INNOVATIONS IN PROVIDING ORAL HEALTH SERVICES TO HIV POSITIVE
PERSONS
NANCY YOUNG, ERNESTO GUEVARA
EAST TEXAS DENTAL/ORALCARE SERVICES
Was established in 1995 as an HIV/AIDS Service Organization serving HIV + and Substance
Abusing Persons in East Texas.
In 2006 serving 1,200 HIV + persons with comprehensive medical and case
management care, we believed that increasing our dental services from 1 day per
week to 2 would make a difference in the health care outcomes of those we serve.
SPECIAL HEALTH RESOURCES FOR TEXAS
SPECIAL PROGRAMS OF NATIONAL SIGNIFICANCE (SPNS) GRANT
• 15 sites around the country were recipients of this grant, SHRT is the only one in Texas.
• Innovation in Oral Health Care Initiative for HIV positive people in partnership with the ECHO research team at Boston University.
DENTAL SERVICESTO HIV POSITIVE PATIENTS
Longview /Tyler /TexarkanaSites
• DDS Services• Oral Health Case Management• Dental Hygiene • Oral Health Education
IMPLEMENTATION
• SHRT model integrates the delivery of comprehensive dental/oral health care into a primary health care services.
• Hired Project Director, Nancy Young, LCDC.• Contracted with Dr. Damon Spencer from Baylor
College of Dentistry in Dallas as our dentist. • Partnership with Texas A&M University Baylor
College of Dentistry provides Dental Student Internship placement in SHRT dental clinics, supervised by Damon Spencer, DDS.
• Hired Oral Health Case Manager, Ernesto Guevara, bilingual, who had 5 years RW Medical Case Management experience.
• Hired Registered Dental Hygienist.• Increased dental chairs from 2 to 7.• Recruitment has been from within our own
agency through Ryan White Medical Case Managers utilizing our referral and follow-up tracking process.
• All newly identified positive persons enrolled in services are referred for a comprehensive oral health exam.
• Partnership with Stephen F. Austin State University as our evaluators.
IMPLEMENTATION
• Unique to this program are the intensive oral health case management services provided during the Baseline and Follow-up Interviews.
• Patient retention rate 88%, due to SHRT one stop shop where patients receive medical services, case management, housing, transportation, medication assistance, substance abuse and mental health services.
• SHRT serves 23 counties in rural East Texas.
IMPLEMENTATION
INITIAL RESULTS FROM THE MULTISITE STUDY
BASELINE RESULTS
• 2494 in database from all sites• Mean age of patients is 44 years old• Mean years HIV positive is 10 years• Patients are: 40% Black, 33% White, 21%
Latino and 75% Male• 53% of patients had not received dental
care in 2 or more years.
Primary languageEnglish 85%Spanish 13%Other 2%
Birth region
US 76%Caribbean Island/West Indies
5%
Puerto Rico 4%Mexico 4%South America 3%
ADDITIONAL DEMOGRAPHICS
HIV STATUS - BASELINE
• 51% have an undetectable Viral Load• 57% have a CD4 of 350 or greater• 78% report current ART use• 98% have a regular place for HIV care• 85% have an HIV case manager• 94% have seen HIV provider in past 6
months
WHAT BRINGS YOU HERE TODAY?
• 55% reported at least one or more presenting problem– Teeth filled or replaced – 47%– Relief of pain – 35%– Denture work – 25%– Teeth pulled – 22%– Gum treatment – 15%
• 39% reported coming in for a cleaning only
SYMPTOMS IN THE PAST 12 MONTHS?
• Tooth decay/cavity52%
• Sensitivity50%
• Dissatisfied with appearance50%
• Toothache 43%• Bleeding gums 36%
HOW WOULD YOU DESCRIBE THE HEALTH OF YOUR TEETH AND
GUMS?
• Excellent 4%• Very Good
10%• Good
23%• Fair 31%• Poor 32%
OVERALL, HOW WOULD YOU RATE YOUR HEALTH IN THE PAST
4 WEEKS?
• Excellent 16%• Very Good 26%• Good 33%• Fair 20%• Poor 5%• Very Poor 1%
BASELINE PRACTICES
• 96% report brushing in the past 30 days; 82% report once a day
• 46% flossing in the past 30 days; 19% report once a day
• 52% report smoking in the past 30 days• 71% report drinking sugary sodas and
62% eat hard candy or chew gum with sugar
ANCILLARY SERVICES: UPDATE
• Total number of encounters: 15,129
• Total number of patients with ancillary data:– 1891 (87% of enrolled eligible
patients, ranges from 20%-98% cross sites)
ANCILLARY SERVICES: UPDATE
• Most frequently reported ancillary servicesSchedule dental appointments/coordinate
referralsDental appointment remindersProvide transportationLink with HIV case managementProvide meal/snack ANDProvide Oral health treatment or self-care
information
ANCILLARY SERVICES: STAFFStaff Services
Case managers (Outreach workers, Patient navigators)
•Schedule appt/coordinate dental services (referrals)•Dental appt reminders•Provide assistance with transportation•Provide peer support•Provide OH treatment/self-care information•Link with HIV case managers
Administrative staff •Schedule appt/coordinate dental services (referrals)•Dental appt reminders•Provide assistance with transportation•Link with HIV case managers•Coordinate care
Dental assistants •Schedule appt/coordinate dental services (referrals)•Provide OH treatment/self-care information
Others: Van drivers, Hygienists (2)
•Provide assistance with transportation•Schedule appointments/coordinate dental services (referrals)
QUALITATIVE STUDY
• 39 patients with Initial & Follow-up interviews
• 6 sites participate in the study• From the patient perspective
– How does this SPNS program impact client oral health care, knowledge, and practices?
– What is the role of dental staff (case manager/patient navigator)?
PRELIMINARY ANALYSIS: PARTICIPATION IN SPNS PROGRAM
Did you learn something new about HIV and oral health care?
Good Oral Hygiene = Good HIV Health“I've learned that it's important to brush
your teeth, gargle and always check your mouth, your tongue and your gums to see if you have any sores because a lot of times you can have a sore in your mouth and not know you have the sore.”
PRELIMINARY ANALYSIS: PARTICIPATION IN SPNS PROGRAM
• Improvements in oral health care practices
Better brushing & flossing techniques & frequency
• “ Now I buy lots of toothbrushes and use them for a short time and replace them.”• “I brush everyday instead of 3 times a
week… I floss a lot more”• “I brush longer”
PRELIMINARY ANALYSIS: PARTICIPATION IN SPNS PROGRAM
• Improvements in oral health care practices
Reduce or stop smoking/tobacco use• “ I still use snuff but I cut back a little and
don’t leave it in my mouth as long...”
Reduce soda intake
PRELIMINARY ANALYSIS: PARTICIPATION IN SPNS PROGRAM
• Biggest difference from receiving care – Relief of pain– Can eat– Improved appearance
• “Can eat so I gain weight…look better”• “Smile more.. No holes”
– Dental staff• Friendly• High quality
– Easier access to care• “I can see dentist on a regular basis”
PRELIMINARY ANALYSIS: PARTICIPATION IN SPNS PROGRAM
• Changes to overall HIV health
Mixed; some noticed no changesOthers; feel their oral health helped
improved overall health• “Physically, I feel better now. My teeth
don’t hurt and stuff like that like they used to. It’s a lot changed, a lot, I feel emotionally I’m able to get out and enjoy myself more. I like to smile, I like to talk and stuff, I mean I can do that now. No, no pain at all. I like it.”
PRELIMINARY ANALYSIS: PARTICIPATION IN SPNS PROGRAM
• The role of the dental case manager– Access to oral health care
• “I would not have dental care if it wasn’t for (name of Dental case manager)
• He (dental case manager) got me into the program and it has been good to me
– Better retained in dental care• “ I feel comfortable with her and makes me want to come to
appointments
– Helped patient communicate with dental and medical providers
– Explains how to take care of mouth and teeth & shares information
PRELIMINARY ANALYSIS: PARTICIPATION IN SPNS PROGRAM
• Advice to others living with HIV about oral health care
Importance of oral health in overall HIV health care
• “Need to keep up with physical, mental and ORAL health.. All are connected..”
• “if you do not know how to take care of your teeth and you are not willing to spend the time and the energy to do proper daily oral hygiene, then you don’t need your teeth. You need to get some wooden teeth or something. You can die.”
• “I would tell them that they need to go because if your teeth are healthier that means you’ll be more healthier and that’ll help on your CD4 counts and stuff like that a lot. After I got my teeth and stuff fixed my CD4 cells they skyrocketed.”
• “Your oral healthcare does affect your other health, your health in general, your HIV health in general. You need to keep care of your teeth and if your teeth are in good shape then you should be all right as far as avoiding any infections or anything like that.”
SUCCESSES AND CHALLENGES
• 350 Persons living with HIV received quality dental care
• 189 HIV + Persons enrolled in SPNS study while receiving intensive oral health case management.
• 595 people received oral health education• Each patient received referrals as needed,
meeting with OHCM at least 3x per year• Partnership with Stephen F. Austin State
University as evaluators of Quality of Life study• Focus Groups in Longview, Tyler, Texarkana
MEETING THE CHALLENGE
• Innovative dental care by Dentist with 14 years experience in HIV dental care
• Dental hygiene care • Intensive Oral Health Case Management• Comprehensive Oral Health education• One stop shop care for HIV positive clients• Multidisciplinary staffing of patients• Purchased a van for transporting patients
