Assessment is the Key to Unlock Your Periodontal Toolbox

You're listening to the Phil Klein Dental Podcast. As individuals, each of us have a unique set of oral health needs. These needs are influenced by a myriad of factors, including our age, medical history, dental history, lifestyle, and genetics. And because of this, oral health assessments are pivotal in both diagnosing existing issues and in crafting preventative strategies to maintain long-term oral health. To talk about the oral health assessment in more depth and give us some super practical recommendations is our guest, Kerry Lepicek. Kerry has over 20 years of clinical experience as a registered dental hygienist and continues to work part-time in a clinical setting. She is an international speaker, a published author, and serves on the advisory board of the American Academy of Oral Systemic Health. Kerry, it's a pleasure to have you on the show. thank you for having me i'm really excited to be here yeah we're very happy to have you and you know this is the beginning of an exam you're just meeting the patient and this assessment phase is just so important in guiding you throughout the whole journey for that patient It's like anything else. It's like building the foundation of a house. If it's not level, the rest of everything is just going to fall apart. So to begin this podcast, tell us why in your mind, because you've been doing this a while, the assessment phase, the oral health assessment is so important to everything that we do on this patient going forward. Just a general overview of the importance of it. I like your analogy of the house and that sort of foundation because I always use a roadmap. And how many of us go somewhere without looking at a map or even better now with Waze and Google Maps? It gives us that roadmap. It gives us that idea so we can avoid the traffic. We can avoid the potholes. And that assessment phase is that roadmap, is that destination so we can have the smoothest trip from disease to health with our patients. And so that's what really gets me excited about the assessment phase. Yeah. And the assessment phase. is also in some states, I believe, mandatory, right? For students like in kindergarten, as they start their K through 12 journey, don't they have to like see the school? I don't know if there's a school hygienist there or dental health consultant. Typically, tell me how that works as young as they are when they're supposed to have these assessments. Well, I know I practice in Ontario, so I'm from Canada. And so in Canada, we do have hygienists that come into the schools and do public health assessments and screen patients for disease. And so I know for us, it's throughout our years, there's usually a primary like a kindergarten screening and then middle aged and then encouraged later on. And this is just the easiest opportunity that earliest we can catch signs of cavities, decay, perio disease, the better we can help predict treatment. and have prevention and not long-term effects to their oral and systemic health. Right, yeah, getting this information ahead of time, getting a jump on the disease process is so important for sure. So reviewing a patient's medical history is part of the oral health assessment. So what kinds of things should we, as dental health care providers, be particularly aware of when reviewing the patient's medical history? So this is something I have become more and more excited about. And as I dive further into the connection, so when you're doing your health history, I no longer am just like, okay, do you have cardiovascular disease? Do you have diabetes? I want to know more. I want to know more about their HbA1c. Why? Well, we know that there's a connection between sugar levels and diabetes, but there's also a concern when that comes down to play with perio risk and even airway risk. And so when we're looking at our health history, we want to sort of think of how many boxes are checked off. The other thing I want to look at is blood pressure. We know we have an opportunity to screen. We should be doing hypertension screenings on our patients on a regular basis because we want to reduce the risk of having strokes. We want to reduce the risk of having harm. And this is our opportunity and our obligation, as far as I'm concerned, to be that screening. In Canada, 43% of people have undiagnosed hypertension. And maybe it is our screening and our opportunity that we can identify that risk for that patient and set them on the path of health. patients thank me when I start talking about this. They're first off shocked when I ask about sugar levels. They're like, well, what does the sugar level have to do with my teeth? And then I remind them of the connection and how uncontrolled diabetes can lead to further perioprogression or caries risk. And finally, I think when it comes to health histories. I don't know about you. I've been in dentistry 20 years. It's not usually the thing that gets updated on a yearly basis. So often we're using a medical history that was around from the inception of that dental office. So maybe it was 10 years ago, 20 years ago. But is cannabis use on your medical history? Cannabis is huge. Why? It's a risk for perio. It's a risk for caries. Also, some key questions you can ask is if they do use cannabis is why are they using it? Is it recreational? Is it medical? What is the mode of delivery? Is it inhalation? Is it gummies? Are they smoking it? Also, I want to know when the last time is that they used it. Because we need to make sure our patients are making an educated decision, that they can make informed decisions. And maybe they're high and maybe they really can't make that decision on whether that tooth should come out or they should go ahead with this sort of treatment plan based on their health history. There are so many risk factors that come into play with it. And when you're reviewing your health history, do you ask about dry mouth? Well, you know, dry mouth could be a sign of diabetes. Dry mouth could be a sign of medication that they're on. And so I think... into this aspect, having a different conversation, taking the time to make sure it's reviewed and updated every visit is so imperative for that patient. What is your recommendation, Carrie, regarding the health history, dental history assessment form in general that we use on new patients and also to update existing patients? Is there some recommended form? It seems to me at this point we should have some guidelines to make sure that we're covering all of our bases when we do these assessments. Do you know what? That is a really great question. And I have seen pages that are literally, it looks like three quarters of a page and I've seen three page questionnaires. And I think the best thing to do is to search, go to different CE events and find out what's out there. There isn't a set template that I have found that every person needs to use this one. But I do think it's something we need to bring awareness to that. As medicine and dentistry is evolving, we need to expand our questions and we shouldn't be using the same template that we started with five or 10 years ago. It is a great opportunity to assess and to evaluate that. And you know what, depending on what you're doing, maybe you do need that long questionnaire for, you know, surgeries and for everything else. And so depending on the care that you're providing, but I do think it's something we need to think about updating. Now, diabetes, you mentioned, is very tied into oral health. We all know that. in depth do you go in investigating what stage of diabetes that patient is at? And they may just say, yeah, I do have diabetes type 2, but it's under control. The dentist can't just stop there, right? And the patient may not know their sugar levels, and they may have no idea of what their hemoglobin A1C is, if they even had it tested. How do you approach that patient as far as how... much information you need to know about the state of their diabetes, because if it's uncontrolled, that's a whole different story when it comes to dental hygiene treatment planning. So then I go to them and I say, so have you checked your sugar levels today? Are you checking them at least at home? Because that gives us a range of where they're at as far as their sugar levels on a regular basis. Are they usually high? Are they not? If the patient can't give me that information and they are a diabetic, I usually write them a little note and I say, hey, can you go to your family physician, go to your... provider. And ask them this. And the reason I'm worried about it is that if your sugars are not as controlled as they could be or in an ideal situation, your mouth is at risk and same with your body. And we know that diabetes is linked with so many other systemic concerns. I don't want to put you at greater risk. And so I try not to scare them. The other thing is in the United States, you guys can actually in some states check sugar levels for patients. And in Canada, we can't do that yet. And I'm hoping soon that we'll come north of the border. So these are opportunities that you can expand your assessment, expand your communication and help provide these services with your patients. Because the key thing is not scaring them, but giving them enough information that they want to do something different. And I find from having this conversation, they usually say, I didn't realize it was that big of a deal. OK, well, tell me more. What can I do to help reduce it? And sometimes that's seeing patients every three months because there's literature out there in systemic and umbrella reviews that show if we don't see patients every three months, we don't have an impact on their HbA1c. Going four and six months does not work. We need to see them more frequently. And so this is how I bring it all together with my patients. So let's pivot to the younger patient. Let's say you are doing an assessment on a patient who's in second grade and the information that's being provided to the health assessment form is coming from the caregiver, one of the parents, et cetera. What are you looking for in a patient that age versus the adult patient that we've been talking about up till now? I think those are great questions. So some of the other things I want to ask on a health history is not just what they currently have, but what their family history or family risk is. Because a lot of times when I'm seeing a patient, we're talking about diabetes, so we'll stick with this zone. You know, maybe that uncontrolled bleeding or that... the decay that just keeps reoccurring is actually diabetes that hasn't been diagnosed yet. And we've seen, unfortunately, so many younger individuals with type two diabetes much earlier than where we used to see it. And so when it comes to a pediatric type of medical history, it's family history, family risk. And then I also am asking some really interesting questions when it comes to vaping, because vaping is a huge problem for my kids. My kids are, you know, in middle. at middle school and they come home and they're like, vaping is happening everywhere. And no parent wants to admit that that's the case. But sometimes I look clinically and I'm assessing what the gingival tissue looks like. And I'm just having these questions and these open conversations with patients. So when you talk about vaping, when you talk about cannabis and those kinds of things, do you get some pushback from the patient saying, hey, you know, you're going beyond the boundary of what I expected to be talking about in a dental practice? Maybe they don't want. to actually give that information that they're getting high or they're smoking pot or they're drinking a lot? Do you have those situations and how do you handle those? I think that that... something that I was fearful of and that would happen more often. And that often stopped me from asking the questions because I was like, I don't want to have this objection from my patients. I want them to like me. I want them to accept care. But after COVID, so in Ontario, we were shut down for four full months. And before COVID, I was actually asking about cannabis. But after COVID, we had a rule in our practice that every patient was going to have an updated health history because everybody had gone through such a stressful incident. More medications were being handed out. More people were not. not necessarily fully diagnosed or stable with many conditions. And that was one of the questions that came up on it. And I was shocked to see how open people works. It was like, do you smoke? Do you drink? Do you use cannabis? That was it. It was straight, simple. And if they said no. Then we just moved on. If they said yes, we'd say, well, you know, how often is it a recreational thing or is it something for medical purposes? And at that point, depending on what their response was, I would push it or I wouldn't. But I did find from keeping it really simple and straightforward, it really wasn't, they didn't have that objection. And almost if anything, some patients were like, I'm so glad I can finally talk to you about it. I don't have to hide it anymore. I'm like, yeah, I thought that those things weren't necessarily just from drinking red wine. I knew that something else was happening here. And it gives them the confidence that, you know, you're a really thorough healthcare provider and you're looking at their whole body and they're probably somewhat impressed with it. But others, they don't want to be announcing that they may be breaking the law. I don't know what the marijuana laws are. Is it Toronto? What part of Canada? Toronto, it's legal. And so that... help and so again going it's it's sort of like the hpv questions how how in detail do you go with hpv and so do what is comfortable but i think asking just straight out and having them say yes or no is at least you are opening up that conversation you're opening up the opportunity for a conversation and then you're right if it is something that's illegal they may not want to talk about it But we do ask about sometimes harder drugs, right? And I've had patients say, yes, I do use cocaine. It's like, okay, that's a whole different conversation that we need to be aware of, especially when it comes down to anesthetics and surgeries. We really, really need to be aware of what people have in their body to understand how they're going to potentially respond and reduce the risk. And I think that that's really where it comes down to play is if you're using those sorts of things or they're having those invasive procedures, we really need to be aware. of what's happening in that health history. Yeah, and HPV is a big factor. It's totally linked to throat cancer in many ways, especially if you have your tonsils. That requires consistent testing along with a good medical history. Obviously, you want to reduce the risk of throat cancer by having that information. So let's talk about risk. Understanding the patient's risk, especially when it comes to periodontal disease, is so important to get an idea of what we're looking at as far as treatment planning, our expectations of success, and so forth. So what criteria or specific indices do you typically use to identify a patient's dental disease risk? So this is something that started my journey. So again, I've been in hygiene 20 years. I want to say almost 15 years ago, I had that wonderful patient that looked healthy. They had, you know, pointed, very pink like gingiva. Yet I started to clean their mouth and their mouth bled like crazy. And I'm like, okay. It's not my insertion of my instrument. I'm not causing harm. Why is it bleeding? And so I went on a journey to figure out what it was or how I could have identified it earlier because visually it didn't show up. Bleeding on probing barely showed up anything. And so there's an indice called the papillary bleeding score, PBS. And this has really been the biggest game changer for me. All you do is use like a soft pick or a tepe brush and go in between the teeth. before you scale and it demonstrates to the patient the disease if there's inflammation and it also shows the patient bleeding and it wasn't my metal instruments that caused it something a brush something rubbery did and it opens a conversation so what i say to my patients is listen i'm going to measure the spaces around your teeth because bleeding on probing is so important but this pic actually is going to tell me how healthy the gum is between your teeth and if it bleeds we know it's infected and if it's sore it means it's inflamed And I need to give you, you've got right now a pot belly. I need to give you a six pack of abs really quickly to get you into the healthy zone. And this has been the biggest game changer in helping me educate my patients and helping them accept the perio care or the caries risk or whatever it is that they need in that treatment plan because they see the disease before I picked up my scalers. Most of the time us in hygiene and dentistry are so quick to get to the procedures we do because we love removing that calculus. We love doing those fillings. But we have to stop and go to the beginning, the root causes of concern. And that is one of the best indices. The other thing I have found is that when they see that bleeding, they automatically say, oh, my gosh, how do I fix it? I'm like, yes, they asked for oral hygiene instruction. And that leads me down this conversation for disclosing. I don't know about you, but disclosing for me had I had PTSD from hygiene school. I really did. It was not something that I loved and was like, I can't wait to do this in clinical practice. I'm like. I don't have to do this in clinical practice. Now I can't practice without it because if they can't see their biofilm, then they can't remove it. And so it starts a conversation as far as what is that true plaque level like and how do we come up with the best treatment plan to reduce it, to reduce that risk. And I must say, Carrie, I think it's a brilliant strategy to approach the patient with a tepe brush or a soft pick initially rather than an instrument because there's such a psychological. difference between doing one versus the other. Can you elaborate on that with your experience using this approach? Because I think it's so important that our audience gets even more clarification on that initial reaction of the patient when they see bleeding that's not induced by an actual dental instrument. So the psychological difference is at any time I'm taking a probe, particularly it's called a probe. So people think that I probe them and I cause the bleeding. What I like to say to my patients is I measure the gums. Measuring doesn't sound traumatic. It doesn't sound like I created an issue. And so with probing, it tells me how healthy the gum is around the tooth. And this papillary bleeding score tells me how healthy the gum is between two different indices. two different evaluations. I'm going to probe on that day, which I always do an assessment, or if I'm doing a full probe, I do that first with bleeding points. Because when you use, like you said, that soft brush between the teeth, I'm not causing harm. I'm just stimulating the gingiva and just rubbing that gingival tissue to see what that response is. If there's a positive response with bleeding, then we have this conversation about risk. because I don't want my patients to have anywhere that bleeds. If you washed your hands and it bled, or you clean under your fingernails and it bled, you'd run to the doctor. Using something like a soft pick, using something like a tepe brush between the teeth is very similar. And I use that analogy. I say, listen, you know, I should be able to rub the soft brush between your teeth and it shouldn't bleed if it's not causing harm. I want to get you to a point where it doesn't bleed because I don't want you to have this risk or have these openings and these little paper cuts in your mouth where it gives a potential risk for systemic concerns. Let's figure out what the best option is for you. So now that we've done the assessment, and let's assume we did a really thorough assessment, give us some examples of how we utilize the information gained from that assessment in our treatment planning. So give us some examples of some of the things we've discovered through the assessment. And then what do we do practically, clinically in the office to tackle some of those problems? in the hygiene world as we move forward to make sure we're optimizing the patient's oral health. So one of the things I find that is missed, like a missed opportunity is really recession. Often it's not recorded enough on the period charting. We're so quick to kind of go through that we skip out recording bleeding on probing and recession. But with recession, when I see that with my high risk patients or my moderate risk patients, because there's been bile foam or there's been bleeding, I want to think about fluoride use. Are your fluoride numbers matching the amount of decay that you're fixing on patients? A lot of times our fluoride numbers are completely low. And I have been utilizing VOCO's pro fluoride varnish for over 10 years. Why do I love it? A, the flavors are great. I don't have to have that mouth completely dry in order to apply it. So patient's ease and use is much easier. The other thing that is great about it is as 5% sodium fluoride and it has xylitol. And so it really is this dual action that helps to prevent the decay, helps to code over that aspect and helps with some situations with the sensitivity. The other thing is what I love about looking at fluoride. I want you to also think about what is it. in it? What is it containing? Because some fluorides do have things and connections with nuts. And so what I also love about the profluoride varnish is that it doesn't contain tree nuts, peanuts, corn, shellfish, eggs, milk, protein, soy, gluten, triglycerides, red dyes, coloring, and aspartame. That's a lot of things it doesn't contain. So I don't have to worry about that health history as much about some of those risks that patients came in. The other missed opportunity I feel like is sensitivity. So when you see recession, one of the questions I want to ask my patients is, do you get sensitivity? Because they're looking for options. They spend thousands of dollars in the drugstore looking for choices. But what if you had an option for that? What if you could use something like Profluoride L or in Canada, I have Bifluoride 10. What's cool about that product, I can apply it chairside before I start to scale on those root surfaces. It is a dual fluoride. It has sodium fluoride, 5% calcium fluoride. And this dual action really helps to protect. And the sodium fluoride immediately helps to release and reduce the sensitivity while the calcium fluoride stores and releases the fluoride over time. It is a thin layer and doesn't require a curing light. In the practice I work in, I don't always have a curing light in the op I'm in. And so I need to have something that's easy and gives me the expected outcomes of reducing that sensitivity. So in your assessment, you have a particular section about tooth sensitivity, along with all the medical history and everything else. Are they asked to identify? which teeth or just you're just asking them a general question are you experiencing sensitivity to hot and cold or things like that yes that's usually how the conversation starts and then i'll say do you ever notice that in the summertime when you go to drink that cold drink it's like oh i can't have the ice i want to have no ice in my water or in the winter time when you go outside are you having difficulty breathing and you're always covering your mouth from there depending on what their response is then i have them help me identify In the chair, it's great. We can blow a little bit of air or we may know which ones are sensitive from using our cavitrons or piezos or air polishers. We almost know which teeth are going to be a little bit more exciting for the patient. So this is sort of how we can help with that identification. The other treatment I have found to be really helpful is using the Admera Protect. What is great about that is it actually is like a dental root sealant. And so we do sealants on the buckle surfaces to help reduce. risk of cavities, but there is this opportunity to do that. And it really does help for up to two years for sensitivity. And I have found to be simple to apply the differences. It does need a curing light. So again, different choices, different options. But it really is an amazing opportunity because it helps to seal those dental tubules. It has incredible bond strength and it's transparent. So aesthetically. People don't even know it was on there. And so you don't have to worry about that being a reason why they're not going to say yes to care. And they will notice the difference right away. Yeah, I do want to say that this is after the differential diagnosis is made that these patients do not have decay that's causing the sensitivity or sensitive to the cold air when they breathe in. Canada gets awfully cold in the winter. And if they're opening their mouth and breathing in and they're holding their mouth from just because they want to protect those teeth. You know, they could have obviously decay, they can have an endodontic implication. So you have essentially ruled those issues out based on a good assessment. They're telling you that their teeth are sensitive. You've ruled out endodontics, you've ruled out decay, or you've already done the restorative work and they're still having the sensitivity. And then it's pretty obvious to you after you examine them that there's exposed roots, either through, mostly like you mentioned, through recession. And those tubules need to be protected. And that's where you're coming in with these materials. I just want to make sure that everybody, I mean, it's pretty obvious, but it's nice to just clarify that you've done a good differential diagnosis first. Yes, absolutely. And we want to make sure we have the radiographs and that we're reading them. And then depending on your state or your provincial guidelines, you're coordinating with the appropriate people to make sure that that is all done. Absolutely. In closing, is there anything else you want to recommend to our listeners regarding? their responsibility in in their initial exam or what we really are calling in this podcast the oral health assessment where we really gain a very thorough understanding of everything about that patient related to their medical and dental history and like you said dental history may not be available very often they may not have been to a dentist in seven ten years but they've been for their physical so we have a good idea of their medical history is there anything else that you think we should be aware of and what's so important in making sure that we get this information early on in their journey to having their care handled? I think one of the biggest things and one of the ways that I sort of stuck... step back from what it was that I was doing all the time, I realized that without a full assessment, I really wasn't providing the right care for my patients. And I had so many missed opportunities because I was so quick to pick up my scalers because that's what they were set for. And I just found that from taking the time to look at your assessment, and we've talked about only a few items, but you could add DNA testing to that. You could add additional treatment and therapy options. We could bring in all these therapy choices and add things to our tray. based on the risk of their assessment. So take the time to do it. It is vital in order to know what it is and where we're going and to rule out other conditions and other concerns. We have to make sure we have that right diagnosis. And if you're skipping corners and skipping things on your assessment, you are going to have missed opportunities. And we just don't want to do that. We want to offer the ideal care for our patients. Kerry, thank you so much for joining us on our show. And the input was excellent. We look forward to having you on future programs. Have a great day. and thank you for your time. Thank you very much for having me.