Patients will visit websites for a better treatment than you recommend. How should you respond?
By Eileen Morrissey, RDH, MS
I teach Periodontology I and II at Burlington County Community College's dental hygiene program, and the second periodontology course takes place as the students embark on the first semester of their senior year. The material is more fun, as they have now been treating patients for six months. The content is less microbiological and theoretical, and has a more practical, meaningful application.
During the semester, I allocate 5% of their entire periodontology grade to a wild card category. This allows me leeway to create assignments when the spirit moves me. I thought it would be fun to have the students research the Internet similar to the way our patients do when they want to treat their periodontal disease with home remedies. For example, let's say that a new patient receives a diagnosis of moderate generalized chronic periodontitis during a recent appointment. She is treatment planned for two sessions of half-mouth periodontal debridement, which will be followed by a six-week evaluation that hopefully reveals a positive healing outcome. The patient will be educated as to the importance of home care, as well as the need to maintain a consistent recare schedule once she is placed in maintenance (assuming a return to health).
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Mrs. Patient decides not to schedule her treatment, stating that she wants to consider other options. (There cannot be a hygienist reading this today that has not heard this at chairside.) I will admit that I do precisely the same thing upon receiving any personal medical updates.
Dr. Internet – how this entity has changed our world! So your patient returns home and researches periodontal disease treatment. She recognizes what was presented at the dental appointment. Yet she is drawn to the alternative approaches. Maybe she is not completely convinced. Finances may contribute to some extent. Was it the unfamiliar terminology? Periodontal debridement? Her uncle went through wound debridement during a recent automobile accident, and she remembers his none-too-positive description of the procedure.
She is thinking: "If there is any other route I can choose, I want to know about it. And better yet, if I can read blogs from the real folks out there who have had success trying alternatives, why the heck not? I can always do what this dental office recommends down the road, if need be."
So there you have it. Next thing you know, this patient is in your treatment room either telling you what she is trying (or she is trying it without telling you, and waiting to see what you notice), or she is asking you what you think, which puts you in the position of how to respond appropriately.
Is Dr. Internet a resource for oil pulling?
I became intrigued with the idea of assigning my students this project after hearing about oil pulling as a means of treating periodontal disease. I was using virgin coconut oil on my skin as a moisturizer, as well as a means of treating a chronic ingrown hair follicle. (Dr. Internet had recommended it to me, and I admit that I gave it a chance because of the numerous comments on the blogs.) For the record, I am completely satisfied with the results.
From there (also due to blogs and anecdotal evidence), I began to ingest two tablespoons of virgin coconut oil daily to help with weight loss. After five months, I am very pleased. Virgin coconut oil will have a permanent place in my kitchen and on my bathroom shelf.
During a continuing education seminar, a dental hygienist commented on the use of coconut oil for pulling as a treatment for periodontal disease.
I had no idea what she was talking about, but I went home and consulted Dr. Internet, attempting to educate myself on this Ayurvedic approach. Since then, one patient has informed me that she is using oil pulling for her periodontal condition. She has chronic, advanced periodontitis with no intention of utilizing conventional treatment. Her intent is to keep her dentition for as long as possible by using alternative approaches.
She, too, became intrigued after reading the Internet blogs. The antimicrobial, antiviral, and antifungal properties of the oil seemed a logical means to this individual as a way of treating inflammation and infection. While keeping the oil in the mouth and swishing forcefully for 20 minutes daily is not easy, she believes that her chronic issues are being helped in a positive way. After only one month, I have not seen enough yet to convince me, but her tissues do seem somewhat more stable than how they have appeared in the past.
This was my rationale for a perfect assignment for the students. They were in the middle of their second semester treating patients, and some already had faced questions in the clinic about alternative "treatments." I asked them to find any random periodontal disease treatment on the Internet, to summarize it on one page, and to include how they would respond to their patient if he came in reporting that he was using such a treatment.
Anecdotal evidence is not evidence-based research. We can only educate and counsel our patients to the best of our abilities. We must inform, make them aware of potential outcomes, with or without conventional treatment, and document the interview. In the end, our patients are masters of their own bodies with every right to choose their paths.
Home remedies
Here are some additional home remedies for periodontal disease treatment that our patients are seeing on the Internet, as researched by the students. If you would like, contact me at [email protected] about your patient or personal experiences on alternatives, and I will write a follow-up column in RDH.
Several students wrote about lemon juice mixed with salt as a "natural" way of treating periodontal disease.
Susannah has a moderately involved periodontal patient who was actively engaged in trying it. The remedy calls for mixing the juice from a lemon and a bit of salt until it turns pasty. It is then applied to the teeth, left on for several minutes, and followed by gargling with water. It is thought that the vitamin C in lemons will have an anti-inflammatory effect.
While this may be true, both students who chose to report on the "treatment" recognized that erosion and possible demineralization of the tooth enamel would be a potential consequence if this formula were applied over a period of time. It seems vitamin C usage in periodontal disease treatment has come full cycle, since I can remember from my early years hearing from more than a few patients who believed that their bleeding gums were due to a deficiency. Their certainty led some to ingest significant amounts of vitamin C in hope that their inflammation would be minimized.
I was proud of Susannah, who curtailed her immediate reaction to scream at the patient, "No, no, no!" She recognized the need for patient education. Her report stated, "My patient needed my empathy and concern, and not a hygienist who would yell at her. Because she has significant recession, I showed her images of teeth that had been dissolved and thinned due to lemon exposure. As anticipated, this had a huge impact." Kaitlyn, who also chose this topic, thought that a recommendation that involved consumption of an anti-inflammatory diet to include a lot of raw fruits and vegetables would harmonize well with a patient's inspiration to use all-natural remedies.
A patient of mine from a decade ago had severe periodontal involvement. He decided to try to avoid a referral to a periodontist for as long as he could with frequent cleanings, so I treated him every two to three months. It was somewhat depressing, as I would see his continued downward spiral. I felt that my efforts were somewhat futile, but I did the best that I could.
He remained steadfast in his determination to stay away from a specialist. I will never forget the last time I saw him. He had lost 25 pounds, and there was a remarkable change in his appearance. As I went through my periodontal assessment, I was astonished. There was a significant improvement in his tissues in every way. Bleeding had minimized, and the exudate I was accustomed to seeing was not evident. His teeth appeared to have tightened to some extent, and pocket depths were shallower. Simply remarkable!
Upon questioning, he reported that his home-care efforts were completely consistent with how I had instructed him previously. The only change he had made was in his diet. He had virtually eliminated carbohydrates, which was how he had achieved his weight loss. Go figure! It was a great maintenance visit for both of us. I left that practice soon afterwards, so I cannot report on his status beyond that point.
I was reminiscing about patients who 30 years ago treated their periodontal inflammation with the Keyes technique, using baking soda and hydrogen peroxide as a tooth-brushing paste. This was resurrected in some of the research that the students reported on, albeit with a contemporary twist. Alternatives now invite the patient to "rinse with hydrogen peroxide but not swallow it." Patients can "brush with baking soda" but it is presented as a caries preventative because it will neutralize mouth acids.
Brandee reported that her Internet article gave a fairly accurate description of periodontal disease and how it affects the periodontium. She appreciated that the article stated that, should biofilm not be removed, it would harden into calculus and require removal by a professional. She did not appreciate that her patients would read that when the bleeding condition becomes painful, it is then considered periodontitis. (In other words, it is just gingivitis, because the person's gums are not hurting!)
Brandee's report mentioned six ways to improve gums naturally. Three of these are vitamins and supplements, including vitamins C and D, and COQ-10. The other three recommend stress reduction, tea tree oil, and drinking four ounces of unsweetened cranberry juice daily.
Again, I was proud of Brandee's hypothetical response to her patient, which involved being supportive of her choices as she sees merit in these options as supplements to care. She emphasized, however, that she would educate her patient as to the importance of professional debridement at consistent intervals as the most effective way to treat her chronic infection.
I cannot close without a mention of Dr. Oz's alleged approach to periodontal disease treatment. So many of my patients consider him to be a guru in every aspect of health care. This excerpt came from a Canadian dentist's website when I googled Dr. Oz and periodontal disease treatment. (I should emphasize that, on every episode, Dr. Oz warns the public about the many who use his name linked to treatments without his endorsement.)
The Canadian dentist observed, "…TV's Dr. Oz recently did a segment on ‘Three Signs of Stress in Your Mouth,' and provided some solutions to relieve tension and to check how healthy your gums are. Our staff at Abba Dental thought we'd pass along his suggestions for a stressful mouth … Gingivitis: Cranberry Floss. Here's Dr. Oz's theory: Gum disease, or periodontal disease, is more common among people who are stressed out because roughly 50% of people do not floss or brush regularly when they are under stress, which causes their gums to recede and pull away from your teeth. Dr. Oz recommends drinking unsweetened cranberry juice to ward off plaque, and said you can even buy cranberry floss…"
We can conclude that our patients will continue to seek out home remedies for all that is ailing them, and that includes any diagnosis of gingivitis or periodontal disease. I appreciate my students' collective effort to "surf" and view what our respective patients will read, potentially believe, and self-treat with (this article merely skims the surface of what Dr. Internet suggests and recommends). If you have not seen these web articles, it behooves you to take a look. We can serve our patients better if we have a sense of the information being presented to them so that we are better equipped to respond effectively in a caring way.
Author's note: I dedicate this article to my beloved student class of 2014, who provided me with some of the research for this feature article.
EILEEN MORRISSEY, RDH, MS, is a practicing clinician, speaker, and writer. She is an adjunct dental hygiene faculty member at Burlington County College. Eileen offers CE forums to doctors, hygienists, and their teams. Reach her at [email protected] or 609-259-8008. Visit her website at www.eileenmorrissey.com.
