September 9, 2016Professor Jocelyne Feine

Faculty of DentistryMcGill University

Editor, JDR Clinical and Translational Research

Challenges of Phasing Down the Use of Dental Amalgam

FDI World Oral Health Forum The Minamata Convention

Challenges

Population

Professional

Policy

Industry

Challenges

Population

Professional

Policy

Industry

Manage Reduce

Replace

Actions

Undergraduate dental education

Manage

Replace

ReduceBest management practices

Continuing dental education

Industry; closed loop

Disposal

Safe handling

Replace

Manage Reduce

Dentists perspective & incentives

EfficacyEffectiveness

Product development

Uptake ofnew technology

Risk-Benefit

Accessibility

Patient perspectives

Advocacy to policy makers, insurers, etc.

Cost

ReduceManage

Replace

Behaviours

Risk factors and social determinants

Implementation strategies

Prevention

Health Promotion

Advocacy

Public health awareness

Manage Reduce

Replace

Behaviours

Risk factors and social determinants

Implementation strategies

Prevention

Health Promotion

Advocacy

Public health awareness

Dentists perspective & incentives

EfficacyEffectivenessProduct

developmentAttitudes to New technology

Risk BenefitAccessibility

Patient perspectives

Advocacy to policy makers, insurers, etc.

Cost

Best management practices

Continuing dental education

Industry; closed loop

Disposal

Safe handling

Undergraduate dental education

Shifting the Focus

• Individual lifestyle approach to health policy• Emphasis on “at risk” populations• One-on-one clinical interventions

• Social policy approach • Shared behavioural risks of NCDs• Broad health promotion models

Common Causes

NCDs Caries

HiAP

Common Causes

NCDs Caries

OHiAP

Basic Science

Discovery

Proposed Human

Application

Proven Clinical

Application

Clinical Practice

Public Health Impact

T1 T2 T3 T4

Defines mechanisms, targets and molecules.

Preclinical and animal studies.

New methods of diagnosis, treatment, prevention.

Proof of concept & Phase I Clinical

Trials.

Controlled studies leading

to implementation and adoption.

Phase II & Phase III Clinical Trials.

Biomedical Research Translation Continuum

Adapted from Drolet & Lorenzi, 2011 and Fernandez-Moure, 2016

Translation to communityTranslation to practice

Translation to patientsTranslation to humans

Phase IV Clinical Trials and Implementation research for delivery of appropriate care to the population.

Basic Science

Discovery

Proposed Human

Application

Proven Clinical

Application

Clinical Practice

Public Health Impact

T1 T2 T3 T4

Manage Safe Handling & Disposal

Replace: New product development and uptake

Reduce Prevention; Implementation

Adapted from Peters et al, 2013Reduce

Prevention; Implementation

Implementation Research

Policy

Programmes

Practice

Intervention

Strategies

Implementation research

aims/questions

Policy

Programmes

Practice

Adapted from Peters et al, 2013

Pragmatic Trials

Effectiveness-Implementation

Trials

Quality Improvement

Studies

Participatory Action Research

Mixed Methods Research

ImplementationOutcomes

→Acceptability

→Adoption

→Appropriateness

→Feasibility

→Implementation cost

→Coverage

→Sustainability

ImplementationOutcomesImplementation

OutcomesResearch

aims/questions

Challenges in Uptake of Technologies

North America→ Private market→ Heavy technology dependence→ Minimal accountability→ Clinicians' autonomy→ Regional, socioeconomic

disparities→ Lack/scarcity of CPGs→ High operative costs→ Competitive environment

Barriers and Incentives in Uptake of New Technologies by Dental Professionals

Example

Participatory Action Research

Mixed Methods ResearchPractice

Qualitative Research

Sequential exploratory design

Quantitative Research

Interpretative Phase

Implementation Research

Policy Proposals to Strengthen the Amalgam Phase Down

Tiered phase-down on amalgam use Establish milestones for phase down period Financial mechanisms to address non-

compliance

Mackey et al, 2014

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