BY LYNNE SLIM, RDH, BSDH, MSDH
A recent headline from a dental journal intrigued me, and I couldn't help but read further. The title said, "3 reasons why a Modern Millennial Hygienist does NOT perio chart." I immediately thought to myself, "Who on earth would suggest to a millennial or any other generation of hygienists not to perio chart and risk facing legal action?" What alternative do we have to conventional periodontal charting?
My mind started racing, and I thought long and hard about this issue while perio charting my patients the following week (and, by the way, I would never not perio chart). The authors gave alternatives to perio charting but didn't provide any references. One of the alternatives mentioned was PCR analysis by OralDNA Labs. Unfortunately, there is insufficient evidence that the type and concentration of specific perio-pathogenic bacteria in saliva is linked to the type and concentration of specific perio-pathogens in the periodontal pocket.
Other articles by Lynne Slim
So, what's wrong with periodontal charting? Nothing, in my humble opinion, is wrong with following universal standard of care for periodontal assessment. I have a few pet peeves and frustrations about charting. Most of the frustration has to do with the "time" element, or lack thereof. What annoys me most about periodontal probing (which is only one component of the comprehensive periodontal evaluation) is not the "notched" metal or plastic stick I insert and walk around each tooth circumferentially. Instead, it's the brevity of a typical practitioner's exam that worries me.
Some practitioners devote less than a few minutes to a periodontal evaluation, and it's not always their fault because they are pushed for time and lack the necessary support/technology/assistance to do a better job. Practitioners who use probing depths only to diagnose and treat periodontal diseases without a more thorough (and more time consuming) comprehensive periodontal assessment are missing valuable diagnostic and prognostic information.
The American Academy of Periodontology has developed a Comprehensive Periodontal Evaluation checklist, and they even suggest that patients bring this checklist to their next dental appointment.1 Visit the AAP website for a copy of the checklist and references. As you can see, a comprehensive periodontal evaluation is not just a recording of probing depths and bleeding points. When done well, it takes time, education, and guidance.
I recently read online about a periodontist named Preston (P.D.) Miller, Jr., who not only takes the comprehensive periodontal evaluation seriously but uses a new periodontal prognostic index as a way to evaluate long-term periodontal prognosis of periodontally involved molars.
P.D. Miller, et al. conducted a retrospective study that assigned scores to patients' molars based on seven prognostic factors: age, smoking, probing depth, mobility, furcation involvement, and molar type. Prognostic factors are different from risk factors that "cause" disease in that they affect disease "outcome" once disease is present2 (I would recommend reading the article at the link in the references below.). About 100 patients met the inclusion criteria for the study and received active periodontal therapy (nonsurgical, surgical, even re-treatment if necessary, periodontal maintenance, and oral hygiene instruction). Diabetes mellitus was included in the methodology but eliminated because there were only two patients identified with diabetes and both were well-controlled.
You can view the scoring index used to compute a score for periodontally-involved molars in the Journal of Periodontology article.2 Without going into all of the study's details, including methodology and data analysis, I'd like to point out some study discussion points and end with some suggestions on how to apply the index to a dental hygiene practice setting.
Research discussion points
The study noted that 639 molars survived 24.2 years with an average initial score of 4.32. Each patient lost an average of 1.7 molars, and those 32 molars lost had an initial prognosis score of 8.68.
Multivariable models used for statistical analysis of molar data showed that the patient's age was not a significant factor for tooth loss. Research to date suggesting age as a risk factor is ambivalent.2
Smoking is the risk factor with the most dramatic impact on molar tooth loss, with 246% greater chance of molar loss compared to a non-smoker.
Supportive periodontal therapy (SPT) is a key factor in maintaining periodontal health and determining prognosis but compliance with SPT is variable and can be as low as 16%. In the Miller study, SPT compliance improved over time, especially in older patients.
Molar teeth are at greatest risk for disease and tooth loss in periodontally involved patients, and this finding was confirmed in the Miller et al. study.2
In this particular study, nonmobile molars, regardless of probing depth or multiple furcation involvement, were treated and could account for the low percentage (3.9%) of molars extracted during active treatment. Periodontal surgery was performed on most molars, with emphasis on meticulous SRP.
In summary, smoking has the most negative impact on prognosis and greatly exceeds the prognostic impact of probing depths, mobility or furcation involvement. In addition, younger patients (ages 20-30) with severe periodontitis can have a favorable prognosis when they receive comprehensive periodontal therapy.
Miller-McEntire Periodontal Prognostic Index
Based on the results of this study and previous research on periodontal prognosis, we know that molar teeth have the greatest risk for disease and tooth loss and that probing depths are not as predictive of poor prognosis compared to smoking. Referral and treatment collaboration of moderate and severe periodontitis with a specialist can result in long-term successful prognosis regardless of the patient's age, as long as the patient is compliant with treatment and SPT.
Adding a simple, statistically validated prognostic index to your periodontal assessment arsenal helps the clinician to more accurately assess the severity of chronic periodontitis and helps patients to better understand periodontal treatment outcomes.
In writing this column, I emailed and called Dr. P.D. Miller about his index. He suggested visiting his website where there's an explanation on how to compute the index. At cureyourgum disease.com, click on "Get started." The next article will deal with simplified scoring, which does not impact the main benefit (a powerful tool for patient motivation and compliance).
Is the dental hygiene community up to the task of taking periodontal assessment up another notch? You betcha, and many of us welcome the idea of providing evidence-based, high quality, and safe care. RDHs are at the center of preventive patient care and we are essential drivers of quality improvement. Not only is quality care embedded in our mission, but it's at the core of what we are educated to do. RDH
2. Miller PD et al. An evidence-based scoring index to determine the periodontal prognosis on molars. J Periodontol 2014: 85(2): 214-225.
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: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.