The Prevention Paradigm: Why Dentistry’s Future Starts Before Disease Begins

Silver diamine fluoride, for those who are unfamiliar with it, it has just simply been a game changer in terms of how we manage caries and how we look at caries disease. It falls in line with prevention and it certainly falls in line with conservation of the tooth structure in minimally invasive dentistry. Welcome to Austin, Texas for the Phil Klein Dental Podcast. Today we're talking about a big shift happening in dentistry, one that moves beyond just treating problems to preventing them before they start. Joining me for this conversation is someone who's been at the forefront of that movement for years, Dr. Joy Void-Holmes, or as most people know her, Dr. Joy. She's a registered dental hygienist with more than 25 years of clinical experience, and she has shared her expertise with audiences all over the country and around the world. In this episode, Dr. Joy breaks down what a prevention-first approach really looks like and why it's not just better for patients, but also better for your practice. We'll talk about why preventive care shouldn't stop at age 18, what steps practices can take to start offering more adult preventive services, and how to navigate insurance roadblocks to ensure patients receive the care they need. So I'm hoping that this conversation encourages you to rethink how your practice approaches prevention. 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. Dr. Joy, it's great to have you back on the show. It's great to be back, Phil. How are you? I'm doing great. Thank you for asking. I do want to tell our audience about your webinar that you did on VivaLearning.com. I think it was September 22nd in that range. It's called Stop Watching and Start Preventing. And it really does... cover the latest on caries prevention, how to manage the disease in the most minimally invasive way. And it makes a lot of sense. And I think that's where the dental profession is moving. And that aligns with my first question, Dr. Joy. There's a paradigm shift in dentistry, for sure, with more emphasis on disease prevention rather than just treatment. So can you explain how this approach can benefit a dental practice? Because typically you would think, If I want to prevent everything, then I got nothing to do, right? I have no services to offer, but that's not really the case. So tell us about that. I think it benefits the practice in many different ways. Number one, you definitely get those. You get better clinical outcomes. So most importantly, I think you see a real reduction in oral diseases, specifically caries disease and periodontal disease. And so when you catch the issues earlier, it means that your treatments ultimately can be more conservative and predictable, of course, when needed. And let's just talk about the elephant in the room, okay? I think there's stronger financial health for the practice that's tied to it. So prevention can be profitable, right? So that's that recurring. revenue. I know we never like to talk about that when we're talking about health care, but in order to keep the doors open, we have to have that recurring revenue. Yeah, and we talked about this on other episodes, Dr. Joy, how a culture focusing on prevention really drives the whole practice. Prevention, in my opinion, often starts in the hygiene department. So you get a more profitable hygiene department. I think you get higher case acceptance, but then I think you get higher team satisfaction and patient loyalty. So if a patient comes to you and you know, you have just kept them carries free and disease free and you know, their gums never bleed, they're going to recommend your practice to their family and their friends. And so Ultimately, I think it is going to future-proof the practice, right? Because as healthcare makes this shift towards a value-based model, and we start to get that medical-dental integration, practices are going to position themselves to be, I guess, at the forefront of being able to treat, you know, not just the mouth, but the whole person. You know, I remember in dental school, Dr. Joy, we used to put the word watch, W-A-T-C-H, in the chart. And yeah, I know that this was a philosophy of care. And then when it got worse, we treated it. And I think patients are smarter today and they understand the value of prevention. Now, in the past, in large part, preventive care has been limited to those under 18 years old. Yet we know that adults are not immune to dental decay. So if an office is not currently offering preventive care to adults, what first steps should they take? to me this is probably the what i'm going to recommend is so very simple and it really doesn't cost you a thing because the tool already exists and that is just a simple carries risk assessment I would say not only a caries risk assessment, a perio risk assessment, an oral cancer risk assessment. There's so many free tools out there. But let's specifically deal with the caries risk assessment. It's on the ADA website. Of course, they have one for individuals under the age of six and then six and up. So that would include the adult population. And it's as simple as checking a box, right? And you can actually take that form and you can make it an electronic form. So something that a patient can fill out, you give them a tablet, they can click it and they can automatically see those results. If it is... No risk or low risk, moderate risk, and high risk. The ADA, in my opinion, has done a really good job of recommending a protocol if you have patients that fall within the low risk, the moderate risk, and high risk. So I don't think an office who's currently not implementing any sort of system, they don't have to reinvent the wheel. Those resources exist. So I would say that would really be the first step. And then the second step, in my opinion, would be to, in addition to the care, risk assessment do some type of salivary diagnostics that you can do chair side and i'm not talking about taking the saliva and sending it off to a lab right that's one thing that we could do but simple test there is a company that offers a chair side test where you can simply test the consistency you can test the ph you can test the flow and that will also give you some insight into what could be going on so those are some very simple things that can be implemented without breaking the bank. Yeah. So when you decide to do this and really move forward with a really high focus prevention practice, and you do the salivary test and you do the camera that you talked about, and you find the patient is someone who is really kind of moderate to high risk, that changes the kind of materials you want to use, right? For your restorative, direct restorative programs. Because if someone's moderate to high risk, and they're young, let's say they're 18 years old, and they have a deep class 2 filling on a lower molar, you might want to change what you typically use to restore a tooth like that, which might be composite, and transition into a glass ionomer, for instance, which would seem to be more appropriate for a patient that's higher risk, higher caries risk. Absolutely. So I'm going to go back to the ADA again, and this is actually in the webinar. So I highly encourage you to go watch the webinar because they actually give you a graphic on how you should proceed with these patients. When I viewed it, the one thing that caught my eye time and time again is the recommendation of silver diamine fluoride. Silver diamine fluoride, for those who are unfamiliar with it, it was first introduced in 2014. And I often say to myself, because I worked in nursing homes prior to having silver diamine fluoride, like what a difference I could have made for my geriatric patients who often suffered from caries. What a difference I could have made for them had I just had access to silver diamine. That was in this country, 2014. I think it was used internationally for a long time. 80 years before we got it. Right. So it has a huge track record of success. Yeah. It does. And a wealth of evidence, a wealth of reputable evidence. And it has just simply been a game changer in terms of how we manage caries and how we look at caries disease. It falls in line with prevention and it certainly falls in line with conservation of the tooth structure in minimally invasive dentistry. So silver diamine fluoride, I've often said, Centrix has silver scents. And it is something that I believe that every single hygienist, every single dentist literally should have. in the operatory within arm's reach. It changes the game. It really does. Just a lot of our adult patients I find are still very fearful of coming into the office. They have childhood traumatic experiences, especially I know my parents where they often didn't receive anesthesia. So it's just the thought of having to get a needle or just, you know, hearing the drill. Like I have sensitivities to drills. And so to be able to use silver diamine fluoride to arrest caries. There is a wealth of research ongoing about preventing Carey's disease. So I think it has just been such a game changer. And just the research is pointing in that direction, whether it's class one, two, three, we could go on and on. Silver diamine fluoride, they're really recommending that as like a first line of defense. Yeah. And that's something that is a behavioral change because there's no doubt about it that it works. Right. What's the conversation with the patient when you decide that this patient is a high risk patient? and it's best to use silver diamond fluoride in there, which means it's so conservative in so many ways because, first of all, you're leaving leathery dentin down there, which is an affected dentin. You don't even need to touch that, which is amazing because you're staying away from the pulp. As an endodontist, now that I'm retired, I can say that's great. Maybe when I was working, it wasn't so great. I don't know. But the bottom line is you're staying away from the pulp. You're putting this silver diamond fluoride in there. Tell us what it does to that leathery dentin. where we don't want to peel it away we just want to remove the mush above it and then whatever we have left tell us how we utilize that and also like i said in the beginning of this question and i got sidetracked what's the what's the conversation with the patient because you know they they hear about this possibly that maybe it causes the teeth to turn black maybe you have to talk to the mother or the parent what's the conversation and then how do you do it So I think the conversation with the patient, I always say we should talk to where our patients are. And some of our patients come to us, you know, chemists. I love when I have a chemist in my chair. I'm like, oh, you know, I got out. But I always keep it really simple. And I like to just break it down. You know, what are the main mechanisms of action with silver diamine fluoride? Right. So of course, it's going to remineralize. And then of course, because it's silver, we know that silver has those antimicrobial properties. And so we're killing the bacteria and we're also remineralizing that enamel. And the beautiful thing about silver diamine fluoride is just how deep it penetrates into that dent. And so we get that hardening. And again, you get the antimicrobial, anti-enzymatic effects from that silver. And so that is kind of depending on... on the educational level of my patients, how I would say that, but that's typically how I would frame the conversation. And then the beautiful thing about Silver Dining Florida is that it's so easy to place. It really just does not require you to purchase an additional armamentarium. If you've learned how to keep the area dry, which we have to do when we're placing sealants or replacing any type of restoration, you keep the area dry. Of course, you want to make sure that it's free from biofilm because we want to make sure that the area is able to respond. We have found in the literature that anytime an area is not free from biofilm, it's poor oral health, the chances of the silver diamine fluoride working. the chances decrease. So you keep the area clean, you apply it, and then you establish a protocol on how often you want to reapply it. And how do you recommend applying it? Centrix has these little micro brushes and I need to ask them, are these brushes proprietary to them? Because I almost feel like it draws in the formulation that they have. I feel like with the brush, you can just take a drop and the brush draws it in. And so you're able to just really precisely place it where it needs to go. So you're painting it on the affected dentin. That's it. It's so very simple. And then when you're done, you can choose to place fluoride varnish on top of it. That's typically the recommendation. If you choose not to, that's fine. But that's it. So when you paint it on, it's a little wet. Do you let it dry first? Yes, you do let it dry. What I encourage people to do is always follow the manufacturer's instructions for use. Right. Because it's going to be not drastically different, but it could be different from one company to the next. But yes, you clean the area, you apply it, you let it dry. I recommend you place fluoride varnish on top of the area. For some people, depending on what they're using it for, you might want to place glass ionomer on top of it or some other sort of restoration, especially if there's aesthetic concerns. You mentioned, Phil, there is the potential for staining. I always like to throw this out here. Silver diamond fluoride does not stain intact dentition. Just decay. So that's the answer to the patient. I mean, if you ever hear that and they say, I turned that down from the last dentist because I didn't want my teeth to turn black. And so you rather leave an active dark lesion than have a medicine kill all that bacteria and turn darker. indicating that it's actually working. Would you rather not have me put this medicine on your tooth? And we're going to cover that darkness up anyway. And you can do that very successfully using glass ionomer. Is that something that you use routinely on top of SDF? So it just it depends. And so you talk to different pediatric dentists, some will place a glass ionomer on top, it just depends on the location and the severity of the lesion. And again, that that guide that we talked about earlier, and how to manage carries the ADA has produced that they actually provide recommendations. And so in some instances, they will recommend that you place a glass ionomer on top of it. And then in that instance, depending on the type of glass ionomer you're using, you may have to If it's a self-cure, then you won't, but you may have to light cure that glass ionomer if you're using some type of composite. And depending on what it is, you would have to light cure that as well. And then, of course, the fluoride varnish on top. But whatever you're using and whatever method, whatever the restoration it is, I can tell you that it's simpler and less time and more affordable than the actual restoration. You know, the typical fill and drill restoration. Yeah. And the key thing is, is that you're preserving. valuable tooth structure in a situation where especially in a young patient who's you know 15 years old and it's a lower molar and they have pretty bad decay there and you know they're a high caries risk patient because you did the assessment that you just talked about and now they're high risk by you putting in a composite in there there's there's a high likelihood that they're going to come back with recurrent decay so by using silver diamine fluoride deep into the into the cavity. You're not removing any tooth structure unnecessarily. You're just taking this really soft infected dentin out. And then you're using the silver diamond fluoride, which is incredibly antimicrobial. It darkens the lesion, showing that it's actually working. It remineralizes it. And then you put glass ionomer on top of that, which essentially fuses to tooth structure chemically and helps to remineralize. the hydroxyapatite as well, which is perfect for a high-risk caries patient. And this could last for years as a very good restoration. that patient. Absolutely. I do want to touch on compensation and I'm talking about third-party payers, i.e. insurance companies. They can be a big roadblock when it comes to expanding preventive care to adults, right? Because they typically cover the kids. How do you overcome this challenge and ensure that our adult patients get the same high level of preventive care that we're providing to our patients that are under 18 years old? So I think the first thing that we need to do is help our patients understand how dental insurance works. And I co-present with Dr. William Pavelitz quite often, and he says it perfectly. It's not insurance. It's a dental benefit. And your dental benefit is there to assist with costs, but it doesn't. In most cases, it is not covering 100% of your treatment. So again, it's a benefit to assist with costs. It is not a permission slip. for care so we have to reframe reframe how our patients view in insurance and so i like to use analogies i love to use car analogies and this is the perfect one like you buy a car your insurance does not cover the cost of your oil change rotating your tires replacing your brakes but you're going to get in that car and if you go to the mechanic and the mechanic says it's fifteen hundred dollars to get this car back up and running you don't question it so why is it that we question it when it comes to our own personal health. So when you start to get your patients to think of it like that, they're like, well, wow. So if you go to the doctor and you say, doctor, I'm not feeling well, and the doctor says, well, you're at risk for this, but if you take this pill every day, or if we do this procedure, you won't be sick. You don't question it. So why, you know, so I like to have those types of conversations with my patients. You have to reframe how they think about dental insurance. And the fact of the matter is that current dental insurance models reflect what we thought about dental insurance in 1960 when the cost of dentistry was significantly lower. We can't possibly expect, you know, for it to be apples and apples type conversations. Yeah, I mean, I do two shows a week on the... on this program. And it seems like almost every week I talk about how little insurance companies are compensating and that some of these dentists are just showing the patient their lab costs and say, listen, you want me to do a veneer and you tell me you have dental insurance. Let me show you the last patient I just did a veneer on. Here's the lab fee. Your insurance doesn't cover the lab fee. So I assume, Dr. Joy, that these kinds of challenges with insurance companies cross over to prevention procedures as well. They stop covering after a certain age. So they don't really, in my opinion, they stop covering for adults. And I feel... as if that's where the greatest need is because once you become an adult you stop listening to your parents you're now eating things doing things your behaviors right um so you're more at risk for for multiple things and so um i find it interesting that some insurances will actually cover ceilings for adults where others stop at the age of 14 or they won't cover a fluoride treatment and i'm thinking are you kidding me Where did insurance company get the notion that adults are no longer at risk for caries, maybe not occlusal caries, but certainly root caries or, you know, inapproximal caries. But wouldn't it benefit them in the long run financially to cover the prevention? procedures that you're talking about so that they don't get this kind i mean they're gonna have to end up paying for the actual restorative work if they don't cover it so to me it makes no sense you need to be a consultant for them you need to set up a company dr joy and start consulting for these uh crazy insurance companies that are living they're living in the 1960s yeah um there's it's a conspiracy i don't know what the conspiracy is because to your point it just doesn't make sense you are spending more money in the long run and run. And maybe more people would sign up for your insurance if you would just actually do the right thing and cover preventative procedures. Yeah. So let's go back to what you do in your office every day. You're a registered dental hygienist. I am. And tell us how an office could expand the prevention services that they could be offering their patients, which is, as we mentioned earlier in the program, what a great practice builder it is. So although I don't practice full-time anymore, what I will say and what was effective for me when I did is that you have got to educate that new patient appointment. When it clicked for me is when I really took the time to talk to my patients and educate them. Long before I opened the mouth, I would sit them down. I'm going to age myself. This is when they had the little Casey educational system. And there were three videos that I consistently played for my patient. It was one on why we took a full set of x-rays. There was one on probing, like what to expect and what the numbers meant. And it was one on this, the new patient visit. So of course, after, you know, we did our hellos, I'm going to see you here. I'm going to play these videos. I'm going to go and, you know, I'm outside the door, but then I'm going to come in. We would start the conversation and explain what I would do. And it was just they knew what to expect, especially when I'm probing. So if I'm calling out a four and a five and they're like, oh, that's bad. Like, exactly. I don't have to sit. And so we finished the probing. They're like, so I'm probably going to need something more than a cleaning. Exactly. So I think education. But I find that most clinicians and even myself at one point, I spent the least time. The least time there. So educating your patients. But the number one thing I would say would be assessments. Your initial assessments, your just assessments in general need to be on. Most people are not doing a caries risk assessment. Most people are not doing a comprehensive perio assessment. Most people are not doing a thorough medical history. The medical history sometimes has all the answers that you need, because if you get what you need from the medical history, you can then now ask the follow-up questions or the qualifying questions to pull out that additional information. When you're able to have that thorough medical history, you can now begin to make the oral systemic connection for your patients. So it makes subsequent. conversations much easier to have so which which leads to very high case acceptance absolutely yeah absolutely so and then word of word of mouth you know they're saying this office is i've never experienced this before in my life i went i've been the dentist for decades and i'm an adult and here this this hygienist was really trying to go deep into my history and look at the root cause of what's causing me to have these issues where no matter what I do at home or whatever I'm doing, it's just not working. And you're kind of partnering with the patient, right? It's you and the patient together working towards a goal. And that is really a great practice. So what do you attribute to the fact that dentists are not doing the assessment, the camera, and doing the other phases, like a thorough medical history where they can really put things together and say, here's where we need to go with you as far as the right track, as far as getting your mouth back healthy. Why are they not doing that? Like, what are they doing then? They're just starting in with treatment before they really know every patient's the same. It's that kind of concept. Every patient is the same. It's not patient-centered care time. You know, they're thinking, well, oh my gosh, I have to meet production. I have to meet my production goal. And the way that I'm going to do that is to schedule more patients, not realizing that your patients here, your existing patients are still full of disease. And if you would just take the time to thoroughly assess your existing patient base, you're going to find that what you need is there. And in addition to that, you're able to help those patients. When we first graduate, we, well, maybe I shouldn't say we, me, I really focused on just getting fast, getting my speed up, perfecting my technique. And then, you know, it becomes habit. You know, you're going from one patient to the next, to the next, to the next. And I felt like we learned about the oral systemic connection, but not the way it was nowhere near what we talk about now. So, you know, I went back to teach and I'm like, I remember four diseases we talked about. Now it's 15 to 16. And then the way that we talk about biofilm and the way that we talk about Carey's disease. So when I went to school, Carey's disease, I thought, oh, strep mutants. That's that's just that's what it is. And now. no caries disease and biofilm. And okay, now I have to look at biofilm differently. So I think that in dentistry, we get stuck in our ways. We don't like to change, especially if things have been working. So it's going to require for us to shift our mindset. And what did that for you? How did you get out of the routine of treating every patient the same and saying, okay, I see Mrs. Jones sitting in the chair. Here's my... formulary that i need to apply to mrs jones she goes up she she pays the front desk she gets scheduled for another appointment and she's mrs jones has been doing this her whole life and she's still in that cycle of dental care and and but the problem is not really getting solved how did you move beyond that I think for me, I went to work for a dentist who had never had a hygienist before. So I got to just do it my way. And after the first two or three patients where I was just, you know, because it's not like I had a book schedule. Right. So I'm like, oh, I can take my time. And, you know, I'm like, wow, it worked for this patient. Well, let me. try this method again. And then it worked with the second patient and the third patient. And for me, that's when the light bulb went off. But I was 10 years into my career before that happened. So by no means am I passing any judgment. It just takes time for certain people. But I also feel like we know a little bit more. And, you know, standards of care are different. I know ADHA just came out with an updated standard of care. So if you're looking for a new playbook, if you will, it's there for you. The resources are there for us where in protocols, there's so many protocols, free protocols, workflows in place where you don't have to go out and recreate the will. You just have to have an open mind and be willing. So when you became the. only hygienist in the practice that you were just talking about you took more time with the patient which some dentists would say well that's eating away at production time but in reality by you taking more time with the patient you actually grew the revenue of the practice tell us how you did that because you're able to actually identify other things sometimes it's simple as you know if you really take the time to do a thorough assessment you realize that hey this person is not just a full mouth debridement and i'm going to bring them back in a couple weeks for a fine scale like no actually they need non you know surgical periodontal therapy we need to bring them in and we need to treat the quadrants and oh my gosh there's um some sensitivity here and they could benefit from some irrigation and they really could benefit from a three to four month recare plan and oh, they're high caries risk. And so while we're doing this, let me recommend this product because some products are designed to treat the perio disease and the caries disease simultaneously. So I think that's how it can translate. And then for me, I know my codes. And so sometimes you're just coding for the wrong thing. read the title of it, but I'm like, no, read the actual description. And then sometimes you'll realize that you're just not even coding for what you do. And the bottom line is you're doing the right thing for the patient. There's no question about it. You're helping the patient in a much more medically focused way where that oral systemic connection is being considered and the patient is benefiting health-wise. They feel like they're under the care of someone who really cares about them. And you're not looking. them as another patient. So as we approach the bottom of this podcast, and we did cover this earlier in the episode about patient communication, but I want to ask you specifically how to effectively communicate to our patients so that they truly understand why a particular preventive treatment, let's say SDF for instance, is so important to their long-term oral and systemic health. How do you do that convincingly? I think we really need to, number one for our patients, not talk about the procedures, but talk about the oral health outcomes, right? Patients are going to invest more in health and less in products. So I would say that would be number one. I think that we need to personalize each of these conversations, particularly with visuals. So pictures don't lie. My intraoral camera, now we have scanners and all types of AI, but at one point I just had an intraoral camera and I'm taking four to five pictures. So those visuals sometimes were enough to drive home the point. I talked about this earlier, using those simple analogies, figure out what makes sense. So if you have a sports enthusiast, figure out a sports analogy. If you have someone that loves gardening, figure out a gardening analogy. I would say always lead with the benefits, not just the negative diagnosis. What would be the benefit of incorporating this preventative solution? And then, you know, close the loop. It's just not enough to have the discussion. Recap the plan with the patient at the end of the visit. Document it. Send them home with brochures. Maybe a follow-up email a few weeks later or a phone call. But I think these are all things that certainly help to reinforce. force value long after they leave the chair. And the one quote that I absolutely love is that prevention is going to serve before it sells. When you educate your patient on the importance of prevention, you do not have to sell, in my personal experience. Yeah, and I agree with that 100%. I think the philosophy of care that you're talking about today is just so admirable and noble in many ways. And there are many other hygienists that are in line with you, but then there are Other offices that are all into production, some of them are corporate-based. Not all corporate-based are bad, but some of them are. And the patient's really not getting the kind of care that you're talking about here. And I think that everybody's capable of doing this right. It's just, like you said, open mind, take some CE courses on this stuff, and spend some time with the patient. Don't schedule these patients where you have no time to learn about what is the root cause of all this. And start looking into silver diamond fluoride, right? That's a wonder drug. That's a wonder medicine. Absolutely. I would like to add something, and it won't take long. You have to advocate. Not only advocate for your patients, but advocate for yourself. And you cannot be afraid. And sometimes it may mean that you have to work someplace else. But if you see something, you see that patients are not being treated appropriately or they are seen as cash cows, you have to say something. It is our jobs, and I'm going to speak specifically for dental hygienists to speak up, say something, and we have to advocate for more time, advocate for the tools, advocate for the products. And when we do that, when we're advocating for ourselves, we in turn are advocating for our patients. So I just wanted to. Thank you so much, Dr. Joy. We love having you on the show and we hope to have you on soon again. Thank you. Thank you, Phil.