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No More Hygiene!

by Thomas Nabors

No more hygiene. That sounds a bit harsh. However, given the statistics of periodontal disease, perhaps we should consider changing our model?

A study released in 2012 by the Centers for Disease Control, called the National Health and Nutritional Examination Survey, included a full mouth periodontal examination to assess mild, moderate, or severe periodontitis for the first time. This made it the most comprehensive survey of periodontal disease ever conducted in the United States. It revealed some sobering statistics. One out of two Americans over age 30 has periodontal disease. That’s almost 65 million adults. For adults over age 65, the percentage increases to over 70%.

Considering the ever-increasing role that periodontal inflammation is playing in health care and systemic disease, I would question if dentistry has placed a proper amount of importance on treating periodontal disease and how has the methodology and scientific advancement changed to make treatment better?

Figure 2

Bone healing after Modular Periodontal Therapy at one year.

Figure 3

Failing implant in site #30.

Figure 4

Healing and bone growth at 6 months post MPT. 

Figure 5

Aggressive periodontal infection treated conservatively and is healthier in full orthodontics with significant force being placed on the teeth.

In 1981, Genco and Mergenhagen wrote the following in their article Host-Parasite Interactions in Periodontal Disease, “The daily non-specific removal of microorganisms as a means of treating a bacterial infection appears unique to periodontal disease. The fact that few, if any, other infections are treated in this manner should warn us that current therapy may not be optimal.”

That was 35 years ago. Think about the changes in dentistry in the last 35 years:

• Digital radiography,

• Implants,

• Sleep Dentistry,

• Cosmetic Dentistry, and many other areas.

So how has the role of the dental hygienist changed? What is our understanding of what periodontal is and how it is treated in 2016 as opposed to 1981?

• Are we still scaling and root planning with no antimicrobials?

• Are we using proper diagnostic testing to make our therapy specific to our patient’s needs, vs. non-specific?

• How does periodontal inflammation and infection affect your patient’s heart disease, diabetes, or other systemic health risks?

Granted, hygiene is important. But, when over half our patients have some form of periodontal disease that has become a bone-based infection, therapy should be far more routine. Most of health care is based on therapy, not hygiene.

Lets discuss some myths about traditional dental hygiene: 

Myth #1- Periodontal disease is not curable.

Many dentists and hygienists were taught that once you had periodontal disease, you always had periodontal disease. However, at one time, disease was based primarily on clinical signs and debris, such as plaque or calculus. Therefore, we were only treating the symptoms of disease, not the cause. The cause of periodontal disease is pathogenic periodontal associated bacteria at a level that triggers the body’s immune response. Once that trigger is removed to a level that restores balance, the body will heal. Just as it will from other infections. By looking at the microbiology through DNA-PCR testing we now can treat the infection specifically, vs. the old premise of non-specifically. By using medicine and appropriate medical based protocols, we can cure periodontal disease. However, as with other infections, we cannot immunize people from periodontal disease. 

Myth #2- The hygiene department is a loss leader.

For some, the hygiene department is something we “have“ to do. It has not been considered a real partner in the practice, but a drag on the practice vs. more profitable procedures. That might be the case if all you are doing is cleaning teeth. In our work with practices all over the country, it is not uncommon to find 80% of the work being done in hygiene centers around healthy mouth cleanings even though there is so much disease in the population. If all the work that is being done in a hygiene department is healthy mouth cleanings, it would be difficult to have anything but loss leader. However, providing therapy and treating disease is a real win-winwin for the patients, the practice, and your hygiene team. Patients get treatment they desperately need, hygienists are much more productive, and the practice thrives because it is providing a needed service that is changing lives. Hygiene is no longer a loss, but truly a leading center of production. 

Myth #3 – you can’t re-grow bone.

Now this will challenge your past belief system. Dee Hock, the founder of Visa, once said that getting new and fresh ideas is the easy part. The hard part is getting the old ones out. Considering that periodontal treatment in the past was based on treating the symptoms of disease, after the symptoms were present, it would make sense that we never could really resolve disease long term and the body could never properly heal. The body is a powerful healer. Compound fractures are serious injuries to bone. When it heals, its not long junctional epithelium. It is new bone. When we bone graft an extraction site after an extraction, we expect that to be a matrix for new bone. Therefore, when we properly remove the infection in a vertical defect, could we not expect bone growth? See Figures 1-5, these cases were completed and healed with no bone grafting.

Myth #4 – Hygiene should make up 30% of your practice production.

This might be the case if all you are doing is cleaning teeth. But for the practice that is truly treating disease, the ratios look very different. For example, my hygiene team generates over 50% of the practice revenue. That is in partnership with a very productive restorative department. As a solo practitioner, it is so helpful to see your hygienists as true partners in oral health care. They are qualified to do so many positive things in your practice and we like to think of them more as nurse practitioners than teeth cleaners. Just like dentists, hygienists love days where they can see fewer patients, treat disease, be more productive, and feel a sense of accomplishment. That’s because they are treating disease, not just cleaning teeth. When you are truly treating disease, the production that comes out of the hygiene department is far greater than 30%.

Myth #5 – Our patients are different. They just don’t have periodontal disease.

This is a trap that many practices in more wealthy areas fall into. Because the patient base is more educated, the thinking goes, they take better care of themselves and have less disease.

Periodontal disease does not choose its victims based on education or household income. What we know now is that periodontal disease has more to do with whole-health issues like stress and inflammation in other areas of the body, than it has to do with income or education. Too often it is our perception of disease and who has it that may impact who gets diagnosed.

So where is your practice today? Are you just cleaning teeth or are you treating disease? Just look at your procedure code analysis and do the math. What proportion of the time is spent “cleaning” vs. treating? It is time we move beyond the myths of hygiene and move on to treating disease.

Thomas W. Nabors, DDS practices in Nashville, TN with an emphasis in cosmetic dentistry, oral health, and early intervention strategies for periodontal disease. He is an AACD Accredited Member and an adjunct clinical instructor in the Department of Prosthodontics and the University of Tennessee College of Dentistry. He is the co-founder and clinical instructor for “No More Hygiene – Secrets of Modular Periodontal Therapy” – a course on the comprehensive treatment of periodontal disease. www.NoMoreHygiene.com

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