Targeted Prevention: The Power of Thorough Risk Assessment

I would like to think that mentally we make these assessments every day. But when it comes to putting it down on a form, there's a mental roadblock that says, I don't have time for that. But if you knew that this one assessment would yield patient acceptance, insurance reimbursement, and then patient trust, and also just more production for you, you do have time to do it, right? Welcome to the Phil Klein Dental Podcast. In today's episode, we're spotlighting the dental hygienist as more than just a provider of cleanings, but as a true prevention specialist. That means shifting from a reactive mindset to a proactive one, taking the time to perform comprehensive risk assessments on almost every patient. Why? Because identifying risk factors early is the key to building targeted effective treatment plans that can help stop disease before it leads into much more serious and expensive problems. We'll break down the major risk categories you should be looking for, explore the stages of demineralization and cavitation, and highlight the most effective products for treating each phase. Plus, towards the back end of the episode, we'll dive into an often overlooked part of preventive care. orthodontics, specifically why every hygienist should have a solid understanding of clear aligner therapy and how correcting misaligned teeth can save your patients from a long list of oral health issues and significant treatment costs down the line. Our guest today is Alicia Murria. She's an RDH with a master's in dental hygiene. She's a member of the hygiene faculty with Align Technology, associate hygiene productivity coach with Inspired Hygiene, and alumna at Forsyth School of Dental Hygiene. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Alicia, it's a pleasure to have you on the show. Thank you so much for having me, Dr. Klein. Yeah, yeah. We're really happy to have you on. And I've listened to some of your webinars and... podcasts and stuff. And I'm in total alignment with your ideology as far as having hygienists step up to really becoming more on the diagnostic side and understanding the root cause of things. And it's the whole philosophy of what you teach is just really phenomenal. I think it's going to be quite an inspiring journey you have for the people that you're mentoring. We've all heard the phrase a million times, an ounce of prevention is worth a pound of cure. And this applies to so many things in life, especially our health. So when it comes to our oral health, Alicia, you are a firm believer that it's more than just treating the problem. It's doing everything we can to prevent it before it actually materializes, which I agree with. So to meet this challenge, you often talk about a prevention specialist. Tell us what that means. Prevention specialists is really a mindset in that you're focused on being more proactive than you are being reactive. Now, obviously, as a prevention specialist, you have to be reactive at a point, but a prevention specialist mindset is looking for risk. Educating the patient on the risk and offering options to the patient based on the patient's risk. It should really be the options that we're providing to the patients in terms of a prevention specialist mindset should truly be commensurate with the patient's risk of disease. But all things considered, the prevention specialist mindset I'm hoping is a wave that catches on and individuals see themselves as a prevention specialist and they start to look for opportunities to engage their patients prior. to drill their patients. So every dental hygienist in your mind should be a prevention specialist then? Every dental hygienist by nature is a prevention specialist, but this is a call to action for all dental professionals to see themselves as prevention specialists. Okay, so if I'm a dental hygienist and I say to you, well, Alicia, I do profis, I scale and root plane, I see eight to 10 patients a day, I do some patient education for those that want to listen to me. Am I not a prevention specialist or do I need to go much further? Oh, that's a great question. And my follow-up question to this dihygienist would be... How much time do you set aside for your assessments? And if this hygienist tells me that they just do what is on the schedule, then I would challenge them to have a different line of thinking that includes the prevention specialist mindset. And that would be to outline assessments based on the patient's demographic that will help us to understand their risk for not only periodontal disease, but also their risk for decay. One of my questions later on in this episode was about caries risk assessment, but we're talking about it now. So maybe we can approach it a little bit now. When you talk about an assessment, a formal assessment is something that's documented, right? Yes. Do you think that most hygienists are doing formal assessments where they're documenting the risk before they actually start getting into the treatment of that patient where they're billing things out? So I feel like... Back in the day, we had carries risk assessments or Canberra risk assessments that outlined to us, you know, where the patient was in terms of their carries risk. Then that transformed into our decodes that tells insurance companies what our patient's carries risk is. You have D0601, D0602, and D0603 that will outline. If the patient is low, moderate or high risk for decay. If we were to attach these claims to the patient's treatment, which would be potentially fluoride, then the insurance company would then know that. We have a recognized opportunity to treat this patient where they are in terms of risk. The same is true with periodontal disease. You really want to treat the patient commensurate with where their disease level is. So for instance, if you have a patient who is stage one, grade A, you wouldn't provide them with the same level of therapy as you would a patient who's stage four, grade C, right? And the same is true in terms of decay. There's a patient who is at high risk for decay. You wouldn't give them the same recommendations as you would a patient who's low risk for decay. And how many dental hygienists, like percentage wise, do you think are utilizing this form of assessment where they're categorizing the patients and then moving forward with treatment that's appropriate to that category? And, you know, I would be willing to venture out there and say goose egg, zero. I would like to think that mentally we make these assessments every day. But when it comes to putting it down on a form, there's a mental roadblock that says, I don't have time for that. But if you knew that this one assessment would yield patient acceptance, insurance reimbursement, and then patient trust, and also just more production for you, you do have time to do it, right? The way you presented it sure does make sense. And I do agree. Mentally, we're assessing our patients. We see them. We've updated the radiographs. We know if they have, you know, medications that cause dry mouth. We know if the patients have bone loss or recession. And we know all of the risk. But then when it comes to the form, we should be able to complete that very quickly as dental professionals because that form access those questions. So there's no doubt, Alicia, you're presenting a very, very compelling case argument. to document this assessment prior to doing anything else. I mean, this is the key thing to set up your patient for the best treatment and the best odds of getting approval and having that revenue come in the office to pay for the treatment that you plan to do that's targeted for the patient's needs. The only reason that I could think of why dental hygienists would not be documenting this on a form is because of lack of time. Either they're being rushed because of shorter visits and there's production mandates. I mean, does that sound reasonable as to why they're not filling out these forms that would really be so useful to them in the future, as you described so well? I strongly agree with that. For the practices that are struggling with, you know, time, if we were to slow the appointments down and build more into the appointment, then we would have time to create these assessments and yield more production per visit so we could work smarter and not harder. So if you would, Alicia, tell us the kind of tools that are needed for a dental hygienist slash prevention specialist to operate on a routine basis and pursue the kind of... philosophy of treatment that we're talking about here? So the tools that I would typically use in my daily workflow are things that are not uncommon. These are medical history updates, periodontal assessments, radiographic interpretation, digital scanning, but we're also using our periodontal staging and grading and Canberra risk assessments. So all within the first 20 minutes of a hygiene appointment, I do have time to document these assessments for my patient. Now granted, every patient is not due for radiographs every visit. Every patient is not due for a period chart every visit. Every patient is not due for a comprehensive medical history update every visit. So I just want you all to consider that as you're prioritizing the first 20 minutes of your appointment, what can I delegate to the next visit? And what is most important in this visit? And I would encourage you to strongly prioritize your risk assessments. This is your periodontal stage in grade and your Canberra risk assessment. And then once you complete those things, share it with your patient. And, you know, so many CE lectures are about Canberra, right? I mean, there's so much caries risk assessment stuff that you could take. You can take it online. You can go to dental meetings in person and they talk about it. And you would think that hygienists would be doing this routinely, but obviously you know that they're not to the extent that you're talking about. So let's get more specific now about products and procedures that you would recommend for patients at different stages. let's begin with the patient who has generalized healthy teeth and gums and you're looking to maintain their good oral health. Let's call that general prevention. What are some of the products that we're talking about for this category? Yeah, these are the patients who are most often... overlooked and we see them as the easy patients and because they have not had a cavity or because they don't have a chief concern we just overlook them but the prevention specialist mindset looks again and you look for the risk is the patient a smoker Does the patient have any medications that may cause dry mouth? Does the patient have a family history or a history of decay? These are all things to consider. And for those patients who are considered the healthy patient, something that I would consider is fluoride varnish. Some of our friends over at Centrix have really dedicated. a lot of their research and time to developing fluoridose, which is one of the award-winning fluoride varnishes that they offer at 5%. And it also really just gives you a great taste and feel, and it doesn't really give you a clumpy texture after you apply it. I think the coolest thing about fluoridose, though, is that it offers multiple flavors that are really tasty, and I haven't had any patience to complain. One of my favorites is actually the melon. Yeah. You know, it's interesting that that product, and I've seen that product at a dental show where, you know, they gave samples out. The taste is the thing that's driving that product because I, yeah, I mean, when patients like something, then the dental hygienist is going to say, yeah, I'm going to use this because my patients like it. It's really phenomenal. It's a great example of business brilliance in a lot of ways because, you know, there's a lot of competitors in this field, in this particular product category. But the taste of this product stands above the rest, hands down. And I hear it all the time. And actually, melon is a pretty popular flavor. So you seem to be right in line with the crowd that loves melon. How is that applied? Like at what stage of the visit is that applied? Is that put on at the end before the patient leaves? Yeah, you can definitely apply this at the end of the appointment, but the cool thing about this is it actually dries clear. So depending on your workflow, especially if you're in pediatrics, you can potentially apply it before the doctor comes in for an exam. Okay, so let's talk about early stage demineralization. So now the patient is no longer in that category of generally perfect health, and you're out of that stage, and you're in the stage where you have some white spots, either from ortho or drinking a ton of Mountain Dew. highly acidic foods and drinks, what's the kind of products that you'd be thinking about when that assessment is made? Yeah, this is where we really have to engage our patients when they have transitioned from health and are starting to categorize themselves in the presence of disease. So we have to educate them, let them know where they are, let them know how bad this could potentially get, and then let them know that there are options. Right. So if the patient does have early signs of decay, white spot lesions or incipient lesions, I would make a recommendation for a product that actually helps to remineralize enamel. And one of my favorites is actually Curadon. Curadon is actually, you know, a little more than fluoride, a little less than silver diamine fluoride. It dries clear. It doesn't really have a wait time postoperatively other than the time that you're in the chair. So it's really easy for the patient to say yes to that when it's not really. disrupting their lifestyle. And it's also a great profit margin for the office because you're doing this in the hygiene chair as well. How is that applied? And what does that material look like? Oh, so it's actually really cool. They have a proprietary... tool that almost looks like a cotton gauze on a on a stick but it's a little different where it has peptide bonding on the inside of it that helps to create some peptide scaffolding within the enamel itself and it helps to draw it with draw in hydroxyapatite and fluoride to help to rebuild the enamel structure itself so this actually looks like a sponge and you really just dab it on after you do an acid etch i mean it takes less than five minutes i believe up Five minutes or so to complete the procedure itself per application. And how long does it take for those white spots to disappear? So I have seen actually in practice up to six months when I'm starting to start to see the very first sign of remineralization of a white spot. Okay, using Curadon. Mm-hmm. And then it takes six months and those spots are slowly fade away. And it's still remineralizing because you're building a scaffold, right? So when I continue to apply my fluoride varnish at subsequent visits, the scaffold is now attracting the fluoride varnish at a higher level. So it's getting a stronger uptake and helping to continue to remineralize this tooth. So yes, it's like once you place it, it just continues to kind of work behind the scenes for you. Yeah. Yeah. All right. So let's talk about the patient. Now they come in, they're coming in for their routine recare visit twice a year, and you notice incipient lesion. You've taken, I don't know, they're due for bite wings or whatever, and you see incipient decay. What do we do for that patient? Yeah, for a patient who has incipient decay, I would definitely double down on oral hygiene instructions and some things that we can do at home. In addition to that, I would also make the recommendation for Curadon, something that can help to repair or remineralize that incipient lesion. And then I would also make that recommendation for in-office treatments like fluoride. Okay. So you would stick with the same approach for the white spots with the incipient lesion, same kind of material, same approach, and make sure that they are getting that fluoride therapy as well. Absolutely. And that's the beauty of Curidon is that it can be used and is recommended to be used for not only white spots, but for also incipient lesions. Okay. And then when the lesion becomes cavitated. Okay, so if the lesion actually presents as cavitated, again, this is another opportunity for us to let the patient know that we want to be proactive rather than reactive. So we have a few options. We can go in and be aggressive and treat all of the decay at once, or we can really slow the progress down if that's an option by placing something like silver diamine fluoride to arrest the decay as we're working through a large treatment plan. Silver diamine fluoride. again, is a little less than curidant, but a little more than fluoride, but it does help the patient to understand that we do have options other than just drilling their teeth or, you know, starting out on a really large treatment plan immediately. Yeah. Now there are doctors that are using SDF and I know Centrix has their own brand. It is really phenomenal as far as the results that they're getting. I mean, they're putting this SDF in there. The leathery dentin is something you're supposed to leave in there. And this stuff just remineralizes it and rebuilds it. And then you later go in there, you could use glass ionomer or something like that afterwards. And it's unbelievably successful without picking up a handpiece. That's very nice. I have not used it in practice, but from what I understand about Centrix's... SDF is they actually have a SilverSense SDF, and it actually helps to not only prevent the bacteria from forming within the tubules, it also helps to produce fluorohydroxyapatite, and it helps to increase the mineral density and the hardness of the dentin and enamel as well. So who places the SDF? That's something the dentist would do, right? Absolutely, yes. And again, speaking for the state of Maryland, that would be something here. that the dentist would place right and what role would the dental hygienist play in recommending SDF to the patient? So again, just in updating the camera risk assessment, letting the patient know, you know, if you are at low, moderate, or high risk for decay, there are several options for us in terms of how we can approach what we're seeing for you today. So when the dentist comes in and we're providing a dental hygiene handoff to the dentist, we can outline that we've discussed the options that we could potentially perform for the patient, starting with SDF all the way up. to the option for tooth removal or grounds. So Alicia, let me ask you this. For those offices that don't officially or formally do a caries risk assessment and the dental hygienist is working in that office and they realize that the office is not pursuing or implementing this process, I'd love to know in your mind the best way to get a caries risk assessment going in an office that doesn't have one. that's a great question um and a caries risk assessment is no different than any other system that you have in your office you know if you have a system for um prepping crowns or, you know, developing or doing a crown on a patient, this would be similar to that. And when you develop a system, it just really helps to create consistency. You know, you know that the margin for error is really thin when you have a really well-defined and thought out system that everyone is implementing. And it also helps to reduce variability, especially in the diagnosis, when you're using a Canberra risk assessment as a part of your system for diagnosis. And then it's really promoting evidence-based decision-making. So that's really important. But if you're not already doing that, I would say one of the easier ways to implement a Canberra risk assessment is by doing it with new patients. We don't see new patients typically in hygiene first. Most times you're seen by the dentist first. This can be a risk assessment that is performed by the patient when they're in the lobby. This is also information, like I alluded to before, that we are already mentally assessing prior to having this document in front of us. It just takes us to put the information on the document and regurgitate it or share it with the patient. So all things considered, I would say... for those who want to implement a Canberra risk assessment, I would say to start with new patients. And then once you have this Canberra risk assessment established with new patients, And then it would be great to alternate the camber risk assessment with your perio charting. So when you're doing your perio chart, you're doing your periodontal staging and grading to let the patient know about their perio risk assessment. But when the patient is due for radiographs, hopefully when it's on the alternating schedule, now you're doing a camber risk assessment based on the radiographs and where the patient is in terms of their medical history and their lifestyle. So that would be another opportunity for us to implement a camber. risk assessment on re-care appointments. It would be when the patient is not due for period charting and when they are due for radiographs. Could you give us an example of a patient where you really turned it around, where you changed the direction of their periodontal health from degrading to improving based on a caries risk assessment? You found something that you would not have identified if you didn't do one. Absolutely. And this involved using voice automated perio charting. At the time, I did not have any AI radiographic interpretation. I just had digital radiographs and I had a digital scan. And I was able to help a patient to close an Invisalign case by showing them their perio chart, their radiographs, and their digital scan and just letting them know how they had secondary occlusal trauma. And due to the secondary occlusal trauma, was causing them to have pocketing and bleeding, and I wanted them to get ahead of it. So after the first round of scaling and root planing, the patient was really passionate after I explained to them that tooth alignment was an option. and also a medical necessity, you know, to help them prevent the progression of bone loss, they were really motivated to see the periodontal therapy work. So when they went home after the SRP was completed, they did everything I asked. So when they returned and we saw some improvement and there was some stability with the periodontal levels, the patient was then able to have their impressions for Invisalign and they were moving into a $6,000 case. So this patient's clear aligners, even just the discussion. of clear aligners was a catalyst for the patient to not only be proactive with periodontal therapy, but also to do something that's going to help them to save tooth structure and bone for the rest of their life. That case is very impressive, and it just hats off to you, Alicia, for pursuing. really solid, thorough assessment to get to where you did with that patient. And it shows what you said earlier in this podcast episode, how when you take the time to lay it all out, you could build the case that will not only help the patient in the long run, but also boost revenue for the practice. So you become, the dental hygienist does, becomes a very valuable asset to the practice. And talking about aligner therapy, that's on an upswing right now. GPs are doing it. 50% of the dentists that do ortho are using clear aligner therapy right now so i think it behooves the dental hygienist to get a better understanding of orthodontics especially with clear aligner therapy because it's much easier to get an adult to proceed with orthodontics when you suggest clear aligner therapy I assume the dental hygienist understands the manifestations of misaligned teeth. Like we talked about, caries, periodontal disease, chipping of teeth because of a malocclusion. Do you think hygienists are proposing orthodontics to their patients enough based on the improvement in a patient's oral health that can occur following orthodontic treatment? I don't think that dental hygienists are recommending this enough, but I will say that the American Academy of Periodontology has recognized that it is the dental hygienist's responsibility to recognize tooth position as a causative factor for periodontal health. or lack thereof. So all things considered, if you are making a diagnosis for periodontal therapy, you should be digging deeper and asking yourself, what is the root cause? Is it truly bacterial in nature? Or is this due in part to tooth positioning or faulty tooth structures like, you know, crowns or restoration overhangs and things like that? Yeah. Now, what kind of technology do you use to show that to the patient? Here's where your teeth are now. And when they see it on the screen, easily understand how difficult it is to maintain that and keep that clean versus what it would look like after some clear aligner therapy if it's appropriate, if it's not that severe where they can use aligner trays. Do you show them the before and after or is that something that would take place in the dentist's operatory and it wouldn't be in the hygiene department? oh no for sure we definitely have time in the hygiene department to do that and you said it earlier an ounce of prevention is worth a pound of cure i'd take it even further to say that every hygienist who wants to be more proactive for their patient they should be discussing this with their patient using digital scans is a great opportunity for us to fully engage the patient on their tooth positioning because if they don't know, they won't make a decision on which way they're going to move forward. It is part of our role as prevention specialists to educate the patient on the role of tooth alignment as it relates to prevention of tooth structure being deteriorated or even bone level starting to decline and periodontal health starting to decline as well. How do you show them? what the options are with clear aligner therapy in the dental hygiene operatory. What do you, what kind of technology do you have access to where the hygienist would be able to say, this is what your teeth look like now. I guess you would scan, right? And then you'd be able to simulate what it would look like after treatment. Yes, it's called a time lapse, I'm sorry, outcome simulation for your patient after your quick two to five minute scan. The outcome simulation not only helps the patient to visualize where their teeth would be, it helps the patient to see, like you said before, an area that was difficult to keep clean is now able to be clean thoroughly. And this can help us to prevent you from having future. tooth structure deterioration. Yeah, it seems to me the value of a dental hygienist is just really expanded to the point where it could really help the practice in a major way. I mean, if the dentist is wrapped up with all the things he or she is doing in his or her operatory, and then you have this brilliant dental hygienist actually looking at the assessment and taking a scan and showing the patient, here's how we could align these teeth so we could change the whole. landscape of how you would maintenance these teeth going forward. In addition to that, which is the revenue from the aligned trays, the patient is actually going to benefit from more conservative restorative work because once those teeth are aligned, the dentist is not necessarily... required to remove as much tooth structure if they are doing a restorative case, especially an aesthetic case in the aesthetic zone. So that's a big sell also. And these types of discussions that dental hygienists are having with patients to that level, like you're promulgating when you teach, Alicia, is to have the dental hygienist step up and take more under their belt as far as diagnostic and treatment planning is a huge benefit to the patient as well as the practice. in revenue. And we'll end on that. Please share with us your last thoughts. Yeah, my final thought would be for dental hygienists who are struggling with, you know, talking about a ticket item like clear liners because it, you know, costs five or $6,000 would just be to think about the life cycle of a tooth. You know, if you're making an assessment for a patient who went from being a healthy patient, then they had, you know, incipient lesion, then it went to a you know, one surface restoration to a two, three surface restoration to a crown, to a root canal, to an extraction, to an implant, the life cycle of a tooth. How much money do you think the patient has now invested for the life cycle of a tooth? And if we were more proactive and we could do something like align the patient's teeth properly to prevent them from having plaque accumulated, to prevent decay and bone loss, how much money and time have we saved on? Yeah, it's huge. Absolutely huge. So please just consider that we're doing our patient a service by making these recommendations for being proactive rather than reactive. And the sooner we get ahead of it, the better the patient's going to be in the long run, especially when we're discussing clear or minor therapies. I thank you for those very inspiring words. I think our listeners will certainly connect to what you just said, and hopefully it will change the course of the way they practice dental hygiene. That would be wonderful. We look forward to having you on another episode. Have a great evening. Thank you so much, Dr. Klein, you as well.