There is universal acceptance of the research demonstrating that statins, low-dose aspirin, and antihypertensive agents reduce the likelihood of a cardiovascular event. Lifestyle recommendations to keep moving, stop smoking, lose weight, and go for the grilled chicken instead of the bacon cheeseburger with fries are in the same category. Identifying, managing, and reducing risk factors are recommendations all health-care providers make, because avoiding a heart attack or stroke is better than having to treat it. This is the essence of preventive medicine, and one would be hard-pressed to find a health-care provider with a dissenting opinion.
However, the dental profession seems to be all over the map when it comes to identifying risk factors for periodontal disease and managing them prior to clinical manifestation of the disease. Given the high incidence of periodontal disease, a shift in our approach is appropriate. Dental professionals seem to be stuck in a disease-management protocol rather than a philosophy of disease prevention. Comprehensive periodontal charting and recording is nothing more than observation and documentation of events that happened in the past; it is a damage report. It tells us nothing about the cause of a particular case of periodontal disease and nothing about what is going to happen in the future. It is a snapshot from that one moment when the evaluation and radiographs were performed. Certainly periodontal charting has merit, but its predictive value is nonexistent or, at most, of limited value.
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Attempting to formulate a preventive plan for a particular patient without identifying the specific causative bacteria involved would be similar to a physician failing to get a patient's blood pressure or blood tests to design a treatment plan. If a patient has a history of periodontitis, he or she should be on a three-month maintenance interval. A detailed assessment of the effectiveness of the patient's home care must be undertaken and recommendations made to optimize biofilm reduction. Periodontal disease prevention should then focus on at-risk patients without periodontitis.
Various factors that need to be considered include the bacteria revealed by salivary testing, family history, smoking, xerostomia, home-care efficacy, diabetes, hormonal variations, faulty dental restorations, diet, stress, whether or not the patient is immunocompromised, etc. Of these, the most important is the specific causative bacteria, because all the others are simply contributing factors-not causative agents. Without the cause, no disease will take place no matter what other contributing factors are in play.
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Let's assume a salivary test has been performed and that it reveals the presence of periodontal pathogens, especially concerning the presence of high-risk bacteria such as Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Tannerella forsythia, and Treponema denticola. Let's assume that this patient does not have clinically evident periodontal disease. Now what? Since the patient does not have periodontal disease, scaling and root planing (SRP) are not indicated, but the bacterial levels need to be controlled since they potentially indicate an elevated risk for periodontal disease development. We now review the risk factors the patient has and manage them the best we can. We can implement measures to minimize the effect of xerostomia, correct faulty restorations, and counsel the patient to stop smoking and improve his or her diet. Then we evaluate the patient's home care. Chances are that it is deficient if a number of bacterial species are present in the salivary test report. Recommendations will include a power toothbrush, interdental brushes everywhere they fit, antimicrobial rinse, and a tongue cleaner. A second bacterial test should be done one to three months after the first test to determine if the bacterial levels have decreased, which would represent risk reduction. Obviously the patient needs to continue the enhanced home-care regimen. Beyond that, bacterial testing once a year should be recommended. A shorter recall interval might be indicated as well.
The credibility of the dental profession is rated very highly year after year. But are we really earning that credibility if we are waiting for disease to develop and then trying to control it? Since periodontitis is a chronic, noncurable bacterial infection, patients who progress from health to gingivitis to periodontitis are condemned to a lifetime of disease management, every 12 weeks for the rest of their lives. The dental profession-that's us-needs to transition from treatment planning to prevention planning.
Richard H. Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 30 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact Dr. Nagelberg at [email protected].
