Ignore the biofilm and calculus - It's time to think differently
Maya Angelou once said, “When you know better, you do better.” This quote echoes a simple and forgiving truth in all aspects of patient care; it’s about lifelong learning.
When it comes to periodontal therapy, both clinician and patient benefit from heeding this poignant statement of awareness. Continued learning and a growing knowledge of all causal triggers (risk factors) are crucial to changing the course of chronic inflammatory periodontal disease through targeted care. While most continuing education courses continue to focus on the elimination of bacteria as the clinical goal, these narrowly focused methods and philosophies fall short in the successful prevention and treatment of periodontal diseases long term. We can do better. An evergreen Einstein quote comes to mind: “Insanity is doing the same thing over and over and expecting a different result.”
In reality, patients with exceptional home care can actually mask active inflammatory disease still occurring just beneath the surface. Just because we cannot detect inflammation with our current limited visual diagnostic methods does not mean it is not there; we need to take a closer look and redefine periodontal health and stability. We now know that periodontal diseases are complex multifactorial diseases involving the entire host; it’s time we start learning and discussing more in-depth truths about treating and managing these diseases comprehensively for optimal oral and systemic health long term. In many cases we need to stop blaming our patients for their shortcomings in home care skills and start looking deeper into host response. Why? Because heightened inflammatory response doesn’t just come from the presence of biofilm; conversely, inappropriate inflammatory response due to host factors can actually create higher levels of thriving biofilms — furthering disease progression.
Is there any real progress?
According to the Centers for Disease Control and Prevention, the percentage of individuals over 65 who are edentulous in the United States decreased from 30% to 25% in the past 10 years. Is this because we are doing better to manage periodontal diseases and prevent tooth loss? No, actually this decrease results from dental implant placement and not from the prevention of tooth loss. In reality the prevalence of periodontal disease has not changed; in fact it has surpassed diabetes as the leading chronic inflammatory disease in the United States.1 Fifty percent of Americans over age 30 have some form of active periodontal disease, and 30% of those have moderate-stage disease; this number jumps to 70% in adults 65 and older.1,2 Since our traditional method of diagnosis relies so heavily on non-definitive technology (clinical observation), we undeniably do not have an accurate assessment of the true prevalence of periodontal disease activity or severity. In addition, the traditional solutions for treating periodontal diseases are for the most part either non-definitive or surgical––yielding short-term or marginal results in many cases, as well as being overwhelmingly cost-prohibitive for the patient. Let’s face it, what average person could afford full mouth surgery or implants, especially multiple times over?
Could some of this be avoided by changing the way we assess and treat periodontal diseases? Are we fully practicing what the American Academy of Periodontology outlined as Comprehensive Periodontal Therapy?3 Are we practicing daily what the American Dental Hygienists’ Association outlined in Standards for Clinical Dental Hygiene Practice?4 Many may not even know that these papers exist, yet these important publications are foundational for every clinician and if put into daily practice would likely create major change in the grim statistics.
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