How to develop the protocol and partnership you need to succeed in periodontal diagnosis and treatment
Today there is more public awareness of periodontal disease than ever before, and the science linking periodontal disease to a host of systemic disorders (including diabetes, cardiovascular disease and pregnancy complications) is growing stronger at a rapid pace. Because of this, many health insurers who offer both medical and dental benefits are now offering enhanced coverage for periodontal therapy in high risk patients, as they find these expenditures are more than offset by the resulting long term savings in medical costs that stem from preventing general health problems. It is also unfortunately the case that failure to recognize and treat periodontal disease is one of the top five categories of dental malpractice claims in this country.
As the above information implies, periodontal diagnosis and therapy have never been more important in dental practice than they are today. The fact that the etiology of this disease process is multifactorial and its course can be a complicated one mandates that the generalist has a game plan to deal with this condition when it presents itself clinically. This makes the need for a comprehensive periodontal protocol in every day practice an imperative. Developing such a protocol can be difficult and confusing, especially in light of the recent guidelines by the American Academy of Periodontology that have been disputed by the Academy of General Dentistry. To resolve this contentious issue, I consulted with the two periodontists I regularly refer to and arrived at a consensus scheme that we all agreed would be sensible and effective in addressing the various periodontal disease states that might present in my general practice.
Developing a protocol
It is very important for all generalists, no matter what their proficiency in treating periodontal disease, to have an established and mutually beneficial relationship with at least one periodontist. In creating such a relationship, look for a doctor who shares the same philosophy of care that you do, one whose manner and communication style are compatible with yours as well as being up to date on different treatment modalities. In other words, look for someone who’s on the same page with you and who is also a dentist you would have no reservations treating you or a loved one. Such a peridontist will want to help you refine your own clinical acumen and won’thave any problems placing mutual patients on an alternating recare schedule between your office and theirs. He or she will also respect you enough to understand that you, as the referring general dentist, are the “quarterback” of the multidisciplinary team (that may include other specialists) treating your patient and your decisions must take precedence.
Having formed this relationship with a team approach, any such strategy must deal with all phases of treatment including; diagnostic procedures and parameters, oral hygiene education/instruction, initial therapeutic protocols (with the proper sequencing), use of adjunctive medicaments, recare frequency as well as criteria for specialty referral. Reassessment with specific benchmarks at each step of the process must be provided for in your system as well. Having such a reference to turn to in all situations promotes an efficacy and consistency of care that will result in the best possible outcomes for both patient and doctor.
Diagnosis
The best care begins with a thorough diagnosis. Only a complete understanding of the patient’s periodontal condition can lead to the right treatment plan and subsequently appropriate therapy. As has been often said in a multitude of different endeavors, you must begin with the end in mind. This means that the examining dentist must not only take into account the existing clinical conditions present, but also the most suitable treatment for those conditions and what the most likely prognosis will be, as well as how the anticipated outcome will affect any contemplated restorative planning. You must decide whether you think that phase I treatment will most likely solve your patient’s problems or whether periodontal surgery with any grafting can be expected. If so, will you be doing this or will you being referring this therapy out? Will pharmaceutical agents be helpful in a particular case? If surgery is anticipated in any event, do you want to do the scaling and root planning in your office first or will you refer the entire case to your periodontist. Having a trusted specialist with whom you have already elaborated a shared vision of care that you can consult on questions like these is an invaluable resource that no general dentist should go without.
All this must be decided as much as possible (based on your devised protocol) at the time of diagnosis and treatment planning, not as you go along. As has also been said many times about restorative dentistry, the doctor should not be treatment planning while holding his or her handpiece. Periodontal care is no different. The entire path of treatment must be carefully thought out before therapy begins. And once the plan has been formulated, its progression and rationale must be communicated clearly to the patient and the specialist, if one is to be involved.
Progressing without pain
Once active treatment in your office begins, it must be as atraumatic for the patient as possible. There are ways of doing this that have been described in the literature as well as methods that you will come up with on your own over time. In many instances, the first invasive treatment that a new patient in your practice receives is periodontal therapy. I believe that if this experience is one that makes my patient apprehensive of further invasive care, I have failed that patient, no matter what the clinical result. The periodontist you refer to should feel the same way as this goes back to philosophy of care and “being on the same page” issues. Your patients will want from the specialists you refer them to what they have come to expect from you. This is how the collaborative approach works best and also how trust is further earned from your patient when they understand that the referral was made with only their best interests in mind to a doctor who treated them as well as you have.
My philosophy of care has always been that if there is a specialist who can perform a particular aspect of needed treatment better than I, that’s where I will refer my patient. Having a comfortable relationship with a highly skilled specialist whose brain you can pick and whose care you can reliably depend upon when addressing periodontal issues is absolutely essential to general practice in my opinion. It will raise the level of care provided in your practice and the level of satisfaction that your patients have in your motives and judgment. Having a methodology in place that precisely outlines the steps necessary to achieve this quality of care can be obtained by taking a team approach where the generalist, the specialist and most importantly the patient all win. This is where the standard of care is headed today.