How To Stay Out Of Trouble With Perio
As a periodontist, I have found that some situations are more likely to get dentists in trouble with their perio patients. It is my hope that the following information helps reduce potential issues that can come up with periodontal patients in dental practices.
Hygienist are terrific at providing preventative maintenance treatment, and also can help "sell" a lot of restorative dentistry. They are not periodontists and should not be used in that capacity. Hygienists play a key role in maintenance of periodontal patients, but maintenance is appropriate after active therapy, not instead of periodontal treatment. It is unfair to put hygienists in a position to provide active periodontal care. When noticing how deep (or should I say shallow?) a scaler can make a scratch on a subgingival root surface - let alone remove all the tenacious bacterial deposits - it is unreasonable to expect non-surgical therapy to control disease in deep pockets. That is not a condemnation of hygienists, but simply recognizing the reality of difficulty in blindly accessing deep root surfaces.
Make sure your hygienists probe at least 6 sites around every tooth at least every other hygiene visit. Without probing, you cannot assess the patient's periodontal status. Also keep in mind that your hygienist needs to record the recessions, as they need to be added to probing depths to calculate attachment loss.
Patients have to be made aware of deeper pockets or the presence of attachment loss. Just like patients are entitled to knowing where they have caries, endodontic problems, signs of trauma from occlusion, the presence of oral infections, etc. If the hygienist probes the pockets but nobody discusses the findings with the patient, they cannot make informed health care decisions.
It is important to explain to patients what the periodontal findings really mean. It is remarkable how often patients come in to see me with the knowledge that they have several "nines". These patients usually claim to be very surprised when they hear that this represents severe bone loss and risk of losing the tooth. Additionally, patients are often very perturbed when they learn that untreated periodontal disease can double their risk for stroke and increase their risk for heart attacks by 40%! Periodontal disease has consequences far greater than simply losing a tooth. When patients are fully informed, they are unnerved that their periodontal disease has been "watched" for years instead of properly treated.
If you decide to provide (or have your hygienist provide) active periodontal care, provide proper reevaluation and refer the patient to a periodontist if the response is not adequate. If there is an inadequate treatment response, there is really no purpose to repeating Arestin treatment multiple times or go in with the laser one more time.
Finally, getting the periodontist involved at an earlier stage of periodontitis allows for a better treatment prognosis. Bone grafts don't really work when the tooth has a class 3 mobility as 90% of the alveolar bone is missing. This is no different than restorative treatment of a tooth being more predictable in an early stage of caries compared to an advanced stage.
Lack of diagnosis, patient information and proper treatment can create serious legal problems or cause a patient to lose confidence in the dental office. The collaboration between the dentist, hygienist and periodontist with shared maintenance after active treatment is a system that has served periodontal patients well for many decades. The fact that the periodontist, with the credibility of an "arms length" third party, can help the patient decide to move forward with needed restorative care is just an added bonus.
For further information, please visit www.thefauchardcenter.com
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