Episode 186 – Requested Replay: Perio Risk Factors

“We have to look at the foundational issue of periodontal disease in patients. I want to make sure if we build something, it’s on a good foundation.” ~Dr. Bruce B. Baird

I have said it before and I will say it again: it’s not your fault. Your patient’s periodontal disease is not your fault but, if your goal is to do exceptional work that lasts as long as possible, you have to start with the overall health of the patient’s mouth and their risk of periodontal disease.

Your patients’ periodontal risk comes from somewhere – their genetics, personal care, medicine, and dietary choices. Your job is to educate your patients and help them understand their oral health and continuing risk of disease if any work you do is going to last.

That’s the beauty of diagnosing risk factors: it gives you the tools to help educate your patients so they understand their likely response to your treatment and buy into making the best choices for their health.

Today, I’m going to share some tips and tricks I’ve learned over the years about diagnosing and communicating with patients about their periodontal risk, including:

• Understanding all the reasons a patient presents with perio-disease
• Sharing the “why” of periodontal risk with patients
• The importance of the phrase “Does that make sense?”

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EPISODE TRANSCRIPT

Dr. Bruce Baird

Hello, this is Dr. Bruce Baird, Productive Dentist Podcast, we’re going to talk today about periodontal risk. You know, in our last podcast we talked about risk factors in general and why I use them and why I think it’s changed everything about the way I think about dentistry. It’s literally changed my feelings about dentistry you know when you’re replacing things, that and you’re taking responsibility for it, and you’re doing it for free for not only is it costing you money, but it’s really not your fault. It was the patient’s fault but yet I just didn’t understand that. I always thought it had to do more with my margins and how much sugar they drank and well, God had pretty good margins and they drank sugar and it failed. So, you know, they didn’t brush their teeth and they had periodontal disease, they didn’t have it to start with, it came from somewhere and so when I talk about periodontal risk, I always use Well, several different analogies and I know John Kois does a program on each one of these risk factors individually and so this can be talked about for hours and hours.

I want to give you my overview of periodontal risk and what am I thinking when you know, what am I thinking about. As I go through the patient, and I always go through this these risk factors, Periodontal risk first, decay risk, you know, then functional risks, then aesthetic risks, then physiologic risks are when I added and then psycho risk, which we’ll talk about, so that we’re going to be doing that over our next six podcasts. So periodontal risk, you know, you have a patient that walks in, and they have six millimeter deep pockets throughout the mouth, have a lot of calculus and tartar, some stain built up. You know, what is that person’s risk factor? Are they high-risk? Are they low-risk? Many times in the seminars I’ll ask and people will say well, “Well, they’re high risk,” and my answer to that is, “Well, let’s look at all the information before we make a judgment on risk factors. What if this patient is 67 years old and has never been to the dentist in their entire life and has the six-millimeter deep pocket? Yes, they still have periodontal disease, no question, but how will they respond to that periodontal therapy and treatment? That’s their risk assessment.”

It doesn’t mean that they have it or don’t have it. It’s their risk for periodontal disease. The toughest patients I see are those who are 30 years old 35, 39,  42 that are coming in every three months for real care but are still having issues with the periodontal risk I will tell you, there are a lot of things that we do to treat periodontal risk. You know, patients come walking in, and again, they say, Well, I haven’t been to the dentist in five or six years. Well, during this recent fast risk factor assessment. I’ll say, “Well, we’re starting to lose bone around your teeth, Mary, and what we’re seeing, this is a bacterial infection, and not only that, this is an infection that can actually lead to a stroke or lead to a heart attack.” We know that it’s causative now, because of the research that Brad Bale and Amy Donini have done and some others, we know that it can be causative.

So how do I handle that with patients? Well, first of all, they’re either going to be a low-risk patient who comes in, they’ve got a little tartar, a little calculus, they’ve been going on six months. It’s not about how often they’ve been coming in for a week here. It’s the damage associated with that. If you have a patient that comes in and hasn’t been in fact I’ve years and has beautifully healthy gums and healthy teeth. What I tell the patient is, let’s get you in, we know that the bacteria can play a role but let’s do this every six months and we’ll do irrigation, we use the laser on low settings, this is going to keep you healthy. The truth is that that patient, I like to see them just in case at least find something else going on in your mouth and I’ll tell the patient, “You know, truth is you haven’t been coming in on a regular basis, but yet you’re doing a great job. In my own mouth, my suggestion would be to come in and get the irrigation and come get the laser. Pocket disinfection does that on a regular basis a couple of times a year, you’re never going to have problems. You know, if you continue to do that.” The moderate-risk patient is the one who misses a few recurs is getting additional pocketing, is having issues is not really committed to coming in and getting their teeth clean and they don’t really understand what this can do what we do know and I tell patients, “You know, your gums are like a turtleneck sweater. They fit around the tooth and it’s very interesting when you go in and probe.” You’ve had patients and you’ve been to dentists before where they’ve said, Do you have one millimeter, two millimeters? They call out these numbers? Four, five, what are those mean? Did they ever explain that to you? 99% of the time you say no, not really. I just knew that the bigger the number, the worse it was. Yeah, well, here’s what happens. It may take you, you know, you’re 51 years old. Now. You know, it may take, oh, when you were 28 or 25, you may have had pockets that were two and three millimeters deep and it may take 25 years or 30 years. For that pocket, the gums get puffy. Most of the time, it’s the puffiness of the turtleneck sweater that starts to deep in the pocket, not the loss of bone until you get to where the number is five when it gets to be four and a half to five millimeters deep.

That’s when I start waving a red flag why do we do that? Well, because the environment goes from what we call an aerobic environment where there’s oxygen to a place where it’s an anaerobic environment, you may or may not have ever heard those terms but anaerobic, there’s no air. So the bacteria that are living in your mouth under the turtleneck sweater, they start to change and when it gets to be five millimeters deep, that’s the stuff that starts to produce toxins that kill bone cells, and you start losing bone and that’s what we’re seeing now we’ve gotten to where it’s six and seven, even some eights and nines or whatever. When it gets to eights and nines, I’m talking about the high-risk periodontal patient, in particular, if they’ve been coming in on a regular basis.

So when these different types of bacteria, the facultative anaerobes, the spiral case, I’m not talking to patients about this, but all of a sudden, we start to see bone loss, we have got to treat this we have got to get you back into good health because we know these bacteria in the 5, 6, 7 and eights and nines can cause a heart attack or a stroke. Patients go oh my gosh, I’ve heard that. What can you do? Well, we have several things that we do. Our hygienist, our experts, if they haven’t been in a long time, they may be we’re gonna get do what’s called deep cleanings. I don’t really go into scaling and root planing, I actually just call it our gum treatment program and our gum treatment program, we use medication under the gums, and we use the laser on pocket disinfection.

This is the latest state-of-the-art stuff that you can have done anywhere and what we want to do is we want to kill those bacteria it may take four or five visits for us to get that done but then it’s going to be a matter we want to keep you coming in. Maybe it’s three times a year, maybe it’s four times a year, but we’ll help you determine what that time frame should be. It may get to a point where you’re doing such a good job we just need to see you a couple of times a year. I don’t fall to the old story that oh yes, just because you have periodontal disease, you’re going to have to have this done. I’m going to have to see every three months now, if you start following the recommendations and following the treatment that we’re talking about, there’s a great chance that you can get on another type of recall but we’ve got to get your gums healthy.

We’ve got to get you healthy because this is a reflection, we know that it affects the rest of your body. Does that make sense? And I always ask the patients what makes sense. They’ll say, “Well, no one else has ever really explained it to me that way. Yes, when can we get started?” What about that patient that has the eight-millimeter deep pockets and they’re, you know, got stuff going on throughout the mouth? Well in those patients. I’ve been doing a map surgery using the perio leis, I love the perio lace. I think it’s an amazing tool. There are other companies out there that make lasers I like the Fatah laser the light Walker, I think it’s because I don’t have one.

I have their diodes. I have three of their diodes. I think they make an amazing, they’d make amazing lasers but I do know that the period laser is what I’ve been using and I’ve been using it now for I don’t know 15 Six 13 years. When I first started using it, I think there were like 50 or 60 of them in the country. Today, there are probably 2000 that are out there. When I started there were no periodontists using it. Except for one, I think maybe two. Today, you know, eight out of 10 dentists who have gone through training are now a periodontist. It took them a while but they realized that Laser Periodontal Therapy does work LANAP, laser new attachment procedure, which is the term that the Millennium company has, has a kind of trademark law map surgery, I know it works, I know that I can get patients to go from a 10 millimeter to five millimeter deep pockets are forced by growing bone and by shrinking tissue. It’s not a typically reposition flap anymore.

I don’t know, maybe there are some indications for that but I want the gums to stay I want to grow new bone. Another interesting part about this is this risk factor of periodontal risk when I’m doing periodontal surgery and how it is associated with functional risk where patients are hitting too much does that have a relationship to the bone loss I’ll tell you it has an amazing relationship. I use a T scan on every single periodontal patient for that I do perio surgery I use a T scan on never made sense to me how the Musial pocket of 19 can have a deep pocket of nine millimeters and the distal pocket of nine if it’s a bacterial infection has a four. You know, it seems like the bacteria wouldn’t care whether it was mesial or distal. If the bacteria wanted to eat up stuff, they’d go all the way around the tooth but it’s not the way it is. It’s not what we see clinically but guess what I see clinically when I’m using the T scan, guess where they’re hitting muscle buccal cusp of 19-way excessive. So we do an Aquila abrasion, I try to get their teeth where they’re all hitting properly. I also recommend that periodontal patients have occlusal guards. So there’s a big connection between periodontal risk and other risk factors as there are with every risk factor and other risk factors.

So there are some people that you know have no periodontal problems, great. You know, there are some that have moderate problems the moderate usually go into our, our four or five appointment gum treatment program, we get them using, you know, some type of electric tooth toothbrush, some love the sonic cares, some love the oral B’s, I just know that the electric toothbrushes, you know, the automatic toothbrushes, do a better job of cleaning than the just a manual brush.

We all have patients who do everything, and we all have patients who floss and brush and use Waterpik I recommend all those things but flossing when you have deep pockets. Yeah, you know, maybe that’s not the best thing to do when you have deep pockets is go around and take bacteria from one area and put it in other areas. The final thing that we’ll talk about is DNA testing, we DNA test our patients to find out what kind of bacteria load we have. There are over 800 different bacteria in the mouth and we know that there are five in the bail Dynein treatment and the kind of protocol that we’ve used, isn’t there five really pathogenic bacteria. You know, they’re the ones that cause most of the overall health problems that we end up with the increased risk of stroke, increased diabetes, and increased risk of a heart attack. So there’s a lot of studies on that and so what we do, you know, people we do DNA testing, and so we test for oral pathogens. We did it on myself, and this is when the research first came in from bail Dynein we did the research. I mean, we did the research and I read it, I was like, “Oh my gosh, I’ve had a few heart problems. I’ve had some issues, I’ve had some periodontal pocketing. I want to know what kind of bacteria I have.” So, you know, we did the testing, and found out oh, my goodness, not only did I have one of the five bad pathogens, I had all five. What did I do myself? I went through and had surgery, I had my partner and went ahead and had surgery.

Why because I believe I believe in what they’re talking about. I also went through and use medications. We use antibiotic therapy with the gums that we’re going to do an entire podcast just on that method of treatment in the future. So hopefully this has been, you know, beneficial to you. Hopefully, you see why we have to look at this foundation issue.

You know, we knew that in dental school, always look at the gums first, always look at the foundation. First, I tell patients, it’s kind of like me being a builder, I always want to make sure if we’re going to build something, it’s on a great foundation. Once you have that great foundation, then you can move to the next, the next step, which might be restorative type things with decay or erosion, those kinds of things, and I’ll talk about kind of how we talked to the patient about that in future episodes, but remember, the gums are like a turtleneck sweater, you know, it may take 20 years for it to go from a three to a five, but to go to a five to 10, it might take five years. It may take three years because the bacteria have become really bad bugs and it’s time to do something. So look forward to our next episode together. Lux not by chance.

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