Leaders in Dentistry: A conversation with Dr. Donald Clem

DrBicuspid.com is pleased to present the next installment of Leaders in Dentistry, a series of interviews with researchers, practitioners, and opinion leaders who are influencing the practice of dentistry.

We talked with Donald S. Clem III, DDS, president of the American Academy of Periodontology (AAP), who also maintains a private periodontal practice in Fullerton, CA. Dr. Clem discussed the importance of the oral-systemic link and dentists' role in screening for medical conditions such as heart disease and diabetes. He also stressed that while the introduction of midlevel providers may alleviate some access-to-care issues, it is crucial that they work under the supervision of a dentist.

Donald S. Clem III, DDS

Donald S. Clem III, DDS

DrBicuspid: The latest research finds that patients with periodontal disease may be at an elevated risk for several systemic conditions, such as heart disease, diabetes, and adverse outcomes in pregnancy. Do you think there is enough awareness of this link within the dental community?

Dr. Clem: The large body of research suggesting that periodontal disease may be linked to other systemic disease has certainly helped to raise awareness of the perio-systemic link within the dental community. I also believe that dental professionals are seeing more real-life clinical examples of the perio-systemic link in their individual practices, which is helping to increase understanding of this growing health concern.

But not all dental professionals are on board with this paradigm. Many still focus on bacterial etiology rather than looking at how the inflammatory burden in the body may impact both periodontal and overall health.

We know that inflammation plays an important role in the progression of disease, and I encourage all dental professionals to pay attention to more than just soft tissue management. Our patients cannot be healthy unless they are periodontally healthy.

Given the growing importance of the oral systemic link, what role do you see the dentist playing in screening for conditions such as heart disease and diabetes?

As dental professionals, we have an obligation to do more than diagnose the existence of periodontal disease. This means looking at risk factors associated with chronic diseases and, when necessary, opening a dialogue with our medical colleagues.

For example, if I were treating a patient with diabetes who was having difficulty controlling his or her periodontal disease, I would certainly consult the patient's physician to determine how I can be of assistance in helping the patient maintain glycemic control.

I envision the dental profession playing a larger role in the screening of systemic diseases, especially as research continues to support the link between periodontal health and overall health.

Do dental insurance companies cover this kind of screening? Do you think if they provided coverage more dentists would be willing to provide screening?

Individual insurance coverage is based on the benefit plan. Some screening tests may be covered, depending on the dental -- or sometimes medical -- plan that the patient has purchased or receives from his or her employer. I'm hopeful that more insurance companies and plan purchasers will consider benefit plans that accommodate these screenings.

As evidence continues to support the link between periodontal disease and other disease, we may see growing numbers of dental professionals willing to provide advanced disease screening, independent of dental insurance coverage.

Last year the Centers for Disease Control and Prevention and the AAP published research suggesting that the prevalence of periodontal disease may have been underestimated by as much as 50%. What is the reason for this underestimation, and what can be done to remedy this situation?

One possible reason may be that not all dental professionals were properly evaluating for it on a regular basis. The AAP recently released a statement on comprehensive periodontal therapy that sets the expectation that all patients receive a comprehensive periodontal evaluation on an annual basis.

According to the AAP's statement, a comprehensive periodontal exam includes:

• An extra- and intraoral evaluation
• Assessment of the presence, degree, and distribution of plaque, calculus, and gingival inflammation
• Probing data around six sites per tooth
• Assessment and documentation of recession and attachment loss around teeth
• A radiographic evaluation of bone loss and identification of vertical defects and furcation involvements
• An assessment of patient associated risk factors such as age, smoking, and other chronic systemic condition associated with development or progression periodontal disease or inflammatory burden

As dental professionals, we each have a stake in reducing the prevalence of periodontal disease. By conducting a comprehensive periodontal evaluation on each patient every year, we can prevent and manage periodontal disease as early as possible.

Lack of access to care is a major contributing factor to the poor oral health of Americans. How does the introduction of midlevel providers and dental therapists affect the situation?

Access to oral healthcare is a complex matter. While it may seem logical that having more individuals available to provide oral care would help alleviate access-to-care issues in dentistry, the multiple barriers that prevent some Americans from receiving adequate oral care must be addressed first. These barriers include, but are certainly not limited to, poverty, geography, language or mobility barriers, and lack of dental health education.

As the ADA stated in its February 2011 report on the oral health workforce, all segments of the dental industry -- including dental professionals, dental hygienists, dental assistants, educators, and other stakeholders (which include some government bodies and charitable organizations) -- "must guard against focusing on any one barrier to the exclusion of others that are equally valid."

While the introduction of midlevel providers may assist in the delivery of oral care services and alleviate some access-to-care issues, it is crucial that these individuals are properly trained and work under the supervision of a dentist. The AAP supports the ADA in its efforts to ensure that midlevel providers in no way compromise patient safety.

Improved access to care ought not to suggest a lower standard of care. The AAP believes all Americans deserve the best that a team approach can provide -- dentists, physicians, and other allied health professionals working together.

Do soft-tissue lasers add clinical value to the treatment of periodontal disease beyond what can be achieved using scaling, planing, and conventional surgical procedures?

Scaling and root planing remain the backbone of fundamental periodontal therapy. To date, the addition of using lasers in the nonsurgical treatment of periodontal disease has minimal evidence to support their use in this fashion alone or as an adjunct.

The use of lasers in a surgical environment may be an appropriate adjunct to conventional periodontal surgery, but more research is needed to understand the benefit of laser use in this context. Patients deserve an evidenced-based approach to new technologies and treatments. Lasers may be an appropriate adjunct to periodontal therapy, depending on the individual patient case and experience and training of the doctor.

Does the adjunctive use of antibiotics during periodontal treatment offer any benefits?

Antibiotic use in the U.S. and associated antibiotic resistance is a real concern in healthcare today. Adjunctive use of antibiotics during periodontal treatment may be appropriate, depending on the individual patient case, but I would urge caution before prescribing antibiotic use without sound diagnosis and rationale. Careful root planing with advanced instruments such as newer ultrasonic or improved hand instrumentation has been shown to be extremely effective in eliminating the most common periodontal infection without the use of antibiotics.

We have the ability to look at different bacterial constellations via culturing technique or DNA testing. While most periodontal disease can be managed quite predictably without the use of antibiotics, there are a small number of patients that may benefit from adjunctive antibiotic use.

What are some of the most important developments in the fight against periodontal disease in recent times?

Periodontal treatment options have evolved over the past several years, and I believe the dental industry will continue to see an emphasis on evidence-based therapies. Improvements in areas such as growth factors and biologics, functional and aesthetic crown-lengthening procedures, periodontal instrumentation, and dental implant technology enhance the scope of periodontal treatment.

Some of the most exciting developments have to do with the periodontist's ability to regenerate both bone and soft tissues for retaining the natural dentition and placing dental implants. The evidence for regeneration is staggering. The use of bone substitutes, barrier membranes, and new tissue-enhancing biologics and growth factors will continue to drive regenerative advancements. Today's patients not only want their disease controlled, they want to be restored to predisease conditions. We see this trend driving advancements in medicine as well as dentistry. Patients not only want to live longer, they want to live better.

This leads me to another important development in the fight against periodontal disease: a renewed commitment to collaboration between general dentists and periodontists. General dentists are often responsible for identifying patients that may benefit from these evidence-based periodontal treatments. By working together, general dentists and periodontists can develop treatment plans that offer the patient the most successful outcomes.