Periodontal Disease

Written by Debra Seidel-Bittke, RDH, BS

Periodontal disease is an inflammatory disease that affects the soft and hard tissues that support the teeth. The early stage of this disease is gingivitis. In later stages, the teeth may become loose, and the bone surrounding the teeth can degenerate. The most advanced stage of periodontitis is termed chronic periodontitis.1 Major risk factors for this disease include an inherited or a genetic predisposition, smoking, lack of routine home care, age, diet, certain systemic diseases, and various medications.2

Any time bleeding is present, pathological change is occurring in your patient’s mouth that needs to be evaluated and appropriately treated sooner rather than later. When periodontal disease is present, the potential for bone loss has already begun. Depending upon the patient’s risk factors, bone loss can occur quickly and become aggressive very easily. In patients with few or no risk factors, periodontal disease can be reversed with early nonsurgical intervention.3 With this knowledge, a patient will be much more likely to say yes to your treatment plan.

Phase 1 treatment is complete after the patient undergoes scaling and root planing, followed by a successful postoperative report from the 6-week re-evaluation appointment. This 6-week re-evaluation appointment is the first of the SPT appointments. During the early stage of periodontal disease and at the end of phase 1, the periodontium has the best chance to reverse the diseased state and, in many cases, halt the progression of further oral and systemic disease. Patients need to know, however, that this is not the end of the story. After phase 1 therapy is complete, a patient is now and forever considered a periodontal patient, which means regular SPT is a must to prevent active disease. A regular prophy just won’t do. If your patient were to ask, alternating prophylaxis appointments with SPT appointments is not appropriate and should not be considered as an appropriate phase for future treatment. Bone loss is not reversible, and it is imperative that patients understand this. Removal of the biofilm and microbiological factors also becomes very important for future health of the patient.4

For years, we have understood that periodontal disease is episodic. Make sure your patients understand what that means. It is another key point to use when explaining why regular periodontal maintenance is crucial. Periodontal pathogens will repopulate a healthy and recently scaled sulcus as early as 9 to 12 weeks post-scaling.5 That means a patient can brush and floss all day long, or even see the dental hygienist every 3 months; yet this may not be enough to prevent the return of periodontal pathogens. Without these pathogens removed, bone loss is likely to continue. Other clinical studies have shown that even with the supragingival environment as the single source for colonizing bacteria, a complex subgingival microbiota can develop within one week.6

You can strengthen your case for preventive care even more when your patient is aware that oral health affects the whole body. Countless studies have emerged during recent years suggesting a strong link between periodontal health and systemic health. For example, when patients with Crohn’s disease receive the appropriate treatment for periodontal disease, research reports a decrease in the enzymes that would normally increase inflammation in the sulcus—and the body.7 In addition, much research states that when a patient with type 2 diabetes mellitus is diagnosed with periodontal disease, nonsurgical periodontal therapy was associated with improved glycemic control.8 The role of the dental hygienist becomes extremely valuable when patients’ teeth are not merely "cleaned." Scaling, root planing, and various adjunct chemotherapeutic intervention along with lasers can improve a patient’s oral health8,9 and thus may actually help a patient live a longer, healthier life.

Your chances of getting a yes to nonsurgical periodontal therapy and routine SPT appointments will increase when patients understand the vital link between their oral health and systemic health. On that note, what’s even more effective is to share science’s good news. Decades of research and advances in periodontal therapy have proven that the majority of patients who receive routine preventive care can retain their dentition throughout their lifetimes.10 Many patients who do routine, long-term, supportive, nonsurgical therapy can maintain optimal gingival health that is free from reinfection.

If you have your patients’ attention at this point, they will probably want to know how often they need to come in for periodontal therapy. Although each patient will need an individualized treatment plan, dental hygiene appointments for routine preventive care will ideally range from 2- to 6-month intervals.11 Presenting the scientific evidence to patients takes good communication, and their understanding will leap forward, giving them a reason to sit up, listen, and take action, saying, "Yes!" to case acceptance of nonsurgical periodontal treatment.

LEAVE A LASTING IMPRESSION WITH STELLAR PATIENT EDUCATION
Now, you must bridge the gap between the hard science and your patients. So that you don’t overwhelm patients with heaps of unorganized scientific facts from your stream of consciousness, use a 3-step approach to present the information in support of your argument to partake in routine supportive periodontal therapy.

First, give patients the disease facts, focusing on tooth/bone loss and systemic health. This is also a good time to discuss risk factors for periodontal disease. Effectively communicate using words your patients will understand when you talk about the periodontal disease process. Not only is tooth loss a fact in their future, but also their health and longevity is at stake if they do not follow the appropriate treatment plan. Back up your facts with brochures, posters, iPad apps, etc, to show patients the importance of optimal oral health in relationship to their total overall health. Mention the risk factors and systemic disease links and highlight their specific risk factors in the information they will take home with them. Explain the complications that arise when periodontal health declines—and explain how easily this can happen without proper treatment and regular supportive periodontal therapy.

Second, when a diagnosis is established that calls for something other than a prophy, take the time to describe the treatment plan with your patients. Outline the treatment process with patients, step by step. You might even share with them a visual aid that shows the drastic difference between a prophy and periodontal therapy, or healthy versus diseased gums, such as the chart12 in Table 2 (Figures 1 to 13). To enhance an engaging communication process, ask open-ended questions, such as, "How do you feel about this treatment approach?" and "What are your concerns?" Then, invite the patient to ask questions. This is all part of the buy-in.

Finally, explain that periodontal disease is episodic and what that means.13 Tell patients that from this point forward, they need to return every 12 weeks, or at frequent, appropriate intervals when SPT is required. Explain that patients may appear healthy for many years after completing scaling and root planing, but the disease process can return at any time. Occasionally, patients may need to go from supportive periodontal therapy back to scaling and root planing. This is an example of the episodic process of periodontal disease, specifically when patients have certain risk factors.

Even with a 3-step approach, talking science isn’t always easy, but there are some creative ways to deliver a powerful message to your patients. Begin by sitting down as a team to discuss and understand the various personality styles of your patients. Then, develop scripts and practice a dialogue between the hygienist and various types of patients. Understand what words are important to your various types of patients and what may be considered hot buttons for your patients. For example, words such as "irreversible," "tooth loss," "bone loss," "pus," etc, are likely to grab their attention. Remember to take out words such as "cleaning" from your vocabulary with patients, and use words such as "preventive care," "supportive therapy," or "periodontal maintenance." Know the various types of words you can use with your individual patients, their health IQ, and their different personality styles when you communicate with them.

Know what motivates your patients. For instance, cosmetic issues are a huge motivator for many. If these patients understand that tooth loss or unsightly teeth and gums are in store for them, they might ask you to schedule an appointment right away. Other patients are motivated by health issues, so one of your scripts might be for the "health-conscious person." Another example is the patient motivated by money. At first, suggesting periodontal therapy may sound counter-productive to this kind of patient, but if you take a preventive angle, you can explain that the patient will save a lot of money in the long run by avoiding costly surgeries and other systemic health complications that may require numerous doctor appointments, pharmaceuticals, and even hospital visits.

Also take time with your team to list all the possible reasons a patient might say no. Then, brainstorm creative ways to counter the argument from your patient. Brainstorm as many personality types as you can, what motivates them, and push those buttons with them. After writing your scripts, practice with each other before you begin this new method of effective communication.

Alongside your script writing, brush up on your scientific knowledge and your ability to deliver it in everyday language. Have each member of the hygiene team bring in information about periodontal disease, risk factors, the oral health-systemic link, etc, and present a few key findings in 5 minutes or less, without looking at notes. Remember, you’re practicing for face time with a patient in a conversational situation. If you have only one hygienist, ask other teammates to participate in this exercise. Set a goal for everyone on the team to understand and embrace how treatment of periodontal disease can benefit a patient and mitigate various risk factors.

Many patients relate well to understanding the science. Some patients will want to know all the details about the disease, the treatment, and cause of this oral health challenge. Because of this, it can be valuable to have the hygiene team educate the entire team about subgingival recolonization of bacteria. Your team may want to spend some time with your local periodontist to learn about how subgingival microflora changes over time. At the same time, you can learn what your local periodontist expects from your office, when to refer, and when the periodontist wants to see a patient. This is another relationship-building opportunity. Set a goal for everyone on the team to truly understand the science and the oral-systemic link. Bottom line: every team member needs to be able to effectively explain the periodontal process and treatment goals to patients.

In addition, take time with your team to discuss your current patient needs. Create various scenarios, including real-life patient situations, and role play as a team. In this exercise, evaluate and discuss your team’s strengths and weaknesses in communicating the appropriate information. Practice until you are certain your communication skills will help patients understand what they need to do to be healthy and what it takes to get a yes to case acceptance.

The takeaway: You can educate your patients to a higher oral health IQ when you follow these suggestions—and you will get more patients to answer yes to the correct treatment plan. As a result, you will spend less time doing nonproductive scaling and have more time for other services that add profits to the practice and wow your patients. This is the true value of a dental hygiene appointment and providing more than "just a cleaning."