Santa Rosa dentist champions preventative oral health over traditional cavity drilling

Katherine Zagami, 34, and her family have been going to Santa Rosa dentist Anthony Fernandez for more than 15 years.

But two years ago, when a young man walked into the local Vitalant blood donation center where Zagami works as a supervisor and offered her a deeply discounted teeth-whitening package, she couldn’t pass it up.

After getting the whitening procedure, she was booked for follow-up appointments and that’s when her new dentist started finding other problems with her teeth, including a cavity and chipped tooth.

“I never had any cavities. My teeth were super healthy,” Zagami said. “There was something happening every time I went. ... I found it strange, I think I had gone to Dr. Fernandez six months before that and he had found nothing.”

Fernandez, a strong advocate of preventive dental care, said Zagami’s experience is not uncommon. Most dentists, he said, are trained to drill out cavities and fill them at the first sign of tooth decay - even though early stages of decay can be treated and even reversed with nonsurgical procedures.

However, dental surgical procedures, such as drilling and filling cavities, crowns and root canals, are how dentists make their money. It’s what the insurance companies traditionally pay for, Fernandez said. But in many cases, it’s not the right thing to do, he said.

Fernandez is part of a vanguard in the dental industry, leading a slow-moving trend away from the “drill and fill” approach toward preventive oral care that assesses and manages dental disease in much the same way physicians manage and treat heart disease and diabetes.

He still drills teeth when necessary, but his practice now consists mostly of teeth cleanings and dental hygiene consultations.

Fernandez’s modest dental office on Montgomery Drive appears almost frozen in time, with decades-old carpeting and old-fashioned wall ?paneling and wooden furniture. He said he puts his money where it counts: staff pay, dental equipment and keeping up on the latest trends in the industry.

Back around 2007, Fernandez started hearing about a new dental treatment protocol called caries management by risk assessment, or CAMBRA, a preventive health regimen developed by dental experts at the University of California’s San Francisco School of Dentistry.

He began reading about it, taking classes and generally “fooling around with it,” he said. He started using it on one of his sons and was amazed by the results.

“When I saw it was working, I had to change my practice,” Fernandez said. “I realized I can’t be treating my own family with this and still drilling on people, because I thought it was not fair.”

Since then, he has become one of the county’s leading advocates of preventive dentistry. A lot of dentists agree with the principles, but old habits are hard to change.

Developed by Dr. John Featherstone and other dental experts at UCSF in the early 2000s, CAMBRA involves an assessment of a patient’s health and lifestyle. It starts with identifying oral health risk factors, such as the presence of harmful bacteria, low levels of saliva and poor diet.

Patients are placed into low-, moderate- and high-risk categories and given appropriate nonsurgical treatments, which could include prescribing high-fluoride toothpastes and antibacterial mouthwash. Patients also are encouraged to make lifestyle changes, such as decreasing sugar intake.

Fernandez became certified in the CAMBRA protocols through UCSF in 2013 and after integrating them into his dental practice started noticing significant improvements in the oral health of his patients. This summer, he got Delta Dental, a leading national dental insurer, to conduct an oral health assessment of a group of his patients.

The study evaluated the risk levels of 450 patients from 2014 to 2019. Low-risk patients have good oral health, while high-risk patients either are experiencing active tooth decay or are sure to get it, he said.

Delta’s review of Fernandez’s patients found that in 2014, between 20% and 25% of them were at high or extreme risk of tooth decay. About 20% of them were low-risk patients.

By 2019, his share of high-risk patients was reduced to about 10%, while the share of low-risk patients increased to more than 50%. That was good news to Delta Dental, because it meant the insurance company was paying less money on dental claims for Fernandez’s patients. He was doing fewer drillings, fillings, crowns and root canals.

“To Delta, it means that the money they normally would have to pay out in claims they are putting it in their pocket,” the dentist said.

Fernandez said more dentists would adopt preventive dental practices if there were more financial incentives for them. The big change will come when insurance companies like Delta Dental start rewarding dentists who prioritize oral health disease prevention over drilling cavities, he said.

Featherstone, the CAMBRA pioneer, agrees. Now retired and professor emeritus at UCSF School of Dentistry, he said such a change will take time but is inevitable.

“There are several insurance companies looking at ways to do that right now,” Featherstone said. “The changes will happen sooner rather than later.”

The preventive care advocacy of local dentists like Fernandez is important because it shows other dentists that you can drill less and still make a living, he said.

“His essential philosophy, which is the CAMBRA philosophy, is to do what’s best for the patient and to keep them healthy,” Featherstone said. “He’s thrilled with the success and yet he can still earn a really good living.”

Many dentists know about preventive ways of treating tooth decay, but the number who champion the approach is extremely low.

“There are probably hundreds of dentists in the country who are doing what he’s doing,” Featherstone said of Fernandez. “But I mean hundreds, not thousands.”

Natalia Camacho-Worms, interim dental director for Santa Rosa Community Health, called CAMBRA a common-sense approach to dentistry. Santa Rosa Community Health, Sonoma County’s largest network of health clinics, operates two large dental clinics for adults and children.

“In general, we do caries risk assessments as part of the initial exam and we counsel patients through motivational interviews,” she said.

Camacho-Worms said one of the preventive dental treatments used is applying silver diamine fluoride on cavities to halt tooth decay. Such treatments have reduced the number of very young patients with decaying teeth who need dental surgery.

“We’re treating bacterial disease as a bacterial disease rather than drilling it out and filling it out,” Camacho-Worms said.

Meanwhile, Zagami, Fernandez’s patient, said she doesn’t think the other dentist she briefly went to was taking advantage of her. After a while, though, she started wondering why he was ordering so many dental procedures for things she had not dealt with before.

She went back to Fernandez after four or five appointments with the other dentist.

“I’m sorry I left him,” Zagami said.