The ENDPOINT, the GOAL, the FOUNDATION upon which Periodontal Therapy is constructed is SUPPORTIVE PERIODONTAL THERAPY or SPT.
It is also called Periodontal Maintenance. I like the term SPT better than Periodontal Maintenance for the following reasons. First, Periodontal Maintenance sounds like something we do for patients, whereas SPT is describing an activity intended to support the patient’s efforts to stay healthy. Secondly, including the words periodontal therapy into the name is genius because it is also the general term we can use to describe all the elements involved in treating periodontitis. The point to the patient is that placing someone into SPT is simply moving them to a new phase of care in order to then maintain the health that was achieved through the phase we call Active Therapy. It’s useful to have a subtle reminder that there may come times in the future where treatment beyond the routine SPT appointment becomes necessary once again.
Since SPT is the destination of Periodontal Therapy, it is important that we establish what arriving looks like both for ourselves as well as for our patients. If we fail to clearly explain the parameters that give us confidence periodontal disease is being well controlled, patients will assume that whatever treatment we perform in Active Therapy will cure the condition and that they will then be able to return to the routine they followed prior to the periodontitis diagnosis. The problem with this thinking is that it sets the patient up for recurrence, which is not simply a return to what they once had. Because attachment is being lost off a root of fixed length, recurrence actually means irreversible progression, in the same way that recurrent caries takes away more tooth structure because teeth don’t regenerate themselves.
In working to understand the cause and progression of periodontitis, dental researchers utilize scores of testing methods. They might culture subgingival plaque or they might analyze bacterial DNA. They might create platforms from which to accomplish periodontal measurements in such ways to achieve even more accurate measurements. The list of research tools is almost endless. Some of these technologies are beginning to filter down to clinical therapeutics, but not many at this point. But let’s take a different approach, a practical clinical one.
To begin with, it is important to understand that periodontitis is such a common condition that expensive, time consuming or technique-sensitive tests are of little help in caring for all the patients who populate every dental office in the world. What we need is something inexpensive, simple and reproducible that is able to differentiate reasonably well between health/stability and disease/breakdown. Fortunately, we have one of the easiest tests in the world to perform. It requires a single inexpensive instrument and takes just a little practice and calibration to be completely proficient. (We will discuss this instrument in more detail in another post). The information we will obtain using this one instrument breaks out to provide us with the two parameters necessary to move patients in and out of periodontal treatment phases. The instrument, if you haven’t already guessed, is the periodontal probe.
I make my next statement as emphatically as I can.
Dental Practices interested in providing SPT for their patients need to commit to periodontal probing at every appointment. Probing around and getting a “feel” for the situation doesn’t cut it. In SPT we rely on a clear running record of measurements in order to effectively intercept sites beginning to break down as early as possible.
If you think this level of probing will be a hassle to implement then may I suggest you may be having trouble with patient retention.
Think of it from the patient’s perspective. If your office is dedicated to measuring and recording at every SPT appointment followed by analyzing current measurements with past measurements in order to detect and treat problems as early as possible, do you think many of your patients will debate for a second where they need to go for their continued care? What other dental office has their important information or carries the level of commitment for their health your office does?
On the other hand, if patients perceive that they are just getting a fancy cleaning at a tighter interval, then wouldn’t it make sense to many of them to shop around to see who can do the same thing for lower cost?
Also, if the periodontist’s office performs measurements and the general dentist’s office does not, and yet both charge essentially the same for the procedure (especially true if treatment is based on an insurance fee schedule), who do you think patients will want managing their supportive care? I am a strong believer that when patients lose the bond to their general dentists, care is not improved, it is compromised. Periodontists and general dentists must strive together to make sure this doesn’t happen. Communication between the two dentists is critical (more to say about this another time as well).
One quick observation that may facilitate periodontal probing in your office before I conclude this post. Usually it is best accomplished by two people, an examiner and a recorder. This moves the procedure along and reduces infection control hassles. Dental hygienists attempting to accomplish this examination by themselves need help and the savvy dental office will figure this out.
Finally, let me simply end this post by stating what the two parameters are. We will go into more detail about them soon, so stay tuned.
1. Bleeding Index under 20%.
2. No pockets greater than 5mm.
I’ll stop here and let you think about this. Please let me know your thoughts and if you have any questions, ask away. Until next time…