Tackling Periodontal Disease Before The Damage is Done

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing how to tackle periodontal disease before it gets out of hand. We'll be discussing how to accelerate periodontal case acceptance, improve patient outcomes, and increase our overall confidence in treating periodontal disease. Our guest is Amber Auger, a practicing dental hygienist, consultant, and international speaker. Before we get started, I would like to mention that Amber will be presenting a live webinar on VivaLearning.com titled Risky Business, Treating Periodontal Disease Based on Your Patient's AAP Classifications. It's scheduled for Thursday, June 2nd at 7 p.m. Eastern, 4 p.m. Pacific. Simply visit VivaLearning.com to register. The webinar is free and you can earn live interactive CE credit. Amber, it's a pleasure to have you on Dental Talk. Thank you so much for having me. I'm excited to be here. Very important topic. We all face these challenges in our dental practice every day. And we're not only talking to periodontists or hygienists, we're talking to everybody, right? Every dental practitioner that sees a patient has to deal with some form of periodontal disease. And as the title states, it's always good to get it early. So what do you find to be the most common mistake when treating periodontal disease? What I find to be the most common mistake is saying, oh, that's only a five millimeter pocket. Let's wait. Or, oh, that could be a pseudopocket. And really the issue here is, of course, if we're not diagnosing and treating early, that only leaves an opportunity for that disease to progress. In addition to that, what is typically linked with that is whether it is the hygienist or the dentist feeling like. they've taken responsibility for that inflammation. We've been treating this patient. We're not getting a good result. That's on us. We must be doing something wrong and not really giving the patient the opportunity to take ownership of the disease. Okay, so that's interesting. So how do you get the patient to, very briefly, how do you get the patient to take ownership of the disease when the patient's coming to you every six months? Yeah, so it all comes back to evidence and trust. So you have to be showing the patient exactly what you're seeing in the mouth. So this is where disclosing comes in. And I'm telling the patient, you may be using an electric toothbrush or a water flosser. However, you're not adapting it correctly. Here's the evidence of disease. Look at all of this stained biofilm that's present. And there is clinical technology that you can actually timestamp that bacteria. So there's no battle of, oh, that was just from lunch. I just ate. And you can actually say, no, this is actually. matured plaque. It's 24 hours, 48 hours old. And then, of course, picking up the intraoral camera, holding up the mirror and showing them what an area of health looks like and then what the area of disease looks like and teaching them that they have the ability to reverse that gingivitis. They have the ability to prevent the progression of that periodontal disease. Do you put any fear factor in that discussion as far as if they don't listen to what you're saying down the road, they're going to have, you know, full dentures? So I think that as dentistry, we've always gone down the route of shaming and fear. And I personally don't feel that shaming and fear work. I do, of course, explain the risk. But for me, it's always about empowering that patient. So if they've always been recommended to floss and they're not flossing, then we have the conversation of tell me why you're not flossing. What do you not like about it? And it's more encouraging. It's more motivational interviewing. It's not yes or no questions, but it's a collaborative approach. And what I will say is. been extremely successful in the case acceptance with my patients. as a practicing dental hygienist for the last 12 years and a consultant, what I find is most practices think that everybody's on board and on the same page and calibrated with Perio, but that's not the case. We have one hygienist who's recommending scaling, the other one who's saying, no, that patient is healthy. So having those conflicts really does create confusion among ourselves and of course, among the patient. So they always need to be hearing that same messaging and then reinforcing it every time they come in. Okay. So you're saying that Within a practice, there could be a diversity of approaches to the same patient as they move through the practice. Or if they move from one hygienist to another, they have a different approach. So you're saying everybody should be on board with one mindset, right? When it comes to treating these patients at the level their dentition is at at that time. Absolutely. Everyone has to be calibrated and on board because if a patient... a different message from another provider in the practice. All trust and continuity is lost. Yeah, no, that's a good point. So in your mind, and you did cover this, and this kind of dovetails this question into what you just said, what are the three key elements, if you could identify those, to achieving a high rate of case acceptance? Because if you can't get case acceptance, you're not going to be furthering the process of treating that periodontal disease. Right, right. So number one, which we just briefly reviewed, is that trust is in the proof of the disease. So disclosing the patient, showing them what they're missing, and then teaching them what they've normalized is not normal. Healthy gums don't bleed. We know that. And they're going to say to you, well, my gums have always bled. Okay, if that's the case, there's something going on systemically that we need to address. Perhaps you have periodontal pathogens that are out of control. Let's get you down a route of salivary diagnostic and identifying what we're trying to treat. Because here's the thing, if we don't understand the pathogen that we're treating, some patients can respond very well to xylitol products where others don't. And we've all seen those patients who come in, they have the sticky orangey hue plaque on their teeth. and you think to yourself, this is going to be full-blown scaling. You pick up your power instruments, you remove that biofilm, and lo and behold, there's nice coral pink tissue versus that patient who comes in and there's barely any deposit and there's no bleeding. The difference here is a slow rate of progression and a rapid rate of progression when we look at the AAP classifications, as well as a balanced oral microbiome and one that is in a state of disease. Then we look at time management. To do this in a way that is effective, we have to remember that if you are scaling for more than 20 minutes, it's not a prophy. And that first 20 minutes of the appointment should be an assessment appointment where you can then identify what gingival track your patient's going down. Is it disease? Is it healthy? Or is it periodontally involved, right? Gingivitis, healthy, periodontally involved. And then you can plan accordingly and use your time very wisely during that one-hour appointment that most of us have. And then we talked about that motivation. interviewing. Yeah, yeah. Tell us about that because that motivational interviewing is a big part of the case acceptance. It is. So what we have to do is we have to identify what is that patient's motivator. Some patients are going to be motivated by... time. How quickly can they get it done? Others are going to be motivated by appearance. Others are going to be fearful of, you know, I don't want to do this. It sounds really painful. So we need to figure out what motivates and what demotivates the patient. And motivational interviewing transfers that conversation of yes or no. We're using electric toothbrush, no. Then the conversation just flops. Why not? I don't know. Where we can then go to motivational interviewing and say, tell me about what you're using. to clean your teeth every day and in between your teeth. Then the patient can answer. And then, have you thought about an electric toothbrush? So this way, it's more of a conversation. They're more involved. And whatever they respond back, I'm never shaming them. It's never, well, you should be using an electric toothbrush, obviously. It's, OK, tell me what you didn't like about it before. Are you open to one or do we need to go down a different avenue? And that's fine. I'd rather have the patient say yes to what they'll do. is compliance convenience because convenience is compliance with the patient right now that's interesting so you have some sort of flow chart in your mind obviously where depending on their response to your question you'll move in a direction that fits their profile and of course home care is key here but i hear a lot of dentists saying You know, to expect a patient to floss regularly and put thread in between 32 embrasures. How many embrasures are there? There's 32 teeth, so there's more than that, but whatever. Then it's really difficult to expect a patient to do that on a regular basis. My wife doesn't floss. I do, but my wife doesn't floss every day. And, you know, it's like, how could you not floss every day? So you have a flow chart in your mind and it kind of tells you where to go. And your goal is to get that patient to feel. comfortable with you where you give them a protocol that they use right I want the patient to feel like I'm treating them as my mother, my father, a sibling. I want them to feel 100% comfortable where they can tell me anything. And the clinical studies show that patients rather clean toilets, stay stuck in traffic, and do dishes consecutively for one month rather than floss. So I've personally tossed the floss recommendation out the window about 10 years ago. Oh, isn't that right? So all of my patients are on a water flosser. All of my patients get better results with it. are instances where you do need floss, of course, if you're eating corn on the cob or you have food impaction and you don't want to leave it there. But yes, my compliance is really high in that realm. And I get my patients thinking differently about it. So we're having systemic conversations when we come in. I'm getting Christmas gifts on patients that have treated one or two times. There's like competitions between spouses on who's water picking more. I create a fun, engaging environment. I'm also a dental hygienist. loves going to work and I I teach, I have a whole course called Thrive in the Op where I teach hygienists how to love going into the operatory. And the reason I do is because every single patient is being treated based on their risk. So it's not a fluff and buff prophy. It's not a every hour on the hour. I'm saying the same thing, doing the same thing. It's really where it's highly engaging on my end, but then on their end, and that's what's really rewarding to be able to see patients when those light bulbs go off and then to watch them transform from disease to healthy in my chair is one of the most rewarding. things I've ever experienced. Yeah. Wow. Power to you, Amber. I mean, you have just about every quality possible to enjoy your career, help patients and thrive. And that's just, it's really exciting to have people like you on the show. So let me ask you this about implementing a protocol in the office. So a dental office thinks they have it all set up. It's all working. They have a couple of hygienists, but they don't really have a systematic approach. they're not really thinking along the lines of what you've just described so well in the last 5-10 minutes. What is the easiest way to begin implementing a systematic approach for a dental practice? so the easiest way to implement of course is number one that calibration across the board for everyone who's making sure you're getting a nice comprehensive periodontal chart if they are periodontally involved it has to be once every three months that can look as simple as carrying the data forward from the previous visit and then updating the changes so we don't have to make this really hard on ourselves And then from there, once you have that solid foundation where you know, okay, five millimeters is active bone loss, we're going to be treating there. And then you can say, what else can we add in to our program to be super comprehensive? We've all treated those patients who we've done scaling and root planning. They come back. two consecutive visits after. So the first three-month re-care visit, they look great. The second one, they look great, but there's a little bit more bleeding. And then next visit, it's all regressed. And you're like, what the heck? What happened? The patient's saying they still done the same home care. Well, what's happened is we never identified what periodontal pathogen we're treating. So there are clinical technologies out there where we can do salivary diagnostics, test the bacteria, and say, okay, based off of this result, we're going to be implementing xylitol. in your home care. We're going to implement a water flosser, and here's what you need chairside. You need a laser. And once we use the laser, then we can confirm that we can knock down these numbers. So in the past, how we've measured perio is, of course, probing and bleeding. And the future way of looking is identifying what pathogens that we are treating and really giving the patient what they need to retrain that biofilm. Yeah, it's amazing you're talking about pathogens because I went to University of Pennsylvania dental school. I went to endo school after that. In dental school, D. Walter Cohn, who just passed away a couple of years ago, who was like the father of periodontics, gave us a lecture when I was a sophomore in dental school. And this is going back. It's got to be 1982. 1982, I was in my second year of dental school. I don't know if you were born then. I wasn't. Yeah, you weren't. So I was in my second year. Right. You were not even born yet. But the interesting thing was he gave a talk about the future of periodontics. by identifying pathogens. And I thought that lecture was so impressive. I took notes on it and kept those notes for decades. They're in a box somewhere in my garage written on a legal size pad. And you're saying the same thing in 2022. And this was in 1982. So that's 40 years ago. It's amazing. Yeah. So as you're saying this, I'm getting a fire in my belly. Like I have full body goosebumps. This is why I do what I do, because that story makes me so upset. We've had that clinical technology. Why haven't we implemented? Number one, the first question is, where is it going to fit in our appointment schedule? And number two is the cost. But we need to be moving out of that mindset, because when we look at medical, whenever a doctor tells us we needed something, we're not saying to prevent. disease to prevent the progression of whatever disease we have. We don't say, I'm so sorry, how much is that going to cost? And are you sure? Is that scan going to be covered by insurance? We say, get me healthier. We'll figure it out. So we need to be moving in that direction. I mean, the paradigm that you're talking about is that it's not just scale, root plane. prophy and send the patient to the dentist, hand it off. Yeah, I mean, it's amazing stuff you're saying. To get this implemented on a broad basis across the dental profession would be the challenge. And like you said, for the last 40 years, it's based on that lecture, we're still facing that challenge. There's a couple more things I want to ask you. One is, you know, with periodontal disease, you get gingival recession, which means you have root exposure. And having that root exposed causes sensitivity. What are some of the things that you do in your practice to handle that? Yeah, that's a great question. And oftentimes that impacts home care, right? So of course, if that cementum is exposed and that patient's leaving biofilm there, I'm automatically concerned. So that's really where I have great success with the water flosser to flush out that bacteria. And when they're chair side, I'm also concerned. I want to make sure that I'm able to remove those pathogens with whatever device, whether it's an air polisher, piezo, hand instrument, and be able to really effectively debride that area. And if they're highly sensitive, I don't have confidence that I can do that. So what we... implemented in our practice is Admira Protect from VOCO. And this is a light curing desensitizer. And this has been just honestly really life -changing for our patients because those patients who were coming in and really sensitive, obviously that creates a higher anxiety from the get-go. And there's been some patients that I've placed it on that they've gone a year, even two years without any sensitivity when they come in. So I'm touted as, you know, the magic hygienist, the whatever Amber says. to do because I've built so much trust in the fact that they're not in pain in my chair. But honestly, what I've done is I've integrated some really phenomenal technology. So when you use that product, when do you apply that? What part of the treatment plan? The patient comes in, they're new to your practice, you see they have early periodontal disease and so forth. When is that applied? So it can really be applied. You have to use your discretion. So if my patients are immediately even probing the area kind of through the roof, then we talk about how we can treat them at home and as well as how we treat them chair side. So if we have if the patient is on board that day, we'll do that light curing desensitizer. It takes a few seconds. I always recommend doing it first. I might have to do it again once if there's so much inflammation on that patient that the tissue gets tighter and then a new area is exposed. I might have to redo it. So I kind of educate the patient in that. And I kind of see where they are with that sensitivity. in that moment. I mean, you can place it and then go right in and scale. You don't have to. It's not something that you have to wait months and months to be able to treat again. And then we usually couple that with a high fluoride treatment at home in a retainer tray. So when we look at the increased risk of decay with our patients and what we're drinking, the coffees, the wines, the seltzer, the tea, working from home and drinking that all day long and having a pH environment drop down to promote demineralization, this is where the remineralization can really step in also a VoCo product to step in to help with that sensitivity in between appointments as well. So two different options, both creating a really great effect for reduction of sensitivity and protection on your patients. Yeah. Yeah. And VoCo is a great company. They do a lot of R&D. We do a lot of podcasts and where KOLs are talking about VoCo products. So hats off to them for the products that they bring to the office that helps these patients. It's been a great podcast, really enlightening. And by the way, I would like to recommend your website. You offer some training on that website? I do offer many trainings. So I speak internationally and then I offer consulting. My website is amberauger.com. And then I'm also on social. Okay, social. AmberAuger.com. So that's A-M-B-E-R-A-U-G-E-R.com. So check that site out. Check out Voco.com as well to learn about some of their hygiene products that Amber just spoke about. So just to wrap up this in another minute, how can an office enhance its current program? Assuming they're running a fairly strong program, periodontally, what can they do to make it better? What they can do to make it better is localized antibiotic therapy, lasers, salivary diagnostics is really the number one because you want to identify what you're treating and then offer the solution to prevent that bacteria from thriving to kill that bacteria. And then, of course, there's some really phenomenal trays out there that you can use with a hydrogen peroxide tray to help decontaminate the pocket. On the salivary diagnostics, what product do you use? So there's many products out there. The latest one that is out is actually created by Dr. Tom Neighbors. It's the HR5 salivary diagnostics test with direct diagnostics. It is the most accurate, but I also find that they are one of the leaders in the industry, the only leader in the industry that's looking at how to treat the pathogen outside of antibiotics. So that's what I love because not all patients want antibiotics, and I don't want to wipe out the oral microbiome with all those patients if they have low levels. bacteria when the clinical studies show that I could maybe prevent it with a xylitol or an air polisher treatment. And what do you do? You send that test to the lab? Super easy. So they actually provide a salivary sample into a tiny little tube. And then it goes, it gets shipped to a magical lab and you get the results in two days. The patient gets a whole patient portal where they can see the results in a report. And then we see that as the provider as well. And then do they make recommendations on how to proceed with those test results? They do. So essentially what an office would have to do as a provider is they go through multiple trainings to be certified to know how to read the report, but they can make suggestions for us. They come up with a very black and white, here's what to recommend for antibiotics if you want to go that route. And then as a hygienist, there's different trainings that we can do to say, okay, if these levels are low enough, we can treat. minimally invasively, maybe a probiotic, a prebiotic. And it's designed at a price point where you can keep retesting. Great stuff, Amber. Really enjoyed it. Again, visit... Amber's website, amberauger.com, A-M-B-E -R-A-U-G-E-R.com. And I'm sure there's a wealth of information there. I would say if you're interested, contact me through Instagram. It's the easiest thing for me. I can do a voice memo back. I'm much better on voice than I am on email. And my Instagram is amberauger, R-D-H. I do weekly live sessions, ask questions and share case studies to allow you to integrate into your practice. Amazing. Great. Hopefully we'll have you again soon, Amber. Thank you so much for your time. Of course. Thank you.