As my dog, Grimsby, and I relaxed on a white sandy beach in Anna Maria Island, Florida, recently, I read the headlines of the British Daily Mail newspaper. I was reminded of the recent London bombings and the disturbing questions that have resulted in British society. In writing about “mainstream U.S. culture” as the British call it, one columnist commented that we have a mainstream culture and set of values to which most Americans happily adhere. He states that the British, on the other hand, are struggling to re-capture and re-define their values.
What about our dental culture? Do we as Americans have a set of dental values that unite us? Are dentists and hygienists united in their philosophy of care to clients in private practice and the community at large? The philosophical divide in dental care delivery in the United States seems to be growing wider, and dentists and hygienists are often on opposite sides of the split. Like the nursing profession, the dental hygiene profession continues to grow in preventive and holistic knowledge. Private practice dentists, on the other hand, tend to focus on the mechanical and repair model of care, and profitability in which the end justifies the means. With the end signifying profit, means may sometimes include overdiagnosis and overtreatment.
This is a very touchy subject, but profit isn’t necessarily a bad word. Hygienists and dentists demand high salaries and a comfortable work environment. Profitability benchmarks are essential components of a healthy business, and practice management consultants use these benchmarks to compare dental practices. As dental practice management consultants look for ways to increase dental practice profitability, the diagnosis of gingival and periodontal diseases and nonsurgical treatment of these diseases becomes a leading practice focus.
This month’s column will focus on the diagnosis of periodontal disease as an essential part of the profit equation.
How many dentists assess new and recare clients for gingival and periodontal diseases? For that matter, how many dentists enjoy performing a comprehensive periodontal exam or a Previser risk assessment? Hygienists were born to be nosy when it comes to periodontal disease assessment and diagnosis. That’s right, when it comes to periodontal health we’re prying busybodies who like to meddle in the periodontal affairs of our clients. If we didn’t assess and diagnose, who would?
Ideally, we should diagnose alongside dentists, and, in many practices, this is the case. In other practices, however, the dentist focuses on repair issues, and the hygienist is entrusted to assess and diagnose gingival and periodontal diseases. So for the rest of this column I will refer to our ability to diagnose (which is a no-no) as our compulsion to be diagNOSEY.
An important component of the periodontal exam is the measurement of pockets. All too often, our final assessment or diagnosis is based on probing depth numbers, especially when diagnosing early periodontitis. A recent article by Gary Greenstein in Compendium 2005 points out that probing depth assessments are the backbone of a periodontal evaluation, but that these measurements are flawed when used to determine disease progression. According to scientific evidence, it is not always necessary to have shallow periodontal pocket sites.1
Don’t become a three-two-three pseudo pocket queen who makes nonsurgical periodontal therapy decisions based on initial probing depths. Even though a healthy periodontium is usually associated with shallow probing depths, pseudopocketing due to altered passive eruption of teeth, drug-induced gingival enlargement or gingivitis may cause deeper probing depths. Probing depths greater than 3 mm are sometimes associated with periodontal health. In addition, diseased periodontal tissues can affect probe penetration, and probing depths can be around 1 mm deeper than the true histological sulcus depth. Probing force, probe width, and probe angulation upon insertion can also affect probing depth measurements and lead to false readings.
The most accurate way to monitor periodontal disease progression is to record clinical attachment loss over a period of time. For those unfamiliar with this term, clinical attachment loss refers to the depth of a periodontal pocket from a fixed reference point, or CEJ. To determine clinical attachment loss, record the distance between the CEJ and the base of the sulcus, then probe gently so as not to penetrate the sulcular (junctional) epithelium at the epithelial attachment. If the gingival margin covers the CEJ, determine the distance from the gingival margin to the CEJ and subtract that from the distance between the CEJ and the base of the pocket. Sometimes, clinical attachment loss will occur without the presence of deep pockets. In this scenario, recession of the gingival margin is associated with the progression of periodontal disease.
Bleeding on probing cannot be relied upon as a diagnostic criterion. Clients who take an aspirin or another type of anticoagulant daily often bleed on probing. It is also important to note that recent evidence indicates that blood loss can double when ibuprofen is taken before periodontal surgery.2 (Did you know that an increased prevalence of bleeding on provocation is associated with increased probing depths in untreated and treated clients?1)
Also important is that several researchers have shown that bacteremias can be induced by periodontal probing.1 Therefore, be sure to follow premedication protocols before probing to determine probing depths and when measuring clinical attachment.
According to Greenstein, there are no universally accepted criteria to indicate that a client has periodontitis.1 Therefore, combinations of factors such as clinical attachment loss, probing depths, and number of affected sites are used in clinical trials to define periodontitis. Since few of us are periodontal researchers who develop criteria to diagnose periodontitis, it is imperative that we collect as much diagnostic data as possible to assist in a diagnosis. At a minimum, diagnostic criteria should include circumferential probing depths, clinical attachment loss, recession, mobility, fremitus, furcation involvement, and a risk assessment profile.
Clinical attachment loss should be noted as slight (1 to 2 mm), moderate (3 to 4 mm), and severe (greater than or equal to 5 mm). It is important not to send only circumferential probing depths when transmitting periodontal charting to an insurance company. If it’s needed, include a narrative with as many criteria as possible and indicate whether or not periodontal disease is localized (less than or equal to 30 percent of the sites) or generalized (greater than or equal than 30 percent of the sites).
Yes, indeed, we are nosy folks who thrust our noses into clients’ oral cavities. Like the people who snooped on canoodling couples in London’s Hyde Park in the sixteenth century (as rumor has it), we are diagNOSEY when our clients’ wellness is at stake. Never re-think your decision to collect diagnostic criteria, especially when a client’s overall health may be at risk. When all is said and done, your commitment and drive to be diagNOSEY will make you a better clinician.
1. Greenstein G. Current interpretations of periodontal probing evaluations: diagnostic and theraputic implications. Compendium 2005; June; 26 (6): 381-390.