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Periodontal referral gone awry

March 1, 2012
I met Ted Bleckstein, DDS, MS, online when he congratulated me on my article published in RDH in January 2011.

Dr. Ted Bleckstein explains why perio treatment often falls short

By Lynne Slim, RDH, BSDH, MSDH

I met Ted Bleckstein, DDS, MS, online when he congratulated me on my article published in RDH in January
2011. When we began our perio talks on Facebook, I learned that Dr. Bleckstein is a periodontist. When I visited his homepage, I found myself staring curiously at the cover of his 2008 book, “Diagnosis: Deception, The Darker Side of a Trusted Profession.”

As an out-of-the-box writer, I was drawn to the title of his book and ordered a copy from Amazon. Reading it, I discovered that I share many of his concerns about the declining ethics in general dentistry, in particular, the GP’s departure from dentistry’s traditional role as a trusted service profession with high ethical standards, to a business model that is solely preoccupied with meeting profits. I’m not implying that all general dental practices operate this way. I am concerned, however, about the growing number of dental professionals who are focused primarily on the profit that can be derived from their business.

Throughout his book, Dr. Bleckstein refers to the reasons why periodontal referrals are dropping off. It is essential for practicing dental hygienists who are dedicated to the prevention and maintenance of periodontal diseases to be able to apply their core professional values, including referral to a specialist when necessary. Many general practitioners, though, are averse to referrals. I asked Dr. Bleckstein some pointed questions about this change in referral patterns, and we discussed the reasons why periodontal referral is important.

Where have all the periodontal referrals gone?

Sadly, many patients who would benefit from referral to a qualified specialist have been denied this opportunity by their general dentists. With the primary pursuit of financial gain clearly in sight, many GP offices have been exploiting their patients’ trust by providing a repetitive, expensive, and often ineffective form of limited periodontal care to their patients under the facade that nonsurgical periodontal care is superior to the clinical services offered by a qualified periodontal specialist.

This nonsurgical and highly profitable form of limited periodontal care is called soft tissue management (STM). When repeated sessions of this care prove to be ineffective and no referral is offered to the patient, it will be called malpractice.

During these past years, a growing number of general dental practices have been expecting their RDHs to perform more clinical work in less time, while the GP was experimenting with their patients’ oral and systemic health, all in their pursuit of increasing practice income. Does this sound familiar? What is probably less familiar to most RDHs is the fact that there has been over a 10-fold increase in unnecessary tooth loss in practices that rely on STM protocols as the sole form of periodontal care as reported in a formal study published in the Journal of Periodontology.1

How did the STM movement begin?

In dental school, all students were taught the importance of maintaining a referral-based approach to achieving optimal patient care. Before the advent of dental management consultants in the 1980s, the ethical delivery of uncompromised, evidence-based oral health care for patients was the consensus.

Today, an aggressive businesslike practice has invaded dentistry, shifting its ethical core values, once viewed as untouchable, into the rearview mirror. This change has caused many GPs to encourage fewer patient referrals to specialists in order to maximize the GP’s practice income goals.

In 2003, the American Academy of Periodontology (AAP) expressed its alarm over the faulty STM protocols as presented in a guest editorial article published in the Journal of Periodontology.2

It stated, “Today, it is not uncommon for some general dentists to proclaim that they alone can identify and treat all of their patients’ periodontal needs. Since 1980, practice management seminars have been encouraging general practitioners to partake in STM protocols, and nonsurgical treatment is looked upon as a much more important income center in the business model of today’s general practice than it was 20 years ago.”

Are there any published reports on the adverse effects of STM?

Yes, there are many excellent articles, but the most compelling article documenting this finding was published in the AAP Journal of Periodontology in 2003 entitled, “Periodontal Referral Patterns, 1980 versus 2000: A Preliminary Study.”3 This study evaluated patient referral patterns made by general dentists for specialist-performed periodontal care in 1980, compared to patients referred in the year 2000. The authors concluded that when patients were finally referred by the GP, they exhibited a greater loss of teeth, had more severe periodontal disease, and required extraction of a greater number of teeth in 2000 compared to 1980.

It was further concluded in this study that many GPs had been keeping patients in their practices for years, performing repetitive sessions of ineffective (STM) treatment. Many of these GPs initiated referral to a periodontist only when the patient’s periodontal condition had deteriorated to hopelessness, which the article described as train wrecks.

The article concluded that the possible reasons for these disturbing trends were:

1. Inappropriate or lack of treatment by the general dentist (GP)
2. Lack of recognition of the severity of the disease by the GP
3. Delayed referral or timely referral for treatment by the GP

Although numerous studies support the total elimination of STM protocols and encourage significantly more referrals, this is clearly not happening because there is no financial reward for the GP to refer. This growing trend of placing the patient’s health secondary to the interests of some GPs prompted me to write my book to inform patients about the many ways they can identify and protect themselves from these unscrupulous dental providers.

What constructive steps have been taken by the AAP to solve the problem of failure to refer?

In response to a dramatic rise in advanced periodontal diseases and associated tooth loss confirmed to be related to the GP’s failure to monitor the effectiveness of their STM programs, the AAP released formal corrective measures on Sept. 5, 2006, to responsibly address this problem. It’s called “Guidelines for the Management of Patients with Periodontal Diseases.”

It has been collectively acknowledged that within the profession of dentistry, there exists a separate specialty academy for each branch of dentistry. For example, the AAP is responsible for monitoring and controlling the practice of its discipline, instituting corrective measures when necessary. General dentists are professionally obligated to follow each academy’s directives to ensure the uniformity and integrity of the dental profession, but now the GPs are threatening the foundation of the dental profession by defying the recent AAP directives on patient management and referral guidelines.

The AAP guidelines were written to help dentists identify if and when a patient should be referred to a periodontist. The guidelines were a responsible attempt to remedy the epidemic-like progression of advanced periodontal diseases and tooth loss caused by over 20 years of irresponsible STM therapy provided by some general dentists, with the Academy of General Dentistry (AGD) in full support.

What has been the AGDs response to the AAP’s Guidelines?

Instead of welcoming the support and interest of the AAP in promoting patient oral health, the AGD shirked its professional responsibility to uphold the integrity of the dental profession by rejecting the AAP’s input. The AGD stood defiantly behind the false presumption that general dentists are well qualified to treat cases of periodontal disease without a specialist’s help.

In an October 9, 2006 statement entitled “Academy Draws a Line in the Sand,” AGD president Bruce DeGinder, DDS, MAGD, took the following position: “We categorically do not endorse this document (the AAP Referral Guidelines) and our board of trustees has communicated through legal counsel to the AAP our critical concerns…” (

This hostile and unfounded position expressed by the AGD is the reason why patient referrals to periodontists have almost stopped. The AGD not only belittled the profession of periodontics when it openly rejected the AAP guidelines; it also demonstrated its arrogant disregard for the health of the patients their member dentists serve by claiming to know more about the science and practice of periodontics than the respected experts at the AAP.

In this new and unfortunate scenario, it would be against the interests of any patient to place their health care in the hands of a GP who may just “feel comfortable” performing a procedure, when it would be wiser to place their trust in the hands of a truly educated specialist who actually knows what he or she is doing.

With regard to the GP’s “competence” in treating periodontal diseases, what evidence exists that dental students receive adequate education to perform the procedures listed in the AAP Guidelines?

While many general dentists claim to competently render most of the periodontal care in this country, any claim of competence should be regarded as suspicious. Clearly, dental students receive only a limited educational background in periodontics that does not support the claim that GPs can supervise, let alone offer, the full scope of periodontal therapy in cases demonstrating high perio risk factors, as evidenced by the documented rise in advanced periodontal diseases and loss of teeth in America.3

A dentist’s training is documented through accreditation standards published by the Commission on Dental Accreditation (CODA), which operates under the auspices of the ADA. The general dentist has the least CODA approved dental education in periodontics with respect to the dental hygienist and the periodontist. Although the general dentist attends a four-year program of general dental study, only 295 clock hours are in the area of periodontics, compared to 2,700 hours for the RDH, and 5,560 hours for the periodontal specialist.

Why do you believe that periodontal referrals are important?

Through years of experience as a periodontal specialist, I have learned that there are no shortcuts to the delivery of effective periodontal care, the effectiveness of which can only be determined through the attainment of definite therapeutic endpoints consistent with a pattern of health.

Some general dentists may claim to deliver most of the periodontal care in this country, but it’s the RDHs who have the responsibility of clinically performing their dentists’ directives, which are usually some form of STM protocol. This assignment may conflict with the RDH’s clinical judgment or sense of professional ethics, but it must be followed or the RDH faces possible termination of employment.

I believe that most RDHs will agree that referrals to specialists are essential to the successful treatment of advanced or complex periodontal cases. But, if general dentistry continues to successfully mislead their patients with false promises of hope through their continued use of substandard STM programs, then it is quite possible that the AGD will someday be able to announce that GPs have eradicated all forms of periodontal disease known to science, as everyone with periodontal disease will have lost their teeth — problem solved!

How would you describe the current standard of care for periodontics?

The Guidelines published by the AAP in 2006 were designed to elevate and define the standard of care for periodontics. Unfortunately, in many general dental practices today, soft tissue management (STM) continues to be the GP’s standard of care in spite of the many published findings linking STM protocols to significant tooth loss.

In a previously referenced article3, the authors emphasized an important, yet widely ignored concept that, “The parameters of care and responsibilities inherent in diagnosis and treatment of periodontal diseases do not differ for general practitioners and specialists.” Still, many GPs strongly reject the AAP’s guidelines, choosing instead to pursue the profits from STM over the practice of evidenced-based oral health care as advocated by the AAP.

The AGD is afraid of the prospect that the AAP Guidelines will eventually become the recognized legal standard for clinical care, ultimately excluding GPs from providing STM to their patients and interfering with their financial goals.4 The irony, however, is that these guidelines published by the AAP are already the new standard of care for periodontics, just waiting for the first case of malpractice to be filed against a dentist for failure to refer and putting the final nails in the STM coffin.

How do you feel about the AGD’s attitude toward midlevel providers?

Turf war! Just look back to the negative reaction of many GPs to the midlevel provider law established in Minnesota in 2009. The GP community immediately petitioned the AGD to stop this law because many GPs felt (and still feel) that the new graduates of this program would not be capable of providing the basic dental care that their patients would need. How do you suppose the majority of dental specialists feel about GPs who boast that they can perform advanced specialized dental procedures on patients without regard for patients’ well-being? While it may be borderline legal, it’s not ethical or responsible to avoid referring patients who require more advanced care than a GP is trained to deliver.

What RDH complaint do you agree with and support the most?

The most common concern I’ve heard expressed by RDHs is that their dentist/employer often has little respect for their education and training. Many of these GPs even go so far as to override their hygienist’s clinical judgment if it conflicts with the practice’s schedule and production goals, especially in the area of following STM protocols.

Additionally, the equipment needs and referral suggestions made by RDHs on behalf of patients who need advanced care are rarely taken seriously by their GP/employers, who often view these requests as a practice loss. This fundamental lack of professional respect for the RDH’s professional training and clinical judgment erodes the integrity of the dental profession.

Are GPs attacking the hygiene and periodontal professions?

Yes, many general dentists feel absolutely threatened by anyone who attempts to interfere with their business of dentistry, as evidenced by the AGD’s strongly publicized stance against both the AAP and ADHA, a senseless attack that has been escalating lately. I’d like to provide you with a couple of examples of what the GPs are publishing about our professions:

In an article written by Helaine Smith, DDS, MBA, entitled “Dentists Must Fight Superhygienist Law,”5 the author makes the following disparaging statement: “It is absurd to think that hygienists can perform at the level of a dentist. Where are the ethics?”

Dr. Smith further writes, “Lower income people often have complicated medical and dental problems. Can hygienists comprehend this without the education that we received? They lowered what we do to a blue collar level and make it sound like they can handle what we do without the training…”

In response to the AAP Guidelines, Marty Zase, DMD, MAGD, president, American Academy of Cosmetic Dentistry, wrote, “The Academy (AAP) believes that all dentists have the right to practice according to their education, training, and experience.”4

He then proceeds to attack the AAP Guidelines by stating, “Then why is the AAP denying that right (to us) by implying that GPs should not do these (perio) procedures?”

Isn’t this exactly what some GPs are doing to their hygienists by (falsely) claiming that hygienists can’t possibly perform at the level of a dentist? It’s ironic that these same dentists turn around only to complain that periodontal specialists, with three more years of advanced specialty education, don’t consider the GP to be as “educationally qualified” as a periodontal specialist. Yes, history has proven that periodontal referral guidelines are necessary for the effective care of some patients!

In my professional opinion these published attacks, encouraged by the AGD, against hygienists and periodontists are unjustified and extremely hypocritical. General dentists would do well to remember that the Commission on Dental Accreditation (CODA) requires general dental students to complete only 295 hours of university-level education in periodontics to graduate with a DDS or DMD degree, far less education and training than dental hygienists in the diagnosis and treatment of gum diseases, who are required to complete 2,700 hours.

Concluding remarks from Dr. Bleckstein

The presence of periodontal diseases has a strong impact on a patient’s systemic/overall health — it is more than just a dental infection. When general dentists rejected the AAP referral guidelines, as referenced above, the patient’s health is left hanging in the balance. When hygienists have their professional judgment dismissed by the GP, they are often forced to perform the treatment decided upon by the dentist based on the general dentist’s diagnosis, which may or may not be accurate.

In recent years, many general dentists have been vigorously attacking the various disciplines in dentistry, sabotaging the referral-based foundation of the dental profession, to the detriment of the patient’s health. Many have been manipulating the hygiene profession for their financial gain without regard for hygienists’ professional judgment, license, or sense of ethics. The question now is, “Do we really need all of these general dentists?

Lynne’s thoughts

Caring for patients is our primary commitment. When dental professionals cloud their clinical decision making with profitability goals, the sacred trust of patients can be violated. Dental health-care professionals need to stop putting their business interests ahead of the interests of patients, and leaders in the profession need to stop acting defensively to protect the institution.

As we enter a new year, do we have the guts to stand up to GPs who do not fully appreciate the contributions of RDHs and periodontists? Do we insist on client-centered care that includes periodontal referral, and are we willing to challenge a profit-oriented system that might not be in the best interests of the patients? Thank you, Dr. Bleckstein, for writing your book and taking a stand to defend the integrity of our profession of dentistry. I’ll bet a lot of RDH readers will be reading your book and sending you a friend request on Facebook.

Lynne Slim, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or


1. Cobb CM, Carrara A, El-Annan E, et al. Periodontal Referral Patterns, 1980 versus 2000: A Preliminary Study. J Periodontol 2003 Oct; 74(10): 1470-1474.
2. McGuire MK, Scheyer ET. A Referral-Based Periodontal Practice – Yesterday, Today, and Tomorrow. J Periodontol 2003 Oct; 74(10): 1542-4.
3. Cobb CM, Carrara A, El-Annan E, et al. Periodontal Referral Patterns, 1980 versus 2000: A Preliminary Study. J Periodontol 2003 Oct; 74(10): 1470-4.
4. AAP Guidelines Should be Changed! Viewpoint; Marty Zase, DMD, MAGD; AGD Impact, pg. 6: January 2007.
5. Dentists Must Fight Superhygienist Law; Helaine Smith, DDS, MBA; published by Dr. Bicuspid (10/30/2008)

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