Are you putting risk assessment to work for your adult patients?
By Donna Lynn Brogan, RDH, BS
Traditionally, dental professionals provided fluoride treatments to children in the caries-active stage, but the face of caries has changed. Large cohort studies have shown that mature people are a caries-active group, experiencing new disease at a rate that is at least as great as that of adolescents.1 Risk factors such as recession, prescription medication use, poor biofilm removal, multisurface restorations, or recent carious activity put them at a high risk for developing caries. All of these factors become increasingly prevalent in people in their 40s and 50s, long before they become "seniors." The most recognized use of fluoride varnish in adults is for dentin desensitization, but the practice of caries management by risk assessment (CAMBRA) has opened clinicians' minds and operatories to a more widespread and purposeful use.
In late 2013, the Council on Scientific Affairs of the American Dental Association published evidence-based clinical recommendations for the use of professionally applied topical fluorides for all ages.2 Two types of professionally applied fluoride were recommended: 5% fluoride varnish, and four-minute, tray-applied acidulated phosphate (APF) gel. Since the majority of adults have composite, porcelain, or ceramic restorations that disqualify the use of APF, this article will discuss fluoride varnish.
Over the years, small interproximal restorations can progress to large lesions and eventually result in a crown. Add xerostomia and recession, and an ominous dark line at the crown margin appears. Adults must be followed closely to put an end to the irreversible restorative cycle that leads to more aggressive treatment and tissue loss.
One of the most significant factors is exposed root surfaces. Enamel demineralizes at a pH of 5.5 but exposed root surfaces demineralize at a pH much closer to neutral, 6.2 to 6.7.3 Dentin and cementum demineralization occurs twice as fast as it does in enamel because they have as little as half the mineral content. Both the initiation and progression of root caries occurs much more rapidly than in enamel surfaces. For adult patients, root caries is an ugly outcome, and it often has far-reaching negative effects.
Patients with xerostomia are another group at risk for the fast progression of caries.4 Over 400 medications contribute to xerostomia.5 The Mayo Clinic reports that 68% of Americans take prescription medication. Over half are on two medications, and 21% are on five or more.6 These patients may lack the benefits of saliva, which clears away food and debris, and has the capability to buffer acid attacks. Without enough saliva, remineralization cannot occur because the enamel isn't exposed to calcium and phosphate.7 Instead of the beautiful demineralization/remineralization balance, teeth are caught in the downward spiral of the demineralization process.
Table 1: Risk factors for adult caries
• Active caries in previous 24 months (automatically high risk)
• Presence of exposed root surfaces
• Xerostomia (medication-, radiation-, or disease-induced)
• Poor oral hygiene
• Many multisurface restorations
• Restoration overhangs and open margins
• Cariogenic diet
• Chemo or H/N radiation therapy
Patients who were diagnosed with decay during the last 24 months are automatically considered high risk.2 They are very likely to develop recurrent decay in the same location or at a new site because the bacterial infection is ongoing. Simply removing decay and placing a restoration is not enough; the oral cavity must achieve a bacterial balance in order to reduce the cariogenic attack.8 After a restoration of any kind has been placed due to caries activity, a fluoride varnish should be performed at subsequent recall visits until the patient has had two caries-free years.2 In addition to professionally applied fluoride, the use of remineralization products, home fluoride, xylitol gum, and/or pH stabilization may be indicated. Many companies provide these therapeutic products, including CariFree, Xlear, and GC America, to name a few.
Numerous risk assessments with simple checklists enable clinicians to determine and show patients the level of risk for caries development. These assessments conveniently divide patients into low-, moderate-, or high-risk groups and can be a wonderful educational tool to involve patients in their preventive treatment plan. Table 1 shows a partial list of proven risk factors for adults.2 Depending on the elevated risk category the patient falls into, applying varnish two to four times a year is recommended.9 The ADA risk form helps dental professionals quickly and easily explain to their patients their risk level, and encourages patient acceptance for the recommended treatment.
Many clinicians do not routinely apply varnish for adult patients. Reasons include lack of insurance coverage, difficulty placing varnish, poor taste and appearance, and the unacceptable sensation the patient feels for hours after treatment. Another reason for not applying varnish four times a year is that the patient may visit the office only every six months. These objections have limited the use of an important preventive tool that can be very successful in disease prevention, if only put to use.
Manufacturers have heard the criticisms and have made many adjustments to fluoride varnish products. If fluoride varnish is clumping on the applicator brush, if it tastes bad or is visible on the teeth, try another product. If adults complain about the fuzzy feeling on their teeth or the sticky residue on soft tissue, try another product. A suggested varnish is one that is smooth, clear, never stringy or clumpy, and in a flavor that adults prefer (Fluorodose).
Fluoride varnish can be easy to apply and doesn't require a chair or even an operatory. It does not have to be applied in the supine position and the clinician doesn't even need an overhead light or saliva ejector. If risk assessment determines a patient would benefit from treatment four times a year but the patient has only two recalls, there's an alternative to the chair; the patient can sit in a normal chair in the consultation room or any private area. Application of the varnish takes less than one minute and then patients can go on with their day.
Fluoride varnish application is easiest when done face to face. The clinician should face the patient so they are close to the same height. Have the patient swallow, open, and look slightly down. Using a unit-dose delivery system, the clinician then loads the applicator brush and swipes varnish along the lingual of the mandibular arch. Have the patient look straight ahead with teeth together, retract the left cheek with a mouth mirror, load applicator brush as needed, and swipe the facial of both arches. Retract the right cheek and repeat. Instruct the patient to open and look up, reload the applicator, and swipe the lingual of the maxillary arch. Supply the patient with a disposable cup and tissue so they can expectorate as desired. Use of a saliva ejector is contraindicated as all varnish products have the opportunity to harden inside the hose and clog lines.
This application technique can be used after the recall exam in the operatory but is just as easily performed in a consultation room. It takes just minutes and does not require the effort or cost of turning over a room. Fluoride varnish patients can be scheduled between hourly blocks, and any qualified dental professional available can perform an easy varnish treatment for drop-in patients.
Addressing the insurance question upfront is imperative. Given the possible negative outcomes of caries, varnish application for a small fee is preferable to more extensive treatment later on. Fluoride varnish is very inexpensive (as low as $1, depending on the product), and this application technique will keep costs minimal for subsequent patient visits.
There is a wide variation in fees across practices, ranging from $15 to $95, but a fee of about $25 is acceptable to most patients for the one-minute application (especially given the cost of alternative treatments down the road). Keeping the fee low will result in more patients accepting treatment. As a result, the practice will treat real oral health needs and provide an additional revenue stream for the practice, which is a win-win for everyone.
Some companies provide educational tools that dental professionals can use to discuss dental health issues with patients. For example, Centrix offers downloadable support tools for adult varnish application, such as waiting room videos and caries-risk assessment forms, at no charge (centrixdental.com). Other companies offering educational and marketing tools include Philips Sonicare (usa.philips.com) and Sunstar GUM (gumbrand.com). RDH
Donna Brogan, RDH, BS, is a graduate and former faculty member of the University of Oklahoma dental hygiene program. She was voted Outstanding Part Time Faculty by her students in 2007, 2012, 2013, and again in 2014. An educational consultant for more than 20 years, Donna has presented a wide range of topics throughout the world and online. Donna serves on numerous boards including as president for the Oklahoma University Alumni Association and secretary for Variety Care Foundation, a non-profit healthcare provider. She has held numerous positions in the Oklahoma Dental Hygienists' Association and is a proud member of the ADHA.
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