Editor's note: Originally published March 1, 2019. Formatting updated September 10, 2022.
Addressing the three components of oral health: biofilm, bacteria, and body
When beginning a hygiene appointment, we all have our routine of updating health histories, talking about home care habits, and any concerns the patient may have. Depending on how the patient answers these questions (e.g., “I use a manual toothbrush and don’t use anything to clean between my teeth,” or “I use a sonic toothbrush twice a day, floss once a day, and use my water flosser once a day”), I find myself automatically anticipating the amount of time I need to allocate to the prophy—the tools I need to use and the products I might suggest—all before looking in the mouth. Then I look in the mouth and begin assessing the situation. Sometimes I see what I expect, but other times I’m surprised, either for better or worse. When I see bleeding gums, I begin to think through the factors at play: is this mostly a biofilm, bacteria, or body issue?
The relationship between these three components manifests in the mouth, and sometimes we need to put on our detective hats to determine which component needs to be addressed first. Let’s take a closer look at the three components, a variety of options available to address each, and procedure codes to consider. By reviewing the options with our patients, we invite them into the decision-making process and hopefully improve compliance.
So, when a patient presents with bleeding gums, where do we begin?
This is the easiest one to determine. How much biofilm is present? You can do a plaque index score or simply show the patient the amount of biofilm by using disclosing solution. Then you can assess the tools the patient is already using and how effectively he or she is using them. This is where we are experts. As RDHs, we tend to think everything going wrong in the mouth is because of biofilm and poor home care.
There are some newer products that address biofilm. Does your office have an aqueous powder streaming device (aka an air polisher)? Subgingival powder streaming with either glycine or erythritol is quickly becoming the standard of care for biofilm management. For home use, disclosing toothpaste, such as Plaque HD, may help a patient achieve better results.
Options to reduce biofilm
Procedure codes to consider
• D1110/1120: Prophylaxis
• D4346: Gingival inflammation scaling
• D4910: Periodontal maintenance
• D1330: Oral hygiene instruction
• D1310: Nutritional counseling
Do you have that patient who comes in with very little plaque but more bleeding and pocketing than you expect? Maybe the patient even flosses on a daily basis or uses a mouth rinse. The patient might have pathogenic anaerobic bacteria waging war under the gums. How can you determine if this is the case or if it is a systemic issue manifesting as bleeding and inflammation in the mouth?
Salivary testing is arguably the best way to determine the specific pathogenic bacteria present, as well as the bacterial load of each pathogen. The three most commonly used salivary testing companies are OralDNA, OraVital, and Hain Diagnostics.i
Another option is using a microscope in the operatory to determine the presence of spirochetes. Remember those motile bacteria we saw on the slides in hygiene school? (For some videos, search for “oral spirochetes” on YouTube.) Using a phase microscope, we can objectively identify the presence or absence of spirochetes. If spirochetes are found, they need to be addressed.
My office doesn’t have a microscope yet, so in addition to recommending salivary testing, I like to utilize laser bacterial reduction (LBR) for therapeutic and quasidiagnostic purposes. In an ideal world, we would use salivary testing on all the patients who need it. If the results come back with high levels of anaerobic bacteria, laser or ozone therapy is a great way to kill the bacteria. If a patient has great results following LBR with no other treatment, I can make an assumption (if the patient didn’t want to pay for salivary testing) that pathogenic bacteria were overwhelming the immune system.
Offices that use a microscope on every patient (including kids) find that even healthy-appearing gingiva can house pathogenic bacteria in quantities that will eventually lead to periodontal or systemic disease. Conversely, it is a good and affordable way to identify a patient whose bleeding is not from pathogens and who may need to see his or her physician. Finding spirochetes before symptoms manifest might also increase your use of laser or ozone therapies in the office.
Options to address anaerobic bacteria
• Salivary testing
• Laser or ozone therapy
• Antibiotics (local or systemic)
• Oral probiotics
Procedure codes to consider
• D0417: Collection and preparation of salivary sample for laboratory diagnostic testing
• D4341/4342: Scaling and root planing (generalized or localized)
• D4381: Localized delivery of antimicrobial agent, per tooth
• D4921: Gingival irrigation, per quadrant
• D4999: Laser therapy (with a narrative)
• D0999: Unspecified (microscope to look for spirochetes, write narrative)
Every day we see people who have similar home care habits yet very different levels of tartar accumulation and bleeding. Instead of seeing tartar and bleeding as only a home care problem, we need to realize that tartar might be an indication of low vitamin K2, and bleeding might be a sign of an elevated HbA1c level. Many other systemic conditions manifest in the mouth (including diabetes, stress, autoimmune diseases, etc.), but these are two systemic manifestations we see every day and generally assume are related to poor home care.
So, what is vitamin K2? Vitamin K2 tells the calcium in our bodies where to go by activating proteins necessary for bone growth. Calcium needs to be directed to our bones and away from our arteries and soft tissue.2 A patient who builds up heavy tartar might have low K2. Recent research suggests a higher intake of K2 can improve cardiovascular health by reducing buildup in the arteries. Maybe instead of reviewing brushing technique for the umpteenth time, ask the patient about dietary supplements. Vitamin K2 is found in free-range animal products (animals eat the grass and turn K1 into K2 for us), and unfortunately, in the US, we generally need to supplement in order to have adequate levels. Steven Lin, DDS, says K2 may also prevent wrinkles, improve glucose control, prevent varicose veins, improve exercise performance, improve fertility, and more.3 It is generally recommended that vitamin D3 be taken in conjunction with K2, so they often come together in supplement form.
As an important side note, vitamin K is associated with blood clotting. Most sources say that K2 is still safe to use in patients on blood thinners, but patients will need to check with their physicians and might need to adjust their blood thinner levels. It is always recommended that you have patients talk to their physicians before adding supplements.
What about HbA1c? The HbA1c level is a snapshot of a person’s average blood glucose level for the previous two to three months. According to the American Heart Association, a normal level is less than 6%.4 An HbA1c level above this can impair the immune system and delay healing. You can ask about other signs and symptoms of diabetes (increased thirst, hunger, fatigue, frequent urination, etc.) to help identify a patient who needs HbA1c testing.
In 2018, a new procedure code was introduced for in-office HbA1c testing.ii,5 In 2019, a new procedure code is coming for in-office glucose testing. In-office glucose testing is generally more beneficial before a procedure than in determining average glucose levels.
Ask diabetic and prediabetic patients for their most recent HbA1c levels, and document them. One of my elderly diabetic patients has good LBR results when his HbA1c level is normal, but when it is elevated, he has bleeding in spite of completing LBR.
Some patients also have a genetic predisposition towards periodontal disease and other diseases. OralDNA is the only lab that currently offers screening for this gene, and the patient needs to sign a waiver before submitting a sample. The interleukin 6 (IL-6) gene is screened for on a specific nucleotide sequence that is a marker of the patient’s immune and inflammatory response.6
If necessary, there are labs that offer direct-access laboratory services to patients (e.g., DirectLabs or Accesa Labs). Vitamin levels, oxidative stress indicators, and other labs can be obtained directly by the patient, but it’s a good idea to involve the patient’s primary care physician.
Options to address the body
• Nutritional counseling
• In-office HbA1c testing
• Salivary testing to determine genetic susceptibility to periodontal disease (OralDNA)
• Referral to physician
Procedure codes to consider
• D0411: HbA1c in-office point-of-service testing
• D0422: Collection and preparation of genetic sample material for laboratory analysis and report
• D1310: Nutritional counseling
• D9311: Consultation with a medical health-care professional
Next time you see bleeding gums, resist the urge to harp on brushing and flossing. Instead ask yourself, “Is this a biofilm, bacteria, or body issue?”
i. To learn more about salivary diagnostic testing, read my article about it from the October 2018 issue of RDH magazine at bit.ly/2CVi3RB.
ii. If you are interested in implementing in-office HbA1c testing, review the American Dental Association’s guideline about it at bit.ly/2RWP222.
1. Runnel R, Mäkinen KK, Honkala S, et al. Effect of three-year consumption of erythritol, xylitol, and sorbitol candies on various plaque and salivary caries-related variables. J Dent. 2013;41(12):1236-1244. doi:10.1016/j.jdent.2013.09.007.
2. Maresz K. Proper calcium use: Vitamin K2 as a promoter of bone and cardiovascular health. Integr Med (Encinitas). 2015;14(1):34-39.
3. 9 vitamin K2 benefits that will improve your health. Dr. Steven Lin website. https://www.drstevenlin.com/vitamin-k2-benefits.
4. Know your health numbers. American Heart Association website. https://www.heart.org/en/health-topics/diabetes/prevention--treatment-of-diabetes/know-your-health-numbers. Updated August 31, 2015.
5. D0411 and D0412 – ADA quick guide to in-office monitoring and documenting patient blood glucose and HbA1c level. American Dental Association website. https://www.ada.org/~/media/ADA/Publications/Files/CDT_D0411_D0412_Guide_v1_2019Jan02.pdf?la=en. Published January 1, 2019.
6. Sample report. OralDNA Labs website. https://www.oraldna.com/pdf/Alert2Report.pdf?t=20180827.