Welcome back to my four-part interview with Tim Donley, DDS. MSH. In part one talked about the role of dental hygienists and the need for change. This month, Dr. Donley shares his thoughts on our “deep beliefs” vs. a science-based treatment approach and provides questions to ask ourselves regarding goals and protocols. Part three is a discussion about chronic inflammatory periodontal disease (CIPD), which throws out most of the guidance I received in dental hygiene school. Part four is the wrap-up, discussing research, our future, and potential collaborators.
Anne Rice: Dr. Donley, I heard you say “deep beliefs that need to be disrupted.” What are those deep beliefs?
Dr. Donley: We must stop basing what we do on what we deeply believe. Science does not care what we believe. We need to become more science-based in our approach to managing oral disease and define the endpoint of debridement. What are we trying to achieve? Then, determine what approach gives us the best chance to achieve that. As a science-based health care provider, I’m not a deep believer in anything. I will tell you what I currently do in specific situations based on what the evidence to date suggests, what the specific parameters of the patient being treated are, and then what my clinical judgment says is the most reasonable approach. That is the evidence-based, critical thinking approach in action.
When you select a method of debridement based on what you deeply believe works best, you are not taking an evidence-based approach. The selection of hand or ultrasonic instrumentation should not be based on what you believe. What you should use for debridement should be based on what you are trying to achieve, i.e., what method, when used properly, gives you the best chance of achieving it, and then, which method is the easiest and most effective.
You shouldn’t select a treatment approach because when you do your patients end up “really looking good.” Really looking good is not an evidence-based outcome. Rather, you should choose a treatment because research suggests that performing that treatment increases the chances of achieving the desired endpoint, which has been demonstrated to be essential to achieving the treatment goal. We are in the age of serious dental medicine and should base diagnosis, treatment recommendations, assessment, and chosen procedures based in science, not what we believe deep in our hearts.
Our blind belief in oral hygiene as the ultimate answer must change, and the dental community must come to terms with an uncomfortable truth. If subgingival disease exists, it is unlikely that improving oral hygiene will have a significant effect. Oral hygiene is not treatment for existing subgingival disease—rather it is part of a strategy for preventing recurrence of disease, only when active disease has been successfully managed.
I think dentistry made a huge mistake convincing patients that the key to a preferred level of oral hygiene is in their hands (“'if only patients would brush and floss”). It is not. The key to a preferred level of oral hygiene for most patients is in partnering with a dental professional who periodically determines if there are any areas of subgingival disease, formulates a focused plan to rapidly get that disease to resolve, manages the risk factors for the disease, and then ensures that health is maintained once it has been achieved.
Oral hygiene is a small part of the overall process, yet it is what most of our patients still believe is the most significant factor. Educate patients that what they can’t see below the gumline is exceptionally important because below-the-gumline disease is linked with a very real increased risk for serious systemic issues.
Even if the pathologic subgingival etiology is successfully eliminated, oral hygiene cannot be based on what you really believe works best for your patients. Instead of being a big believer in water flossers or power toothbrushes or chamomile infused floss, it is better to determine where the surfaces are in a particular patient’s mouth where daily hygiene is inadequate and decide which device or aid will give that patient the best chance to address those surfaces. Then, ensure that the patient is using the recommended device properly, and then regularly evaluate whether the daily efficiency is being maintained. That is science-based, which is essential to health care.
Read more from Dr. Donley: Dentistry needs a new narrative
Rice: Tomorrow, when we go into the office, what can we do immediately to help our patients with respect to systemic health?
Dr. Donley: Make sure everyone in the office is not only on the same page, but reading from the same book as to:
- What is our goal for our patients, and what is our main message to our patients?
- Who are our priority patients (those with risk factors for periodontal disease and systemic disease that can be affected by ongoing oral inflammation)?
- Which sites do we treat (what is our definition of a healthy site)?
- What methods of debridement give us the best chance to achieve the desired outcome?
- How do we tell if our treatment worked, and what do we do next if it did not?
- What are the main things we need to consider during recare visits (e.g., risk status, location of problem sites, history of treatment at these sites, any restorative/prosthetic/orthodontic)?
Dr. Donley’s comment about the office needing to be not only on the same page but also reading from the same book was a bit of a mic drop. Please read part three next month where Dr. Donley takes a deep dive into chronic inflammatory periodontal disease (CIPD) and oral health management.
Editor's note: This article appeared in the September 2023 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.