Profitable Care: Financial Benefits of Medical Management of Caries

SDF, this is Dr. Niederman's study, shows that SDF alone is 80% effective, takes five minutes, and costs five bucks. Glass ionomer is also 80% effective, takes 15 minutes, costs 12 bucks. Silver diamine fluoride and glass ionomer is 96% effective, takes 20 minutes, and costs 15 bucks. Now, 96% effectiveness is also supported by the prominent cariologist, Dr. Margarita Fontana, as published in the Canadian Dental Journal in 2020. Welcome to the Phil Klein Dental Podcast. In a previous episode with Dr. Frachella, we talked about the science, clinical applications, and clinical steps regarding the use of SDF, silver diamine fluoride, and glass ionomer. It turned out to be quite a fascinating episode, as it highlighted an approach to treat dental decay that requires no drilling and no local anesthesia. Treating dental caries this way is known as MMC, Medical Management of Caries. For the most part, it's not taught in dental schools, and it's certainly not used nearly enough among practicing dentists. Removing the infected dentin with a microbrush or cotton pledget on the end of a pair of college pliers and then treating the affected dentin with SDF followed by the placement of glass ionomer can result in an incredibly high success rate. In fact, according to the literature, clinical success exceeds 95%. So the question is, why aren't more dentists doing this in their practice? Dr. Frachella believes a good part of the reason is that most dentists don't look at this treatment as profitable. He disagrees. In fact, treating carries medically with silver diamine fluoride and glass ionomer can be just as or more profitable than doing the routine drill and fill dentistry. So let's find out more from our guest, Dr. John Frachella, who is not only knowledgeable on this topic, but also you'll find quite entertaining. Dr. Frachella is a pediatric dentist with 50 years experience in the delivery of dental services in public and private settings. He's worked in private practices across the country and for a decade was on staff at Oregon Health Sciences University Dental School. He lectures at NYU Dental School for the largest dental residency program in the United States. Dr. Frachella, pleasure to have you on the show. Well, thank you for having me. It's a real honor to be here. Yeah, we're happy to have you here, Dr. Frachella, because you're covering a topic that is not emphasized in dental school and in some schools probably not talked about at all. It serves as a very specific benefit to the patient, especially those patients that have limited access to care, those patients that you may only have the opportunity to see one time and then they just don't come back. You used a specific word to describe that patient. Itinerant. Itinerant. Yes, itinerant. So today we're going to be talking about medically managed caries, how it serves those patients very, very well, and actually can be quite profitable to the practice. So to begin, tell us what you mean by medically managed caries. And then later on in the podcast, we'll get into how this approach can actually become profitable for the practice. I'd like to caveat the itinerant comment first, and I'd like to say that I don't say that derogatorily of my patients, because as I said in the previous episode, I am as itinerant as they are. I am usually a hired hand. I'm called into an office to do this, and then I may never show up again. So I consider that every patient I see, I may never see again. That's on me, not on them. So I just want to make that clear. I'm not derogatory against this patient population or towards any patients. But as I said in episode one, the medical management of caries treats cavities. The bacterial affected, but not... infected symptoms of the disease by healing and sealing while simultaneously preventing the disease in patients. So it desensitizes, it deactivates these caries-causing microbes in a preventive way. And it does this with topical liquid and solid medicines that contain mineral ions that remineralize, detect, prevent, and without needles and drills. And we're replacing the minerals that were lost in the decay process. Yeah, so a dentist that is working in a practice is trained to get the patient numb, pick up their handpiece after the diagnosis is made, of course, and start going forward with, let's say we're talking about direct restorative work here. Decay removal, prep design, and go there with some of the most beautiful aesthetic materials sold today, which just look great. philosophy is more on the medical management of caries where we don't do that. That's not the approach that we use, especially initially. So preliminary studies are showing that medical management of caries can be more profitable than routine drill and fill direct restorative procedures. So what I'd like you to do on this podcast episode, if you would, Dr. Frachella, clarify this finding and tell us why this might be the case. Sure. You know, Our studies are showing that silver fluoride, glass ionomer, providone iodine, hull crowns, and combinations of these medicines control Terry's lesions while also creating provider, patient, and payer savings. So the reason for that is that when using liquid and solid dental medicines, We don't remove that leathery affected dentin because we know that that causes inflammatory pulp reactions. And we also know that material can remineralize. So the medical management of caries controls the disease so it doesn't control the provider or the clinician. But it also helps to manage the behavior of phobic children and adults. And it fills in food traps by restoring to function with solid medicine. So it can often be delegated to non-dentists in your office. So there's a brand new 2024 Journal of Dentistry paper that shows that with silver fluoride and glass ionomer, we achieve high remineralization rates while also saving chair time in managing otherwise unmanageable biofilms and or behaviors in patients. So, you know, Dr. Rick Niederman. from NYU and NYU researchers shows why we can be profitable at this. SDF, this is Dr. Niederman's study, shows that SDF alone is 80% effective, takes five minutes, and costs five bucks. Glass ionomer is also 80% effective, takes 15 minutes, costs 12 bucks. Silver diamine fluoride and glass ionomer is 96% effective, takes 20 minutes, and costs 15 bucks. Now, 96% effectiveness is also supported by the prominent cariologist, Dr. Margarita Fontana, as published in the Canadian Dental Journal in 2020. We'll be getting right back to Dr. Frachella in a minute, but first. Silver diamine fluoride, SDF, is a game changer in caries management, offering clinicians more time to plan appropriate care while effectively desensitizing teeth and arresting caries. Centrix, a trust... leader in dental materials offers SilverSense SDF, a cost-effective, fast, and easy-to-use solution. Its bactericidal silver particles stop carrier's progression in its tracks and instantly eliminate hypersensitivity, providing a more comfortable experience for your patients. Unlike other SDF products, Silversense SDF won't stain healthy tooth structure. Only the treated lesion darkens, which can later be restored to full form, function, and aesthetics. So it's time to elevate your caries treatment with Silversense SDF from Centrix. To learn more, visit centrixdental.com. That kind of high-level disease management translates into fast, easy profits when we bill silver fluoride and glass ionomer as composites per surface because the Dental CDT book lists glass ionomer as composite. But unlike composite, silver fluoride and glass ionomer don't require needles or drills or aerosols. So providers can see many more patients per unit of time. And MMC, medical management, can be provided by non-dentists. In that way, it's both a winning financial numbers game as well as being vaccine-like. So providers sometimes make less profit per unit. of appointment time. But at the rate of six times or more, as many appointments say, per day, medical management quickly offers financial incentives. We actually have randomized clinical trials. One of them was done by Dr. Scott Tomar at the University of Florida that studied the economic impacts. of silver diamine fluoride on Cary's treatment experience and outcomes on Medicaid kids. And his team found significant expenditure reductions by averting expensive Cary's treatment options while also preventing stress by using medical management. Now that saves everybody money. Another 2020 study shows that SDF helps to reduce hospital ER visits for kids with early childhood caries by 80%, which decreases overall system costs that are paid for by our tax dollars. And in Oregon, we did in 2020 a study, a randomized clinical trial. showing 70% less dental general anesthesia need for zero to 14-year-olds who were successfully treated in school settings, not in... clinics, but in school settings with silver diamine fluoride, glass ionomer, and providone iodine applied by non-dentists. And there are three studies showing that silver ions heal gingival inflammation, meaning less referrals to periodontists and more money in your pocket. You know, it's less expensive also, SDF is, at reducing dental hypersensitivity than the much more expensive products we use like Glooma, again, that is a plus for provider profits. Yeah. So there's no question there's tremendous advantages to using STF, as you just described, with glass ionomer. It costs a whole lot less. It's faster to do the procedure. The practice can get reimbursed basically at the same level as a analogous composite resin, right? If it's a three surface, they build it at a three surface composite. Now, To me, this is phenomenal for those patients that come in, maybe patients that have difficult or challenging situations to get access to care. And like you said, they may come into this practice one time and you may never see them again. You have the opportunity to treat multiple teeth at the same time. The kid's nine years old. He's got decay on eight different teeth. And you just go through these teeth one at a time and you do the SDF glass armor treatment. And that could be a tremendous impact on that kid's life because of what this medicine is doing in these situations. Now, you're saying that this same type of treatment applies to every patient or doctors that are seeing these itinerant patients or doctors that are seeing 20 to 30 patients a day. They're in what we call a volume practice. No, let's just talk about human patients. You know, at any stage of demineralization, short of irreversible pulpitis, remineralization with silver diamine fluoride and glass ionomer is possible. So it doesn't matter whether they're itinerant or not. So it never makes sense to treat any patient's single lesion or even single quadrants. while leaving other active lesions untreated since silver diamine fluoride and glass ionomer can be applied painlessly in mere minutes and even by non-dentists. Now that's a moneymaker because offices can immediately begin disinfection at any child or adults. first appointment, and even at a first exam when cleanings, x-rays, or extractions are scheduled because non-dentists can disinfect and remineralize savable teeth while dentists wait for numbness in teeth that no one can save. Now, that allows providers to function as firemen first and make money at it. Then, They can become carpenters or jewelers later when money, time, and behavior align. Now, more specific to your question, glass ionomer is listed in the dental CDT book as composite, as I said earlier. So, silver diamine fluoride and glass ionomer without local anesthesia or nitrous brings in as much insurance money as composite resin per surface with... local anesthesia and nitrous. Not having to wait for teeth to get numb and not having to manage the behavior of needle and drill phobic patients, providers actually make more money per tooth surface treated when they use MMC. And let's not forget hall crowns without needles and drills, which are MMC too. And they make the same insurance reimbursement as conventional stainless steel crowns with needles and drills. Now, hauls are 90 percent effective versus conventional stainless steel crowns that are 94 percent effective. So 97 versus 94, probably a little insignificant, but we don't need needles and drills. If you would, for our audience, go over what a haul crown is briefly. Sure, sure. So a hall crown is when we take, a hall was originally for primary teeth only. I have two hall crowns in my own mouth. okay on permanent teeth i put them on permanent teeth on patients that can't afford gold don't want gold don't want zirconium we don't need needles we don't need drills for it what we do is uh we make space if there isn't space you know with a lot of patients there is and with a lot of patients there isn't we can make space with two separators send the patient home A week later, they come back. We take orthodontic tooth separator out. Now we have enough space. We fit a crown over them, not the conventional way. You know, we're not crimping it. We're not cutting away tooth structure. We put it down. Now, on adults, we have to take occlusal away. And sometimes we just remove. So we take it out of occlusion. And a lot of times we don't need local anesthesia for that on most teeth. But anyway, we put on children. We don't have to worry about it because. In primary and mixed dentitions, the teeth equilibrate themselves occlusally, and we don't have to worry about high teeth, and kids don't complain about it. But anyway, then we treat the tooth. We call it silver-modified hall. Hall wasn't originally done this way, but silver-modified hall. We apply silver diamine fluoride to the affected but not infected. We remove infected material. Then we fill the crown with glass ionomer and drive it home. And that is 97% effective. And these crowns are out of a box, right? These crowns are out of a box. I like to use the 3M variety, ION, 3M ION, and they make them for permanent teeth. There are other brands, whatever you happen to like. I like the 3M IONs because they're pre-crimped. We'll be getting right back to our guest in a second. But first, thanks to GC America, we're now able to incorporate all the advantages of glass ionomer into a beautifully aesthetic, strong, long-lasting restoration. That's a great reason to try GC Fuji Auto. AutoMix LC. You'll love the convenient AutoMix delivery system and ergonomic dispenser, which allows precise placement into the preparation. And GC Fuji AutoMix LC is bioactive, allowing for a high rechargeable fluoride release, which is ideal for high caries risk patients. And because it forms a chemical bond to tooth structure, even in the presence of saliva, there's no need for etchant and adhesive bonding. This saves steps and is ideal for challenging patients where access and isolation are difficult. And the small filler particles in the material allow for superb polishability and excellent aesthetics. So when you're thinking glass ionomer for your clinical cases, think GC America, a world leader in dental materials. To learn more, visit gc.dental. So realistically, Dr. Frachella, what are we looking at as far as lifespan? How long could a tooth survive using this modified Hall technique? You know, I like to use real life examples. So one day I was working on a patient and I felt a presence behind me because my doors are always open and I work in open days. And here's this kid standing there and I don't recognize him. I mean, I call him a kid, but he's, you know, he's well into his 20s and he's standing there and watching me. And I go, I wonder who that is. So I just turn around. I remember you, Billy. And he opens his mouth and he's got four hall crowns that I did when he was a kid. So these are on permanent teeth. OK, so I'm looking at permanent first molars. So this kid, you know, I probably put these on when these first molars came in his mouth, which was somewhere in the vicinity of six, seven, eight years old. And he's had them and he's in his 20s. I've also seen them come back at that amount of time. And the whole crowns have a wear spot or they they've actually perforated them through to occlusion. And and what I do is I seat them in the chair and. I take a round burr on a dental handpiece and tell them, this isn't going to hurt. I don't need to give you a needle. And I just go into the perforation just a little bit. You know what? I put glass ionomer on that perforation. And that becomes their sacrificial wear spot. And I tell them, when this wears more, come back to me and I'll put more glass ionomer in that wear spot. That's incredible, Dr. Frachella, talking about minimally invasive dentistry. It doesn't get any more minimally invasive. than that basically the the approach of just being so careful about the integrity of the existing tooth structure and doing things conservatively that makes sense you're getting remineralization of the tooth you're getting uh you're eliminating the risk of polymerization shrinkage and all the different post-operative sensitivities that go along with some of these composite resins. There's a lot to be said for that. And it makes money, which is to our point in this episode. You know, I like to quote Ray Bartolotti. I don't know if you remember Ray. Sure. composite resin pioneer. You're shaking your head, you remember. Ray says hourly returns for practice are not negatively impacted by the medical approach. It actually increases practice income with happy patient repeats and referrals. With the medical approach, good dental care becomes more affordable for more patients. Plus, I think you can appreciate. that the medical management of caries also helps providers pocket more humane, painless treatment money instead of making hospital dentists rich. You know, MMC actually rescues dental phobics from life-threatening hospital OR encounters that cost Medicaid and taxpayers tens of millions of dollars a year. So it can save... on our tax bill, as well as allowing us to pocket more money for ourselves. It's a win-win financially. And we have RCTs between 2011 and 2021 that prove that SDF applications actually qualify as indirect pulp treatments because SDF clearly affects pulps favorably in deep lesions. So at 70 cents a drop, SDF can be coded and charged as indirect pulp treatment. Now, how can anyone not make money doing that while also being 90% effective against the disease where nothing in the history of dentistry has ever been 96%? Okay, so let me ask you another. First of all, I want to, clarify to the audience that we're not talking about smile line here. So the six anterior teeth, upper and lowers, are not applicable to using this methodology, obviously from the black stain that occurs from the SDF. If you review a previous episode that I did with Dr. Furchella, he goes over that. But again, we're talking about primarily posterior teeth. That's what we're talking about here. and the indications for it are far beyond what we're currently doing i think in the general dental population it can be used to a much greater degree than it is now i'm not saying every single tooth should go this way I don't think Dr. Frachella is saying that, but there are options, affordable options that can be utilized on a much wider scale than they are currently being used today. So as we approach the last five minutes of this podcast, and it's been very interesting, as usual with you, Dr. Frachella, somewhat entertaining as well. That's why we like having you on. We know that in order to proceed with any dental treatment in the treatment operatory, the patient needs to consent. So what does MMC, medical management carries, do for case acceptance? And on top of that, what does it do to help grow the practice? Okay, so case acceptance. We use honest, evidence-based messaging for patients, parents, everybody. We tell them that SDF is an antibiotic liquid that arrests decay. desensitizes painful teeth. It detects questionable lesions. It remineralizes soft decay. It controls decay without needles or drills. It has to be reapplied regularly. It's a combination medicine, like triple antibiotic cream. It stains decay black, but not healthy tooth structure. It prevents future decay. It heals and prevents gum disease. We tell them that SDF stain decay can always be made white later without needles or dress. That's not case acceptance. It's not hard sell. It's not sell at all. It's just the truth. If you want, I'll give you three very quick real life examples of dentists who found financial success doing MMC. We have about four minutes or so. So if you can fit it in, sounds good to me. Yes. Dr. Johnny Norris has multiple clinics in four New England states where he serves a 70% Medicaid population. In essence, he has public health practices with private practice facades. He heard me speak in 2017 when he was finishing his residency and he began immediately with MMC. By 2019, he had 9,000 patients. Today, he has 20,000. treats adults, even though he is a pediatric dentist and kids, in great need and makes a handsome living doing so by completing all necessary SDF applications at the first appointment. For him, it's a financial slam dunk. For Dr. Ned Robinson at the Penobscot Indian Reservation in Old Town, Maine, children and adults on Indian Island afraid of needles and drills allow SDF applications 99% of the time, making SDF one of the miracles of modern dentistry for Dr. Ned. He says that once they see how simple it is, patients are happy to return for routine three months silver fluoride applications. And finally, Dr. Jeanette McLean. who is in private practice in Glendale, Arizona, says that having more options on her patient menus improves patient retention, referrals, and hourly production because MMC can be done at first and recall appointments by dental assistants and hygienists, not dentists. Ka-ching! Now, is that a state thing? Dr. Frachella, are there certain states that still require a dentist to be present, even if they're placing STF with glass on them or with no drilling? Correct. And it was worse before because now we're changing it. We're actually going into state legislatures from coast to coast, changing the rules by impressing upon dental boards and upon state legislatures that it is in the patient's best interest, especially in Medicaid populations that aren't being served by dentists because the dentists don't want to treat Medicaid patients. Come on. We've got to do something for these people. So we changed the law. And so, yes, it's different in every state, Phil. And we have charts on that. We can provide that for the listeners if they want it. Yeah. And it seems like a tremendous solution for mobile dental practices, having this unit driving around to different communities and the kids line up, they get treated, they're in and out fairly quickly and everything's under control. Their teeth are remineralized. They have the glass on top of the SDF. And like you said, the kid could show up. And you could run into him when he's 25 years old, even though he's six or seven when he goes into one of those mobile units. We're trying to do that with mobile units in Lahaina right now at ground zero of the wildfires, where we have 10,000 displaced persons living in tents with medical and, of course, great dental needs. So we've written grants that have been approved, and we are now getting mobile dental units. So we're flying to Lahaina to teach dentists in Hawaii and non-dentists and actually physician teams, medical teams. to do exactly what you said, Dr. Phil. Amazing, amazing stuff. Yeah. You certainly have a tremendous passion for this. And I'm happy for you, Dr. Frachella, that you found something that you think is the right thing to do. It's conservative. You've been doing this a long time. And I think you certainly have found your purpose in life. As they say in Japanese, ikigai, which means purpose. That's what gets you out of bed. Everybody needs that. to stay happy and driven and motivated to live. You need purpose. You need ikigai. You certainly have that with this approach, this conservative dental approach of treating patients with silver diamine fluoride and glass ionomer, patients that would otherwise may never get the kind of dental care they need to save their teeth. So hats off to you for what you are doing. for the profession, for humanity. And we really appreciate having you on the show to share all this incredible stuff. Thank you so much. Thank you so much, Dr. Phil.