EBD and Health Care Plans

Frederick Eichmiller, DDS

VP & Dental Director
feichmiller@deltadentalwi.com

Evidence-Based Dentistry

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

Business-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 Eddy

Health Affairs 2005

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. Blacks 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 question
2. 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 conclusions
2. Re-analyze pooled results based upon common
meta statistics
3. 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 Nations Health Care Dollar

Physician & Clinical Services 22%

2
Nursing
Home and
Home
Health

31

29

14

14

Hospital Care

Physician Services

Prescription
Drugs

Admin

Other
Professional
Services

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

1
Durable Medical
Products

Percent of GDP

Health Costs Represent Largest Sector

of GDP

18%
16%
14%
12%
10%
8%
6%
4%
2%
0%

16.5% = $2.2 Trillion

16.5%

10.5%
4.6%

3.4%

Auto

9.6%

National Housing
Defense

Source: Bureau of Economic Analysis Q3 2006

Food

Health

*Projected by Centers for Medicare and Medicaid Services 2006

Private vs. Government Spending

Government

80%

Private

75%
70%

62%
57%

60%

50%

43%
38%

40%

30%

59%

55%
45%

54%

55%

46%

41%

45%

25%

20%
1965

1970

1980

1990

2000

2002

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

2003*

Consumer Mindset

The nations 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?

Employer Mindset

Health care costs hurt

profitability
Employee cost-share must rise
Ancillary benefits (dental) easily
sacrificed
Changes must demonstrate a
return on investment

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 OTHERS
BRING 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

Insurance Industry Response

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

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.

EBICP

Provides one extra preventive visit

during pregnancy

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.

EBICP

Provides four preventive-maintenance

visits per year

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

EBICP

Provides four maintenance visits per year

and fluoride varnish tx

Awareness as part of the EBICP

Check
Eligibility

Dentists
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 babys tooth developmental
health
Oral health maintenance during pregnancy
Periodontal disease and preterm, low birthweight 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
Babys first teeth
Dental injuries in infants and toddlers
Fluoride supplements for infants
Babys first dental visit
In-home dental care for infants

Evidence-Based Guidelines
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 Fluoride

Evidence-based clinical recommendations
American Dental Association Council on
Scientific Affairs
JADA, Vol. 137 http://jada.ada.org August 2006

Wheres the payoff?

Pregnancy Outcomes
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!

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.

Participating PBRN Dentists (n 400) by U.S. State (24) & Countries (3)
after First Year
Alabama
Connecticut
Delaware
Florida
Georgia
Idaho
Maryland
Massachusetts

Minnesota

Pennsylvania

Michigan

Rhode Island

Mississippi

Utah

Montana

Virginia

New Hampshire

Vermont

New Jersey

Washington

New York

Washington DC

Ohio

Scandinavia

Oregon

Sweden
Denmark
Norway

American
Dental
Association

American
American
Medical
Association of
Association
PBRN
Patient
Dental
Public Health Representative
Advocate
Research
Dentistry
Representative

American
Dental
Education
Association

PEARL
PRECEDENT
DPBRN
NIDCR

Hispanic
Dental
Association
NIDCR

Biomedical
American
Informatics
Dental
Input
Hygienists
Association

Native
American
Dentists
Representative

Ophthalmology
PBRN
Representative

National
Dental
Association

PBRN Study Ideas

Prevention

Management

Treatment

Uncommon
Rare
Disorders

Admi
n

Total

33

17

178

230

42.1%

Prosthodontics

25

29

5.3%

Endodontics

35

43

7.9%

Periodontics

12

24

42

7.7%

Oral Medicine / pathology

20

19

41

7.5%

Oral Surgery

12

16

2.9%

Orthodontics

10

11

23

4.2%

Pediatric Dentistry

14

18

3.3%

Special Needs Patients

1.3%

Implants

30

34

6.2%

Admin & Practice Characteristics

28

34

6.2%

Epidemiology & Patient

characteristics

18

3.3%

Other

10

11

2.0%

Total

57

89

362

37

546

10.4%

16.3%

66.3%

0.2%

6.8%

Restorative Dentistry

102195

PRECEDENT

PREC001

Oral Disease Prevalence - Survey of PRECEDENT

Practices

Thomas Hilton

3/2/2006

tbd

PRECEDENT

PREC002

Salivary Markers in Caries Risk Assessment

Joel Berg

11/1/2006

10634

ALL

PREC003

Trans-PBRN Case-control Study of ONJ-UW

Philippe Hujoel

4/26/2006

tbd

PRECEDENT

PREC004

Computer-assisted Relaxation Learning (CARL)

Susan Coldwell

3/1/2007

tbd

PRECEDENT

PREC005

Cracked Tooth Registry

Thomas Hilton

11/15/2006

tbd

PRECEDENT

PREC006

Pulp Capping with MTA vs. Calcium Hydroxide

Jack Ferracane

3/1/2007

tbd

PRECEDENT

PREC007

Referrals for Third Molar Extraction

Greg Huang

3/1/2007

96267

PEARL

PRL0501

Deep Caries Treatment Survey

Kay Oen

11/10/2005

101577

PEARL

PRL0602

Post Operative Hypersensitivity

Gary Berkowitz

5/12/2006

10

101566

ALL

PRL0603

Trans-PBRN Case-control Study of ONJ-NYU

Ken Goldberg

4/21/2006

11

105661

PEARL

PRL0604

Removal of Deep Caries

Kay Oen

8/29/2006

12

108126

PEARL

PRL0705

Endodontic Treatment Outcomes

Susan Bernstein

12/13/2006

13

Pending

PEARL

PRL0706

Medications Usage

Pending

14

101884

DPBRN

DPBRN 1

Questionnaire on Caries Diagnosis & Caries Treatment

Valeria Gordan

7/15/2005

15

101883

DPBRN

DPBRN 2

Reasons for Placing the First Restoration on Permanent

Tooth

Ivar Mjr

7/15/2005

16

tbd

DPBRN

DPBRN 3

Reasons for Replacement or Repair of Dental

Restorations

Ivar Mjr

7/15/2005

17

tbd

DPBRN

DPBRN 4

Patient Satisfaction with Dental Restorations

Riley

12/9/2005

18

tbd

DPBRN

DPBRN 5

Longitudinal Study of Dental Restorations

Ivar Mjr

12/9/2005

19

tbd

DPBRN

DPBRN 6

Early Occlusal Lesions

Makhija

12/9/2005

20

106037

ALL

DPBRN 7

Trans-PBRN Case-control Study of ONJ-UAB

Andrei Barasch

1/20/2006

21

tbd

DPBRN

DPBRN 8

Restorations in Primary Teeth

Guelmann

1/20/2006

22

tbd

DPBRN

DPBRN 9

Restoration of Endodontically Treated Teeth

Burgess

1/20/2006

23

tbd

DPBRN

DPBRN 10

Dental Hygienists Cariology and Periodontal

McEdward

3/3/2006

24

tbd

DPBRN

DPBRN 11

Chronic Pain and OHRQOL after Root Canal Therapy

Nixdorf

3/3/2006

25

106030/10603
1

DPBRN

DPBRN 12

Retrospective Cohort Study of Osteonecrosis of the

Jaws

Jeffrey Fellows

1/20/2006

26

tbd

DPBRN

DPBRN 13

Dentinal Cracks

Benjamin

12/8/2006

Pending

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