Your patients aren't truly healthy, but they're also not losing teeth. This “gray area” is keeping them in perio purgatory! In this episode of Clinical Edge Fridays, Kirk Behrendt brings back Rachel Wall, CEO and founder of Inspired Hygiene, to explain what perio purgatory is, why it’s dangerous, and how to pull patients out of it to improve their health. To learn how to put an end to your perio blindness, listen to Episode 864 of The Best Practices Show!
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“Patients unknowingly are stuck in this perio purgatory. So, to the hygienist and the dentist in the practice, maybe these patients aren't really healthy. We know we're seeing some bleeding there, and there are some things happening. A lot of times, dental teams will call it the “gray area”. There's a patient in the gray area where we're calling it perio purgatory, where they're not healthy, but they're not coming in with vertical bone loss that is extensive, and they're not losing teeth to periodontal disease. They're somewhere in between. And unless a team has a really clear, defined, communicated, and written standard of care around that threshold from when we move them from adult prophy or even perio maintenance back into active therapy — unless that is really, really clear — a lot of times, patients get stuck in that perio purgatory. We see it in general practices. We see it in periodontal practices, even, and it is a huge opportunity to elevate care for patients and help them get healthy.” (4:14—5:23) -Rachel
“The next layer of the “why” to really address this is because we now know that this is active inflammation, and inflammation is a risk factor for type 2 diabetes, heart disease, some types of cancer, stroke — there are so many different connections with inflammation. That's what we're still seeing 20 years later. That's one of the primary things that we help teams really move through, is going from patients in that perio purgatory to now, all of a sudden, the doctor is seeing patients and doing a crown prep, and they're not bleeding. Now, these patients are in perio maintenance and they're actually healthy. So, it ultimately makes the clinicians’ jobs easier and the patients healthier.” (5:24—6:12) -Rachel
“There is an incredible body of research now that is, in my opinion — and based on the research — very clear that there is a connection between periodontal disease and many, many other health conditions that can be fatal. Heart attacks can be fatal. Type 2 diabetes can result in a lot of fatal complications. So, in my mind, there's no question that there is a connection between periodontal disease and inflammation and increased risk for heart attack, type 2 diabetes, Alzheimer's, all of these numerous things.” (6:51—7:26) -Rachel
“As our patients are getting sicker, they have more things that are taxing their immune system. So, it takes two things for an infection to occur: bacteria — a pathogen — and a susceptible host. If, all of a sudden, more people are developing type 2 diabetes, that means we have more susceptible hosts. We have more patients whose bodies are not able to resist the attack of these periodontal pathogens. And while there is also this quest and this trend of health and wellness — there's a percentage of patients and people, in general, in the U.S. that are taking control of their overall health — there's still a population that diabetes is increasing dramatically. So, in both of those books, Beat the Heart Attack Gene and Healthy Heart, Healthy Brain, and it's on Dr. Amy Doneen's website as well, are these red flag risk factors. This is something that we work with all of our clients on so that they're recognizing what are these risk factors for heart attack, stroke, type 2 diabetes, even some of them that they're seeing on patients' medical histories. I just watched a video that Amy Doneen posted about these risk factors, and one of them is migraines. Who thought migraine headaches is a risk factor for cardiovascular disease?” (11:40—13:14) -Rachel
“A practice I was with last week said, ‘Yeah, we just had a patient cancel because they had a migraine.’ We need to note that. That needs to go in their medical history if it wasn't already. So, as clinicians, and really, even any team members, we don't just teach team members protocols and help them put in place protocols — we're teaching them critical thinking. When we're hearing these things from patients, it's not just, ‘Oh, they called and they had a migraine.’ That should be a huge red flag for our team. Why did they cancel? Because their rheumatoid arthritis flared up. We need to know these things because it affects their oral health, and it creates a hugely strong “why” for why we need to get these patients out of perio purgatory and into treatment, or refer them, whatever you feel like is appropriate, so that that inflammation can be eliminated.” (13:25—14:22) -Rachel
“There are often obstacles that are keeping us from implementing this. I'll tell you a really common one right now is the lack of sufficient capacity on the hygiene schedule. So, you can see all this periodontal disease. You're like, ‘Oh my gosh, we've got to come up with a protocol and a way to address this.’ But if there's nowhere to put them on the schedule, what are we going to do? So, the hygienists are looking at it, and they're like, ‘This patient is bleeding. But even if I recommended scaling, root planing, and periodontal therapy, I don't have anywhere to put them for six months.’ There are practices that are booking out six, seven, eight months.” (15:01—15:42) -Rachel
“Very often, the hygienist just puts his or her head down and says, ‘I'm going to do the best I can today.’ Whatever procedure they're in, usually, it's an adult prophy. ‘We'll check them the next time they come and see if they're any better.’ So, they're often doing a level of periodontal therapy that they can in that situation — which is typically not enough because they don't have enough time. And they don't have the time to talk to the patient and really address what's happening and draw a line in the sand to say, ‘You have periodontal disease, so now we have to treat this accordingly and treat you, going forward, accordingly.’ They're not having the opportunity to do that. So, that is one very common obstacle to getting patients out of perio purgatory, is they don't have time on the schedule to get the patients in.” (16:04—16:54) -Rachel
“In my experience as a hygienist and also as a coach is, without an assistant, when you drop down to 45 minutes or less, the hygiene department is going to be more on the prophy hamster wheel. One of the first things that drops is diagnosis. And that's not just hygiene diagnosis — that's restorative diagnosis as well. So, think about this in a long-term plan. The hygiene department really is the engine behind recurring patient care and diagnosis into the doctor's schedule. If you take out 15 minutes, it's going to be 15 minutes of diagnostic and patient education time. It's not going to be 15 minutes of scaling time because the hygienists have a certain standard that they're not willing to compromise from a scaling standpoint. They're like, ‘This patient is paying for a prophy. They're going to get a prophy.’ Now, a lot of times, hygienists are doing more than a prophy, and that's another conversation. But in my experience, if you're cutting that time down, that's what's going to happen, is patient relationship, education, and hygiene and doctor services are going to be reduced because there's not time to diagnose that in those hygiene appointments. Now, the alternative is, if that hygienist is working with a dental assistant — and we are advocates of assisted hygiene. That's not the only way to work, obviously, but that is one way. It can be done very well when a hygienist and an assistant work together to serve that patient.” (17:34—19:14) -Rachel
“[Another obstacle is] mindset, in general, of, ‘How am I going to tell my patients they have periodontal disease when I've been seeing them for seven years and they trust me?’ And it's like, that's why you have to tell them, is because they trust you. It is our duty to do that. So, we give teams very specific methods to bring the patient alongside them in the diagnosis. You've got to tell the patient what you're doing. You can't wait till the dentist comes in at the end of the appointment and then drop the bomb on them. It must be a collaborative approach to diagnosis with the patient being one of the collaborators, them being brought into the conversation early on by letting them know, ‘Look, we're going to be evaluating your gums and the bone that supports your teeth. Healthy gums don't bleed. So, if you hear me call out a lot of areas of bleeding, something is going on, and we'll talk about it.’” (19:36—20:29) -Rachel
“One team member could be calling a procedure one thing, and another team member can be calling it something else, and they wonder why patients get confused. Or the big one is they call periodontal therapy a “deep cleaning”. Well, a patient thinks, especially if a lot of your patients have insurance in your practice, ‘Well, I get two free cleanings a year, so why is this $1,200? I'm very confused.’ So, we don't recommend using the term “deep cleaning” at all.” (21:01—21:30) -Rachel
“One other obstacle is really making it matter to the patient. So, we have a framework that we teach about how to present periodontal therapy, and it applies to restorative therapy as well. One piece of it is, ‘I'm concerned.’ Why am I concerned about this patient's condition, and them, specifically? It's not, ‘I'm concerned because you're getting ready to have crowns, and it's going to be really hard for the doctor to prep these teeth if you're bleeding.’ No. It's not about me. ‘I'm concerned because I know you've shared with me that you're really serious about controlling your diabetes. This is going to make it harder. But when we treat this disease, it's going to make it easier for you to control your diabetes.’ Or maybe they're healthy and they don't have any risk factors. ‘I'm really concerned because I know you've really been serious about taking care of yourself, and you have an active infection. You're doing all these other things to reduce your risk for diabetes, and yet you have this inflammation. Let's work together to get that under control.’ So, really making it specific to the patient is huge.” (22:02—23:17) -Rachel
“You have to practice [your verbal skills]. We do in-office coaching with teams, and they practice. They pull out patients from the next week that they expect they're going to be presenting to. We look through the case together. They're practicing all of that so that when they sit down with that patient, it's not the first time they've said it. They can have a little more confidence. Then, the second time they say it to a patient, they're going to be that much more confident. Then, the tenth time, imagine how confident they'll be then. All of that translates into patients feeling more comfortable accepting the treatment that you're recommending.” (23:34—24:11) -Rachel
“The other obstacle, which is somewhat related to the mindset of recognizing that there's disease that needs to be treated, is — I'm going to call it bleeding blindness. It's when we've been seeing a patient for a long time, and they're bleeding, their inflammation isn't getting any worse, but it's not getting any better. So, a lot of times, that gets defined as stable. But really, what it is is chronic inflammation. Bleeding is our indicator of active disease. If our patients come in every time and they're bleeding every time, even if it's the same areas that they're bleeding, we're allowing them to have that chronic inflammation, which is not healthy. So, we develop blindness to inflammation, or bleeding, or that there's a problem there. Because we see it so often, it just becomes normal. We’ve normalized it for that patient. This is normal for them. But just because it's normal doesn't mean it's healthy.” (24:25—25:38) -Rachel
“Sometimes, you do have to triage. You have to set different thresholds for when you're going to move patients into therapy based on patient flow, availability, and that kind of thing. It's kind of like you're in the emergency room, and you've got the gunshot wound, and you've got somebody with the flu, and you've got someone having a heart attack. Sometimes, you have to prioritize where you're going to get these patients in, knowing that maybe we need to hire another nurse so we can see all three of these patients instead of just number one.” (25:53—26:25) -Rachel
“We utilize the AAP standards and their definition of health versus disease and their staging and grading periodontal classification system, sit down with that and develop a really clear written standard of care. So, everybody is collaborating as a team, ‘When we see this, we're going to recommend this. These are the diagnostics that we're going to do. This is the interval, the frequency we're going to do those.’ Get everybody on the same page with your standards from a diagnostic and a treatment standpoint. That's number one. Then, they figure out, how are we going to now introduce this to patients that we've been seeing for a long time? It's typically easy with new patients. You don't have that relationship with them. If you see something, you can bring it up and you can recommend treatment. But it's those patients that we've been seeing, and we know their spouse just went through cancer, and they're recovering, but they've been going through all this. It's like, ‘I don't want to tell them this now.’ But what if the spouse has a history of cancer? What if they've had a stent put in in an artery and they have diabetes? You don't want them to have a heart attack, so we should be proactive with their health instead of holding things back. So, that's a shifting of the mindset of, ‘We can't tell patients this,’ to, how can we? We can't not tell them that they have active disease and really develop that “why”. And then, I would say really supporting each other in holding each other accountable to the standards of care and really looking at those obstacles and how to overcome those. So, everything revolves around that standard of care.” (27:30—29:15) -Rachel
“I recently worked with a periodontal practice. Even in their hygiene department, they had some patients that had gone through active therapy and then had gotten stuck in periodontal maintenance purgatory. So, they needed to really set their thresholds for, when do these patients need retreatment? When do they need to go back through non-surgical therapy or surgical therapy? So, even in those practices that have a very high perio awareness, they can develop that blindness to how their patients are presenting.” (31:12—31:45) -Rachel
“I remember I had a patient who had lupus. After we did periodontal therapy, she said, ‘I don't know if this is related, but I've been able to go off all my pain medication.’ That's awesome. So, it's all inflammatory there. You have to look at those anecdotal examples as well and know that when you address this, it's really making a difference. It's making a difference for your team because hygienists actually have time to do what needs to be done and not trying to cram it all into a prophy. And it makes a difference for the patients too.” (32:00—32:35) -Rachel
“Increased inflammation in Americans, for sure, is unbelievable. In my observation, one of the big problems is not getting to the root cause. So, if we can help our patients get to even one of the root causes of the problems that they're having, it can make a big impact.” (32:55—33:14) -Rachel
Snippets:
0:00 Introduction.
0:44 Rachel’s background.
2:56 Why this is an important topic.
6:14 The link between periodontal disease and fatal diseases.
9:06 Why patients fall into perio purgatory.
11:12 Migraines can be red flags.
14:23 Overcome lack of capacity in your hygiene schedule.
16:55 Get off the prophy hamster wheel.
19:20 Use a collaborative approach to diagnosis.
20:30 The importance of verbal skills.
24:21 Bleeding blindness, explained.
26:32 Everything revolves around your standard of care.
30:10 Final thoughts.
33:22 More about Inspired Hygiene.
Rachel Wall, RDH, Bio:
Rachel Wall, RDH, BS, coaches dental teams to build highly productive hygiene departments by implementing systems for high-quality periodontal care, enrolling restorative care through hygiene and letting go of negative mindsets and old beliefs while managing the logistics of a high-performance hygiene department.
Drawing from her 20-plus years of experience as a hygienist and practice administrator, Rachel delivers to-the-point clinical speaking presentations around the country. Her interactive teaching style coupled with a workshop environment creates a learning space where dentists and team members are compelled to get to the heart of what’s held them back, and inspire them to reach for more for themselves and their practices.