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to Wring the Most Information Out of Your Perio Radiographs Here Are Some Low-Tech Hints That Save Time Boost Your Self-Esteem And (Surprise!) They Probably Won't Cost You a Cent! By Larry Burnett, DDS A distressing statistic… I’ve heard that half of America’s hygienists (50%!) leave the profession within 5 years of graduation. That’s a dropout rate unheard of in any other health-related field. And I think I know one major reason. It’s a profound sense of personal inadequacy. The more conscientious the hygienist, the greater her despair once she discovers that she lacks the skills to produce the results she was taught to expect. The problem isn’t her skills. The problem is that she was taught to expect impossible results. I know because I’m one of the culprits. I teach conservative periodontal therapy to dentists and hygienists. For years we taught that our goal in treating periodontal disease is to restore pink, stippled gingiva, eliminate all bleeding and leave the patient with shallow 3mm pockets. Nonsense. All nonsense. A periodontal pocket (3mm, 5mm or 7mm) does not indicate an active disease process. A pocket is simply an anatomical defect. It may be the result of disease…but it’s not the disease. In fact, the “3mm-pocket myth” has probably caused more over treatment, more patient suffering and more feelings of professional inadequacy than any other misconception in dentistry. Similarly, bone loss may be the result of periodontal disease but it doesn’t tell you whether the disease is active. For years, we told students that true professionals routinely achieve calculus-free, glass-smooth roots. More nonsense. The fact is, roots are rarely calculus free…even after the most meticulous scaling. (Fortunately, calculus-free roots are not essential to restoring periodontal health.) Another myth. If calculus-free roots, pink gingiva, osseous regeneration and 3mm residual pockets are your criteria for success, you’re going to be very disappointed. These may be valid ideals but they’re not realistic goals. The goal of periodontal therapy is very simple: Stop the progression of the disease. Accomplish and document this and you’ve fulfilled your moral, ethical and legal responsibilities to the patient. Write that down because it’s important. Whether you’re a hygienist or dentist, it’s central to enjoying a fulfilling career treating periodontal disease. So how do we know when we’ve stopped the disease? There are some fascinating high-tech developments in the study of periodontal disease. And I don’t want to diminish their importance. But in this practitioner’s humble opinion, their diagnostic potential remains largely in the future. So far, none of this impressive technology can answer the one critical question: “Have we stopped the progression of the disease?” There are only two ways to measure success. The only reliable indicators of an active disease process are (1) attachment loss and (2) a loss of boney support. If successive probings show the periodontal attachment is heading apically, or the radiographs reveal ongoing bone loss, it’s time to ratchet up your efforts. In this short article, I’d like to concentrate on that second indicator and offer a few suggestions for getting more bone-loss information out of your x-rays. First of all, bite wings (not periapicals) provide the most accurate indication of the interproximal bone level. It is very difficult to read the bone level when the picture elongates or foreshortens the tooth. (To point out the obvious: you can’t compare a periapical with a bite wing.) You must be able to visualize the bone level around each tooth. Occasionally, when you examine a horizontal bitewing, the bone will drop off the film. (Illustration 2) You just “know” it’s immediately below the picture so it’s tempting to live with the shot. Don’t do it! Shooting vertical bitewings almost always lets you visualize the bone level. (If it doesn’t, then you have to resort to a periapical, with all its weaknesses.) In the horizontal bitewing, the maxillary bone level looks pretty good. But notice the blind-spot around the first bicuspid (left) Only when a vertical film is shot (right) does the depth of the pocket become apparent. You must be able to visualize the bone level around each tooth. Second, use XCP® rings or similar holders to position the head of the X-ray tube. This is pretty much standard procedure in periodontally-oriented offices…but if you’re not using them, get a set. They’ll consistently reproduce the same angle, allowing accurate comparison over a period of time. And my most important suggestions concerning There’s Mrs. Smith in the supine position, staring at the ceiling while you’re playing solitaire on the viewbox with 26 films taken over 3 years…trying to arrange the pictures of each tooth in chronological order. (Then of course, once you finish, you have to get everything back into the right envelopes.) The traditional mounts used in many practices aren’t much better because they require you to juggle three or four sheets in order to visualize the same tooth at different appointments, (Illustration 3) The solution is the Bite Wing History
Mount (also called a “serial Holder.”) It’s a simple plastic or
cardboard sheet that arranges your films in columns and rows. Just
mount one bitewing series in each row with the date written to the
left. That way, you can glance down a column and see the same tooth
at each angle at four points in time. It’s almost like sequential
frames in a movie. (Illustration 5) Once they’re mounted in serial holders, radiographs become so easy to understand they provide a terrific opportunity for patient education. When I’m faced with a dental slacker, I generally start my presentation with a model that features a removable rubber gingival. I whip off the ersatz tissue to reveal the bone level; healthy on one side…severely resorbed on the other. Now that’s pretty academic stuff. If I stopped there, I probably wouldn’t win too many converts. What hammers home the punch line is what I do next. I take the patient, the model, plus my serial holder over to the X-ray viewer and show the patient exactly what’s happening in his own mouth. In each sequential film his tooth looks more and more like the tooth in the resorbed ridge on the model. You may be succeeding without realizing it And even if you don’t shock all your difficult patients into compliance, you’ll be amazed at how switching to serial mounts can change your view (literally and figuratively) of treating them. Every time Mr. Jones shows up, probing reveals blood…maybe even a little pus. You’ve tried lectures. You’ve demonstrated brushing, flossing and irrigation till you’re both sick of it. Maybe you’ve even tried some shock tactics and threatened to send him out for (shudder) surgery. But nothing seems to work for this unmotivated patient. Every appointment, it’s “déjà vu all over again.” You have this
frustrating sense that Mr. Jones is inexorably sliding downhill.
(Here come those feelings of inadequacy again!) Success is measured by your ability to halt the progression of the disease. Left on his own, there’s a good chance that Mr. Jones might be edentulous by now. Your intervention every 6 months (or 4 months or 3 months) is the only thing standing between him and a set of complete dentures. Diagnosing the new patientI’ve known dentists and hygienists who took one horrified look at the initial radiographs and immediately referred a new patient to a periodontist. Now maybe the patient’s problems were over their head but there was no way they could possibly know from a single set of radiographs. A low bone level indicates only that disease has been active. Not that it is now present. When a new patient presents with periodontal disease, your must (must!) contact the previous dentist and get copies of prior radiographs. Not just the last series, mind you. But the series before that, too. In fact, the more series you can get, the better. That’s the only way you can set up your serial mounts and see what you’re up against. Are you looking at the results of long-past episodes or is the disease still active? And if it’s active, are you facing chronic adult periodontitis? (Unless you’re highly experienced, RPP is best handled by a specialist.) Don’t misunderstand, I’m not suggesting that you defer conservative treatment till you have the entire radiograph history. If you discover bleeding, inflammation and pus, you have to act. I am suggesting, however, that you defer any irreversible treatment until you can see exactly what’s been going on for the past year or two. Improving your periodontal diagnostic skills and learning to enjoy your profession may be as simple as remounting your old radiographs. Skeptical? Try it. About
the Author...
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  What you can’t see CAN HURT.   Illustrations #3 & 4: It’s all how you look at it.  Illustration #5 Like sequential frames in a movie. In a war of skirmishes (which is what most periodontal therapy is), it’s easy to lose track of who’s winning and who’s losing. Mr. JF here was a real challenge. Poor home care. Constant bleeding. Extensive bacterial plaque. Yet, as this column from his serial mount shows, for 14 years the bone level has remained rock solid. If you look carefully, you’ll notice that at various times the disease has flared up and retreated. However, even a cursory glance at the serial mount leaves no question that the Forces of Evil are not in control. Primary method of treatment? Since 1985, antimicrobial ultrasonic debridement. |