The absence of periodontal inflammation

BY KAREN DAVIS, RDH, BSDH

In July 2011, the American Academy of Periodontology (AAP) published a statement titled “Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology.”1 I wonder how many reading this column have read it. It is available online at www.perio.org.

A sentence from the AAP statement that jumped out at me was simply “A healthy periodontium is characterized by the absence of inflammation.”

That is not new information. But how many clinicians really seek that as a realistic goal with patients under their care? For some of us, achieving and sustaining the absence of inflammation with periodontal patients is experienced regularly, and includes a cooperative partnership between the patient and the clinician in order for that to take place. For others of us, though, bleeding and obvious signs of inflammation are seen in the course of a routine day and recorded in chart notes:

• Without a new diagnosis or treatment recommendations
• Without risks identified to help the patient modify
• Without recommendations to alter the next interval for reassessment

It almost becomes “business as usual” to provide treatment in the presence of inflammation.

So, what is the key to achieving the absence of inflammation routinely?

Much insight to this question is woven into the AAP statement. Under the section, “Evaluation of Therapy,” there are five outcomes that should be documented in the patient’s record. I’d like to highlight only the first one, although all five are worth reviewing:

“The patient has been counseled on why and how to perform an effecive daily personal oral hygiene program including managing their own personal risk factors associated with development and/or progression of periodontal diseases.”

This implies that the clinician has identified how far the patient is from optimal oral hygiene and has intervened with specific recommendations and instruction to remove plaque biofilm effectively. That should include realistic interproximal care. For a very small percentage of the population able to master an effective technique, that includes use of dental floss. For others, however, we should be directing them to devices such as the AirFloss for interproximal biofilm removal or the Water Flosser for biofilm removal in deeper pockets. Professional recommendations should also be made for power devices such as the Sonicare DiamondClean, or the Oral-B ProfessionalCare SmartSeries that have been shown to remove more plaque than manual brushing.

Counseling patients on effective daily personal oral hygiene means we need to direct patients to technology that is clinically effective in biofilm removal, but that is also easy for them to use, since management of disease is a lifetime commitment. Let’s ask ourselves, are we initiating communication that guides patients toward use of the most effective and easy-to-use methods for daily disease control? And, for those patients who are currently financially unable to invest in the use of power technologies for effective biofilm removal, how are we customizing their counsel? Herein lies one key toward achieving the absence of inflammation: Instruction in the use of tools that are effective and realistic for daily disease control.

But that’s not all. The second part of the AAP statement focuses on the role of the professional in counseling the patient on how to manage their own personal risk factors associated with development and/or progression of periodontal diseases. This implies that the clinician has identified specific risk factors for individual patients, including the use of technologies such as OralDNA’s MyPerioID PST salivary diagnostic test to identify whether the patient is genetically predisposed to periodontal diseases.

Being able to counsel a patient on how to reduce risk assumes that we understand which risks are present.

At least 30% of the population is PST positive, which certainly increases their risk for disease development and progression. Modifications generally have to be made for those individuals for periodontal maintenance more frequently than 3-month intervals to manage disease effectively. Effective personal daily oral hygiene is not optional for individuals who are genetically inclined toward disease progression.

Tobacco use increases a patient’s risk for periodontal disease development and progression, especially for those who are genetically predisposed. But we cannot assume that patients understand the associated risk between periodontal disease and tobacco use. Does counseling on increased risk for tooth loss and support for tobacco cessation routinely come up in conversations with tobacco users under your care?

What about the 25 million individuals in the United States with diabetes?2 Are those patients under your care fully aware of their increased risk for periodontal infection? Are they aware of how active infection in their gums can impact the daily management of their blood sugar levels? As dental professionals we need to heighten the education to all patients with diabetes about how critical effective daily oral hygiene and professional visits are for reducing their risk of periodontal disease development and disease progression.

Other methods for helping patients reduce their risk for periodontal disease include:

• Counsel regarding healthy dietary and beverage choices
• Assessment and treatment of any occlusal diseases
• Counsel on effective stress management

Herein, lies a second key to achieving the absence of inflammation: Identification of risk factors for periodontal diseases and counsel on methods to reduce those risks.

So what do you think? Is the absence of inflammation realistic? For all our patients? Just for some? Which ones? Good questions to consider. My experience has been that the more invested I am as a clinician in counseling patients toward effective daily personal oral hygiene and reduction of personal risk factors, the more often I see the absence of inflammation during periodontal maintenance visits. Thank you, AAP, for reminding us of some key considerations to help our patients achieve and sustain optimal oral health. RDH

References

1. J Periodontology July 2011. Comprehensive Periodontal Therapy: A statement by the American Academy of Periodontology.
2. http://www.diabetes.org/diabetes-basics/diabetes-statistics/ Accessed September 10, 2012.

Perio Team TakeAways:

1. Download a copy of the 2011 AAP statement on Comprehensive Periodontal Therapy and share with all clinicians on the team.
   
2. Initiate instruction for effective daily personal oral hygiene, including power devices to effectively remove plaque biofilm.
   
3. Identify individual risks and initiate counsel to help patients reduce the risks associated with periodontal disease development and progression.
   

KAREN DAVIS, RDH, BSDH, is the founder of Cutting Edge Concepts, an international continuing education company, and practices dental hygiene in Dallas, Texas. She is an independent consultant to the Philips Corp. and serves on the review board for Dental-antioxidants.com. She can be reached at [email protected].