That three or six-month dental visit patients schedule and appreciate for their clean and polished teeth is so much more important than they realize. That visit is an integral part of their health and wellness. Let’s pause for a moment and recall that 47% of American adults (over age 30) have periodontitis – that’s 64.7 million Americans – which means they have chronic infected ulcerations. The situation is so pervasive that hygiene departments can legitimately be renamed “Chronic Oral Wound Care Centers.”
Our unacceptably high rates of disease contrast with our conviction that treatment is essential. Gum disease is the number one cause of tooth loss in adults. Chronic gingival infections and inflammation also play a large enough role in chronic systemic inflammatory conditions that treating periodontal disease indicates positive effects on patient general health. Diseased-induced halitosis, a quality of life issue, is alone important enough for treatment to be considered.
So, it is not for lack of information or concern for patient health that prevent us from more effective outcomes. We need two things: 1) a simple approach to focus on the disease that will sustain our attention and capture patient interest and 2) more effective homecare.
In his book Better: A Surgeon’s Notes on Performance, Atul Gawande discusses the greatest difficulty that the hospital infection control team has in the prevention of infections being spread: getting clinicians to wash their hands. The infection control team searched – for years – for a solution to the problem, made worse by the spread of antibiotic resistant bacteria. Top-down approaches, telling people what to do did not work. Infection rates stayed high. Patients died. It was only when the team began to look at the capabilities people had and sat down with health care workers at every level, focusing their consistent attention on the problem and requesting their input on solutions, that the situation finally improved. Their spread of infection rate dropped to zero.
To apply these lessons to improve periodontal health, a first step should be focused attention on bleeding scores. Bleeding on probing (BOP) data is readily available to the dental team, and years of research has shown that continuous absence of bleeding on probing is a reliable predictor for the maintenance of periodontal health or, stated differently, for no further periodontal damage.
If we accept that bleeding on probing is an important clinical assessment for periodontal health and maintenance, sustaining attention to the number of bleeding points gives us an easy number, quickly calculated from data that is already collected, to raise awareness on this silent epidemic. Imagine doctors asking hygienists at every appointment for the patient’s number. It would focus attention to help determine what to evaluate next so that you can educate the patient and plan for treatment. Patients already know the acceptable range for numbers relating to blood pressure, blood sugar, A1C, and cholesterol to name but a few. Why not a simple number to understand how acute their periodontal condition is in real time?
A simple number will not determine severity or diagnosis, but it will be useful. Severity is best determined with the American Academy of Periodontology’s revised classifications for the staging and grading of periodontitis. Based on clinical attachment loss, bone loss, tooth loss and pocket probing depths, these revisions also don’t help diagnose disease but “clarify extent, severity, and complexity of the patient’s condition” as well as the need for surgery, “difficulty of treatment, prognosis for the dentition and expectations during maintenance therapy.” These welcome revisions address new understandings of disease and allow for nuanced, multidimensional documentation of its complexity. The complexity in disease is reflected in the classification itself, necessitating overviews and published FAQs to understand. In short, it is not easy to use the classification in everyday practice.
Simplicity will help. Gawande’s discussion suggests that to do better we need mundane diligent attention to the problem (high rates of infection, inflammation and disease) and that we should look to the capabilities that people have, the assessments they are already using, to focus our attention. It does not mean that we ignore complex classification. The goal with a simple number like BOP is to direct our attention to 1) diagnose disease, 2) educate patients about it, and 3) treat it at the earliest stage possible.
The next logical question is what is your number? How much bleeding is acceptable in your practice? If you have a number that serves as a threshold, or standard of health, you know that everyone above it requires more attention, diagnosis, then education and treatment. It’s not realistic that every patient will get to zero bleeding points. Focus groups of >500 dental professionals agreed on 10 BOP as a good threshold for new or maintenance patients.
When you have your number, you and your entire team know when and why they are educating patients about Perio Protect: because it’s important to treat infected tissue. Perio Tray™ therapy from Perio Protect gets medication deep below the gums to fight the infections that toothbrush, rinse or floss can’t reach. When this targeted delivery is combined with scaling or surgery, it effectively reduces bleeding, inflammation, pocket depths, and gram-negative bacterial loads more than scaling or surgery alone.
There are times when everything advocated – initial treatment, surgery, maintenance, homecare – fails, but we can do better and our patients deserve better. Periodontal disease is one of the most underdiagnosed diseases in North America. It is always easier to address disease at the earliest stages. Help your patients make the hygiene paradigm shift away from cleaning to health. Combining a simple number like BOP to focus attention on gingival health with effective, non-antibiotic homecare strategies is an excellent first step.
The next step is presenting to patients. In addition to focusing on the comfort and efficacy of this convenient treatment, especially for patients with co-morbidities, and on its cosmetic benefits, you should also consider sharing these talking points on value:
The point is that health has a lasting financial value and improves our quality of life.
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