The two-day CAMBRA (caries management by risk assessment) conference held in San Francisco last week sought to address some of the biggest challenges facing the movement, including patient education, practitioner adoption, insurance codes and payments, and policymaker support.
The conference was sponsored by the California Dental Association Foundation.
"It's hard to convince the public to pay for prevention when they're used to paying for procedures," said Margherita Fontana, DDS, PhD, an associate professor at the University of Michigan School of Dentistry, in her introductory remarks.
But the true goals of CAMBRA advocates were summed up by an anecdote she shared about the difference between the definition of a physician and that of a dentist -- as described in her first-grader's textbook. According to the book, a physician is "a person who is trained to help people stay healthy," while a dentist is "a person who is trained to fix and examine teeth." Dr. Fontana said she hoped that the two would mirror each other more closely in the future.
— Margherita Fontana, DDS, PhD
When it comes to advancing the CAMBRA model, the development of a standardized caries risk assessment (CRA) form was a critical first step. "Ten to 15 years ago you would have had to create your own," Dr. Fontana said. Now several universities have adopted it.
But challenges to expanding the adoption of these forms outside of academia remain, according to Ronald Inge, DDS, vice president of professional services and dental director for Washington Dental Service. He recalled his experience in testing employee benefits packages in Washington that included CRA forms. The form asked dentists to determine if the patient was at a high or low risk for caries and the level of benefit the patient would receive corresponded to his or her level of risk.
Dentists' reluctance to use the form was "significant," he said, and the general opinion was that there was no time for it.
"I wasn't ready for the fact that dentists didn't want to make that call [about the risk level for caries]," Dr. Inge said. He attributed their resistance to "a lack of understanding about what our profession is."
The role of CRA forms sparked an informal debate among several attendees. A hygienist suggested that dentists have a professional duty to perform such evaluations, regardless of compensation. A dentist disagreed, stating that dental professionals "absolutely deserve compensation" for their skill, knowledge, and judgment in performing the examination and determining risk. The importance of establishing a pattern of compensation for preventive medicine with a preliminary, quantifiable document that could be submitted to insurers was noted as well.
A retrospective study performed by Sophie Doméjean-Orliaguet, DDS, PhD, from the Clermont-Ferrand School of Dentistry; John Featherstone, MSc, PhD, dean of the University of California, San Francisco (UCSF) School of Dentistry and an assistant professor in the department of operative dentistry; and colleagues lends further support to the value of the CRA form. They examined the relevance of the items listed on the form and how effective the classification system was in predicting the occurrence of caries. After reviewing nearly 13,000 CRA forms, they concluded that its use was validated and that "the caries risk score at baseline is related to the presence of cavities at follow-up" (Journal of the California Dental Association, October 2007, Vol. 35:10, pp. 703-707, 710-713).
During his talk, Mark Wolff, DDS, PhD, a professor at the New York University College of Dentistry, advocated getting rid of the dental explorer and classes I through IV from G.V. Black's Classification of Caries Lesions and placing more of an emphasis on curing disease.
"It's time to move from fixing teeth to restoring oral health by prevention and remineralization," Dr. Wolff said.
There is growing support for CAMBRA-like philosophies at the federal level, according to Burton Edelstein, DDS, MPH, a professor of dentistry and health policy and management at Columbia University and president of the Children's Dental Health Project. In particular, he described a section of the Children's Health Insurance Program Reauthorization Act of 2009 that establishes a national grant program to demonstrate the effectiveness of research-based dental caries disease management as a "home run."
Insurers play a pivotal role as well and were seen as potential allies during the meeting, in part because CAMBRA-style prevention can bring down costs, explained John Luther, DDS, chief dental officer at United Healthcare. But a major obstacle to getting compensated for this type of treatment lies in the absence of insurance codes, the approval of which is committee-based and time-consuming.
"Carriers' challenge is to develop and apply benefits appropriate to the new paradigm," Dr. Luther explained. They must evolve from procedure-based benefits to insuring the health and wellness of individuals in covered populations. To do that, he said, a focus on risk-based, patient-centered healthcare is necessary.
While the methods of G.V. Black were largely described as out-of-date throughout the conference, his foresight was commended by some. A quote attributed to Black in 1898 summed up the goals of the gathering quite well: "Surely, we'll move in the future from treatment to prevention."
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