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September 9, 2016
Professor Jocelyne Feine
Faculty of Dentistry
McGill 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
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
Efficacy
Effectiveness
Product
development
Uptake of
new
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
Efficacy
Effectiveness
Product
development
Attitudes 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 community
Translation to practice
Translation to patients
Translation 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, 2013
Reduce
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
Implementation
Outcomes
→Acceptability
→Adoption
→Appropriateness
→Feasibility
→Implementation cost
→Coverage
→Sustainability
Implementation
Outcomes
Implementation
Outcomes
Research
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
DZIĘKUJĘ Ci

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What are the challenges of phasing down the use of dental amalgam? (Jocelyn Feine)

Editor's Notes

  1. Can the title of presentation be shortened? YES Since your suggestion is merely to shorten the title using the same wording, we can change the title. (In the past, I have left the original title, but added underneath my new title. Then I would explain to the audiences why I changed the title.)
  2. ENVIRONMENT CANADA (1999): More than 1/3 of the mercury load in sewage systems is due to dental practice.
  3. Refs: Sheiham and Williams, Billions with oral disease: A global health crisis—a call to action JADA 146(12) 2015. http://jada.ada.org
  4. Biomedical Research Translation Continuum Ref: Translational research: understanding the continuum from bench to bedside BRIAN C. DROLET, and NANCY M. LORENZI Translational Research 2011;157:1–5 Fernandez-Moure JS (2016) Lost in Translation: The Gap in Scientific Advancements and Clinical Application. Front. Bioeng. Biotechnol. 4:43. doi: 10.3389/fbioe.2016.00043
  5. Please move the brown box (Prevention; Implementation Education) below the green box (Safe Handling Disposal), and bring each of the boxes into the slide one at a time, starting with ‘New product development’. Since the safe handling and prevention are on the feed back loop from public health impact to clinical practice, I put them below the continuum and the new product is in the opposite direction I put it on the top (closer to the direction of the left to right arrow). Biomedical Research Translation Continuum Ref: Translational research: understanding the continuum from bench to bedside BRIAN C. DROLET, and NANCY M. LORENZI Translational Research 2011;157:1–5 Fernandez-Moure JS (2016) Lost in Translation: The Gap in Scientific Advancements and Clinical Application. Front. Bioeng. Biotechnol. 4:43. doi: 10.3389/fbioe.2016.00043
  6. Implementation research is the scientific inquiry into questions concerning implementation—the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions).”
  7. Implementation research seeks to understand and work within real world conditions, rather than trying to control for these conditions or to remove their influence as causal effects.
  8. Implementation research is especially concerned with the users of the research and not purely the production of knowledge.
  9. Put some ”teeth” into the policy GENERAL MINAMATA PAPER The Minamata Convention on Mercury: Attempting to address the global controversy of dental amalgam use and mercury waste disposal Tim K. Mackey a,b,c,d,⁎, John T. Contreras a, Bryan A. Liang a,b,c Science of the Total Environment 472 (2014) 125–129