To fill or not to fill: That is the question

2009 12 11 14 00 01 405 Second Opinion

One of the greatest challenges facing dentistry is the lack of agreement among dentists regarding how to consistently manage dental disease after it has been diagnosed. Two providers will often not agree on the proper treatment protocol indicated because there are no consistent guidelines for managing different levels of disease. This can lead to very different treatment plans between dentists and confusion for the patient.

This inconsistency should be a call to action as we develop quality measures, refine treatment protocols, and continuously improve educational objectives. It is also an opportunity to design better compensation systems.

Once treatment guidelines are adopted, a standardized risk assessment tool, such as Caries Management By Risk Assessment (CAMBRA), can be used as a common dialogue for professionals when evaluating patient risk and developing a treatment plan. CAMBRA is a robust risk assessment and treatment protocol program that we employ at the DentaQuest Oral Health Center (OHC).

Does preventive dentistry work?

Since 1999, the DentaQuest OHC has made CAMBRA the core of its clinical practice. We have partnered with CAMBRA to develop CAMBRA-based resources for prevention and disease management for private and safety net dental programs. This includes protocols, tools, resources, and technical assistance to support oral health practitioners who are committed to incorporating CAMBRA concepts into routine clinical practice.

The reduction in rates of new disease at dental offices utilizing the protocols demonstrates that this approach is successful in arresting early disease and preventing new disease in at-risk children and adult patients.

By eliminating risk factors and boosting protective factors, we can be more comfortable in what James Bader, DDS, MPH, a research professor at the University of North Carolina School of Dentistry, referred to as "watchful waiting" in a recent New York Times article, "A Closer Look at Teeth May Mean More Fillings." And ultimately, we can keep patients out of the "drill and fill" cycle.

Diagnostic codes are key

Of course, patients need to partner with the dental team for this approach to work. They need to know their options and their risk. If they don't think they can manage their risk factors, then it may be appropriate to design different treatment plans to eliminate disease.

One way to move forward with quality and consistency in care is for dentistry to agree on a set of diagnostic codes, as John Yamamoto, DDS, MPH, vice president of Delta Dental, suggested in the New York Times article. Diagnostic coding would facilitate improved communication between insurers, providers, and, ultimately, patients. A defined set of disease descriptors would lead to more predictable and reliable treatment planning.

If a provider is able to code a lesion as incipient and not in need of restoration, this could trigger a set of benefits and compensation to activate a disease management protocol. If the provider codes a lesion as cavitated, that could trigger a different protocol and compensation designed to incent the most minimally invasive restorative procedure(s) possible.

The bottom line is that we need to focus on a patient-centered quality approach and on prevention and disease management. Today's patients are becoming more and more aware of the concept of overall wellness and their ability to proactively manage their health, reverse undesirable conditions, and adopt lifestyles that help to prevent disease. We need to agree on quality guidelines and diagnosis- and risk-assessment tools.

We need to do better for our patients.

Peter Blanchard, DDS, MBA, is director of evidence-based practice at the DentaQuest Oral Health Center in Westborough, MA.

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