Doing Good While Doing Good Questions

1
Doing Good While Doing GoodQuestions?

• 1. Is it worth it?
• 2. Can I do it?

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What is Dental Caries?

• Dental caries is a pandemic infectious,
  multi-factorial biofilm disease leading to
  demineralization, cavitation and ultimately loss
• of the teeth. It is the most complex and
  difficult disease there is to diagnose and treat.

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Biofilm Characteristics

• Sessile bacteria, up to 85 gene changes
• Complex multi-species community with recognized
  infrastructure, mushroom columns
• 85 matrix, 15 bacteria
• Intercellular communication
• Rudimentary circulatory system
• Nutrient, metabolic and waste channels
• Antibiotic, antibody, antimicrobial resistant

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Cariogenic Biofilm

• Exposure to sucrose leads to increased Mutans
  streptococci activity (ATP)
• Population shift from 96 Ms and Lb
  (acidogenic,aciduric,cariogenic)
• pH shift to 4.5-5.0 (4.7) occurs with the
  population shift
• The acidic environment begins enamel
  demineralization

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Independent research from multiple sites,
utilizing reverse checkerboard analysis of DNA
sequencing, and population studies have
accumulatively identified up to 23 different
bacterial species significantly implicated now in
the caries process .

• Kutsch VK, Kutsch CL, Nelson BC. A clinical look
  at CAMBRA. DPR August 2007. 41(8)62-67.

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Bradshaw DJ, McKee AS, Marsh PD. Effects of
carbohydrate pulses and pH on population shifts
within oral microbial communities in vitro. J
Dent Res 1989. 681298-1302.

• Two mixed cultures, 9-10 species at pH 7.0
• Both had MS and LB
• Pulsed 1X day with glucose for 10 days
• Control had maintained pH of 7.0
• Test group had lowered pH for 6 hours, followed
  by 18 hours of pH 7.0
• Control group no impact on microbial balance
• Test group MS and LB comprised 55
• Additional study showed direct relationship
  between pH level and MS/LB levels

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Collectively, these studies showed conclusively
that it was the low pH generated from sugar
metabolism rather than sugar availability that
led to the breakdown of microbial homeostasis in
dental plaque.

• Marsh PD. Dental plaque as a biofilm and
  microbial community implications for health and
  disease. BMC Oral Health 2006. 6 SupplS14.

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The Wellness Model

• Is it worth it?
• Can you do it?
• What skills do you need?

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Is It Worth It?

• Evidence based, ADA recommends
• Better treatment outcomes
• Ethical considerations
• Standard of Care
• Not optional

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Too late it was appreciated that inserting
fillings, even at a great pace, had little to do
with arresting or treating disease, although it
had the temporary effect of creating relief from
pain and restoring function of the teeth.

• Fejerskov O, Kidd E. Dental Caries The disease
  and its clinical management. Blackwell Munksgaard
  2003 Oxford UK. Pp4-5.

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Retrospective Study of Fluoride in Adults

• Plan A 14,859 patients fluoridated area, 61 Low
  risk, 28 Moderate risk, 11 High risk
• Plan B 30,834 patients non-fluoridated area, 55
  low risk, 41 Moderate risk, 4 High risk.
• Periods 1 year prior, 6 months, 2 years
• In-office and at-home 5000ppm fluoride.

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Among 45,693 individuals in the two plans, those
categorized as being at high caries risk were
approximately four times as likely to receive any
caries-related treatment as those categorized as
being at low caries risk. Those categorized as at
moderate risk were approximately twice as likely
to receive any treatment. In addition, for those
at elevated risk who required any treatment, the
number of teeth requiring treatment was larger.
The results of this study provide the first
large-scale, generalized evidence for the
validity of dentists' subjective assessment of
caries risk.

• Rindal B, Rush WA, Perrin NA, Maupome G, Bader
  JD. Outcomes associated with dentists risk
  assessment. Community Dent Oral Epidemiol 2006.
  34(5)381-6.

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The authors concluded there was incomplete
compliance with guidelines for recommendation or
administration of preventive treatment for
patients at elevated risk for caries. They also
failed to identify any significant reductions in
caries-related procedures for individuals
receiving a fluoride intervention, compared with
those who did not, when stratified by risk
level.

• Dasanayake A, Caufield PW. At-home or in-office
  fluoride application does not significantly
  reduce subsequent caries-related procedures in
  ambulatory adults of any caries-risk level. J
  Evid Base Dent Practce 2007. 7155-157.

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The approach to primary prevention should be
based on common risk factors. Secondary
prevention and treatment should focus on
management of the caries process over time for
individual patients, with a minimally invasive,
tissue preserving approach.

• Selwitz RH, Ismail AI, Pitts NB. Lancet February
  24, 2007. 369(9562)639.

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Factors such as past and current caries, diet,
fluoride exposure, presence of cariogenic
bacteria, salivary status, general medical
history and socio-demographic influences should
be included when evaluating a patients caries
risk status.

• Fontana M, Zero DT. Assessing patients caries
  risk. JADA September 2006. 137(9)1231-1239.

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A structured caries risk assessment should be
carried out based upon the concept of the caries
balance. Following the risk assessment, a
treatment plan is devised which leads to the
control of dental caries for the patient. The
balance between pathological and preventive
factors can be swung in the direction of caries
intervention and prevention by the active role of
the dentist and his/her auxiliary staff.

• Featherstone JD. Pediatric Dent. Caries
  prevention and reversal based on the caries
  balance. 2006 Mar-Apr28(2)128-32 discussion
  192-8.

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Can I Do It?

• Basic understanding of the science
• Motivated staff/team
• Verbal skills

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Verbal Skills

• Nail in the Tire Analogy
• Weeds in the Lawn
• Driving Nails in a House Thats on Fire

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Detection Nail in Tire (cavity)
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Diagnosis Nails in the Driveway (caries)
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CariFreetm New Simple System

• A Clinical Approach

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Although all of the above ingredients have been
studied individually, they have not been studied
collectively as the Carifreetm system. The
culturing methods and bioluminescence need to be
validated. Therefore, more research is warranted
for this promising approach.

• Spolsky VW, Black BP, Jenson L. Products old,
  new and emerging. CDA October 2007. 35(10)724-37.

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Caries Risk Assessment and Treatment Strategies
for the Private Practice Easy as 1-2-3

• 1. Assessment
• Screening Tests
• Caries Susceptibility Test
• Caries Risk Assessment Form
• 2. Diagnosis
• At Risk versus Low Risk
• 3. Prescribe
• Therapeutic Strategies
• Antimicrobial products
• Remineralization strategies
• pH strategies

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1. Assessment

• CariScreen Caries Susceptibility Test
• Caries Risk Assessment Form

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CariScreen score had a strong positive
correlation r 0.76 with total cell count, a
positive correlation with MS counts r 0.69, and
a positive correlation to caries risk status r
0.55 with high significance p 0.000001.

• (Measurement of ATP Bioluminescence from Oral
  Bacteria Contained in Dental Plaque Basic
  Sciences and Clinical Assessments for Testing of
  Caries Risk by Drs. R. Sauerwein, J. Kimmell, T.
  Finlayson, S. Fazilat, P. Pellegrini, I. Kasimi,
  D. Covell, P. Gagneja, J. Engle, K. Kutsch, T.
  Maier, and C.A. Machida , representing not in
  corresponding order, Department of Integrative
  Biosciences, Academic DMD Program and OCTRI
  Research Fellowship Program, Department of
  Pediatric Dentistry, and Department of
  Orthodontics, School of Dentistry, Oregon Health
  Science University, Portland, and Oral Biotech)

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We observed strong statistical correlations
between total bacteria, total streptococci and
mutans streptococci, versus ATP-driven
bioluminescence, with calculated r values of
0.895, 0.843, and 0.781, respectively. We
conclude that ATP-driven bioluminescence is
highly predictive of the numbers of total oral
bacteria and total streptococci, and by
statistical extension, is also reflective of the
numbers of mutans streptococci.

• Sauerwein R, Pellegrini P, Finlayson J, Kimmell
  J, Kasimi I, Covell D, Maier T, Machida C. Oregon
  Health Science University, Portland, USA. ATP
  Bioluminescence Quantitative Assessment of
  Plaque Bacteria Surrounding Orthodontic
  Appliances. IADR Abstract 1288 2008.

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This study supports consideration of ATP
bioluminescence as a useful tool for the rapid,
chair-side quantification of bacterial load and
as a general assessment indicator of oral hygiene
maintained during orthodontic treatment.

• Sauerwein R, Pellegrini P, Finlayson J, Kimmell
  J, Kasimi I, Covell D, Maier T, Machida C. Oregon
  Health Science University, Portland, USA. ATP
  Bioluminescence Quantitative Assessment of
  Plaque Bacteria Surrounding Orthodontic
  Appliances. IADR Abstract 1288 2008.

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A randomized double-blind clinical examination
comparing the Cariscreen (ATP) score to the
patients Caries Risk Assessment demonstrated a
sensitivity of 95 and a specificity of 93.
These results indicate that ATP is a reliable
chair-side real-time risk assessment tool.

• Kutsch VK, Lemerande J. ATP Bioluminescence
  Correlation to Caries risk in 80 adults.
  Unpublished January 2008

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CariScreen to Caries Risk Correlation January 2008
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ADA Council on Scientific Affairs Guidelines

• Low Caries Risk (all age groups) no incipient or
  cavitated primary or secondary lesions in past 3
  years and no risk factors
• Moderate Caries Risk (last 3 years but at least one risk factor
• Moderate Caries Risk (6 yrs.) 1 lesion in
  past 3 years or at least one risk factor
• High Caries Risk (Any lesion past 3 years, multiple risk factors,
  low socioeconomic status, suboptimal fluoride
  exposure, xerostomia.
• High Caries Risk (6 yrs.) Any of the following
  3 or more lesions in past 3 years, multiple risk
  factors, suboptimal fluoride exposure,
  xerostomia.
• JADA August 2006 Special Supplement

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2. Diagnosis

• At Risk
• Low Risk

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3. Prescribe

• Fluoride varnish treatment
• 3-month product kit
• 3-month recall

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Carifreetm Fluoride Varnish

• Fluoride varnish
• 5 Sodium Fluoride
• Syringe-syringe mix

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0.1- 0.5 sodium hypochlorite for patient self
care. These antiseptics have significantly
broader spectra of antimicrobial action, are less
likely to induce development of resistant
bacteria and adverse host reactions, and are
considerably less expensive than commercially
available antibiotics in controlled release
devises.

• Jorgensen MG, Aalam A, Slots J. Periodontal
  antimicrobialsfinding the right solutions. Int
  Dent J February 2005. 55(1)3-12.

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CariFreetm Patient Kits

• Treatment Kit
• Prevention Kit
• Starter Kit

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Oral Neutralizing Gel

• Oral non-dentifrice with elevated pH 9.0
• Non-abrasive
• Contains pH balancers to raise the pH, xylitol,
  glycerin, fluoride, antimicrobial agents,
  proprietary buffering agents

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Oral Neutralizing Spray

• Oral spray for patients with dry mouth/xerostomia
• Contains pH balancers to raise the pH, xylitol,
  glycerin, antimicrobial agents, proprietary
  buffering agents

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Xylitol Neutralizing Gum

• Chewing gum with xylitol
• Contains pH balancers and buffering agents to
  raise the and maintain neutral pH.

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Less caries was observed in children of mothers
who chewed gums with xylitol as the single
sweetener during the time of eruption of the
first primary teeth compared with those who used
gums containing fluoride, sorbitol and lower
amounts of xylitol.

• Thorild I, Lindau B, Twetman S. Caries in
  4-year-old children after maternal chewing of
  gums containing combinations of xylitol,
  sorbitol, chlorhexidine and fluoride. Eur Arch
  Paediatr Dent December 2006. 7(4)241-5.

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3 Month Re-assessment
Still At Risk

• Fluoride varnish treatment
• 3-month product kit
• 3-month recall
• Annual recare system

Low Risk
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Clinical Examples

• A Systematic Clinical Approach

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Low Risk Patient

• No incipient or cavitated primary or secondary
  lesions in past 3 years and no risk factors.
  Cariscreen

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Low Risk Patient

• Maintain primary oral health
• Counsel patient about risk factors
• Screen annually
• Monitor risk factor changes
• Prevention products

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At Risk Patient

• (3 years, multiple risk factors, low socioeconomic
  status, suboptimal fluoride exposure, xerostomia.
  
• (6 yrs.) Any of the following 3 or more
  lesions in past 3 years, multiple risk factors,
  suboptimal fluoride exposure, xerostomia.
• ATP3500 RLU .

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At Risk Patient

• Direct counseling to specific risk factors as
  appropriate
• Treat bacterial infection at same time as any
  lesions
• Fluoride varnish, 3 month treatment cycle with
  treatment products
• Re-assess in 3 months
• Monitor and treat patient until low risk

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Create Value in Your Practice

• Create Value
• What better value than helping them stop having
  cavities? Doing good while doing good!

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The Financial Model for Wellness

• The Paradox Dentists worry that they may be
  putting themselves out of business, but patients
  dont really buy dentistry until they stop
  getting cavities. If they do, its a recipe for
  disaster

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How Do I Do Good while Doing Good Practicing
Wellness Dentistry?

• Improved treatment outcomes
• Reduced decay rates and restorative failures
• Direct fees for procedures
• Sale of products
• Increased restorative requests
• Increased patient referrals

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CDT VII Codes

• D0145 Oral Evaluation with primary caregiver
• D0415 Bacteriology Studies
• D0421 Genetic test for susceptibility to oral
  diseases
• D0425 Caries Susceptibility Test
• D1206 Topical Fluoride Varnish therapeutic
  application for moderate to high risk caries
  patients
• D1310 Nutritional counseling for control of
  dental disease