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 at-home 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-the-counter 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.

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