Authors: Marco Mazevet1, Stéphanie Tubert-Jeannin2 and Sophie Doméjean3
1) Dental Innovation and Translation Centre, King’s College London Dental Institute, United Kingdom
2) Public Health, UFR d’Odontologie de Clermont-Ferrand, Université Clermont Auvergne, France
3) Operative Dentistry and Endodontics, UFR d’Odontologie de Clermont-Ferrand, Université Clermont Auvergne, France
Corresponding author: Professor Sophie Doméjean, Operative Dentistry and Endodontics, UFR d’Odontologie de Clermont-Ferrand – Université Clermont Auvergne, 2 rue de Braga, 63100 Clermont-Ferrand, France.
Email: sophie.domejean@uca.fr
Abstract: Evidence-based guidelines and recommendations do not systematically translate into clinical practice. Minimal intervention (MI) in cariology is backed by a substantial amount of publications, recommendations by scientific societies as well as professional guidelines. However, studies have shown that for many French dental practitioners (DPs), MI is a therapeutic concept that is not used on a daily basis. This article proposes to compare the current best practices in MI in cariology with the declared frequency of performance by French DPs (when available), French dental health policies and health economics data in order to explore the barriers to implementation. Three phases of MI concepts in cariology were identified in the literature, with both high-quality evidence and support from various scientific and professional societies. Weak integration into daily clinical practice can be explained by various factors such as the lack of recognition in the French classification of medical and dental procedures (CCAM), the absence of funding by the National and Complimentary health insurances or the lack of continuing professional education. Adaptations to the CCAM, as well as improved resource allocations by the financers seem to be necessary in order to maximise the translation of current scientific data into daily clinical practice.
BACKGROUND
In a recent article (2016) Pegon-Machat et al., described the specificity of the French oral health system, essentially organised around a fee-for-service model.1 It is funded by a mix of public and complementary health insurance schemes as well as out-of-pocket money from patients. A national insurance body (Caisse Nationale) negotiates periodically with the medical and dental trade unions in order to establish a list of treatments eligible for partial, or total reimbursement. A national fixed fee (cap) may be applicable for each of these items, corresponding to the maximum level of reimbursement by the national health insurance. Other procedures can be partially reimbursed or completely funded by either private insurers or out-of-pocket money.
In June 2014, the General Classification of Professional Acts (Nomenclature Générale des Actes Professionnels or NGAP) (Table 1), in force since March 1972 gave way to the Common Classification of Medical Acts (Classification Commune des Actes Médicaux or CCAM) for the codification and billing of fees for procedures performed in dental practices in France.2 More recently, a new convention was signed on the 21th June 2018 by the French dental trade unions, the national health insurance (Union Nationale des Caisses d’Assurance Maladie or UNCAM) and the union of complimentary health insurers (Union Nationale des Organismes d’Assurance Maladie Complémentaire or UNOCAM). The different parties reaffirmed their desire to rebalance the remuneration and funding of dental procedures towards more preventive and conservative care.
The CCAM allows the identification of each medical procedure by a specific code, regardless of whether this procedure is financed by the French National Health Insurance.2 Article I-6 states that: “Each code describes a global procedure that includes all the actions necessary for its realisation, at the same time of an intervention or examination, in accordance with the acquired scientific data and with the description of the procedure in the list”. It is important to underline that the procedures are suggested by learned societies and confirmed by the High Authority of Health (Haute Autorité de Santé or HAS).
The creation of the CCAM has crystallised many hopes among dental practitioners (DPs); indeed, the NGAP was obsolete and poorly adapted to scientific developments, particularly in the field of cariology. Over the last two decades, knowledge about the carious process as well as the technological developments of diagnostic devices and biomaterials in particular, have led to a change in the principles of care. The World Dental Federation (Fédération Dentaire Internationale or FDI) validated, more than 15 years ago, the principles of Minimal Intervention Dentistry (MID) in Cariology (first edition in 2002,3 update in 20174) (Table 2). MID is, overall, characterised by preventive and therapeutic strategies based on the individual caries risk of each patient. It embraces the domains of primary, secondary and tertiary prevention.5-10 More recently, in June 2016, the National Order of Dental Surgeons (Ordre National des Chirurgiens-Dentistes or ONCD) proposed a report entitled ‘White Paper’ with 23 measures aimed at responding to the identified dysfunctions of the French oral health system.11 One of these measures is to focus on prevention with strategies that should be guided by the preservation of dental tissues, thus embracing the general concepts of MID.
Nevertheless, despite the recent introduction of the CCAM, some inadequacies still persist between the registered dental procedures and current scientific evidence in cariology, which leads to a gap between evidence and dental practice in France. Indeed, it has been shown that, taking the example of dental sealants, French DPs are prone to change their practices and perform a procedure when it becomes registered in the general classification and thus financed by the French National Health Insurance.12 This narrative review proposes to examine current best practices of MI in cariology, and compare their registration in the CCAM for adequacy of clinical practice with the objectives that place prevention at the heart of the French national health strategy. Three phases of MID in cariology were identified: the diagnostic, the prophylactic and the restorative phases.13
TABLES
Table 1: List of acronyms
| Acronyms | Definitions | English meaning |
| CAMBRA | Caries management by risk assessment | |
| CCAM | Classification commune des actes médicaux | Common classification of medical acts |
| CRA | Caries risk assessment | |
| DCL | Deep carious lesion | |
| DP | Dental practitioner | |
| € | Euros | |
| FDI | Fédération Dentaire Internationale | World Dental Federation |
| HAS | Haute Autorité de Santé | High Authority of Health |
| ICDAS | International caries detection and assessment system | |
| MI | Minimal intervention | |
| MID | Minimal intervention dentistry | |
| NGAP | Nomenclature générale des actes professionnels | General classification of professional acts |
| ONDPS | Observatoire national de la démographie des professions de santé | National observatory of the demography of health professions |
| ONCD | Ordre national des chirurgiens-dentistes | National order of dental surgeons |
| PS | Preventive sealant | |
| PTE | Patient therapeutic education | |
| TS | Therapeutic sealant | |
| UFSBD | Union française pour la santé bucco-dentaire | French union for oral health |
| UNCAM | Union nationale des caisses d’assurance maladie | National health insurance |
| UNOCAM | Union nationale des organismes d’assurance maladie complémentaire | Union of complimentary health insurers |
Table 2: Minimal Intervention Dentistry (MID) according to the FDI (2017)4
| Overall statement: The aim of MID is to maintain as much healthy tooth structure as possible and – keep teeth functional for life. |
| Six major MID components: 1) Early detection of carious lesions and assessment of caries risk and activity; 2) Remineralisation of demineralised enamel and dentine; 3) Optimal measurements to keep sound teeth sound; 4) Tailor-made dental recalls; 5) Minimally invasive operative interventions to ensure tooth survival; 6) Repairing rather than replacing defective restorations. |
DIAGNOSTIC PHASE
The overall management of caries and the establishment of a treatment plan are based on the elements from the diagnostic phase, which includes: 1) the anamnesis, 2) the detection and evaluation of the severity of carious lesions after prophylactic cleaning according to visual and radiographic criteria, 3) the evaluation of lesion activity and 4) the caries risk assessment (CRA).10
Several concepts of CRA have been developed such as the Cariogram14 or the Caries Management by Risk Assessment (CAMBRA) system.15 In 2005, the HAS published its recommendations for France and defined two risk levels (low versus high) based on criteria such as the presence and / or history of carious lesions, dental morphology or oral hygiene status. A survey was conducted, through a random sample of 2,000 general DPs, 10 years after the publication of the HAS recommendations, to investigate the use of CRA in daily practice. The results showed that more than 38% of respondents had not included a CRA in their practice (only 4.5% used a dedicated form) and that more than 32% did not plan their treatments based on the individual risk levels of their patients.16 The reasons most frequently cited for not assessing caries risk were a lack of time (67%) and issues related to its funding (58%).
A code exists in the CCAM for periodontal assessments, whereas the CRA is still not coded. However, the CRA is part of good practices since the HAS recommends preventive pits and fissures sealants17 or topical fluoride applications18 according to the patients’ risk status (high).
A CCAM code for a global/comprehensive CRA would allow the appropriate performance of this diagnostic phase and its national monitoring within the health system (in terms of frequency at the individual level and distribution at the population level). Funding by the National Health Insurance would provide DPs a financial incentive to perform CRA at a regular basis.
PROPHYLACTIC PHASE
Prevention and health education
The aim is to provide patients with the necessary skills to manage their oral health and to reduce risk factors, in order to allow a successful management of dental caries and associated chronic diseases such as obesity and diabetes. This phase is directly related to the individual CRA that identifies the pathological and protective factors involved in the initiation and progression of the disease. The two flagship themes of the prophylactic phase are thus related to the promotion of good oral hygiene and balanced nutrition. The French Union for Oral Health (Union Française pour la Santé Bucco-Dentaire or UFSBD) recommended in 2013 several related policy changes.19
The CCAM does not include any code related to patient therapeutic education (PTE), for example through motivational interviewing, allowing the DP a necessary time of dialogue with the patient. It has to be noted that dental nurses, hygienists or dental therapists do not exist in France (DPs can be assisted by a chairside dental assistant who is not allowed to perform any kind of care but only provide a technical/ administrative assistance). PTE sessions are considered to be very time-consuming and in the absence of funding, likely to be underperformed. Moreover, it can be hypothesised that, in France, the patients who can afford out-of-pocket money for PTE are, unfortunately, not those who need it the most. PTE is, however, the key to comprehensive management of non-communicable diseases, by acting on common risk factors, such as the consumption of sugar, tobacco and alcohol.20,21
A CCAM code for sessions of therapeutic patient education (motivational interviews for example) would be likely to benefit the patient’s oral and general health. Funding by the National Insurance would provide DPs a financial incentive to perform this PTE.
Preventive care – primary and secondary prevention
Professional application of topical fluorides
Fluoride is the molecule classically associated with caries prevention.22 There are different sources of fluoride; topical and systemic. The topical agents are widely accessible in France.23 Among the topical agents, some are used at home (toothpastes, mouthwashes) and others are used professionally (varnishes and gels). This section deals with topical agents for professional use, as the others do not belong to the CCAM.
Marinho et al., reported in two different Cochrane systematic reviews the preventive effectiveness of fluoride varnishes and gels for both temporary and permanent teeth in children and adolescents.24,25 Since 2010, the HAS recommends the application of varnish every 3 to 6 months for high caries risk patients alongside periodical follow-ups.18 Fluoride varnishes can also be used in secondary prevention for the remineralisation of non-cavitated carious lesions.24,26-29 Repeated applications are necessary; however, the optimal frequency of application does not yet make consensus. Indeed, remineralisation has been described in temporary dentition with two applications at T0 and four months30 but also with four successive applications at seven-day intervals.31 In the permanent dentition, remineralisation has been described following four applications at seven-day intervals32 as well as for monthly applications for six months.33
The topical application of fluoride is registered in the CCAM with two codes: one for ‘Intraoral oral fluoride application’, and a second for ‘Dental application of a remineralisation varnish on a dental arch’. Following the recent dental contract negotiations of June 2018, two yearly application of fluoride varnishes will be funded (25€ each) starting the 1st April 2019, for 6-9-year-old patients identified like being at ‘high’ caries risk.
As evidence shows that topical fluorides are just as effective, in terms of primary prevention in cariology, in all age groups, an extension of the funding may be beneficial to the entire population. Moreover, a code for the management of non-cavitated lesions (secondary prevention) would allow non-invasive interventions on early lesions, with traceability for both the health system and the DP. Funding from the National Insurance would provide and financial incentive for DPs to perform early treatments that may prove to be cost-effective and maximising in terms of health outcomes, by avoiding treatment re-interventions.
Sealing of pits and fissures and non-cavitated carious lesions
Sealing is a procedure that can be indicated in both primary and secondary prevention. In primary prevention, sealants are placed in high caries risk patients, on healthy dental surfaces showing deep pits and fissures in order to reduce the incidence of a carious lesion. They are most often referred to as ‘preventive sealants’ (PSs). In secondary prevention, the purpose of sealants is to halt the progression of non-cavitated carious lesions; they are called therapeutic sealants (TSs) and are indicated for patients whose carious risk factors are under control.
Preventive sealants: Their effectiveness has been shown for posterior teeth of children and adolescents with a high level of evidence.34,35 The HAS recommends them for the first and second molars of high-risk patients under 18 years of age.17 Although their effectiveness has been shown mainly in children and adolescents.35 Gore describes their interest in adults.36 Similarly, their effectiveness has been mainly studied on permanent molars, but it seems that their use could be benefit all deep pits and fissures, even on premolars.37 PSs were coded in the NGAP in January 2001 for the first and second permanent molars, in high caries risk subjects less than 14 years of age, with a funding limited to one sealant per tooth. A study conducted in Auvergne-France showed a rapid increase in their use during the first five months following their coding in the NGAP in January 2001.12 Their coding in the CCAM was made under the same billing conditions as the NGAP. It appears, however, that the age limits given by the HAS and the CCAM are not identical: 18 years for the HAS and 14 years for the CCAM. The PS retention rate decreases over time, 35,38 which requires a follow-up in order to intercept possible losses and fractures, as well as regular re-applications, especially for teeth that are in the process of eruption, and if the individual risk level remains high.
Therapeutic sealants: They are indicated to arrest the progression of initial carious lesions (ICDAS 1-3) and more advanced but non-cavitated dentinal lesions (ICDAS 4) in children, adolescents and young adults.39-41 TS are a therapeutic option seldom used by French DPs. Indeed, a questionnaire survey undertaken in 2015 amongst a random sample of 2,000 practitioners showed that 90% of respondents declared they performed PSs, but only 42% included TSs in their routine practice.42 The arguments put forward for their non-use were the risk of aggravating lesions (33%), the lack of recommendations for good practice (32%), the lack of education (27%) and the lack of funding by the national health insurance (15%). Indeed, TSs are not integrated in the French recommendations whereas the American recommendations have taken them into account since 2008.40 TSs are also not subject to code in the CCAM for funding by the National Health Insurance.
The lifting or at least the harmonisation of the age limit announced in the texts of the HAS, the possibility of re-application and extension to all types of teeth would allow preventive sealants in all cases where they are needed. It would also seem appropriate to extend, without any age limit, the indication of sealants for the non-invasive management of initial and non-cavitated carious lesions.
RESTORATIVE PHASE
The goal of the restorative phase is to restore the physical integrity of the dental crown either by remineralisation (non-invasive care) or by compensation for the loss of hard tissue (cavitated lesions) through more conventional restorative / invasive treatments. Nowadays, restorative care is indicated only in the case of cavitated lesions or for lesions involving the internal third of the dentine. In all other cases, non-invasive and minimally invasive techniques should be favoured.10 Placing restorations when non-invasive strategies could have been indicated may be considered iatrogenic. Indeed, restorations have a limited longevity, despite technological advances in the field of dental biomaterials. Moreover, they do not treat the caries disease itself and the main reason for failure is secondary carious lesion occurrence.43-45 The CCAM integrates codes and fees for restorative care and these codes are amongst the most frequently used. Indeed, the National Observatory of the Demography of Health Professions (Observatoire National de la Démographie des Professions de Santé or ONDPS) has shown that, in 2012, restorative care due to caries (initial and secondary lesions), accounted for 45.6% of the total consumption of dental care reimbursed.46
Amongst the items listed in the ‘Restoration of the hard tissues of the tooth’ section of the CCAM, all but one are related to restorative dentistry. Cost and reimbursement vary according to the number of surfaces involved and the use or not of a root canal post. For restorations involving one, two or three surfaces, the regulated fees are €19.28, €33.74 and €40.97 respectively, whereas for endodontic treatments on incisors, premolars and molars, they are respectively €33.74, €48.2, and €81.94. Regrettably, the complexity of the clinical procedure is not taken into consideration, and only one code for direct pulp capping relates to the preservation of the vitality of the pulp.
Deep carious lesions
For deep carious lesions (DCLs), despite a substantial amount of evidence indicating the effectiveness of selective dentinal removal47, French DPs still prefer complete carious tissue removal before placing a restoration.48 This attitude is iatrogenic as, in such cases, pulpal exposures are frequent (nearly 50%)49,50 and the success rate of direct pulp capping is low.51 Considering the poor prognosis of vital pulp treatments, two alternatives have been described in the literature: the partial/selective excavation followed (after a period of temporisation (stepwise excavation)) or not by a complete excavation.47 In both options, excavation to sound tissue is performed at the amelo-dentinal junction and on the walls adjacent to the cavo-superficial angle. Stepwise excavation involves a first phase of partial/selective excavation at the pulpal wall of DCL and a temporary sealing period aiming the remineralisation of the dentine left at the pulpal wall or least the carious process passivation. The lesion is reopened after three months in order to complete the excavation, before placing the restoration. Partial / selective excavation at the pulpal wall can also be considered without re-opening the lesion, and the restoration is placed in the same session. Current recommendations advocate towards the second option, on the basis of numerous publications of and high-quality evidence.47 As previously mentioned, a survey showed that, in 2014, French DPs were extremely reluctant to integrate partial / selective excavation into daily practice for DCL: indeed, 91% of respondents did not plan to use this procedure.48 The CCAM does not consider the technical procedure of selective / partial dentine excavation which probably does not facilitate their integration into clinical practice.
A CCAM code for the selective / partial dentine excavation in DCL, following the example of the HBFD010 procedure (direct pulp capping), and the definition of an associated fee support would allow their realisation in the dental practice and limit the risk of pulp exposure and failure of vital pulp treatment.
Defective restorations
The replacement of defective restorations is associated with an inevitable increase of the size of the cavity, with additional loss of sound tissue.52,53 Thus, reparations must be considered in certain circumstances, as a viable alternative to complete replacement.4 Clinical studies on the topic are rare but the available results show that re-polishing as well as partial repairs improve the longevity of initial restorations.54-58 At present, there is no recommendation in France concerning the management of defective restorations, there is no code in the CCAM and it is likely that this lack of recognition favours complete replacements, contradicting the concepts of tissue preservation.
A CCAM code for the repair of defective restorations would allow their performance in dental practices and limit the risk of additional iatrogenic tissue loss. An appropriate funding by the National Insurance would provide a financial incentive for DPs to perform these treatments.
DISCUSSION
MI in cariology remains in France a poorly known subject and is inadequately integrated in daily practice.16,42,48,59,60 This gap between science and practice may be due in part to the fact that the CCAM is not adapted to current scientific data, which does not encourage practitioners to modernise their practices. Indeed, the method of financing healthcare is a major factor influencing therapeutic decisions in dentistry61 and financial incentives can facilitate the evolution of professional practices, particularly in the field of conservative care.62 It also appears that the CCAM is not fully in line with the recommendations of the HAS, themselves sometimes at odds with the current scientific evidence. Changes in the CCAM are therefore necessary to financially support the implementation of MI into daily practice and to allow French DPs to treat according to best practice recommendations. Registration of each new CCAM code is subject to a complex procedure that analyses the admissibility, the feasibility and the desirability of each demand.63 A simplification of this procedure would facilitate the dialogue between learned societies and the HAS.
Closing the gap between science and clinical practice in cariology requires considering the financial aspects but also other factors such as dental education in both undergraduate and postgraduate education. The European recommendations on the education of cariology integrates the notions of MI since 2011.64 It appears, however, that French DPs need to be encouraged to undergo continuing education in this field. Indeed, a survey conducted in 2015 showed that only 37.1% of the responding DPs had participated in continuing education sessions in cariology during the previous five years.17,18 On the other hand, the same survey found that the MI concept was often misunderstood as only 53.4% of respondents thought it was applicable to liberal general practice. Moreover, approximately 12% of the respondents clearly announced that they did not know about MI. Another area that is rarely discussed is patient demand; indeed, it has been shown to play a determining role in professional practice evolution65 Unfortunately, it seems that the level of knowledge of the public concerning the caries disease and the preventive and non-invasive alternatives to restorations is low; patient awareness requires to be developed by the diffusion of easily accessible information, comprehensible by the greatest number.66
CONCLUSION
An evolution of the CCAM, integrating scientific evidence and MI in cariology seems essential in order to create a set of preventive and non-aggressive (non-invasive and minimally invasive) procedures, giving the clinicians the opportunity to access a practice in line with public health objectives. Such measures could help to improve the performance of the dental healthcare system, in line with the French national health strategy.67 This means guaranteeing to each patient the set of therapeutic procedures that ensures the best health outcome, in accordance with the current state of science, at the best cost for the patient, at the least iatrogenic risk, for the greater satisfaction in terms of results and human contacts within the health system.68
Declarations
Ethics approval and consent to participate: not applicable Consent for publication: not applicable Availability of data and material: not applicable Competing interests: the authors declare that they have no competing interests. Funding: not applicable
Acknowledgements
The authors would like to acknowledge Drs Deschamps Mathias and Louis Espinasse for the preliminary work done under the supervision of Pr Sophie Doméjean and that initiated this narrative review. They also thank the editorial board of Information Dentaire for allowing the use of the article: Doméjean S, Deschamp M, Espinasse L, Mazevet M, Tubert-Jeannin S. Intervention Minimale en cariologie : l’intégration indispensable à la CCAM. Inf Dent 2018 ; 31 : 33-39.” as basis of the present work.
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ABOUT THIS PAPER
Manuscript submitted: 28 October 2019. Manuscript accepted: 21 November 2019.
DOI – https://doi.org/10.36161/FJDM.0002
