Wild, Wild West
Risk assessment strategies minimize the feeling that it’s a lawless, anything-goes environment out there in the untamed lands of dental diagnosis.
This year, the poker explosion rocked the world as televised tournaments made their way into the living rooms of millions of viewers. The coverage of the World Poker Tour on the Travel channel and ESPN’s broadcast of the World Series of Poker has sparked the interest of the “kitchen table” poker players as well as some people who have never played before. The game that has everyone buzzing is Texas Hold ‘em. This game, like any type of gambling, has inherent risk in it. Gambling involves taking a risk in the hope of gaining an advantage or a benefit. The definition of risk is chance or probability of loss, harm, failure, or danger. For many, the risk is the thrill.
How many people gamble with their dental health? We could easily say that the nearly 50 percent of the population who do not regularly seek dental care likes to gamble with their health. As professionals, we know research has identified periodontal disease as a risk factor for heart and lung disease; diabetes; premature, low-birth-weight babies; and a number of other conditions. The 2000 Surgeon General’s report, Oral Health in America, has called attention to this connection and states that, if left untreated, poor oral health is a “silent X-factor promoting the onset of life-threatening diseases which are responsible for the deaths of millions of Americans each year.”
But what about the population that seeks professional care? We are gambling with their health by not using a structured methodology to reduce their risk of disease. Three categories of clients exist:
• Those who are healthy and will remain so
• Those who are healthy but will develop disease
• Those who have disease.
Some healthy clients surely will eventually suffer from disease, as every client with disease was at one time healthy. Withholding preventive treatment is a gamble that the client will not get disease.
The model of dentistry practiced most often in our country is a disease based/reparative model: “If it ain’t broke, don’t fix it.” This implies treatment is not needed until disease exists, or prevention is a nonentity. Professor and researcher Per Axelsson, DDS, points to the absurdity of not acting to prevent disease. He said it this way, “Imagine having to amputate a finger every five years and replace it with a gold finger due to an infectious disease, in an age when this disease could be successfully prevented.”
Think about the following statements:
• Disease drives reparative treatment.
• Treatment for disease is targeted to the disease and its effects.
• Disease deals with the visible.
• Detection occurs too late in the disease process to prevent disease.
• Repair involves surgical removal of hard and soft tissues.
• Repair rarely results in a condition as good as the original healthy state.
A majority of the diagnostic tools used on a daily basis in clinical practice seek disease and have scant utility until the disease process becomes obvious; yet cardiovascular disease begins with plaque deposits in the vessels, the division of a single cell is the first event of cancer, and the initial event of caries is decalcification. The first stage of disease is invisible and undetectable using routine diagnostic tests. Caries is a late stage manifestation of the breakdown process, while bone loss is the determining factor for recognition and diagnosis of periodontal disease.
Every individual with disease - whether it is caries, oral cancer, or periodontitis - was, at a prior time, healthy and at risk for disease. Sounds like a “Duh” statement, doesn’t it? Yet, as professionals, do we really get it? The primary role of dental hygienists is as prevention specialists. Are we really doing all we can do to prevent disease?
Our current reality is that - although there is extensive knowledge on caries dynamics and progression rates, and we have access to many new and effective preventive measures - most hygienists just “scratch around” with explorers to detect caries. The sharp explorer standard for detecting pit-and-fissure caries was perfected in 1880.
This 125-year-old diagnostic protocol detects the late-stage manifestation of the carious process. How would you like your physician to offer to detect heart disease using a 125-year-old detection method? What care do many hygienists then offer? We perform routine prophies and yell about flossing. For someone with many caries, we take it a step further (if the person is under age 14) and give traditional fluoride treatments, and tell them not to eat so much sugar. Caries, for nearly any other age group, is just expected and routine. We view it as normal and think in our minds - even when we don’t say it - “If they would just floss...”
Oral cancer is the sixth deadliest cancer in the world. There are nearly 30,000 new cases per year, accounting for 4 percent of all cancers diagnosed, with a higher rate of death than Hodgkin’s disease, and cervical, skin, ovarian, and brain cancers. Fifty-two percent will die within five years of diagnosis, with 8,000 people - one per hour - dying each year. Yet, what do many brochures on oral cancer tell people to look for?
• A sore that bleeds easily or does not heal
• A color change of the oral tissues
• A lump, thickening, rough spot, crust, or small eroded area
• Pain, tenderness, or numbness anywhere in the mouth or on the lips
• Difficulty chewing, swallowing, speaking, or moving the jaw or tongue
• A change in the way the teeth fit together
These are late-stage manifestations of a disease process that started with the division of a single cell. Oral cancer screening is part of the evaluation/exam code descriptors for dental benefits; yet the most common abbreviation in dental charts, if there is any at all, for oral cancer screening is WNL. This is supposed to stand for “within normal limits”; more often it stands for “We never looked.” Oral cancer screening is within the purview of dentistry, yet the statistics are abysmal and have not improved in the last 30 years.
For periodontal disease, often the only data gathered is pocket depths and maybe bleeding points; the disease is not really diagnosed, and certainly not anticipated, just treated. When a perio diagnosis is made, it is often based on outdated thought processes and classification systems. The American Academy of Periodontology (AAP) updated and replaced the classification system in 1999, yet few practitioners have taken the time to learn it, and fewer utilize it regularly.
We have many treatment options, but according to Casey Hein, RDH, MBA, “In many respects, the approaches used for case management of chronic periodontitis may look a little like the Wild, Wild West during the frontier movement of the 1880s - unregulated activity with everyone doing their own thing.”
Bloody prophies and active disease during maintenance care are considered normal, and the reason people need to see us regularly. We expect to see disease and, too often, until we have disease to see, we have no response. All clients do not need the same treatment.
A specific treatment is not equally effective for all clients. Certainly, clients with advanced disease need more treatment, which is likely to be more aggressive. However, it is logical to expect that more preventive interventions, which might include treatment categorized as aggressive, are required for the client at high-risk with disease of low severity.
We have adjunctive treatment and preventive options, but what do we use for whom, and when? Once used, how can we measure effectiveness? We have no system. We just hope our clients will improve. We gamble with the total health, not just the oral health, of the people that have given us their trust.
There is a trend in medicine and dentistry to develop more biological and tissue-preserving techniques and treatments. The public is becoming increasingly health conscious as well as more informed and demanding about their choices, which also promote this trend. Yes, the public is demanding more prevention.
There are practitioners, those in industry, and others hearing this message and embracing the concept of minimally invasive therapy - or, in hygiene, minimal intervention (MI). This ranges from the primary prevention of disease to surgical methods that involve minimal trauma. MI stresses early diagnosis and risk assessment as a prerequisite for ultimate minimal intervention and maintenance of health. MI is an intriguing concept that, without guidance from risk assessment, could result in treatment interventions that are too conservative, with the outcome being inferior. The tendency is to become more aggressive when the disease becomes severe, which is too late for optimal results. MI is the popular message today, and outcomes are what need to be measured.
There exist treatment modalities to stop decay when dental care is not available. These are already being used in other parts of the world for underserved populations. Because our model of practice is disease/repair-based, these techniques are not well known. Atraumatic Restorative Treatment (ART) is within the purview of hygienists when our view of health changes. (See Box 1.)
Systematized risk assessment
In spite of recent improvements in diagnostic methods, the earliest stage of disease is unlikely to be detectable. Early stages of disease and health need preventive treatment, not reparative. Caries requires restoration; decalcified lesions need interventions that result in re-calcification. Interventions to reverse early disease stages are essentially the same as preventive interventions; hence risk assessment can render detection of the earliest lesion unnecessary.
Early detection of disease processes, before they become blatant, and the management of risk factors causing the disease are the keys to prevention. Our current model for care is two-dimensional, in that the treatments offered to two clients with the same diagnosis and histories are basically the same. We need to add a third dimension, as does medicine. That missing dimension is risk assessment. Reparative treatment implies that disease exists and will progress; hence risk is 100 percent.
The first stage of disease is invisible and undetectable using routine diagnostic tests, but can be accurately predicted with risk assessment. Risk usually describes an undesirable event like disease, pain, and tooth loss. The World Health Organization Health Report 2000 said risk assessment is “a systematic approach to estimating the burden of disease and injury to different risks.”
Tables 1-3 give some of the options and modalities we have for examination, prevention, and treatment. What do we use? For whom? When? How often? How can we measure effectiveness? PreViser Corporation, founded by clinicians, has developed what may be the first usable, objective, and clinically validated technology for accurately assessing disease risk. The tool is easy to use, inexpensive, and provides an effective picture to the client and clinician of current and probable future disease status. Dr. Chester Douglass of the Harvard School of Dental Medicine describes the PreViser system as establishing “a higher standard of practice for the management of disease.” PreViser’s tool is a good starting point for incorporating risk analysis into the practice of dentistry. (www.PreViser.com)
Systematized risk assessment (SRA) helps us to make better client-centered, evidence-based decisions. The problem is that we are not trained in risk assessment. The literature on risk assessment provides only a laundry list of risk factors with no real method to quantify risk. If at all, we perform some kind of fuzzy risk assessment. It is estimated that the average dental health professional correctly assesses the risk of periodontitis for less than 34 percent of clients.
The method used by many professionals to assess risk is subjective. Such assessments, even when conducted by skilled practitioners, produce widely differing conclusions and have proven to be unreliable as a predictor of future disease potential.
Many clients are assigned a level of risk too low and receive insufficient treatment. We have already discussed the abysmal results of our oral cancer detection. Caries is an infectious disease that could be eliminated but has not been. The leading cause of tooth loss is still periodontal disease. With research showing the connections between oral and total health, it is time for change. We can do better!
Is every person we see equally susceptible to dental disease? Obviously, the answer is no. Statistically, 80 percent of caries occur in 20 percent of the clients. Does that mean only 20 percent need SRA? No, because more clients are at risk for disease than have disease. SRA identifies currently unidentified high-risk clients. Risk is used to determine if conservative or aggressive treatment is indicated. With or without disease, risk is used to determine the best treatment to prevent new disease from occurring. Risk management should be used to prevent the occurrence of a condition or the worsening of a current disease state. This is the essence of prevention. Risk should drive preventive treatment. Risk reduction can intercept invisible disease processes.
Reducing the gambling
We need a way to take our profession from the “Wild West” into a scientific realm. Back in 1978, Kenny Rogers recorded a song called The Gambler, with the famous lines, “You gotta know when to hold ‘em, know when to fold ‘em, know when to walk away, know when to run.” Systematized risk assessment can reduce the gambling with our clients’ health.
This is the first article in a series committed to moving the paradigm of hygiene care toward the minimal intervention/wellness model through systematized risk assessment (SRA).
Patti DiGangi, RDH, BS, is a speaker, author, and practicing dental hygiene clinician. She has continually performed preventive dental hygiene care and periodontal therapy since graduating from William Rainey Harper Dental Hygiene in 1973. She received her bachelor’s degree in health care leadership from National Louis University in 1996. As a lifelong learner, her education continues with her pursuit of an MBA with a Certificate in Educational Management at DeVry’s Keller Graduate School of Management. Patti received a special Presidential award from the Illinois Dental Hygienists’ Association as the 2000 Illinois Dental Hygienist of the Year. Patti is also a Fellow in the American Academy of Dental Hygiene.
Atraumatic Restorative Treatment
▼ Atraumatic Restorative Treatment (ART) introduced in South Africa by its Dutch inventor, Jo Frencken, in 1996.
▼ ART restores tooth decay without using the drill or injecting a local anesthetic. Instead, caries is removed using hand instruments, sometimes together with a caries-softening gel. After the caries is removed, the tooth cavity is restored with high-viscous glass ionomer cement.
▼ ART was officially endorsed by the World Health Organization in 1994.
▼ The American Academy of Pediatric Dentistry identifies ART as Alternative Restorative Treatment and recognizes its value and use as an acceptable treatment for the management of caries when traditional cavity preparation and placement of traditional restorations are not possible.