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Second Opinion: The New Aggressive Attack on Gum Disease Chris Kammer, DDS

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The New Aggressive Attack on Gum Disease
– Chris Kammer, DDS

Second opinions are common in health care; whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dental professionals to share their opinions on various topics, providing you with a "Second Opinion." Perhaps some of these observations will change your mind; while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession. — Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine
Bleeding gums were everywhere in my office and I couldn't take it anymore. My patients were diseased but believed everything was fine because our office would continue to see them for their routine six-month prophylaxis without making a big deal of their unhealthy gums. We would tell them to brush more thoroughly and to floss more often but the advice was conventional and commonplace; nothing they hadn't heard before.

They felt confident they were receiving good care and certainly didn't question a bit of blood after a cleaning. The dentist would surely tell them if something different needed to be prescribed. Wouldn't he?

I finally got so fed up with the bleeding that I set my sights on a new standard of care. What if our office had a zero tolerance for bleeding gums philosophy? What could we change to achieve this "Gums of Steel" ideal?

Instead of crediting the blood to sensitivity rather than disease, we would give the patients the real story on what was happening inside their mouths. We would give them the chance to rectify the problem by recommending therapies, home care and nutrition. The days of the supervised neglect (and financially draining) "chat and polish" were over. If the treatment of periodontal disease is what helps my patients to live longer, how could I have settled before for less?

Change is hard though. Especially when I had instilled in my patients that a little bleeding was normal. I never told them the inflammation and infection may shave years off their lives. It's hard to take back this kind of casual attitude once expressed about bleeding gums and still keep the confidence of patients. How would they take the news of going from a clean bill of health to six months later needing a thousand dollars' worth of perio therapy? In order to practice state-of-the-art dentistry I knew it had to be done. My staff and I transformed my practice, and I would like to share with you the strategies we used to get over some of the biggest hurdles of the process.

The Basics
A six-month prophy is defined as a preventative procedure according to the American Academy of Peridontology. A prophy is a procedure for normal, healthy mouths to keep them from becoming diseased. Therefore, if a patient already has gingivitis and bleeding, it is too late for the "preventive" procedure. Gingivitis is not normal and it is not healthy. However, in a National Institute of Dental Research (NIDR) study, more than 90 percent of persons 13 and older experience some form of periodontal disease. Most Americans do not have disease-free mouths, yet most Americans who visit the dentist continue to receive six month prophies… and that's wrong!

The NIDR also stated that if a person has supragingival tartar, chances can be as high as 90 percent that the person will have subgingival tartar as well. Although bacterial biofilm is the culprit of the disease, tartar and calculus must also be removed in order to treat it. When the disease is already present, a routine prophy is not enough to treat the bleeding gums. According to the American Dental Hygienists' Association, the definitive treatment for gingivitis or early periodontal disease is therapeutic scaling and/or root planning. The American Academy of Periodontology (AAP) and the American Dental Association (ADA) allow for treating cementum and dentin in this way, when there is contamination with toxins and microorganisms. In other words, a person does not necessarily have to have tartar present or 4+ mm pockets to do root planing. They recommend performing root planing on all bleeding pockets, even those with depths less than 3mm.¹

Such a big procedural change is hard to implement, especially when everyone must be onboard to make the effort a success. If your team needs a supercharge for their enthusiasm, I recommend they view my "Gums of Steel" Intro Webinar,2 a zero-tolerance approach to bleeding gums.

Remember communication with your patient is key. Here are some helpful hints for the implementation of this approach:

Step 1: Start your patient's visit by asking questions. Get a feel for the attention he gives to his teeth and gums. What is your home care regime? What type of toothbrush do you use? How often do you brush? How about floss? Do you use a Waterpik? Explain the way your office formerly addressed gum disease and explain the change. Make clear it is both the office's responsibility to treat it and the patient's responsibly to adjust his home care.

Step 2: Perio-chart the entire dentition. I have found communicating the presence of bleeding, and what it means, is practically the only thing you need to do to convince patients of a serious problem.

Step 3: Take an intraoral photo or two of the most significant areas of bleeding and let the patient have a visual of the problem. If this isn't possible, use a hand mirror. Remember the blood can rapidly disappear so make sure the patient doesn't swallow, close his mouth, or touch the area with his tongue until he can view it.

Tell the patient you have been monitoring the condition of his gum tissue for a while now. At times, it seemed as if he were keeping things under control with his home care and regular visits. However, today you are seeing significant disease and bleeding, which would not occur in a healthy mouth.

Questions to ask: Has anything changed in your life in the last six months? Is your irrigator broken? Are you under more stress than usual? Have you been ill? Are you flossing less? Most often the patient will give you the reason for the disease that is present.

Make sure the patient understands that healthy gums do not bleed and unhealthy gums can lead to other health problems throughout the whole body. Complete the rest of the clinical exam and make a diagnosis.

Step 4: Give the patient a handout on periodontitis produced by the ADA or your state dental association. Also, give him mainstream media reports, which relate the link between periodontal disease and other serious diseases of the body (e.g. heart attack, stroke, diabetes, cancer) These articles have appeared in Reader's Digest and Consumer Reports, among others. Send him to www.zt4bg.com to view studies. You'll find many patients are already aware of the mouth-body connections and the germs present in the mouth, which can spread throughout the circulatory system.

Step 5: Communicate the need for treatment. Explain how your nonsurgical perio therapy involves going below the gum line to remove the toxins, which are causing disease. Clarify that the usual six-month cleaning is designed for healthy mouths and does not address the therapy needed below the gum line. Relate that the goal of the approach is to eliminate the need for more extensive surgical treatments later.

Step 6: Layout treatment options. Fees can be discussed by the appropriate team member after the patient accepts treatment.

Step 7: If the patient consents to treatment, start with an ultrasonic subgingival scale of the entire mouth. Although you shouldn't typically need anesthesia for this procedure, make sure the patient is comfortable.

The subgingival biofilm can be broken up nicely all the way around the tooth with this method and it does not tear the gums. There might be blood, but this will decrease with subsequent ultrasonic therapies. Using the ultrasonic is diagnostic, as well as therapeutic since healthy gums shouldn't bleed during treatment.

Step 8: Reschedule the patient if time doesn't allow treating the entire mouth; however this process goes relatively quickly when pockets are not deep and there is very little tartar. We treat the entire mouth because the ultrasonic may elicit bleeding in areas the probe may not have elicited.

Schedule the patient for an ultrasonic of the entire mouth again (at no additional charge) in a month. Make sure the patient doesn't leave without explicit instructions on home care and the tools to get his disease under control.

Step 9: If your patient declines treatment, have him sign a release form. Let him know any restorative treatment he may have in the future cannot be guaranteed until the underlying infection is eliminated.

If the patient is hesitant about the four quads of perio therapy, you do have the option of still performing the prophy and then requiring him to return in 30 days for a bleeding check to see if he is able to get the disease under control. If the bleeding is still present, which it will likely be, reiterate that the disease is still present and needs the recommended therapy.

Conclusion
It's time to stop gingivitis, bleeding gums and early perio disease in America. The correct treatment calls for comprehensive periodontal therapy. Have a zero tolerance for bleeding gums in your office and help to change America's embarrassing statistics regarding gum disease.
Author's Bio
Dr. Chris Kammer is a founding member of the American Academy of Cosmetic Dentistry and the Masters of Progressive Dentistry lecture series. He has been a dental expert for USA Today, Reader's Digest, Fox News, NBC's Today Show and CNN. He trains dentists to be in the media through his Dental Media Power seminars. He is holding the founding meeting for the American Academy for Oral Systemic Health in October. For information on Chris Kammer's "Gums of Steel" Hygiene Transformation seminars and coaching visit www.gumsofsteel.com. Contact Dr. Chris Kammer personally at drchris@thesmileexperts.com.
Dentaltown Magazine
April 2024
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