The importance of addressing periodontal disease

Originally published in the November/December 2016 issue of Dispatch

Despite steady progress in the field of periodontology, periodontal disease remains the most common cause of adult tooth loss.

Here are some common scenarios:

A patient with poor oral hygiene persistently declines the dentist’s recommendations for an examination and radiographs. The patient maintains that his teeth are just fine and he only needs a regular cleaning once a year. The dentist gives in, but fails to document their discussions.

A patient with no insurance, and obvious signs of a gradually worsening periodontal condition, repeatedly declines the dentist’s referral to a periodontist for evaluation. After several attempts, the dentist admits defeat and never raises the issue again.

A patient has two upper crowns inserted. Soon after, the patient attends a second dentist’s office on an emergency basis, complaining of discomfort with both teeth. The second dentist finds that the periodontal condition of both teeth is hopeless and recommends they are extracted.

A patient presents to a periodontist’s office and complains of a loose tooth. After years of regular attendance at her general dentist’s office for recall and hygiene appointments, she claims that she has “never been told” about her generalized, advanced periodontal disease.

Each of these situations could result in legal action or College complaints with allegations of failure to diagnose, failure to treat, failure to refer and/or supervised neglect.

WHAT ARE THE BARRIERS PREVENTING PATIENTS FROM OBTAINING ADEQUATE PERIODONTAL CARE?

There are a number of reasons that patients may not seek or dentists may not pursue adequate periodontal care.

Patients may not:

• realize they have periodontal disease, because they have few or no symptoms
• understand the effects and consequences of untreated periodontal disease
• know the treatment options and advances in periodontal therapy
• fully appreciate the value of recommended periodontal treatment
• have the financial resources to access such treatment
• understand the importance of good oral hygiene and prevention

Dentists may not:

• have sufficient knowledge or interest in the field of periodontology
• regularly perform a comprehensive periodontal examination and charting, and establish an accurate periodontal diagnosis
• take the time to educate patients about the importance of periodontal disease prevention and treatment
• have the communication skills to clearly convey information in a way that is easy to understand
• invest the energy to motivate their patients
• be comfortable recommending extensive, expensive periodontal treatment plans to patients who present just for a regular cleaning
• treat periodontal disease before performing restorative, endodontic, prosthodontic or orthodontic procedures

ADVICE

Dentists should recognize and address the barriers that prevent patients from accepting and proceeding with treatment.

1. Establishing a periodontal diagnosis

Determining whether periodontal disease is present and identifying its type, distribution and severity are key factors in the establishment of both the periodontal and overall treatment recommendations. For an accurate diagnosis, the dentist must:

• Review the medical history and identify periodontal disease risk factors.
• Perform a comprehensive full-mouth periodontal examination and charting whenever possible. Alternately, a screening tool such as Periodontal Screening and Recording (PSR) may be used, provided an appropriate comprehensive periodontal examination and charting is carried out for those patients whose screening results warrant more in-depth follow-up.
• In addition to probing depths, a comprehensive periodontal examination and charting should include, if applicable, documentation of mucogingival problems, gingival anomalies in colour, texture and/or contour, bleeding points, purulent exudate, furcation involvement and mobility.
• Take appropriate radiographs.

2. Overcoming barriers and managing the periodontal case

To gain acceptance for periodontal services, especially when there may be financial concerns, educate patients on the health benefits of periodontal disease prevention and early intervention. Good communications skills are important.

Provide visual aids, such as information pamphlets, demonstration videos and/or models. These have all been shown to increase patients’ interest and understanding of their periodontal health. Use radiographs to point out calculus and bone loss, and intraoral photographs to show bleeding, staining, calculus and any suppuration.

Describe the purpose of periodontal probing by telling patients:

• what you are looking for, and why
• before probing, what the numbers mean
• while probing, what those numbers are, by calling them out; by hearing the numbers, patients are more likely to become engaged in the diagnostic process.

Explain why nonsurgical and surgical periodontal therapy may be necessary. Describe the consequences of not proceeding with recommended treatment (e.g., bone loss, tooth mobility, tooth loss, halitosis).

Explain why the expense of replacing lost teeth may be far greater than the expenses associated with preventive and corrective measures to achieve and maintain periodontal health. Consider offering a payment plan to patients whose finances are preventing them from accessing care.

Emphasize how the patient can work with the dental team to improve and maintain periodontal health.

If referral to a periodontist is indicated:

• Explain the reason for the referral and what patients can expect at an appointment with the periodontist.
• Maintain the continuity and quality of care amongst all general dentists and specialists involved through effective communication and collaboration among the practitioners and their dental teams.
• Determine who should be the most responsible dentist or coordinator of the patient’s periodontal treatment and have a clear understanding of each provider’s role.
• Following periodontal therapy and during the maintenance phase, monitor patients’ periodontal status regularly for recurrent or refractory periodontal disease and intervene, as appropriate.

Dentists should also:

• Ensure all members of the dental team coordinate their efforts and collaborate on implementing office protocols for periodontal disease prevention and management.
• Pursue continuing education to refresh and increase their knowledge about advancements in periodontology.

3. Documenting informed consent

Dentists should respect their patients’ autonomy. Some patients may refuse treatment after the periodontal diagnosis, treatment plan and consequences of no treatment are presented and discussed; that is their choice. Dentists should consider, however, that the provision of elective treatment may be contraindicated in the presence of active periodontal disease.

Whether patients accept or refuse recommended treatment, the informed consent discussion should be carefully documented.

Dentists should document:

• all periodontal examination findings, including periodontal charts and radiographic reports • the periodontal diagnosis and prognosis
• all discussions relating to treatment options, including benefits and risks
• the likely consequences of not proceeding with recommended treatment
• any referrals and reports to or from other general dentists and specialists
• the patient’s informed consent or informed refusal

OVERALL

In order to fulfill their professional, legal and ethical obligations, dentists should take the time to perform periodontal examinations on a regular basis. Educate patients about the importance of periodontal disease prevention and management, and ensure all members of the dental team are committed to early detection and treatment of periodontal disease. When dentists are dedicated and enthusiastic about seeing periodontal health improvement, their patients are more likely to accept treatment recommendations, improve their home care regimens and return for maintenance appointments.