The Third Phase—Implementation

As the relationship between oral and systemic health continues to be explored, the treatment of carious lesions must also be investigated. Minimally invasive strategies that continue to be perfected in the field of medicine should be of equal importance to dentistry. Dental professionals must challenge themselves and decide, “Are we doing all that we can to treat the etiology of dental caries?”

Traditional dentistry is based on the foundation of detecting the end stages of dental disease (a cavity) and repairing the damage. Treating a tooth with a restoration does not prevent the disease process. Disease prevention and the use of early detection modalities are available, yet the dental community has been slow to move toward a more individualized approach for early caries management and prevention. Caries management by risk assessment or CAMBRA is such an approach. From a scientific viewpoint, implementing CAMBRA into private practice and clinical settings may be the standard dentistry should be striving for. As with any new methodology, integrating CAMBRA into an existing dental practice requires a forward thinking clinician who can educate the dental office team about the benefits of CAMBRA.

IMPLEMENTATION

The success of CAMBRA implementation may vary from office to office depending on the approach used. Dental professionals may be hesitant about implementing new preventive ideas if they will cause significant changes in the routine, as any deviation from standard practice requires time, as well as staff and patient education.

Finding the correct CAMBRA program leader will help facilitate a smooth transition. This team member must be able to develop CAMBRA goals and methodologies, as well as delegate responsibilities.¹ Providing resource information and assigning each team member a section of the CAMBRA protocol will make the task less daunting. In large offices, teams can be created to investigate one product or procedure. Together, the team can gather the necessary caries risk assessment forms, products, and saliva screening tools. This reinforces the value of the program and increases staff understanding.

DENTIST

The dentist’s role in conveying an understanding of CAMBRA is very important. In order to implement this new philosophy, the education of and subsequent support by each member of the dental office are important. All aspects of the practice will be affected—from scheduling, to billing, to patient management. Providing information that supports CAMBRA allows team members to play an active role in communicating why this practice philosophy is so important and in the best interest of patients. The ultimate goals are to educate and motivate patients to improve their own oral health and to offer strategies to reduce the bacteria that cause dental decay.¹

TRAINING, MEETING, AND BUY-IN

These new evidence-based protocols should be studied by all staff members. Staff meetings should be convened to discuss the evidence. The importance of preventive care, the value of minimally invasive dentistry, and the fact that CAMBRA is part of the best patient care must be emphasized. Providing an opportunity for an experienced CAMBRA clinician to provide a training meeting is an ideal introduction to the process. This allows the staff to ask questions and exchange ideas on how to develop a program specific for the needs of the practice.

The caries risk assessment screening tool helps staff determine if patients are low, moderate, high, or extremely high risk for caries. At the time of the meeting, each staff member should have undergone his or her own complete caries risk assessment. This exercise is important for several reasons. The staff can see how the caries risk assessment works. Practicing with each other in the safe environment of a staff meeting allows for role-playing and practicing questions and answers. It quickly helps to assess the next step in determining caries risk. Following the caries risk assessment is the saliva test. Each staff member should have the opportunity to perform a saliva test to understand the process and to determine his or her own saliva content. At the end of the training session, questions to stimulate discussion include: Given the evidence you now have, would you prefer CAMBRA or just restorative dentistry alone? Why? How is this different for patients in our care?

The training meeting will help participants realize the need for CAMBRA. Each member of the dental team plays a pivotal role in supporting a CAMBRA prevention-focused practice.² At subsequent meetings, the role of each team member must be discussed. As with any new protocols and procedures, there will be questions and concerns among team members and patients. Maintaining a positive environment, specific responsibilities for each team member, and open communication between staff and patients are all paramount to the success of transitioning CAMBRA into a practice.

RECEPTIONIST OR OFFICE MANAGER

Once the office is on board and ready to implement CAMBRA, the process of educating patients begins. A website, personal letter, newsletter, or brochure, are all ways to introduce the benefits of CAMBRA. Communicating these new methodologies to patients along with explaining the higher level of service available are often helpful. The office manager/receptionist is the first person with whom the patient comes into contact. This is the perfect opportunity for this team member to inquire if the patient received the updated information regarding the latest approach to preventing dental decay. The conversation may be prefaced with a description of the caries risk assessment. Informing patients of what to expect before they are seated allows for a smooth transition into the operatory.

DENTAL ASSISTANT

The CAMBRA model of care may add an exciting new dimension to the position of the dental assistant. With proper education and training, the dental assistant can play a key role providing services such as interviewing the patient, taking diagnostic radiographs and photos, and performing saliva and bacterial testing (depending on the rules of the particular state Dental Practice Act). Once the patient’s caries risk has been assessed, the dental assistant can explain the results and offer nutritional and oral hygiene counseling if needed. This allows dental assistants to expand on their responsibilities—making them critical and valued members of the CAMBRA team, as well as providing a new income stream for the practice from billable procedures such as saliva/bacterial testing or treatment interventions.²

DENTAL HYGIENIST

Dental hygienists are educators so they can use this role to further expand patient knowledge about CAMBRA. The information obtained from the dental assistant can be further explored at the recare appointment. This information along with the use of caries lesion detection devices provides additional information sometimes helpful in the decision process related to treating and preventing early occlusal lesions.³ The dental hygienist can then finalize a caries management program that may include chemical treatments such as antibacterials, fluoride, xylitol ,or pH modification.^2,3

THE BUSINESS OF CAMBRA

Being committed to a new protocol can be time consuming, confusing, and expensive. There is an initial cost involved in purchasing the products that may be used in treatment (oral rinses, topical pastes, or sprays) and the saliva testing materials the dental office may be recommending. It is often difficult for patients to find the products the dental team may recommend for treatment, therefore, as a courtesy to patients, offices should consider dispensing needed products directly or providing an online source where these products may be easily obtained. In most cases, offices can purchase the needed products at a discount from manufacturers and either pass the savings along to the patients (a cost-recovery model) or mark items up to retail (a for-profit model). Either way, there is perceived value to patients in not having to have to track these unfamiliar items down themselves. It is advisable to decide ahead of time which team member will perform which task and train (and cross-train) individuals accordingly.

The fear that integrating caries prevention into a dental practice will reduce revenue is unfounded. On the contrary, good news travels fast. Some practices have reported a significant economic benefit through the greater acceptance of treatment plans and new patient referrals, especially once patients are caries disease-free.¹ Dental work may no longer fail due to recurrent caries and patients may be more apt to do elective work. Happy, healthy patients will refer more new patients.

Patients determined to be low risk for caries can be seen for dental examinations every 6 to 12 months and have bitewing radiographs taken every 24 to 26 months. Having radiographs once every 24-26 months frees up valuable chair time for dental hygienists during the recare or periodontal maintenance appointment (time the clinician could be spending on periodontal therapy). Patients who continue to remain at high caries risk should have caries examinations done every 3 to 4 months and bitewing radiographs every 6 to 18 months until they are no longer at high risk for caries.³ These two caries risk scenarios have a theme. Patients have a choice. Once their caries risk has been determined, they need to understand their status. It can change with diet, medications, changes in oral hygiene, and other factors such as age, smoking, immune status, etc. Patients then become a partner in their treatment and prevention.¹

Using the various assessment tools, such as saliva testing, laser caries diagnostic tools, and radiographs, helps empower patients. Seeing measurable changes is motivating. Understanding that they can change and reduce their caries risk may enable them to have restorative dentistry done, which they may have delayed because previous dentistry redecayed. Seeing the value in prevention, the American Dental Association created CDT (Current Dental Terminology) codes for the services, tests, and products associated with providing care (see Table 1).

Dental and dental hygiene students are using evidence-based research to increasingly make their preventive and treatment decisions.⁴ Preventive measures taught in dental and dental hygiene programs include the use of dental sealants and topical fluorides to prevent and minimize caries risk. Glass ionomer sealant materials contain more fluoride and are more tolerant to a moist field than traditional resin-based sealants, which may increase the rate of success when a rubber dam is not practical. A glass ionomer sealant can even be placed on partially erupted teeth, increasing the value to both the patient and the dentist. In states where dental hygienists and dental assistants can place dental sealants, having them place sealants allows the dentist to spend valuable time on other procedures. Table 2 provides a list of CAMBRA-related therapy recommendations.

STANDARD OF CARE

Standard of care entails many different facets of dental and dental hygiene care. It is more than individual philosophies in the way dentistry is practiced, or what is taught in dental schools, or even what appears in peer-reviewed publications. Standards continue to evolve and change as research challenges us to move in new directions. Webster’s New World Medical Dictionary defines the standard of care as “a diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.” The California legal system defines the standard of care as what a reasonably careful dentist should do under similar circumstances.⁶ Thus the dentist, who puts into practice the idea of benefits exceeding the risks, has adopted a standard of care that is considered reasonable in the legal system.⁶ Patients expect their dental health team to use scientifically safe and effective practices.

CAMBRA protocols are based on the most current research available to us, yet there is more to the treatment decision. The expertise of the clinician is only a part of the overall assessment. We need to engage our patients as co-therapists. We do this by educating them and providing the opportunity to make an educated decision regarding their oral health care. This leads to better patient compliance and brings patients on board as an active participant in their dental health.

CONCLUSION

Using the team approach to CAMBRA provides a solid foundation for implementing an improved standard of care in the treatment of dental caries. Recognizing that caries is an infectious disease that is preventable is one of the most important steps toward improving the dental health of our patients. As dental health professionals, we need to stay current on research and incorporate new information into the way we practice dentistry and dental hygiene. The CAMBRA approach seems like a natural fit for the practice of dentistry in the 21st century.

REFERENCES

1. Kutsch VK, Milicich G, Domb W, Anderson M, Zinman E. How to integrate CAMBRA into private practice. J Calif Dent Assoc. 2007;35:778-785.
2. Gutkowski S, Gerger D, Creasey J, Nelson A, Young DA. The role of dental hygienists, assistants, and office staff in CAMBRA. J Calif Dent Assoc. 2007;35:786-789, 92-93.
3. Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez FJ, Spolsky VW, Young DA. Clinical protocols for caries management by risk assessment. J Calif Dent Assoc. 2007;35:714-723.
4. Autio-Gold JT, Tomar SL. Dental students’ opinions and knowledge about caries management and prevention. J Dent Educ. 2008;72:26-32.
5. Definition of standard of care. Available at: www.medterms.com/script/main/art.asp?articlekey=33263. Accessed February 26, 2009.
6. Young DA, Featherstone JD, Roth JR. Curing the silent epidemic: caries management in the 21st century and beyond. J Calif Dent Assoc. 2007;35:681-685.

From Dimensions of Dental Hygiene. March 2009; 7(3): 28-31.