BY JOANN R. GURENLIAN, RDH, PhD
I attended the RDH Under One Roof conference in August and participated in a group discussion and debate about the guidelines for comprehensive periodontal therapy developed by the American Academy of Periodontology (AAP).1 During this discussion, Kristy Menage Bernie, RDH, BS, RYT, advanced a concept that is worth revisiting. When discussing what might be missing from these periodontal guidelines, Ms. Bernie noted that we are not adequately addressing the issue of wound treatment.
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Consider an all-too-familiar scenario in which a patient presents to your office with moderate, generalized periodontitis. Time is devoted to charting probing depths, clinical attachment loss, topography of the gingiva, bleeding and/or suppuration upon probing, furcation status, and the extent of biofilm, calculus, and gingival inflammation. Periodontal treatment, including quadrant debridement, and reevaluation for surgery are planned. The patient is scheduled to begin treatment three weeks later, and the quadrant debridement and reevaluation span a time frame of four months. What is wrong with this picture?
If you are pondering this question and thinking that nothing is wrong with this scenario — i.e., This is how we treat our periodontal patients — let us regroup.
Consider this situation. You slip and fall on ice and lacerate your leg against gravel and ice. Your calf has a wound the size of an orange. You notice debris embedded in the wound and present to your family physician. He advises you that you have a serious wound that could become infected. He schedules you to return in three weeks, at which time he will debride one-fourth of the wound. You will continue to return for debridement of the remaining three-fourths of the wound, and receive a final evaluation approximately four months later. Does that seem plausible to you? Would you be happy with that level of care, or might you consider it the basis for a malpractice claim?
Would you advocate quadrant therapy for coronary artery blockages, bowel impactions, gall stones, removal of tumors, and cataracts? Well, if you are shaking your head, now is the time to return to how we treat our patients with periodontal disease. They present with ulcerated and infected wounds. We treat them without really considering the biology of wounds and wound healing. Remarkably, wound care is fairly easy to understand from a biologic perspective. We can predict when epithelial and connective tissues begin to re-form. We know that wound healing is influenced by a number of factors. We know that connective tissue heals within six to eight weeks. Yet we fail to treat periodontal wounds properly. Further, these new guidelines for comprehensive periodontal therapy do not address a time frame for this wound care.
Once again, we are presented with a fascinating situation that could allow us to reframe our paradigm of periodontal disease treatment. This issue might be one that all oral health professionals can discuss openly and realistically, using the biologic basis of wound healing to create a new approach to periodontal treatment protocols.
Imagine conducting periodontal examinations on a patient new to the practice, identifying the disease state, and scheduling the patient for full-mouth debridement even with several appointments needed — all within the same week. That patient would then return in six to eight weeks for a reevaluation appointment. He or she can be reassessed safely and appropriately without creating new wounds that need to be healed. Can you picture that occurring in your practice?
If you are not really certain about this concept, perhaps it has been a while since you were treated to the wonderful world of wounds. Link to your favorite book-selling source and consider purchasing a text on wound management. Hundreds of these books are readily available. Look for something that starts with the basics of wound healing and then proceeds to wound treatment.
Another option might be to host a continuing education course or study club session that addresses this topic as a refresher. Invite the entire dental team to hear this review and allow time to discuss how this information influences your treatment protocols.
This discussion of wound care is important for the health of our patients and our practices. We all strive to provide the very best care to our patients. Somehow though, we missed the boat on this topic and have left patients more wounded than we ever realized. Let’s do what we do best — create opportunities for rapport and open discussion, develop solutions, and change our practice pattern to incorporate wound care in a timely manner. What an exciting opportunity for our patient care practices! RDH
Reference
1. American Academy of Periodontology. Comprehensive periodontal therapy: A statement by the American Academy of Periodontology*. J Periodontol. 2011; 82(7): 943-945. Doi:10.1902/jop.2011.117001.
JOANN R. GURENLIAN, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing-education programs to health-care providers. She is a professor and interim dental hygiene graduate program director at Idaho State University, adjunct faculty at Burlington County College and Montgomery County College, and president-elect of the International Federation of Dental Hygienists.
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