That gray area of disease

No doubt about it, hygiene protocols are changing. We are now embracing diagnosis-based hygiene services. We are probing and charting each of our patients. We use ultrasonic debridement and chemotherapeutic agents in our treatment protocols. As a result, we are enjoying an increased awareness on the part of patients regarding periodontal disease. As much as we have moved forward with these changes, some gray areas remain about when to treat and when to monitor the periodontal condition.

Beverly Maguire, RDH

No doubt about it, hygiene protocols are changing. We are now embracing diagnosis-based hygiene services. We are probing and charting each of our patients. We use ultrasonic debridement and chemotherapeutic agents in our treatment protocols. As a result, we are enjoying an increased awareness on the part of patients regarding periodontal disease. As much as we have moved forward with these changes, some gray areas remain about when to treat and when to monitor the periodontal condition.

The struggle for many hygienists and doctors involves uncertainty and a lack of agreement on the issues of disease activity. Determining appropriate hygiene care begins with complete probing and charting. It's the only way in which the hygienist can ask the questions, "What does this chart tell me? Is this a healthy patient?"

If the chart has several 4 mm pockets, perhaps 25 bleeding points on gentle probing and not a lot of bone loss on the films, is it really bad enough to justify treatment? That gray area of disease is confusing! Too often, I hear doctors say to patients, "With some better flossing, that bleeding should clear right up," or "It's been three years since you've had your teeth cleaned. A good cleaning should turn things around."

Hygienists and doctors alike seem to justify the disease. They identify contributing factors such as stress, lack of good flossing, or a long lapse between appointments as the cause of the bleeding and destruction of the bone. Does it really matter why things look the way they do? Is it enough to note inflammation, infection, bleeding, and attachment loss, and then simply offer options for treatment?

Throughout the past 29 years of practicing dental hygiene, I have come to change the way in which I look at health and disease. The surprising thing to me has been the level of health attained by the patients I treat. Patients experienced better health and stability once my standards changed and when I offered treatment at the first sign of disease activity!

My current standards for health include pocket depths of 1-3 mm, 10 or less points of bleeding upon probing, and no loss of bone. That to me indicates a healthy "prophy" patient. Reviewing the definition of prophylaxis in the CPT Manual from the AAP, 7th edition, will confirm the coronal nature of the prophy procedure. When looking at disease activity, I typically see pocket depths of 4 mm and greater accompanied by more than 10 points of bleeding upon probing, as well as attachment loss. Healthy tissue does not bleed!

I treat periodontal disease activity aggressively and often. When I notice the patient's status has changed according to the above parameters, I offer treatment. The winners in this situation have been my patients.

We need to get off the fence and treat more aggressively with this conservative, nonsurgical approach. When patients move outside of the zone of stability, take action! Advanced periodontal problems require a surgical approach. Referring the patient to the periodontist in a timely way is a service to both your patient and the periodontist. The days of expecting periodontists to be miracle workers and save teeth when they are too far gone has been of no benefit to anyone involved.

Take some time to think about your unspoken standards for periodontal health and disease. Many of us are unclear on these standards. We have waited far too long to begin the process of treating our patients with both new and recurrent periodontal disease. Use your gray matter to eliminate the gray areas of treating disease!


Beverly Maguire, RDH, is a practicing periodontal therapist. She is president and founder of Perio Advocates, a hygiene consulting company based in Littleton, Colo. She can be reached at (303) 730-8529 or by e-mail at perioadv@aol.com.

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