Regeneration: a how-to for hygienists

Identifying the right patients for regenerative treatment

By Andre Grenier, DMD

As we are all aware, periodontal disease is a growing epidemic. Approximately half (47.2%) of American adults, aged 30 years and over, have some form of periodontal disease, as reported in a recently published study conducted by the Centers for Disease Control and Prevention (CDC).¹ The prevalence of periodontal disease is even higher in the aging population -- 70.1% in the age group 65 and older.¹ Periodontal disease is particularly challenging for clinicians because it not only influences an individual's dental health, but also impacts their overall health, with links to cardiovascular disease and diabetes.²

The treatment of periodontal disease has historically been challenging. The chronic inflammation associated with periodontal disease weakens and destroys the soft tissue and bone structure surrounding teeth, and may eventually lead to tooth loss. While we always prefer to treat periodontal disease in the least invasive way possible, the disease becomes so advanced in some cases that bone and tissue are permanently affected, requiring more drastic treatment.

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Thankfully, today we have more treatment options, specifically with regeneration. This is preferable to both patients and clinicians because we have the opportunity to restore lost hard and soft tissues, as well as decrease probing depths. However, effectively completing regeneration and other treatments necessitates collaboration beyond just specialists. It requires that hygienists and general practitioners become involved in the early detection of disease and identify potential candidates for therapy. The ability to effectively identify not only where disease exists, but where there may be a need for regenerative therapy, presents an opportunity for hygienists to become a greater part of the treatment approach.

In advanced periodontal disease, we often see tooth mobility and even tooth loss. The treatment aim of vertical periodontal defects is the regeneration of a true functional attachment of the tooth to the gums. By definition, periodontal regeneration involves the reconstruction of three different tissue types: cementum, periodontal ligament, and aveolar bone:

>> Cementum is a specialized calcified substance covering the root of a tooth.

>> The periodontal ligament refers to a group of specialized connective tissue fibers that attach the tooth to the aveolar bone. These help the tooth withstand destruction during chewing.

>> Aveolar bone is the ridge of bone that contains tooth sockets.

The process of regeneration enables us to reverse some of the damage, like lost bone and tissue. The procedure involves folding back the gum tissue and removing the disease-causing bacteria. Then, a variety of materials and techniques can be used to encourage the body's natural ability to regenerate bone and tissue.

While regenerative treatment holds much promise for patients with periodontal disease, if we cannot properly identify the right candidates for regeneration, then we are doomed to fail. The first point of contact with a patient is usually in the general dentist office, where the patient is seen by a hygienist.

Because hygienists are often the first to observe and communicate with the patient, they play a critical role in identifying opportunities for regeneration, as well as educating patients about what periodontal disease is and how it can be managed throughout a patient's life.

Team approach to regenerative treatment

So, we've educated ourselves on regeneration and identified the right patients -- now what?

Regeneration is a multistep process that can take multiple visits over the course of weeks and months, so it is extremely important that a patient's whole team be briefed on the goals of the regenerative process, so that the patient can be supported throughout the process. This includes the specialist performing the regenerative procedure, as well as the patient's general dentist, hygienist, and even general practitioner in some cases. In addition, it is important to recognize that care does not end with the regenerative treatment. Periodontitis is a chronic condition that requires continuous monitoring and intervention by a dental hygienist, dentist, or periodontist, depending on the severity of the disease.

An interdisciplinary approach to caring for patients with periodontal disease is essential and will benefit the patient and the practice both. Each professional on the team plays an important role. Treatment plans and decisions can be discussed and defined, within the team, and together with the patient. Post-surgery, the patient is seen in the office and monitored on a regular basis. Protocols must be established for determining which patients are at risk for complications. The hygienist's role becomes critical in identifying potential complications:

Swelling and/or infection
Signs of periodontal disease returning or spreading

Dental hygienists continue to be very involved in post-treatment management of the patient. They evaluate the physical condition of the gingiva at every appointment, probe all areas, and provide home-care instruction at every visit to reinforce areas where the patient is lacking in their own care. The patient plays a vital role in disease management by complying with good oral hygiene practices at home. Everything a hygienist can do to educate the patient and instill confidence and enthusiasm in them will ensure the long-term success of the procedure. That is what the team approach is all about -- optimal clinical outcomes in the patient's best interest.

Identifying opportunities for regeneration

In order to ensure that we are considering regeneration at the earliest possible time for patients, resulting in the greatest benefit, it is important that hygienists be educated on key criteria for selecting patients:

Physical characteristics -- During an exam, there are several "red flags" that indicate when a patient is not only suffering from advanced periodontal disease, but also is a candidate for regeneration. Simply put, the following indicators are key:

Probing depths of 4mm or greater
Bleeding upon probing
Possible presence of calculus

Patient characteristics -- It's no secret that hygienists get to know their patients very well, and because of this they can play a key role in recognizing which patients could most benefit from this form of therapy. In addition to identifying the physical appearance of periodontal disease that can be treated with regeneration, identifying the right patients and understanding any hurdles that must be overcome are critical to success.

Periodontal disease is often related to other health conditions and issues that the patient may have. Periodontitis is actually considered the sixth complication to diabetes.⁴ It is important that diabetic patients maintain a regular schedule with the hygienist. These patients can have more rapid developments of attachment loss and need to be closely monitored at their appointments. Many of the prescriptions that patients now take have effects on the gingiva as well. Patients with certain heart medications can have overgrowth of their gums5 which will hold and hide more of the bacteria, leading to further periodontal problems. These patients are also more likely to bleed, and may shy away from cleaning an area if they see bleeding. They have to be well monitored and instructed in proper home care.

ANDRE GRENIER, DMD, is a board-certified specialist in periodontics and implantology. His practice (www.andregrenierdmd.com) specializes in conservative treatment of gum disease. He is a diplomate of the American Board of Periodontology and a member of many professional organizations including ADA, Florida Dental Association, Atlantic Coast District Dental Association, and Broward County Dental Association. Dr. Grenier also served on the inaugural editorial board of Regenerative Update, a science-based e-newsletter focused specifically on the field of regenerative dentistry.

References

1. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of Periodontitis in Adults in the United States: 2009 and 2010. Journal of Dental Research 2012;91(10):914-20.
2. Otomo-Corgel J, Pucher JJ, Rethman MP, Reynolds MA. State of the science: chronic periodontitis and systemic health. J Evid Based Dent Pract 2012;12(3 Suppl):20-8.
3. Loe H. Periodontal disease: The sixth complication of diabetes mellitus. Diabetes Care January 1993 vol. 16 no. 1 329-334 (http://care.diabetesjournals.org/content/16/1/329.abstract).
4. How Medications Can Affect Your Oral Health, JADA, Vol. 136 www.ada.org/goto/jada June 2005 (http://www.ada.org/sections/scienceAndResearch/pdfs/patient_51.pdf).