The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation, and Research Team Division of Oral Health Centers for Disease Control and Prevention

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The Evidence Base for Community Preventative
Services and Examples from States of ASTDD Best
PracticesDolores Malvitz, DrPHChiefSurveillanc
e, Investigation, and Research TeamDivision of
Oral Health Centers for Disease Control and
Prevention (CDC)Atlanta, GeorgiaTexas Oral
Health Summit Advocacy, Equity AccessAustin,
TexasSeptember 9-10, 2004
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Promoting Oral Health

• Systematic Reviews and Evidence-Based
  Recommendations

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The Community Guide Is

• A set of recommendations for action based on the
  scientific evidence
• Evidence comes from systematic reviews
• Reviews coordinated by CDC staff
• Recommendations determined by independent Task
  Force

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What Will Be Reviewed in the Community Guide?
Specific Conditions
Risk Behaviors

• Vaccine Preventable Disease
• Pregnancy Outcomes
• Violence
• Motor Vehicle Injuries
• Depression
• Cancer
• Diabetes
• Oral Health

• Tobacco Use
• Alcohol Abuse/Misuse
• Other Substance Abuse
• Poor Nutrition
• Inadequate Physical Activity
• Unhealthy Sexual Behaviors

The Environment

• Sociocultural Issues

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The Community Guide is Part of a Family of
Federal Initiatives
Healthy People 2010
Guide to Clinical Preventive Services
Priorities for Prevention
Put Prevention into Practice
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Promoting Oral Health

• Recommendations from the
• Guide to Community Preventive Services

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Oral Health ChapterCommunity Guide

• Interventions for Preventing
• Dental Caries
• Oral and Pharyngeal Cancers
• Sports-related Craniofacial Injuries

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Methods for Conducting Systematic Reviews Five
Steps

• Develop conceptual approach
• Search for and retrieve evidence
• Rate quality of evidence
• Summarize evidence
• Translate strength of evidence into recommendation

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Key Findings
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Oral Health ChapterCommunity Guide

• Strong evidence for
• Community water fluoridation
• School sealant programs

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Translate strength of evidence into
recommendations

• Preventing dental caries
• Community water fluoridation
• (strongly recommended)
• School-based sealant programs
• (strongly recommended)

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Oral Health ChapterCommunity Guide

• Insufficient evidence for
• Community-wide sealant promotion programs
• Oral cancer awareness and screening programs
• Promoting use of dental and craniofacial
  protectors in contact sports

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Insufficient evidence should not be confused with
evidence of ineffectiveness
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Benefits of the Community Guide

• Stronger foundation for advocacy, research, and
  programs
• proof of effectiveness may be better
  (semi-quantitative vs. narrative summary)
• recommendations issued by independent, objective
  Task Force

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• www.thecommunityguide.org

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ASTDD Best Practices Project

• Putting science
• into practice
• www.astdd.org

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Purpose of the Project
(1) Provide guidance for programs (2) Meet
the Surgeon Generals Call to Action (3) Help
achieve Healthy People 2010 objectives
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Best Practice Approaches

• Dental public health strategies
• supported by evidence
• of effectiveness.

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Best Practice ApproachesStrength of Evidence
Promising Proven Approaches .......
..................... Approaches
Strength of Evidence Research Research E
xpert Opinion Expert Opinion Field
Lessons Field Lessons Theoretical
Rationale Theoretical Rationale
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Strong Evidence

• Research Evidence
• Systematic review
• Expert Opinion
• Multiple authoritative sources
• Field Lessons
• Cluster evaluation of several states

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Best Practice ApproachesStrength of Evidence
Best Practice Research Expert
Field Theoretical Approaches Opinion Lessons
Rationale Surveillance Systems
State Coalitions State
Plans State Mandate for
Program Community Water
Fluoridation School Sealant
Programs School Fluoride
Programs Workforce
Development
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Community Water Program Evidence Supporting
Effectiveness

• Summary of Evidence Supporting
• Community Water Fluoridation
• Research
• Expert Opinion
• Field Lessons
• Theoretical Rationale

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School-based Sealant ProgramsEvidence Supporting
Effectiveness

• Summary of Evidence Supporting
• School-based Dental Sealant Programs
• Research
• Expert Opinion
• Field Lessons
• Theoretical Rationale

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Best Practice Criteria
Effectiveness
Efficiency
Sustainability
Best Practice
Rationale Objectives
Collaboration Integration
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ASTDD Best Practices Project

• Community Water Fluoridation

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Description of a Community Water Fluoridation
Program

• ? Legislation policies
• ? Advocacy promotion
• ? Supporting communities starting fluoridation
• ? Training, monitoring, surveillance, reporting
  and inspection

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Description of a Community Water Fluoridation
Program

• ? Collaborate with water quality and other
  partners
• ? Develop human resources to support community
  water fluoridation efforts
• ? Secure financial resources to support community
  water fluoridation efforts

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Best Practice Criteria(1) Effectiveness

• State population with optimally fluoridated water
• Illinois 99
• Indiana 95
• Texas 66
• Arkansas 60
• Mississippi 39
• California 29

• Review Standard
• Compare population served by water systems with
  optimally fluoridated water to HP 2010 target
  (75).

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Best Practice Criteria(1) Effectiveness

• In 2002 44 of the 50 largest cities in the U.S.
  fluoridated
• Illinois 860 of the 1800 community water
  systems adjust their fluoride levels
• Indiana 482 water systems adjust their fluoride
  levels

• Review Standard
• Document number of communities or public water
  systems with optimally fluoridated water.

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Best Practice Criteria(2) Efficiency
Estimating costs ? Initial cost of capital
equipment ? Replacement cost of capital
equipment ? Annual operational costs (chemicals,
human resources, maintenance repairs)

• Review Standard
• Compare average state cost for fluoridation (cost
  per per person year) to national estimates.

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Best Practice Criteria(3) Sustainability

• Review Standard
• Demonstrate sustainability through the number of
  years that identifiable water fluoridation
  program at state level has operated.

State Community Water Fluoridation
Programs Indiana since 1950s Oklahoma since
1950s Missouri since 1960s Virginia since
1980s
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Best Practice Criteria(4) Collaboration
Integration

• Review Standard
• Demonstrate partnerships coalitions with
  stakeholders and organizations to provide
  political, financial and scientific expertise to
  local constituents.

Fluoridation Partners Professional
association Grant makers Health departments Water
authorities Universities (dental, medical and
public health schools) Dental hygiene
programs Local community leaders
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Best Practice Criteria(5) Rationale Objectives
Healthy People 2010 Objective 21-9 Increase
proportion of U.S. population served by community
water systems with optimally fluoridated
water 2010 target 75

• Review Standard
• Program is linked to state /or national goals
  and objectives.

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ASTDD Best Practices Project

• School-based
• Dental Sealant Programs

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Description of School-based Sealant Programs

• ? Program conducted within the school setting
• ? Provide education to increase awareness of the
  benefit of sealants
• ? Obtain parental consent for screening/sealants
• ? Program provider teams include dentists,
  dental hygienists and dental assistants
• ? Utilize portable dental equipment or a fixed
  dental facility within the school setting

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Description of School-based Sealant Programs

• ? Usual practice Dentists examine the children
  and prescribe the sealants dental hygienists
  apply the sealants
• ? For quality assurance, children re-examined
  within 1 year after sealant placement to check on
  retention and need for repair
• ? The program should address unmet dental care
  needs of children

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State Practice Examples

• Illinois Dental Sealant Grant Program
• Ohio Dept. of Health School-based Dental Sealant
  Program
• Arizona Dental Sealant Program
• New Mexico School-based Dental Sealant Program

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Best Practice Criteria(1) Effectiveness

• Review Standard
• Program delivers to a large number of high risk
  children.

• Sealant Programs
• Ohio 28,000 children
• Illinois 21,000 children
• Target Schools
• 50-65 students in
• free reduced lunch programs

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Best Practice Criteria(1) Effectiveness

• Review Standard
• Program maintains a quality assurance system.

• Sealant retention
• Arizona
• 1-week assessment
• 1-year assessment
• New Mexico
• 1-year assessment

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Best Practice Criteria(1) Effectiveness

• Sealant Prevalence
• Ohio children aged 8
• 11 in 1988
• 30 in 1999
• New Mexico 3rd graders
• 47-52 in health district
• with program
• 19 in health district
• without program

Review Standard Documentation of program
benefits or outcomes.
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Best Practice Criteria(2) Efficiency

• Review Standard
• Program uses the least expensive personnel
  permitted by state law.

New Mexico Dentists screen children Dental
hygienists apply sealants Dental assistants also
apply sealants
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Best Practice Criteria(3) Sustainability
Sealant Programs New Mexico 26 yrs. Ohio 20
yrs. Illinois 19 yrs. Arizona 17
yrs. Funding OhioMCH/Tobacco ArizonaMedicai
d

• Review Standard
• Program with a track record or a plan for
  covering program expenses.

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Best Practice Criteria(4) Collaboration
Integration

• Review Standard
• Partnerships are established to administer
  sustain the program.

Sealant Partners Local health departments Communit
y agencies School health services Medicaid Primary
Care Office Foundations Private dentists
dental hygienists
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Best Practice Criteria(5) Rationale Objectives

• Review Standard
• Program is linked to state /or national goals
  and objectives.

Healthy People 2010 Objective 21-8 Increase of
children who have received sealants on
their molar teeth Aged 8 years 50 Aged 14
years 50
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ASTDD Best Practices Project

• Putting science
• into practice

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www.astdd.org
ASTDD Web Site

• Best Practice Approach Reports

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www.astdd.org
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Building a SystemOngoing and Dynamic Development
Identify Best Practices
Collaborate Integrate
Supportive Environment
Science Art
Cultivate Best Practices
Promote Best Practices