Is it time to reevaluate your one-size-fits-all approach?
BY Patti DiGangi, RDH, BS
Categories make it possible for us to put similar things together-a method for sorting things and knowing where to retrieve things. Organizing helps keep people on track. Often in dentistry, a calendar is used to sort. The care and time needed is decided by the patient's age. This often equates to all children getting a 30-minute appointment and fluoride every six months. But they don't get periodontal charting or oral cancer screening. For adults, this equates to every adult receiving some type of scaling but no time for vital signs.
As a business, dentistry needs organized systems, but should we continue to categorize and sort people with a calendar as the basis?
Is there truly an accurate response for asking what is the basis of all prevention? Traditionally it has been brushing, flossing, and fluoride. Have you seriously questioned this premise? Isn't that one-size-fits-all? It is not the intent here to say brushing, flossing, and fluoride are not important.
Rather, it is to examine other choices. It is not just the hammer-nail analogy. A common quotation is: "If your only tool is a hammer, then every problem looks like a nail." If our hands are full and our brains are closed, then change is not likely to happen. You can't learn anything new, if you already know it. It's time to redefine prevention (see related sidebar).
Dr. John Featherstone is thought by many to be the Father of CAMBRA (Caries Management by Risk Assessment). He offers courses that provide the scientific basis for up-to-date caries risk assessment and practice interventions. The 2006 evidence-based clinical recommendations for professional fluoride application, per the American Dental Association's Council on Scientific Affairs states:
• Fluoride gel applied four minutes or more is effective
• Fluoride varnish applied every six months is effective
• Two or more applications of fluoride varnish per year are effective for high-risk individuals
• Professional topical fluoride applications added no benefit for low-risk individuals
The last two bullets should be of greatest interest. The heart of CAMBRA is part of the name, "by risk assessment." This means one size definitely does not fit everyone, as Dr. Featherstone clearly points out.
The last bullet is even harder for many professionals to swallow and, more importantly, to change. Low risk means no fluoride is needed. The question is the way risk is determined. This idea of risk assessment was further supported in CDT 2015 where there are three caries risk assessment codes (see related sidebar).
There is further synergy when other ingredients are combined with fluoride. Xylitol is now recognized as an important factor in reducing the growth and acid production of cariogenic bacteria. Xylitol's 5-carbon structure can be processed by humans but cannot be processed in the same way by many pathogenic bacteria. Xylitol decreases the bacteria's ability to adhere to body tissues. It has the unique effect of diminishing bacteria's ability to produce biofilm. Xylitol has medical, dental, and nutritional implications; many patients can benefit from xylitol. Yet one size still doesn't fit all. Risk assessment again identifies the need and best delivery system for specific individuals.
The hydroxyapatite of tooth enamel is primarily composed of phosphate ions and calcium ions. Under normal conditions, there is a stable equilibrium between the calcium and phosphate ions in saliva and the crystalline hydroxyapatite that comprises 96% of tooth enamel. If a patient has inadequate salivary flow (hyposalivation), then xerostomia will occur. This is a lack of calcium/phosphate in the saliva, and they will not receive optimal fluoride uptake. As we know, the body is constantly trying to stay in balance, and this includes the saliva. Demineralization is loss of hydroxyapatite as a result of a drop in pH. In other words, hydroxyapatite readily loses trace minerals from its crystal lattice in an acidic environment. The good news is that it also readily incorporates trace minerals into its crystal lattice if the particles are small enough.
Nano-hydroxyapatite (nHAP) is utilized for its bioactivity, biocompatibility, and similarity to the mineral composition of teeth. Nano-hydroxyapatite is easily integrated into the dentinal tubules, enhancing their occlusion. It seals the tubules and prevents exposure of the nerves to external stimuli, thereby reducing dentinal hypersensitivity. Nano-hydroxyapatite provides multiple results in a variety of studies including:
• Reduction in caries infection cavitation
• Sealing of tooth surfaces leading to desensitization
• Remineralization of incipient caries infection breakdown
• Delaying of plaque formation and smoothing surfaces
• Teeth whitening and gloss increase
Remin Pro by VOCO America combines three components: hydroxyapatite, fluoride, and xylitol that have been clinically proven to deliver effective protection against demineralization and erosion. It is dispensed by the dental practice for at-risk patients. It is easy for the patient to apply whether the problem is sensitivity, dry mouth, or the many ways the oral environment can be at risk.
Finding the Right Fit
So we can agree that one size doesn't fit everyone very well. At the same time, many patients can benefit from using products that are more than brushing, flossing, and fluoride. How do we find the right fit? The results of Dr. Featherstone's very large 2011 study with 12,954 participants can shed some light:
• 15.5% at low risk
• 21.9% at moderate risk
• 62.6% at high/extreme risk
What the above statistics can mean in your practice is that nearly 85% of your patients need some kind of assistance beyond your routine! How do you identify them? By using a variety of risk assessment options. The really good news is there is a high possibility that with proper documentation, your patients' dental benefits may cover these assessment tools.
Calendars are great for staying on track and efficient. There are many better ways to make health decisions. Efficient doesn't necessarily mean effective. We best serve our patients and the practice's bottom line when we take the time to find the right fit. RDH
Author Note: CDT codes are risk and diagnosis based, not product based. VOCO America offers specific code suggestions that are made to facilitate best coverage under a policy.
• Primary prevention
>> Entirely avoid the development of disease
>> Eliminate the principal risk factors
• Secondary prevention
>> Detection of early disease
>> Stage at which intervention may lead either to an outright cure or to a signiﬁcant reduction in damage
• Tertiary prevention
>> Reduce the risk of disease recurrence following the treatment
>> Minimize the risk of disease-related complications
CDT 2015 Caries Risk Assessment Codes
• D0601 caries risk assessment and documentation, with a finding of low risk
• D0602 caries risk assessment and documentation, with a finding of moderate risk
• D0603 caries risk assessment and documentation, with a finding of high risk
The description for all three codes includes "using recognized assessment tools." Because the code contains the word documentation, writing the dental/medical necessity is needed. A wide variety of quantifiable caries risk assessment tools are available:
• Health/medication history
• Paper/computer-based Q&A (visit links below for examples)
>> mydentalscore.com (open access to 60 million Delta Dental participants)
• Saliva tests
• Bacterial tests
• Luminescence technologies
Patti DiGangi, RDH, BS, is a certified health information technology trainer shaping the changes in our interoperable electronic health record world. Patti is an ADA Evidence Based Champion and holds publishing and speaking licenses for "Current Dental Terminology" (ADA) and SNODENT Coding. She is the author of the DentalCodeology series of bite-size books for busy people. Patti was awarded the 2014 Sunstar Award of Distinction and the 2013 Sonicare Mentor of Distinction award. Visit DentalCodeology.com for more information about her books.