Making caries prevention SMART: Adaptive interventions for precision dental medicine in schools

About This Grant

Dental caries is the world’s most prevalent noncommunicable disease, with considerable health disparities found in low-income rural white children and low-income urban Hispanic/Latino and black children. To combat this silent epidemic, school-based caries prevention can increase access to critical dental care, reducing caries risk and mitigating its severe health and socioemotional consequences. However, despite the use of evidence-based interventions, approximately 30% of children participating in school-based caries prevention fail to respond to treatment (“nonresponse”), developing new caries and remaining at high risk for subsequent complications. Additionally, the sustainability of school-based prevention is jeopardized due to prohibitive costs, limitations of the professional workforce, and relying on treatments that are not optimized for individual patient needs. We propose to develop and assess personalized, resource-efficient approaches to school caries prevention using adaptive interventions. Evaluated by embedding dynamic treatment regimes (DTR) within a sequential multiple assignment randomized trial (SMART) design, we will explore a number of hypotheses related to adaptive preventive interventions for caries. First, we will test the effects of adaptive interventions on reducing treatment nonresponse using generalized linear mixed models, followed by identifying the best dynamic treatment regime using augmented inverse probability weighted marginal structural models for causal effect estimation. We will subsequently build an optimal adaptive intervention using Q-learning, tailoring treatments to individual patient attributes and responsiveness. We will conclude with a microcosting analysis of the adaptive interventions, ultimately quantifying the intervention costs under different implementation scenarios and taking the first step towards understanding how much payers should reimburse for adaptive interventions. To facilitate completion of these aims, we will implement our adaptive prevention model in the CariedAway network: a multistate community-based participatory research group of schools serving predominantly low-income children that are committed to innovative approaches to caries prevention. This will simplify site and patient recruitment, embeds community engagement into our research process, and has a demonstrated history of both successful clinical care and research. Successful completion of this project will produce resource-efficient adaptive prevention interventions (API) to reduce treatment nonresponse and improve oral health.