Comment

Caries Protocol Compliance Issues

William F. Bird DDS, DrPH

William F. Bird, DDS, DrPH, is a clinical professor, associate dean of clinic administration, and vice chair of the Department of Preventive and Restorative Dental Sciences, University of California at San Francisco School of Dentistry.

Copyright 2003 Journal of the California Dental Association.

Any caries control or caries protocol program must consider compliance as a measure of success. Lower bacterial counts on saliva tests and lower defs and DMFS scores suggest that some change has occurred. However, compliance with a caries risk protocol is about more than simple and convenient clinical outcomes measures. We tend to think of compliance as an individual activity, but all influences on an individual need to be considered. Change may be from external influences rather than from the individual or even from providers interacting with an individual or community. Few studies have directly addressed caries risk protocol. The paradigm change described in this manuscript suggests six key global areas -- beneficiary education, health provider network education, community and state agencies, legislative commitment, access to care, and research -- as significant factors to be considered in compliance. An outline of the major areas and subheadings for a global caries protocol compliance paradigm are presented.

When considering caries control compliance, it is clear that most issues of behavior change and patient, provider, and payer compliance have not been adequately studied. Many people seem to put the blame on the patient and caregiver for the lack of compliance with and follow through on treatment and prevention recommendations, but the true cause lies in a complex set of interacting and underlying factors. Only a few studies have discussed compliance with caries treatment/prevention regimens.^1-5 This lack of research demonstrates the complexity of behavioral modification and compliance with dental caries reduction regimens. Since behavior change and compliance are so complex, it is not an area of study in dentistry that has received much funding support or, therefore, has a strong scientific basis. More studies will be necessary to validate the efficacy of any protocols that are developed.⁶ In addition, by looking outside of dentistry, it is possible only to generalize compliance outcomes based on other behavioral science/disease and pharmacological compliance studies.^7,8 In studies of compliance with recommended medication therapy, it has been estimated that roughly one-half of medications are taken incorrectly and that nearly 20 percent of prescriptions are not even filled. This has strong implications for the type of caries preventive protocol that is recommended. To prescribe only self-applied processes or medications will not be effective. Other interventions and follow-up measures are needed. As reported by Haynes and colleagues,⁸ almost all of the interventions that had some effect on long-term care were complex and included combinations of more convenient care, information, counseling, reminders, self-monitoring, reinforcement, family therapy, and other forms of supervision. Even these did not lead to large improvements in adherence and treatment outcomes.

It is not reasonable to expect a layperson to consider dental health as important as dental professionals do. Therefore, basic dental health education needs to be directed to all education levels. School curricula need to be revised to incorporate the paradigm shift, and community health education and mass media messages need to be expanded. Brochures in the dental offices will not get the message to the needy. Using radio and television ads and technology such as videos and DVDs is necessary to get the message out to the masses. Drug companies are using this approach to promote their prescription medicines.

An example of the difficulties of establishing a caries prevention program is shown in the school-based Head Start xylitol gum pilot program tried in Florida. While children accepted the three times per day chewing of the xylitol gum, teachers indicated that it interfered with the school day; and four out of five indicated that they were not willing to participate in another such program.² Collaboration of the statewide curriculum committees and education of teachers is necessary to gain acceptance of a supervised school-based caries prevention protocol. Attempts at getting compliance for children through parental consultations and group education programs have not shown much success either.³ Children with a high caries rate who were treated by dentists did not change their behavior as a result of more treatment visits. Those that were less cooperative as judged by the dentist had higher rates of re-treatment needs than did those who were judged more cooperative.¹ It is unclear whether this indicates that compliance is worse in the noncooperative child or that there is less effort to integrate preventive interventions into the treatment of such children.

Legislators need to make dental disease as much a priority as other major acute and chronic diseases. Most legislators do not see the thousands of hours of schooling and employment lost to dental disease as a significant problem. In the surgeon general’s report, it was estimated that more than 50 million school hours are lost each year due to dental-related illness.⁹ Frequently, budget cuts for health funds are taken from dental programs. An example of this shortsighted thinking is exhibited in California budget deliberations. Adult Denti-Cal funding is frequently considered for drastic reduction or elimination as a way to save money. Most legislators are not aware of the problems created by transmission of dental caries disease to children from untreated caregivers, usually mothers. It is easier to cut or reduce dental funds because it causes less public outcry than medical program cuts. Even though dental disease is less of a life-threatening condition for the most part, it has a significant impact on overall health. The message that dental decay is a contagious disease needs to be promoted to the insurance industry, funding agencies, and legislators. The decision to reduce allocation of resources for a high-risk disease such as dental decay can have a devastating effect on access to care¹⁰ and the development and implementation of programs that can assist in the patient's compliance with the recommended protocols.

Access to care for people with low incomes is abhorrent. Many areas of California have no dentist or so few that it is a major barrier for a patient to receive routine and sometime emergency care, let alone preventive care. Certainly, public health measures such as fluoride can help. However, the disease challenge cannot be eliminated by such measures. External, social, economic, and education barriers contribute to the access to care problem.¹⁰ Agencies and insurance providers need to include caries risk testing and preventive treatments as benefits. When medical and dental providers are not compensated for their provision of these services, it translates into a lack of access for the patient. Wider access to preventive risk assessment tests could reduce the severe early childhood caries problem in California.

In addition, there needs to be a continued effort to provide education programs for the physicians, nurses, educators, social services counselors, dentists, and all licensed health care providers concerning the huge dental disease problem and the causes. The paradigm shift information must be transmitted to all. If there is not a concerted educational program, any protocol that is recommended will have only moderate success. Dental, dental hygiene, medical and nursing schools need to prepare their graduates with this information. Most schools have not incorporated these important concepts into their curriculum. This is easily seen by questioning the recent graduates about the paradigm shift and prevention and risk assessment strategies. Many are unaware of them. If this is the case, not only will patient compliance be poor, but provider compliance will also be poor . This needs to be remedied in a strategy to implement the caries risk protocol.

For a caries protocol compliance program to be successful, the following components need to be addressed.

Beneficiary Education

Individual/family/caregiver -- A positive reinforcement program should be in place. An example would be a "compliance calendar" that can be checked and followed daily and shared with the oral health provider team for each individual and the family.

Educational material development and distribution -- Material needs to be available in appropriate languages and various media, such as CDs, DVDs, videos, and brochures. These educational materials should be focused on a single concept. The DVD included in the February Journal of the California Dental Association is an excellent resource.

School curricula revisions -- Since early learning is so powerful, it is important for the paradigm shift message about caries risk to be included in all messages about oral health. Dentists and hygienists should take an active role in reviewing what is taught at all levels of education and providing guidance to curriculum committees. At the state level, people responsible for curricular oversight need to be informed and urged to take an active role in ensuring that the health components of the curriculum include these current oral health concepts.

Teacher oral health education workshops -- Early exposure to formal education about health, and in particular oral health, is usually provided by teachers. It is important to give them the most accurate and current information. This can be done by in-service or annual education seminars provided by members of the local dental society. Also, it is important that teachers be provided with curricular materials to assist them in their educational efforts.

Health Provider Network Education

Medical, dental, nursing, hygiene students -- Although many dental and dental hygiene school curricula are changing to include the caries risk paradigm, it is lacking in the curricula for physicians, nurses, and other heath care providers. To promote patient caries protocol compliance, it is imperative that all health care provider schools have a component of their curriculum that addresses the caries risk paradigm.

Physicians, dentists, hygienists, nurses (all licensed categories) -- The existing provider network needs to be informed of the paradigm shift for caries risk management. This can be done through media such as this journal and continuing education programs at national, state and local professional society meetings.

Social workers and counselors -- Since many caries protocol follow-up activities and treatment visits are coordinated through social workers, they can be an important link in achieving compliance.

Agencies

Development of local and community action programs -- Public health workers must be involved in the planning of education programs in their communities. School-based or community clinic-based prevention and caries risk programs will have a better chance of succeeding and getting compliance from all concerned if public health workers are part of the team.

Third-party and state indemnity/insurance program changes -- It is important for third-party and state indemnity/medical providers to include payment for caries risk tests and prevention programs. The money spent on preventive services and tests will reduce the severity of dental caries and ultimately the cost for care. Providers can have a great impact on implementing the caries risk assessment and early treatment programs and monitoring the compliance of their patients, but they must be compensated for their time and materials.

Legislative Commitment

Grant support for community action programs -- It is well-established that money spent through the grant process has a great impact on the ability of a community to initiate programs. Grants aimed at developing community action caries risk assessment and treatment programs should be supported by federal and state agencies. There should be mechanisms for communities to develop unsolicited proposals for grants to fund such initiatives. Once begun, the benefits of such programs will become recognized, and their continuance will become important to the people of the communities.

Recognition of the need to increase funding to support program and treatment efforts -- This is largely dependent upon the various professional societies and individual providers getting the attention of legislators to support various program initiatives by schools and communities. Legislators are usually not health care providers, so they also need to be educated as to the benefits of risk assessment and education programs.

Scholarships for providers to go to underserved areas of the state -- Since a great deal of untreated caries is seen in the areas where there are few if any health care providers, in particular dentists, one way to encourage providers to locate in underserved areas is to provide dental school scholarships and educational loan forgiveness in return for service in the specified areas. Some of these providers might decide to permanently locate in those areas. Patients cannot comply if they have no access to care.

Access to Care

For physicians and dentists, inclusion of prevention and risk assessment tests and treatment procedures in the reimbursement schedules by state and insurance agencies is paramount.

By having a reimbursement mechanism for the providers to receive compensation for tests and prevention treatments, it is more likely that they will provide these services. This will ensure an increased level of care and thus compliance by the patient.

Programs to support dentists’ acceptance of low-income patients -- The lack of acceptance of low-income patients for routine care, and particularly risk assessment and treatment programs, is tied to the lack of adequate compensation for providing such care. It would be better to fully fund these prevention and early treatment services than to have a large number of tertiary services covered at a low level of compensation.

Programs to encourage dentists to seek practice in underserved population areas -- Scholarships, educational loan forgiveness programs and licensure by credential are examples of means to encourage dentists to locate in underserved areas.

More dental provider education programs to increase comfort in providing care for young pediatric patients -- There is a shortage of pediatric dentists and general dentists to provide care to infants and children age 0 through 6. One way to increase the access to care for children is to provide pediatric dentistry education programs for general dentists. Having more general dentists being comfortable with providing pediatric dental care will increase the access to care for these children.

Such a program could consist of didactic education multimedia seminars, laboratory simulation for various procedures, a mentoring system and consultation network by pediatric dentist mentors, and a certificate course on sedation techniques.

Research

Products to control the bacterial disease and transmission -- Industry and academia need to continually develop and certify the effectiveness of new products to reduce decay-causing bacteria.

Simple chairside caries risk tests and assessment -- Current caries risk tests must be incubated for 48 hours or mailed to a testing center/laboratory to obtain the results. This delay impedes the success of the utilization of these tests. A test that can be used at chairside for immediate feedback to the patient or that can be used in field screenings is more likely to ensure compliance with an assessment program. This chairside test needs to be specific for the particular strains of bacteria known to cause the tooth decay.

Studies on caries protocol compliance -- There are very few studies in the literature on the compliance with protocols to reduce the risk of caries by any means. Identification of factors that ensure or impede compliance is needed to aid in the development and refinement of such protocols. This is an area for behavioral scientists to explore. Compliance with dental disease prevention protocols can be greatly improved by this area of research. National funding for such research would be a great asset to initiating such research.

Educational programs evaluation -- For educational programs to be successful, they need to be kept current. Also, the effectiveness of the educational programs and methods of delivery are an important aspect of the message being acted upon and complied with. Continuing research in this area for caries risk assessment/treatment and compliance to protocol can be helpful for the developers of education materials.

Summary

Many factors contribute to a successful compliance outcome for any health improvement program. Achieving compliance with a dental caries risk assessment protocol is no exception. Patients, parents, providers, educators, legislators, and agencies all need to work together for a successful result. For compliance to occur, everyone concerned needs to understand the important role that he or she has in achieving this success. The provision of information on the paradigm shift about dental decay and prevention is one step. The next step, and the measure of success, is compliance.

References

1. Varsio S, Vehkalahti M, Murtomas H, Dental care of six-year-old high-caries patients in relation to their cooperation. Commun Dent Health 16:171-5, 1999.

2. Auito JT, Courts FJ, Acceptance of the xylitol chewing gum regimen by preschool children and teachers in a Head Start program: a pilot study. Pediatr Dent 23(1):71-4.

3. Primosch RE, Balsewich CM, Thomas CW, Outcomes assessment an intervention strategy to improve parental compliance to follow-up evaluations after treatment of early childhood caries using general anesthesia in a Medicaid population. ASDC J Dent Child 68(2):102-8, 2001.

4. Anusavice KJ, Chlorhexidine, fluoride varnish, and xylitol chewing gum: underutilized preventative therapies? Gen Dent 46(1):34-8, 40, 1998.

5. Caries diagnosis and risk assessment. A review of preventive strategies and management. J Am Dent Assoc 126Suppl:1S-24S, 1995.

6. Milgrom P, The impact of behavioral technology on dental caries. J Dent Educ 65(10):1102-5, 2001.

7. Kehoe WA, Katz RC, Health behaviors and pharmacotherapy. Ann Pharmacother 32(10):1076-86, 1998.

8. Haynes RB, Montague P, et al, Interventions for helping patients to follow prescriptions for medications. Cocrane Database Syst Rev 2000(2):CD000011.

9. US Department of Health and Human Services, Oral Health in America: A report of the Surgeon General. US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, Rockville, Md, 2000.

10. Axelsson P, External modifying factors involved in dental caries. In, Diagnosis and Risk Prediction of Dental Caries, vol 2. Quintessence Publishing Co, Carol Stream, Ill, 2000, pp 77-90.

To request a printed copy of this issue, please contact/William F. Bird, DDS, DrPH, UCSF School of Dentistry, 707 Parnassus Ave., Box 0758, San Francisco, CA 94143 or birdb@dentistry.ucsf.edu.