The Role of Technology in Periodontal Evaluation and Treatment Acceptance a Peer-Reviewed Publication Written by William L
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Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants. The Role of Technology in Periodontal Evaluation and Treatment Acceptance A Peer-Reviewed Publication Written by William L. Balanoff, DDS, MS, FICD and Cris Duval, RDH PennWell is an ADA CERP Recognized Provider 1-888-INEEDCE This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives leukin-1 can be found inside atherosclerotic plaque; TNF-α Upon completion of this course, the clinician will be able to antagonizes insulin.12 Interleukin-6, which is also produced, do the following: increases the production of fi brinogen (which is also associated 1. Know the prevalence of periodontal disease and with the creation of thrombi).13 Unhindered, once pockets and understand treatment needs. subgingival plaque are present, home-care is ineffective, irre- 2. Be knowledgeable about treatment obstacles. spective of the degree of care. Professional care is required.14 3. Understand the technology options available that assist in probing, charting and treatment planning and the Periodontal Disease Prevalence advantages of these. Periodontal disease is prevalent. Gingivitis around at least 4. Understand the role of technology in patient treatment three to four teeth was estimated in the NHANES III study to acceptance, practice-building and risk management. be experienced by 50 percent of adults.15 The majority of the adult population suffers from mild to moderate chronic peri- Abstract odontitis, and advanced periodontal disease affects between 5 The prevalence of periodontal disease and estimates of pro- and 15 percent of adults.16,17 More than 50 percent of adults vided treatment are indicative of treatment needs. Current between 30 and 90 years of age have been estimated to have at technology offers standardized probing, automated charting, least 3 mm of CAL.18,19 (Table 1) In particularly susceptible risk assessment, differential diagnosis and suggested treat- individuals, periodontitis is evident during adolescence and ment plans, as well as enabling clinicians to involve patients early adulthood.20 The single most important determinant of in the process. Patient awareness and treatment acceptance disease progression is the host response.21 Individual deter- can be encouraged with full evaluation, a consistent protocol minants include genetic, systemic and behavioral factors.22 and message, and through the use of technology. Table 1. Disease prevalence in adults 80% Introduction 80 Patients’ perceptions of dentistry and periodontal disease are 70 evolving. As patients become aware of the oral-systemic link — in part as a result of marketing by consumer oral care companies, 60 50% >50% and are educated by clinicians about this, they are beginning to 50 view periodontal health as an important component of their over- 40 all well-being. While there is increasing attention to periodontal Percentage 30% health and the oral-systemic link, periodontal disease remains 30 prevalent. Patient awareness and treatment acceptance — in- 20 cluding in the earlier stages of the disease when it is often asymp- 5% – 15% tomatic — can be encouraged with full evaluation, a consistent 10 protocol and message, and through the use of technology. Given 0 Gingivitis; CAL 2 mm CAL 3 mm CAL 4 mm Severe the importance of treating periodontal disease for both oral and at least or more; or more or more; periodontitis systemic health, it is key that patients understand the necessity of 3 – 4 teeth at least at least accepting periodontal therapy when they are diagnosed. 1 site 3 – 4 teeth Periodontal disease and periodontopathic bacteria have been Treatment Estimates and Needs found to be associated with cardiovascular disease, diabetes, re- An estimated 28 million periodontal procedures, including 12 spiratory disease, and low birth-weight.1,2,3,4 Severe periodontitis million quadrant scalings and root planings, were performed in has been found to be associated with a 400 percent increased risk 1999 in the United States, and an estimated 226 million prophies of stroke, and even gingivitis has been found to be associated with occurred.23 Considering that at least 35 percent of the dentate an increased risk.5,6 Diabetes increases the severity of periodontal population is estimated to have mild periodontitis, and another disease, and conversely some studies have found that treating 12.6 percent to have moderate or severe periodontitis,24 this is in- periodontal disease helps improve glycemic levels in patients.7,8 dicative of considerable undertreatment of periodontal disease. Periodontopathic bacteria, together with their by-products and cytokines, stimulate the liver and white blood cells to increase production of infl ammatory proteins;9 they have also There is a significant need for increased peri- been found attached to blood vessel walls.10 The infl ammatory odontal treatment acceptance and delivery. response includes the release of neutrophils, antibodies and lymphocytes. Tumor necrosis factor alpha (TNF-α) and inter- leukin-1 — both released by leucocytes — are responsible for Standard-of-Care stimulating matrix metallo-proteinase (MMP), with resulting It should be the standard-of-care to probe every patient every clinical attachment loss (CAL) and bone destruction.11 Inter- time he or she is seen at recall by the hygienist. Every new pa- 2 www.ineedce.com tient must be screened and evaluated for periodontal disease. Limiting Beliefs Evaluating and educating patients about their clinical situation Predictably Old Information and Protocols lower acceptance and presenting them with therapeutic options to prevent, cor- Ineffective Communication rates for periodontal rect or manage disease is what is best for patients — the merits Outdated Technology therapy of diagnosing periodontal disease are ethical and required. By evaluating, diagnosing and educating patients, revenue, and ultimately profi t, will increase. Although clinicians may Lack of treatment and undertreatment result in the ongo- feel uncomfortable mentioning profi t and ethics in the same ing existence of disease, a threat to systemic health and a lost breath, the fact is that dental practices are businesses that must opportunity for the practice to provide optimal patient care generate revenue and profi t while providing excellent care. while optimizing practice-building opportunities. They also expose dentists to the risk of being sued. An assessment of treatment provided over the previous 12 months using pre- It should be the standard of care to probe ventative and therapeutic codes will indicate the mix and level every patient every time he or she is seen of periodontal treatment in an individual practice. (Table 2) at recall by the hygienist. These can be infl uenced by treatment obstacles, as well as ap- pointment time being consumed with scaling and polishing. The vast majority of hygiene procedures are coded as adult The Periodontal Examination prophies (1110),30 which by defi nition would entail scaling The only method of detecting and measuring periodontal and polishing in the presence of health. In addition, if most pockets is careful exploration with a periodontal probe.25 procedures are prophies, this leaves little chairside time for Pocket depth, clinical attachment changes, gingival recession, periodontal evaluations and treatment. bleeding on probing and the presence of exudate (pus) must all Table 2. Treatment Mix be assessed. Alveolar bone levels are evaluated by clinical and radiographic examination, and mobility is graded according to 12-month production by provider the ease and extent of tooth movement. It is important to re- Code # Treatments member that pocket depth and attachment level measurements 1110 Adult prophy A do not determine whether the disease is active or inactive, and 4910 Periodontal maintenance B inactive lesions may have little or no bleeding. Additional 4341 Periodontal therapy per quadrant (4+ teeth) C testing and information may also be indicated, such as micro- biological fi ndings. Ultimately, the objectives of probing and 4342 Periodontal therapy (1–3 teeth) D associated charting are to diagnose periodontal disease and to Calculations have patients accept treatment. Appropriate techniques and communication are essential to achieve these objectives. A + B + (C +D)/2 = X B + (C +D)/2 = Y The ultimate objectives of probing and charting Y divided by X = Percentage of therapeutic periodontal treatments are diagnosis and treatment acceptance. Defining a Protocol A defi ned protocol and integrated approach to periodontal Obstacles to Treatment examination, diagnosis and treatment help toward the goals Patients are typically motivated to seek treatment by pain, of fully evaluating and treating all periodontal patients. esthetics and health considerations. Periodontal disease is often Protocols must consider the risk and susceptibility of an in- asymptomatic until it is advanced — the patient will have no dividual patient and treatment should be planned for health pain, no associated esthetic concerns, and be unaware of health as the outcome. It is important to make a clear distinction issues. Patients may lack awareness, recognition or acceptance of between preventive care and periodontal therapy. If peri- the need for treatment.