Risky business

Sept. 1, 2005
Recently, I planned a brief outing to the Fernbank Museum in Atlanta with my little niece, Rebecca.

Recently, I planned a brief outing to the Fernbank Museum in Atlanta with my little niece, Rebecca. “Grossology” is the name of a special exhibition at the museum that I wanted to see, and I was certain that Rebecca would enjoy it as well. “Grossology” is a humorous but educational exhibit that focuses on the slimy, oozy, crusty, and stinky characteristics of the human body. There were hands-on, minds-on activities, and it all began with a trip through big plastic lips and teeth and into the world of gross “factoids” about our less desirable physical attributes.

As we turned our attention to the “Sniff-Sniff” section after completing the “Toot-Toot” section (in which kids can recreate quiet or noisy “toots”), we were ready to embark on a new adventure. Within “Sniff-Sniff,” think P.U. - people stink! I was intrigued by the statement, “Inside your mouth live millions of bacteria...” I was prepared to read about the important connection between bacteria and gum diseases or dental decay. Unfortunately, the exhibit focused on what they called “slimy morning breath” and the information presented was nothing out of the ordinary.

This experience started me thinking beyond the burp machine and other bodily processes to my favorite topic - periodontal diseases and educating the public about gum disease. Back in the 1960s, Bob Barkley got the public’s attention when he suggested serving clients “plaque on a cracker.” What a marvelous dental box-office attraction he became while lecturing around the United States about human motivation and behavior. How can we, as periodontal co-therapists, best educate our clients about their disease? This is a challenge with which we continue to struggle.

How did the heart community find clever ways to get the word out about the Framingham heart study results, which forever changed the way we look at heart disease? The Framingham heart study, which began in 1948, provided conclusive evidence that cardiovascular disease is mostly the result of measurable and modifiable risk factors. Once the risk factors were identified, one of the talented spin masters who co-designed the Framingham study released important tidbits of information to the news media before it was released at a national scientific meeting. Local papers carried the stories and then later, the national news media would report the study’s results.

The news media has been very successful in getting the word out about the possible association between cardiovascular and periodontal disease. Our clients are paying more attention to the mention of the words “gum disease” when it is diagnosed because of the recent successful media launches. Here’s the problem, however. I’ve yet to meet many “Bob Barkleys” in dental practices who can successfully take the media “spin” and get clients excited about improving their oral health. For that matter, even the scientifically proven advice to prevent atherosclerosis, based on the Framingham study results, continues to be largely ignored by the American population.

What can we do to raise the bar and get clients motivated to treat and prevent periodontal diseases? One way to begin improving our educational and motivational strategies is to educate our clients about periodontal disease risk and calculate an individual’s risk profile.

Where did the term risk factor originate? In 1961, the landmark paper that revolutionized 20th-century medicine and altered the slant of medicine from treatment to prevention was titled, “Factors of risk in the development of coronary heart disease: Six-year follow-up experience.” Those three words at the beginning of that particular title were eventually changed to “risk factors.”

When did dentistry, and even more specifically, periodontology, begin to discuss risk or susceptibility to periodontitis? Are we taking the time to calculate a client’s risk for this chronic and sometimes debilitating disease?

I first read about periodontal risk in various publications by a famous Swedish periodontal researcher named Per Axelsson. Axelsson points out that - even though we know that untreated, plaque-induced gingivitis can eventually progress to periodontitis - only a minority of individuals who fit this susceptibility group develops progressive periodontitis. I also learned from Dr. Axelsson that the great majority of adults experience gingivitis and only a minority will develop periodontitis. Dr. Axelsson also mentions in his writings an intermediate group, and that particular group is one that is composed of individuals with a long history of poor biofilm control and irregular maintenance care. This is why we see a higher prevalence of periodontitis in the elderly population groups.

As with dental caries, many other factors may modify the prevalence, initiation, and progression of periodontal diseases. Dr. Axelsson has spent many years studying these factors and divides them into environmental and internal risk factors. Analysis of which risk factors are to be significantly associated with the increased prevalence of a periodontal disease is calculated mathematically and is based on extensive research of various cross-sections of adult population groups.

Examples of environmental risk factors for periodontal diseases are smoking, use of smokeless tobacco, irregular dental care, low socioeconomic level, infectious and other acquired diseases, side effects of medications, and poor dietary habits. Of the various environmental risk factors, smoking has been shown to be the most powerful one. Internal risk factors include genetic factors, impaired host factors, chronic diseases, and reduced salivary flow and quality.

It appears that Axelsson was the first to develop a tool to grade an individual’s risk, and he grades risk into one of four classes. Dr. Axelsson uses criteria based on medical and dental history, established clinical diagnostic criteria, and supplemental bacterial sampling and laboratory tests as needed.

What really fascinated me when reading Axelsson’s writings was his discussion of “key-risk” teeth and surfaces. In his various studies of vertical attachment loss, he shows that bone loss around the distal surfaces of the maxillary first molars is already much greater than loss on mesial surfaces, making future furcation involvement more likely on the “inaccessible” distal surfaces. In addition, by studying the patterns of sites with furcation involvement in the adult population, he talks about needs-related plaque control and the importance of targeting the interdental surfaces of posterior teeth (especially maxillary molars). He also emphasizes the overall importance of targeting groups, individuals, teeth, and surfaces predicted to be at risk. This information is particularly valuable to public health dental hygienists who focus on cost-effectiveness of oral hygiene measures.

Dr. Axelsson likes to produce colorful graphic risk profiles for clients with very high periodontal risk that show how and why they can successfully lower their periodontal risk. Clients are also educated in self-diagnosis and are treated according to “full-mouth disinfection strategy,” which involves three sessions in one week’s time. Needs-related biofilm control is also implemented, and re-evaluation is conducted after two months.

What I especially like about the Swedish Axelsson risk assessment model is the emphasis on “case presentation” with a colorful graphic illustration that is used as a tool for communication with the client. Axelsson also emphasizes educating the client in self-diagnosis, in order to confirm the client’s diagnosis and treatment needs. Treatment strategy is a shared responsibility between the client as the owner of the oral cavity and the oral health providers at the Swedish dental clinics.

In the United States, some dental practices are now purchasing the Previser RiskCalculator to determine a client’s mathematically calculated risk profile for periodontitis. The risk analysis software comes with full-color printable report (www.previser.com). Risk analysis profiles are, however, only as good as the effort and time spent in educating clients to “take ownership” of their disease. Only dedicated clinicians who effectively coach clients to accept responsibility of their risk factors and to “drive” the process of lowering the level of risk are achieving success in bridging the treatment gap.

If you adopt a risk assessment tool for periodontal disease, make sure you don’t dump too much information on your client at once. Take the time to become well skilled in informing clients in a form they can understand so that they can make decisions based on their values. Here’s but another example of how hygienists can adopt a “take-charge” approach to our clients’ welfare. Let’s continue to go for the gold!

Lynne H. Slim, RDH, BSDH, MSDH, is a practicing hygienist/periodontal therapist who has more than 20 years experience in both clinical and educational settings. She is also President of Perio C Dent Inc. (Perio-Centered Dentistry), a practice management consulting firm that specializes in creating outstanding dental hygiene teams. Lynne is a member of the Speaking and Consulting Network (SCN) that was founded by Linda Miles and has won two first place journalism awards from ADHA. Lynne is also owner/moderator of a periodontal therapist yahoo group: http://yahoogroups.com/group/periotherapist. She can be contacted at [email protected].