Making Dental Prevention Pay

An Expert Interview With Pamela Maragliano-Muniz, DMD

Laird Harrison

October 13, 2011

October 13, 2011 (Las Vegas, Nevada) — Editor's note: Many dentists have struggled to implement Caries Management by Risk Assessment (CAMBRA), a protocol for identifying patients at high risk for caries and providing them with intensive prevention.

A presentation on CAMBRA was featured here at the American Dental Association (ADA) 2011 Annual Session, held October 10 to 13. Medscape Medical News interviewed presenter Pamela Maragliano-Muniz, DMD, a prosthodontist and assistant clinical professor at Tufts University in Boston, Massachusetts, whose team won the ADA's 2010 Adult Preventive Care Practice of the Year.

Medscape: Why did you decide to try CAMBRA?

Dr. Maragliano-Muniz: Our hygienist, Dona Roberts, RDH, got very interested in it because her grandmother lost all her teeth while Dona was living with her. We tried to implement it exactly the way it was written in November 2007 in the Journal of the California Dental Association, but we had problems with it. We had issues of compliance, particularly with chlorhexidine.

Medscape: How did you modify it for your practice?

Dr. Maragliano-Muniz:We didn't use a lot of the questionnaires. They are very time-consuming. We designed our own system. It's a sticker format; part of the chart is dedicated to CAMBRA, and the hygienist circles all the risk factors and places a star next to the high-risk factors. And we added some risk categories. For example, if you have a bridge in your mouth, the biggest cause of failure for a bridge is caries, so why not prevent that? If you had just 1 high-risk factor, we treated you as a high-risk patient. We find that dentistry is not just a science, it's an art, and we needed an individualized approach.

Medscape: What kind of practice was this?

Dr. Maragliano-Muniz: All of the restorative doctors were prosthodontists. The practice had been around for 35 years, so the patients' average age was 63. All our patients were at high risk for caries.

Medscape: What procedures did you include?

Dr. Maragliano-Muniz: Instead of this whole CAMBRA kit, we narrowed down the products to a fluoride varnish with calcium phosphate and a paste with fluoride and calcium phosphate. The fluoride varnish is an in-office procedure, and we dispense the paste to the patients with instructions for using it at home. Sometimes we recommend over-the-counter products such as xylitol gum, a baking soda rinse, or dipping a toothbrush in baking soda before brushing. We didn't prescribe a lot of chlorhexidine. There are a lot of organisms in plaque, some of them beneficial, so to go in and kill everything — I don't know if that's the best for my patient.

Medscape: Did you do any saliva tests?

Dr. Maragliano-Muniz: There were a few patients in whom we still weren't sure why they were getting caries. For these patients, we did bacteria tests and pH tests, and sometimes prescribed chlorhexidine.

Medscape: What kind of results did you get?

Dr. Maragliano-Muniz: We were getting really good results, so we did a chart study and looked at 132 patients. Of 254 new carious lesions, we were able to reverse more than 200. We found we were able to reverse caries in every oral hygiene category. I just submitted a paper on remineralization of root caries.

Medscape: If you prevent cavities, where does the practice get its income?

Dr. Maragliano-Muniz: It had a tremendous impact on our practice. Dona, by herself, brought in an extra $50,000 in 2008. We saw a tremendous number of referrals. It's mostly word of mouth, but we also got some physicians referring to us. We would contact physicians and let them know that their patients were at high risk for caries. In return, the physicians referred us some of their other patients. We charged $35 for the varnish and $17 to $20 for the paste. We recalled patients every 3 to 4 months.

Medscape: Did the patient's insurance cover this?

Dr. Maragliano-Muniz: Insurance is getting better. We had the patient pay for the varnish up front, and then we submitted the claim to the insurance company. If the insurance paid, we reimbursed the patient.

Medscape: How did you persuade the patients to accept this approach?

Dr. Maragliano-Muniz: Dona went out of her way to communicate with the patient. She kept in constant contact with them by email. I have to say, it was very exciting. The patients were happy, we got more referrals, and the practice was more profitable.

Dr. Maragliano-Muniz has given paid webinars for 3M, the maker of the fluoride varnish and paste products she prescribes. She also markets instructional material on the prevention of caries, which she helped develop.


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