Endodontics

5.3%29002531Prosthodontics

42.1%230201781733Restorative Dentistry

TotalAdmin

Uncommon Rare DisordersTreatmentManagementPrevention

12/8/2006BenjaminDentinal CracksDPBRN 13DPBRNtbd26

1/20/2006Jeffrey FellowsRetrospective Cohort Study of Osteonecrosis of the JawsDPBRN 12DPBRN106030/10603

125

3/3/2006NixdorfChronic Pain and OHRQOL after Root Canal TherapyDPBRN 11DPBRNtbd24

3/3/2006McEdwardDental Hygienists Cariology and PeriodontalDPBRN 10DPBRNtbd23

1/20/2006BurgessRestoration of Endodontically Treated TeethDPBRN 9DPBRNtbd22

1/20/2006GuelmannRestorations in Primary TeethDPBRN 8DPBRNtbd21

1/20/2006Andrei BaraschTrans-PBRN Case-control Study of ONJ-UABDPBRN 7ALL10603720

12/9/2005MakhijaEarly Occlusal LesionsDPBRN 6DPBRNtbd19

12/9/2005Ivar MjörLongitudinal Study of Dental RestorationsDPBRN 5DPBRNtbd18

12/9/2005RileyPatient Satisfaction with Dental RestorationsDPBRN 4DPBRNtbd17

7/15/2005Ivar MjörReasons for Replacement or Repair of Dental RestorationsDPBRN 3DPBRNtbd16

7/15/2005Ivar MjörReasons for Placing the First Restoration on Permanent ToothDPBRN 2DPBRN10188315

7/15/2005Valeria GordanQuestionnaire on Caries Diagnosis & Caries TreatmentDPBRN 1DPBRN10188414

PendingPendingMedications UsagePRL0706PEARLPending13

12/13/2006Susan BernsteinEndodontic Treatment OutcomesPRL0705PEARL10812612

8/29/2006Kay OenRemoval of Deep CariesPRL0604PEARL10566111

4/21/2006Ken GoldbergTrans-PBRN Case-control Study of ONJ-NYUPRL0603ALL10156610

5/12/2006Gary BerkowitzPost Operative HypersensitivityPRL0602PEARL1015779

11/10/2005Kay OenDeep Caries Treatment SurveyPRL0501PEARL962678

3/1/2007Greg HuangReferrals for Third Molar ExtractionPREC007PRECEDENTtbd7

3/1/2007Jack FerracanePulp Capping with MTA vs. Calcium HydroxidePREC006PRECEDENTtbd6

11/15/2006Thomas HiltonCracked Tooth RegistryPREC005PRECEDENTtbd5

3/1/2007Susan ColdwellComputer-assisted Relaxation Learning (CARL)PREC004PRECEDENTtbd4

4/26/2006Philippe HujoelTrans-PBRN Case-control Study of ONJ-UWPREC003ALL106343

11/1/2006Joel BergSalivary Markers in Caries Risk AssessmentPREC002PRECEDENTtbd2

3/2/2006Thomas HiltonOral Disease Prevalence - Survey of PRECEDENT PracticesPREC001PRECEDENT1021951

Dental Practice-Based Research Networks

http://www.dentalpbrn.org

https://web.emmes.com/study/pearl/index.htm

https://clinicaltrialsworkbench.axioresearch.com/nwprecedent/

EBD Future Implications

•Will continue to keep dentistry at the “health care reform” table

•Will play a growing role in employer decisions on dental plans

•Will result in new clinical guidelines (sealants, fluoride supplements, oral cancer)

•Oral-systemic studies will take a dominant role in clinical research

•Results from EB reviews and new guidelines will guide insurance benefits

Thank You!feichmiller@deltadentalwi.com