Dentistry’s Proactive Role in Preventing Disease

It is interesting to note, however, that preventive dentistry was not widely practiced in the United States until the 1960s. Dr. Alfred C. Fones championed the concept of preventive dentistry in the early 1900s and is considered to be the founder of “preventive dentistry” and father of “dental hygiene.” Dr. Fones was concerned about the number of patients losing their teeth due to dental caries and periodontal disease and the fact that dentistry was only reactive to oral diseases rather than proactive with prevention. He argued that millions of dollars in public and private funds were spent to restore the sick to health, but only a very small portion of funds were used to maintain the health of well people. As a result, Dr. Fones trained the first dental hygienist in his office to perform dental prophylaxis and later opened the first dental hygiene school, Fones School of Dental Hygiene, in Bridgeport, Connecticut, in 1913.

Today, preventive dentistry and dental hygiene play prominent roles in any successful dental practice. The dentist’s primary function in preventive dentistry is to implement protocols for performing a thorough comprehensive oral examination and to work in collaboration with the dental hygienist in establishing a preventive maintenance program individualized to each patient’s specific need. The dental hygienist’s primary role is to promote oral health through proper screening techniques, delivery of preventive care, management of disease, and patient education in nutrition and healthy lifestyle choices.

Even with all of dentistry’s efforts, however, dental disease continues to be a major public health concern. Tooth decay continues to affect more than 40% of US children aged 2-11 years and approximately 59% of children 12-19 years old.^1,2 Periodontal disease affects about 50% of adults in the United States, and the Centers for Disease Control and Prevention (CDC) is reporting a rise in the number of oral cancer cases seen in the US year over year. More than ever, establishing and implementing sound protocols for performing a comprehensive oral evaluation in an effort to prevent or manage dental disease in its earliest stages is vital for the overall health of dental patients.

Although tooth decay continues to be the most common oral disease in dentistry, it is largely preventable through healthy habits and good oral hygiene. Early detection and management of incipient decay and patient education is essential for an individual’s long-term oral health. Caries management by risk assessment (CAMBRA) is a methodology embraced by many clinicians and implemented as a best practice into their comprehensive examination. The CAMBRA philosophy is designed to aid the clinician in accessing, preventing, and treating dental caries at the earliest stages. The examination philosophy takes into consideration biological reasons (risk assessment) for current or future tooth decay and assesses protective factors for prevention of future decay. Once a clinician has identified the patient’s caries risk, a therapeutic or preventative plan unique to the patient’s own risk factors can be implemented. The American Dental Association and several other professional organizations offer risk assessment forms that can help simplify or streamline the examination process. These forms can be downloaded from the Internet at no cost.

The CDC recently reported in the Journal of Dental Research³ that the National Health and Nutrition Evaluation Survey (NHANES) estimated 47.2% of American adults over the age of 30 have mild, moderate, or severe periodontitis. Prevalence rates rise above 70% for adults over the age of 65.3 This recent survey included for the first time a full-mouth periodontal examination. Earlier studies from NHANES used partial-mouth periodontal examination protocols, which are believed to have underestimated the prevalence of disease by as much as 50%.⁴ This more recent data supports the need for a complete full-mouth periodontal examination to be performed annually for adults as part of the comprehensive exam and preventive maintenance program. Perhaps the most important instrument a clinician has for evaluating a patient’s periodontal health is the periodontal probe.

Educating patients about the prevalence of periodontal disease and the prevention of it while involving them in the comprehensive evaluation will help create value for the examination and the proposed treatment plan. As more information becomes available about the association of periodontal disease to other systemic diseases, such as heart disease, diabetes, and stroke, it becomes more important than ever that the dentistry profession focus on the prevention and early intervention of periodontal disease, including the early management of gingivitis.

Perhaps the greatest opportunity for dentists to make a difference in the quality of care delivered to their patients is the oral mucosal examination. Oral cancer is on the rise, as, according to the Oral Cancer Foundation website (www.oralcancerfoundation.org, accessed October 19, 2012), 2011 marked the fifth year in a row in which the rate of this disease increased, and approximately 40,000 new cases of oral cancer are expected to have been diagnosed in 2012. Oral cancer has long been associated with middle-aged men and the excessive use of tobacco and alcohol, however an increased number of diagnosed cases is being linked to younger generations and exposure to the HPV-16 virus (human papilloma virus 16)—the same virus that is largely responsible for cervical cancer in women. Performing a thorough head and neck examination, including a thorough oral mucosal exam, is perhaps the best tool dentists have for the early detection of oral cancer.

Detection of oral cancer at an early stage significantly increases the 5-year survival rate.⁵ However, visual and tactile examination, coupled with subjective interpretation of the visualized tissue inconsistencies, has its limitations. For this reason, adjunct tools for assisting in the discovery of oral abnormalities may be considered. All clinicians, as well as dental hygienists, need to be aware of the technological advances in adjunctive screening devices and adopt them as appropriate.

As healthcare providers in the profession of dentistry, clinicians have a responsibility in the prevention and early detection of oral diseases. Establishing protocols and adopting technologies to enhance the comprehensive examination is paramount to the oral and overall health of dental patients. To paraphrase my mentor and good friend, Scott Benjamin, DDS, “Performing a quality comprehensive exam is actually performing a quality of life exam.”

Preventive dentistry is a cornerstone in the dental profession, and treating oral diseases requires a team effort. The dental hygienist plays a key role in the comprehensive exam, gathering data, educating patients on risk factors for disease, and collaborating with the dentist for an effective preventive and therapeutic treatment plan.

Jan LeBeau, RDH, BS
Director of Dental Hygiene
Pacific Dental Services, Inc.
Irvine, California