We’ve all had it happen. Patients who have been away for a while finally make an appointment, and their mouth is a mess. They have multiple teeth in need of restoration, periodontal disease has ravaged their gums, their health is in danger, and their smile and self-esteem are in tatters.
It’s a tragedy. And as our understanding of oral bacterial colonies improves, it’s fast becoming a preventable one. Recent advances in our understanding of biofilms, the interplay between different types of bacteria, and our patients’ unique genetics all affect their risks for cavitation, periodontal disease, and systemic diseases.
It’s time to make true prevention, not simply prophylactic cleanings and inevitable restorations, a part of your practice. Shifting to a prevention-focused system of appointment scheduling means that you’ll have to change how you structure appointments, what services you’ll offer, and how you train your team. These changes are worth the effort, because you’ll have happier, healthier patients and a productive practice that does good by doing good.
What’s Coming Down the Pike
Dentistry is on the cusp of a major change in how we approach health and treatment. For more than a century, we’ve basically been in the cleaning and restoration business, even with the introduction of fluoride. A typical dental appointment includes x-rays, a cleaning, some fluoride, and then about 5 minutes as the dentist checks for oral cancer, looks at any trouble spots flagged by the hygienist, and makes a recommendation either for restorative work or a checkup in 6 months’ time.
We’re just playing catchup. We can’t spot cavities before they happen. We fix them when we see them, and then send our patients on their way.
The caries management by risk assessment (CAMBRA) protocol has given us a few new tools. If we see patients presenting with cavities, we can manage their oral bacteria with an eye toward prevention. We can prescribe products that can eliminate the damaging bacteria and lifestyle changes that will prevent reinfection.
We’re also making great strides in understanding how the particular mix of bacterial colonies in the mouth can affect a patient’s risk of periodontal disease. Researchers have discovered that, in the presence of Porphyromonas gingivalis, other oral bacteria colonies change their behaviors and transform from benign to pathogenic. These changes result in the inflammation that eventually leads to pockets, irreversible damage to the gums, and tooth and bone loss.
Current treatments for periodontal disease are basically aimed at reversing or preventing damage once the disease is already in progress. However, researchers are working to develop a vaccine that would protect against P gingivalis infection, and there is some evidence that C3 inhibitors could halt and reverse the inflammatory process in the gums. So, in the future, we may have tools to prevent periodontal disease in the same way that we’re finally getting the tools to prevent dental caries.
This will change how we structure appointments, since we’ll have to take the time to do more complex risk assessment and analysis of oral microbiomes for our patients. On the other hand, once we can control for these bacterial risk factors, many of our patients will have easier exams and cleanings.
Scheduling for Productive Prevention
Shifting our focus from cleanup dentistry to preventative dentistry requires a change in how we structure our appointments. Currently, most of the typical appointment is spent on prophylactic cleanings. Our less complicated patients may only see the dentist, rather than a hygienist, for about 8 minutes every 6 months. In many practices, it’s become almost like a cameo role in a movie. You show up, smile, wave, and glide out and into the next bay where you repeat the meet and greet.
If you want to schedule for productive prevention, you’ll need to initially schedule a little bit more time with each patient, at least in the beginning. That’s because productive prevention doesn’t just represent a major paradigm shift for you and your staff. It will also be new and unexpected for your patients.
Imagine you go into your mechanic for your regular oil change and tuneup, and he says, “Look, I’ve been doing oil changes and tuneups for years. I’ve replaced belts and fans and lights and whatever needed replacing. But it turns out that if I use a different oil, I may be able to reduce your long-term maintenance costs. And many other mechanics already use this oil. It’s been out on the market for a while and all the new mechanics in the field learned about it in training.”
You’d be a little annoyed, wouldn’t you? You just got a new fuel pump 3 months ago, and now he’s telling you that maybe he could have prevented that? If he doesn’t take the time to listen to your questions and address your concerns, you may be on your way to a new mechanic.
You need to have a conversation with your patients about real prevention of pathogenic oral infections, and you need to have it at the start of their next appointments, not at the end. If you’re switching to the CAMBRA order, you’ll also need to gather more information on each patient so that you can accurately access risk and plan appropriate treatments.
For the first appointment for existing patients under the new treatment model and for any new patients that join the practice after the switch, you’ll need to schedule one, slightly longer, more-in depth appointment that includes:
- An introduction by you, the dentist, explaining why your practice is changing the treatment approach format to better serve patients;
- A complete medical history focusing especially on risk factors related to caries, P gingivalis infection, and other aspects of oral health—for instance, medications that could cause xerostomia, heart-health factors, diabetes, osteoporosis, auto-immune disorders, inflammatory disorders, or impaired immune function;
- Testing to determine the composition of oral cultures, which could be a DNA test, a bioluminescence test, or some combination of tests;
- A hygiene exam followed by the dental exam;
- Discussion of a treatment plan based on risk factors and current damage;
- The prophylactic cleaning.
The big difference with the new exam structure is that you’ll have to restructure your personal time. You’ll be seeing each patient twice, instead of once, and your total time with patients will initially be quite a bit longer. Your hygiene team will also have to readjust, because the old pattern of imaging/cleaning/exam has been put in a different order.
The main benefit of this new schedule is that it will allow you to focus more on patient health and provide preventative services. After the first 6 months, most of your regular patients will have gone through the new intake procedure and will understand your new focus on treating the causes of caries and periodontal disease rather than just managing symptoms.
The question is, won’t this new approach ultimately harm your practice and make it harder to earn a living?
One Dentist’s Story
Kim Kutsch, DMD, of Albany, Oregon, has firsthand experience with this dilemma:
When I started my CAMBRA journey 17 years ago, I thought I might be putting myself out of business, but I was headed to retirement anyway and CAMBRA wasn’t something I could choose to not do. I’ve always wanted to do my best for my patients, and it was clear to me that what I had been trained to do wasn’t working. CAMBRA really represented better care. So I took the leap and decided to follow my conscience.
It took a couple of years in my practice to really implement this philosophy completely, but then I experienced an unanticipated outcome. Instead of getting less busy, my schedule got busier. And I was consistently restoring larger and more complex treatment plans. It took me a while to understand what was going on. It didn’t come as a gradual realization. It came as an abrupt moment of clarity.
I had a patient spontaneously ask if she could still have the 5-unit bridge I had finally given up proposing to her years earlier. In my surprise, I asked why she suddenly wanted it now. She explained to me that because of CAMBRA, she was now healthy and knew how to stay cavity free for the rest of her life. She was confident now that the bridge would last, and it wouldn’t be a waste of money. Immediately I got it. Patients don’t really start buying dentistry until they stop getting cavities. And now I don’t blame them.
This patient wasn’t unique. Numerous patients have elected full mouth reconstruction after I got them healthy with CAMBRA. One patient’s case totaled more than $50,000. And the great news is he was at extreme risk for decay before, and he has maintained a healthy decay-free mouth for 7 years and has an awesome smile. It changed his life!
In fact, because of CAMBRA, my practice has never been more successful. My elective procedure rate has increased, and I am providing the best care possible. It’s a win-win, but it requires a leap of faith.
When you make prevention your practice’s number one priority, you help your patients regain their health. When they’ve regained their health, they’re more willing to take an active interest in their teeth and their treatment, because you haven’t just given them health. You’ve given them hope. They appreciate you, because they realize that you see them as people who deserve better lives, not simply as numbers on a ledger.
Those first steps that you took toward scheduling for productive prevention soon cascade, and you have a thriving practice that makes real, noticeable improvements in the lives of your patients.
Khan SA, Kong EF, Meiller TF, Jabra-Rizk MA, Periodontal Diseases: Bug Induced, Host Promoted, PLOS Pathogens, July 30, 2015.
O-Brien-Simpson NM, et al, A Therapeutic Porphyromonas gingivalis Gingipain Vaccine Induces Neutralising IgG1 Antibodies That Protect Against Experimental Periodontitis, NPJ Vaccines, December 1, 2016.
Maekawa T, et al, Inhibition of Pre-existing Natural Periodontitis in Non-human Primates by a Locally Administered Peptide Inhibitor of Complement C3, J Clin Periodontol, March 3, 2016.
Dr. Baird practices comprehensive treatment planning and full-mouth restorative care in the Dallas/Fort Worth area. In 1990 he established the Texas Centers for Implant Dentistry, a mobile practice that allowed him to work with more than 25 doctors in the region. Recognizing his ability to help other dentists achieve the same success, in 2004 he founded the Productive Dentist Academy and partnered with Vicki McManus Peterson, RDH, in 2005. He is also the founder of Comprehensive Finance. He can be reached at email@example.com.
Dr. Kutsch completed his DMD at the University of Oregon School of Dentistry. He is a past president of the Academy of Laser Dentistry and the World Congress of Minimally Invasive Dentistry. He has also served on the board of directors for the World Clinical Laser Institute and the American Academy of Cosmetic Dentistry. He serves as CEO of Oral BioTech. As a clinician, he is a graduate and mentor in the prestigious Kois Center and maintains a private practice in Albany, Oregon. He can be reached at firstname.lastname@example.org.
Ms. McManus Peterson, RDH, is the cofounder of the Productive Dentist Academy, a public speaker, and the owner of a dental practice in Wisconsin. She is the collaborative author of FUNdamentals of Outstanding Dental Teams and recently published her latest book, Frustration: The Breakfast of Champions. She also is an expert in the industry regarding leadership communication, rock solid hygiene strategies, and effective dental practice marketing. She can be reached at email@example.com.