Dear mr. Laurisch thank you for your time, and profusely answering our questions. Let’s go directly to them.
When did you start intensively introducing the prevention to „everyday routine“ of your work?
In the early 1980s, Axelsson P. in Sweden showed that continuous professional plaque removal was able to significantly reduce the prevalence of caries. However, this publication primarily referred to the care of periodontally diseased patients. At the same time, the prevailing plaque theory changed. While Axelsson assumed that the plaque was pathogenic per se, Loesche W. J. was able to show that the plaque consisted of both caries-promoting germs and germs that did not pose a risk of caries because they were not able to metabolize carbohydrates into acids. These findings were implemented in our practice from 1985, although the general conditions were extremely unfavorable. The mainstream that prevailed at the time actually did not allow pursuing a restoration avoidance, especially since there were no accounting positions at all with the insured for preventive measures or advice. One was forced, so to speak, to provide preventive services free of charge as an accompanying service with a restorative measure. From the integration into our practice, it has therefore turned out to be very advantageous to start with the prevention with the children. Parents – themselves affected by dental problems – naturally wished for “better” or healthier teeth for their children. This was a favorable starting point for our prevention. Experience has shown that the children in the family were the first members to receive preventive services. The parents saw the reason and success of our efforts and of course wanted to take advantage of these services.
What was the spark for your deep interest in prevention?
In the book by Bo Krasse: Caries risk – a practical guide for assessment and control (1985). Here, for the first time, the bacterial aspect of the disease and the connections were clearly described. From that point on, saliva diagnostics became a crucial aid in assessing a patient’s health or illness. It was also impressive for the patients that suddenly the „mechanical performance“ of oral hygiene was associated with a disease caused by certain bacteria. The entire preventive care concept opened up at once under a medical aspect. It was no longer just about brushing your teeth. It was about controlling an infection of the oral cavity with germs relevant to caries. In particular, therefore, also about Streptococcus mutans. In the course of the following 40 years, the plaque theory changed again: but the germs Streptococcus mutans and lactobacilli, which have been identified since the 1980s as being important for the caries process, are still there and continue to play a decisive role in the carious disease process. The fact that Streptococcus mutans is a first colonizer of the infant’s oral cavity and its ability to form extracellular polysaccharides contributes significantly to the prevalence of caries.
Is it necessary to diagnose all risk factors?
Nor two patients are the same – patients are interindividually different. But the individual patient is also different depending on their age. Every age entails different risks for dental health. What the child or young person needs in terms of preventive services is not what he might need as an adult or as a „senior“. It is therefore important to know age-related risk factors in preventive care and also to determine these in the patient. Since caries and periodontitis are multifactorial diseases, we should know these factors and determine them in the patient. It’s much easier for us to prevent caries than to prevent periodontitis. While genetic factors often also play a role in the latter, this area is almost completely absent in caries prevention in most patients. If we then not only rely on what we see clinically in the risk assessment – i.e. anamnestic and clinical findings – but also determine subclinical parameters such as the number of cariogenic microorganisms (S.mutans and lactobacilli) and functional saliva parameters, we get a more complete picture of the patient’s health status or disease risk. Our diagnosis is therefore no longer limited to the question: is plaque or caries present or not? Risk determination leads to a more comprehensive diagnosis and thus also to a much more differentiated therapy. The more extensive our diagnostics, the more targeted our therapy will be. At the same time, we also gain an opportunity to objectively check the success of our prophylactic measures and the compliance of the patient. But ultimately it is always important not only to know what risk factors are present, but also what these risk factors can cause. This is the prerequisite for diagnosis-based individual prophylaxis.
Have the proceeds of your prevention interest evolved over time and how?
When prevention was introduced in practice – due to a lack of billing options – prevention was of course deficient. However, this has changed from the moment charging codes were introduced, allowing preventive measures to be billed to the patient. The preventive service area is now an essential business pillar for the management of the practice. It should also not be forgotten that the personnel costs must be also taken into calculation, this means: that the employees not only earn their own salary, but also increase the earnings of the practice. Unfortunately, many practices try to calculate the cost of the first prevention session. In my opinion, you should never calculate the first prevention session from a business point of view – it just doesn’t pay off. What can be achieved in the first prevention session is to get the patient excited about prevention and our practice goals. This often sets a chain of needs in motion: the patient not only wants clean and healthy teeth, but later maybe also whiter teeth, straighter teeth, healthier gums, „better“ dentures, etc. It is this hierarchy of needs that ultimately brings the economic profit for the practice, and not a perhaps overpriced, economically calculated first prophylaxis session.
This is an important moment that you are talking about, how to organizationally ensure that prevention is a connecting line across the entire operation, such a red thread. How to have the internal processes set up correctly?
It is important to tell the patient from the beginig that the carious defect in the tooth is only a symptom of a comprehensive disturbance of the oral biome. This can only be achieved by a complete change in the treatment system. The patient is used to going to the dentist and, after a brief initial examination, receiving immediate restorative treatment. The connection between dentist and „drilling“ is thus „algorithmically“ stored in the patient’s mind. This system must be changed. Therefore, in the first session with the patient should not be treated invasively at all – of course, pain elimination is excluded from this. The content of the first session with the dentist should be exclusively diagnostic and consultative. The conversation that follows should convey to the patient that the preventive measures we offer him serve to keep his teeth healthy. Only if he has a basic technical knowledge, he will be able to understand this treatment goal. For the organization of the practice, this means that after the first consultation with the dentist, the next session takes place with a prophylaxis employee. Only after this session does any necessary restorative or conservative treatment take place at the dentist’s office. This is then the patient’s third visit to the practice.
Cooperation with the patient is inherently related to this. Many dental professionals strive for comprehensive primary prevention, but often the cause of the failure is the patient himself, whether through his reluctance to cooperate, insufficient motivation to stick to the set preventive program, or simply because of ignorance. How do you work with your patients in your practice?
The foundation and permission for prevention-oriented dentistry is the conversation. This discussion must serve to provide the patient with professional background information about his or her disease, so that the patient is able to recognize his or her own disease, and so that he or she is able to appreciate and accept the individual health-promoting measures we offer. Motivational aids here are image magnifying aids such as an intraoral camera. This shows the patient a magnified image of his problems. He thus clearly recognizes that he is affected by the disease.
Saliva tests are the next important motivating factor. Regardless of the fact that the determination of bacterial and functional saliva parameters is necessary for our diagnostics, the result of these tests is another important motivating factor for the patient. He realizes that dentistry is not only a localistic – mechanical measure, but treats a medical problem. This is usually a completely new insight for the patient, which is also a strong motivating factor.
Finally, allow me to ask a more personal question. How do you keep up with it all? You have a huge publishing activity behind you, several inventions and patents, you give lectures, you are actively involved in professional groups in Germany also in the world, and at the same time you are a practicing everyday dentist in a small West German town?
Usually, the practice time is divided into a morning and an afternoon consultation. This usually results in a treatment time of 6 -7 hours a day. I have organized my practice time differently. I work in weekly rotation either from 7.30h to 13.30h – continuously. In the other week I work from 13.30h to 19.00h. This leaves enough time to take care of other things, provided you have the motivation to do so. If this is present, one has energy and time to deal with other issues in dentistry.
Basically, however, the core question always remains: why did I actually become a dentist? And when answering this question, there are of course many different possibilities, which in turn also influence the motivation to continue to deal with the content of the profession after the treatment period.
- Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. Results after 6 years; P Axelsson, J Lindhe; PMID: 6947990 DOI: 10.1111/j.1600-051x.1981.tb02035.x; https://pubmed.ncbi.nlm.nih.gov/6947990/
- Role of Streptococcus mutans in human dental decay; W J Loesche; PMID: 3540569 PMCID: PMC373078 DOI: 10.1128/mr.50.4.353-380.1986; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC373078/
- Historical and contemporary hypotheses on the development of oral diseases: are we there yet?; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4100321/