In a 1960s Broadway play that became an early 1970s movie, Fiddler on the Roof, the main character, Tevye, sings a famous song that even those who haven’t seen the movie might recognize: “Tradition.” Tevye’s song is about change; the tune extols the virtues of keeping life as it has always been. Though Tevye’s life is not the greatest, he is comfortable ... sort of. Another more timely TV show is Desperate Housewives, about people who have a positive outward appearance while underneath they deal with their troubles and dissatisfactions in some very unhealthy ways. For hygienists, Tevye’s tradition may be part of why there are many “desperate hygienists.”*
Clinical traditions
Sometimes, we just do things a certain way because we always have - just like Tevye. Dentistry is riddled with tradition. Traditions are not inherently bad, but many behaviors and patterns tend to be followed day in and day out without any real thought as to why they exist or, more importantly, if they should still exist. Are these traditions creating the outcomes we desire?
Does your practice preschedule hygiene appointments, send confirmation cards, and call to confirm appointments? These behaviors are rarely questioned; it is the norm for most practices. When these traditions are questioned, the reaction is almost akin to questioning the flag, motherhood, and apple pie. These traditions are deeply seated in dentistry; they are considered musts. Consultants, authors, and speakers continue to tell professionals this is the way to success. We think the reason we must do these things is because patients expect it and won’t come if we don’t. Have you ever had a patient tell you the reason he/she missed the appointment was because the office didn’t call him/her? The idea of prescheduling, cards, and confirmation calls may have had it roots in providing a sincere service, but in reality we have created a codependent relationship.
The term codependency was popularized with substance abuse. In a codependent relationship, one party doesn’t have to take responsibility because the other party will. The behaviors that have become unquestioned traditions and deep beliefs may actually give us unintended outcomes and even produce the opposite of what we desire.
There is also the business aspect of empty chair time stemming from another traditional belief that empty chair time means loss of production. The tradition goes that not only does the hygiene chair always need to be full, but we must continue the traditional time frame for hygiene care at 45 to 60 minutes, which has been the same for the last 50 years. How is the amount of chair time needed for hygiene care determined?
Form follows function
A concept in architectural design first defined by Louis Sullivan, Father of the Skyscraper,1 is that form follows function. Sullivan’s famous axiom “form follows function” became the touchstone for many architects. This meant that the purpose of a building should be the starting point for its design. Yet with hygiene appointment time, function follows form. The time frame for hygiene care is not based on what needs to be accomplished; rather, what needs to be accomplished is supposed to fit into a certain time frame. This is backwards! This traditional time frame - touted as being based on optimal productivity - is really based on 1950s traditional thinking that the role of the hygienist is to “clean” people’s teeth. Hygiene care must be viewed differently; function should not be dictated by the time frame form. The form of a hygiene appointment should be dictated by the function. With appropriate time frames for diagnosis, treatment planning, and presentation, productivity will increase.
It makes little sense to continue these traditions in light of our growing knowledge of the oral-systemic link. Daily, the potential of oral-systemic links are more strongly forged with links to coronary artery disease, heart attack, perio pathogens on coronary balloon catheters, electrocardiographic abnormalities, cerebrovascular accidents, adverse pregnancy events, respiratory conditions, diabetes,2-19 and more we probably don’t yet know. The time frame tradition for appropriate assessment, diagnosis, and treatment planning - a majority occurring in the hygiene chair - needs to be revisited.
Perio does not just mean periodontitis. Gingivitis is reversible and often treated with a prophylaxis. This leads to the incorrect and unfortunate assumption that gingivitis is not as harmful as perio. Systemic effects can also happen with gingivitis. Gingivitis starts with biofilms which move into bacteremias when pathogens in the gingival crevices act as a portal into the circulatory system.20 The body defends itself from the bacteremia by sending inflammatory defenses. Periodontal destruction is not the bacteria eating away bone; it is the body defending itself. Are periodontal pathogens only in pockets deeper than 3 mm? No, perio pathogens can be present in any oral biofilm and, therefore, are a risk to systemic health. Researchers believe chronic gingivitis may put patients at an even higher potential systemic risk than previously thought. There needs to be so much more to dental hygiene than just a prophylaxis. Prophylactic means preventive. The care for gingivitis needs to be different than prophylactic/preventive care. Hygiene care is more than just a prophy.
Anti-infective therapy
The traditional way of waiting for disease and then referring to a periodontist is no longer an effective strategy. Roy Page, a prominent periodontist and researcher in Seattle, states, “In a patient with moderate to severe periodontal disease, the amount of gingival surface area involved in the disease is about the same surface area as the palm of the hand. If you went into a hospital ER with the palm of your hand bleeding and swollen, you would be admitted on the spot.”21 Treatment of the hand would not involve caring for only a quarter of the wound, learning how to clean the wound, and returning in two weeks to be sure you are caring for that quarter of the wound properly. But this is still often the manner in which periodontal therapy is performed. Anti-infective therapy (formerly called and still identified in CDT-5 as Scaling and Root Planing) needs to be performed more aggressively, with the use of antibiotics, as would be the case with an infection the size of one’s palm.
Research shows that systemic antibiotic therapy may not be the best approach. Biofilms are strong organizations with resistance to systemic antibiotic therapy. The extracellular matrix is very dense, and it acts as a shield to antimicrobials. Some bacteria produce enzymes called beta-lactamases, which degrade antibiotics faster than the antibiotics can diffuse inward. Bacteria in the deeper layers of the biofilm become dormant, not dead, because they are cut off from essential nutrients or oxygen. The antibiotic will kill replicating bacteria.20 After the antibiotic course is finished, the dormant bacteria reactivate using the dead ones as nutrients, rebuilding the bacterial load to the preantibiotic level in a matter of hours. There are at least 46 different combinations of perio pathogens, thus at least 10 different antibiotic regimens might be required to specifically target the various types.22 The goal of our anti-infective therapy is to try to attain a root surface that is biologically compatible with maintenance and the reformation of health and functional attachment, and convert pathogenic flora to flora that are compatible with health.
In 2002, Dr. Michael Jorgensen and Dr. Jorgen Slots of the University of Southern California School of Dentistry said it this way: “A multifaceted antimicrobial approach is necessary for the successful management of destructive periodontal disease. Effective antimicrobial periodontal therapy aims to overwhelm periodontal pathogens with aggressive initial therapy and prevent previously suppressed pathogens from rising up anew through daily oral hygiene measures and frequent professional cleaning.”23
Routine vs. protocols
By now you understand the connections and may be concerned that the current care provided by your office is not adequate. You know that the care you personally give may be up-to-date, but the other hygienists just don’t seem to get it. Author and educator Casey Hein (editor of Grand Rounds in Oral-Systemic Medicine, http://gr.pennnet.com) said it this way: “In many respects, the approaches used for case management of chronic periodontitis may look a little like the ‘Wild, Wild West’ during the frontier movement of the 1880s - unregulated activity with everyone ‘doing their own thing.’”24
The norm seems to be a routine rut or just haphazard guessing when treatment planning. How should the care be chosen? Should it be anti-infective therapy alone? Should we use adjunctive modalities? There are so many choices, including the chlorhexidine chip (PerioChip; Omnii Pharmaceuticals, West Palm Beach, Fla.), doxycycline gel (Atridox; CollaGenex Pharmaceuticals Inc., Newtown, Pa.), and minocycline HCl 1 mg microspheres (ARESTIN(r); OraPharma Inc., Warminster, Pa). Which one? When? Why? How? How much? How often? How can you get agreement and calibration with other professionals? By creating office protocols together. Protocols for oral cancer screening, radiographs, remineralization, and periodontal therapy are needed by many practices. The appropriate time frame can be formulated by using protocols. This is form following function.
The word protocol is often met with a blank stare. Protocols are not boxes we fit patients into. That would be function following form again. Protocols are not routines. With the potential perio-systemic link so vitally important, the use of protocols can be particularly helpful. Yet in the paradoxical way that life often occurs, many practitioners - rather than using flexible protocols - are stuck in a rut using routines of which they are not even aware.
An example of a specific up-to-date protocol was created by OraPharma Inc., the makers of ARESTIN®, when the company put together the Periodontal Treatment Protocol™ guide for general dental practitioners. The manual includes a step-by-step standardized method for care management from diagnosis through treatment, with everything from flow charts, forms, and billing codes to sample scripts. This manual is available by contacting your local OraPharma representative or the company directly at www.arestin.com. It is an excellent guide for developing your individual practice protocol for treatment of disease. These protocols will work best when individualized by you and your practice for your individual patient. This guide shouldn’t be viewed as a one-size-fits-all for every practice. Instead, it is a guideline, a starting point for important discussions. Creating protocols is not a static, one-time activity. Rather, protocols need to be flexible enough to evolve as our knowledge grows so they, too, won’t become just another tradition.
Difficult to change
There are forces outside of dentistry that will force change whether we want it or not. A lawyer in Arizona is now advertising on the Web, stating: “Periodontal disease has been scientifically connected to the following systemic diseases . . . If you or someone you know had periodontal disease, diagnosed or undiagnosed, and either ignored or treated unsuccessfully, before or during the same time as any of the mentioned systemic diseases, you may be eligible for damages caused by these systemic diseases. You may have a case. Contact us today for a FREE Case Evaluation!”25
Insurance carriers are getting it too. On March 20, 2006, Aetna and Columbia University announced the results from a study showing a relationship between periodontal treatment and a reduction in the overall cost of care for three chronic conditions. The research was a two-year retrospective study using 145,000 Aetna members. When the medical and dental records were correlated, it was found that earlier periodontal care resulted in lower medical costs for patients with diabetes, cardiovascular disease, and coronary artery disease.26
Change is difficult. Like Tevye, we can be comfortable “sort of” with our traditions. Where is your thinking on periodontal care? Is it steeped in tradition? Is function still following form? Are you a “desperate hygienist”* desiring change? It can happen, but first change needs to happen in you. Each individual predicates his or her own professionalism. You can create change to make form follow function in your practice of dental hygiene.
* In the fall of 2006, Patti DiGangi and RDH columnist Deb Grant will offer a brand-new course titled “Desperate Hygienists.” In the course, they visit Wisteria Lane, a seemingly perfect American suburb with beautiful homes, neat lawns, minivans and SUVs in the driveways, and an occasional baseball game in the street for the youngsters. Wisteria Lane is much like our seemingly perfect dental hygiene career. We love our dental family, both the patients and peers, but there are troubles beneath the surface. This interactive course addresses those troubles with a fresh, new view and finds solutions to better serve our patients and improve our outlook. Contact Patti at [email protected] or Deb at www.oraspa-rdh.com to schedule a course in your area.
References
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2 Yeo BK, Lim LP, Paquette DW, Williams RC. Periodontal disease - the emergence of a risk for systemic conditions: pre-term low birth weight. Ann Acad Med Singapore Jan. 2005; 34(1):111-116.
3 Paquette DW. The periodontal infection-systemic disease link: a review of the truth or myth. J Int Acad Periodontol July 2002; 4(3):101-109.
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5 Desvarieux M, Demmer RT, et al. Relationship between periodontal disease, tooth loss, and carotid artery plaque: the oral infections and vascular disease epidemiology study (INVEST). Stroke Sept. 2003; 34(9):2120-2125.
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11 “Infectious periodontitis is more than teeth and gums.” American Dental Association Feb. 2006. Available at: www.ama-assn.org/ama1/pub/upload/mm/31/16010rel_genco.pdf Accessed Feb. 27, 2006.
12 “Periodontal inflammation: the sixth complication in diabetes mellitus.” American Dental Association Feb. 2006. Available at: www.ama-assn.org/ama1/pub/upload/mm/31/16010rel_rose.pdf Accessed Feb. 27, 2006.
13 “Oral infections and cardiovascular disease: where do we stand?” American Dental Association. Feb. 2006. Available at: www.ama-assn.org/ama1/pub/upload/mm/31/16010rel_desvarieux.pdf Accessed Feb. 27, 2006.
14 “Pregnancy risks associated with periodontal disease” American Dental Association Feb 2006. www.ama-assn.org/ama1/pub/upload/mm/31/16010rel_offenbacher.pdf Accessed Feb. 27, 2006.
15 Pussinen PJ, Alfthan G, et al. Antibodies to periodontal pathogens and stroke risk. Stroke Sept. 2004; 35(9):2020-2023.
16 Pussinen PJ, Mattila K. Periodontal infections and atherosclerosis: mere associations? Curr Opin Lipidol Oct. 15, 2004; (5):583-588.
17 Pussinen PJ, Alfthan G, et al. High serum antibody levels to Porphyromonas gingivalis predicting myocardial infarction. Eur J Cardiovasc Prev rehabil Oct. 2004; 11(5):408-411.
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19 Engebretson SP, Hey-Hadavi J, et al. Gingival crevicular fluid levels of interleukin-1beta and glycemic control in patients with chronic periodontitis and type 2 diabetes. J Periodontol Sept. 2004; 5(9):1203-1208.
20 Donlan R, Costerton JW. Biofilms: survival mechanisms of clinically relevant microorganisms. American Society for Microbiology. Available at: http://cmr.asm.org/cgi/content/abstract/15/2/167 Accessed May 10, 2006.
21 Page RC. The microbiological case for adjunctive therapy for periodontitis. J Int Acad Periodontol Oct. 2004; 6(4 Suppl):143-149.
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23 Jorgensen MG, Slots J. The ins and outs of periodontal antimicrobial therapy. J Calif Dent Assoc April 2002; 30(4):297-305. Available at: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12005374&dopt=Abstract. Accessed May 12, 2006.
24 Hein C. Challenging the process of care: developing clinical pathways that increase accountability for success outcomes. Contemporary Oral Hygiene Nov-Dec 2002. Available at: www.pointperio.com/periodontitis/published_articles/peer_reviewed/feature111202.pdf Accessed Jan. 12, 2004.
25 Law Offices of David Burnell Smith, Atty. Available at: http://www.meddentlaw.com/ Accessed May 8, 2006.
26 “Aetna And Columbia announce results from study showing relationship between periodontal treatment and a reduction in the overall cost of care for three chronic conditions.” Aetna March 20, 2006. Available at: www.aetna.com/news/2006/pr_20060317.htm. Accessed April 21, 2006.
