The American Academy of Periodontology recently released some guidelines to assist general dentists on referral protocols. Guess what? Some dentists didn’t like the guidelines. How do the AAP guidelines affect you?
For several years, a controversy has been brewing over treatment of the periodontal patient and appropriateness of referral to a periodontist. With various treatment options available today for the periodontal patient, the trend has been to defer referral and treat the patient conservatively in the general practice. However, the central question remains: What is best for the patient?
Periodontal diseases are chronic inflammatory conditions that destroy the supporting structures around teeth over time. Patients present with varying degrees of severity from mild to advanced. The goal of treatment is to stop the progression of the disease and assist the patient in achieving and maintaining good oral health. This goal may be achieved through a treatment plan that involves nonsurgical and/or surgical modalities of therapy.
Prior to the early to mid 1980s, most new patients with periodontal disease were referred to a periodontist before any restorative dentistry was done to ensure a healthy and stable periodontium on which to build future dentistry. Many periodontal patients were treated surgically. When they returned to the general practice for the restorative phase, their oral tissues were healthier. However, root exposure and sensitivity (often lasting for years) were common.
However, somewhere in the early to mid 1980s, the phrase “soft tissue management” hit the periodontal treatment scene. First developed and presented by ProDentec, this nonsurgical method of treating periodontal disease appealed to many dental professionals. General practices implemented a nonsurgical protocol that involved anesthetizing the patient and treating only a quadrant of teeth in one visit. Hygienists and dentists were amazed at the good tissue response, and patients were happy to avoid periodontal surgery.
The trend to treat periodontitis “in-house” in general practices continues today. Many clinicians feel empowered and confident in treating periodontitis nonsurgically in light of the positive clinical outcomes achieved in many cases. A financial incentive to treat the periodontal patient in the general practice also exists. Periodontal procedures such as root planing and debridement are higher production procedures than prophylaxis procedures. General practices that see a high percentage of periodontal patients also reap those financial rewards.
Frustration among periodontists
With the trend to keep the periodontal patient in the general practice, periodontists have noticed a decline in the number of referrals to treat periodontitis. Other procedures, such as implants and cosmetic tissue treatments, command more of the periodontist’s time now.
However, periodontists have observed that many of the periodontal patients who are referred are “train wrecks.” These patients have already been through root planing/scaling procedures in the general office yet continue to lose attachment. An article published in the Oct. 2003 Journal of Periodontology titled, “Periodontal Referral Patterns, 1980 versus 2000: A Preliminary Study” supports this observation with these results and conclusion:
“The following trends were noted: 1) an increase in the average age of patients at the time of the initial examination; 2) a decrease in the percentage of patients using tobacco at the time of the initial interview; 3) an increase in the percentage of periodontal Case Type IV patients with a concomitant decrease in the number of periodontal Case Type III patients; 4) an increase in the average number of missing teeth per patient at the initial examination; and 5) an increase in the average number of teeth scheduled for extraction per periodontal treatment plan.”
To that end, the American Academy of Periodontology (AAP) commissioned a task force to develop guidelines for the management of patients with periodontal diseases to encourage referring dentists and periodontists to work together to optimize the health of patients. The guidelines were made public in September 2006 (see http://perio.org/resources-products/pdf/management.pdf).
The AAP Guidelines stratify three levels of patients (see chart on page 22).
One of the most controversial sections in “Level 2” stipulates referral for pocket depths 5 mm or greater. Many general dentists and hygienists are of the opinion that adhering to this particular guideline would result in “over-referral” of cases that they feel competent to treat and maintain in the general practice. Also, root exposure is listed as a referral criterion. If general dentists and hygienists referred every patient with root exposure to the periodontist, that would include better than 50 percent of their patient base.
Frustration expressed by the AGD
The AAP guidelines state that the academy sought input from three other large dental associations: American Dental Association, Academy of General Dentistry, and American Dental Hygienists’ Association. However, the AGD took a strong stance in disagreeing with some of the AAP referral guidelines. In a letter drafted by the Board of Directors of the AGD to the AAP, the AGD expressed concern that the AAP portrayed inconsideration for the role, education, and ability of the general dentist to treat his or her patients. They called the guidelines “extremely offensive to well-qualified AGD members.” The AGD was also offended at the guideline’s implication that the AGD endorsed “such an erroneous set of guidelines for referral of periodontal patients.” The current AGD president, Dr. Bruce DeGinder, stated, “We categorically do not endorse this document, and our board of trustees has communicated through legal counsel to the AAP our critical concerns.”
It should also be noted that the word “hygienist” is only mentioned once in the AAP guidelines. The words “clinician” and “practitioner” are used liberally. However, in the majority of general dental practices, it is the dental hygienist who provides most of the care delivered to periodontal patients. Hygienists also play a pivotal role in the nonsurgical management of periodontal patients in the periodontal practice.
Evidently, the AAP anticipated that the publication of the new guidelines for referral might rankle some people. This statement in the “Frequently Asked Questions” section is an attempt at clarification.
The Guidelines suggest that certain patients can only be treated by a periodontist. Is this true? No. Some patients can be well managed within the general dental practice, whereas others would benefit from co-management with a periodontist. The Academy understands that the education, experience, and interests of individual general practitioner dentists vary, and, therefore, specialty referral may occur at different stages of a patient’s disease state and risk level.
Several factors influence outcomes for the periodontal patient, such as:
- The severity of the disease. The more advanced the disease, the more bone loss, and the greater the difficulty in thorough debridement and management of the pocket.
- The patient’s own host immunity. Patients with compromised immune systems often have poorer outcomes with both modalities of therapy.
- Lifestyle factors, especially smoking. Smokers will have about half as much improvement with either surgical or nonsurgical modalities of therapy as nonsmokers.
- Skill level of the clinician. Hygienists with limited clinical experience will not be as clinically adept as seasoned hygienists and may feel inadequate to treat certain case types.
- Anatomical considerations. Closed furcations and deep pockets with limited access increase difficulty in nonsurgical modalities.
- Systemic diseases, such as diabetes. Many systemic diseases have been shown to negatively influence outcomes in periodontal treatment.
It should be mentioned that even when some patients are referred to the periodontist, the patient refuses to follow through with referral. The most common reasons given are:
- Financial constraints with the patient
- Fear of pain
- Inconvenience/time issues.
General practitioners are sometimes compelled to maintain patients in a “less than ideal” situation. Patients do have the right to have a say in what happens to their bodies, and that includes the right to refuse referral or other treatment recommendations. Be sure to document in the patient chart any conversations about referral and the patient’s refusal, or use a “Refusal of Referral” form. Have the patient sign the refusal.
In addition, there has been reluctance on the part of some general dentists to refer to periodontists. Some of those reasons include:
- Once a patient is referred to the periodontist, the patient is never released back to the care of the general practitioner, a form of stealing patients.
- There is no periodontist within easy driving distance.
- The local periodontist does not porvide documentation and updates about the patient to the referring doctor as treatment progresses.
- The specialist makes disparaging remarks about care or quality of dentistry received in the referring doctor's office, and the referring doctor learns of these remarks from returning patients.
When is it appropriate to refer?
The answer to this question should be determined by the evaluation of many factors affecting the patient and should come from a thorough examination and periodontal charting. Nonsurgical therapy has its limits, and there are situations that call for the expertise of a specialist.
Periodontal diseases are caused by microbial infections that, over time, cause breakdown of the supporting ligaments and bone. The primary etiological factors are periodontal pathogens, while calculus is a secondary factor. According to periodontal researchers Rams and Haffajee, there is a subset of patients that continue to lose attachment, no matter if the patient is treated in the general or periodontal practice. Their research has further revealed that certain microbial species respond to a microbiologically based strategy using a systemic antibiotic adjunctively. The antibiotic is selected based on its proven effectiveness with the particular pathogen that has been identified through culturing.
What are the primary reasons to refer to a periodontist? In a nutshell:
- Any patient who continues to lose bone and/or attachment despite your treatment or has unresolved inflammation.
- Any patient needing bone regeneration procedures around teeth supporting bridgework.
- Any patient needing grafting procedures.
- Any patient with gingival overgrowth issues that do not resolve after the cause of the overgrowth has been addressed.
- Any patient whom you do not feel comfortable treating for any reason.
Whether or not a doctor chooses to refer a patient to a periodontist, our patients deserve the most excellent care available. Our patients also deserve to have a part in the decision-making process concerning their treatment.
The AAP Guidelines Stratify Three Levels of Patients
Level 3: Patients who should be treated by a periodontist
Any patient with:
- Severe chronic periodontitis
- Furcation involvement
- Vertical/angular bony defect(s)
- Aggressive periodontitis (formerly known as juvenile, early-onset, or rapidly progressive periodontitis)
- Periodontal abscess and other acute periodontal conditions
- Significant root surface exposure and/or progressive gingival recession
- Peri-implant disease
- Periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat
Level 2: Patients who would likely benefit from co-management by the referring dentist and the periodontist
Any patient with periodontitis who demonstrates at reevaluation or any dental examination one or more of the following risk factors/indicators known to contribute to the progression of periodontal diseases:
Periodontal risk factors/indicators
- Early onset of periodontal diseases (prior to the age of 35 years)
- Unresolved inflammation at any site (for example, bleeding upon probing, pus, and/or redness)
- Pocket depths greater than 5 mm
- Vertical bone defects
- Radiographic evidence of progressive bone loss
- Progressive tooth mobility
- Progressive attachment loss
- Anatomic gingival deformities
- Exposed root surfaces
- A deteriorating risk profile
Medical or behavioral risk factors/indicators
- Smoking/tobacco use
- Drug-induced gingival conditions (for example, phenytoins, calcium channel blockers, immunosuppressants, and long-term systemic steroids)
- Compromised immune system, either acquired or drug induced
- A deteriorating risk profile
Level 1: Patients who may benefit from co-management by the referring dentist and the periodontist
Any patient with periodontal inflammation/infection and the following systemic conditions:
- Cardiovascular disease
- Chronic respiratory disease
Any patient who is a candidate for the following therapies who might be exposed to risk from periodontal infection, including but not limited to the following treatments:
- Cancer therapy
- Cardiovascular surgery
- Joint-replacement surgery
- Organ transplantation
Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or e-mail firstname.lastname@example.org. Visit her Web site at www.professionaldentalmgmt.com.