Partners in Care

Why is the partnership between dental hygienists, general dentists, and periodontists so important?
Ms. Rethman: Dental hygienists are the preventive specialists. While our hope is to offer primary prevention for the individuals we see, often patients are in a diseased state when they come to us. We-dental hygienists-can alert patients and dentists when we see signs of early disease in the general practice. In fact, our general dentist colleagues frequently rely on us to provide feedback. Dental hygienists in the general practice also often establish a close relationship with a periodontist and his or her team. This open, inclusive relationship fosters better communication and, ultimately, better patient care.

When should a patient with periodontitis or other oral soft tissue problems be referred?
Dr. Rethman: A referral should be made whenever it is in a patient’s best interest. General dentists and dental hygienists ought to refer any patient with periodontitis who is under the age of 35 or any patient suffering from other oral mucosal problems such as lichen planus or pemphigus. Periodontitis patients who are over 35 usually suffer from chronic periodontitis and can sometimes be successfully managed in a general practice. However, these patients should be referred if they don’t respond well to therapy in the general practice.

What constitutes not responding well?
Dr. Rethman: A patient’s response to therapy is an important diagnostic tool in ascertaining what the next course of action is. Practitioners need to consider each periodontal site individually-at least when deciding whether to treat the patient in general practice or refer out. Too often, both patients and practitioners are lulled into a false sense of security by the average improvement in periodontal health that follows better oral hygiene and limited professional intervention. However, even if only one site is not responding well, ideally that site should be evaluated and treated by a specialist. One school of thought is that chronic periodontitis patients can be managed in a general practice until new attachment loss is noted (2 mm increase in probing depth and/or attachment loss) at several sites. Others think that a patient with continued signs of periodontal inflammation, despite good self-care and meticulous scaling and root planing, should be referred before any signs of additional attachment loss occur. The rationale is that these patients remain at some risk for attachment loss. Unfortunately, the first approach results in under-referrals, while the second approach results in over-referrals.

How do you handle patients’ concerns about seeing a specialist?
Ms. Rethman: When a referral is needed, explaining that the situation is best handled by a periodontist can help allay concerns, provided a relationship of trust has been established. Maintaining an ongoing, close relationship with the periodontist’s team is important also. In fact, make sure that your practice’s philosophy and the periodontal practice’s philosophy mesh. If there is discordance, find another periodontal team.

Are there better assessment tools available to make the referral process more straightforward?
Dr. Rethman: Improved statistical tools are now permitting careful re-assessments of data from large population studies. The results of these studies are the basis for commercial products that improve dentists’ and dental hygienists’ abilities to perform validated risk assessments. New assessment tools are now available. With such tools, general dentists and hygienists will be able to make better decisions and have objective reasons for doing so. No system is perfect, but this approach is an improvement over the inconsistencies and ambiguities of today.

Should dental implant patients be referred to periodontists?
Dr. Rethman: Periodontists are uniquely qualified to team with restorative dentists in cases where implants are the preferred choice. Implant therapy is often a better choice than the alternatives. For example, where a tooth supported 3- or 4- unit bridge is considered, one- or two-implant supported crowns may be a better choice-especially in comparison to the risk of preparing healthy teeth as abutments. Implant-supported mandibular dentures are much better than conventional full lower dentures. An implant can be a better choice than a complicated root canal. In patients with reduced salivary flow, which is a growing problem in our aging population along with it being a side-effect of many common medications, implants may be better than natural teeth because they don’t develop caries.

Who usually places implants?
Dr. Rethman: Generally, periodontists and oral and maxillofacial surgeons place implants. However, some prosthodontists include implant placement and more general dentists will be adding implant placement as time goes by. Indeed, many dental students are getting at least some exposure to these procedures while still in school and this trend will grow in the future.

Does the new information about chronic inflammation and systemic disease affect the referral process?
Dr. Rethman: Epidemiological studies suggest that the presence of chronic inflammation anywhere in the body can aggravate diabetes and may play a role in heart attacks, strokes, low-birth-weight deliveries, and serious lung problems in institutionalized patients. As periodontitis is a chronic infection and fairly widespread, it’s not surprising that the relationship exists. However, until intervention studies demonstrate that treating the periodontal diseases will favorably affect these systemic risks, the jury is still out. However in my opinion, the intervention data that exist for pregnant women with periodontitis appear strong enough to recommend that mothers-to-be should attain and maintain excellent periodontal health during their pregnancies. Even if oral health has nothing to do with pregnancy outcomes, when weighing the low risk of dental treatment and improved oral hygiene in comparison to the high morbidity associated with low-birth-weight deliveries, providing needed periodontal therapy is the obvious choice.

What is oral plastic surgery and what can it accomplish?
Dr. Rethman: Oral plastic surgery is the addition, removal, or modification of tissues to achieve optimal oral functional and esthetic outcomes. It is usually accomplished in close coordination with the restorative dentist. A few straightforward examples are the coverage of exposed tooth roots following gingival recession, removal of excess gingival tissue (and sometimes bone) to improve a gummy smile, and alveolar ridge augmentation to make pontics indistinguishable from natural teeth.

Ms. Rethman: In reality, these oral plastic surgery procedures are frequently performed. When I present my periodontal update program to dental hygiene audiences, they are often surprised to hear that pocket elimination surgery is not the most frequently performed periodontal surgical procedure. Of course, there will always be some patients who need pocket elimination surgery. But regenerative surgery, such as bone grafting, guided tissue regeneration, and enamel matrix protein is the focus today.

Why is the “team” concept so important?
Dr. Rethman: I believe that virtually every general practice in America ought to have one or more periodontists on its team. Such teamwork will improve patients’ health and well-being and make dentistry more profitable as well. Well-educated and motivated dental hygienists can play important roles in working to build these teams. This has been a key focus of my work with the American Academy of Periodontology over the years and I hope that increased involvement of periodontists with dental hygienists will produce even more benefits for patients in the future.

Ms. Rethman: Don’t forget the ever-important element of trust! Patients trust you to provide the best possible care or to refer them to someone with the highest skill level to treat them appropriately.

From Dimensions of Dental Hygiene. November 2004;2(11):30-31.