California dental experts push prevention

SAN FRANCISCO - Too many dentists are acting like mechanics instead of doctors, according to organizers of the California Dental Association (CDA) fall meeting, which kicked off Thursday with an all-day session on caries management by risk assessment (CAMBRA).

"It's a new practice philosophy," said Rolande Loftus, program director for the CDA Foundation. "We're trying to engineer a shift from the restorative model to more of a medical model of prevention."

CAMBRA, which started in California, is spreading to the rest of the country, she said. Eastern and Central CAMBRA coalitions have recently formed, and an impressive list of caries experts signed on to a consensus statement supporting the concept, printed in the November 2007 Journal of the California Dental Association (JCDA).

In practical terms, CAMBRA means figuring out which patients are most likely to get caries, then working to modify the patients' diet and prescribing fluoride, xylitol, chlorhexidine, and calcium phosphate, said speakers -- a range of academic and private practice experts from around the state -- at the CDA session.

Though the JCDA devoted two entire issues last fall to laying out the principles of CAMBRA in detail (JCDA, October and November 2007, Vol. 35:10, 11), only five out of almost 400 people who attended the seminar -- most of them dentists -- raised their hands when asked if they practice CAMBRA.

"I would venture to say that the people in this room have never ever used antibacterial therapy for caries," said John Featherstone, M.Sc., Ph.D., dean of the University of California, San Francisco School of Dentistry.

That may put the dentists themselves at high risk of a lawsuit, he said, noting that some patients have sued their dentists for not helping them prevent cavities. "I would recommend that you go out Monday and start using it on your high-risk patients."

If they aren't CAMBRA practitioners yet, however, California dentists may be ready to start. Organizers had to turn people away at the door after all 400 seats had been taken.

"I thought it was helpful," said Clark Hubbs, D.D.S., of Los Angeles, adding that he attended after hearing about the lawsuits. "I've been practicing preventive dentistry for 30 years, but this is new material."

For example, he said he learned for the first time that patients should wait to use chlorhexidine until two to four hours after applying fluoride.

Putting CAMBRA to work

The presenters were at pains to explain how CAMBRA could work practically in a dentist's office -- and still make money for the dentist.

CAMBRA starts with a careful evaluation of a patient's risk, the presenters said. Several risk assessment charts are available. "I don't care which one you use, just use one," said V. Kim Kutsch, D.M.D., an Oregon-based dentist and inventor who consults with many dental products companies.

The most important disease indicators are lesions and restorations more recent than three years. Tools for measuring bacteria levels are just reaching the market but may soon become the standard of care.

But doctors shouldn't just look for disease indicators. They should analyze risk factors such as low saliva flow, smoking, and a diet that feeds caries-causing bacteria, the presenters agreed.

Doctors, or their staff, should take a detailed history of dietary information, noting how often and how much the patients eat sugary foods and beverages, foods like hard candy that linger in the mouth, or foods like dried fruit that stick.

"You or your assistant can sit down with them and provide recommendations," said W. Stephen Eakle, D.D.S., of San Francisco.

He gave the example of a patient who had no caries until he was prescribed a new medication that caused xerostomia. To compensate for the dryness, he had begun to suck hard candies and drink Gatorade, and developed lesions as a result. Solutions include recommending that patients switch to water and xylitol candy.

Counseling might also include careful scrutiny of the patient's dental hygiene.

Patients at high risk should receive fluoride varnishes, more frequent cleanings, xylitol, chlorhexidine, fluoride with 5,000 ppm fluoride, and calcium phosphate, the panelists agreed.

They acknowledged that the approach was difficult to implement. Success requires careful discussions with the staff to ensure everyone is aboard. Hygienists and assistants may feel that they are already too busy to add CAMBRA procedures to their workload. Dentists may feel that they will go out of business if their patients no longer have cavities.

But once patients are convinced that you can help them avoid new cavities, they will become more loyal. They may even ask for restorations they resisted before. Dr. Kutsch gave the example of a patient who had been resisting the recommendation of a bridge for five years on the argument that it would be a waste of money as long as he was just going to get more decay around it. Once his caries was arrested, however, he requested the bridge.

Dr. Kutsch said he has had patients drive up to four hours to his practice after being referred by other patients. Though advertising "I do CAMBRA" won't ring a bell for very many patients, the term "minimally invasive" does mean something, he said.

Reimbursement

Many CAMBRA procedures are reimbursable, the presenters noted. They laid out the following examples of insurance codes that apply:

D0145 oral evaluations in children less than 3 years of age and counseling with primary caregiver
D0415 bacteriology studies
D0421 genetic test for susceptibility to oral disease
D0425 caries susceptibility test
D1206 topical fluoride varnish; therapeutic application for moderate- to high-risk caries
D1310 nutritional counseling for control of dental disease
D9630 other drugs and/or medicaments by report
D1203 topical application of fluoride - child
D1204 top application of fluoride - adult
D1206 top application of fluoride varnish; therapeutic
D1320 tobacco counseling
D1330 oral hygiene instruction
D1352 sealant
D9630 other drugs
D9920 behavior management, by report

With these tips available, dentists have no excuse for procrastinating, according to Dr. Featherstone.

"This is not something you can sit here on a Thursday morning and say, 'Ah hah, that's cool.' It's something you have to put into practice on Monday," he said.