Collaborative care: Periodontist urges that hygienists be part of the triangle of periodontal care

By Lisa Masters, DDS, MS

For as long as I have been in practice, I've come to understand that referrals to the periodontist can be a touchy subject for general dentistry offices. Their reluctance to refer is often buoyed by the common concerns of never getting their patients back, about the pain and cost of periodontal surgery, and about the general dentist's ability to treat disease independently.

Trends have indicated that referral patterns often traverse a generational divide. Older practitioners are more comfortable identifying disease and referring patients to the periodontist. Younger periodontists, however, are less likely to follow this model, often under the advice of practice management consultants who emphasize soft tissue management programs and the positioning of the hygiene department as a practice profit center. Consequently, patients with periodontitis are not referred for specialty care until their cases are very severe, and the dentition is often hopeless. This does a major disservice to the most important person in the operatory: the patient.

Collaboration among dental hygienists, general dentists, and periodontists is a cornerstone of positive patient outcomes. The central objective of working together is to serve more patients with the best care.

Periodontists are trained to treat of cases of disease in the gum tissue and supporting bone. They are also dependent on strong partnerships with hygienists whose expertise provides a first line of defense against the development of infection and identifies which patients are in need of specialized treatment. As the one who spends the most chairtime with both healthy and diseased patients, hygienists can play the primary role in the collaboration between a general dental office and the periodontal office.

The increased level of interaction results in conversations about each patient's personal life, their physical and financial limitations to health-care services, and changes in oral conditions that may require surgical procedures. While this information may seem inconsequential on the surface, it offers insight to a patient's concerns and contributes to an atmosphere of comfort and trust.

Frequent attendance at continuing education events often affords exposure to a periodontist's skill set and proficiency, allowing the hygienist to understand and speak with some level of familiarity not only about the onset of periodontal disease but about such treatments as root coverage procedures, esthetic crown lengthening, and even implants that require special preparation at the placement site. Hygienists who have this background and work in a dental office with protocols for the non-surgical treatment of periodontal disease may wonder what a periodontist can offer that their offices cannot.

Here are some circumstances aside from periodontal disease in which collaboration is key and the role of the hygienist is vital.

Excess Gum Tissue

For adults whose teeth appear to be "short" in length because they are covered in excess gum tissue, esthetic crown lengthening is a conservative surgical procedure that offers considerable cosmetic improvement. During crown lengthening surgery, incisions are made to carefully preserve the papillary tissue and create a more scalloped margin. The bony tissue is contoured to provide the ideal biologic width and support for the dentition.

The osseous tissues remain stable over time, and the patient has been converted from a thick, heavy periodontium to a more ideal periodontal dimension. The post-operative recovery time is only a few days, and patients can see the improvements immediately after surgery. Using a laser to perform the procedure can remove excess gingival tissue, but if the alveolar bone is within closer than 3-4 mm of the cervical enamel junction (CEJ), the improvements will only be temporary. The gingival tissue will rebound, and if any restoration has been placed, the marginal gingival will always be inflamed. The position of the gingival margin is ultimately controlled by the position of the bone.

Root Exposure and Gingival Recession

Many patients suffer from the opposite of a gummy smile-root exposure and gingival recession. Root coverage procedures have advanced dramatically in the past 10 years, transforming into minimally invasive techniques that provide exceptional root coverage with perfect color and contour.

In many scenarios, gingival augmentation improves the long-term health of patients. The hygienist is often the person who recognizes the changes in recession defects, and he or she can alert the dentist of the opportunity to cover a root surface, preventing sensitivity, and root caries. Recession defects often occur in gingivally healthy patients who have had orthodontic correction, with the prominent roots of the canines and premolars becoming exposed in adulthood. Recession defects are most predictably treated before they advance beyond the mucogingival junction, so early identification and treatment are essential.

Tooth Replacement

One of the most frequent treatment collaborations between general dentists and periodontists is the anterior tooth replacement. Many general dentists have become quite skilled at extraction/socket preservation and implant placement in the molar and premolar region.

The need for advanced site preparation, which may include both bone and soft tissue augmentation in conjunction with implant placement, often occurs in the anterior area. The bony architecture is naturally more challenging in this space, and patients' demands are even more elevated when it comes to the front teeth. This is probably the most valuable time for a general dentist to maximize his or her relationship with the periodontist's surgical skills and the restorative dentist's forte in tooth form and function. Technology now allows treatment teams to plan both the provisional and final restorations prior to the removal of the failing tooth.

This type of treatment sequence demands adequate communication among all involved parties, including the hygienist, who maintains and observes both the healing tissues and the long-term health of the implant patient.

Erosive Mucocutaneous Conditions

Patients with erosive mucocutaneous conditions can also be co-managed best with the help of a periodontist. Although these cases can be referred to oral medicine specialists, there are periodontists in many areas who can manage and offer support for patients with oral lichen planus, phemphigoid, and phemphigus.

In essence, the relationship among the general dentist, the hygienist, and the periodontist is that of a perfect triangle. Each professional represents one side of the triangle, acting as a supportive base to the other. The symbiotic nature of the collaborative care model provides an array for benefits for the general dentist, hygienist and the periodontist. It also keeps those who sit in our chairs at the center of our work; patient health, function and esthetics are always at the tip of the triangle. RDH

Dr. Lisa Masters earned her dental degree from The University of Texas Health Science Center San Antonio School of Dentistry and continued her education at the dental school with a three-year specialty program in periodontics. She is a board-certified periodontist whose expertise is in the diagnosis and treatment of all types of gum diseases, and performing both aspects of surgical and nonsurgical therapy. Dr. Masters is a member of the American Academy of Periodontology, the American Dental Association, and Southwest Society of Periodontists. She is also a clinical associate professor at the UTHSCSA Dental School.