Going beyond a caries risk assessment to create and maintain a management plan
By Kari Kuempel, RDH
The idea of a caries risk assessment is not new. The idea of formal risk assessment has been around for almost 20 years, but dental hygienists have been using their intuition combined with clinical expertise to help patients fight dental disease for as long as the profession itself.
When I speak at events, I often ask clinicians how many of them perform a caries risk assessment. Only about 10% of them raise their hands when I phrase the question that way. However, when I ask how many of them just know when they see a patient that is in trouble, just about all hands shoot into the air.
As clinicians, we are constantly assessing risk. What’s often missing is patient engagement, which can take the pressure off, as we often wish to solve all of a person’s issues at one appointment. A caries risk assessment doesn’t have to be a strict, time-consuming process that is the same from patient to patient. Instead, it actually benefits everyone involved if the process is personalized.
The landscape of dentistry is changing, and we’re seeing more integration of oral health into overall health. With increased access to information, patients are savvier than ever, so it’s on us to establish and maintain a trusting relationship with them, encouraging them to implement our recommendations on their own time.
Since the caries process is so dynamic, there’s no one silver bullet that will cure caries for everyone. However, there are some steps you can take to make sure patients are onboard and are making the most of the management plan you create together. I suggest three steps in this article.
Establish the risk level
Using your clinical judgment is crucial, but so is your patient interaction. Ultimately, patients are the experts on their own lives, and their disclosures are necessary for you to identify their level of risk. Sometimes, the challenge is getting them to open up.
Asking open-ended questions without making patients feel judged or reprimanded is a great way to get more information on their family history, self-care, dietary habits, and exposure to fluoride. Through these honest conversations and what you’re seeing in the mouth, you should be able to quickly identify whether the patient is at a low, medium, or high caries risk.
The caries disease process is like a scale. Balancing the key factors that can contribute to disease is the key to risk assessment. Each patient is different, but I’ve found the categorization of the below factors to be helpful in working with a patient to establish his or her risk level:
High risk—Clear indications of high risk are if a patient has hyposalivation or has experienced decay in the last three years. Consider keeping an eye on orthodontic patients as well, as they have to deal with appliances that get in the way of being able to brush and floss properly, which can create a high-risk environment.
Patients that are on medications often experience xerostomia, which, as mentioned above, is an automatic high-risk indicator. Some patients, including elderly folks, might suffer from limited mobility, dexterity, or experience mental decline, impacting their ability to brush correctly.
Moderate risk—These patients are more of a gray area, as one small factor could tip the balance one way or another. If two or more of the following factors are present, I would classify a patient at more of a higher risk: plaque, orthodontic appliances, multiple exposures to sugar throughout the day (including beverages), and exposed root surfaces.
If a patient has frequent exposure to fluoride, calcium, and phosphate, you might consider keeping them in the moderate risk level due to the balance of protective factors tipping the scale.
Low risk—Patients who experience very few of the above factors can typically be described as low risk. I believe it’s important to let them know what they’re doing right and make sure you’re sharing with them what factors could tip the scale in the other direction so that they can keep an eye on their habits.
Create a management plan
I’ve found success in describing what clinical evidence says about their situation so that patients know I’m not just giving my personal opinion. Third party credibility is important—not just to establish trust, but also to add a scientific background to what patients are discovering about themselves as they begin to understand caries as a disease.
Try asking patients for permission before diving into what could be done to arrest the progression of their caries. For example, you can ask, “Can I walk you through some things that may help you at home to help stop this disease from progressing any further?” Asking for their participation and letting them guide the conversation increases patient involvement, making them feel more in control and less like they’re being told what to do.
While patients are in your chair, they may hand their treatment over to you, but that doesn’t mean their involvement should stop.
Involving the patient in the process by using a visual caries risk assessment form can be an eye-opening tool and is key for success. If patients feel empowered, they will want to take control of their own health! Have them show you how they brush/floss and ask if you can give them some suggestions. Make a note of what you discussed and follow up at the next appointment. Even before I worked at 3M, I would prescribe 3M Clinpro 5000 1.1% Sodium Fluoride Anti-Cavity Toothpaste for patients to use at home on their own time.
Most patients feel empowered when their management plans don’t cause a disruption in their daily lives. That’s why Clinpro 5000 fits beautifully, since all patients have to do is swap out their normal toothpaste to get the prescription treatment. With little change to patients’ routines, they receive the benefit of Clinpro 5000, which is formulated to release high levels of bioavailable fluoride, calcium and phosphate—components for remineralization.
While patients are in your chair, they may hand their treatment over to you, but that doesn’t mean their involvement should stop. To continue building trust, consider explaining what you’re doing and why. For example, if you’re applying 3M Vanish 5% Sodium Fluoride White Varnish, explain that you chose it for its 24-hour fluoride release. Patients are smart; help them see the value and understand that the longer the fluoride stays in contact with the teeth, the better.
Frequent in-office fluoride application is a power tool in lowering risk. I have even had my high-risk patients come in at three months between their recare visit for short fluoride appointment to apply Vanish Varnish. It takes less than 10 minutes to apply the varnish on a wet surface, yet it shows the patient that you’re invested in their health and are working with them to stop their caries.
Compliance typically increases if patients feel like they are getting a plan that’s individually created for them. If you prescribe Clinpro 5000 to a patient, let them know how many times a day they should use it based on their own risk level, how much they should be using, and educate them on how it will help strengthen their enamel. If they seem concerned, let them know that the taste is mild and appealing to most patients.
Where restorative procedures can be billed the same day, usually the financial benefit of prevention is a little less immediate. Luckily, the industry is placing more of a priority on arresting caries before restorative treatment is needed. In fact, we can be agents for change by using one of the below informational procedure codes on patients’ bills.
• D0601: Caries risk assessment and documentation, with a finding of low risk using recognized assessment tool
• D0602: Caries risk assessment and documentation, with a finding of moderate risk using recognized assessment tool
• D0603: Caries risk assessment and documentation, with a finding of high risk using recognized assessment tool
While the codes may be informational at this point, using them is the first step toward insurance reimbursements in the future. They assign a value to risk assessment in the patient’s eyes and enhances patient documentation and tracking.
While most of this advice for creating a management plan applies to all patients, I’ve found the below tips to be successful for specific patient groups:
• Orthodontic patients—Recommend a water flosser to help them dislodge food particles and make cleaning the hard-to-reach areas a little less of a pain.
In addition to prescribing Clinpro 5000, think about incorporating Vanish Varnish every three months, and applying 3M Vanish XT Extended Contact Varnish at bonding for up to six months of rechargeable fluoride protection.
Many ortho patients are preteens or teenagers, which means they’re likely facing a lot of pressure to look good and be cool. Explain to them what white spot lesions are, what they look like, and how sticking to their management plan can help avoid these spots, as well as other issues like bad breath.
• Pediatric patients—They may be too young for Clinpro 5000, but applying 3M Clinpro Sealant at their appointment can help go the extra mile for preventing and arresting caries. Plus, you can show them how it turns from pink to white, which is guaranteed to pique their interest. Sealants are for everyone, not just kids, and they must be checked carefully at each appointment and retouched as needed.
Engaging the parents is so important! Since children are often too young to brush/floss appropriately at home, parents are instrumental in setting up their children for lifelong oral health.
• Elderly patients—Use fluoride varnish when they’re in the office to add extra protection. Recommend xylitol mints or gum to increase the flow of saliva. Recommend the use of an electric toothbrush and/or a water flosser to overcome dexterity issues.
Maintain the plan
The most crucial part of maintaining a management plan is documenting everything and ensuring follow up. If a patient isn’t seeing the same hygienist every time they come in, the plan could fall by the wayside if the documentation isn’t there or if the next clinician doesn’t check in. If I was the hygienist who saw a patient last, I’ll remind him or her of what we discussed, and then check in by asking open-ended questions that require more than a yes or no. For example, I may ask patients about compliance in using prescribed or recommended home care products, or how “you been addressing your risk for getting cavities?”
If a patient saw another clinician at the last appointment, I review all of the documentation and ask similar open-ended questions that reference what I see in the notes. “It looks like you had a great discussion at your last appointment about how you can lower your risk for cavities. How’s that going?”
Regardless of whether you see the patient at every appointment or if they rotate hygienists, make sure you are diligent about your documentation. This helps ensure the patient will stay on track for better oral health.
While working with patients on their management plans, we shouldn’t make individuals feel bad or fearful about caries. It’s our job to arm our patients with the tools they need to fight the disease. Ultimately, however, they need to know that we are here for them if they do end up in trouble.
Building trust with patients, empowering them to take control of their own oral health, and keeping the line of communication open is good for business as well as their overall health. If a patient feels genuinely cared about, it’s likely they’ll refer patients or come to you first if they have questions or need further treatment. Not to mention the benefit to you and your job satisfaction that results in helping patients improve their oral health.
For more information on implementing a caries risk assessment protocol, my employer, 3M Dental Products, offers Caries Management by Risk Assessment (CAMBRA) resources at its website.
Kari Kuempel, BSc, RDH, is the US professional services manager, Prevention for 3M Oral Care. A dental hygienist with 15 years of experience, Kari is a graduate of Dalhousie University in Nova Scotia, Canada. She is currently pursuing her master’s degree at the University of Minnesota with a focus on education and research. Her experience includes full-time faculty at the University of Minnesota School of Dentistry and Continuing Dental Education. For her efforts, she has received several faculty of the year awards. Kari is also an active member of American Dental Hygienist’s Association.