By Richard H. Nagelberg, DDS
Thinking beyond the oral cavity and modifying the manner in which dental services are provided has gained traction slowly in many dental practices. At the very least, we, as dental professionals, should be educating our patients about the elevated risks for a variety of serious systemic health issues that exist with periodontal disease and certain periodontal pathogens.
Lack of knowledge or a vague sense of the interconnections between the mouth and the body are among the barriers to incorporating research findings into daily practice. Similarly, failing to understand or provide the specific services, tests, and follow-up create barriers to change. The inconsistent manner in which periodontal treatment is provided is well documented. This fact alone is among the biggest barriers impacting patients' health beyond the oral cavity.
A 2014 study in the Journal of Dental Education (J Dent Educ. 2014 Sept.;78(9):1252-1262) examined this issue by means of a survey sent to 1,350 dentists in North Carolina. Approximately half of the surveys were completed and returned (49%). The purpose of the study was to ["identify current practices and perceived barriers regarding incorporation of oral-systemic evidence into the delivery of patient care"]. Three-quarters of the respondents practiced in urban or suburban settings. Significant barriers included perceived patient objections to additional fees and lack of patient acceptance. Younger dentists were the ones who most frequently reported these barriers. Dentists in rural practice locations reported a lack of appropriate referral options as a barrier.
The number of survey respondents represents about 14% of the approximately 4,800 dentists in North Carolina. The results of a larger sample size might have some differences, but the responses would likely be very similar in terms of the perceived barriers to oral-systemic practice. The authors concluded that dental schools need to prepare students for their roles in the assessment, management, and interprofessional collaboration that will be needed in the future.
Another potential barrier is the difficulty some individuals have with change in general. We live and practice in a comfort zone, and extending that can create anxiety. We need to think, however, first and foremost about our patients. Does our resistance to change affect the level of care we provide for them?
Among the ways to overcome barriers is to develop a practice philosophy with input from all team members. This can be discussed during a team meeting. Having everyone on board is critical to successfully implementing changes. It may be appropriate for some practices to jump in and implement all aspects of an oral-systemic practice. For others, making changes in stages is appropriate. An early aspect, and perhaps the most important, is educating patients about the increased risk for cardiovascular diseases and events, diabetic complications, development of atherosclerosis, etc., created by periodontal disease and bacteria. The message must be consistent among all clinical staff members. Incorporating power toothbrush recommendations is another simple step that can be taken, explaining that reducing the bacterial population in the mouth on a daily basis is the most important aspect of preventing periodontal disease along with knocking down the number of periodontal pathogens.
If comprehensive periodontal services are not yet in place in the office, making this change would come before utilizing additional tests such as bacterial and periodontal disease susceptibility salivary testing. Having a timeline to fully incorporate the changes will help avoid falling back into old familiar, comfortable habits. It might take up to a year to fully implement the changes, but the results will be rewarding, most importantly for the patients.
Among the most challenging changes is to transition from a bloody prophy practice to providing periodontal services, billing and charging appropriately. A consistent question often encountered is how to make this transition. The perception is that patients of record have been treated inappropriately in the past if they only had prophies, and thus a different approach is now necessary. Hand in hand with this barrier is explaining the need for periodontal maintenance every three months for periodontal patients. First steps might include probing every six months and using phrases such as, "We now know ..." or "Recent research indicates ..."
The most important step is to make the decision to provide the best services possible for our patients and give them a reason to keep coming to our offices.
Richard 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, and he lectures on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].