Dental Student’s Last Stand:Back in the Saddle

Amanda Campbell &Kendra Velasquez

Overview• Study Visits for Periodontal Study

• CNOHR Research Components 1 & 2 (RC1/RC2)

• Motivational Interviewing

• Approvals for RC1/RC2– NIDCR– COMIRB– Tribal

• Trip to Pine Ridge

Periodontal Study

• Overview of the study:– Collaboration with the Barbara Davis Center.– To determine if there is a correlation between

Type I Diabetes and Periodontal Disease.

• Observe patients at the dental clinic.– Exams– Plaque Samples– Charting using Axium

Early Childhood Caries (ECC)• Disparities exist in American Indian/ Alaskan Native (AI/AN) communities,

especially among the Oglala Lakota tribe.¹• Results from IHS Oral Health Surveys show ECC in AI/AN continues to increase²• Compared to other children ages 2-5, AI/AN children have more than 3 times

the amount of untreated decay (19% vs. 68%).³

¹U.S. Department of Health and Human Service. The Oral Health of Native Americans: A Chart Book of Recent Findings. Trends in Regional Differences: USDHHS;1991. ²U.S. Department of Health and Human Services Indian Health Service. The 1999 Oral Health Survey of American Indian and Alaskan Native Dental Patients: USDHHS;2002.³Vargas CM, Ronzio CR. Disparities in early childhood caries. BMC Oral Health. 2006;6.

ECC• The biggest challenge in treating and preventing ECC in AI/AN

children is access to care

• AI/AN mothers are least likely to receive prenatal care• They are the highest risk group for preterm birth

Dental Decay in Children

Children Ages 2-5 with Untreated Cavities, National Institutes of Healthhttp://drc.nidcr.nih.gov/report/dqs_tables/dqs_1_3_1.htm

comparable IHS National Survey. 1999http://www.dentist.ihs.gov/downloads/Oral_Health_1999_IHS_Survey.pdf

11%

22%

30%White

Black

Hispanic

American Indian

68%

Promoting Behavioral Change for Oral Health in American Indian Mothers and Children

(RC1)

RC1

• Research component 1 (RC1) is a Phase III, randomized controlled trial. • 600 consenting pregnant women/mothers of newborns from the Pine Ridge

Reservation will be enrolled

• The mothers will be randomized to one of two groups:– The enhanced community services will receive: dental aids, brochures, and

public service announcements focusing on the important risk factors for ECC. – Motivational Interviewing (MI) group will receive: these services plus MI.

• 4 MI home visits; – one shortly after childbirth and the rest at 6, 12, and 18 months

• Both groups will receive three oral examinations by calibrated dental hygienists.– 1st exam= shortly after teeth erupt– 2nd &3rd exams will be annually after the 1st exam.

RC1Specific aims include:

1. To collaborate with AI community service providers to develop culturally appropriate educational and health promotional materials to emphasize the value of family oral health from birth;

2. To create a manual for an MI intervention on oral health, focusing on AI mothers and their newborn children;

3. To demonstrate the effectiveness of this intervention in a randomized trial designed to assess its impact on the prevention of ECC.

• Hypothesis: – Enhanced community services plus an MI intervention will reduce the dmfs

measures of the children at ages 1, 2, and 3, compared to enhanced community services alone. It is also hypothesized that MI interventions will improve the mother’s dental knowledge, attitudes, and behaviors about oral health care.

MI History

• Developed by William Miller (University of New Mexico) & Stephen Rollnick (University of Cardliff, Wales) in the 1990’s.

• Originally developed to help motivate individuals to change addictive behaviors, such as alcohol abuse and drug dependence.

• MI is now being used to address a wide range of different behaviors, such as developing proper oral health habits.

• The basis for MI is to use communication skills to increase an individual’s natural desire to change.

What is MI?•MI is a calm and peaceful means of talking, which

focuses on drawing out the motivation for change within the individual.

•The technique is designed to help individuals identify and process their own feelings about change.

•Native people have often referred to MI as “empowering”.

MI Techniques• MI employs the use of four basic principles to support client change:

1. Express Empathy Understand, accept and reflect on the client’s thoughts and

attitudes.

2. Develop Discrepancies Change must come from a mismatch between present behavior and

desired personal goals or values.

3. Roll with Resistance Never try to force change on the client. Allow the client to develop

his/her own answers and solutions.

4. Support Self-Efficacy Believe in the client’s ability to change and convey that to him/her.

MI session

• Each session of the MI will include:

– introduction to a specific subject for the session

– exploration of the pros and cons of change in this specific area

– assessment of the importance of change to the participant

– confidence of the participant in her ability to make the change

– enhancement of the participant’s self-efficacy through identification of what she

thinks she will be able to accomplish

– elicitation of commitment language to follow through on the decisions reached in

the session

– Lastly, development of a follow-up plan with specific action steps.

MI and Oral Health

• 240 South Asian children (6-18 mths)

• Randomly assigned to either MI group or control group.

• The control group received a pamphlet and video on infant oral health and the prevention of tooth decay in infants and toddlers.

• MI group received the pamphlet and video as well as a 45-minute MI session, followed by 6 follow-up telephone calls.

• All children received dental exams at 1 and 2 years post-intervention.

• Results:– The MI group had approx. 46% lower rate of decayed, missing & filled

tooth surfaces (dmfs) at age 2 than the control group.

Harrison, Benton, Everson-Stewart, Weinstein (2007)

Preventing Caries in Preschoolers: Testing a Unique Service Delivery Model in American

Indian Head Start Programs (RC2)

• Focuses on training community members, called Community Oral Health Specialists (COHS), to administer health information and fluoride varnish.

• Children ages 3-5 will be randomized into one of two groups:• Group 1: Quarterly fluoride varnish and oral

health promotion will be provided for 2 years by COHS.

• Group 2: Fluoride varnish made available at IHS clinics, quarterly for 2 years.

RC2• Primary Objectives:

– To train lay community members– Implement and evaluate the two groups– Assess the efficacy by comparing dmfs between the two

groups.

• Secondary Objectives:– To assess specific caries patterns, cost and

mediators/moderators.

Pilots• Measures Pilot

– Testing the electronic computer system (ACASI)• Cultural appropriateness, understandability, user

friendliness

– Used for all follow-up surveys for RC1/RC2

• MI Pilot– Assessment of trained MI research staff.

• COHS Pilot• Assessment of trained COHS staff.

NIDCR Approvals

• Pilots:– Summaries– Consent Forms– Revising Pilot Protocols

• Studies:– Revising Protocols– Revising Consent Forms

COMIRB & OSTRRB• Tedious practice in completing expedited,

exempt and full board COMIRB applications.

• Oglala Sioux Tribe Research Review Board:– Support from the Health and Human Services

(HHS) Committee. • Information about the project is given to members of

the HHS Committee for review. • Field Office Director gives a brief presentation the HHS

Committee. • If endorsed, a tribal resolution is drafted .

OSTRRB cont.

– Support from Tribal Council• Resolution submitted to the Tribal Council for approval. • The Tribal Council must approve the resolution in order

for the study to commence on the reservation.

• Once study is completed, all data belongs to the tribe.– Before submitting any official

reports/presentations, tribe must release the data to us.

Pine Ridge Reservation• Location of the study-

Pine Ridge Reservation in South Dakota

• Pine Ridge is the second largest reservation and is comprised of Shannon and Jackson counties.

– 2.7 million acres¹

• These are two of the poorest counties in the U.S. The average income per family is $ 3,700 per year.²

• Many families have no electricity, telephone service, running water, or sewers and must use wood burning stoves to heat their homes.¹

¹Running Strong For American Indian Youth. 16 July. 2009 Pine Ridge Indian Reservation, SD. http://www.indianyouth.org/pine-ridge-sd.htmlU.S. Census Bureau. Pine Ridge CDP, South Dakota-DP3. Profile of Selected Economic Characteristics: 2000. http://factfinder.census.gov/

Pine Ridge Reservation

• The unemployment on Pine Ridge is around 85%, with 45% below the Federal poverty level. ¹

• The life expectancy is among the shortest in the Western Hemisphere: males = 48 years and females are round 52 years. ²

• Infant mortality on Pine Ridge is five times the National Average.²

¹U.S. Census Bureau. Pine Ridge CDP, South Dakota-DP3. Profile of Selected Economic Characteristics: 2000. http://factfinder.census.gov/²Pine Ridge Area Chambers of Commerce. Eagles Nest Center. Pine Ridge. Wisconsin. 1992. http://www.eaglesnestcenter.org/index.htm

Pine Ridge

Health Fair

Health Fair

Pow-Wow

Thank You!

• We would like to thank all of CAIANH for letting us take part in their current research.

• A special thanks to Judith Albino, Terry Batliner, Dallas Daniels, Valerie Orlando, Judy Sandoval, and Eugene Brooks.

QUESTIONS???