A Guide to Selecting Preventative Products for Your Practice

Treating patients' oral health problems once they present is a lot, if not most, of what you do. It is also mostly what insurance pays you to do. However, preventative care is also essential to your practice.

Jason Goodchild, DMD, Vice President of Clinical Affairs for Premier Dental Products Company, says a frustrating problem is the business of dentistry doesn't reward prevention. Dentists get paid when treating a cavity, not when preventing one. 

"It makes me feel like a tooth carpenter versus a dentist because I get paid when I fix something, not when I prevent something," Goodchild says. 

Preventative care has a lot of components. Jeff Lineberry, DDS, FAGD, says his practice's preventative care appointment includes diagnostic imaging, oral cancer screenings, prophy, and polishing. Lineberry is also a firm believer in Dr. Bob Barkley's philosophies about patient education and treatment consultation.

"Dr. Barkley spoke highly about getting patients involved and active in their home care. It's not about just coming to see us twice a year to get your teeth cleaned. It's about getting patients involved in their oral health," Lineberry says.

However, preventative dentistry has also overlapped with restorative dentistry in recent years. Bioactive restorative materials are working to prevent the necessity of further future treatment. John Kanca, III, DMD, CEO and chemist for Apex Dental, thinks this direction of development over the past several years in restorative materials could provide a new way to provide preventative care for patients. 

“As clinicians, we are now equipped with materials that can do more than fill a void. These materials can play an active role and provide ongoing treatment within a restoration,” Kanca says. “This is exciting and is leading to overall better long-term patient outcomes.”

Here's what the experts had to say about optimizing the preventative appointment and selecting the right preventative products for their practice.

It Starts with Scheduling

Goodchild says a significant part of dental preventative care is the recall hygiene schedule. It's not only a prophy appointment with exams and radiographs but also an opportunity to provide preventative care and diagnosis.

"That part of general or pediatric practice is the lifeblood of the entire practice, and so getting that schedule solid, efficient, and running well is vital to the practice," Goodchild explains. "Dentistry is about prevention."

Lineberry agrees, adding that you need to provide enough time to get to know your patients. An essential part of preventative care is understanding your patient's history, what they are doing and what they aren't, their nutrition, and how they are brushing and flossing. 

Make Sure Hygienists Have Everything They Need

Lineberry says it is vital that hygienists have all the tools they need to do their jobs properly. After the COVID-19 pandemic, ultrasonics have been sidelined for the moment in some states, making hand instruments the preferred method for a prophy. 

"To make your hygienist more effective, honestly, they should be using magnification and illumination, just like we do in restorative care," Lineberry says, adding that his hygienists won't practice any other way now. 

Diagnostic Imaging is Now Crucial to Preventing Significant Problems Later

Imaging is crucial to preventative care. Radiology has always provided insight into what is happening in the patient's oral cavity. 

Intraoral cameras are another way you can use imaging to prevent significant issues from moving forward. Kim Miller, RDH, BSDH, says using the intraoral camera at every hygiene visit to do a video tour of the patient's mouth can take advantage of the magnification, and patient engagement benefits the cameras provide.

"Isolating those areas where the patients existing dentistry is failing will allow you to replace that existing dentistry in a preventive way before it becomes emergent or an urgent situation to manage for the patient," Miller says. 

Miller says that using the intraoral camera for preventative care can also identify other treatment opportunities. For example, it can reveal crowding, which indicates the patient is a candidate for Invisalign. Straightening the teeth can prevent future interproximal decay and periodontal disease that is often related to crowding in a patients' mouth. It can also expose abfraction from clenching and grinding, which, if left untreated, can require jaw treatment to correct a temporomandibular joint disorder (TMD).

"Finding TMD early can prevent major problems for the patient moving forward," Miller says.

Imaging technologies also detect carious, precancerous, and dysplastic lesions when they are small and less destructive. Goodchild says the best instrument is the one you use rather than the one sitting on your shelf. Products like VELscope^®VX enhanced oral assessment system (Apteryx Imaging), ViziLite^® TBlue oral cancer screening system and ViziLite PRO^®oral lesion screening system (DenMat), DEXIS CariVu™ portable caries detection device (Henry Schein), DIAGNOdent™ Pen decay detection from (KaVo Kerr), and Goccles^® (Pierrel) are imaging tools that can help you detect oral cancer and other carious lesions. 

"All of this technology is good when you understand how it should be used, how you should interpret it, and what it means for the patient," Goodchild says. 

Miller also recommends that you do a tactile exam for head and neck cancer, in addition to the oral cancer screening. Globally, there are around 650,000 cases of head and neck cancer and 330,000 deaths from it every year.¹ In the U.S., there are 53,000 cases and 10,800 deaths from head and neck cancers.

Lineberry has been using DIAGNOdent for about 15 years. He finds it to be a useful caries detection tool for patients and not only for him.

"Patients are very aware of the noise it makes when it takes a reading," he says. "It is also helpful when you are monitoring areas to see how much the reading increases over six months. It gives you something to look at and discuss with patients."

Lineberry uses a camera to take extraoral pictures also. He says the images allow the patient to engage about things they would like to improve in their smile, from cosmetic treatments, like whitening, to other therapeutic or corrective procedures. Lineberry says he appreciates how the pictures start a conversation about treatment planning. 

"It's a whole different situation when patients are talking to you and asking questions versus you telling them," he says. 

Fluoride Varnish Products Can Make a Difference in Patients of all Ages

Miller says that fluoride has many benefits for preventative dental goals. Fluoride not only helps prevent tooth decay, but it also encourages remineralization and protects against root caries, as well as managing the symptoms of patients with Xerostomia. Moreover, fluoride can protect the margins and integrity of a patient's existing dentistry. Most practices prefer fluoride varnish because of its prolonged activation. For example, 3M™ Vanish™ with 5 % sodium fluoride white varnish with calcium phosphate has an extended-release formula designed to release fluoride for up to 24 hours.

Moreover, fluoride treatments are associated with children and not adults. However, Steve Jones, head of international sales for Centrix Dental, says that this is a mistake. 

"Preventive dentistry and fluoride treatment, in particular, are not just for children. A simple applicate of fluoride varnish is extremely beneficial to patients of all ages and should be part of most hygiene appointments," Jones says. 

"The benefits of fluoride varnish do not stop at 16 just because the insurance stops paying for it," Goodchild agrees. 

Moreover, Jones says caries are increasing in the adult population for all age groups above 18. The National Institute of Dental and Craniofacial Research published the following statistics from 2018:²

• 92% of adults aged 20 to 64 had dental caries in permanent teeth, and 26 percent of them have untreated decay³
• 93% of seniors aged 65 and up have dental caries in permanent teeth, and 18 percent of them have untreated decay⁴

Centrix Dental’s number one product is FluoroDose, a fluoride varnish that contains five percent sodium fluoride (22,600 ppm of fluoride). After coming into contact with saliva, it dries within seconds and then remains on the tooth for four to six hours to optimize the fluoride uptake. In addition to the clinical benefits, Jones thinks that the appeal of the Centrix offer to clinicians is the quick, easy application and cleanup. Also, the smooth texture feels less gritty to patients, making them more comfortable leaving it on for the recommended time and ensuring the fluoride uptake. 

"The flavors are terrific, and it goes on the teeth smoother than the others, so patients love it," Jones says. 

Miller says sometimes patients do not want to use fluoride on their teeth for various reasons. In those cases, she recommends having MI Paste^® (GC America), which uses RECALDENT™ that comes from milk protein and releases amorphous calcium and phosphate to the surface of the teeth. 

"It binds with our saliva and helps the teeth to re-mineralize, which is a natural event our bodies are designed to do," Miller explains. 

Silver Diamine Fluoride (SDF) is another product with significant preventative benefits. Although the FDA approves it as a desensitizer, it can also arrest caries. Goodchild thinks it can be another useful preventative tool for patients at high risk for caries.

"It's especially great for geriatric patients and little kids that come in with massive decay on their primary dentition," Miller agrees. 

Make Restorations Part of Your Preventative Care

Traditionally, preventative materials seem like what happens before you need a restoration. However, Kanca says bioactive restorative material development is changing from simply replacing tooth structure to taking an active role in healing and preventing future recurrent decay. 

“The concept is simple: place a bioactive material directly in contact with the tooth so the two can interact and become homogeneous over time.  The result is a restored tooth where the transition between tooth and the restoration is difficult to define that eliminates any potential leakage or failure, while preventing recurrent caries,” Kanca explains.

Challenges with previous restorative materials claiming to interact with tooth structure, like those that release fluoride or calcium and phosphates, is that they often ran into problems, Kanca says. 

“Fluoride doesn’t create a bio-response and the more complex materials were separated from the tooth surface by a bonding agent,” Kanca says. “How could the interaction take place unless the adhesive layer was porous or flawed?”

Kanca says this challenge inspired work on creating a bioactive bonding agent to allow intimate contact between the tooth and restoration. This concept led to RE-GEN™ Bioactive Adhesives, which used Bioglass, a material used in hip and knee replacements since the 1970s. By taking advantage of proven science from other disciplines, the bioactive components were in direct contact with the tooth and the two could interact and facilitate the desired bio-response. 

“In the decades I spent working toward improving restorative results, these are the most exciting times since wet bonding and acid etching.  Keep your eye on this technology as we continue to move forward,” Kanca says. “We could be experiencing a paradigm shift and a new way of providing preventative care for our patients.”

Helping patients manage Xerostomia. 
Patients experiencing dry mouth are more susceptible to decay and other oral health problems. Finding ways to lubricate the oral cavity for these patients is essential to preventative dentistry. 

There are many products available to treat Xerostomia. 3M™ has Xerostomia Relief Spray and TheraMints™ with 100% Xylitol that help manage the symptoms. Premier offers Enamelon^®, a high-fluoride toothpaste that also lubricates the oral cavity, while the Bioténe^® products are another line that addresses these issues. 

For your patients who shy away from chemical or fluoride in general, Miller recommends homeopathic products to combat patients' dry mouth symptoms. She recommends StellaLife Gel, a certified homeopathic plant-based product for treating dry mouth and mucositis. 

"StellaLife has a line of products that are completely homeopathic that are front-loaded with things like echinacea and calendula that are known for centuries to reduce inflammation and help to heal," Miller says. 

Goodchild says you should base your product recommendations on the individual case. A patient experiencing dry mouth as a side effect from medication might have different needs than a patient who recently had cancer treatments and is now having problems with their salivary glands. 

"The best approach is to try all of them until you find the one that works for you," Goodchild says. 

Find a Hydrophilic Sealant

Sealants prevent pit and fissure caries. The CDC says that dental sealants prevent 80 percent of cavities in posterior teeth, where 90 percent of cavities occur.⁵   

Placing sealants used to be a massive ordeal because the teeth had to be completely dry. Miller says new sealants have changed that. Products like the 3M™Clinpro™ Sealant have a low viscosity to flow smoothly into pits and fissures, and they also release fluoride. Hydrophilic sealants, like UltraSeal XT™ hydro (Ultradent Products), do not require the environment to be too dry. 

"Now, sealants are super easy to place because they are hydrophilic," Miller says. "Having moisture on the teeth draws the sealant into the pits and fissures."

Consider Proactive Protection Against Periodontal Disease

Prevention of periodontal disease is an essential component of preventative dentistry. In 2012, the Journal of Dental Research published a study based on research in 2009 and 2010 that suggested that 64.7 million adults had periodontitis (47 percent of the sample).⁶

Miller believes it is essential to offer patients Perio Trays^® by Perio Protect. The trays treat periodontal disease once it presents or prevents it in patients at high risk. Using a 1.7 percent H₂0₂ slow-release gel, the tray design draws the gel into deep pockets, destroying pathogenic biofilm.

'The trays create a mini-hyperbaric chamber around every tooth," Miller explains, adding that she and her husband both use the trays; his for treatment, hers for prevention. 

Don't Forget About the Benefits of the Product

When it comes to products, there are many options to choose from, which leads to commoditization. For example, dental professionals often consider dental hygiene products like prophy angles or paste and fluoride varnishes commodities, leading to the hunt for the best deal. 

Goodchild says to be careful about putting price first in your decision-making. There are other advantages to consider, like the ingredients, delivery system, flavors, or even packaging. 

Jones agrees. For example, Centrix uses single-use packaging for FluoroDose and its other preventative product lines. Initially, the main benefit was that it was easy to use, but in today's post-pandemic environment, it prevents cross-contamination. 

"In this new era, it is important to remember that more than just PPE needs to be incorporated into practice to provide the required level of safety for both practitioner and patient," Jones explains. "When performing preventive dentistry, and for that matter, all of dentistry single patient use packaging is a very effective and proactive way to prevent cross-contamination."

"If it were just a race to the bottom for the price, there would be no differentiation in products," Goodchild says. "So, dig into those details and find the product that supports your practice model to prevent as much as possible and provide the best patient experience."

References

1. Stenson, Kerstin M. “Epidemiology and Risk Factors for Head and Neck Cancer.” UpToDate, Wolters Klewer, 21 Jan. 2020, www.uptodate.com/contents/epidemiology-and-risk-factors-for-head-and-neck-cancer#:~:text=Worldwide%2C%20head%20and%20neck%20cancer,from%20the%20disease%20%5B2%5D. Accessed June 10, 2020.
2. Dental Caries (Tooth Decay). Nidcr.nih.gov. https://www.nidcr.nih.gov/research/data-statistics/dental-caries/seniors. Published 2018. Accessed June 10, 2020.
3. Dental Caries (Tooth Decay) in in Adults (Age 20 to 64). Nidcr.nih.gov. https://www.nidcr.nih.gov/research/data-statistics/dental-caries/adults. Published 2018. Accessed June 10, 2020.
4. Dental Caries (Tooth Decay) in Seniors (Age 65 and Over). Nidcr.nih.gov. https://www.nidcr.nih.gov/research/data-statistics/dental-caries/seniors. Published 2018. Accessed June 10, 2020.
5. Help children avoid cavities. Centers for Disease Control and Prevention. https://www.cdc.gov/vitalsigns/dental-sealants/index.html. Accessed June 10, 2020.
6. Dye, B.A., et al. "Prevalence of Periodontitis in Adults in the United States: 2009 and 2010 - PI. Eke, B.A. Dye, L. Wei, G.O. Thornton-Evans, R.J. Genco, 2012." SAGE Journals, Journal of Dental Research, journals.sagepub.com/doi/pdf/10.1177/0022034512457373.