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Inside Dentistry
October 2008
Volume 4, Issue 9

Preventive Dentistry Can Be a Win-Win Situation

Gordon J. Christensen, DDS, MSD, PhD

Dentistry is well recognized as a profession interested in and highly involved with prevention of oral diseases including, but not limited to, dental caries, periodontal disease, excessive tooth wear, and other occlusal conditions. Usually, the delegation of preventive procedures to dental hygienists is common practice. However, incorporating preventive procedures into dental practice, while still maintaining adequate revenue to support a typical practice, can be a frustrating experience requiring thought, organization, and the delegation of responsibilities to qualified, educated staff.

In this article, the author will make suggestions on how to integrate preventive procedures for dental caries, periodontal disease, and excessive tooth wear into the dental hygiene portion of a dental practice, with identification and administration of these procedures primarily being delegated to dental hygienists, and with treatment being accomplished by hygienists, assistants, or dentists.

Dental Caries

Most dental practices provide preventive measures for dental caries and periodontal disease, including tooth scaling, root planing, and polishing, as well as topical fluoride application. However, a significant portion of patients in any general dental practice have the possibility for highly active dental caries. Previously, the author has made suggestions relative to how to prevent dental caries in some of the following high-caries potential groups.1-2 Situations of high-caries activity include:

  • Bulimia
  • Chemotherapy
  • Juvenile caries
  • “Meth mouth”
  • Post-restorative rehabilitation
  • Radiation therapy
  • Senile caries

These categories of patients are easily identified in any general dental practice during routine dental hygiene appointments. Dental hygienists can make a list of these potential high-risk patients, consult with the dentist about the patients, decide together if the patients have high-risk potential, then encourage patients to accept clinical and at-home therapy. When possible, using staff members to accomplish those procedures where allowed by law can help the practice to offer patients affordable preventive treatment. Fluoride therapy is well proven and is accomplished easily by hygienists or assistants where legal. American Dental Association codes for potential third-party payment are:

  • D1203 Topical application of fluoride (prophylaxis not included)—child
  • D1204 Topical application of fluoride (prophylaxis not included)—adult
  • D1206 Topical fluoride varnish; therapeutic application
  • D5986 Fluoride gel carrier or fluoride applicator (for patient use)

When patients are advised of their high caries potential, most accept preventive therapy, making the delegated procedure in this “preventive appointment” a significant service to them and providing additional revenue to the practice.

Sodium fluoride, 5,000 ppm, applied daily in trays for 5 minutes has had positive supportive research for many years when used in the various techniques such as the one described.3-14 Additionally, in the author’s longtime clinical experience, use of 5,000 ppm fluoride in trays on a daily basis either eliminates or greatly reduces future dental caries if the following or other clinical techniques are used.

Clinical Appointment for At-Home Fluoride Application in Trays

  1. Clean teeth well, removing calculus, stain, and plaque.
  2. Make alginate impressions of both arches and pour casts in fast-setting stone, such as Snap-Stone (Whip Mix Corp, Louisville, KY). This stone sets in 5 minutes.
  3. Make rigid vacuum-formed trays using 0.02-inch tray material extending approximately 1 mm apical to the gingival margins.
  4. Show the patient how to place 5,000 ppm fluoride gel in trays. Six drops, equally spaced and placed in the tray around each arch, are usually adequate.
  5. As noted in the previously referenced studies, the trays should remain in the mouth for approximately 5 minutes each day, preferably just before bedtime, to optimize fluoride contact with the teeth without food contamination.
  6. If the patient drinks fluoridated water, he or she should expectorate the excess fluoride from the mouth and rinse with water after removal of the trays.
  7. If the patient is not drinking fluoridated water, he or she should expectorate, but rinsing with water is not necessary.

Periodontal Disease

It has been estimated that at least one third of the patients in a typical dental practice have mild to moderate periodontal disease.15 Many patients will not accept conventional periodontal therapy, but they need preventive therapy to reduce the progression of their periodontal disease condition. Dental hygienists can make a list of patients who they consider to be in the described category and meet with the dentist to confirm likely candidates for conservative periodontal therapy. Based on the estimate stated above, a typical practice of about 2,000 patients has about 700 patients who need this therapy. Many of these patients will accept conservative therapy after receiving adequate education. All of the conservative procedures the author mentions in this article can be easily accomplished by dental hygienists, providing conservative preventive and treatment options for patients with a significant increase in revenue for the practice. Some of the procedures can be reimbursed by third-party payment companies. The author has promoted conservative periodontal techniques for many years.16 Some of these preventive procedures include:

  1. Frequent (four to six times each year) scaling and root planing, reducing the aggressiveness of the procedure as soft tissue responds positively.
  2. Oral hygiene instruction reinforcement on each of the appointments to the office.
  3. Implementation of tongue cleaning on a twice daily basis to reduce the reservoir of available organisms in the mouth.
  4. Alternating therapeutic oral rinses, changed frequently, such as chlor-hexidine 0.12% (Peridex™, 3M ESPE/Omnii Preventive Care, St. Paul, MN), Crest Pro-Health™ (Procter and Gamble Co, Cincinnati, OH), Listerine® (McNeil-PPC, Inc, Skillman, NJ), and others.
  5. Sub-systemic antibiotics, such as doxycycline HCl 20 mg twice daily (Periostat®, CollaGenex Pharmaceuticals/Galderma Laboratories, Ft. Worth, TX), delivered for up to 9 months, if soft-tissue response is less than desired after the first scaling and root planing.
  6. Local antibiotics, such as Arestin® (OraPharma, Inc, Warminster, PA), Atridox® (TOLMAR, Inc, Fort Collins, CO), and PerioChip® (Dexcel Pharma Technologies Ltd, Fairlawn, NJ), delivered to non-responding pocket areas after 2 or 3 months of therapy using the previous steps.

The author notes that this information was confirmed by personal oral communications with periodontists Dr. Robert Schallhorn and Dr. Jon Suzuki.

Commonly Occurring Pathologic Occlusal Conditions

Many patients in a typical dental practice have bruxing or clenching habits, resulting in significant premature tooth wear. The author believes that most of these patients go untreated in many practices. Dental hygienists see the patients on a routine basis. The patient’s tooth wear is obvious. Patients can recognize the tooth wear when advised by a dental hygienist or dentist and compared with teeth or casts of normal tooth anatomy. Severe tooth wear may preclude further preventive procedures, and require restorative therapy. However, in the author’s experience, many patients with only slight or moderate tooth wear caused by bruxism or clenching need and will accept occlusal splints when educated to the need for them. Dental hygienists are the logical practitioners to provide this education because they see the patients on a routine basis, have the time to educate them, and if it is legal where they are practicing, can place the occlusal splints. In localities where hygienists cannot place the occlusal splints, dentists may accomplish that task. The preventive service provided to patients by placement and routine wearing of occlusal splints has long been evident, and the increase in revenue for the practice will soon be realized.

Conclusion

Three of the major oral conditions requiring treatment—dental caries, periodontal disease, and occlusal wear—can be observed easily by dentists, dental hygienists, and even patients. Because dental hygienists see patients on a frequent and routine basis, they can educate patients about the need for preventive measures for these conditions. Along with assistants and dentists, hygienists can also provide preventive or treatment procedures for each of the conditions. The resultant service provided to patients is significant, and as a result, additional practice revenue is produced. Contrary to the beliefs of some dentists, practicing preventive dentistry can be a “win-win” situation.

References

1. Christensen GJ. Oral care for patients with bulimia. J Am Dent Assoc. 2002;133(12):1689-1691.

2. Christensen GJ. Special oral hygiene and preventive care for special needs. J Am Dent Assoc. 2005;136(8):1141-1143.

3. Newbrun E. Topical fluorides in caries prevention and management: a North American perspective. J Dent Educ. 2001;65(10):1078-1083.

4. Bader JD, Shugars DA, Rozier G, et al. Diagnosis and management of dental caries. Evid Rep Technol Assess (Summ). 2001;(36): 1-4.

5. van Rijkom HM, Truin GJ, van’t Hof MA. A meta-analysis of clinical studies on caries inhibiting effect of fluoride gel treatment. Caries Res. 1998;32(2): 83-92.

6. Wright WE, Haller JM, Harlow SA, et al. An oral disease prevention program for patients receiving radiation and chemotherapy. J Am Dent Assoc. 1985;110(1):43-47.

7. Ripa LW. Professionally applied and self-applied topical fluoride gels. J Public Health Dent. 1989;49(5 Spec No):297-309.

8. Alexander SA, Ripa LW. Effects of self-applied topical fluoride preparations in orthodontic patients. Angle Orthod. 2000;70(6): 424-430.

9. Mellberg JR. Remineralization. A status report for the American Journal of Dentistry. Part I. Am J Dent. 1988;1(1):39-43.

10. Mellberg JR. Remineralization. A status report for the American Journal of Dentistry. Part II. Am J Dent. 1988;1(2):85-89.

11. Walsh LJ. Home care self-applied fluoride precuts: current concepts for maximal effectiveness. Dent Pract. 2006;30:66-67.

12. Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol. 1999;27(1):31-40.

13. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc. 2000;131(7): 887-889.

14. Walsh LJ. Fifteen strategies for caries prevention: towards target zero. ADA News. 2000;279:5-8.

15. Stoltenberg JL, Osborn JB, Pihlstrom BL, et al. Prevalence of periodontal disease in a health maintenance organization and comparisons to the national survey of oral health. J Periodontol. 1993;64(9):853-858.

16. Christensen GJ. Adjunctive periodontal therapy. J Am Dent Assoc. 1999;130(6): 869-870.

About the Author

Gordon J. Christensen, DDS, MSD, PhD
Director, Practical Clinical Courses
Senior Academic Advisor
Scottsdale Center for Dentistry
Scottsdale, Arizona

Senior Consultant
Clinicians Report
Scottsdale, Arizona

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