Richard H. Nagelberg, DDS
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Wellness is a concept and practice philosophy that is long overdue. Health professions as a whole, including the dental profession, have followed a disease model far too long. There was a time in which it was the leading edge, prior to the advent of the ability to predict disease with the wide array of tests and imaging technologies currently available.
Perhaps it would be more accurately described in dentistry as the “bleeding edge.” We necessarily had to wait for disease to manifest physically before we could intervene, since we had no way to assess risk and predict the course of events. If we pause to consider the protocols we follow routinely, we may more fully understand the disease and wellness models.
When we identify a patient with periodontal disease, we start collecting data to arrive at an accurate understanding of the severity and distribution of the problem. The periodontal evaluation and radiographs, however, merely represent the history of the disease process.;The clinical parameters — pocket depths, redness, swelling, bleeding, and bone loss — are manifestations of events that happened in the past. The damage is done.
Periodontal evaluation is nothing more than a damage report. The disease process is a continuum of activity that started sometime in the past and will continue to progress unless intervention occurs. Even if a patient initially presents to our offices with moderate to severe disease, the wellness model applies. It involves three levels of prevention:
- Primary prevention is for patients who enjoy excellent periodontal health.
- Secondary prevention is for patients with gingivitis.
- Tertiary prevention is for patients with periodontitis.
After patients with gingivitis and periodontitis are returned to health, they then need primary prevention since there is an absence of disease.
A starting point for practicing with a wellness approach is an evaluation of the patient’s risk factors for disease. The most common are heredity, diabetes, smoking, poor oral hygiene, faulty restorations, immunocompromise, hormonal variations, stress, nutrition, previous history of active perio disease, medication-driven xerostomia, connective tissue disorders, and occlusal considerations. Counting the patient’s risk factors provides an understanding of their impact on the predictability of disease resolution.
A patient with multiple risk factors has a poorer prognosis than a patient with few or none. Risk factors cannot cause periodontal disease, but they do increase the chances that it will happen. Evaluation of risk is not limited to those with active disease. Scoring healthy individuals’ risk provides an assessment of the likelihood of disease occurrence.
Healthy patients with a number of risk factors, especially if they include diabetes and/or smoking, have a higher probability of disease development. Helping patients understand their risks and discussing strategies to reduce them prior to disease development is wellness in practice.
Another important way to assess risk is by salivary testing for genetic susceptibility to periodontal disease. The PST test (OralDNA Labs) determines the presence or absence of a genetic marker for disease development. If a patient is PST positive, an exaggerated inflammatory response to the bacterial load will occur, initiating and increasing tissue breakdown.
This is a powerful tool to predict a patient’s chances for disease occurrence. Nutritional counseling — including antioxidants, probiotics, and other dietary recommendations — is also part of a wellness model.
The wellness model is not limited to the oral cavity. The implications for general health are the most important aspects of this practice philosophy. Systemic events including heart disease, stroke, diabetes, and rheumatoid arthritis, among others, are life-changing and life-threatening. The total inflammatory burden from all sources — including an ingrown toenail, periodontal disease, and everything in between — contributes to the risk for systemic disease occurrence.
The mere notion of oral-systemic connections is flawed since it implies that there is some degree of separation. There are no ophthalmic-systemic connections, renal-systemic connections, or pulmonary-systemic connections. Similarly, there are no oral-systemic connections. The oral cavity is just another part of the body, as are the eyes, kidneys, and lungs.
The end stage disease model of practice is inadequate to address the health needs of our patients. A new mindset among providers, including those in the dental profession, is overdue. The bottom line is, the care we give to our patients with a wellness practice approach is the future of health care.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 28 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. In-office consultations are available. Contact him at [email protected].