Managing caries and motivating change part 1: Caries risk assessments

Caries prevention is a central tenet of a successful in-office dental hygiene
program. However, this practice is much easier said than done. Caries is a
complex, chronic, multifactorial disease that’s difficult to manage on its
own. Add in keeping your entire team on the same page and explaining
the situation to patients, and it can become that much more challenging.
Nonetheless, by utilizing systematic methods of caries detection,
classification, and risk assessment, you can set your team and your
patients up for success.

In this two-part series, we’ll explore caries risk assessment systems and
patient communication strategies for more streamlined procedures,
improved teamwork, increased acceptance, reduced caries risk, and
healthier smiles.

The caries conundrum: Challenges of caries prevention

Caries management and prevention can be complicated. There are a
variety of challenges that can stand in the way of a productive, consistent
strategy – both within your practice and with your patients

Practice challenges
There are a variety of challenges that come with operating a dental
practice, including business administration, inventory management,
patient expectations, and the general economic landscape. A few of
these challenges will directly affect your caries management strategy:

Practice consensus
While there are many ways to approach dental care, in order
for your practice to do its best work, it’s vital for everyone to
be on the same page. Everyone on your team may be working
toward the same general goal – creating healthy smiles – but
unless everyone agrees on how to go about that,
opportunities for success may fall through the cracks.
Your practice’s treatment philosophy as well as any new
assessment protocol should apply to everyone on your team.
Not only does this create a culture of confidence and
cooperation, but it ensures patients receive a consistent level
of care. It’s important to keep the lines of communication
open and regularly check in that your team is in sync. This may
look like consistent team meetings to review practices, answer
questions, and ensure the latest evidence-based protocols,
products, and services are included in the treatment protocol.

Time
In a busy dental practice, time management is always difficult,
and incorporating a new system can present new challenges.
How do you fit something new, like a caries risk assessment,
into your day-to-day flow? We need to be mindful of chair
time without seeming rushed or compromising quality of care.
Dental providers don’t have a lot of “downtime” in an
appointment; however, if you’re creative with your time, there
are many opportunities to multitask and gather valuable
information from the patient that could be useful later (for
treatment planning and recommendations).
In the end, it’s all about balance. Take a step back and analyze
how you do things now and determine how to insert the
assessment seamlessly into the appointment. For example,
building in the risk- assessment as a conversation rather than a
checklist saves time and is more personalized to the patient. It
may also help practitioners feel like they’re not adding
something else to their plate, since self-case discussions are a
regular part of patient care.

Patient challenges

Beyond treatment, there are a variety of challenges associated with the patient themselves, including oral health literacy, treatment acceptance, and compliance.

Every patient’s smile is unique, as are their circumstances, experiences, expectations, motivations, and communication styles.
There is no one-size-fits-all solution, which means adjusting your approach to fit each individual. However, this isn’t often a challenge that can be addressed in a single appointment – these challenges can take time. It means getting to know your patients and building a relationship of trust – which we’ll explore in detail in part two.

Caries classification and assessment systems

Implementing a caries classification and assessment system in your office
has more benefits than simply helping categorize lesion progression.
These systems are evidence-based, preventive care models that help
identify individual patient medical, behavioral, environmental, and
societal risk factors that may cause decay, as well as classify and monitor
existing or potential lesions along a structured scale. From there, this
information can be used to recommend preventive and restorative
treatment to reduce the risk of future decay.
Plus, caries risk assessments are inherently designed to help preserve
tooth structure, which aligns with minimally invasive strategies. They
encourage treating the disease process rather than the outcome. And
while the assessments are standardized, they actually help individualize
preventive treatment planning.

Open up! Assessments and patient communication
Beyond classifying existing risks, caries risk assessments can be
helpful in determining oral health literacy – to see what
patients already know and where you may need to educate
them further.

Depending on how the clinician presents and implements the
assessment, it can be very personal, which can help the patient
identify goals they want to work on – and help the clinician
identify any barriers that are getting in the way of the patient
achieving their best oral health. These assessments can help
identify things we can’t otherwise sift out in the medical history
or hygiene instructions. It can also be a way for patients to
open up and give you a lot of valuable information that you can
then use in a standardized way to tailor your treatment and
home care recommendations.

Dental professionals know that moderate to high-risk patients
can benefit from regular applications of in-office fluoride or athome prescription toothpaste, but not all risks are obvious.
CAMBRA covers saliva and hyposalivary medications, diet, OTC
fluoride use, and existing disease indicators to help guide
treatment recommendations. For example, a patient with
reduced salivary flow has an increased risk of caries. If they are
also low on their essential salivary buffers like calcium and
phosphate, you may want to recommend a product that has
those minerals in addition to fluoride. Some offices offer
bacterial testing, out of which you might recommend
antimicrobial therapy. CAMBRA can also help us identify and
treat patients with medical conditions (chemo or radiation,
Sjögren’s syndrome, etc.) who would benefit from more
frequent fluoride applications. CAMBRA reminds us to take a
holistic approach to caries prevention and management—
looking at the whole person and their unique circumstances.
Through these assessments, you can recommend over-thecounter products for lower-risk patients or identify whether
prescription products are better suited.

Risk assessments in practice
Thankfully, a team interested in implementing one of these
protocols wouldn’t have to start from scratch – there are
existing tools rooted in scientific literature that have already
proven effective with patients.

Existing assessments with accompanying recommendations –
to be used with our own clinical judgment on a case-by-case
basis – can be used as a guide for treatment recommendations
for all patients. For example, Caries Management by Risk
Assessment (CAMBRA), developed by the California Dental
Association over 20 years ago, is still widely used,
straightforward, and easy to implement. Questions are worded
in a way that you can work them into a conversation rather
than reading from a checklist. Keep in mind that many of these
systems are categorized by age, so depending on who you
service, you may need more than one to cover all your
clientele. In addition, these assessments are designed to be
regularly updated with patients – so that we are routinely
checking their risk at set time intervals for progress or changes
– as well as refreshed with new scientific evidence, so you and
your practice can stay up to date.

Assessments like CAMBRA can be implemented as is or used as
a template/guideline to develop your own system – whatever
works best for you and your practice. You don’t have to
abandon what you already use; bringing CAMBRA or something
like it into your day could help keep you at the top of your
game: making sure each patient gets the treatment they need.

Risk assessments put to the test

In a 2014 CAMBRA-PBRN (Primary care practice-based research networks) study, 460 patients of varying caries risk levels had caries risk assessments calculated and recorded over a 2-year period, with recalls at 6, 12, 18 and 24 months. ¹ Patients were randomly sorted into an “active intervention” group, who received products and recommendations based on CAMBRA guidelines, and a “standard of care” control group, who received care without these guidelines.

Over the two years, the percentage of newly developed disease indicators decreased in both groups; however, those in the intervention group showed a much lower percentage of indicators: 30-35% vs 50-55% in the control group. In the
intervention group, only 25% of patients remained at a high caries risk, as opposed to 54% in the control group. These results demonstrate that caries risk assessments, like CAMBRA, can have a significant impact on caries – decreasing both risk levels and developing new indicators.

Conclusion

Caries risk assessments are a fantastic tool for modern dental practices and not just to streamline evaluation and diagnosis. CAMBRA and caries risk assessments emphasize prevention and early intervention to prevent or reduce caries development – strengthening patient care through a customized, comprehensive, long-term approach and helping patients take charge of their dental health. These systems can also improve practice teamwork and collaboration, encourage treatment consistency, and help build patient relationships. And while adding new procedures to your practice may be a challenge, the benefits greatly outweigh any potential downsides.

In part two, we’ll explore acceptance, patient communication, and motivational interviewing, and how the right tactics can help you make the most of your assessment system.