2003 IHS OHP/DP Award Proposal
Fort McDermitt (NV) IHS Clinic
I. Background/Problem.
The ********** Health Clinic, located in **********, Nevada (on the Oregon border), is a remote health facility that serves the 600 tribal members of the ********** Paiute-Shoshone Reservation.
The ********** Reservation once fluoridated community drinking water, with the support of the Phoenix Area office and the ********** Service Unit. However, in 1994 the service unit began a long process of decentralization whereby individual facilities were left to manage fluoridation and dental programs with little service unit support. Consequently, the fluoridation of community drinking water at ********** ceased in 1994.
As a result of the cessation of water fluoridation, ********** has experienced a significant prevalence of dental caries, especially in children 3-18 years of age. In 2002, for example, the caries prevalence in this age group was 100.0%, and 96.3% of children in this age group had untreated caries.
The ********** Service Unit has continued to provide dental staffing support to the remote, two-operatory facility. Dentists from four service unit facilities rotate each month to the ********** Clinic, providing 2.0 days of dental services. Unfortunately, with caries and periodontal disease so prevalent in the population, the dental teams are unable to “get ahead” and significantly reduce caries through tertiary prevention (treatment of existing caries to prevent progression to pulpal necrosis). Instead, primary prevention activities – the fluoridation of drinking water – and secondary prevention activities – topical application of fluoride in high-risk patients - are desperately needed.
Because the service unit dental teams are unable to provide more than two days of coverage each month at the ********** Clinic, many patients, including children, must wait months for dental care, and even then mostly palliative treatment is rendered. In 2002, only 81 of the 136 children residing on the reservation were seen in the dental clinic, only 54 received comprehensive dental examinations, and only 11 were treated with fluoride varnish therapy. These low numbers are even more significant when one realizes that the ********** Clinic is the only option for dental care for these patients, since the nearest city with dentists is more than two and a half hours away. With access to care so limited, continuous fluoride therapy not only through water fluoridation but also through topical application by qualified medical staff is a necessity to reduce the prevalence of caries at **********
The point of contact for this project is LCDR Timothy L. Ricks, Chief, ********** Dental Program and Acting Chief, ********** Service Unit Dental Program, P.O. Box 227, **********, Nevada 89424; telephone number (775) 574-1018 extension 224; e-mail – .
II. Goals/Objectives.
The goal of this Oral Health Promotion/Disease Prevention project is to establish a comprehensive fluoridation program at the ********** IHS Clinic utilizing primary and secondary prevention approaches.
Specifically, the objectives of the project are:
(1) Establish a water fluoridation program at the ********** IHS Clinic by December 2003.
(2) Establish a topical fluoride program at the ********** IHS Clinic by October 2003.
III. Methodology.
A. Water fluoridation program
********** has one well and two pumps that supply water to residents of the reservation. One of the pumps has an upflow saturator and a LMI B111-91FS chemical feed pump. However, as stated before, fluoride has not been used in the pump since 1994.
A tribal volunteer (unpaid) currently monitors all aspects of the water system. The first step in water fluoridation will be to employ this person under this project, to ensure that the individual will properly monitor and use purchased fluoride. The Reno, NV Office of Environmental Health (an IHS entity) has agreed to oversee the training of the tribal employee in monitoring fluoride levels in the community drinking water (Dominic Wolf of OEH will be responsible for this aspect of the project).
The second step in the implementation of the fluoridation project will be to establish a reporting system for **********. Connie Bain and Doug Akin, contractors with the Phoenix Area Office, will provide training to the tribal employee in the Water Fluoridation Reporting System (WFRS), a system operated by the Centers for Disease Control and Prevention that entails data input through an automated system.
Evaluation and monitoring of this project will be the responsibility of ********** Paiute-Shoshone Tribe (Point of contact – Leora Greenwood, ********** Health Director), the Project Officer (LCDR Ricks), and the team of service unit dentists that travel to ********** each month. With the latter, the dental team traveling to ********** will be trained by the Project Officer on how to evaluate progress and monitoring devices with the system, and each will be allotted approximately 30 minutes to evaluate the system each month during their regular visit to **********
All of those with responsibilities in this project – the Office of Environmental Health, Phoenix Area Office fluoridation contractors, service unit dentists, and the ********** Health Director – will report directly to the Project Officer monthly on the progress of water fluoridation implementation.
B. Topical fluoride program
It may take several months to implement the water fluoridation program at **********. In the meantime, however, a topical fluoride program will be introduced in the health clinic, employing existing medical staff in the application and prescription of topical fluoride therapies.
The first step of this phase of the project will be in-service training of the health director (who also serves as the only medical provider at the facility) and two community health representatives. The Project Officer will train these individuals in April 2003 on the correct application of fluoride varnish (Cavity Shield, 5% sodium fluoride varnish).
The aim of this phase of the project is to apply fluoride varnish on children aged six to 18 years on a quarterly basis. The health director and community health representatives, once trained, will provide fluoride varnish applications to children in the health clinic. All applications will be recorded and reported to the Project Officer. These fluoride applications will supplement fluoride varnish applications by the dental teams traveling to ********** two days per month, with the ultimate goal being increased access to care by employing non-dentists to complete this project.
The Project Officer will supply the training and fluoride varnish to the health staff at **********, and the Health Director will be responsible for the reporting of all fluoride varnish applications to the Project Officer. In addition, the Health Director may prescribe home fluoride regimens (Prevident) to patients after training by the Project Officer (the Prevident will be stored at the facility).
IV. Budget.
I. Water Fluoridation project.
(a) Granular fluoride powder $2,438.00
Purchased at Sierra Chemical Company in Sparks, NV, the granular sodium fluoride powder is to be used in the fluoride pump at **********. The initial supply of 200 pounds will be to fill the fluoride chemical feed pump in July 2003, and 300 pounds will be added on a quarterly basis (estimate only) in October 2003, January, April, July, and September 2004, and January, April, and July 2005. Therefore, the total amount of fluoride to be purchased will be 2,300 pounds at a cost of $1.06 per pound at Sierra Chemical.
(b) Acu-Vac fluoridation test $ 676.00
The Acu-Vac fluoridation testing kit is recommended by the Office of Environmental Health. The contract tribal employee who will oversee the fluoridation program will perform this test twice daily, five days per week. The cost of the Acu-Vac is $0.65 per kit, and a total of 1040 kits (enough for two years) will be purchased.
(c) Employee contract $7,800.00
The tribal volunteer currently overseeing the water system at ********** will be paid $15 per day for monitoring the fluoride system, using the WFRS program to submit reports, and maintaining adequate fluoride concentrations in the water (1.0 ppm). The total length of the contract will be 104 weeks, and a total of 520 paid days. By paying the unpaid tribal volunteer, we hope to ensure compliance with the testing protocols set forth by the CDC and OEH.
(d) Training funds $ 784.00
The Project Officer and a representative of the OEH office will travel to ********** once in 2003 and 2004 to train medical staff and the contract employee in the monitoring system and project specifics. Based on the 2003 rate, the expected cost of travel and per diem will be $196 per person per visit.
Total for water fluoridation project: $11,698.00
II. Topical fluoride project.
(a) Cavity Shield fluoride varnish $ 0.00
Cavity Shield fluoride varnish, the single-application type that will be used by the health director and community health representatives, is provided at no cost by the Phoenix Area Dental Director on an annual basis. Cavity Shield will be applied to children 3-18 years of age.
(b) Duraflor varnish $ 168.00
The dental teams will apply Duraflor varnish during their regular trips (2.0 days per month) to **********. This will complement the application of Cavity Shield by the non-dental providers. A total of 24 tubes at a cost of $7 each will be purchased to cover a two-year period (July 2003 – July 2005).
(c) Prevident home fluoride therapy $ 802.40
The health director or dental teams may prescribe home fluoride therapy to patients 6-18 years of age. The request is for 272 tubes of Prevident, enough so that every child under 18 years of age (136 total) may have at least one tube of Prevident prescribed for each of the two project years (July 2003 – July 2005). The unit price (federal supply schedule) is $2.65 per tube.
Total for topical fluoride project $ 970.40
TOTAL FUNDS REQUESTED $12,668.40
Continuation of these two projects past July 2005 will be the responsibility of the ********** IHS Health Clinic. The anticipated costs in future years will be approximately $6,000 per year.
V. Evaluation.
The water fluoridation project will be evaluated using the CDC Water Fluoridation Reporting System as previously described. Success will be measured by the number of days optimal (1.0 ppm) fluoridation is maintained by the contract employee.
Other evaluation measures (process objectives) will be ascertained on the following timeline:
Ø August 1, 2003 – finalization of a written contract for the employee who will monitor the water system (Responsible Party: Project Officer)
Ø September 15, 2003 – training of the contract employee completed by the Office of Environmental Health (Reno District Office) and the fluoridation consultants contracted with the Phoenix Area Office (Responsible Party: Dominic Wolf, Office of Environmental Health)
Ø October 1, 2003 – fluoride powder added to chemical feed pump, and monitoring system begun (Responsible Party: Contract tribal employee)
Ø December, 2003 – fluoride levels maintained at 1.0 part per million (Responsible Parties: Contract employee, Connie Bain, WFRS consultant for the Phoenix Area Office).
Ø January 1, 2004 – Initial six-month report issued by Project Officer
Ø July 1, 2005 – Final report submitted by Project Officer
The topical fluoride project will be evaluated utilizing reported data on the number of children receiving fluoride varnish applications or Prevident home fluoride therapy. The Resource Personnel Management System (RPMS) will be used to track the patients receiving these benefits. A specific timeline for implementation of all aspects of this project follows:
Ø April 14, 2003 – training of non-dentists (health director, community health representatives) in applying Cavity Shield topical fluoride varnish (Responsible Party: Project Officer)
Ø July 15, 2003 – project begins; fluoride varnish applied on a quarterly basis (Responsible Party: Leora Greenwood, PA, ********** Health Director)
Ø September 15, 2003 – Prevident available as prescription by the Health Director (Responsible Party: Project Officer).
Ø January 1, 2004 – Initial six-month reported issued by Project Officer
Ø July 1, 2005 – Final report submitted by Project Officer
Attachment:
Letter of support
Submitted:
03 March 2003
LCDR Timothy L. Ricks
Chief, ********** Dental Program
P.O. Box 227
**********, NV 89424
(775) 574-1018 ext. 224