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Periodontal Surgery: Avoiding and Maintaining Periodontal Treatment Before and After

Collaboration Cures 2021 Presentation by Michael McDevitt, DDS 
 
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Periodontitis is highly prevalent in the adult population globally as well as in the USA (approximately 42%). Obstructive sleep apnea has been reported to occur in younger adults in the ranges of 6% to 17% while the experience of older adults has been found to be as high as 49% with age, gender, and body mass contributing to greater susceptibility. Both diseases are inflammatory diseases and they both influence oral and systemic health so revelations of their research-based and suspected associations will be presented.
  1. Understand periodontitis as an inflammatory bone disease with systemic implications
  2. Suspect periodontitis could be influencing or is being influenced by sleep-disordered breathing
  3. Recognize clinical observations that may be indicators of this possible association

 

  ---- "Patients started to heal before they needed surgery."

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About the Presenter:

Mike McDevitt has focused nearly all of his fifty-plus years in ‎dentistry providing care for persons with periodontitis. His ‎disappointment with the inability of patients to sustain their ‎periodontal health after well-trained, well-intended procedure-based treatment redirected his career early in his private ‎practice. He has been incredibly fortunate to have had ‎exceptional dentists as mentors, often serving as role models, ‎who directed and facilitated his continuing education from ‎extremely valuable sources. Being invited to teach at major ‎dental meetings, at the Pankey Institute for many years, and at ‎both graduate residencies in Georgia prompted both the desire ‎and the need for ongoing outstanding learning opportunities. ‎Over forty years ago the evolution of person-driven care for ‎patients with periodontitis began and grew exponentially as the ‎percentage of patient successes accumulated. He received ‎further wonderful mentoring by those who taught him the goal of ‎preparing patients to be able to make their own health choices. ‎More recently his educational focus has been on systemic ‎influences of periodontitis and how systemic disease may amplify ‎susceptibility to periodontitis. Helping each person discover their ‎opportunities for improved health and to make choices in their ‎best interest remains his primary passion.‎

Video Transcript

Unique Outcome-Based Planning of Periodontal Treatment

The process of discovery and the patient engagement with the process is equally important to me as their susceptibility. I'll never treat two patients who are identical the same way. It's just impossible, there are too many factors - 

  • genetics
  • history
  • anatomy
  • TOO MANY individual aspects
This is the present understanding. Now, I qualify that because next week we may think of something else! I certainly didn't think this 45 years ago when I finished my second residency.

 

It's a chronic destructive bone disease it's not a gum disease

and it's most similar in the human condition to those unfortunate folks who experience rheumatoid arthritis. It's genetically modulated which means that it's influenced by genetics. How many of your patients have you seen in clinical settings where you look at them and think "the first thing I got to do is introduce them to the fuzzy end of the toothbrush.. I mean obviously, they're using the smooth end."

>> You clean it all you know, you go through your wonderful care and everything and they don't have any Periodontal disease. Then you see someone else who's really making an effort within the scheme of what they already know and their personal hygiene is awesome and you start measuring pockets, you look on the radiographs, and they've got 30 and 40 percent bone loss at 29 years old. What's that about?

Well, I think what we're looking at is a dysfunctional excessive inflammatory response with or without attendant gingivitis that's driven very harshly by an element of genetics. There are other variables, including airway and the nature of the bacterial invasion - is it all in the biofilm?

I think the majority of it is but Dr. Nabors [view his presentation here] presented the whole microbial invasion as part of the equations. I think that's the first time I've heard some real credible information about culturing. We cultured and nothing was different, we'd prescribe an antibiotic and in three months they were back in trouble, based on the culture, for years. So the patient is expecting gum problems. They need to know that it's much more than that.

This is what I got out of the lecture from Dr Costerton. His article was published several years later. I think it's the only really good article on perio in the ADA journal, the rest of it unfortunately is kind of misleading.

So they have a biofilm infection. those pathogens - Dr. Costerton estimated at least 90 percent of the pathogens - are on proximal surfaces and proximal line angles.

When patients learn that, it helps them understand why we're getting interested in flossing. The bad critters (critters are bacteria) are where you floss. We've got to deal with them.

Bacteria are causing bone loss.

Bacteria are responsible for this infection.

This is kind of a sticky film and they're protected within it. It would be like pouring water through motor oil.

My wife taught me the concept of prior knowledge. She's a PhD educator. Kids learn without that they don't have any prior knowledge. They're like blank IPads. But adults have all this experience. If you can connect a previous experience or previous knowledge with what you're trying to share, they're going to connect more easily.

It works. It really does work. I talk about that stuff.

I talk about the film being as resistant as motor oil. I tell them that if antibodies can't get in and your mouthwash and your toothpaste are not therapeutic in any way possible, how did your hot dog and your know spaghetti get in there? They're not waiting for you to eat.

Food debris is about cavities and personal hygiene.

Have you had any cavities recently? Say they're 48 and they say "well i haven't had one since I was in college and I had some as a kid." I said all right, I observe that your personal hygiene is quite good. So you had two missions in your oral care, and I'm going to introduce you to a third one. One that I think will really open some doors to you becoming healthier. 

The biofilm is really gooey and because of that, it's also adherent to the tooth. Now, something else that's hard to remove is cooking oil that's spilled on a kitchen counter.

I say to the patient with a grin on my face, you know I haven't met a patient yet, who cleans up cooking oil with wax paper. Would you ever think of that?

They know I'm messing with them, they know I'm joking around but you know what they remember when they come back? That silly analogy. Okay. Now I know why I'm using unwaxed floss.

If the bacteria recover, let's say in 10 hours, in the absence of food (that's arbitrary) and the patient doesn't want me to show up in a little bite truck every 10 or 12 hours, I acknowledge that with patients every once in a while. You don't want me to show up. I mean sooner or later you're either going to get a shotgun or a big dog. So who has to be the primary therapist for a disease that's ongoing and fed that frequently at least twice a day? I mean isn't that a logical conclusion?

I can't treat their disease. I can help them treat their disease, my team is amazing. Now I tell them that since I regard them as a person, a unique special capable person, I feel a sense of privilege to offer to help them so they know where I'm coming from. This is the first discussion with them. The other thing that I share - you know I bet there have been times when you've heard a statement that sounded critical because I was trained to be critical of patients who didn't take care of their mouths.

There are at least a few hygienists who have had that training. I see they have a heart for you they're trying to do their best, but they've been taught to communicate it as criticism and judgmentalism. I want you to look, I want you to know that I only have one rule:

No one who comes to me for help is allowed to feel guilty. That's the rule. We do grace every time. We never do guilt. We will never criticize. We never come across that you're not living up to it. That you're not healing fast enough. That you're not doing all you can do.

I'm going to exhibit whatever patience is necessary, as my team will, for you to succeed. People succeed at different rates. I only ask you to be patient with the learning because this is not a quick learn.


If you can get it healthy and you don't keep it healthy is that acceptable it wasn't to me I'm sure it isn't to any of you so we've got to keep it sustainable well their susceptibility to the inflammatory disease didn't go away even though they became rather healthy if they give it up it comes back they know that okay.