Periodontics for profit

For many years patients have tended to seek dental care only when a tooth needs repair or when pain of dental origin has arisen. The major focus in many dental practices has been on restorative or prosthetic concerns. There are significant numbers of patients walking into dental offices every day with legitimate periodontal treatment needs. There are now significant reasons to address those needs. Yet, too often those patients leave the dental surgery without having those needs acknowledged, let alone addressed.

The focus in the clinical management of patients whose periodontal disease has been diagnosed, has rarely ventured beyond removal of detectable debris in an effort to prolong the functional life of teeth.

However, evidence is strongly suggesting that ongoing periodontal therapy provides benefits beyond simply slowing down the progression of alveolar bone loss (Figure 1).
Patient preference plays an important role in determining what treatment is actually provided to patients. Seeing a dental professional only when a problem arises is a strategy employed by patients in a wide variety of cultures.

Many patients have long partnered with their dental professional with an implicit desire for their dental professional to simply solve any immediate problems that may arise. Historically the emphasis has been on repairing carious teeth and/or replacing missing teeth. For reasons including the lack of awareness, patients only rarely seek treatment for oral pathologies, like periodontal disease, that often have no compelling signs or symptoms.

Inflammatory mechanisms
The inflammatory basis of periodontal diseases has long been known (Figure 2). A now well accepted awareness of the importance of inflammatory mechanisms in the development of many of the chronic serious diseases of aging means that it certainly is time for the focus of dental care to be squarely on what is best for the patient not just what is best for the patient’s teeth.
The vast majority of dental therapists have historically approached their professional responsibilities with an impressive desire to do what is best for their patients. Because of the chronic and recurrent nature of periodontal disease it will ultimately be the sum total of all of the treatments that have been provided over the life of a patient that will ultimately determine if the provided care has, indeed, been what is best for the patient.

Linking oral health to overall health
The emergence of strong data linking oral and overall health has led to an urgent and significant need to reassess the value of varying treatment philosophies. The acknowledgment that what happens in the mouth can have serious consequences throughout the body certainly should compel patients to consider partnering with a dental professional so that their oral inflammation can be kept to a minimum over their lifespan. Evidence suggests that doing so will pay dividends to the patient’s oral and overall health. Despite the long-overdue acknowledgement of the need for dental care providers to use an evidence-based approach when making treatment decisions, most recurring dental visits continue to consist of little more than prophylaxis, perhaps some degree of subgingival scaling and oral hygiene instruction. Evidence suggests that a more comprehensive approach would be prudent.
Interpretations of the inherent value of the various periodontal diagnostic routines and therapeutic protocols are almost as varied as the practitioners themselves. Rather than being outcome based, the actual routine that is followed during recurring maintenance visits in many offices is typically based on that particular practitioner’s personal belief (or lack thereof) in the value of a particular periodontal diagnostic approach or therapeutic option. Some practices consider periodontal therapy only when pocket depth exceeds a subjective threshold. Others recommend little more than supragingival prophylaxis (and devote the bulk of time allotted for the visit to providing little more than this service) to all patients regardless of the degree of periodontal involvement.

Key points
• Ongoing periodontal therapy provides many benefits
• Paying attention to oral health pays dividends to overall patient health
• Inflammatory mediators appear to be critical factors
• Dr Donley is lecturing in London next month

Periodontal endpoints
Methods used to evaluate the success of reaching a desired periodontal endpoint (in addition to the actual endpoints themselves) are also quite varied. Removing all calculus that can be seen or felt is traditionally thought to be an impressive and highly desirable endpoint. However, with the potential links between oral and overall health in mind it is imperative for periodontal therapy providers to reassess which aspects of the maintenance visit protocol will have the most profound impact in their effort to do what is best for their patients. That reassessment has to begin with a clear vision of the preferred endpoint in the life-long management of a patient’s oral health.
Inflammatory mediators appear to be critical factors in the development and progression of many of the chronic diseases of aging. There is now unmistakable evidence that the mouth is a significant source of these inflammatory mediators when periodontal disease is present. Thus, while reducing pocket depths continues to be important the major emphasis of periodontal intervention must be on eliminating oral inflammation and then maintaining an oral cavity that is inflammation-free.

Biofilm to plaque
Subgingival bacterial plaque is widely accepted as being primarily etiologic in the periodontal disease process. When that bacterial plaque calcifies, calculus forms. It is not surprising that calculus removal was thought to be of primary importance in any therapeutic approach. Recently, the realisation that bacteria in the oral cavity exists in the form of a biofilm suggests that removal of just the evident calculus may not maximise the resolution of periodontal inflammation is many patients.
Biofilm is a microscopic phenomenon. Bacterial plaque forms only when the biofilm amasses in size to a degree that it becomes clinically detectable. But not all biofilm grows into clinical plaque. Furthermore, calculus itself is a microscopic term. We assign the term, ‘calculus’ to calcified biofilm crystals which have enlarged and coalesced into a detectable mass on the tooth surface. But, not all calcified biofilm crystals grow to the point of clinical detectability. Interruption of biofilm in all of its forms (microscopic, plaque microscopic calculus, clinical calculus) clearly is a more desirable treatment goal.

As such, continuing to employ treatment philosophies aimed solely at removing only the calculus that can be seen or felt, or, doing little more than removing supragingival plaque via prophylaxis, is clearly no longer doing what is best for the patient. To stave off the adverse effects of periodontal destruction and to reduce any oral contributions to the overall inflammatory burden of the patient, consistently adequate and periodic subgingival debridement (using a therapeutic option) over the life span of the patient has to form the foundation of any periodontal treatment philosophy.

Tim Donley is lecturing in London 28-29 September

Day 1: 28 September – The new periodontics
‘Better patient outcomes, better patient incomes’
• The latest science regarding the links between oral and overall health
• What approach works best for you (evidence-based or risk-based approach)
• How to make the hygienist visit maximally productive
• Learn to make sense of treatment options
• Host modulation therapy- treating and controlling disease
• How to motivate patients to follow through with treatment recommendations
Pick up seven hours of verifiable CPD
Dentist price £355 + VAT        *call for DCP rate

Day 2: 29 September – Translating technology into practice
Live patient demo and hands on training in periodontal therapy:
What to use and when to use it. See how:
• To use ultrasonic instrumentation properly
• To become more comfortable with instrument selection and technique application
• To have a site-specific philosophy of debridement
• A treatment protocol makes deciding what to use and when, easy
• To help your patients and help the practice
• Limited to 40 delegates with Tim Donley and Mervyn Druian
• Live patient demonstration and treatment plan
• Classroom style hands on session – ultrasonic insert – proper selection and use on models
• Local antibiotic delivery technique on models
Pick up six hours of verifiable CPD
Two-day price only £650 + VAT.
Don’t miss out on this hugely popular seminar. Call 0800371652 to attend. The seminar will take place on the 28-29th September 2012 in London.

Dr Tim Donley is currently in the private practice of Periodontics and Implantology in Bowling Green, KY. He is the former editor of the Journal of the Kentucky Dental Association and is an adjunct professor of periodontics at Western Kentucky University. He lectures and publishes frequently on topics of interest to clinical dentists and hygienists.

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