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834: Hygiene Exam Essentials Part 2: AAP Staging & Grading – Katrina Sanders

Over half of your patients have some form of periodontitis — and they don't even know it! How many are you letting walk out of your doors? It’s time to empower patients by helping them to understand and treat their disease. In this final part of her Master Class, Katrina Sanders, The Dental WINEgenist, shares key tools and resources to help you build confidence in diagnosing, treating, and improving the clinical outcomes of your perio patients. To get patients closer to 100% health, listen to Episode 834 of The Best Practices Show!

Learn More About Katrina:

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Episode Resources:

Main Takeaways:

  • Incorporate the learnings from Part 1 of this lecture!
  • Stop waiting to recommend treatment until later stages of disease.
  • Periodontal disease can present differently from one patient to another.
  • Understand AAP’s staging and grading system to accurately diagnose patients.
  • Learn how to effectively communicate the urgency of your patients’ level of disease.  
  • Empower patients to improve home care by recommending innovative oral health tools.

Quotes:

“I want to remind all of you that a large portion of your patients who are presenting for a routine cleaning are highly likely individuals where periodontal treatment is going to need to be proposed. The challenge is those are the patients that are presenting into that hygiene column every three, four, or six months. So, they're on the hamster wheel, the recare system in the practice, which makes it very easy for the patient to blame the clinician for the presence of their disease. Patients will say things like, ‘Well, I was just in three months ago. So, did you not give me a good cleaning last time when I was in three months ago?’ Never mind the fact that the patient just added one new medication increase to the dosage of another medication, is currently going through testing right now because they're pre-diabetic, and they aren't actually using the toothbrush that you encouraged them to use for two minutes, twice a day, along that gingival margin with the Bass method.” (12:22—13:22) -Katrina

“The reality is, while for our patients, they are looking at the fact that this disease process, periodontal disease and gingivitis, is oftentimes “asymptomatic” — and I'm putting that in quotes — we know that gingival diseases are actually not asymptomatic. There’s bleeding that occurs. There's halitosis that occurs. There's redness of that gingival margin that occurs. However, the patient's body does a beautiful job of shutting off pain receptors. The patient's body does a beautiful job of saying, 'We're not going to cause pain until this moves into a very severe area.' So, for the average patient, if they're not experiencing any pain and you start telling them, ‘You have active infection in your mouth, and we need to have this treatment done, and it's going to cost you out-of-pocket to have it done. And, by the way, your insurance may or may not actually cover it because that's a big question mark,’ then your patient is going to be upset.” (13:24—14:21) -Katrina

“For whatever reason, patients are concerned about an extremity at the other end of the body bleeding. But a hole in their skull that is just inches from the brain and inches from the heart muscle that is bleeding, for whatever reason, our patients tend to think that is completely normal.” (17:54—18:15) -Katrina

“When patients are surveyed about why they declined their periodontal care plan — patients who have received a comprehensive care plan for SRPs, local delivery of antibiotics, custom perio trays, whatever it is — the number one reason why they decline their treatment plan is because they actually do not trust their dental healthcare professional — which is crazy.” (18:40—19:02) -Katrina

“I think that a decent portion of dental practices will, in fact, wait until the patient gets into at least stage two periodontitis before they will actually talk to the patient about the disease in their mouth. Even at stage one periodontitis, I believe a decent portion of dental practices are fearful about graduating or elevating that patient into performing therapeutic care. So, by the time a dental professional actually says something to a patient, ‘This is an area of concern, and we need to move forward,’ more often than not, that disease process has progressed a lot further than we would like it to. Why do we wait until the patient moves into stage two disease? Because at stage two disease, there's a greater likelihood that the insurance company will probably cover it. That's why.” (19:35—20:24) -Katrina

“We wait to tell our patients about this irreversible disease process that is linked to, has a biological plausibility that it is an exacerbative modality, accelerating upwards of 57 unique diseases and conditions systemically, like stroke, heart disease, upper respiratory tract infections, diabetes, adverse pregnancy outcomes, and certain types of cancers. We will wait until we feel confident and comfortable that there's a high likelihood that the insurance company will pay for it. And even still, we will give our patient a bare-bones treatment plan. ‘Here's four quads of SRP. Let's just start there.’ “Let's just start there” is what many of us say. ‘And then, we'll re-evaluate and see what you look like and see how you heal.’ When, dentistry, are we going to start looking at the complexity of our patients and say, 'Mr. Jones, I'm concerned. You have stage two periodontitis. And at this stage two periodontitis, it's going to be even more complex than it was in stage one to treat it. If we don't treat it now, it's not a matter of if — it's a matter of when that stage two periodontal condition is going to accelerate to a stage three periodontal condition.’” (20:59—22:11) -Katrina

“I have yet to see a single research study that indicates that a patient can floss their way out of an irreversible disease process. I have yet to see a single research study that says if we use the F-word and tell them to, ‘Go ahead and floss better, and we'll check you out in three more months,’ I have yet to see a research study that says that that flossing habit, by the way, your patient for many decades has never done and, all of a sudden, now you think that you've reformed that patient and they're going to go ahead and start flossing, and they're going to be the world's best flosser — I don't mean to say that that never happens. But let's be honest, dentistry. It would be a Christmas miracle if all of our patients paid attention to our recommendations and followed them.” (22:12—22:53) -Katrina

“The challenge that we see across the United States in dental practices is that despite our patients knowing toothbrushing habits, interdental care, knowing that many of their medications do, in fact, cause dry mouth or could accelerate inflammation in their mouth, knowing that our patients are coming in and sitting down in our chairs and receiving routine screenings and evaluations, still question our authority, our understanding of the complexities of this disease process. This, for me as a periodontal hygienist, is the essence of what I believe is holding dentistry back from moving all of our patients who are entrusting us with their care to as close to 100% health as possible. And that's our goal, isn't it?” (22:53—23:40) -Katrina

“If we get back to the essence of what we need to do in educating our patients about the complexity of the disease process and explaining to our patients what that disease process means in a way that is meaningful for them, we help to empower our patients with the right knowledge for them to make a decision — true informed consent — giving our patients the autonomy to decide the level of care they wish to receive. Because we are, in many ways, robbing our patients of autonomy if we decide that we’re not going to recommend care until their insurance company might cover it. Respectfully, you have patients in your practice right now who are watching family members suffer from Alzheimer's disease. Respectfully, you have patients in your practice who have family members who are suffering from cardiovascular disease. You have patients in your practice who are suffering with infertility complications. And a decent portion of those patients would do a lot — would pay a lot — to help prevent their infertility issues, to help prevent their potential Alzheimer's disease down the road, to help prevent a potential cardiovascular event from happening. So, dentistry, the empowerment that we have now is in understanding how incredibly important and valuable our work is.” (23:53—25:15) -Katrina

“One of the other important modalities that we do need to focus on once we start seeing patients demonstrating the sign, stages, or symptoms of disease is, what are the things that we are going to do to empower that patient to take care of their gum health at home? I mentioned earlier I have yet to see a patient floss their way out of an irreversible disease process. However, I have seen patients improve their self-care when they have an inflammatory condition and reverse that inflammatory condition back to a state of health. So, this is really where we want to capture our patients. I don't mean to say if they're a perio patient — they need SRPs or a 4910 — that we don't talk to them about home care, because we know how valuable that is. However, it is important for us to know that these gingivally diseased patients, their involvement at home becomes so, so, so, so, so critical to the story.” (1:22:37—1:23:32) -Katrina

“As much as I love to joke about our patients not following our directions, and not using the electric toothbrush, and all of those things, it is important to know, in my perio office there's a large portion of patients that do follow our recommendations to the tee. They are brushing multiple times a day. They're using multiple interdental aids. They are doing everything they can. And still, the destruction in their mouth exceeds the small, tiny, minuscule amount of biofilm they have in their mouth, which means they have an exaggerated response, which means their immune system isn't fighting as readily. The host response is in a panic mode and in a constant state of panic.” (1:44:28—1:45:06) -Katrina

“When we have a patient with an advanced grade of the disease process, it is a good indicator that their immune system needs some additional support. One of the best ways that I've found that we in dentistry can support our patients with that is by recommending that our patients take dental-specific probiotics.” (1:47:03—1:47:23) -Katrina

“We've heard about probiotics for gut health. Some of us might have even heard about probiotics for colic health or bone health. Yes, there are even probiotics for oral health. We've found that these probiotics — these are bacteria that are health-producing in the mouth, designed for oral health — give some incredible benefits. So, when we compare patients who have not been given probiotics from our friends at BioGaia versus patients who have received probiotics, we find that the probiotic group experiences things like reduction in bleeding tendency, reduction in periodontal pocket depths, a clinical attachment gain of 54% when compared with individuals who are not on probiotics. We also find that these health-producing bacteria starve out your periodontal pathogens. So, you are reducing your prevotella intermedia, porphyromonas gingivalis, and aggregatibacter actinomycetemcomitans by upwards of 90%. You are also reducing the inflammatory markers. So, we see lower tumor necrosis factor alpha, interleukin-1, and interleukin-7 in the crevicular fluid. These probiotics really sparkle and shine particularly when a patient has advanced probing depths. So, we find in perio that when a patient has a probing depth of seven millimeters or greater, we see amazing efficacy. And this is one of my favorite things about these probiotics. It significantly reduces the amount of bone loss or the acceleration of that bone loss in periodontal patients.” (1:47:44—1:49:25) -Katrina

Snippets:

0:00 Introduction.

4:53 The prevalence of periodontitis.

15:33 Don't wait to tell patients about their level of disease.

25:25 Katrina’s background and objectives.

26:42 Staging and grading is not an exact science.

29:14 The framework for staging and grading.

40:06 The spectrum of clinical health.

43:58 Case example: Intact periodontium.

45:43 Case example: Reduced periodontium.

50:13 Case example: Reduced periodontium (non-periodontitis).

51:16 Case example: Reduced periodontium (successfully treated periodontitis).

52:43 Case example: Intact periodontium (incipient gingivitis).

56:10 Case example: Stable patient on reduced periodontium (non-periodontitis).

59:50 Case example: Stable patient on reduced periodontium (successfully treated perio).

1:03:11 Case example: Gingivitis on a reduced periodontium (successfully treated perio).

1:06:25 Effectively select the appropriate instruments.

1:07:48 PDT kit for hygiene.

1:11:39 Dental biofilm-induced gingivitis.

1:12:25 Non-dental biofilm-induced gingivitis.

1:14:29 Gingivitis, defined.

1:16:39 Case example: Moderate to severe gingivitis (intact periodontium).

1:18:44 Case example: Gingivitis on reduced periodontium (non-periodontitis).

1:20:51 PDT kit for gingival inflammation.

1:22:36 Patient empowerment: Stannous Fluoride.

1:25:16 Patient empowerment: Oscillating rotating-motion toothbrush.

1:28:13 The AAP guidelines for staging patients.

1:36:15 PDT kit for debridement.

1:37:59 The AAP guidelines for staging patients, continued.

1:39:37 The AAP guidelines for grading patients.

1:46:50 Patient empowerment: Dental-specific probiotics.

1:51:34 Katrina’s free webinar.

1:53:17 Q&A: How do we legally deal with patients who refuse periodontal treatment?

1:56:07 Q&A: How do you explain the cost difference of a prophy and perio maintenance?

1:59:08 Conclusion.

Katrina M. Sanders RDH, BSDH, M.Ed, RF Bio:

In the ever-changing world of dental science where research, technology, and techniques for patient care are constantly evolving, dental professionals look to continuing education to provide insight, deliver actionable steps, empower, and create a dramatic impact within their clinical practice.

With wit, charm, and a dash of humor, Katrina Sanders enchants dental professionals with her course deliverables, insightful content, and delightful inspiration. Her message of empowerment rings mighty throughout her lectures and stirs a deep sense of motivation amongst course participants.

Katrina is the Clinical Liaison for AZPerio, the country's largest periodontal practice. She performs clinically, working alongside Diplomates to the American Board of Periodontology in the surgical operatory. Katrina perfected techniques during L.A.N.A.P. surgery, suture placement, IV therapy, and blood draws. She instructs on collaborative professionalism and standard-of-care protocols while delivering education through hygiene boot camps and study clubs.
ACT Dental Team

ACT Dental Team

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