You, the gatekeeper: Overcoming barriers to diagnosing periodontitis

"In all of my years practicing, I have had many different general dentists tell me what periodontal disease is or is not, as if I was not trained to diagnose it myself. I had one even tell me that he doesn’t “believe” that periodontal disease has a disease process."

Nov 16th, 2016
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"In all of my years practicing, I have had many different general dentists tell me what periodontal disease is or is not, as if I was not trained to diagnose it myself. I had one even tell me that he doesn’t “believe” that periodontal disease has a disease process."

In our not-so-distant past, we dental hygienists began learning about the elusive anaerobe. During that era of bad perms and bad bacteria, we thought that only a select few bacteria were the whole cause of the breakdown of the periodontal tissues. As time passed, our haircuts calmed down, and our science evolved, we learned that there are a vast majority of reasons that some patients can control periodontal flare-ups and others seem doomed to endlessly repeat scaling and root planning treatments.

To take a moment and identify that, as dental hygienists, we are a profession of some of the hardest-working and sometimes undervalued segment of the health-care field is appropriate. I know the struggle is real and want to make clear that there is real skill in employing tact when your patient wants to talk about her divorce. You truly care but are also looking at that clock and envisioning “that” look of disapproval from the next patient who just had to wait three and a half minutes longer than his appointment time. With that said, we have an important job to do. We are the gatekeepers. I’ve heard that phrase many times from different consulting firms. They use it to encourage an increase in periodontal disease diagnosis to increase revenue. I’m all for my boss keeping the doors open and still having a job, but we do this work because we want to help people.

Thirteen years into my dental hygiene career and three periodontal practices later, I am still surprised how people will ignore an issue like periodontal disease. If you were bleeding from anywhere else in your body for 10 or more years, would you not do anything to stop it? There is a perceived “mouth-body” disconnect in the general population, and most will not set foot in our periodontal practice without a healthy nudge from their general dentist. In all of my years practicing, I have had many different general dentists tell me what periodontal disease is or is not, as if I was not trained to diagnose it myself. I had one even tell me that he doesn’t “believe” that periodontal disease has a disease process. He thought some people just get it and others do not. Sounded to me like someone wasn’t having any success treating it and didn’t know what else to do. At that point I thought to myself, “How many hygienists are trying to diagnose inflammation, gingivitis, and trying to treatment plan with this kind of a barrier?”

A study published in the Journal of Dental Education states that there is an “undue variation in periodontal diagnoses and treatment plans” in dentists and dental students. The study wanted to test the efficacy of “consensus training.” They found that there were “variation(s) involving diagnosis of extent and severity of periodontal condition, as well as variation in the extent and choices of treatment planning.”1 How could this finding not affect how well we are able to treat or refer our patients? We can educate, discuss, and finally have the patient accept a treatment plan, only to have a doctor come in and decide that we are exaggerating the situation. This is an extreme case—most doctors want that revenue—but how many other scenarios can you remember in your career?

What we can do now, in the practical real world, is have a conversation with the dentist about consensus training within our own offices. I love a good flowchart. We all know what the guidelines should be. The American Academy of Periodontology provides them for us. We know that systemic diseases exacerbate many cases of periodontal disease. We need to screen health history forms with scrutiny, looking for certain diseases and medications. Would it be helpful to have that on the back of your cabinet door? Talk with your dentist about his or her consulting periodontal specialist. What are that doctor’s capabilities? Maybe we are sending our patients to the wrong places, if any periodontal referrals go out at all?

Did I hit a nerve? If I did, you really need to have that discussion with your dentist and any other hygienists that work with you. Believe me, unless they are hoping to get sued they will need to listen to you. The tools are all there for you. Put on your big-girl or big-boy pants and remember that you are a professional just as they are and this is your specialty and your license.

One final thought I would like to share comes from the American Society for Microbiology: “About 50% of the adult population has gingivitis around three or four teeth at any given time. 30% have periodontitis. Between 5%–15% of those with periodontitis have advanced forms. Another 3%­–4% of individuals will develop an aggressive form of periodontal disease, known as early onset periodontitis, between the ages of 14 to 35.”2 Are you diagnosing accordingly?

References
1. John V, Lee SJ, Prakasam S, Eckert GJ, Maupome G. (2013). Consensus training: An effective tool to minimize variations in periodontal diagnosis and treatment planning among dental faculty and students. J Dent Educ.2013;77(8):1022-1032.
2. Loesche WJ, Grossman NS. Periodontal disease as a specific, albeit chronic, infection: Diagnosis and treatment. Clin Microbiol Rev. 2001;14(4):727-752.


Ayla Dervisevic RDH, BS, is a dental hygienist who has been practicing in New York for 13 years. Her undergraduate work was completed and the State University of New York at Farmingdale and she is currently working towards her Master of Science at the Fones School of Dental Hygiene at Bridgeport University. Her dream fulfilled would be a world where everyone considers oral health a key component to overall health and dental hygienists are encouraged to use their skill set to their fullest capacity.


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