December 12, 2017
by Irene M. Iancu, BSc, RDH, CTDP
I think we can all agree that we have acquired newfound knowledge since graduating Dental Hygiene School. For myself, a 2007 graduate I can attest to the wealth of knowledge I have ascertained moving from working environment to working environment. New opportunities with every resignation and new knowledge with every new team.
My journey has led me from Pedo to Perio, GP realm to Ortho and now education. My burning question that has puzzled me for years has been, “Is this really Perio?” It can’t possibly be so simple and it can’t possibly be so easy to diagnose. Over the years I have berated the Internet or “Dr. Google” as some might call it and in reality I’m finding images that can’t possibly be what perio is by definition.
Unlike our brothers and sisters from the south, the Canadian Academy of Periodontology doesn’t have a true definition on their website as the AAP does.
Where the AAP defines Periodontal Disease as the following:
“Periodontal disease is an inflammatory disease that affects the soft and hard structures that support the teeth. In its early stage, called gingivitis, the gums become swollen and red due to inflammation, which is the body’s natural response to the presence of harmful bacteria. In the more serious form of periodontal disease called periodontitis, the gums pull away from the tooth and supporting gum tissues are destroyed. Bone can be lost, and the teeth may loosen or eventually fall out.
Chronic periodontitis, the most advanced form of the disease, progresses relatively slowly in most people and is typically more evident in adulthood. Although inflammation as a result of a bacterial infection is behind all forms of periodontal disease, a variety of factors can influence the severity of the disease. Important risk factors include inherited or genetic susceptibility, smoking, lack of adequate home care, age, diet, health history, and medications”1
Suspect for me to believe it is that easy. Where the diagnosis is said to “rely on a visual assessment of the patient’s overall oral condition in addition to charting pocket depths with a periodontal probe.”2 Now this information is being broadcasted to our clients who really don’t know any different than the two realms of information: the Internet and chairside communication.
More often than not, our clients direct their questions to the virtual world. Posing questions in forums and looking at images that would help them make the decision to accept or question treatment recommendations.
When searching Periodontal Disease on Google.ca, this is what comes up on images:3
Now as specialists in the oral cavity moving from left to right on the screen, can we all agree that many of these images are not really telling us the whole story.
My question to you is; Can this be related to malocclusion and systemic health concerns? Are our Perio clients truly those that have an uncontrollable amount of harmful pathogens, suffering from bacterially induces oral disease or could this all have started with poor occlusion and less-well controlled systemic diseases? Could this have been prevented and can this epidemic be reduces with the correction of occlusal forces caused by traumatic occlusion?
Before we get into the description of this case let’s take a moment to evaluate the images presented below. Imagine this is your 4 p.m. client presenting for routine maintenance. Upon intra oral assessment of soft tissue you determine the ever so slight presence of gingival recession and clefting. Old Irene in 2007, would likely have told this client she brushed to hard. 2016 Irene scratches her head and wonders, “Could this be related to Malocclusion?”
I am this client. These photos taken in January 2014 to further evaluate what I was told was Aggressive tooth brushing. As a client newly diagnosed as an aggressive tooth brusher I navigated to images in comparison to my latest diagnosis.
As a clinician I was scared to find anterior open bite cases, cross bites, localized gingival recession, edge-to-edge bites and abfraction lesions only 2 or 3 teeth in a quadrant. I don’t know about you but my clients aren’t really that talented to be brushing only on 2 or 3 teeth creating excessive damage.4
Upon further evaluation of my function and an occlusal assessment it was quite evident that the cause of my newly discovered recession, wearing, shifting and chipping was the destruction of my teeth.
I had never been recommended for orthodontics. I was never referred to an orthodontist and I was never told that there would be long-term effects to what seemed to be minor imperfections in a relatively aligned dentition.
I suppose, I’m depicting my own dentition as a learning tool. For us to evaluate everyone as part of comprehensive care. We would not let a client out the door without a visit from the DDS if we spotted a questionable lesion on soft tissue or possibly a carious lesion.
Malocclusion should be no different and even the most minimal of rotations or inclinations can make a significant difference long-term, as it has for my own dentition. I will never get back the 1-3 mm of attachment or my once natural cusps.
My challenge to all of us is to pose that question silently while doing our intra oral and extra oral evaluations. Can this be related to malocclusion?
Irene M. Iancu, BSc, RDH, CTDP