WHY THE DICHOTOMY?

Like much of healthcare, dentistry approaches the control of pain and the control of anxiety as synonymous. “Big” procedures requiring big pain control, such as impacted third molar removal, are viewed as “deserving” big control of anxiety (ie, general anesthesia). Conversely, minor procedures requiring only a local anesthetic for pain control are viewed as “unworthy” of receiving apprehension management.
In reality, psychology has long established that pain and fear are not proportionately linked.

BASIC PRINCIPLES

Figure 1. Emotions increase as event approaches.	Figure 2. Successful approach/avoidance conflict.

Figure 3. Distressed approach/avoidance conflict.

Two basic psychological principles strongly influence dental patients’ behavior.
The first is that emotion intensifies as the time of an event approaches (Figure 1, solid line). Regardless of whether one is contemplating a positive or a negative experience, such as a vacation or a surgery, the emotion that is evoked from thinking about the event increases as the time of the event draws near.
It is noteworthy that not all individuals intensify their emotions linearly. Some patients experience strong emotional feelings about their upcoming dental appointments long before the actual time of the appointments (Figure 1, dotted line), and escalate even higher at the end. These individuals may dwell on their dental appointment for days or even weeks before the actual time they are to be seen by the dentist. Their emotional journey begins even before they call to schedule the initial appointment, as they work up the courage to phone the office.
Alternatively, other individuals are able to postpone their feelings about dental care (Figure 1, dashes) until they reach some arbitrary trigger (eg, driving to the office, entering the operatory, having the patient bib placed).
The second principle of human behavior is called the approach/avoidance conflict. Take a young boy joining organized baseball for the first time. He eagerly desires to play with his friends, be part of a team, hit a home run, and win the league championship. At the very same time, he dreads being hit by a pitch, dropping an easy pop-up, being embarrassed in front of his teammates, and finishing in last place. If potential benefits (approach) outweigh the risks (avoidance), he will endure spring training, develop better playing skills, and be a better athlete. However, if avoidance prevails, he will quit the team.
Dental patients behave exactly the same way (Figure 2). They desire to approach dentistry (solid line) because they perceive a positive benefit: relief of pain, improved health, enhanced aesthetics. Concurrently, they desire to avoid dentistry (dotted line) for a variety of reasons to be discussed later.
The key to managing a patient’s apprehension is simple. The dental team needs to keep the solid line consistently above the dotted line. If the 2 lines cross even briefly (Figure 3), appointments are cancelled, treatment plans are rejected, patients fail to appear for their appointments, or patients literally walk/run out of the office.
In order to avoid the situation in Figure 3, practice management experts have traditionally focused on elevating the solid line to keep consistently above the dotted line. They search for patient motivators and seek to satisfy them in order for the patient to have a stronger approach to dentistry than a desire to avoid it. While this approach works, it is limited. A patient’s positive emotions can only be elevated so far. Therefore, an equally important component in helping patients pursue treatment is to help them reduce the dotted line.
As part of verbally taking a traditional dental history, I explore a patient’s reservations about pursuing dental care. To help understand their barriers to treatment, it is important to know the answers to 3 questions:

• Why is the patient fearful of dentistry?
• How intense is the fear?
• What type of personality is this patient?

The answers to these 3 questions (avoidance), coupled with understanding the patient’s goals (approach) and an accurate diagnosis (comprehensive exam), will result in a treatment plan that best meets the needs and desires of the patient.

FOUR TYPES OF DENTAL FEAR

Given the frequency of dental fear in the population and the adverse effects on both patients and dentists, it is surprising that more research is not being done in this area of dentistry. However, some insights have emerged from the Dental Fear Clinic at the University of Washington by Milgrom, Weinstein, and Getz.1 They have categorized dental fear into 4 groups. Although these groups are not formal psychological or psychiatric classifications, they are a convenient system for dentists in clinical practice.

INTENSITY

Sadly, one important consideration that has not been thoroughly examined academically involves the intensity of a patient’s fear. Two patients might be fearful of injections, but if one is mildly anxious and the other is truly phobic, the clinical approach should be different. Although there are a limited number of written self-assessment tests that include fear intensity, they were developed for academic settings. I have found these are considered too intrusive by patients for use in a private office setting.
One simple yet surprisingly effective technique to assess the intensity of dental fear is to simply ask the patient. I ask the patient to describe the intensity of their fear on a scale of 1 to 5, with 5 representing “sheer terror.” I do not offer zero as a possible answer, nor do I define what number “1” means.
During the balance of the patient’s appointment my staff and I determine whether the patient’s behavior is consistent with their self-assessment. Although some patients clearly behave differently from their self-assessment, most patients are remarkably accurate and open about their fear issues.

UNDERLYING PERSONALITY

Despite similarities in the cause and intensity of their dental fear, seemingly comparable patients will behave differently. A simple yet highly effective technique to understand an individual’s personality is called DISC profiling (a trademarked term). Although a detailed description of this system is beyond the scope of this article, the premise revolves around assessing a person’s disposition toward being logical versus intuitive, and introversion versus extroversion. For further insights, please visit the Web site at discprofile.com.

SUMMARY

Collecting the answer to the 3 basic questions discussed above is both an art and a science that takes practice on the part of the doctor. Yet, by doing so, a treatment plan can be tailored that not only addresses the patient’s motivators, but also considers their barriers to treatment.
Patients who present with dental fear need not be viewed as challenging or difficult. Instead, they often represent the ideal patient (only in disguise). They often need extensive dental care. They are loyal, staying with a dentist despite changes in dental insurance coverage or moving away from the office. They are proud of their success and are genuinely most outgoing in serving as referrals. And finally, they are deserving of the very best care we have to offer.

Reference

Suggested Reading

Egan G. The Skilled Helper. A Problem-Management And Opportunity-Development Approach To Helping. 7th ed. Pacific Grove, CA: Brooks/Cole (an imprint of the Wadsworth Group,  a division of Thomson Learning); 2002.

Dr. Sangrik is a 1979 graduate of The Ohio State University College of Dentistry. He is a nationally known lecturer on the topics of dental fear, medical emergencies, vital signs, and sedation techniques in dentistry. He maintains a full-time general dental practice in Chardon, Ohio, with an emphasis on the treatment of apprehensive patients with IV sedation. He can be reached at (440) 286-7138.

RISK-BASED ASSESSMENT IN DENTISTRY

Figure 1. Diagram of endodontic abcess.	Figure 2. Endodontically treated tooth with additional surgical fill.
Figure 3. Mandibular overdenture with 3 FDA-approved ERA Implants and 2 transitional implants that allow for immediate loading the day of surgery.	Figure 4. Implant Logic Systems’ surgical guide for ERA Implant placement.

Figure 5. On the left, ERA Implant with Black Processing Male. On the right, pictured with White Active Retention Male, the arrow shows the 0.4-mm resilient spacer area.

Dentistry offers several good examples of this decision matrix being applied. Some dentists perform root canal treatment, but not necessarily all of the cases that they could (Figures 1 and 2). They often choose certain teeth that present with an easier series of steps and outcomes that improve their odds of successful treatment. This is a risk-based assessment. TMD cases, comprehensive reconstruction, and periodontics have examples as well. Extractions (especially third molars) are an excellent example. After considering a number of scored parameters (age, radiographic appearance, disposition of the patient, overall health, etc), one makes a reasonable decision regarding whether to proceed with treatment or to refer. You may not have written this assessment down, or applied a mathematical score to the parameters, but you did create a decision matrix even if it was unconscious.
I have recently begun to perform a surgical procedure that is clearly outside my traditional comfort zone: placing implants for immediate load overdenture cases. I could not do this without a risk-based assessment. I stumbled upon a very viable treatment protocol that could provide a much-improved prosthetic solution for a more affordable cost than traditional implant-retained overdentures. It also had the potential of significant financial gain for the practitioner.
Like many of the “seems-too-good-to-be-true” stories I have heard, I listened to a presentation about this with some healthy skepticism. My cynical psyche was summarily disappointed quite rapidly, though, when the discussion began with the term risk-based assessment. This immediate load implant-retained overdenture protocol using ERA Implants and Attachments (Sterngold) had several good things in its favor (Figure 3). Here are the reasons I like Sterngold’s protocol:

Figure 6. Acetate overlay showing adequate room for fixtures using 125% radiographic magnification adjustment. Note the distance from the mental foramen even for the 15-mm ERA Implant.	Figure 7. Using the 4-mm surgical punch in a broad surface of the mandible in lieu of an incision or flap procedure to gain access for ERA Implant placement.

Some patients are healthy enough. Some mandibles and maxillas are large enough (both in width and depth). Some bone is dense. Some nerves and osseous irregularities are far from the surgical site. And, un-fortunately, some are not. That is the key in a risk-based assessment. If we understand the procedures, and we can evaluate the patient and the sites prior to doing a punch or laying
a flap, we can determine which cases we are comfortable with and capable of treating, and which we are not (Figures 6 and 7).
Now, do not misunderstand me. My good friend and Sterngold surgical mentor, Neil Thomas, DDS, can treat many cases that I would not. His “go” and “don’t go” signs are farther apart than mine. I think of it like a stoplight. We both have green and red lights that tell us without question when to proceed and stop. They are just in different places. Neil’s yellow light is broad and long. He can treat many challenged mandibles and maxillas that would be a big red light for me. That is fine. It is less about where his lights are and more about assessing where mine are. I might prefer a surgical guide at first and to do only cases that could utilize a punch incision instead of laying a flap (about 17% of the time).

Figure 8. Using the Countersink/ Drill (Sterngold) and 0-degree alignment device to prepare a second site for an ERA Implant.	Figure 9. Using ERA PickUp material to capture the ERA Males in their metal housings over the transitional implants on the day of surgery. Black Processing Males without metal housing cover the uncaptured 3.25-mm permanent ERA Implants. They will be left to osseointegrate fully before picking them up at a later date.
Figure 10. After coring out the Black Processing Male Attachments, the White Active Retention Males are placed with a special tool into the metal housing picked up in the procedure above.	Figure 11. Neil Thomas, DDS, and surgical assistant Carrie Davies working on an ERA Implant overdenture patient.

Having Neil at my side during my first few forays into the world of implant placement was helpful in finding the position of my stoplights. In the hands-on typodont course and lecture that Sterngold gives, there is excellent instruction, documentation, and practice to “teach” me how to place these fixtures (Figures 8 to 10). Just because I was “taught” everything does not mean I had “learned” anything. And therein lies the difference. The cost of entry is not steep to acquire the armamentarium. The real question is, “Will I take out my new surgical handpiece and kit and place the first one after just practicing on acrylic for a day?” May I answer for most of us, “When donkeys fly!” The kit and noninterest-bearing capital investment would likely sit quietly gathering dust in a hidden enclave of my office were it not for the mentor program.
In the one morning that you can schedule 2 surgeries (Neil does 2 in just more than an hour each) you can generate enough income to pay for the kit, handpiece, and Neil to come and watch to make sure we stay the right course. His insight and understanding of our implementation barriers to new technologies and procedures is awesome. I felt confident both in the assessment we made to-gether prior to the Saturday morning appointment as well as the protocol itself (Figure 11).

WHEN DONKEYS DO FLY

Take it upon yourself to use a risk-based approach to clinical decision making in your practice. Find mentors familiar with the procedures you wish to undertake. Observe them and learn from them. Invite them to oversee your first steps into this new and exciting, yet uncharted ground. You do it every day with dozens of procedures, materials, and decisions that you make. Instead of the old adage, “tell, show, do,” perhaps we should consider “listen, watch, do with oversight first.” In fact, I think that is how we learned what we do know in dental school—the caring eye of the instructor helpfully guiding you to correctness at every turn. Well, at least that was their intent.
Sometimes old dogs like me can learn new tricks. Sometimes donkeys do fly. But they check the weather and file a flight plan.
Oh yes, and they do their first flight under the watchful eye of one who has gone before.

Dr. Murphy is a featured presenter for the National Dental Network and the National Lab Network, and he lectures internationally on a variety of dental, clinical, and behavioral subjects. He practices part time in Rochester Hills, Mich, and teaches at The Pankey Institute in Key Biscayne, Fla, where he serves as the director of professional relations. He can be reached at mmurphy@pankey.org.

Figure 1. Ceramo-metal bridge and model, demonstrating preparations.	Figure 2. Ceramo-metal bridge, internal aspect.
Figure 3. IPS Empress bridge (Ivoclar Vivadent).	Figure 4. Translucency of IPS Empress bridge.
Figure 5. Partial denture with metal clasps.	Figure 6. Partial denture demonstrating lingual bar.
Figure 7. Partial denture with Valplast clasps.	Figure 8. Partial denture with Valplast clasps for anterior missing tooth.
Figure 9. Full maxillary denture.	Figure 10. Mandibular denture.

Ideally, the initial examination should allow the patient to envision long-range treatment.^1,2 At this stage, the dentist should try to ascertain what the patient wants and what is relevant to him or her. The doctor and patient should learn together the problems that exist in the patient’s mouth and the consequence of not treating.³ In the following visits, these findings can be discussed and options for treatment explored. The examination appointment should be used only for the purpose of obtaining a case history, comprehensive examination, charting, complete radiographs, vitality testing (if needed), and diagnostic models if warranted.³ Patient education can also be initiated. They should be made aware of existing conditions and any areas of neglect in their dental health. They can be given a mirror, or images of problem areas can be captured and presented on a computer screen. The advantage of the latter is the ability to magnify areas so that the patient can see better, and the presentation is technically more advanced. The patient’s desires in seeking treatment should be explored at this time. A case presentation should address these desires and explore treatment options.⁴
The time between the first and second visit allows the dentist to arrive at a diagnosis based on the clinical exam, radiographic findings, and study models.³ The treatment plan should be suitable for that particular patient. Some dentists only formulate one treatment plan, while others formulate several. If too many choices are presented, it may be confusing for the patient. The ideal treatment plan should be the first to be presented. Sometimes a holding plan is required if the patient cannot undergo optimal treatment due to financial, physical, or time constraints, but can proceed at a later date. A third alternative is to proceed with emergency treatment so as not to lose any teeth. The doctor should recommend the treatment that would be suitable for the doctor or his or her family. A fixed bridge, if suitable, should be recommended rather than a removable bridge. The desire for fine dentistry should be instilled at this time and at future visits.
At the case presentation the patient should become aware of the benefits of treat-ment.4 The patient should be able to visualize what the treatment will entail and how it will affect his or her health, appearance, and function. The patient should be made aware that he or she is paying for the treatment or services performed and not just for merchandise. Without education, patient comprehension or motivation will not occur.
A variety of tools can be used to explain treatment options. Photographs of similar cases are excellent, but models that demonstrate future treatment and that the patient can actually see and touch provide a more tactile sensation. Models that have been professionally fabricated (Sun Dental Laboratory) present an ideal way of demonstrating to the patient a variety of treatment alternatives. Models of the most common procedures are usually the best to obtain.³ Procedures that are increasingly being performed in the office can be added as needed.
A patient who presents with missing teeth can have one missing tooth, several missing teeth, or all the teeth missing or requiring extraction. A patient with one missing tooth in the anterior area can have the tooth replaced with an implant, a conventional ceramo-metal bridge (Figures 1 and 2), an all-ceramic bridge (Figures 3 and 4), a Maryland type bridge, or a removable bridge. The benefits and disadvantages of these can be explained to the patient. Ideally, one should be selected as the recommended treatment and the others as alternatives. The patient can be shown how the teeth have to be prepared for a fixed bridge (Figure 1) compared to an implant, where the adjacent teeth are not compromised. They can see the translucency to light of an all-ceramic bridge (Figure 4) compared to one that is metal-supported (Figure 2). Another alternative would be a removable partial denture with metal clasps (Figures 5 and 6), or one with gingival retentive arms (Figures 7 and 8). The patient can see how much display of metal occurs and also how much coverage of the palate may be required for the prosthesis. The impact of actually seeing these models can’t be underestimated.
If a patient is missing one or more posterior teeth, treatment options may include implants, a ceramo-metal prosthesis, sometimes an all-ceramic prosthesis, or a partial denture. By reviewing a model of a partial denture, for example, the patient can see how much material will be on the palate in the maxillary arch, or the bar on the lingual of the lower arch (Figure 6). The difference between a metal framework and one without can be demonstrated readily. When all remaining teeth need to be removed, it is devastating to the patient. Showing a full maxillary (Figure 9) or mandibular denture (Figure 10) removes the fear of the unknown. The aesthetics that could be achieved is readily realized, and problems with retention, especially in the lower arch, can also be appreciated. This can then lead to discussions of implants for fixed or overdenture-type attachments.

CONCLUSION

The more visual aids we provide the patient, the more often an increased understanding of the depth of treatment being offered can take place. Pictures, computer animations, and especially professional models all contribute to this comprehension. If it is presented to them appropriately, patients will allow more comprehensive treatment. They have to understand what dentistry can do for them and that optimal dental care may be financially feasible.3 This will be of great benefit to the patient’s long-term stability. Patients also appreciate the time clinicians spend  explaining the options in a noncondescending manner.

References

Acknowledgment

Models provided by Sun Dental Laboratory.

Dr. Trushkowsky is a clinical associate professor of the CDE Advanced Aesthetic Program and associate director of international aesthetics, New York University College of Dentistry. He maintains a private practice in Staten Island, NY, and is a Fellow of the AGD, the Academy of Dental Materials, both the International and American College of Dentistry, and the Pierre Fauchard Academy. He is a lecturer in the ADA Seminar Series, an evaluator for CRA, and a senior consultant for The Dental Advisor. He wrote a chapter on direct composites in Mosby’s Esthetic Dentistry and a chapter on indirect restorations in Dental Clinics of North America. He has patents on 2 instruments for achieving contacts and curing posterior composites.He can be reached at (718) 948-5808 or composidoc@aol.com.

Illustration by Nathan Zak

Insurance carriers employ utilization data as a basis for many aspects of dental plan design and usage. Utilization data has also traditionally been drawn upon to assess treatment variations against what a carrier has established as a “norm.” If a dentist performs certain procedures at a higher rate than other dentists in his or her zip code, a carrier may decide that the dentist’s practice patterns are not typical. Dentists who practice atypically are undesirable in networks. They can strain plan resources. In addition, reporting more procedures than others means “overutilization” to most carriers, implying that the procedures being claimed are probably not necessary or are being reported incorrectly. A dentist who is an “overuser” may be audited or face other consequences.
A major problem with utilization statistics is that they do not reflect the whole picture. A general dentist may report more endodontic procedures than others in his or her zip code because the clinician refers fewer cases out. A general dentist may report more periodontal maintenance procedures because he or she has a superior screening and treatment system to identify periodontal patients.
While it is one thing to label a dentist as an overuser, it is another to use a dentist’s practice profile as a method of distinguishing a “good” dentist from a “deviant” dentist (deviant here meaning practicing outside the “norm”). When utilization data identifies a deviant dentist, that dentist may be branded (as Delta of Minnesota did in 2000) as not showing “an orientation to provide economic value in treatment approaches.” Such dentists had their fee reimbursements frozen by Delta of Minnesota that year. Dentists who were shown to be extremely outside the norm had their fee reimbursements reduced!
While the year 2000 has long passed, the evolution of utilization review and its implications has continued. Although the term utilization review is still prevalent, a new incarnation of the concept is being called P4P or Pay for Performance. In a special column in the ADA News on February 13, 2007, P4P was explained. According to the article, “A new initiative with strong backing by the federal government has been introduced that, if successful, will have a major impact on the delivery of dental care…That initiative is called pay for performance; a reimbursement plan built upon the philosophy that those who perform well should be reimbursed more than those who perform at a lower level.” P4P, on the medical side, has already been embraced by medical insurers, as well as the government in its Medicare and Medicaid plans.
While explanations abound as to the true elements of “performing well,” it appears that the driving force behind P4P is money, just as it has always been with utilization review. It is known that healthcare costs in the United States are among the highest in the world. Managed care and the use of networks of providers have held prices down in the past. However, physicians, hospitals, clinics, and dentists have had their fees squeezed year after year. There is little left to reduce. Enter, “consumer purchasing of healthcare” and the need to “differentiate among providers.” According to the ADA, under a P4P plan, providers in a network are given incentives to meet evidence-based performance criteria. In order to work with the plan, not only must they meet the criteria, but they must report their performance using office management systems (computerized systems and electronic records) that track patient care. Incentives for dentists to provide “quality” treatment are another aspect of P4P. According to the ADA News, these incentives are typically both financial and reputational. The financial incentive is in the form of increased reimbursement for “preferred behavior.” The reputational aspect is a public release of provider performance data that can affect a provider’s reputation in a community.

PREFERRED BEHAVIOR: WHAT IS IT?

“Preferred behavior” appears to be based on 4 elements in a P4P plan. These are performance measures, data collection, performance targets, and performance incentives.

• Performance measures are typically thought of as an account of the utilization of services and the cost to provide these services. In other words, how many services has a dentist performed and what did it cost the plan to pay for these. Additionally, clinical quality and outcomes of treatment may be considered. However, there is no consensus as to how clinical quality and outcomes in dentistry might be measured fairly. On the medical side, the American Medical Association has developed 100 performance measures used to evaluate medical treatment outcomes. In the future, it is possible that the ADA and others may develop a system of dental outcomes measurement. For now, cost appears to be the main criterion of performance.

• Data collection typically refers to the quantity of claim forms processed and the codes for treatment reported on these forms. Nationally, there is a strong push for full electronic data collection in the form of an EHR: electronic health record. Electronic data maintenance of all types is a goal of both the government and insurance carriers. However, the development and acceptance of digitized records appears to be slow and erratic. Many industry watchers predicted completely computerized systems long ago, but this has not happened. Industry-wide computer program incompatibility and other issues are delaying full implementation of digitized systems. (While an electronic record may help manage data concerning patient care, a July 2007 article by Reuters reported that in a study of 1.8 billion medical doctor visits, there was no advantage of electronic records over paper charts in the quality of patient care. According to the article, there were 14 “quality indicators” for which electronic and paper records appeared to be of equal value. These included prescribing the correct antibiotic, ordering and tracking screening tests for various conditions, and supplying appropriate prescriptions for the elderly. Interestingly, when it came to prescribing statins for patients with high cholesterol, doctors using electronic records did worse than those with paper charts.)

• Performance targets are considered to be the heart of any P4P plan. Performance, also sometimes called best practice, can mean whatever a plan wants it to mean. For example, when utilization data is used as a performance criterion, a “best practice” profile might be one that provides for the least expensive treatment, as opposed to other treatment considerations. It might be doing more standard prophys and fewer root planings, or periodic exams once every 2 years instead of once annually. Best practices or performance targets can mean less treatment, depending on who is defining the practices.

• Performance incentives can have a huge impact on any plan. While reputational in-centives may influence dentists, financial incentives are key. The idea of using a financial bonus to reward dentists who are providing the “best value” under a plan is simple enough to understand. However, the concept gets complicated when it comes to deciding from where financial bonuses will come. Should the money for the “good” providers (as defined by the plan) come from the “bad” providers compensation? Should the money come from increased premiums? What about the “bad” providers? Should they be eliminated from a plan? Should they have their compensation reduced? Should they just be eliminated from receiving a bonus? With all the issues surrounding monetary rewards, it is difficult to imagine how financial incentives might actually lower the cost of care as defined as one of the objectives of a P4P plan.

NETWORK REMOVAL AND “INSURANCE FREE”

In my home state of Colorado, Delta financially rewards “good” dentists whose utilization data supports the Delta definition of comprehensive treatment. These dentists’ statistics reflect Delta’s standards of “reasonable” utilization with no hint of “overtreatment.” Dentists who do not fall into the “good” category may eventually be removed from the network. Since Delta covers 1 in 4 patients nationwide, being removed from a Delta network can be a terrific financial blow to a dentist. Many patients will leave for another dentist on the “list” because of economic pressures and an underlying distrust of a dentist who has been dropped from a plan. Pa-tients may believe that their plan is looking out for them and that the dropped dentist is “no good.” Dentists who witness the consequences of others being dropped from a network may become afraid to leave the network on their own, even if they are unhappy with their situation. An unhealthy, coercive situation can develop.
This type of atmosphere can cause many dentists to think about going “insurance free.” While this may work in some practices, many patients rely so heavily on their insurance and on the dentist’s staff to help them navigate through their benefit issues, it may be difficult to achieve. In fact, in a 2003 ADA survey it was revealed that 65% of patients seeing dentists have insurance! For these patients, no insurance would likely mean no dental care. (Even if an office decides to discontinue filing claims on patients’ behalf, as long as patients rely on their benefit plans, an office is actually never totally “insurance free.”)
Some dentists may simply want to reduce certain problems surrounding the office’s responsibilities in dealing with insurance. They may decide to become nonparticipating. Nonparticipating or nonnetwork providers are under fewer contract constraints; for example, there is no annual fee submission, no requirement to accept a maximum plan allowance, and no evaluation for “best practices.” However, patients going to nonparticipating dentists are required to pay a larger portion of the bill, and any payment check comes directly to them. Being “par” or “nonpar” both present problems for dentists. P4P plans are likely to build on, not eliminate, is-sues such as these that have surrounded dental benefits for years.
As we have seen, P4P programs and utilization review programs seem to be primarily focused on a desire to reduce costs to insurers. While P4P plans on the medical side are forging ahead quickly, such plans on the dental side are just developing their criteria. The ADA is involved in attempting to influence plan designs to address other aspects of performance rather than just insurer costs. These include the relationships among diagnosis, treatment outcomes, and patient satisfaction.

UTILIZATION REVIEW AND THIRD-PARTY AUDITS

Because utilization review is such a prominent feature in a plan’s process of “policing” contracts, dentists need to be aware of the audit process. Dental insurers may decide to audit a dentist who is flagged during a standard utilization review process or who comes to their attention for some other reason, such as a patient complaint. The audit process is designed to discover if a refund is due to a carrier, to discourage plan “abuses,” and to cut down on “deviant” claims in the future. Dentists who are faced with an audit have only their records to protect them. Without detailed and thorough patient records, whether computer or paper, the dentist has nothing to back up treatment and claims submitted. Information contained in a patient’s record should include, but not be limited to the following: reason for first visit, comprehensive data collection, complete diagnosis, treatment plan based on diagnosis, progress notes, and outcome of treatment. If treatment is performed that does not conform to the initial diagnosis, it is difficult to support treatment decisions. Documented information supporting treatment decisions is essential during an audit.
Many dentists believe that an insurance plan auditor has no right to look at patient records without the patients’ written consent. However, HIPAA specifically gives insurance plans the right to access information they think is necessary to pay claims and police their plans. Employers who purchase a plan for their em-ployees, who subsequently become your patients, give an insurance carrier this right by virtue of accepting the benefit contract. In the ADA HIPAA Privacy Kit there is a list of situations where a health plan may access private health information under HIPAA. These include the following:

• Determining eligibility and adjudicating claims for patients.
• Reviewing healthcare services for medical (dental) necessity, coverage, justification of charges, and payment history.
• Utilization review.

Previously, financial records of nonsubscribers could also be scrutinized to match up to charges made to subscribers; however, HIPAA regulations do not permit this anymore. Only subscriber financial records may be viewed.
To comply with HIPAA regulations, and to let their patients know about the dentist’s obligation to provide health information to insurance carriers and government officials, every dental office should have a “Notice of Privacy Practices” brochure where office policies are spelled out for patients.

RECORDS ARE THE KEY

As always, patient charts are the key to all aspects of dealing with insurance carriers, government agencies, and malpractice situations. Record keeping is an essential function of any dental office. Whether paper or computer, detailed records support the dentist’s diagnosis and treatment plan, as well as provide a diary of services rendered. In the arena of utilization review and P4P, records will continue to provide the most important documentation for the patient, the staff, and the dentist. Without them the dentist has no way of verifying why treatment was indicated and what treatment was accomplished. Dentists who are facing an audit by a plan might contact the ADA Council on Dental Benefit Programs, the AGD Dental Care Council, or the American Academy of Periodontology Third Party Manager. These organizations may have input to help you. In addition, your own attorney should be notified to provide any advice or support that you might require.

Ms. Tekavec is the author of the Dental Insurance Coding Handbook 2005-2008. She is the designer of a dental chart that has been endorsed by the Colorado Dental Association, as well as author of a series of patient brochures explaining various dental procedures. Still practicing as a clinical dental hygienist, she is the president of Stepping Stones to Success, a frequent lecturer at major dental meetings, and a presenter for the ADA Seminar Series. She can be reached at (800) 548-2164, or by visiting her Web site steppingstonestosuccess.com.

Illustration by Cheryl Gloss

Security

Patients must feel that they receive the best treatment available and need reaffirmation for their medical, dental, and physiological needs. When these physical and emotional needs are satisfied, the personal encounters flow more readily. The mood must be positive from the initial contact. The patients must feel that your office is a respite from the outside world; they need a place to feel safe where many of their health needs can be addressed.

Relationship

Patients should be the epicenter of a dental practice. Every person on the dental team must make the patient feel better about him- or herself. Communication needs to be a two-way street. Patients want confirmation that they are making excellent decisions; they want reassurance that their voice is heard and their medical needs are your foremost priority. Being part of the process is comforting.

Value

As Sy Syms, chairman of Syms clothing stores, states, “An educated consumer is our best customer.” Patients expect professionalism in all phases of the en-counter. Their need to be fully informed of all the treatment phases and costs are a given; all the positives and potential negatives of treatment must be highlighted. When the staff delivers these clear messages with courtesy and clarity, the patients feel the value of the practice.
Every day the dental staff has the opportunity to build customer loyalty. These moments of truth can come at any time during interaction with patients. The doctors and the staff must be well-prepared to handle these interactions and ensure that each patient is being treated as if he or she is the only patient being seen during the day. We have outlined 7 key areas where these moments of truth appear; they are presented below.

Trust

Building trust translates to establishing relationships. Both the doctor and the staff must have strong people skills to manage the flow of patients throughout the day. Each practice must manage 2 types of trust; the first is functional trust. Sometimes this is the most difficult, as many patients are accustomed to waiting inordinate amounts of time to see the doctor. Unfortunately, they expect to wait. The solution is to meet and greet early. A staff member should always be present to greet patients coming in the door. Patients always are delighted when seen on time, their functional trust is on the rise, and they will probably tell others about it.
The business systems that the doctor sets up and that staff members perform seamlessly impact the other areas where functional trust is built. These include sharing the value of a service when presenting payment options and handling insurance questions. Loyal customers appreciate when this part of the transaction is handled with ease. The person is fully aware of all costs, and at no time is surprised by cost-added services, such as when a beautiful white restoration replaces an amalgam filling. In fact, these are the people who will give you feedback both positive and negative about things that were or were not handled properly. Loyal patients provide the practice a chance to improve and avoid future problems.
The second type of trust is personal trust. All of the 3 critical needs are established and can be fulfilled during this phase. People feel comfortable and safe in your office, they feel better about themselves by making the appointment, and they know they will be treated kindly and fairly.
Loyal customers always feel good about the people in your office. Building trust requires us to make adjustments and remain flexible with customers. The relationship is much like a bank account. What does one need to make a withdrawal (be-sides the ATM card)? The account must have money in it; thus, deposits have been made. When we need something from a patient, we must have something in-vested. When the office is cold and heartless, patients are likely to feel an increasing deficit in the account. Strong relationships are a must for the successful dental practice.
The final area of trust comes with reliability. The loyal patients come to expect the same level of professionalism with each visit. In fact, they are so confident in the service that they concentrate on 2 things: their oral hygiene and the interactions with the people in the office. These interactions turn the routine dental visit into a pleasant experience.

Responsiveness

Have you and all your team members listened and heard your patients today? Did you wait for an answer when you asked Mrs. Johnson what you could do for her?
Often, the doctor sets his or her business infrastructure around the ability to perform needed tasks. The daily schedule shifts to meet the doctor’s needs, and pa-tients wait for the “right time” to see him or her. On a good day, the schedule runs smoothly and patients do not wait an unreasonable amount of time. On other days, the scheduled patients wait, and the unscheduled are told there are no openings. This is an old paradigm—the practice is built around the doctor.
The new paradigm, the 21st century mindset, is the patient-centric practice. All activities focus on them. While even the best-run practices cannot always squeeze in patients, those dedicated to killer customer service make the effort and often accommodate the patient who needs an immediate assist. Trust plays a role, as the staff might need to ask someone to switch an appointment. Loyal patients are always glad to help out. The practice is run as a business should be run—the patient comes first. Customers so appreciate such responsiveness that they rave about it to others.
Why? The answer is easy: most dental practices do not follow these common business practices.

Competence

The doctor’s ability to perform excellent treatment is only a part of a patient’s concerns. They want the entire staff to be equally professional and competent. As in any business, behavior modification and skill development come from training. Are the people in the office prepared to manage both the patient interaction and the patient account? Loyal pa-tients understand that these needs are being met regularly. They do not have that uneasy feeling that the transaction has some loose ends. They feel equally good about the treatment by the doctor and the staff. If the doctor is excellent but the staff performance is me-diocre, then some patients might return, but there are no guarantees for how long they will stay. These pa-tients are in the danger zone.

Courtesy

All dental practices want to be busy. The base concept for all businesses is supply and demand. With so many people paying attention to oral hygiene, what gives a practice the competitive advantage? In short, it is the practice that values people and treats them with courtesy, care, and dignity. A practice cannot afford to be overwhelmed to the point where patients are barely acknowledged when entering the office. They cannot afford to ignore those who have been waiting for awhile. Of course, every office must go into crisis mode at some time or another. At these hectic times every practice faces critical moments of truth in developing loyal patients. How these interactions (during a flurry of activity) are managed make the difference between leaving patients in the danger zone or converting them to loyal patients.

Communication

Communication is the lifeline of any business. A dental practice is no exception. When developing loyal patients, we need to look at both internal and external communication. Both are equally important. Internally, do the staff and doctors communicate well with one another? Are there internal conflicts that are not resolved? A practice is a team of people working together for a common objective: to provide the best oral care for its patients. The team approach allows for conflict resolution and establishes the advantage of developing loyal patients. Formally, there should be team meetings held on a regular basis. Informally, there should be daily “huddles” where the staff gets together to manage the challenges of the day. This builds trust and loyalty among team members, a necessity for the practice that maintains loyal patients.
External communication provides the vital link between the practice and its patients. This communication centers on 3 areas: pre-appointment, face-to-face, and post-appointment. In pre-appointment communication the patients should be confirmed for their appointments. Many practices are now finding success with e-mail confirmations. Perhaps this is less personal, but the e-savvy and the very busy patients find this to be effective and efficient. There still needs to be a process of calling the patients who do not prefer e-mail communication. Another aspect of pre-appointment communication is letting the patient know how to best prepare for the appointment. Some patients need a reminder to premedicate; others need to remember to bring a letter from the insurance company.
The second area of external communication is face-to-face. The staff needs to let the patient know what to expect during this appointment. This level of communication is important for even routine procedures such as x-rays, cleanings, and consultations. The most important part of face-to-face communication is the doctor’s ability to connect with the patient. A doctor who is competent, listens, and cares is far more likely to have loyal patients than those who are competent but cold.
Post-appointment communication is the one area most practices do not perform well. After a difficult procedure, the staff should call the patient to see if there were complications. Most practices follow the concept that “no news is good news,” but this is not a characteristic of Killer Customer Service. A simple follow-up call leaves a lasting impression of genuine concern on a personal level.

Understanding

Patients want to be understood. They need to know that the dental staff has excellent listening skills and provides the empathy needed to make them feel secure. A big complaint that pa-tients have is that the practice does not understand their complete overall health concerns and only wants to “process” them through their appointment. A patient who feels that the staff is listening and understanding feels that everything is being done to provide them with the best possible service.

Tangibles

Tangible results are the most important part of patient loyalty. First, patients want their pain alleviated; second, they want to “look” better; and third, they want to forget about any problems they have with their teeth. Without these tangibles, patients will not return. Other tangibles in-clude the cutting-edge products that they can purchase at the office. For example, they enjoy the newest toothbrushes, the best water irrigators, and other leading-edge products. Another tangible that patients love is the free “goodie bag” that they receive at the end of a visit: a new brush and new floss. Loyal patients come to expect such treats at the end of their appointments.

CONCLUSION

Killer Customer Service is the complete process of taking care of patients through a developed and skillful effort by the dental practice. In the United States today, we are in the golden age of dentistry. Never before have Americans been so aware of how oral hygiene impacts their overall health. As a result, there is a demand for excellent service. Far too many dental practices are not versed in the rigors of customer service. The most successful practices are the ones that implement a program, develop it over time, and refine it continuously. They have the competitive advantage of gaining lifelong loyal patients.

Dr. Varallo is a 1980 graduate of Farleigh Dickenson Dental School. He is a member of the International Academy of Dental-Facial Aesthetics, an AGD trained speaker,
an associate fellow of the World Clinical Laser Association, and serves on the clinical advisory board for DENTSPLY. He owns and operates the Nantucket Dental Society as well as maintains the successful patient-centric practice, Ho Ho Kus Dental Associates, in Ho Ho Kus, NJ. He can be reached at (201) 670-9076.

Mr. Varallo, senior-level consultant, has more than 20 years of experience as a facilitator, a coach, and a trainer with global companies. His projects include Killer Customer Service, Presenting With Impact, and Executive Coaching. His clients include Citigroup, Hoffmann-La Roche, The Chase Manhattan Bank, and BMW. He uses an interactive style that engages and motivates his audience members to improve their communication skills. A top business consultant and public speaker, he helps organizations achieve success in customer service. He can be reached at (201) 444-1946.

Illustration by Brian C. Green

Such is the case when the emergency patient sits in your chair. Up until this moment, that person may not have been interested in what you have to offer. But his or her situation has prompted consideration not only of immediate treatment but, quite possibly, comprehensive care as well. Yet dental teams miss this opportunity time and again. According to the industry standard, 80% of all emergency patients should be converted to comprehensive exams. If yours is lower, then it’s time to develop a plan to seize the “teaching moments” that emergency cases present.

GOOD CALL OR BAD?

Patients and staff often view emergency appointments as negative and potentially problematic. Consequently, practices commonly send the wrong message to those pa-tients with whom they must interact under pressure. The person is squeezed into an already full schedule. Although it’s probably not intentional, the emergency patient is frequently viewed as an annoyance and an interruption to the day rather than an opportunity.
When the emergency patient calls your office, what’s the reaction? Irritation? Frustration? Increased stress? Depends on the time and the day? Here’s what happens in many offices. The scheduling coordinator takes the call and scans the already full schedule. With a labored sigh, he or she tells the patient it’s going to be very difficult for the practice to work the appointment in, but it will. Oh, and doctor expects payment up front. Within the first 60 seconds of contact with that emergency patient, your practice is laying the groundwork for conversion to a comprehensive exam…or not.
No matter what the circumstances—full schedule, stressful situations, etc—emergency patients must be treated with compassion and understanding. Each day the dental team should identify where emergency patients are to be placed in the schedule; this way, there are no surprises for the clinical staff, and the scheduling coordinator knows exactly where emergencies are to be placed.
Next, increase awareness among your team. Business staff members, who tend to be more task oriented and are much more comfortable when the day runs according to a specific plan and schedule, occasionally need to be reminded that emergency patients are likely to require more empathy and concern than they may typically convey in their day-to-day patient communication. The emergency patient should feel that your practice is one that is understanding and helpful—not punitive.
Listen to how the emergency patient calls are handled. Are these conversations warm and welcoming? How would you feel if you were an emergency patient calling your office? Would you be glad you chose this practice or would you feel that the practice’s primary concern is the payment rather than the patient?
I recommend that dental teams develop phone scripts to help them effectively communicate with emergency patients from the very first word. The script provides a general guide to assist all staff, no matter who picks up the phone, in gathering necessary information, conveying essential details, and continuously expressing a helpful and caring tone and attitude throughout the exchange.
Welcome the patient when he or she enters the practice and greet him or her with a smile. Assure the patient that the clinical team is excellent and will provide very good care. Let the patient know approximately how long the wait will be. Ask if the patient would like assistance completing his or her paperwork. If the patient is in con-siderable discomfort, then take him or her into a consultation room or other quiet area, where a staff member can assist with completing practice medical forms and other documents. The focus should be on making the process as easy and comfortable as possible for the patient.

READ THE CUES

Each member of the team plays an important role in putting the patient at ease as well as gathering information that will be essential in understanding the likely barriers to future treatment. Pay attention to cues the patient is giving. The conversation that the assistant has with the individual can be particularly useful in identifying those issues that will need to be addressed in order for the patient to consider further care. Does the patient appear anxious or fearful? Does the patient comment that he or she is concerned about the cost of the treatment, or the pain, or the time the procedure is going to require? Is the patient apologizing because it’s been such a long time since he or she has been in for an appointment? Has the patient had a negative dental experience in the past? Is the patient angry or frustrated?
In talking to the patient, the assistant should be able to identify the most likely obstacles the dental team will encounter when encouraging this patient to pursue comprehensive care.

PREPARE FOR THE COMMON BARRIERS

Track the most common reasons why emergency patients wait until there is a problem before coming into the practice. Understanding the “why” behind patient reticence is essential to addressing it. From there the team can develop a patient communication strategy through the use of scripts and educational materials to overcome those barriers. Just as scripts are essential at the front desk when answering phones, they are also critical when educating patients about the value of ongoing dental care. Moreover, they are a safety net that prepares the staff to know what to say, how to say it, and when to say it. If the patient is highly anxious, then team members should have a specific script and protocol that they follow to put the patient at ease. If the patient is concerned because he or she doesn’t understand why a specific procedure is needed, then the staff should be prepared to respond through educational videos, printed materials, dental models, etc. Companies such as ADA Intelligent Dental Marketing offer several short, patient-friendly videos covering numerous topics, including dental hygiene, implants, crown and bridge, endodontics, and much more.
Anticipating patient concerns and being prepared to address them enables staff to educate patients confidently and consistently, to seize the teaching moments effectively. Staff members aren’t in a situation in which they have to think on their feet; they have anticipated the barrier and have a plan to address it. What’s more, patients appreciate the ef-fort to address their concerns and help them understand. Dental team members aren’t just trying to get the patient out of the chair as quickly as possible so that they can return to their regular schedule.

EFFECTIVE SCRIPTS AND ROLE PLAYING

Set aside time during the weekly or monthly staff meetings to develop scripts. Don’t get bogged down in ad-dressing every possible scenario immediately. Pick a couple of key barriers and address those initially. The doctor and team should work together to fine-tune the documents over time and to develop an easy and natural flow. Once you feel confident in using those, create a few more.
Keep in mind that the best scripts use words, phrases, and questions that prompt patients to respond the way you want them to respond. Those who are able to use scripts most effectively understand the message they need to convey. They know the information and material thoroughly. They are not reciting the copy verbatim; rather, they are able to use the scripts as a guide and adapt them so they come across naturally, as if they were chatting with the patient over coffee. What’s more, teams that use scripts to their full advantage practice, practice, practice, and regularly engage in role-playing.
Role-playing is essential to help staff members with average communication skills raise their level of performance. In addition, it enables the team to determine how best to phrase questions and determine the most appropriate sequence for statements and questions. For example, business staff would carefully script where they place questions involving insurance or statements regarding the practice’s financial policy so as not to send un-intended messages to emergency patients.
What’s more, role-playing enables team members to pay close attention to their tone and how their words come across to others. Are they perceived as being warm and caring, yet still assertive? Do they seem tim-id and easily flustered or manipulated? Or might they appear abrupt and cold? Listening to responses and coaching each other on how to improve those responses ensures that team members are well prepared to handle emergency patient communication. Moreover, it en-ables the doctor to hear how staff would react in specific situations and to redirect that approach if it is inconsistent with practice protocol or policies.

LASTING IMPRESSION

After the treatment, escort patients to the front desk and impress upon them once again the importance of on-going care. Explain to the scheduling coordinator that the patient needs an ap-pointment for a comprehensive exam. Time should be set aside in the schedule to allow emergency patients to be scheduled for comprehensive exams as soon as possible, not in 6 weeks or 6 months, but preferably within the next week.
That evening or the next, the doctor follows up with a phone call to check on the patient and express the doctor and staff’s appreciation for the opportunity to provide care. A few days later the patient should receive a package in the mail with printed information about your practice and your services. Attached to that is a handwritten note from the doctor’s assistant that speaks specifically to the patient’s experience, expresses concern for his or her well-being, and indicates that the staff is looking forward to seeing the patient again for a comprehensive exam on the designated date. Encourage the patient to learn more about the office and the team by visiting the practice Web site, and urge the patient to call with any questions.

CONCLUSION

In stressful situations, people remember not necessarily what you did but rather how you made them feel. Nothing could be truer when caring for an emergency patient. Take steps to make sure you make your emergency patients feel good about your staff, your care, and their decision to choose your practice. Seize the teaching moments and watch your conversion rate increase significantly.

Sally McKenzie, certified management consultant, is a nationally known lecturer and author. She is CEO of McKenzie Management, which provides highly successful and proven management services to dentistry and has since 1980. McKenzie Management offers a full line of educational and management products, which are available on its Web site, mckenziemgmt.com. In addition, the company offers a vast array of practice enrichment programs and team training. Ms. McKenzie is the editor of the e-Management newsletter and The Dentist’s Network newsletter sent complimentary to practices nationwide. To subscribe, visit mckenziemgmt.com and thedentistsnetwork.net. Ms. McKenzie welcomes specific practice questions and can be reached toll free at (877) 777-6151 or at sallymck@mckenziemgmt.com.

Photo Illustration by Brian C. Green

BASICS

• You, the dentist, need at least 2 operatories designated just for your use.
• You need to have 2 dental assistants working with you. One should be an EFDA or equivalent of your state’s advanced assistant training. We will discuss how we use our EFDAs and CDAs using Pennsylvania’s rules and regulations.
• Our office has 3 dentists, 3 CDAs, and 4 EFDAs. We have trained our EFDAs to place and carve restorations to our office quality standards. This is very important. Just because someone has an EFDA certification does not mean he or she will be up to your particular standards. The same can be said for dentists. Each of us has our own standards for placing our restorations. An EFDA can be trained to place and carve restorations to your quality level or even better. If you don’t have confidence in your right-hand person, then you will have difficulty delegating procedures for him or her to perform. You may need a training period for a new EFDA to achieve the level of proficiency that meets your standards.

SCHEDULING

Figure 1. Restoration of tooth No. 13.	Figure 2. Crown prep and subsequent insert visit.
Figure 3. Three-tooth fixed bridge.	Figure 4. Bridge try-in and insert.

You now have 2 operatories, an EFDA trained to your standards, and a CDA trained to your standards. You are ready to begin a program for increased efficiency and productivity. The next critical part is scheduling. Each doctor has a level of comfort regarding which procedures he or she will delegate. I chose to do most anterior fillings, start to finish; I have chosen not to delegate these cosmetic procedures. What I do delegate on a regular basis are all posterior fillings (from the distal of canines to posterior). This includes all classes of fillings. If, on occasion, I feel a restoration will be extremely difficult to place for one reason or another, then I will schedule this patient with the doctor only.
Our EFDAs and CDAs can make beautiful temporary crowns and bridges. They also take preliminary impressions, counter model impressions, and bites. When we schedule our next appointments, we use a “V” to guide our appointment secretary. We place the time needed in units (each unit in our office is 10 minutes). So, if I want to do a direct composite restoration on tooth No. 13 comprising the disto-occlusal surfaces, it will be requested as indicated in Figure 1. This means 2 units with the doctor, then 2 units with the EFDA, or 3 units with the doctor to do the entire procedure if this is scheduled when an EFDA is not available.
Scheduling is very important, and your appointment secretary has to know the doctor’s and EFDA’s schedule so that appointments are made effectively. For a single crown prep and its subsequent insert visit, see Figures 2a and 2b. This designates a 4-unit preparation and impression with the doctor followed by a 3-unit temporary, bite, and countermodel impression with the EFDA or the CDA (who can also make temporary crowns). For a 3-tooth fixed bridge the appointment might appear as indicated in Figure 3. This is followed by a try-in (doctor only), followed by an insert (doctor only), as indicated in Figures 4a and 4b. Part of many dentists’ problem is allowing someone else to do this auxiliary work. Once you get over that psychological hump and know your assistants can do the work up to your standards (and sometimes better, since they may have much more time to fabricate this work), then you can feel very comfortable with this type of program.

GETTING THE PATIENT’S ACCEPTANCE

How do you make patients accept having assistants doing work where once only the dentist performed these tasks? Patients are expecting the doctor to do the work and are paying for the doctor to do the work. I simply say to my patient after I’ve prepared his or her tooth or teeth, “Mrs. Jones, I am now going to have Denise place the fillings for us, and I will be back in a few minutes to check and finish.” Then I get up and leave! That’s it. I am simple and direct, and I don’t make it a big deal. I tell them what is happening and that I will return, thus not abandoning them, and will be there to finish and check everything. If the patient has confidence in you, then he or she will have confidence in your EFDA and your judgment. My EFDA, Denise, will sit in my chair and ask the patient how he or she is doing, and then proceed. She may even tell the patient (if she thinks it is appropriate) that she is specially trained and certified to place these restorations. If you know you have a very difficult patient or a difficult procedure, then you may appoint to have the dentist do the entire procedure.

PERFORMING EFFICIENTLY

While your EFDA is placing these restorations, you are in the next operatory doing another procedure with your CDA. You are next door anesthetizing and prepping some teeth, and when you’re finished prepping, your EFDA (who should be finished next door) will then come in and restore the teeth that you have prepped.

CONCLUSION

Your overall personal productivity can increase substantially with this program. You have the added expense of an EFDA, the additional cost of a second operatory, and related overhead expenses. You can become more efficient and more profitable, and your dentistry can be more enjoyable and less stressful.

Dr. Hopenwasser has been a practicing dentist for more than 30 years and has lectured extensively on dental management. His practice management articles have been published in Dental Economics, Dental Management, Dentistry Today, and the Journal of the American Dental Association, and he has also written a chapter in the book Success Guide for New Dentists, published in 1990 by Anadem Publishing in Columbus, Ohio. He can be reached at (215) 493-4022 or howarddmd@aol.com.

Illustration by Cheryl Gloss

THE ORAL-SYSTEMIC CONNECTION

The effects of periodontal disease have long been understood with regard to the local deterioration of the periodontium. An abundance of new science is now instructing us, however,  that gingival inflammation from oral bacteria allows bacteria and their endotoxic by-products to enter the general circulation. These inflammatory cytokines up-regulate the liver to create C-reactive protein (CRP).
It is now agreed that this systemic inflammation has a negative effect on distant organs and tissues. Most notable is the impact on the cardiovascular system, diabetes stability, and pregnancy complications, among other problems. A good literature review finds that “systemic inflammation” is a common thread that connects a wide number of seemingly disparate medical conditions. This serves to underline the importance of our involvement in dentistry’s role in what has been dubbed The Oral-Systemic Connection.
Ironically, for years many have claimed oral microbiology was at the heart of the matter. With all double meanings intended, we now discover it is. Periodontal disease is a medical problem. It is why informed dentists are now measuring CRP, HbA1c levels, and blood lipids, and are working closely with physicians.
Since periodontal disease is now considered an independent risk factor for heart disease, and CRP is a stronger predictor of future coronary events than is cholesterol levels, conscientious dentists must get involved. They must refer periodontal patients to physicians for medical management of its comorbidities, and encourage and accept referrals from physicians who cannot diagnose or treat chronic oral infections.
As physicians become aware of this science and the potential legal scrutiny from liability risk-managers and malpractice attorneys that accompanies it, they will no longer overlook the teeth and gums on their way to the throat. Indeed, the world of medicine is changing for physicians as well as dentists.

SLEEP APNEA—DENTAL SLEEP MEDICINE

With the discovery that a positive pressure device worn over the nose provided a pneumatic splint to reinforce and hold open collapsing airways during sleep, physicians finally found a viable treatment for obstructive sleep apnea (OSA). However, due to the discomforting effects of a continuous positive airway pressure (CPAP) device, many people are intolerant of the therapy and cannot or will not cooperate with nightly treatment. Thus they remain at-risk for the significant co-morbidities of this condition, which notably include cardiovascular disease, hypertension, excessive sleepiness, accidents, lowered cognition, depression, etc.
Sleep medicine has now emerged as a viable subspecialty in medicine. Sleep clinics and labs are multiplying around the world. New practice parameters from within sleep medicine declare that oral appliances that hold the mandible forward and open the airway are indicated for mild to moderate obstructive sleep apnea. They are often the only hope that CPAP-intolerant patients have.
Sleep physicians are looking for qualified dentists trained in the discipline of dental sleep medicine. Physicians can’t manage occlusion, appliances, and TMJ problems. While the legal standard of care does not allow dentists to diagnose  sleep apnea or provide snoring appliances without proper testing for hidden sleep disorders, we can screen and refer patients for sleep evaluation, provide oral appliances where prescribed and preferred, and generally build a strong reciprocal referral relationship with physicians and sleep labs so that proper diagnosis happens and appliance titration can occur. Remember, oral appliances require healthy, restored, and stable teeth or implants in order to work.

HEADACHES—TMJ

An exceedingly large number of our population suffers from headaches. Patients generally turn first to medical doctors for relief. Physicians, ENTs, and neurologists do their best to treat sinus problems and vascular headaches, and attempt to rule out significant neurologic and organic problems.
However, a large percentage of the remaining head-ache pathology can be attributed to occlusion, posture, and TMJ/TMD problems. These problems lend themselves to dental therapies generally requiring a combination of orthodontics, splint therapy, and balancing the forces of occlusion and muscle tension. Physicians are beginning to understand that many of their headache patients need to be treated and managed by an informed dentist. As dentists work locally at the grass-roots level with physicians, they can educate and inform these healthcare providers on how to help manage headache patients successfully to everyone’s satisfaction and the patient’s delight.

MARKETPLACE FORCES DRIVING DENTAL MEDICINE

Dentists and physicians aren’t the only ones interested in this new paradigm. Corporate and media interests, medical insurance companies, attorneys and liability risk managers, and the natural interest of an aging population are all moving forward to drive demand for services and products.
To be sure, none of this is lost on the corporations who sell toothpaste and antimi-crobial products, or the major media outlets that have tapped into the new science and aging demographics to educate the public about the life-threatening dangers of untreated gum disease and sleep apnea. It is a “popular science” that is selling advertising, magazines, and news shows. Billions in supportive product sales are at stake.
Medical insurers are now paying for periodontal treatments during pregnancy as well as for those people with diagnosed cardiovascular disease and diabetes. This trend is sure to continue as they rightly conclude that their treatment costs decrease in populations of periodontally healthy subscribers. Risk managers and malpractice attorneys represent opposite ends of the coming medical/legal scrutiny that will have physicians meticulously aware of the need to refer medical patients to dentists for management of gum disease.
Over the past decade, new technology created the cosmetic dentistry phenomenon. Now we find modern science driving systemic inflammation to the forefront. It is now labeled “the silent killer.” Suddenly, in addition to looking good, baby boomers have a serious if not newfound interest in wellness and reducing risk factors. After all, they are 10 years closer to an “event” that can end their lives! The science of systemic inflammation now empowers dentists with new treatment offerings, creates new marketing strategies, and gives dentistry a place in the new playing field of dental medicine. With 3 out of 4 deaths being caused by cardiovascular disease and cancer, and numerous other medical problems attributable to related causes, dentists now play a pivotal role in saving lives and working with physicians to treat co-morbidities. This can be done by reducing systemic inflammation through effective treatment of periodontal disease and sleep apnea.
To make the point: gum disease is a chronic infection now linked to death. Sleep apnea kills, and headaches are life-altering. Indeed, dentistry has now entered the world of systemic medicine.

WHAT DENTISTS CAN DO

Most physicians do not have a dentist in their network to whom they refer patients or consult with. This is the opportunity that exists for dentists who want to be among the first in their community to get physician referrals. The implications of this positioning strategy from a marketing perspective are self-evident. However, it doesn’t happen by magic.
Dentists who successfully differentiate themselves and are timely with this in their community will make every effort to learn the underlying science and how to present themselves professionally. In this way both they and their message will demand attention, command respect, and build confidence. For dentists to present themselves professionally they must learn how to approach physicians. Announcing your presence with a business card and some common vocabulary isn’t enough to merit a welcome invitation to be part of a referral network. Professional marketing materials, newsletters, referral strategies, PowerPoint presentations, brochures, a patient report system, and referral aids are all part of a well-choreographed marketing effort that builds professional confidence and differentiates you from all others in the community vying for referrals.
A good strategy is to begin internally with existing patients by communicating with each patient’s physician about his or her oral health status, CRP and HbA1c blood results, sleep survey scores, and headache or face pain status. Dentists can offer a Physicians Resource Manual (part of the Physicians Referral and Education Program Marketing System found at MDReferrals.net) to the physician, or conduct a short inservice training for physicians with handouts, slide presentations or flip charts, and referral cards.
These are excellent opportunities to train physicians and their staff how to screen for periodontal disease in the medical office, how oral appliances can help sleep apnea, and how TMD therapy can resolve many headaches. Frequent informative newsletters sent to or “dripping” on the medical office remind the physician of the dentist’s expertise and knowledge.
While much of this is very laborious and time consuming, many of these strategies can be outsourced and are turnkey and “plug-n-play.” Training resources, marketing strategies, and communication materials can be secured, customized, and used quickly with minimal time requirements from the dental office. Practice management companies now offer coaching and expertise on building a productive periodontal therapy program offering modern, high-end, antimicrobial periodontal care, and how to manage the marketing behind the physician referrals program.

SAVING LIVES—ONE SMILE AT A TIME

This new era of dental medicine creates a new standard of care for all dentists to meet. The excellent care rendered in tens of thousands of dental offices around the world by knowledgeable dentists working with physicians will save millions of lives. The emerging science demands a new posture as we communicate to our patients and their physicians that gum inflammation kills. It demands that we not allow gingival bleeding to continue unchecked, that we control periodontal problems in pregnant women and people with heart disease, and that we work with physicians to manage the co-morbidities associated with systemic inflammation and sleep apnea.
Dentists who develop good referral relationships with physicians in their community will differentiate themselves and grow their practices. Each referral brings a mouth full of problems to fix. And while we are putting smiles back on these patients’ faces, we are helping them to enjoy more productive and healthy years with their children and grandchildren.
Building professional referral relationships is an idea whose time has come. The science demands it! Sharp dentists in every community will lead in this effort—and by so doing they will differentiate themselves and make dentistry (and themselves) look good in the process.

Dr. Ostler practices general dentistry in Richland, Wash. He is the author of The Physicians Marketing Handbook, and has created the Physicians Referral and Education Program (PREP) Marketing System. For additional information, or to read a special report on How to Market to, and Get Referrals From Physicians, visit MDReferrals.net. Dr. Ostler can be reached at (509) 946-6566 or
LeeOstler@MDReferrals.net.

Photograph by Nathan Zak and Cheryl Gloss

Albert Schweitzer postulated that all patients come with a doctor inside, ie, with more knowledge about their present condition than they realize. The role of the doctor in the enhanced model is to unleash that internal physician. The staff, too, must take on new roles in this patient-centered process. In the classic medical model, the assistant records data, remaining seen but not heard. In the enhanced process, the assistant is an active participant, making statements and asking questions that engage the patient. Because patients often turn to dental assistants to answer their questions and concerns, these essential team members must wholeheartedly support the process and, ideally, have experienced it themselves. When this occurs, the assistant can provide the most powerful answers to the patient’s questions and endorsement of the dentistry, namely: “I believe in it. I had it myself. And I paid for it.”

There are 5 key steps in creating an enhanced patient experience:

(1) Seeing Your Vision for Ideal Care
(2) Sharing That Vision With Team and Patients
(3) Implementing It
(4) Being Compensated Fairly
(5) Measuring Results

SEEING YOUR VISION FOR IDEAL CARE

Before trying to improve your patient’s experience, create a clear, compelling picture of the outcomes you want to achieve through this change. If your values are inconsistent, then you can unwittingly confuse your team and patients with mixed messages. For example, one dental practice sends new patients a letter noting, “Our mission is to provide patients with warm, caring, and exceptional service.” Yet the dentist rushes into the room 30 minutes late, immediately dons mask and gloves, and begins the clinical exam. Transforming the vision into a driving force in your practice requires more than simply citing it in a letter. Only when you, the leader, see the vision clearly can you act to make it a reality.

Your vision must include the following:

• the balance you seek between work and home
• the type of dentistry you want to do
• the ideal patient you strive to serve
• the qualities for which you want to become known in your community
• the role you expect your staff to play in realizing your vision.

SHARING THAT VISION WITH TEAM AND PATIENTS

After formulating your vision, share it with your staff, patients, and everyone you deal with. Your team members need to embrace the vision in order to create and manage systems to achieve it. You need to broadcast your message to them from their favorite radio station, WIIFM (What’s In It For Me?), so that they see actual benefits to themselves in helping you accomplish your vision. This does not mean dangling the carrot of a bonus before your team members if they promote ideal care and service. Seeing how the vision benefits everyone means that your team members fundamentally believe in the practice values, recognize and respect the quality of your dentistry, take pride in fully supporting recommended treatment, and link their own professional growth and fulfillment to the noble calling of your practice.
A key tool in sharing the vision is a written statement of it that the dentist creates. Some facilitators call this practice vision a “mission statement” because it represents the reasons for the team members to exist, the things they hope to accomplish, and the methods by which they will hold themselves accountable. In order to flesh out this proud document of your guiding principles and give it the force of reality, it must be more than a mental picture. A carefully crafted written statement will transform the vision into a tangible guideline for action. This important statement includes the following: who we are; why we came together; what we will accomplish together; whom we will serve; what we can expect from each other; and what we expect from those we serve.
The practice vision makes it possible to create team goals that support it. These goals will include the following:

• your business expectations, including the production levels required to support
  the practice
• the number of new patients needed
• the marketing strategy for communicating your unique image and finding your targeted patients.

The vision will vary by dentist. The vision of a dentist who desires a casual, fun-loving, home-like atmosphere to attract children and families in a small town will be different from one who seeks an adults only, aesthetic practice for urban professionals.
Sharing the vision with your patients means conveying a consistent message reflected in every patient encounter with the practice. The telephone discussion, marketing materials, patient education forms, and correspondences must all communicate how you wish to be seen. If your marketing materials state, “We cater to cowards,” then you will attract patients who fear the dentist. A statement such as, “We offer the highest quality of care for your long-term oral health,” targets those wanting complete dentistry. If your vision is to give comprehensive care, then sharing it may be as simple as inviting those patients who already know and trust you to experience a comprehensive evaluation. Going beyond disease control and becoming partners in their dental health is what these patients may well be waiting for.

IMPLEMENTING IT

After you create and share your vision, the next step is, à la the Nike slogan, “Just do it.” Because you have been trained to observe and collect clinical data, the more challenging part of “just do it” lies in communicating what you see in terms of the patient’s values, needs, and concerns. For example, you may discuss the need for a crown in terms of how it will allow the patient to eat his or her favorite food without discomfort, improve the person’s smile, or relieve pain, depending on that individual’s circumstances, temperament, and objectives.
As you conduct the exam, communicate what you see by asking questions: How long has this been bleeding? How long has pus been coming out here? How long has this tooth been loose? Show your patients what you are seeing and observe their eyes, facial expressions, and reactions as you draw them into the evaluation process. The enhanced experience is one of dialog rather than monolog. The dentist stops at something noteworthy, withdraws instruments from the patient’s mouth for a moment, and invites the patient to comment. In the enhanced model, the doctor shows a heightened awareness of the patient, not just the patient’s dental needs. One skill for doing this is listening to patients with wonderment and curiosity, following the dictum, “When I speak, I voice what I already know. When I listen, I learn.” This heightened level of communication with patients is far more significant than a 5% courtesy adjustment, or any other mechanical device, in their understanding and embracing ideal oral health.
In order to implement your new approach without undue stress and confusion, begin gradually. Schedule a few enhanced exams per month, then set goals to increase their number incrementally. Throughout the implementation process, meet with your staff to identify successes, challenges, and modifications needed.

BEING COMPENSATED FAIRLY

If practicing your best dentistry does not compensate appropriately, then you will feel that your vision is impractical, become discouraged, and give up your dream. This is why being profitable is essential to your success.
Proper compensation rests on setting appropriate fees. To do this, you need to know your numbers, ie, the fixed and variable costs—lab, dental supply, and general and administrative costs—of providing the treatment, as well as the compensation you need to be fulfilled personally. It is all too common to find dentists who spend copious amounts of time with their patients, invest in technology, and create an ideal experience for the patient, yet charge fees that are not in sync with those expenses. Exceptional practices need to set commensurate fees and be comfortable in explaining them to patients. When a shopper says, “Dr. Smith charges less for the same procedure,” your answer might be something like this: “I can’t speak for Dr. Smith. But we know our fees represent the high level of care and service we deliver and the quality of materials we use for effective, long-lasting restorations. Our patients appreciate our care and gladly pay the fees that permit us to provide it.”
Patients will feel the fee is appropriate if (1) they like and trust you, (2) they are committed to the treatment presented, and (3) you can make that treatment affordable through flexible financial arrangements. You gain the patient’s trust and commitment through the comprehensive evaluation because this process uncovers the patient’s needs, desires, and values and allows you to present treatment in terms of them. Instead of focusing on a concern for cost, emphasize how appropriate treatment will address the patient’s real wishes for life—like the ability to go to dinner with a beloved grandchild and enjoy eating favorite foods with complete comfort. This puts the dentistry into the patient’s life and makes a solution to the problem priceless.
It is also vitally important that doctors be willing to quote fees and feel comfortable in doing so. This means you may have to work on gaining that comfort. When you are 2 minutes into a treatment discussion and the patient asks how much it will cost, you must reply. Look the person in the eye, quote the “based-on-everything-I-know-now-it-will-not-exceed” fee, and then continue when the patient is ready to move on. If you avoid answering the question and pass this task to a staff member, then it may seem as though you don’t know the fee or you lack confidence in the appropriateness of the dentistry or your ability to provide it. If the patient senses that you feel uncomfortable, then he or she will have difficulty accepting the treatment, let alone deciding how to pay for it. A comprehensive evaluation provides you with the necessary information to feel confident in the plan you have presented.
After gaining commitment, a final barrier often is the cost. Many patients are not concerned with the actual cost of the treatment but with the inability to write a check for the lump sum right then. This can be resolved by continuing to understand the patient’s circumstances, temperament, and objectives, and arriving at payment options that are both practical for the patient and financially sound for the practice.

MEASURING RESULTS

In order to ensure that your evaluations are effective and meeting your patients’ needs, you need to keep an ongoing statistical evaluation of results. This includes knowing, and thereby controlling, the following factors:

• your ideal patient profile
• the size of your active patient base
• the amount of delayed treatment in your base
• the number of new patients you are seeing
• the percentage of new patients that meet your ideal patient profile
• the percentage of ideal treatment presented that was accepted as compared to your goal.

Before marketing for new patients, answer the question, “How many are enough?” If you are currently seeing a large number of new patients who do not meet your ideal profile, then you must consider why those patients are attracted to your practice and redesign your marketing efforts appropriately. If you have sufficient patients of record and dental treatment needed by them, then you can attract fewer new patients, focusing instead on bringing your current patients to a new understanding of their dental condition. If your patients are accepting 100% of the treatment you are presenting, then analyze if you are shying away from offering comprehensive care for fear that patients will scoff at the cost or leave your practice. Numbers give a wealth of information to assist you and your team in pinpointing problems, modifying strategies and procedures, improving results, and ultimately attaining your practice vision.

CONCLUSION

Ascend the 5 steps described in this article and you will be well on your way to developing a comprehensive evaluation. In doing so, you will enhance each patient’s understanding of his or her health and needs, raise your level of patient care, fully meet your patients’ long-term oral health needs, and improve your practice. You will be the best that you can be.

Ms. Morgan is CEO and lead trainer of Pride Institute, the firm helping dentists master the business side of their practices. For 2 decades Ms. Morgan has consulted one-on-one with hundreds of doctors to end cash-flow crises and to improve practice management. She is a lively speaker at major dental conferences and conducts seminars and workshops for dentists and teams to turn average or underperforming practices into satisfying and successful ones. For more information on leadership and management study, continuing education courses, and training materials, or to reach the author, call Pride Institute at (800) 925-2600 or visit prideinstitute.com.

Dr. DeWood is clinical director of the Pankey Institute. He and Ms. Morgan are co-teaching a 2-day seminar, “New-Patient Exam,” which aids dentists in implementing the enhanced new-patient model in their practices. For cities and dates and to reserve your place in this program, call Pride Institute at (800) 925-2600 or visit the Web site prideinstitute.com. To reach Dr. DeWood, call (305) 428-5500 or e-mail him at gdewood@pankey.org.

Two features provide a diagnosis/prognosis leading to a treatment plan. Caries activity describes the process (demineralization or remineralization) on an individual tooth surface,^11-13 while caries risk describes the status of the whole patient, defined as the likelihood of the patient getting a new cavitation (Tables 1 and 2). Combining these 2 features provides the basis for 7 groups of patients that we will discuss. Patients receive treatment using a medical model (Table 3) consisting of 4 steps:

(1) bacteria are controlled by using restorations (surgical approach/incision and drainage) and medications (chemotherapeutic combination of chlorhexidine, fluoride varnish, and xylitol gum); (2) risk levels of at-risk patients are reduced; (3) active sites are reversed by remineralization; (4) long-term follow-up and maintenance are performed at home and in the dental office.

TREATMENT BY RISK/ACTIVITY STATUS

We have now finished our quick review of the medical model for the treatment of dental caries. For a detailed look at the medical model and for references please refer to Part 1, which appeared in the February 2007 issue of Dentistry Today. Remember that the steps all flow together. Many of the individual parts can be done simultaneously.
So, how do we use this model to treat Mrs. Jones? The medical model gives us an overall conceptual framework. For any given patient, however, what is needed is a diagnosis/prognosis that can place her into a treatment group. By combining the 3 risk levels (Table 1) with the 2 caries activity states (Table 2) we get our 7 diagnosis/prognosis groups, which then become our 7 treatment groups. Each of these treatment groups has its own unique protocol. First let’s investigate the 7 treatment groups, which are listed in the left column of Table 4.First, there is the low-risk level (LR). This group will always be inactive.
Next, there is the moderate-risk level, which can be either active or inactive depending on the presence or lack of rough, chalky white spots. There are thus 2 moderate-risk treatment groups. In the presence of orthodontic brackets or xerostomia (moderate risk), but no rough, chalky white spots (activity), a patient would be classified as a moderate-risk inactive (MRI). If rough, chalky white spots are present, ie, a patient presents with activity, this patient would be classified as moderate-risk active (MRA). The MRA patient can present without any obvious risk factors. Upon closer investigation one or more risk factors can usually be identified.
We now come to the high-risk level, which can be broken down into 4 treatment groups. Remember that the high-risk patient has at least one cavitated lesion. We will assume in this article that the cavitated lesion is active. This gives us the high-risk active (HRA) category. If in addition to at least one cavity, a patient presents with rough, chalky white spots elsewhere, this patient will need more treatment than the high-risk active category. We will need to address the rough, chalky white spots in addition to any cavitations. Therefore, we have designated a second high-risk active category named high-risk active/active (HRA/A). We use the term active/active because of the 2 activities. The cavitation is active, and the rough, chalky white spot is active. There is a sixth category, high-risk inactive (HRI), which is for patients who have gone through the protocol and are not active any longer but need continued risk-reducing therapy. Patients are kept in this category for 3 years. Finally, for patients who present with 8 or more cavitated teeth, we have a category designated as very high risk (VHR).
As noted earlier, each of these treatment groups has its own unique protocol. By using the medical model and a treatment protocol table, we can decide upon the treatment for our Mrs. Jones.
Let’s look at the protocol. The column on the left in Table 4 lists the 7 treatment groups. The top row lists all of the individual parts of the treatment protocol. To identify which parts apply to any individual treatment group, identify the treatment group on the left column. Then follow along the row to the right and you will see the relevant protocol for that treatment group. A blank space means we do not use that treatment for that group. Numerals are used to represent the number of times treatment is repeated or the number of months involved. The details of the listed treatments have been covered in Part 1.

The actions listed on the top row of Table 4 are as follows: the first 3 items are fillings, temporary crowns, and sealants (surgical treatment). A “+” indicates that we do the listed treatment, while a blank box indicates that we do not apply that treatment. As we continue to the right, the next item listed is the number of fluoride varnishes applied when we first use this treatment (1 to 3 applications). The next item is the number of months that chlorhexidine rinse is used. Next is whether xylitol gum or GC America’s MI Paste or MI Paste Plus (fluoride added) is used. Continuing to the right, the next item shows in which month of the series of chlorhexidine treatments the CRT bacteria test (Ivoclar Vivadent) is administered. In the next column to the right the continuing care or recall interval in months is listed, followed by whether a fluoride varnish is done at that continuing care visit. Finally, we list the home fluoride protocol.
As you can see from Table 4, the low-risk patient requires a 6-month continuing care interval and regular over-the-counter toothpaste at 1,000 ppm. All this group needs is step 4 of the medical model. Remember, this is most of the patients in the average dental office.
The moderate-risk inactive group is treated with xylitol gum, MI Paste, or MI Paste Plus, a 6-month continuing care interval at which a fluoride varnish is applied, and 5,000-ppm toothpaste with 230-ppm rinses at home. This group receives care with step 2 and step 4 of the medical model. While this group does have risk factors, we have not as yet detected actual disease. This is, therefore, a preventive therapy group.
The moderate-risk active group is treated chemotherapeutically for the active disease process. After an initial fluoride varnish is applied, chlorhexidine is used once a day for one week per month for 6 months, and xylitol gum is used. You will recall this is step 1-B of the medical model (chemotherapeutic antimicrobial treatment). Step 1-A, surgical antimicrobial therapy (fillings), is unnecessary here as there are no cavitations. Steps 2, 3, and 4 follow. In   Table 4 we see MI Paste (or MI Paste Plus) used for re-mineralization and the CRT test administered in month number 6. Continuing care/recall visits are every 3 months with a fluoride varnish treatment at each visit. Home care again consists of 5,000-ppm b.i.d. toothpaste and 230-ppm oral rinse during the day.
Recall that high-risk patients have at least one cavitation. As such they will need the entire medical model. High-risk active patients have at least one cavitation but no rough, chalky white spots. Beginning with surgical antimicrobial treatment (restorations) they are treated with fillings, temporary crowns, and sealants as needed. Since they have no active rough, chalky white spots we apply only one fluoride varnish at the first round of treatment. We use chlorhexidine for 6 months and xylitol gum to round out the chemotherapeutic antimicrobial treatment. Steps 2 and 4 follow. Notice that without the chalky white spots we do not need remineralization therapy. In Table 4 the rest of treatment can be seen as MI Paste (or MI Paste Plus), CRT test in month number 6, continuing care interval of 6 months, and a fluoride varnish at that continuing care visit. Home fluoride is as noted above.
High-risk active/active patients, in addition to at least one cavitated tooth, present with at least one rough, chalky white spot. They differ from high-risk active patients in that they do need remineralization therapy. They get the entire medical model. Looking at Table 4 one can see that they differ from high-risk active patients in only 2 respects. They get 3 fluoride varnishes at the first round and the continuing care interval is 3 months.
Let’s move to the very high-risk group. They get the entire medical model, intensified. Due to the risk of increased bio burden, all surfaces are sealed, including those with amalgams. Three fluoride varnishes are given in the first round. Chlorhexidine is used for 12 months, and the CRT test is administered at the end of that period of time. Continuing care is 3 months with fluoride varnish applied. Home fluoride is 5,000-ppm paste in a tray once a day and by toothbrush once a day in addition to rinses. Due to the high risk, a custom fluoride tray is used to ensure the best exposure of the surfaces of the teeth to fluoride.
Finally let’s look at the high-risk inactive group. This is the only high-risk group that does not have cavitations. This is a special group for patients who have been high risk and have gone through initial therapy and are presently inactive. They are, however, at increased risk for several years due to their history. With this group we want to prevent the return of the disease process. Notice that their protocol is exactly the same as the moderate- risk inactive group. This points out something very important in the new paradigm of caries management. We must take care to use precise terminology. We are confusing prevention and therapy. Prevention is before disease occurs. Therapy is after disease occurs. There has been a major shift.
In the past, prevention referred to preventing cavitations. Treatment consisted only of treating existing cavitations surgically (restorations). Now, we are preventing demineralization (fluoride, MI Paste or MI Paste Plus, xylitol). We are also treating existing demineralization chemotherapeutically, ie, by remineralization (fluoride, chlorhexidine, MI Paste or MI Paste Plus, xylitol). After remineralization or surgery, we once again try to prevent further demineralization (fluoride, MI Paste or MI Paste Plus, xylitol).
Notice that the medications used are virtually the same regardless of the purpose for which they are being used. This can introduce some confusion in our terminology. We are not remineralizing using preventive modalities. We are remineralizing using therapeutic modalities (chemo-therapeutics), even though 3 out of the 4 medicines are also used for prevention purposes. It is important to understand we have moved caries treatment to an earlier stage. We are no longer focused on cavitation; we are focused on demineralization as the key factor. We want to prevent demineralization in the first place (moderate-risk inactive patient). If demineralization (ie, the caries process) begins, then we treat the demineralization with remineralization and risk-reduction chemotherapeutics. If demineralization has led to cavitation, then we add restorative therapy. Then we prevent redemineralization (high-risk inactive patient). Now that is a paradigm shift!

CONCLUSION

This paradigm builds on the success the dental profession has had in the past. More importantly, it enables us to improve our understanding of the caries disease process. With this new understanding we are focusing on prevention and treatment of caries at an earlier stage than ever before. We’ve also developed protocols enabling us to treat higher risk patients effectively. These protocols can be implemented in any dental practice.

References

Dr. Steinberg received his DDS degree from the University of Illinois College of Dentistry. He completed a general practice residency at the University of Illinois and West Side Veterans Administration hospitals. An externship in geriatric dentistry was completed at the Long Island Jewish Hospital in New York. Dr. Steinberg practiced dentistry in Illinois from 1982 to 2005. He is currently a clinical consultant for the University of Illinois College of Dentistry Continuing Education Online course on dental caries. He was director of the Ark Dental Clinics in Chicago and currently serves on that organization’s board of directors. He is available to speak to groups large and small. He can be reached at (847) 800-5918, ssov@comcast.net, or by visiting cariesspeaker.com.

Disclosure: Dr. Steinberg has a paid lecture sponsorship with GC Am