Periodontal Therapy: Patient Outcomes–Based or Profit Center–Based?
Charles M. Cobb, DDS, PhD; Stephen K. Harrel, DDS; Michael P. Rethman, DDS, MS; John S. Sottosanti, DDS; and Lee N. Sheldon, DMD
Multiple recent articles have called for outcomes-based and patient-centered guidelines for periodontal therapy.1-6 Simply put, periodontal therapy must be in accord with evidence-based treatment and doing what is right for the patient at the clinical level. With this in mind, the present authors contend that many patients with periodontal disease are not receiving acceptable and timely treatment and disease management.
Even if one assumes that a timely and accurate diagnosis of periodontitis has been rendered, the treatment performed often may be inappropriate and/or incomplete, leading to eventual failure. Periodontal patients who are improperly treated and poorly managed are not receiving ethical care, likely due to either ignorance on the part of the provider or profit-motivated decisions that show a lack of concern for the patient.
While a high percentage of periodontal treatment is genuinely intended to restore patients' periodontal health, a quick search of the internet (using search words "periodontal" and "profit") yields numerous results that are clearly aimed at creating a profit center and never mention the health of the patient. Much of what can be found in a search for periodontal treatment/profit is under copyright, so we are not quoting from these sites, but even a cursory review reveals an alarming tendency toward treatment recommendations that are driven by profit rather than patient outcome. Treatment planning to maximize profits is characteristic of transitioning into a trade guild and away from the professional and science-based periodontics that dictates appropriate patient management and care.
A Different Form of "Supervised Neglect"
There was a time when periodontal disease was often underdiagnosed. Patients were frequently seen for a routine 6-month "prophy," but their periodontal condition was never measured or addressed. This was colloquially referred to as "supervised neglect." Currently, many patients are correctly diagnosed with periodontitis but the treatment recommendations and therapeutic waypoints at re-evaluation are inadequate to control the disease. This appears to be a different form of "supervised neglect." The present situation of adequately diagnosing periodontal disease but rendering inadequate therapy seems to sadly fulfill the statement of philosopher Eric Hoffer: "Every great cause begins as a movement, becomes a business, and eventually degenerates into a racket."7
Today's "periodontal profit center" concept and soft-tissue management programs are short-sighted and inappropriate for a number of reasons-the most glaring being they prioritize income and profit rather than quality and evidence-based care.8-10 In the case of various cookbook-like "soft-tissue management" programs, the name says it all; that is, bone loss, furcation invasion, and gingival recession seem to be of no concern. What happened to soft- and bone-tissue augmentation treatments, customized maintenance intervals, and continuous re-evaluation of periodontal status, etc.? In other words, the concept addresses only the soft-tissue inflammation part of periodontitis. This type of approach does not recognize that periodontitis is a multifactorial disease and, if not treated appropriately, will exhibit progressive hard- and soft-tissue deterioration.
In medicine and dentistry, what is considered a fact is frequently, in due time, revealed false in an unpredictable and nonlinear manner. Often, what is promoted as a scientific truth may unreliably double back, ie, a truth one day can suddenly become less so the next day and may eventually be scrapped. Again, a quick internet search will reveal numerous untested or poorly tested products reported to "reduce tooth pain," "regrow healthy gum tissue," and "promote healing of tissue and bone." Consider, for example, the "cures" claimed by brushing with baking soda and hydrogen peroxide, oil pulling, turmeric paste, sage oral rinse, green tea, etc.11 Many oral rinse products claim a "reduction in gingivitis and gum disease." We might accept a "reduction in gingivitis," but which "gum disease" is vaguely being addressed? If it be periodontitis, then our response is: prove it with well-designed clinical trials and good science. This was done for the so-called Keyes technique that used salt and hydrogen peroxide.12,13 No clinical benefit was found when well-designed strict multicentered scientific testing was performed. Also, there is a reason, after all, why chlorhexidine mouthrinses are not advertised as a treatment for periodontitis-probably because the liquid does not penetrate deeper than 2 mm to 3 mm into a pocket.14 Clinicians must avoid latching onto the latest fad-cure and disregarding good science.
What's Dictating the Decision?
All too often, trusting patients receive what they think is adequate periodontal care. But is it? Following post-scaling and root planing (SRP), how often is there radiographic evidence of retained calculus or bleeding on probing (BOP)? How often is the treatment properly re-evaluated? Is the clinical data collected at the re-evaluation used to make a reasoned decision about further therapy, or is the patient simply told "we'll watch and see if this gets better" and assigned to a maintenance schedule ("recall bank")? Another less-than-ideal option might be to do the SRP a second time, in hopes of achieving a better result. Often the recommendation of further SRP is dictated by insurance benefits that allow a second treatment. Research, however, has consistently shown that repeated sessions of SRP seldom alleviate the problem.15-18 When periodontal disease persists, usually based on continued BOP, one must consider advanced therapy options or referral.19
With dental implants being represented as a replacement for the natural dentition, many dentists, dental hygienists, and patients have become convinced that periodontitis is a one-way street to tooth loss and that implants are the ultimate solution. This belief, however, is not necessarily so, and in reality, too many teeth are being extracted that have a diagnosis of stage III or stage IV periodontitis when the scientific literature supports that most, if not all, periodontally involved teeth can be treated and maintained for many years-often for the life of a patient.20-22 Indeed, it is likely to be less expensive to treat and maintain such teeth than to extract and place a dental implant.23,24 This becomes particularly relevant as peri-implant mucositis and peri-implantitis are reported to have prevalence rates of 43% and 22%, respectively.25-30 These conditions often lead to implant failure.
Whether the type of disease prevalence seen in implants represents a significant improvement over that seen in the natural dentition is questionable. Are clinicians simply exchanging periodontitis for peri-implantitis? Implants are a wonderful treatment when a tooth is truly hopeless, but they are not the problem-free "cure-all" that they are sometimes made out to be.
The Patient's Best Interest
It's time to define, promote, and strongly support science-based parameters for the management of periodontitis across all of dentistry.3-6 All providers should be advocates for treatments shown to be effective in countless clinical situations and that are supported by the scientific literature. All clinicians should have a contemporary understanding of how to appropriately manage periodontitis in general practice and when advanced periodontal treatment is in the best interest of the patient. A true professional diagnoses, treats, and maintains a patient's oral health based on science and with concern for the patient's well-being. Diagnosis and treatment based on insurance coverage or what the patient wants, instead of what the patient needs, helps neither the patient nor the dental practice. If the primary practitioner does not have the training or legal authority to perform advanced periodontal therapy, it is ethically imperative that the patient be referred to someone who does have the training. Supervised neglect is unethical treatment and never in the patient's best interest.31
About the Authors
Charles M. Cobb, DDS, PhD
Professor Emeritus, Department of Periodontics, School of Dentistry, University of Missouri-Kansas City, Kansas City, Missouri
Stephen K. Harrel, DDS
Adjunct Professor, Department of Periodontics, Texas A&M College of Dentistry, Dallas, Texas
Michael P. Rethman, DDS, MS
Adjunct Associate Professor, University of Maryland, School of Dentistry, Baltimore, Maryland; Adjunct Assistant Professor, Ohio State University, College of Dentistry, Columbus, Ohio
John S. Sottosanti, DDS
Former Associate Clinical Professor, University of Southern California, School of Dentistry, Los Angeles, California; Private Practice, San Diego, California
Lee N. Sheldon, DMD
Former Associate Clinical Professor, University of Florida College of Dentistry, Gainesville, Florida; Private Practice, Melbourne, Florida
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