Practicing in the dark is not good enough

July 19, 2016
Dr. Richard Nagelberg says that if we are not using salivary diagnostics to identify the bacteria that causes a particular patient's case of periodontal disease and identifying other patients who are at risk for developing the disease, we are not giving patients their best chance for health.

Richard H. Nagelberg, DDS

At this point, it is embarrassing for the profession to acknowledge that we are still using a "notched stick"—with its inherent subjectivity, lack of standardization, and inconsistent results—as a means of determining pocket depths for periodontal charting. We have been using this method of measurement for generations.

If it provided consistent and accurate data, perhaps it would be acceptable, but that is not the case. The time is coming when new technology will bring collection of this primary diagnostic information into the 21st century, and those who still use the notched stick will be behind the times. A perfect analogy is digital x-rays. Those who still use film are cultivating an image among their patients of being on the leading edge of antiquity. New pocket- measuring technology and devices are not yet available, so we are stuck for the time being with old, inadequate instruments and protocols.

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This is not the case, however, regarding the ability to simply and quickly identify the bacteria that cause an individual patient's case of periodontal disease or those patients who are at risk for developing it. It takes only a minute or two to collect a saliva sample and send it off to a laboratory for analysis. Reports are generated in about two or three days. With rare exceptions, the dental profession does not use laboratory studies and reports. It would be inconceivable for a physician to conduct a physical examination without blood work or urinalysis, among other tests. Blood and urine samples are collected in advance so the doctor has the report in hand at the time of the physical exam. Without this data, it is impossible to accurately address most diseases and conditions.

It is also embarrassing for the dental profession to acknowledge that despite the easy availability of salivary diagnostic technology for more than seven years, most dental offices are not using these services. Salivary identification of the bacteria that cause your patient's case of periodontal disease offers many advantages including accurate treatment planning targeting the causative bacteria, accurate antibiotic selection, reaching therapeutic endpoint, accurate risk and outcomes assessment, and lowered risk of recurrence. The disease-causing ability of oral bacteria varies widely. The description of the high-risk pathogens Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis is as follows: very strong association with periodontal disease; transmittable, tissue invasive, and pathogenic at relatively low bacterial counts; associated with aggressive forms of disease.

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Is that description relevant to the outcome of therapy? Would the treatment plan take into account the extremely high toxicity of these bacteria? Would the treatment plan consider the high likelihood of nonresponding sites when these bacteria are present? Would this information provide insight into successfully addressing refractory cases of periodontitis? Would children of parents with periodontal disease be well served by testing? How do you decide on the type of adjunctive antibiotics to prescribe without knowing which bacteria you are trying to eradicate? Salivary testing reports identify the exact systemic antibiotics to use including the dosage, duration, and administration, as well as which locally applied antimicrobials (LAAs) to use based on the bacterial profile.

Other questions need to be considered. Will the time come in the future when it is considered practicing outside the standard of care to treat and prescribe antibiotics for periodontal disease without identifying the bacteria being targeted? Is it not a requirement to document the causative factors when any medications are prescribed? Of course it is. Is it adequate simply to state that antibiotics are being prescribed for periodontal disease without stating which bacteria are at play? Perhaps it is at this time, but does that mean we are providing optimal care? Standard of care is dentist-centric. It just means that you are doing the same thing an office down the street is doing. Optimal care is patient-centric, because it goes beyond the minimal standard of care sufficient to defend oneself in a courtroom.

If these questions are pondered, the overwhelmingly obvious response is that addressing a serious oral infection in the dark, without salivary diagnostics, is not the best we can do. Practicing this way does not give our patients their best chance for health. It means we are doing the minimum we need to do because it's what they are doing next door, and that's good enough. It's not.

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].