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Preparing for the Futurepage 1

April 2013

Perio Reports Vol. 25 No. 4page 3

Periodontal MaintenanceMessage Board, page 10

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»Inside This Section3 Perio Reports7 Profile in Oral Health: The RDH’s Approach to Periodontal Therapy10 Message Board: Periodontal Maintenance

Preparing for the Futureby Trisha E. O’Hehir, RDH, MSHygienetown Editorial Director

Two things should be considered when looking into thefuture of periodontal therapy. First, our efforts as dental pro-fessionals to eradicate dental disease, periodontal disease andcaries have not succeeded. According to the research, thesediseases are completely preventable, but not with the preven-tion approaches we follow today and have followed for thepast 50 years. Brushing and flossing will not prevent dentaldisease because the average person is not effective with eithera toothbrush or dental floss.

Second, the growing number of dental hygienists is out-pacing the shrinking number of dentists. Hygienists nowoutnumber dentists, leaving many hygienists withoutemployment. There are currently approximately 350 dentalhygiene programs in the U.S. and 65 dental schools. Granted,dental school classes are generally larger than dental hygieneclasses, but the numbers no longer balance. Most dentalschools now graduate as many women as men, with womenworking part time more often than men. This creates theneed for new work environments for dental hygienists. It isnot financially feasible for dental hygienists to open their ownpractices to provide non-surgical periodontal therapy. A fewhygienists have done this successfully, but the majority wouldprefer to focus on prevention and not on recreating a dentalpractice to provide a full range of dental hygiene services.

To address this problem, three Hygienetown Townies arecreating an international, online university where licenseddental hygienists can complete a Bachelor of Science Degreein Oral Health Promotion, and soon a master’s degree willprovide the opportunity for hygienists to create new workmodels taking oral health promotion outside the dentaloffice. O’Hehir University, created by Sarah Cottingham,Tim Ives and myself, is preparing for the future with a focuson eliminating dental disease through the creation of newprevention-focused hygienist positions. n

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Air polishing in the past used a bicarbonate of soda pow-der that was effective for plaque and stain removal, but dam-aging for the tissues. Today, glycine powder is available forair polishing that can be used with a new tip to polish sub-gingivally, reaching into both shallow and deep pockets.

Researchers at the University of Washington in Seattle,Washington, compared full-mouth Glycine Powder AirPolishing (GPAP) to traditional scaling and root planingwith curettes plus rubber cup polishing. All patients hadundergone initial periodontal therapy prior to this study.

Subjects were all found positive for intra-oral levels of P.gingivalis and T. forsythia. Probing depths ranged from4mm to 9mm. Patients were instructed to rinse twice dailywith 0.12 chlorhexidine mouthrinse for two weeks follow-

ing treatment. Microbial and clinical indices were repeatedat day 10 and day 90.

At all time points, the patients receiving the subgingivalGPAP had lower total viable bacterial counts in the moder-ate-to-deep pockets compared to those receiving instrumen-tation with curettes and rubber cup polishing. Patientsfound both treatment approaches comfortable. Air polishingwith glycine power in subgingival pockets is more effectivethan using curettes to shift the oral flora from one conduciveto infection to one more conducive to periodontal health.

Clinical Implications: Despite our tradition of instrument-ing all subgingival areas during a perio maintenance visit,

these findings suggest that air polishingwith glycine power in the subgingival areasjust might be able to replace subgingivalinstrumentation with curettes. n

Flemming, T., Arushanov, D., Daubert, D., Rothen, M., Mueller, G.,

Leroux, B.: Randomized controlled trial assessing efficacy and safety of

glycine powder air polishing in moderate-to-deep periodontal pockets. J Perio

83:(4)444-452, 2012.

Lasers Used in Supportive Perio Therapy, No Added Value

Laser therapy shows promise for bactericidal and detoxi-fication effects. Lasers remove granulation tissue, plaque andcalculus without harming tooth root surfaces. The Nd:YAGlaser is often used as part of non-surgical therapy. It may beadvantageous to use a laser in non-responding pocketsencountered during periodontal supportive therapy.

Researchers at the University of Amsterdam in theNetherlands compared periodontal maintenance therapy withand without the adjunctive use of an Nd:YAG water-cooledlaser. A total of 30 subjects who had been seen for regularperiodontal maintenance care and still had 5mm probingdepths with bleeding were included in the study. Each subjecthad an average of 11 treatable sites. After baseline data collec-tion, all received supragingival and subgingival instrumenta-

tion and oral hygiene instructions. Following this treatment,subjects were randomly assigned to either laser treatment orno further treatment. Laser treatment was applied subgingi-vally against the tissue for no more than 60 seconds per site.

Subjects were instructed to rinse twice daily with 0.12percent chlorhexidine mouthrinse for two weeks and weregiven a questionnaire to complete at home that evening andmail back the following day. Questions about pain, bleedingand medication needed were included.

At six months subjects returned for clinical examination.No differences were observed between the groups. No addedbenefit was provided by the laser therapy for probing depthsor bleeding. The laser treated group reported more pain,bleeding and swelling. Both groups improved significantly.

Clinical Implications: Laser treatment might not provide added benefit to supportive therapy. n

Slot, D., Timmerman, M., Versteeg, P., van der Velden, U., van der Weijden, F.: Adjunctive Clinical Effect of a Water-Cooled Nd:YAG Laser in a Periodontal Maintenance Care Programme: A Randomized Controlled

Trial. J Clin Perio 39: 1159-1165, 2012.

Perio Reports Vol. 25, No. 4Perio Reports provides easy-to-read research summaries on topics of specificinterest to clinicians. Perio Reports research summaries will be included in eachissue to keep you on the cutting edge of dental hygiene science.

Air Polishing to Replace Subgingival Instrumentation

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Herbal Toothpaste Comparable to Fluoride Toothpaste

Despite disease starting between the teeth, tooth-brushing is still the primary approach to plaque biofilmcontrol. Mechanical and chemical means are used tocontrol bacterial biofilm. Plant-based herbs have beenused for centuries as medicinal remedies and are botheconomical and have fewer side effects than currentpharmaceutical options. Several food-based substances have been used intoothpastes over the years, including:myrrh, chamomile, Echinacea, sage,rhatany, essential oils, peppermint,ginger, cloves, tea tree oil, coriander,lemon and spearmint.

In India, Himalaya Dental Creamis a new herbal toothpaste now avail-able. Public health researchers inBelgaum, India compared Colgate flu-oride toothpaste and the HimalayaDental Cream in a group of 55 youngwomen. The women, ages 18 to 25 years, resided in aworking women’s hostel in Belgaum, India. Researchersevaluated plaque and gingivitis scores over six weeks,with scores recorded at baseline, three and six weeks.

Half the women brushed with Colgate fluoridetoothpaste and the other half brushed with HimalayaDental Cream which contains several herbal ingredients.All subjects were instructed in a circular toothbrushingmethod and asked to refrain from using other dental aidsincluding mouthwash and dental floss.

Both groups showed significant reductions in plaqueand gingivitis at each of the three exam time points.When asked to complete a questionnaire at the end,both groups reported they liked the color, taste and smellof their assigned toothpaste.

Clinical Implications: More herbal and alternativetoothpaste brands are becoming available. Recommendtoothpaste based on ingredients you and thepatient want. n

Hebbal, M., Ankola, A., Sharma, R., Johri, S.: Effectiveness of Herbal and Fluoridated Toothpaste

on Plaque and Gingival Scores Among Residents of a Working Women’s Hostel - A Randomized

Controlled Trial. Oral Health Prev Dent 10: 389-395, 2013.

Baby Tooth Wipes as Effective as Toothbrushing

Early childhood caries is a significant problem todaythat requires early intervention to disrupt and removebacterial biofilm on babies’ teeth. Mothers and caregiversprovide daily oral hygiene, generally using a toothbrush,

a finger-adapted toothbrush or wet gauze. Severaltooth wipes are now available. A company in Brazildeveloped one of which contains xylitol, sorbitoland chamomile.

Researchers in Brazil compared the new babytooth wipes to toothbrushing and cleaning with wetgauze in two groups of babies cared for by eithertheir mother or a caregiver. Babies ranged in agefrom eight to 15 months and only had anteriorteeth. The babies were all considered high risk, asthey were given sweet drinks in bottles with no oralhygiene afterward.

The study design began with baseline biofilmscores using disclosing solution followed by a rubber

cup polishing and four days of normal oral hygiene. Thenext two days no oral hygiene was performed followed byinitial biofilm score and seven days of one of the threeoral hygiene approaches: toothbrush, gauze or tooth wipefollowed by the final biofilm score. Each of the 50 babiesparticipated in all three approaches with a rubber cuppolishing between.

Mothers removed 84 percent of biofilm compared to 45 percent removed by caregivers. Baby tooth wipeswere as effective as a toothbrush and were better toler-ated by babies.

Clinical Implications: Encourage parents and care-givers of babies to use baby tooth wipes after feedingand before putting the baby to sleep since this is eas-ier and better accepted by the babies. n

Abanto, J., Rezende, K., Carvalho, T., Correa, F., Viela, T., Bönecker, M., Salete, M., Correa, N.:

Effectiveness of Tooth Wipes in Removing Babies’ Dental Biofilm. Oral Health Prev Dent 10: 319-

326, 2012.

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According to the World Health Organization,malocclusion ranks third – after caries and peri-

odontal disease – in oral health prior-ities. Malocclusion is not a disease butis a group of deviations from normaltooth position. Most malocclusionsare caused by acquired habits,including a soft diet, harmful oralhabits and mouth breathing. Leftuntreated, malocclusion can causeboth physiologic and social problemsfor the individual.

Researchers at Estadual PaulistaUniversity in Aracatuba, Brazil evalu-ated 1,385 children, ages five to six

years, who were students in 56 public schools in SaoPaulo, Brazil. Ten dentists and 10 assistants weretrained to clinically evaluate occlusion for this study.

Pacifier use was reported in 44 percent of chil-dren, bottle use by 86 percent and digit sucking by18 percent. Tooth crowding was found in 10 percentof the children and four percent had tooth rotation.Harmful habits were associated with moderate tosevere overjet in 22 percent of children. Posteriorcrossbite was found in 15 percent of children, whichis lower than other studies reporting 29 percent inthis age group.

Occlusion in these children was classified asClass I in 75 percent and Class II in 19 percent.Eight percent showed edge-to-edge occlusion andtwo percent had anterior cross bite. Short to highoverbite was found in 44 percent of children.

Orthodontics is part of the Brazilian health caresystem and more prevention should be included toaddress the impact of harmful habits and mouthbreathing on development of malocclusion.

Malocclusion is Associated with Oral Habits

Malocclusion Rates Remain High in Japanese Girls

Recognizing malocclusion helps determine future ortho-dontic needs. In large-scale studies of more than 500 adoles-cents, the prevalence varies from 48 percent to 90 percent.Factors influencing these variations include age, race, ethnic-ity and social class. Most studies show an overall prevalenceof more than 50 percent malocclusion.

Over the past 40 years researchers at Osaka University inJapan have evaluated malocclusion using the same criteria instudents at the same schools. The current study evaluated2,378 schoolgirls in seventh and 10th grades studying in sev-eral private high schools. Those who were found to needorthodontic treatment were classified as having malocclusion.

Malocclusion was found in 56 percent of seventh gradersand 55 percent of 10th graders. These numbers are similar tothose reported in several studies of the same population overthe past 40 years. Findings were similar for both class groups

in these areas: maxillary protrusion, 9.4 percent and 7.8 per-cent; cross-bite 0.6 percent and 1.3 percent; edge-to-edgebite 4.1 percent and 1.2 percent; open-bite 0.6 percent and1.2 percent; crowding 19.1 percent and 20.1 percent. Theonly difference was found in the deep-bite category with 8.4percent of seventh graders reported to have a deep-bite and5.8 percent of 10th graders. The lower score for 10th graderswas explained by changes due to eruption of permanentmolars in the older girls.

The popularity of early intervention orthodontics inJapan might explain lower rates for anterior cross-bite andedge-to-edge bite.

Clinical Implications: Malocclusion is an ongoing problem that requires recognition and early intervention and treatment. n

Uematsu, S., Yoshida, C., Takada, K.: Proportions of Malocclusions in Japanese Female Adolescents over the Last 40 Years. Oral Health Prev Dent 10: 373-377, 2012.

Clinical Implications: Check children early forsigns of malocclusion and harmful oral habits. n

Santos, R., Nayme, J., Garbin, A., Saliba, N., Garbin, C., Moimaz, S.: Prevalence of

Malocclusion and Related Oral Habits in 5 to 6-Year Old Children. Oral Health Prev Dent

10: 311-318, 2012.

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hygienetownprofile in oral health

by Trisha E. O’Hehir, RDH, MSHygienetown Editorial Director

Past 1960-1985

Scientific Basis for Periodontal TreatmentCalculus was considered the cause of periodontal disease in

the 1960s. It was viewed as a mechanical irritant to the tissueand removal was considered the primary treatment for peri-odontal disease. This was followed by the “non-specific plaquehypothesis” that suggested plaque was the primary etiologicalfactor and all plaque was bad plaque. It was the amount ofplaque that caused disease. No research was able to prove this, assome patients had so much plaque they deserved disease, butdidn’t have any pockets. And others had very little plaque ontheir teeth, but the connective tissue and bone seemed to bemelting away.

Plaque was considered “white sticky stuff ” on the teethmade up of bacteria and it was stained red to show patientswhere they missed with brushing and flossing. It wasn’t untildental offices in the 1970s began using Phase ContrastMicroscopy that clinicians actually saw the bacteria as living,growing, multiplying creatures. This enhanced the clinician’sview of plaque, captivated some patients and frightfully scaredothers. It changed the focus from just calculus removal to theimportance of daily plaque removal. It was in the 1960s whenDr. Bass, having lost a tooth to periodontal disease, studied andpublished his findings on the importance of daily plaque controlusing his Right Kind toothbrush and dental floss.

Next came the “specific plaque hypothesis” that suggestedjust one bacteria was responsible for periodontal disease. In the1970s it was widely believed that the identification of a specificbacteria responsible for periodontal disease would be discoveredand a vaccine would be developed to eliminate both periodon-tal disease and the dental hygiene profession. Who would needhygienists if periodontal disease no longer existed? During the1980s, periodontal researchers were on a quest to identifypathogens within plaque. Each month the periodontal researchjournals heralded the discovery of yet another pathogen thoughtto be the “one” responsible for periodontal disease. Identificationof bacteria within plaque was done with Scanning ElectronMicroscopy. Plaque samples are placed on a slide, dried, sput-tered with gold and evaluated to identify bacteria. As the

months grew to years, it became known as the “bug of themonth club” as more and more pathogens were identified.Periodontists identified six to eight potential pathogens among500 identified species in plaque and research never confirmedone specific bug responsible for gingivitis or for converting gin-givitis to periodontitis.

With a top-10 list of bacteria identified as the virulentpathogens, the research turned to the episodic nature of the dis-ease. Periodontitis was characterized as having periods of quies-cence and periods of disease progression.

Dental Hygiene EducationDental hygiene education in the 1960s focused on supragin-

gival deposit removal. Periodontal disease was identified byholding the radiographs up to the light to determine bone loss.Severe, generalized bone loss on the radiographs was a conclu-sive diagnosis of periodontal disease and these patients werereferred to the periodontal department where periodontal prob-ing was done. Probing was not done in the hygiene department.

Hygiene students did see periodontal patients for calculusremoval, since calculus was the enemy and had to be removed.Power scalers were used only on the toughest cases, followed byextensive hand instrumentation to achieve glassy smooth rootsurfaces. Power scalers were used for a single pass around themouth to remove only gross deposits. The bulk of the instru-mentation was done with curettes. The importance of calculusremoval carried over to the state board examinations requiring,still today, removal of a specific number of calculus deposits. Inthe 1960s calculus was considered a mechanical irritant thatcaused periodontal disease.

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TreatmentTreatment of periodontal disease by dental hygienists

included scaling and root planing performed with primarilycurettes and scalers but also some power scalers used prior tohand instruments for gross supragingival deposits. The curetteswere generally Gracey and Columbia designs. The Graceycurettes were designed by Dr. Clayton Gracey in the 1930s to beused during flap surgery, not for closed instrumentation as theyare used by hygienists even today. But since these were the onlyinstruments available to hygienists to remove subgingivaldeposits, they became the standard. These site-specific curettesadapt well to root surfaces when the gingival tissue is reflectedback during flap surgery, but when used by hygienists to accesssubgingival deposits, they presented unique problems and chal-lenges to effective deposit removal.

Present: 1985-2013

Scientific Basis for Periodontal TreatmentCalculus is no longer thought of as the cause of periodontal

disease, but the result of periodontal infection in the tissues. Theintroduction of Laser Confocal Microscopy by engineers study-ing biofilm changed the focus of the dental world from identifi-cation of specific bacteria within a biofilm to identification ofthe structure, composition and function of the polysaccharideslime that housed the bacteria in a biofilm. Instead of drying out a plaque sample to view it using a Scanning ElectronMicroscope, the oral bacteria were allowed to form a biofilm ina fluid environment on a stage of sorts. Digital images are takenas slices through the living biofilm and digitally assembled toprovide a video film of living biofilm in action. Learning moreabout the way bacteria live and function has changed the viewof periodontal disease. Periodontal pathogens within a biofilmrelease toxic waste products that pass through the junctionalepithelium and trigger an immune response from the body. It isthis immune response from the body that destroys connectivetissue and bone, not the bacteria directly.

It’s not just about the bacteria either, as smoking and dia-betes were the first recognized risk factors observed to interferewith periodontal healing. Today, epigenetic differences, changesin gene expression due to environmental factors, stress and dietimpact the disease process and healing. Although basic DNAdoesn’t change, how the genes are expressed does change andthis impacts periodontitis, cancer and other inflammatory dis-eases. Eliminating the stressor, nutritional deficiency and bacte-ria can reverse alterations in gene expression, or they can remainand be passed on to future generations with potential detrimen-tal effects. Research is focusing on the link between the oral cav-ity and the rest of the body. Periodontal disease doesn’t causesystemic disease, but oral and systemic health are linked.

Today bacteria in oral biofilm are identified by genetic test-ing, with estimates that only 50 percent of pathogens can be cul-

tured. Today genetic identification of bacteria estimate themouth is home to more than 800 genetically different species.Bacterial species are grouped by colors denoting their virulencefrom red, the worst, to orange, yellow, blue and green.

Antibiotics, both systemic and locally delivered, are used tofight the pathogens of periodontal disease. Systemic antibioticswill effectively target bacteria that have found parking spaceswithin the ulcerated epithelial pocket lining. They are not effec-tive against pathogens within the biofilm on the root surfaces, asthese surfaces are outside the body. Locally applied antibioticsand antimicrobials target bacteria on subgingival root surfaces.

Dental Hygiene EducationBoth assessment and diagnosis of periodontal disease pro-

vide the foundation of periodontal education for dental hygien-ists today. Hygienists need to recognize the signs and symptomsof periodontitis and distinguish between gingivitis and early,moderate and severe periodontitis. They must also identify riskfactors and devise a dental hygiene treatment plan to bring apatient back to periodontal health and keep those who are peri-odontally healthy, just that: healthy.

TreatmentHygienists still provide non-surgical therapy today, and

nearly all hygienists are now licensed to provide local anesthesia,no longer needing to wait for the dentist to anesthetize theirpatients. Power scalers are used as the instrument of choice foraccess and removal of subgingival deposits. Hand instrumentssupplement the primary work done by power scalers. Newinstrument designs provide some minor alterations in blade andshank length for Gracey curettes. New instrument designs arebeing introduced to access subgingival areas more effectively andwith no tissue trauma from the offset blade of traditionalcurettes. The O’Hehir curettes have a tiny scoop blade, with nooffset blade and provide easier adaptation to narrow subgingialareas as well as supragingival sites. Lasers are now used byhygienists in addition to power and hand instruments.

The endoscope was introduced and is still used by manyhygienists to “see” the subgingival root surface and tissue wallmagnified up to 46 times. Endoscopy allows hygienists to effec-tively remove all subgingival deposits associated with pocket wallinfection. Although the perioscope is no longer being produced,prototypes of advanced endoscopes are being developed to fur-ther enhance subgingival instrumentation. Soon blind subgingi-val instrumentation will be a thing of the past.

In addition to instrumentation, the patient’s immune systemis enhanced with nutritional supplementation. Several productsspecific to periodontal tissue health are now available that con-tain vitamins, minerals and herbs. Salivary testing is also avail-able to determine exactly which bacteria dominate the bacterialbiofilm. In some cases, systemic antibiotics are recommended.Mechanical disruption of bacterial biofilm is still the primaryfocus of patient oral hygiene activities.

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Future: 2014 and Beyond

Scientific Basis for Periodontal Treatment The focus until now has been on treatment of periodontal dis-

ease with scaling and root planing. Moving forward the focus willbe on early intervention for prevention. Why wait until the dam-age is done to find effective preventive methods? Today’s researchshows that dental disease is completely preventable, and it is alsoclear from the research and from the level of disease still seentoday that brushing and flossing do not effectively prevent dentaldisease. The future will provide patients with the tools and coach-ing they need to effectively manage their oral biofilm. More willbe available than mechanical disruption of plaque biofilm.Adding xylitol to the diet five times daily results in a 50 percentreduction of biofilm. That’s better than toothbrushing, which isshown to reduce plaque by 42 percent in the hands of patients.Oral probiotics will change the balance of bacteria in oral biofilm,leading to a healthy microflora rather than a flora conducive todisease. Mouth breathing will be addressed to shift people back tonose breathing, which protects oral tissues, but also promotesregenerative sleep, better brain development in children, idealpalatal growth and optimal airway development. The pH of theoral cavity determines which bacteria dominate the bacterialbiofilm. Acid levels will encourage acid-producing bacteria whilealkaline levels will discourage acid-producing bacteria. Since dis-ease begins on interproximal surfaces first, the focus will now beon cleaning in between the teeth with things other than stringfloss. Flossing with water or using various interproximal devicesare easier to use and more effective than string floss.

Dental Hygiene EducationOral health coaches will be RDHs with a Master of Science

Degree in Oral Health Promotion. They will be experts in thescience, business and communication of oral health practicesand interventions. They will work with both fee-for-servicecoaching contracts with individuals and families, as well as withmedical insurance companies focused on the financial bottomline, recognizing the cost savings on many levels from optimaloral health. The science supporting new approaches to preven-tion will be the foundation of this education, along with skill-building in the business of dental hygiene and effectivecommunication. Education of the future will not be based onstructured courses, but rather reflective and inquiry learningthat ask questions about what they are doing now to promoteoral health and how effective it is. Reflective learning and actionresearch will guide RDHs in their development of new workopportunities focused on oral health promotion.

Treatment Treatment in the future will still require subgingival removal

of bacterial biofilm and calculus within the dental office settingas it is provided today with non-surgical periodontal therapy ingeneral and periodontal practices. The use of endoscopes will

become the standard of care in the future, looking at the subgin-gival area rather than providing treatment blindly. Subgingivaltreatment will be done with lasers and instruments designed foreasier subgingival access.

The future will also bring diagnostic codes to be used in con-junction with treatment codes. This will bring clear delineationbetween health, gingivitis, early, moderate and severe periodon-titis. With detailed diagnostic codes come the necessary treat-ment codes to eliminate the problem of treating gingivitis andearly periodontitis with a preventive procedure, a prophylaxis, asis the case in many dental offices today. Specific treatmentscodes will be created for the various clinical procedures providedby dental hygienists.

In the future, effective preventive services will be provided insettings other than the dental office. Oral health coaching willbecome the approach that succeeds in preventing initial diseaseas well as preventing recurrence of disease after successful treat-ment. RDHs will go to the consumers rather than the consumerscoming to the dental office. They will bring their preventionmessage to the general public through family practice medicalpractices, OBGYN practices, breathing and myofunctional ther-apy centers, schools, nursing homes, hospitals, senior residentialcenters, homes, sports clubs, shopping malls and wherever con-sumers find oral health coaching convenient. Today’s dentalpatients have invested time and money for cosmetic dentistrythat requires significant daily attention to prevent root caries andperiodontal disease. Three- to six-month maintenance visits in adental office without adequate steps taken on a daily basis toaddress biofilm formation, salivary pH, nutrition and immuneresponse will fail. Dental hygienists are needed to provide weeklycoaching visits for these individuals and families.

Parents report difficulty “brushing and flossing” their chil-dren’s teeth. With so many more tools now available, RDH oralhealth coaches will be hired by families to come to the home ona weekly basis to ensure effective biofilm control, salivary pHcontrol, nutritional counseling, remineralization when necessaryand daily xylitol use. These visits will also address mouth breath-ing and tongue positioning to ensure optimal oxygen reaches thebrain for restorative sleep and optimal brain development forgrowing children.

Brushing and flossing will no longer be the mantra of pre-vention. Instead, control of the biofilm environment and thesalivary pH will be the focus of weekly oral health coaching vis-its. Xylitol-containing products, oral probiotics, nasal breathing,tongue position and nutritional supplementation will be used to achieve and maintain oral health, not just with periodontalhealth, but with overall health. All of these preventiveapproaches provided by the future RDH oral health coaches willprevent more than just periodontal disease; they will begin withinfants and children to set them on the right path to optimalgrowth and development and prevention of dental diseases overtheir lifetime. n

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hygienetownmessage board

sruthe05 Member Since: 09/10/12 Post: 1 of 15

catsmeowrdh Member Since: 09/25/08 Post: 2 of 15

shazammer1 Member Since: 12/20/00 Post: 3 of 15

Debbie-The Paleo Hygienist Member Since: 11/17/07 Post: 6 of 15

Periodontal MaintenanceA Townie looks for ways to encourage perio patients to maintain more frequent appointments.

»Our office has recently been having problems scheduling our perio maintenance patients

every three months. Since insurance only covers two regular prophies a year, patients do notwant to pay out of pocket for the other two appointments. I am looking for any suggestionson how to bill insurance so that these appointments can be covered. Also, if anyone has anyinput on how to explain to patients the importance of the maintenance appointments, Iwould greatly appreciate it. Thanks! n Shantel RDH

As far as I am aware, there is no way to work the insurance for four perio maintenanceappointments per year, unless patients are really lucky to have great insurance. The ADAhas a great handout on perio maintenance and it explains why more frequent appointmentsare necessary.

I try my best to get patients on a four-month schedule so that they only have one out ofpocket maintenance appointment per year. There are a few who just have to comeevery three months. It also helps that I express that we can try four-month maintenance andif we see concerns going forward, we can always try to back it up to three months and seehow that works. They seem to appreciate that I am aware of, and sensitive to, their financialconcerns. We have good compliance with our perio maintenance patients and I think thatconversation contributes to it. n

I was at an insurance seminar last Friday and learned that companies like FedEx,for instance, have up to 12 different dental plans for their employees, I guess, depend-ing on the rank of the employee and how much they wish to kick in themselves, likea junk store policy and a jewelery store policy.

You might mention that getting too loosey-goosey with maintenance appointmentscould easily lead to perio surgery, which nobody wants to hear. Mention the systemic rami-fications of allowing bacteria to circulate the bloodstream and that keeping the gums healthykeeps the entire body healthy. If your patient already has systemic situations going on likeheart disease, diabetes, circulatory, certain meds, BP, etc., pull that into the conversation overand over. Keep them aware that oral health supports systemic health. n

I always tell my patients that their brushing, flossing, etc., at home will only reach three,maybe 4mm deep, so any bacteria down in those 5mm and deeper areas will remain, there-fore I need to see them every three or four months (as needed) to reach the areas they can’treach on their own. I explain that if we let those areas go for too long between cleanings, thepocket will likely deepen causing more bone loss and require perio surgery to correct, andthat this extra DH visit per year is needed to keep them stable. I work in a perio office wherea large portion of my patients have had at least one perio surgery already, so anytime I tellthem that I’m trying to keep them out of the surgery chair, they appreciate it. I’ve noticedmany insurers often cover a third or fourth PMT per year once they see the patient has hadSRP, but again, depending on the particular plan, this is not always the case. n

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drtoast Member Since: 08/24/05

Post: 7 of 15

lindadouglas Member Since: 06/09/06

Post: 8 of 15

drtoastMember Since: 08/24/05

Post: 10 of 15

Patients in a perio practice are totally different than those in a GP. Just by virtue of thefact that they have opted to see a periodontist means they are more motivated than the gen-eral population of patients. I think all of the information that you propose to share with yourpatients has merit.

However, for many patients, I don’t think they need to respond, nor do they respond, tomore information. In my experience we need to get to know each patient as an individualand determine where his values lie: e.g. money, health, time, etc. Once you get a read on this,you can tailor your motivating words to this individual. If you attempt to use the sameapproach on all of your patients, in my experience, you are going to miss connecting withmany of them. In dentistry, we almost have a reflex reaction when a patient is not showinginterest in what we are saying. We just heap more information on them. Sadly, this is notwhat many of them need or want. n

A great reminder, drtoast. Years ago I read a great quote in a dental assisting jour-nal which motivates certain patients, who focus on money. “Every $1 spent on preven-tive dental care saves between $8 and $50 in averted emergency and major dentalprocedures.” n

I just happened to hear a presentation at this year’s American Academy of Periodontologymeeting and one of the presenters touched on the critical importance of regular periodontal

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lindadouglas Member Since: 06/09/06Post: 11 of 15

Debbie-The Paleo Hygienist Member Since: 11/17/07 Post: 13 of 15

adventuregirl Member Since: 12/01/06 Post: 14 of 15

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SEP 30 2012

SEP 30 2012

SEP 30 2012

maintenance for the long-term success of overall periodontal health. He referenced a classicalarticle that was written by a periodontist, Thomas Wilson, back in the 1980s. Dr. Wilsonlisted the following four reasons for lack of patient compliance: lack of information, fear, eco-nomics and lastly, patient perception of a lack of compassion on the part of the clinician. n

Here is an extreme example of showing how much you care. A few years ago, I toldour FD that I felt like crying over the deterioration of a non-compliant patient. Shetold the patient that I actually cried, and the turnaround was amazing! The improve-ment in self-care, and her appreciation of the importance of regular dental care

increased immensely. To quote one of our super Townie colleagues (Izdent), “People don’t care about how

much you know, until they know how much you care.” We all know that we care, (which iswhy this thread began) but sometimes the patient does not perceive that. n

I want to respond to drtoast regarding his comment that patients in a perio office differfrom those in a GP office. Having worked in both, I disagree. Patients don’t come beatingdown the door of the perio office because they are more motivated when it comes to theiroral health. Honestly, I think it is quite the opposite. The bulk of our patient base is fromGP referrals. A handful of our patients are self-referrals when they had a friend or familymember that told them of a great experience in our office, but our patients are with usbecause their GPs have referred them out and tell them they need to see us. I still get patientsasking to be on a six-month recall and asking when they can return to their GP’s office. It’sreally no different. I don’t want to generalize, but I just don’t see that perio patients in a periooffice are any more motivated. Frankly, there is a lot of denial going on in perio offices. Ihave patients with a 30-year smoking history and yet they still state, “Well, my parents hadbad teeth so I have bad teeth.” Whether in the GP office or the perio office, many just don’twant to take personal responsibility for their health. n

While there are always exceptions, my experience has been that patients who have seena periodontist are, in general, more educated about their disease and their responsibility inkeeping up with maintenance and oral hygiene. I worked in a perio office for 10 years andwe made sure that every patient was fully educated, treated like an individual and werepeated things every single appointment. I’m in a general practice now, and many periopatients don’t seem to get it no matter what we tell them (although brochures have helped).Non-compliant patients usually have reasons for not listening and finance is a big part ofthat. I tell them that oral hygiene is free and that health depends on them if they can’tcome in as often as I would like. I also let them know that we are a team, the patient andI, and together we can help them keep their teeth, but I can’t do it alone. I try to let themmake the choices instead of telling them what they should do. Ultimately it’s our respon-sibility to continue to try to connect with each patient. If they keep showing up, they arehearing something! n

SEP 30 2012


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