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Finally Treating PerioMessage Board, page 8

May 2014

Perio Reports Vol. 26 No. 5 page 1

Feature Creating a Perio ProgramPart 2, page 4

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Mothers share many health outcomes with their chil-dren. This is due, in part, to shared genes, shared social envi-ronment and shared health knowledge and attitudes.Mothers also share oral bacteria with their children. Specificstrains can be identified in both mothers and their children.Mothers with high salivary levels of mutans streptococci (MS)are more likely to have children with MS colonization.Mothers of children with caries are also more likely to havehigh MS levels.

Researchers at several universities in California partici-pated in a long-term observational study of mothers andtheir children. Mothers were entered into the study duringtheir second trimester of pregnancy in a community clinicnear the U.S./Mexico border. Mothers were 18 to 33 years

of age. Their saliva was tested for MS and lactobacillus (LB)during pregnancy and at four, nine, 12, 24 and 36 monthspostpartum. Clinical exams were also done at these timesplus a series of questions. The study included 243 mother-child pairs from low-income, Mexican-American families.

All of the mothers had experienced dental caries. Nearly60 percent of the mothers had untreated decay at all visits.At 36 months, 34 percent of the children had caries.Mothers with high levels of MS were likely to have childrenwith high MS levels as well. Mothers with high levels of MSduring the study were more likely to have children withcaries. Mothers with low levels of MS were more likely tohave caries-free children.

Clinical Implications: Mother’s oral healthand bacterial levels will predict early child-hood caries in their children. ■

Chaffee, B., Gansky, S., Weintraub, J., Featherstone, J., Ramos-Gomez, F.:

Maternal Oral Bacterial Levels Predict Early Childhood Caries Development. J

Dent Res 93:(3) 238-244, 2014.

Lower Right Lingual Most Difficult Area to Clean

Several authors have reported that the area in the mouthmost likely to be missed with toothbrushing is the lower rightlingual. This area is also reported to have the highest levels ofplaque and gingivitis, compared to other areas of the mouth.

In a clinical practice, the hygienist noticed many patientswith problems brushing the mandibular right lingual sur-faces. These surfaces had more plaque and more inflamma-tion than other areas of the mouth. It was decided to changethe pattern of toothbrushing to begin in this area.

Ten patients with puffy, swollen lingual tissue were invitedto participate in this Action Research Project. An intraoralcamera was used to capture images of both the right and leftmandibular lingual tissues. These images were shared with the

patient and the difference between the sides was discussed.Following their routine prophylaxis, they were given a newtoothbrush and instructed to brush the lower right inside sur-faces first, before brushing the rest of the teeth. They weregiven a disposable mouth mirror and asked to evaluate the tis-sue for any changes after brushing this way for two weeks. Thehygienist either telephoned or emailed, per patient request,after two weeks to see if any difference was noted.

Of the ten patients who participated in this study, six patients reported improvement in the tissue color and no bleeding upon brushing or flossing. Three patients didn’tnotice any difference and one forgot the instructions anddidn’t make any changes to the brushing pattern.

Clinical Implication: Teaching patients to begin toothbrushing on the lower right lingual will effectively reduceplaque and inflammation. ■

Rogers, C.: Would Starting Toothbrushing on the Lower Right Lingual Reduce Tissue Swelling from Inflammation? OHU Action Research 9A-13, 2014.

Perio Reports Vol. 26, No. 5Perio Reports provides easy-to-read research summaries on topics of specificinterest to clinicians. Perio Reports research summaries will be included ineach issue to keep you on the cutting edge of dental hygiene science.

Mom’s Oral Health Predicts Infant’s Oral Health

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Xylitol Baby Gel Used on a Denture Eliminated Oral Infection

Denture stomatitis is a common infection resulting in mildinflammation and redness under the denture. It is due to leav-ing the denture in the mouth rather than removing it duringsleep, poor oral hygiene and/or a compromised immune sys-tem. In 90 percent of denture stomatitis cases, Candida albi-cans is involved. Anti-fungal drugs are used but not alwayseffective in controlling these infections.

In this case study, an elderly man residing in a long-termcare facility suffered from severe denture stomatitis and angular

cheilitis. Because of the oralulcerations, he was unable to wear his denture verylong, eating was difficult,his mouth burned and helost his sense of taste. Anti-fungal medications had notremedied the situation.

The patient’s father was a dentist who wanted tofind a solution to this prob-lem. The hygienist sug-gested using xylitol off labelto control the infection.There were no contraindi-

cations, so the Spry Xylitol Tooth Gel was used five times dailyon the denture. After cleaning the denture, a small amount ofgel, the size of a nickel, was spread on the denture before insert-ing it into the mouth. The gel was also used on the corners ofthe mouth.

Within one week, the angular cheilitis was healed andwithin two weeks, the oral ulcerations were gone, which allowedthe denture to be worn all day. The patient was pleased with theoutcome. The patient’s quality of life was positively impacted ashe was no longer in pain and could eat comfortably.

Clinical Implications: Spry Xylitol Tooth Gel is an effectiveremedy for oral candidiasis associated with dentures. ■

Payne, J.: Is Xylitol an Effective Anti Fungal Treatment for Oral Candida Infections? OHU Action Research

9A-13, 2014.

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Reducing Mandibular Lingual Calculus Formation

Despite repeated oral hygiene instructions,patients return time after time with moderate toheavy supragingival calculus accumulating on thelingual of the lower anterior teeth. Two solutionshave been presented to reduce plaque biofilm andthe resulting supragingival calculus formation.The biofilm can be mechanically removed withdry toothbrushing on the lingual surfaces first.Blocking biofilm formation with xylitol use threeto five times daily will also prevent supragingivalcalculus formation.

Six patients with moderate to heavy supragin-gival calculus formation on the lingual of thelower anterior teeth were invited to participate inthe study. The two with the heaviest deposit wereinstructed to dry brush the mandibular lingualsurfaces first, before brushing the rest of themouth. They were then instructed to add tooth-paste and repeat the brushing. They were alsogiven 100 percent xylitol-sweetened gum andmints and told to use them after meals and snacks,five times daily. The second two patients wereasked to follow the xylitol protocol and followtheir regular oral hygiene. The last two patientswere instructed in the dry toothbrushing tech-nique. Subjects were examined two weeks later.

Both dry toothbrushing lingual surfaces firstand xylitol use five times daily effectively reducedthe supragingival calculus formation. Xylitol wasslightly more effective and easier to use, thus com-pliance was better. One of the patients wasn’tproperly placing the toothbrush on the lower lin-gual surfaces to effectively remove the plaque. Histechnique was corrected and upon further evalua-tion two weeks later, the biofilm and calculus wereeffectively controlled.

Clinical Implications: Both dry brushing andxylitol can prevent biofilm formation and theresulting supragingival calculus formation. ■

Anguiano, E.: Can Dry Brushing and the Use of Xylitol Mints and Chewing Gum Help

Reduce Supragingival Calculus Deposits? Action Research 9A-13, 2014.




Baking soda (sodium bicarbonate) has long beensuggested for toothbrushing and as a tooth whitener.Actress Julia Roberts reports following her grandfa-ther’s advice to brush with baking soda for a brightersmile. Sodium bicarbonate dates back to ancientEgypt. The ability of baking soda to neutralize acids

makes it an inexpensivehome remedy for full bodyissues as well as the preven-tion of dental disease.

Ten patients ranging in age from 20 to 60 yearsparticipated in the studyinvolving toothbrushingwith baking soda. At base-line they were screened for

hypertension, salivary flow, salivary pH, gingival tis-sue appearance and bleeding.

They were instructed to brush daily with bakingsoda instead of toothpaste. They were to put half ateaspoon of baking soda into the palm of their hand,wet their toothbrush with water and scoop up thebaking soda with the bristles and brush their teeth.They were also asked to add a teaspoon of bakingsoda to a glass of water to make a mouth rinse. Afterrinsing, they were to spit out the baking soda watermix and not rinse with water. They were given pHstrips and asked to record the pH of their salivaupon waking up each morning and to record it onthe form provided.

Patients returned one to two weeks later. Thegroup showed reduced pH scores over the test periodand also reduced bleeding and signs of gingivitis.Patients reported their mouths felt cleaner.

Baking Soda Elevates pH and Reduces Inflammation

Blood Test Screening for Diabetesin the Dental Office

Many people have diabetes and don’t know it. Accordingto the CDC, in 2010, 25.8 million people or 8.3 percent ofthe U.S. population had diabetes. Within this number, theundiagnosed cases account for 7 million or 21 percent ofthose with diabetes. Early treatment is essential to preventingserious complications including kidney failure, blindness,heart disease and stroke. Periodontal disease is also a risk fac-tor for those with diabetes. Screening for diabetes in the den-tal office may provide an opportunity for early intervention.

Researchers at the University of Buffalo in New Yorkscreened patients for signs of diabetes in 11 general and peri-odontal practices and one community clinic in Providence,Rhode Island. Patients were asked a series of diabetes riskquestions and given an HbA1c finger stick blood test. Scores

of 5.7-6.4 indicate pre-diabetes, 6.5 or greater indicates dia-betes. Patients with scores of 5.7 and higher were referred bythe dentist to their physician for a definitive diagnosis. Atotal of 1,022 people 45 years and older participated in thestudy. Half of those tested at the community center were athigh risk for diabetes, compared to one-quarter in privatedental practices. Community clinic patients were more likelyto follow up with their physician than those seen in privatedental office. Twenty-two percent of those referred by thedental office actually went to the physician compared to 79percent from the community clinic.

Clinical Implications: It is feasible to screen for diabetes and pre-diabetes with the HbA1c finger stick blood test.Follow-through on the referral to a physician may be a problem. ■

Genco, R., Schifferle, R., Dunfor, R., Falkner, K., Hsu, W., Balukjian, J.: Screening for Diabetes Mellitus in Dental Practices. JADA 145:(1) 57-64, 2014.

Clinical Implications: Baking soda is an inex-pensive and readily available product for elevat-ing salivary pH and reducing inflammation. ■

McKenzie, S.: Will Sodium Bicarbonate Change the pH Levels of Saliva and Reduce Gingival

Inflammation? Action Research 9A-13, 2014.



hygienetownperio program feature

Getting the conversationgoing between the dentist

and hygienist and discussing periodontaltreatment philosophy

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How healthy are your patients and how healthydo you want them to be? Answering these questionswill provide the basis for discussing the oral healthphilosophy of the practice. This is the focus of oursecond in this series of articles on Creating a PerioProgram for Your Practice. Getting the conversationgoing between dentist and hygienist is often the hardest step in this process. We asked clinician andperiodontal therapist, Diane Brucato-Thomas, andconsultants Sarah Cottingham and Jamie Marboe forinsights on how to get this conversation going andwhat questions to ask.

Diane Brucato-Thomas, RDH, EF, BS, FAADH: The first step in getting this conversation going

with the doctor is to identify common values or goalsby asking questions. These questions are not easy, buthelp to clarify head and heart. Actually, they are goodquestions for the whole team. If the team approachesthese questions together, a common vision for the prac-tice will begin to emerge. The idea is to identify whatis most important for the dental practice. You mayhave a good idea that is really important to your doc-tor just by comments made on occasion. Getting thedoctor to voice what is important and building the dis-cussion around those values will go a long way in advo-cating for change.

Often a common value or goal is optimum dentalcare. This is the doctor’s practice and his or her reputa-tion depends on providing optimum dental care. Byproviding an evidenced-based periodontal program,win-wins are created for everyone across the board.Excellent periodontal health as a foundation lays thegroundwork for all restorative work to follow. The doc-tor’s preps will be better if the tissue is healthy, as wellas the quality of the impressions. So the client receivesbetter quality, longer lasting dental work for theirinvestment. Successful business follows a good reputa-tion. That discussion alone can be very convincing.

Adding further discussion about the financial ben-efits in terms of production resulting by incorporatinga periodontal treatment program as a successful profitcenter for the practice will sell itself. Even with all thegenuine caring in the world, the bottom line for a den-tist must point to financial success for the practice as awhole, or the practice will fail.

Exactly when this discussion should occur reallydepends on the doctor’s style of practice. In one prac-tice I worked in, the doctor was a genuinely nice guy,who bought the practice from an elderly dentist who

had retired. He was afraid to tell people that they hadrecurrent decay or periodontal disease for fear of los-ing them. He did not hold team or staff meetings, soI talked with him before work one morning. I basicallyasked him to trust me and support me by not undoingmy communications regarding periodontal diseaseand dental treatment, and “just see what happens,”because hesitating to speak about their need for treat-ment was not serving anyone in any way. He did andI tripled the hygiene production in one month. Inaddition, his production skyrocketed, because hebegan providing much needed care. The patients?Well, they loved him!

In another practice, the discussion took place at aseries of team meetings, before I was even hired. As theteam began to vision the potential of care that could beprovided, the dental hygienist actually invited me in,because she did not feel comfortable providingadvanced periodontal care. An ideal team was createdand I was able to provide advanced conservative peri-odontal therapy within a general practice setting.Meanwhile my “hygienist partner” provided regularpreventive maintenance for healthy clients. The doctorenabled the team to buy into creating the vision, andin turn, the entire team supported the program withthe clients. This practice had an exceptional whole-per-son, values-based, team-centered approach to their phi-losophy of care. The practice was dynamic, because thedoctor valued the opinions of his team members andtruly cared about them and the clients, like an exten-sion of his family.

Obviously, not all practices are like this. As pointedout by the late, Avrom King, dental management guru,the important thing to realize is that “when they areready to hear the next message, they will hear the nextmessage, and not a moment before!” If they are ready,as the two doctors highlighted above, the sky is thelimit in terms of quality periodontal care. On theother hand, the doctor may never be ready to hearwhat you have to say. In that case, it is time to under-stand that sometimes, the only way to change theirminds is to “literally” change their minds. With a doc-tor or practice setting that is closed to change, the bestanswer may be following my mother’s advice: “This orsomething better!” The right practice for you may besomewhere else.

Sarah Cottingham, BCS Leadership: As a consultant, I have the advantage of setting up

a meeting between the dentist and the hygienist. The




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trick is to get the conversation started and flowing inthe direction of developing a periodontal treatmentphilosophy. The first thing I do is ask each one towrite down on a piece of paper their drop-dead crite-ria for treating periodontal disease. When they havefinished, I have them exchange papers and see whatthe other person wrote, then tell me the other person’scriteria for treating periodontal disease. Many timesthe hygienists will list two criteria: 5mm or 6mmprobing depths and bleeding upon probing. The den-tists are generally more aggressive with 4mm to 5mmdepths, bleeding upon probing and radiographic cal-culus, plus other issues. This opens the door for dis-cussion of the criteria and why they would be used.

I ask them if radiographic calculus is needed forperiodontal disease to be present. Not necessarily andthis moves the discussion to the goal of reaching a bio-logically acceptable root surface and what that meansto each of them. At this point I ask them to review theAAP Guidelines for Classification, especially the fineprint relating to localized versus generalized and slight,moderate and severe. Slight being defined as 1mm to2mm of clinical attachment loss. Going back to thebasics is the key! Ask the team loaded questions like:

• What would you do with a patient that has a4mm pocket?

• What if the patient was also bleeding?• What if there was 3mm of recession?• What if the patient had a Class I furcation

involvement?• What if the tooth had Class I mobility?The point is to open up the discussion to the fact

that most hygienists are not consistently document-ing the complete periodontal condition. They will allsay that the tooth requires treatment based only onprobing depth and bleeding.

The big question then is why is there a problemdiagnosing periodontal disease with clear-cut guide-lines to follow. Where is the hygienist getting the ideathat 5mm depths and bleeding are the criteria to beused? It may, in fact, be the front office staff that haverelayed this based on a particular insurance standard,not on diagnostic criteria. A mindset of asking “why”will move the discussion forward and help the dentistand hygienist come together on a practice philosophyfor treating periodontal disease. We have found thatonce the philosophy is established in the practice and

the team understands the “why” and the “how,” get-ting the insurance companies to pay is quite simple.

Jamie Marboe, RDH, BS, Inspired Hygiene: Our consulting firm generally works with offices

with multiple dentists and hygienists. To get the con-versation going, we find it’s good to get all of the doc-tors and hygienists to sit down together and have adiscussion regarding the team perio protocol. We wantto create, as a team, a clearly defined hygiene perio pro-tocol. In order to accomplish this we ask everyone tocome to the meeting with an open mind in an effort tooffer our patients the very best care they deserve.Explain that there will be no “good cop, bad cop” orfinger pointing during this conversation. It is purely touncover some of the obstacles that may be keeping usfrom having a solid system in place. We make sure thatthe discussion stays safe and that everyone is encour-aged and comfortable with discussing their philoso-phies, possible apprehensions and viewpoints openly.

We schedule plenty of time for this initial discus-sion. It doesn’t work squeezing it in during lunch orbefore work, taking a chance on running late or out oftime. Block out enough time to allow for a thoroughdiscussion. This process may need several meetings tocreate the perio protocol and system.

Key things to be discussed in the initial meetinginclude: Where are we now compared to the AAP’sperio percent? What is working and what is not?Discuss core philosophies and identify obstacles. Makea list of these items discussed and find solutions to theobstacles and what’s not working. Decide why it’s notworking. How do we correct this or do we simply needto eliminate it? The team needs to agree on what levelof disease to recommend various treatment options.

We emphasize to our teams that they all get to pushthe reset button and move forward as a team, helpingeach other be accountable with staying on target withthe new perio philosophy.

The Next StepWith the conversation started and the practice

philosophy developing, it’s now time to focus on thethird step, creating the perio program with details forinsurance codes, treatment options, fees, times andproducts. Look for this in our next installment in theJuly issue. ■


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hygienetownmessage board

docbruce Member Since: 06/20/09

Post: 1 of 11

KonarockyMember Since: 10/08/05

Post: 2 of 11

LindadouglasMember Since: 06/09/06

Post: 3 of 11

Ann Thresher Member Since: 05/11/06

Post: 6 of 11

I am very impressed with the knowledge and professionalism on this board. It’s refreshing toread how much you all care for your patients and of your desire to provide the best possible treat-ment to them. That being said, a little background: I’m a general dentist who practices with anolder dentist. I merged my smaller practice with his larger one and I would really like to diag-nose and treat more perio. We have four hygienists, two per day Monday through Thursday.

My partner is “old school” and more than 90 percent of hygiene is comprised of D1110swith a little perio maintenance. I know there are tons of undiagnosed perio disease amongour patients. We recently had a hygienist retire who had been with the practice for more than25 years. I think for the past few years, she was just “marking time”—very little, if any,patient education going on, just crackin’ tarter, suckin’ spit and “see ya in six months, hon.”

Thankfully, we hired an experienced hygienist who is really motivated to take great care of thepatients and she and I have had a few discussions about addressing the widespread need to step upthe diagnosis and treatment of perio. We are both concerned about the best way to approach thepatients regarding their perio needs. We’re worried that the patients will respond with, “I’ve beencoming here every six months for years to see (retired hygienist)—why do I have this problem?Why has nobody (including the doctor) ever told me about this?” On my side, no new patient isseen in hygiene first. I do a comprehensive new patient exam, so the concern is really the patientsof record. Two of the hygienists are motivated to be better; the other two really resist change.

I know there is a lot of experience among all of you, so I welcome your suggestions ofhow to get us out of the “prophy palace” and into a hygiene department that really wants tohelp our patients move toward health and away from disease. Thanks for your input! n

Unfortunately, there is no easy solution to inform recall patients that they have activeperio when they have been receiving bloody prophies for many years. Here’s what I often do.Recall patients often fail to do two things: maintain the recommended recall interval andfloss daily. If I have a patient in my chair who has mediocre homecare and hasn’t been seenin nine, 10 or 12 months, I just present to them what I see and emphasize the reasons whyinadequate homecare and not maintaining recommended recall interval can lead to theirpresent condition. If they ask about the previous dentist or hygienist, I just say, “I don’t knowwhat they saw X number of months ago. All I can say is what I see today.” n

Great post, Mark. This is the approach I use also. It is tough to inform the patientwhat is happening without throwing your predecessor under the bus; this is a good wayto handle it. n

So many good ideas here! The only one I could add would be the fact that perio isepisodic in nature. I would say to them, in other words, there are times the disease is quietand times when it is active. Sometimes after an active episode, more bone loss is evident on

Finally Treating PerioHow do you change the way your practice handles perio?

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hygiene and preventionmessage board

HippychickMember Since: 08/03/07Post: 9 of 11

bajt1987Member Since: 06/22/09Post: 10 of 11

the radiographs...this is what we see here today along with all this bleeding in the gums whenthey are touched by our measuring stick (perio probe) and our instruments. Then of course,you explain healthy gums do not bleed when you measure for pockets, etc. Good luck—soglad to hear of your enthusiasm to help these people. n

I feel all the advice given from the other responses is great! One thing to remember isthat at times patients can be within normal limits then in six months they are bleeding likecrazy! Many times stress, health changes and medication can make a negative impact intheir periodontal health. One can start off the conversation by telling them what yourfindings are, then ask has there been any changes in their health or stress level? Many timesthe answer is, “Well, yes!” n

We have made the decision in our practice to be more proactive in treating periodontal dis-ease. We have always treated the severe cases, but often the slight-to-moderate cases have simplybeen “prophys.” Our doctors provided us with several continuing education classes over a year, sowe used that as our springboard. We tell our patients that we are always learning new things, andmade a decision in our practice to change the way we are treating periodontal disease. We discussthe benefits to their overall health. For the most part they have been very receptive. We are also see-ing many new patients who have come to us because their dentist retired—he did not treat periomuch at all, so we basically use the same approach. Even though periodontal disease has beenaround for a long, long time, new treatments and products come out all of the time. We tell themwe never stop trying to improve on the care we provide our patients. Good luck! n

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Prophy Palace

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