Involving your patients in the process of monitoring and maintaining their health is critical.
By Trisha E. O'Hehir, RDH, BS
The potential link between periodontal disease and systemic conditions reinforces the importance of recognizing, treating, and preventing periodontal disease. Understanding the disease process and recognizing early signs of disease are skills you can share with your patients. This information — plus suggestions for controlling interproximal bacterial plaque — will improve the periodontal health of your practice and involve your patients in the process.
Tip #1 ... Infection rather than inflammation
The terms "infection" and "inflammation" are used interchangeably in discussions with patients, but elicit different responses. Technically, inflammation more accurately describes the periodontal disease process. The terms "gingivitis" and "periodontitis" include the "itis" ending, indicating an inflammatory process. The destruction is definitely a result of a complex inflammatory process.
The definition of infection is, "Invasion of the body by living pathogenic microorganisms which reproduce and multiply, causing disease by local cellular injury, secretion of a toxin, or antigen-antibody reaction in the host." This is where bacterial plaque biofilm comes into the equation. This is the bacterial infection aspect of periodontal disease. Here's an interesting concept to ponder — there can be inflammation without infection, but there can't be infection without inflammation.
Before an infection can occur, there must be a breakdown in the body's normal defenses. That happens when the junctional epithelium is altered by volatile sulfur compounds and becomes more permeable, allowing bacterial toxins to pass through into the underlying tissues. The immune system is alerted, triggering the complex series of events in the inflammatory process. This process is generally the body's way of preparing for repair and healing. It is also defensive in nature, as it walls off the infection and keeps it from spreading throughout the body. If more toxins enter the area, more destruction than healing occurs.
Both infection and inflammation are taking place during periodontal pathogenesis. Subgingival bacterial biofilm accumulates and matures in the sulcus, releasing toxins that penetrate the junctional epithelium and pass into the underlying connective tissues — infection. This infection triggers the immune response and begins the complex inflammatory cascade.
We are dealing with both infection and inflammation, so both terms are correct. You understand the difference, but patients don't. People often associate inflammation with something they can't influence like arthritis or a bruise. "Infection" is perceived as a much more serious word. The term "infection" better communicates your message to patients. Infection ties in the importance of the bacterial component. Telling patients they have a "bacterial infection" gets their attention faster than discussing "gingival inflammation."
Tip #2 ... Bacteria trigger the infection, but destruction is caused by the body's own immune sy
Bacterial toxins trigger the immune system, sending signals that the body recognizes and responds to by sending white blood cells — polymorphonuclear leukocytes (PMNs) — to the area. This is our body's first line of defense against infection.
This is where we will see the immune response in action and the start of connective tissue breakdown associated with periodontal disease. Chemotaxis is the migration of white blood cells from the blood vessels in the connective tissue through healthy connective tissue and epithelium to the sulcus where they attack the bacteria. The PMNs phagocytize the bacteria, stopping the production of toxins and thus allow the body to heal.
To reach the sulcus quickly and to avoid moving cell to cell, the PMNs use cytokines (chemical machetes) to cut their way through the healthy tissue. Cytokines released by the PMNs include collagenase, prostaglandin, and interleukin. They destroy healthy connective tissue in order to allow the white blood cells to move quickly to the site of bacteria. If the immune system is healthy, this destruction is a small price to pay for effectively controlling the bacteria in the sulcus. A healthy immune system is able to keep the tissue destruction and tissue repair in balance.
The number of bacteria and the virulence of their toxins can overwhelm the immune system. What may be a manageable level of bacteria in one mouth may lead to destruction in someone with immune system problems. A compromised immune system sends out the PMNs but they may not be effective at phagocytosis when they reach the bacteria. They cause connective tissue destruction, but don't effectively get rid of the bacteria. Since they aren't effective, the signal keeps ringing out to the immune system to send more PMNs. This imbalance leads to continued destruction of the connective tissue and bone by the immune system. The bacteria trigger the immune response, but the destruction is caused by the body's own defense mechanism.
Tip #3 ... Start cleaning in between
People who brush their teeth everyday can't understand how they developed gum disease. They tell you they're brushing hard and often. Isn't that enough?
You and I know that periodontal disease begins between the teeth for several reasons. Interdental areas are more prone to infection than facial and lingual surfaces simply by the anatomy. Tissue in the "col" area under the contact is not keratinized like tissue found on the facial and lingual surfaces. This non-keratinized tissue is much more susceptible to breakdown. It's also a very protected area, not reached by brushing or rinsing.
As the most susceptible area, it only makes sense that daily cleaning would start between the teeth. However, years of hearing about toothbrushing have most people cleaning facial and lingual surfaces but not interproximal surfaces. Just look at the marketing figures for how much is spent on toothbrushes and toothpaste compared to dental floss and other interdental tools.
Often our instructions to patients reinforce the myth that brushing is more important than cleaning between the teeth. Brushing instructions often precede any instructions for interproximal areas. Getting the brushing right seems to be number one, with interproximal cleaning always taking second place. Since the disease starts between the teeth, doesn't it make sense to start cleaning in between and then brush? Try this. Next time you see patients with generalized interproximal bleeding, tell them to stop brushing. Then tell them that instead they need to put all their efforts into cleaning between their teeth. Sometimes it takes a dramatic statement to get someone's attention. Don't worry, people are in the habit of brushing — after they've cleaned between their teeth they will pick up the toothbrush. Even if they didn't brush and only cleaned between their teeth, the areas most at risk would be addressed rather than the areas of least risk.
Tip #4 ... The toothpick self-test
Here's another easy way to change the focus from facial and lingual to the area at most risk – between the teeth. It's a toothpick test that can be done in the office or at home as a self-test. It's called the Eastman Interdental Bleeding Index (EIBI) as researchers at the Eastman Dental Center in Rochester, N.Y., developed it in 1985. All you need for the test is a triangle-shaped wooden toothpick such as the J&J Stim-U-Dent™ or the Butler Go Between™ Sticks. Simply insert the toothpick into the interdental area from the facial aspect. No need to go from the lingual as the stick will be effective from just the facial. Keep the toothpick perpendicular to the long axis of the tooth and move it in and out four times. Look for bleeding within 15 seconds on either the facial or lingual and record those points. For someone with 28 teeth, there are 26 facial and 26 lingual interdental sites to check. The goal is a score of zero. Bleeding in all possible interdental spaces would be a score of 52.
Researchers at the Eastman Dental Center evaluated the accuracy of this screening test compared to the traditional bleeding upon probing approach and found both methods comparable. Surprisingly, the EIBI is more reliable. The uniform pressure exerted across the col area with the toothpick seems to be more reliable than the traditional bleeding on probing method. Use of the probe can be influenced by probe size, location, and, most importantly, pressure. With enough pressure, even healthy tissue will bleed. The EIBI has fewer variables to influence results and reports a low frequency of false positives. This quick and easy toothpick test is a very reliable indicator of disease.
Linking infection to each bleeding point puts it into perspective. Instead of a few 4 mm pockets and some bleeding and inflammation, tell your patients they have infection at each bleeding point. It's much more impressive to have 23 areas of infection than 23 bleeding points. Pick the words that will be sure to get your message across quickly and easily.
Tip #5 ... Suggest alternatives to dental floss
Despite our traditional allegiance to dental floss, the number of people who actually floss daily is very low. Depending on the research study you read, it's between 5 and 35 percent. This is self-reported daily flossing so accuracy depends on honesty. We can't be sure those who said "yes" were telling the truth or telling the researchers what they thought they wanted to hear. Even more surprising is the ineffectiveness of floss to remove interproximal plaque, especially for people with periodontitis. In these cases, the use of interdental brushes and triangular wooden sticks is more effective than dental floss.
Reduction in interdental bleeding is the true measure of effectiveness, not just removal of visible plaque. Oral irrigation studies show dramatic improvement in pocketing and bleeding at interproximal sites in just two weeks. The cytokines associated with tissue breakdown are also reduced despite the presence of stainable plaque. The oral irrigation probably alters the biofilm and flushes toxins out of the sulcus in order to allow the immune system to heal the area.
It doesn't have to be dental floss. There are interdental brushes, picks, sticks, and oral irrigation that effectively control and prevent interdental breakdown. And for most people, they're all easier to use than dental floss.
Oral bacteria trigger a complex cascade of immune system events leading to breakdown of connective tissue and bone. Use the toothpick test for a quick in-office screening tool to identify areas of "infection" that need to be treated both in the office and at home. Choose from a variety of interdental cleaning tools to find just the right approach for each patient.
Discussing these five basic facts with patients is sure to improve the periodontal health of your practice and increase the dental awareness and involvement of your patients.
Trisha E. O'Hehir, RDH, BS, is a senior consulting editor of RDH, a sister publication of Dental Equipment & Materials. She is also an international speaker,author, instrument designer, inventor, and oral health detective. Her Web sites are www.perioreports.com and www.toothpastesecret.com. She can be reached at (800) 374-4290 or at [email protected].