Is adopting a CAMBRA approach to treatment doing yourself out of business? By Andy Kollmorgen
No self-respecting dentist would skimp on preventative treatment just to make sure patients have a reason to come back and spend more money. Well, at least not deliberately. But adopting a Caries Management by Risk Assessment (CAMBRA) approach, regarding as international best practice these days, inherently involves trying to reduce the need for invasive procedures. The goal is to prevent cavities, not fill them. Are Australian dentists who are embracing CAMBRA putting their economic lives at risk? The consensus among the seasoned practitioners we spoke to is no, but putting the onus of prevention on patients does mean changing the way you practise dentistry.
The problem with CAMBRA from a business standpoint is that much of it takes place outside the dental surgery, where billable services are few and far between. The patient management and monitoring side of the philosophy includes a strong emphasis on oral hygiene, proper teeth brushing, plaque control and diet, especially the reduction of sugar. In short, the approach is a lot more holistic than most Australian patients are used to. But with the growing emphasis on holistic health in the medical profession as a whole, could Australian dental culture be changing with the times? It turns out the idea of a patient-led approach to prevention has been kicking around for a while. Five years ago the Australian Dental Journal published a study on the idea of applying a Caries Management System to Australian dentistry and laid out a no-nonsense case for its importance: “The challenge today is to develop a non-invasive model of practice that will sustain a low level of primary caries experience in the younger generation and reduce risk of caries experience in the older generations.” And some elements of CAMBRA have long been in play, mainly in the form of fluoridated water and toothpaste.
The concept is also alive in the halls of academia. The principles of CAMBRA are currently being put to the test through a six-year trial at the University of Sydney started in 2009 and funded by the National Health and Medical Research Council. The trial, which also uses the term Caries Management System, is tracking the progress of 920 patients under the guidance of Sydney University Associate Professor Wendell Evans, who reported a 31 per cent decline in the need for invasive treatments at the trial’s halfway point in July 2011.
Achieving the positive results didn’t require extreme measures—trial subjects showed big improvements just from brushing their teeth twice daily with a fluoride toothpaste and receiving a fluoride application during regular dental visits. “Simple non-invasive practise can halt the decay process completely,” A/Prof Evans said. Participating dentists also got some hands-on help in how the system works.
“We trained dentists in how to coach their patients on removal of the daily plaque build-up. We also guided them on how to apply professional-strength topical fluoride systematically on tooth surfaces to promote the restoration of lost mineral and tooth hardening, and how to monitor the outcome.”
But could it really be the beginning of the end of the drill-and-fill era? After all, preventative dental care has shallow roots in Australia. Calling the dentist when you have a problem, as opposed to making an appointment to prevent one, has long been the default option.
Bite talked to a few seasoned pros who advertise themselves as preventative dentists and got some interesting responses. None of the practitioners we spoke to were practising CAMBRA in the strictly scientific sense, but they drew from its principles to come up with a system that works for their respective practices.
Dr Adel Zayed, a principal of the Monash Dental Group in the Melbourne suburb of Clayton who’s been practising for 27 years, told us that drilling the fundamentals of oral hygiene into patients’ heads is the best way to avoid having to drill into their teeth. Ideally, the lessons will be passed down.
“A main focus for us is to educate young parents about good oral hygiene—basic things like brushing, flossing and, when appropriate, applying a topical fluoride treatment. The benefits of these simple steps can be quite profound. We’ve found that the quality of a patient’s oral health has a lot to do with the family environment.” Dr Zayed also offers everyday advice, such as choosing tap water over bottled water (since it’s fluoridated) and applying the right kind of tooth mousse.
Is showing patients how to look after themselves chipping away at the bottom line? “It’s really the opposite,” Zayed says. “When you can get your patients into good prevention programs, the scope of dentistry that you practise might change. But there will still be lots of work. In general, there will be less caries and cavities, but other aspects of dentistry will flourish.”
Dr Stephen Lising, a former chair of the ACT branch of the ADA and currently the owner of Preventive Dental Care in the ACT suburb of Deakin, says much the same thing. He’s been practising for 15 years, but the principles of prevention for this particular practice go back to the 1970s, when the first hygienists had to be imported from America due to a lack of local expertise. For CAMBRA candidates, a bit of tough love can go a long way.
“We tell patients why they’re in a high-risk category, and then structure a home-maintenance protocol. It does take some effort to teach them. We use a camera to show patients’ what’s in their mouths so they can see for themselves.
Dr Lising also scoffs at the notion that teaching patients to take their oral health seriously might be a bad business move. In his view, practitioners who may not focus as much on prevention as they should, unconsciously or otherwise, are probably stuck in the past. “Some old-school dentists might have that attitude, but I’d say the majority of dentists don’t take that approach. The main thing our hygienists are trying to prevent is periodontal disease. And that means visits at least every six months. These days I’m mostly dealing with cracked teeth and caps. Seeing a lot less caries doesn’t mean the practice is less busy.”
