Ignore the biofilm and calculus - It's time to think differently

August 14, 2015

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.


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.

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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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Critical thinking vs treating disease topically

Whenever and wherever we see periodontal inflammation, our minds should automatically assume it is not related entirely to biofilm and calculus. In fact, we should train our minds to ignore the biofilm and calculus, at least initially. Yes, there are other obvious risk factors we may easily identify such as smoking or diabetes, but we should always assume there are several more important modifiable and non-modifiable risk factors at play. This is how we determine cause instead of just treating symptoms and history of disease reactively. This is how we solve the puzzle and become proactive with targeted therapy for long-term solutions. When we learn to think critically by connecting the body to the mouth as one, we gain a new level of understanding in the etiology and progression of chronic disease. “When we know better, we do better.” So let’s definitively remove the subgingival calculus and provide adequate home care instruction, but let’s also play detective like the tenacious and inquisitive detective in “Columbo” and figure out exactly what is creating this perfect storm for chronic inflammatory disease. As Peter Falk as Columbo often said, “Oh, just one more thing ….” Dig, dig, dig for root cause until you can’t dig anymore, and then do something about it.

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Individualized periodontal medicine

So what are we to dig for and what does individualized periodontal medicine look like? True periodontal medicine is uncompromising in finding root cause by uncovering all risk factors in order to address them definitively. How often do we have patients in our chair who have not had comprehensive blood work ordered by a physician in many years, including these very important laboratory studies: prediabetes testing (hemoglobin A1c), complete blood cell count and assessment of deficiencies such as vitamin D and B12, thyroid disease (thyroid-stimulating hormone), lipids and inflammatory biomarkers? How often do we have patients who have undiagnosed and untreated airway issues, including obstructive sleep apnea, mouth breathing, tongue thrusting or tongue ties? Does our health history ask detailed questions about diet and supplementation? Do we carefully assess possible oxidative stress issues through definitive testing and nutritional assessment, or both? Do we carefully consider gut biome? Does our health history form include questions about family history of all diseases to better determine overall risk of all inflammatory diseases, including PD, diabetes, cardiovascular disease, arthritis, cancer and dementia? Are you using that information? Are we determining exactly what pathogens our patient is carrying orally and possibly systemically? Are we targeting these pathogens with systemic antibiotics and/or appropriate anti-infective measures - even if no outward signs of oral disease appear? And most important, do we know and understand our patients’ detailed genetic inflammatory profile? Do we understand how and when to incorporate host-modulated therapy into practice when non-modifiable chronic inflammatory risk factors are present? These questions take us from technicians to true clinicians.

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The co-therapy solution

If the answer to any of the above questions is no, there is opportunity for advanced education and positive change. When discoveries are made and then shared with patients, something truly impactful begins to take place as patients become more interested and motivated in their own care; they become a co-therapist. At this point the physician or ND (and possibly other health care professionals) is also playing an integral role in vital co-therapy, with the hygienist as the linchpin director leading the way. Yes, that’s right; the hygienist is leading and directing the entire process! Periodontal diseases are multifactorial and in many cases very complex. It is the hygienist’s role to tease out risk factors with good detective work and collaborate with other health care professionals for more comprehensive care. We are fooling ourselves if we continue to think that we fully understand and can effectively treat periodontal pathogenesis by focusing mainly on local factors and teaching better home care. We can never have meaningful and lasting impact without understanding and addressing the host more definitively and individually. Learn to ignore the calculus and biofilm, at least initially, and then push yourself to think more critically. Hygienists are the most important and integral health care professional on the team - it’s time we start realizing it.

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Author's Note: Look for our coming series of articles that will focus more in-depth on important modifiable and non-modifiable risk factors and how to effectively evaluate and treat them.

Continuing education to consider: Scientific Session Annual Meeting (www.aaosh.org), Bale-Doneen Preceptorship Course (www.baledoneen.com), Perio-Nutrition (www.perio-nutrition.com), A New Era in Periodontal Therapy (www.periopeak.com), Cross Link Radio (www.crosslinkradio.com)

Further reading

“Healthy Gums for Life: beyond just clean teeth”


LinkedIn forum: Periodontal Endoscopy and Integrative Care https://www.linkedin.com/groups/Periodontal-Endoscopy-Integrative-Care-6556091/about


1. Centers for Disease Control and Prevention. Periodontal disease. http://www.cdc.gov/OralHealth/periodontal_disease/index.htm. Retrieved 8/14/15.

2. American Academy of Periodontology. CDC: Half of American adults have periodontal disease. https://www.perio.org/consumer/cdc-study.htm. Retrieved 8/14/15.

3. American Academy of Periodontology. Comprehensive periodontal therapy: a statement by the American Academy of Periodontology. J Periodontal. 2011;82(7):943-949. Published online before print as doi: 10.1902/jop.2011.11700. [http://www.joponline.org/doi/pdf/10.1902/jop.2011.117001]

4. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. http://www.adha.org/resources-docs/7261_Standards_Clinical_Practice.pdf. Retrieved 8/14/15.