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Dr. Whitehouse: Many practitioners, especially members of WCMID, have successfully charged for caries testing, or the application of CAMBRA. The value provided to the patients is communicated by helping them control the disease that has, in many cases, negatively impacted their lives and dental health. I have found that patients are very willing to embrace a course of action that will reduce the disease process. There are two portions of CAMBRA: the risk assessment form that will identify the habits that lead to risk and, secondly, the testing that can quantify the biologic risk factors such as acid production and saliva flow. There is no charge for the first portion, but prices vary for the quantifiable tests such as Ivoclar Vivadent's Caries Risk Test, Saliva-Check by GC America, or Cari-Free by Oral Biotech. Costs for CAMBRA range from $35 to $70. In my office, our regimen includes initial testing, antimicrobials and zylitol, and a charge for 5,000 ppm fluoride tooth paste and MI Paste. Patients are aware that their dental benefits probably will not pay for this caries control program, but nearly all accept it for its benefits. If any benefits program is billed and pays, patients do appreciate it.
Dr. Whitehouse: Restoring endodontically treated teeth do not, in my opinion, fall into a single category but must be assessed case by case with an MID approach. For example, if a tooth requiring a root canal due to decay on the facial aspect could be restored with a composite or an inlay, the tooth would be much stronger than if a crown were placed. The same goes for an anterior tooth with proximal decay. Too many anterior lateral incisors and lower incisors have broken because the crown preparation took away valuable supportive structure. A glass post alone may be beneficial in these cases. When dentistry comes from a paradigm of crowning all root canal treated teeth, it takes time and focus to adopt a less invasive approach. There are many teeth that I do not crown but, instead, selectively place the restoration that will enable the tooth to survive the longest, often with onlays. In fact, I rarely place crowns; I usually use the remaining good tooth structure and an onlay and, perhaps, a post to accomplish this outcome. I do believe that a prefabricated post may be more important, in some cases, than crowning teeth. This is because the reduction for the crown robs the tooth of some of its inherent strength. Bondable posts along with onlays, if appropriate, are the most common restorations for root canals in my office; but placing no onlays/crowns is common, also. MID seeks to find the best long-term outcome for the remaining tooth structure; its aim is not to compromise that structure by uniformly providing a crown for teeth that have undergone a root canal, however financially profitable such a policy might be.
Dr. Whitehouse: There are several factors to be looked at when a patient does not respond to initial CAMBRA intervention. The first question you want to ask is whether the patient was at high risk from the outset? If so, it normally takes more effort and time to treat a biofilm that is notoriously complex. The latest research tags 23 bacteria as implicated in the caries process. Because of this complexity, it may take multiple long-term cycles of therapy to reduce the impact of caries. Dr. John Featherstone’s Caries Balance Model includes risk factors that inhibit a move from cariogenic bacteria to a better balance in the biofilm. For example, in a case where response is not taking place, you want to ask whether the patient has encountered a new risk, such as medication that decreases saliva flow. If so, this would lesson the protective action that saliva naturally provides. Other questions you would want to ask include: Is the biofilm in this patient more highly populated with acid producing bacteria than other patients? Has the patient, in fact, followed the regimen prescribed? Because caries is transmissible, is the patient being reinfected? Should something be added to the regimen? For example, have you provided zylitol? Antimicrobials? Fluoride varnishes? pH neutralizing dentifrice? dietary counseling? Initial decay removal? The main factor in helping a patient control he/her disease is continuous monitoring with testing, observation with a Diagnodent, and x-rays every three months.
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