QA RESEARCH:
INCREASING COMPLETE FLUORIDE VARNISH APPLICATION IN
GENERASIKU HARAPANKU (GKHK) PROGRAMME
AT KLINIK PERGIGIAN TENGKERA
PEJABAT KESIHATAN PERGIGIAN DAERAH MELAKA TENGAH (PKPDMT)
Dr Siti Amira binti
Ahmad Dardiri
Dr Nur Syareena binti
Tajuddin
Dr Aisyah Badihah binti
Azni
Dr Nurazreen binti
Abdul Rahman
Dr Muhamad Atiff bin
Muhamad Noordin
Dental Officer in
KP Ayer Keroh
Meet the team
Pn Nurul Azah
binti Aziz
Dental Officer in
KP Tengkera
Dental Officer in
KP Ayer Molek
Dental Officer in
KP Peringgit
Dental Officer in
KP Molek
Dental Therapist in
KP Ayer Keroh
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3
Presentation Outline
11. Process of Care
12. Model of Good Care
13. Remedial action
14. Conformation of MOGC
15. Findings
16. ABNA
17. Next Step
18. Conclusion
19. Gantt Chart
20. References
4
No | Problem | Achievement (Jan 2018) |
1 | Low number of toddlers with complete fluoride varnish application in Generasiku Harapanku Programme | Standard: 60.0% Finding: 4.0% |
2 | High percentage of rejected intra-oral x-ray taken | Standard: 11.0% Finding: 5.0% |
3 | Low percentage of patient at outpatient clinic to be attended within 30 minutes waiting time. | Standard: 86.0% Finding: 79.9% |
4 | Low percentage of NTR(no treatment needed) in 16 year old patients at school | Standard: 70.0% Finding:54.9% |
Problem Identification
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NO | TOPIC | VOTE | TOTAL | ||||
S | M | A | R | T | |||
1 | Low number of toddlers with complete fluoride varnish application in Generasiku Harapanku (GKHK) Programme | 13 | 15 | 11 | 7 | 7 | 53 |
2 | High percentage of rejected intra-oral x-ray taken | 7 | 11 | 7 | 5 | 6 | 36 |
3 | Low percentage of patient at outpatient clinic to be attended within 30 minutes waiting time. | 7 | 12 | 11 | 12 | 7 | 49 |
4 | Low percentage of NTR (no treatment needed) in 16 year old patients at school | 10 | 8 | 7 | 5 | 5 | 35 |
Weightage: 1=Low 2=Medium 3=High
Problem Ranking: SMART Criteria
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Reason For Choosing
Technique
7
Introduction
28.7%
30.6%
2015 National Oral Health Survey of Preschool Children
Caries-free prevalence among 5 year-old
Caries-free prevalence among 5 year-old
(NOHPS)
7 of 10
Preschool children have caries
8
Generasiku Harapanku (GKHK) Programme
Established in October 2015
Early Oral Health Intervention done in this programme
Lift the Lip
Fluoride Varnish
Anticipatory Guidance
1
2
3
Toddler adoption programme by Dental Officers & Dental Therapist
Moderate
High
Caries Risk
0-4
Years Old
3-6
monthly
Follow up
Until 6 years old
MARINHO ET. AL (2013)
Concluded their updated review remain the same as those when it was first published in 2002 and suggest a substantial caries-inhibiting effect of fluoride varnish in primary teeth. [3]
WEINTRAUB ET. AL (2006)
Claimed that fluoride varnish added to caregiver counselling was effective in reducing early childhood caries incidence. [2]
MARINHO ET. AL (2002)
Found that fluoride varnish application applied professionally two to four time in a year would substantially reduce tooth decay in children. [1]
Literature Review
[1] Marinho et al.(2002) Fluoride Varnish for preventing dental caries and adolescents(Review). Cochrane Database of Systematic Review. Retrieved from https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002278/abstract
[2] Weintraub et al.(2006) Fluoride Varnish Efficacy in Preventing Early Childhood. Retrieved from Carieshttps://journals.sagepub.com/doi/abs/10.1177/154405910608500211.
[3] Marinho et al. (2013) Fluoride Varnish for preventing dental caries in children and adolescent (Updated Review). Retrieved from https://www.cochrane.org/CD002279/ORAL_fluoride-varnishes-for-preventing-dental-caries-in-children-and-adolescents
[4]Su et al (2019) The effect of fluoride varnish Duraphat in preventing deciduous dental caries in preschool children Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/31080999
[5] Oral Health Division, Mninstry of Health. National Oral Health Survey of Preschool Children 2015 (NOHPS 2015) Volume 1: Oral Health Status and Caries Treatment Needs. MOH/K/GIGI/5.2017(RR0
COMPLETE FV
4
3-6
times of Fluoride Varnish application
monthly
[5]
Stick to tooth surface
Increase contact duration on enamel
Act as slow releasing reservoir of fluoride
Aid in resistant to acid attack
Prevent tooth decay
SU ET. AL (2019)
Concluded that fluoride varnish is effective in decreasing caries incidence.[4]
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Cross sectional (Jan-Dec 2018)
Toddlers who have caries and fail to attend appointment
EXCLUSION CRITERIA
Type of Study
11
Low Number of Complete Fluoride Varnish in GKHK Programme
Poor Follow Up System
Inefficient method of follow up through phone call
List of patients who missed appointment unavailable
4
Poor Promotion
Outdated promotion materials
Lack of interaction with parents
3
Lack of Dedicated Operators
Lack of time
Lack of soft skills
1
Unclear with mission & vision
Lack of Parent’s / Guardian’s Cooperation
2
Lack of time
Forget appointment
66.7%
41.7%
41.7%
90%
75%
91.7%
50%
58.3%
66.7%
based on questionnaires to operators & phone call interviews to parents
Problem Analysis
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3
4
5
1
To increase complete fluoride varnish application among toddlers in GKHK Programme
GKHK is an intervention programme to increase caries free
prevalence among toddlers 0-4 years old through fluoride
varnish application 3-6 monthly until reach 4 times application
Factors contributed to the problem were lack of dedicated operator, lack of parents / guardian cooperation, poor follow up system and poor promotion of programme
Low percentage of caries free among toddlers when they reach 5 years old
Low number of toddlers with complete fluoride varnish application in GKHK Programme
Problem Statement
Introduction
Problem
Effect
Problem causes
Aim of study
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13
GENERAL
Objective
To increase number of toddlers with complete fluoride varnish application in GKHK Programme
SPECIFIC
Objective
To determine the factors that causes low number of complete fluoride varnish application
2
To determine number of toddlers with complete fluoride varnish application in GKHK programme
1
To recommend and institute remedial measures on how to increase number of toddlers with complete fluoride varnish application
3
To evaluate the effectiveness of the remedial measures taken
4
Objectives
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Indicator | Formula | Standard |
Percentage of toddlers GKHK with Complete FV | Total number of toddlers GKHK with complete FV x 100 —————————————————— Total number of participated toddlers GKHK | 60% |
Based on Plan of Action PKPDMT & Pelan Strategik JKNM 2018-2022
4 times of fluoride varnish application
Indicator & Standard
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Screening toddlers
0-4 years old
Indicated for
GKHK?
Caries risk assessment
Parents or guardians' consent
FV 1 application done
Appointment card given
Treatment record
FV 2 / 3 / 4 application done
Data recorded in GKHK/BKPNM/02
Follow up appointment after 6 month
Caries free?
Data recorded in database DB18
& GKHK/BKPNM/03
End
outpatient clinic
Disqualified from GKHK
but follow up review every 6 month
No
Yes
No
Yes
Process of Care
Follow up until 6 years
(FV if needed)
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No | Procedure | Criteria | Standard | Pre-remedial |
1 | Screening toddlers as early as 6 month old | Toddlers screened during outpatient clinic, KKIA, KD, daycare and kindergarten from age 6 month old to 4 years old who are caries free . | 100.0% | 75.0% |
2 | Caries risk assessment | - Case chosen according to Appendix 1a (Caries Risk Assessment). - Indicated case has moderate or high caries risk. | 100.0% | 66.7% |
3 | Parents or guardian's consent | - Program details explained to parents or guardian. - Consent form filled in and signed by parents or guardian (GKHK/BKPNM/01) | 100.0% | 100.0% |
Model of Good Care (MOGC)
16
17
No
No
18
1
2
3
4
Specific Slot for GKHK in Daily Schedule
Home Visit
Whatsapp Bluestacks
GKHK Dedicated Squad
Remedial Actions
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To cater the problem:
Consist of Dental Officers &
Dental Therapists
ECO-TRAINING
FOLLOW UP PATIENT
PATIENT LIST
about GKHK that include:
Database DB18
Printed list of patients who missed appointment
responsible to sort out & produced printed list of all the patient who missed appointment from our database DB18.
GKHK Dedicated Squad
Lack of Dedicated Operators
1
20
AM
PM
GKHK slot | Mon | Tue | Wed | Thu | Fri |
am | Dr Aishah | Dr Ding | Dr Ainin | Dr Wafiy | Dr Aishah |
pm | Dr Fatin | Dr Sim | Dr Khor | Dr Lee | Dr Ong |
GKHK Specific Slot in
Daily Operator Schedule
Lack of Dedicated Operators
1
Sort out Patient who missed appointment using DB-18
Call or whatsapp parents for appointment reminder
Assesing new toddler for
GKHK
Updating DB-18
To cater the problem:
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To cater the problem:
patients' card were organized according to same specific location
home visit in group of 2 or 3 with driver
fluoride varnish application
dental health education
BK 8- appointment
letter note
BK 8 was left inside letter box
Home Visit
22
interesting infographic materials
remind parents about appointment date
Whatsapp Bluestacks
To cater the problem:
23
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No | Procedure | Criteria | Standard | Pre-remedial | Post-remedial |
1 | Screening toddlers as early as 6 month old | -Toddlers screened during outpatient clinic, KKIA, KD, daycare and kindergarten from age 6 month old to 4 years old who are caries free | 100.0% | 75.0% | 91.7% |
2 | Caries risk assessment | -Case chosen according to Appendix 1a (Caries Risk Assessment). -Indicated case has moderate or high caries risk. | 100.0% | 66.7% | 83.3% |
3 | Parents or guardian's consent | -Program details explained to parents or guardian. -Consent form filled in and signed by parents or guardian (GKHK/BKPNM/01) | 100.0% | 100.0% | 100.0% |
Conformation MOGC
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No | Procedure | Criteria | Standard | Pre-remedial | Post-remedial |
4 | FV 1 application | Following procedures done: -lift the lip -anticipatory guidance (AG) -fluoride varnish application | 100.0% | 100.0% | 100.0% |
5 | Appointment card given | Follow up appointment given 6 month from date seen. | 100.0% | 75.0% | 91.7% |
6 | Treatment record | Treatment done recorded in patient's card (LP8) | 100.0% | 100.0% | 100.0% |
7 | Data recorded in GKHK/BKPNM/02 | Details of toddler's name, parents' name, address, contact number, date FV done recorded in this form | 100.0% | 80.0% | 100% |
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No | Procedure | Criteria | Standard | Pre-remedial | Post-remedial |
8 | Data recorded in GKHK/BKPNM/03 & Database DB18 | -number of GKHK toddlers adopted and number of FV done are compiled in this form. -date of current visit recorded and date of next appointment visit automatically generated | 100% | 100.0% | 100.0% |
9 | Follow up appointment after 6 month | -Procedures as in No. 4 are repeated. -If caries noted, toddlers are terminated from GKHK but still under follow up appoinment under outpatient clinic for FV or filling. | 100% | 70.0% | 100.0% |
10 | FV 2 / 3 / 4 application done | Complete FV application | 60% | 4.0% | 26.3% |
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Month | January 2018 | Jan-June 2018 | July-December 2018 |
Achievement | 29/727 x 100 = 4.0% | 116/681 x 100 = 17.0% | 164/623 x 100 = 26.3% |
� Percentage of Toddlers with Complete Fluoride Varnish Application
Sustainability
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ABNA= 56%
ABNA = 33.7%
4%
26.3%
60%
% toddlers with complete FV
Achievable Benefit Not Achieved (ABNA)
Complete FV vs Caries-free Toddlers
4%
39.2%
26.3%
58.7%
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Increase complete fluoride varnish application up to 60% by 2020 according to Plan of Action PKPDMT
Continuous closed monitoring and achievement through periodically meeting to meet Pelan Strategik JKNM 2018-2022
Implemented in all dental clinics in Melaka
By August 2019, Melaka adopted 25,417 toddlers
Next step
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Conclusion
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Gantt Chart
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1) Jamil, A. et al. (2012) QA Workbook: The Problem-Solving Approach. Shah Alam, Selangor: IHSR MOH.
2) Marinho et al. (2002) Fluoride Varnish for preventing dental caries and adolescents (Review). Cochrane Database of Systematic Review. Retrieved from https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002278/abstract
3) Weintraub et al. (2006) Fluoride Varnish Efficacy in Preventing Early Childhood. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/154405910608500211.
4) Oral Health Division, Ministry of Health. National Oral Health Survey of Preschool Children 2015 (NOHPS 2015) Volume 1: Oral Health Status and Caries Treatment Needs. MOH/K/GIGI/5.2017(RR)
5) Marinho et al. (2013) Fluoride Varnish for preventing dental caries in children and adolescent (Updated Review). Retrieved from https://www.cochrane.org/CD002279/ORAL_fluoride-varnishes-for-preventing-dental-caries-in-children-and-adolescents
6) Su et al (2019) The effect of fluoride varnish Duraphat in preventing deciduous dental caries in preschool children Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/31080999
References
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Acknowledgment
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Thank You