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October 2, 2009

Dear Dianne,

My boss went to a continuing education meeting where he learned about expanded use of fluoride varnish. He decided to mandate application of fluoride varnish on all our adult patients. His reasons were that varnish is very good at helping control caries and sensitivity, and that all patients benefit from it. Of course, there's also the extra $40 added to the patient fee.

What we're learning is that dental benefits do not cover adult fluoride treatments, and many of our patients are irate over this issue. One patient said she felt it was “overtreatment.” Some patients complain about the unpleasant feel of the varnish on their teeth. I know the doctor wants us to push this, but I feel very uncomfortable with the whole premise. It feels like a way to gouge people, like a money thing. But I also know fluoride varnish is a very good product. Can you help me see how I should approach this problem clearly?
Needing Clarity

Dear Needing,

Several issues have surfaced in your question. First, it sounds like the doctor heard about using fluoride varnish treatments as a “profit center” in the practice. Touting any treatment as a “profit center” reeks of questionable motivations and leads to unnecessary treatment. Yet the math is impressive. Consider eight adult patients each day at $40 per fluoride each. That's an additional $320 each day. Multiply that by four days and you get $1,280 per week. Multiply that by 48 weeks, and you get a whopping $61,440 additional revenue per year! Even if only half your adult patients get fluoride, that's $30,700, which is a significant amount. So it's easy to see why some doctors are quick to proclaim the benefits of fluoride varnish. The question is, who does it really benefit?

Does every adult patient need a fluoride treatment? To answer this we need a credible source. In May 2006, an article appeared in the Journal of the American Dental Association entitled “Professionally Applied Topical Fluoride ? Executive Summary of Evidence–Based Clinical Recommendations.” The ADA Council on Scientific Affairs compiled the article. This well–written and comprehensive information source recommends that we base our fluoride administration decisions on each patient's risk. In the panel conclusions, it is stated: “Patients whose caries risk is low, as defined in this document, may not receive additional benefit from professional topical fluoride application.” Low risk is defined for all age groups as, “No incipient or cavitated primary or secondary carious lesions during the last three years, and no factors that may increase caries risk.” Factors that increase caries risk include but are not limited to:

• Poor oral hygiene
• Developmental or acquired enamel defects
• Eating disorders
• Drug or alcohol abuse
• Active orthodontic treatment
• Xerostomia

The document further states, “Two or more applications of fluoride varnish per year are effective in preventing caries in high risk populations.” Read the whole document for more information on risk factors and levels at http://ebd.ada.org/ClinicalRecommendations.aspx.

Let's pretend that I'm your patient. I have excellent oral hygiene, I have not had any caries for over 20 years, I eat a healthy diet and avoid sugary drinks, I have no sensitivity issues, I have no medical problems that cause xerostomia, and I have none of the other risk factors. Do I need fluoride varnish? Absolutely not. In fact, the recommendations state there would be no additional benefit for someone like me. Fluoride varnish is not recommended for me based on my lack of risk factors.

How about Joe Blow, a 40–something patient with terrible oral hygiene and a high caries index? Would he benefit from fluoride varnish? Most likely, yes.

We are taught to make clinical decisions based on need. Just as you would not recommend orthodontics to a patient with straight teeth, no TMJ issues, and perfect bite, you should not recommend fluoride varnish to patients without certain risk factors. Blanket mandates on treatment are seldom appropriate for every patient.

Another issue is the unpleasant feeling of fluoride varnish on the teeth. When the average person comes in for a professional “cleaning” visit, he or she enjoys that nice slick feeling from having the teeth polished. However, fluoride varnish leaves a waxy residue that is difficult to remove. It is most unpleasant to have fluoride varnish gunked all over the teeth. I'd wager that most dentists who push fluoride varnish on their patients have never had it applied to their own teeth.

If they experienced it, they might feel a little sympathy for their patients.

A third issue is benefits coverage. I do not know of any benefits carrier that covers adult fluoride varnish. So patients that are insurance–dependent are upset when they find out they have to pay out–of–pocket for something extra that was unpleasant and unwanted. Remember that to unpleasantly surprise a patient is to lose a patient.

Third party benefits become a side issue for people with multiple risk factors for caries. The evidence is clear that such patients benefit from topical application of fluoride, either fluoride varnish or a four–minute fluoride gel treatment. Those patients should have the benefits spelled out, and then be allowed to take part in the decision–making process.

A sure way to harm, or even destroy a dental practice is for patients to perceive that they're being ripped off. Patients aren't stupid! When they have an unpleasant experience in the office, they will tell 20 or more people. When we base treatment decisions on profit motive, we eventually lose patients' trust. If we lose their trust, we lose them and anyone they might have referred to us in the future.

After the death of my husband, I had to attend to my own car maintenance, which was totally foreign to me. Once when I took my car for an oil change, the mechanic told me I needed a very expensive brake job. He expounded on the dangers to my car and me if I procrastinated. For some reason, I doubted him. On my brother's advice, I took my car to a different garage for a second opinion. The mechanic removed my tires and inspected my brakes thoroughly. He could not find any reason to do a brake job on my car. Needless to say, the first garage will never get any more of my business.

We should treat people like we would want to be treated if we were in their position, i.e., fairly and ethically. To do otherwise is immoral, unethical, and just plain wrong.

My point is that all adult patients do not need fluoride treatments, but those with certain risk factors may benefit from topical fluoride. Fluoride varnish is a fabulous product that should be used where indicated. As with all clinical treatment, we should base the decision to use adjuncts on the patient's need and according to their risk factors, not on blanket mandates that may be inappropriate.

Best wishes,
Dianne

About the Author

Dianne Glasscoe–Watterson, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe–Watterson for speaking or consulting, call (301) 874–5240 or e–mail dglasscoe@northstate.net. Visit her Web site at www.professionaldentalmgmt.com.

by Dianne Glasscoe–Watterson, RDH, BS, MBA
dglasscoe@northstate.net

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