by Lynne H. Slim, RDH, BSDH, MSDH
I was an ugly kid. When I look at my childhood photos, all I can see is a tall, nerdy-looking kid with a potbelly and ghastly eyeglasses with pale blue cat-eye frames. Even though I was a Plain Jane, I didn't know it, and I can thank my parents for that because they thought I hung the moon. You've heard the expression, "ignorance is bliss"? In my case, it's a good thing that, when I looked in the mirror, I saw Cinderella rather than one of her ugly sisters.
When we approach treatment planning for conservative periodontal therapy, doesn't it make sense to apply evidence-based decision making to our thinking, or do we just "go with the flow" and conform to tradition? I may not know much, but I do know that our patients want us to make informed decisions about the care we offer. If you don't believe me, just ask them. I like to ask them what they value in someone like me, especially since they have to sit with me for a full hour or more! (Thank goodness our infection control gear — loupes, full-face visor and mask — hide a multitude of sins!)
But in all seriousness, I not only like to review the literature (an incredibly nerdy pastime), I also like to exchange ideas with others who are tops in their field. Over the last five years or so I have become friends with Dr. Paul H. Keyes, who inspires and challenges me on many issues. Last summer I was able to meet Dr. Jorgen Slots at a course at USC, and I found him to also be a wealth of information on the anti-microbial/anti-viral treatment of periodontal diseases. He challenges all of us to pay attention to research that seems to implicate herpes viruses as infectious agents in some cases of severe periodontal disease.
What stumps me more than anything else are patients or colleagues who present "testimonials," usually in the form of a statement or anecdote, about a particular product or service. During the last few months, I"ve tried hard to debunk the common myths that unwaxed floss is superior to waxed floss, and that dental flossing posterior teeth provides superior biofilm removal in posterior embrasures. I can talk until I"m blue in the face and present objective information, but there are still folks who won"t believe the literature or me!
Just this week, members of the periotherapist Yahoo! group were discussing "testimonials," and Dr. Mike Rethman, periodontist and past president of the American Academy of Periodontology, said, "Testimonials are, at best, "handwavers," indicative of some possible benefit or detriment. It's possible that the subject being debated is the greatest thing since sliced bread. More likely, it's worthless. Unless fairly tested, usually by the manufacturer paying for someone else to do it, there is little reliable evidence on which to base decisions." I agree with Mike, but the problem is that it"s tough to take on the naysayers, especially patients who are adamant in their beliefs.
Here's a situation I recently struggled through. Sally Sue, age 25, presented with chronic gingivitis and rampant dental caries. She had read all the books and Web sites on natural cures for any and all diseases. She ate only raw organic fruits, vegetables, nuts and seeds and refused to use any commercial products, especially commercial toothpaste. She believed that mercury poisoning is linked with multiple sclerosis, and she asserted that fluoride is a poison that should be avoided at all costs. I didn't ask her about endodontic therapy because I was sure she"d tell me that chronic degenerative diseases are caused by root canals. (I've read this in many of the bestselling books on natural cures). It's important for me to listen to my patients and not dismiss their concerns or beliefs, and I actually find patients like Sally to be some of the most fascinating and challenging.
My approach to patients like this can be summed up in two words: tread carefully. I don"t want to lose her, I want to help her, and in doing so it"s important not to disrespect her beliefs. It would be easy to dismiss her theories and label her as an uninformed extremist, but that"s not my role as a compassionate and caring therapist. When I asked her about toothpaste, she told me that she used to use gum powder consisting of golden seal and myrrh. Instead of dismissing it as useless, I collected a subgingival biofilm sample, and together we looked at it under a phase contrast microscope. (By the way, she hadn"t brushed her teeth for the last two years because she thought it was "unnatural" to brush.)
There is nothing more motivational than the phase contrast microscope! What did Sally and I see? Anyone viewing the video monitor for the first time would be shocked to see the masses of microorganisms. I once read an excellent description of the microbial ecosystem: "Teeming masses of highly organized organisms concentrate along the outer surfaces of the dancing mat (biofilm). Schools of rods spin and flip about like fish, seemingly with no particular purpose, but the school stays close together as if protecting itself. Large rods glide around like barracuda on the prowl, and teeming masses of thin spirochetes that resemble moray eels twist around like corkscrews, in and out of every nook and cranny of the whole living ecosystem. It is almost like viewing a patch of jungle infested with hundreds of thousands of snakes frantically writhing about. On the outer surface, the larger spirochetes are lined up side by side in a very dense pattern and beat in unison."1
Sally and I eventually compromised and came up with a workable treatment plan, and I respected her desire to work with "natural" substances that would suppress the microorganisms responsible for her chronic gingivitis and caries disease. She was willing to brush with a baking soda paste, and we modified her diet to limit the fructose smoothies she sipped throughout the day. I even talked her into using a topical crème with calcium phosphate and fluoride, and I directed her to a variety of educational Web sites.
My desire is for patients to have objective, scientific evidence. Testimonials make me nervous and I view them as anecdotal, tenuous, deceptive, and designed to evoke an emotional reaction that can easily confuse the consumer.
About the Author
Lynne H. Slim, RDH, BSDH, MSDH, is an award-winning dental author who has published extensively in dental/dental hygiene journals. She 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 the general dental practice. Lynne coaches dental hygienists and dentists in ultrasonic instrumentation and other advanced hygiene initiatives. Lynne is also the owner and moderator of the periotherapist yahoo group:www.yahoogroups.com/group/periotherapist. In addition, she is the editor of Sunstar America"s e-newsletter "The GUMline." Lynne welcomes speaking engagements on the topic of conservative periodontal therapy and other dental hygiene-related topics. Lynne can be reached at: [email protected] or www.periocdent.com.
1. Watt DL. Second opinion. Taking the bite out of dentistry. Self-published; 1989.