SCIENCE & TECH
The use of technology and devices that extend our
ability to see are also necessary to determine if a patient
is truly WNL. Enhanced oral cancer screening devices,
caries detection devices, CBCT imaging, and laboratory
testing all enhance the extent to which we can see. Would
we accurately conclude that a patient has no oral mucosal
abnormalities without utilizing devices that see beyond
the surface, or that there aren’t any noncavitated carious
lesions without employing the use of enhanced caries
The periodontium needs six-point probing to provide
information regarding attachment loss. Spot probing or
periodontal screening and recording (PSR) will undoubtedly miss one or more areas that are periodontally involved.
Recession needs to be recorded as well, since attachment
loss is a more accurate measure of periodontal health than
pocket depth alone. Comprehensive periodontal evaluation
and charting are necessary to adequately determine if a
patient’s periodontal health is WNL.
There is, however, another less commonly known meaning to WNL—”we never looked”—which no one would ever
document in the patient record. Looking goes way beyond
visual observation and includes radiographs, scans, and
lab work, among other tests.
Consider the scenario in which a patient has gingivitis
for an extended period of time and develops rapid periodontal breakdown over a short period of time. If we identified the bacteria in the oral cavity by salivary testing prior
to the breakdown, we might have noted highly pathogenic
bacteria, which would have predicted the periodontal
breakdown and perhaps given us the information needed
to intervene in advance. But we never looked.
When we diagnose a patient with periodontal disease
and identify the causative bacteria, we are able to determine
has practiced general
dentistry in suburban
Philadelphia for more
than 30 years. He is a
speaker, advisory board
member, consultant, and
key opinion leader for
several dental companies
and organizations. He
lectures on a variety of
topics centered on
understanding the impact
dental professionals have
beyond the oral cavity.
Contact Dr. Nagelberg at
Richard H. Nagelberg, DDS
GP PERIO: THE ORAL-SYSTEMIC CONNECTION
the likelihood of a successful outcome postoperatively. This
powerful information gives us the opportunity to treatment
plan nonresponding sites in advance, because we did look.
When we identify periodontal disease and treat without
testing, we are treating pocket numbers, swelling, bleeding
on probing, etc., which are merely the signs and symptoms
of disease. But when we identify the specific bacteria responsible for the patient’s case of periodontal disease, we
can then address the cause and reduce the likelihood of
disease recurrence in the future. Without testing, we are
Is looking limited to identifying diseases and conditions
that are currently present? Risk factors for a variety of
pathologies need to be looked at as well, since disease
prevention is more impactful than disease management.
Identifying risk factors for periodontal disease—such as
xerostomia, diabetes, smoking, and many others—is
important to predict the likelihood of periodontal disease
development and therapeutic success.
Human papillomavirus-derived (HPV) oral cancer is on
the rise. Salivary testing for the presence of HPV has been
available for years. Providing this testing for at-risk patients
and those in target populations would ensure that they are
truly within normal limits.
Looking is not limited to the boundaries of the oral
cavity. A large body of research has concluded that specific
periodontal pathogens are causative or involved in the
development of atherosclerosis, cardiovascular disease,
rheumatoid arthritis, and pregnancy complications, among
other problems. Testing for the presence of these bacteria
in the absence of periodontal disease should be provided
for those patients with a health history or family history
that indicates elevated risk. Patients with a family history
of heart attack, stroke, diabetes, or rheumatoid arthritis
should be considered for salivary testing to identify the
presence or absence of bacteria, including Porphyromonas
gingivalis, Aggregatibacter actinomycetemcomitans, Fusobacterium nucleatum, and others.
It is worthwhile to periodically step back and examine
the way we do things on a daily basis to determine if we are
really looking and providing optimal care for our patients.
Are they within normal limits, or did we never look?
DURING VIRTUALLY EVERY DENTAL EXAMINATION, there is a review or
update of the patient’s health history as well as a clinical and radiographic
examination. If everything is consistent with good oral and overall health, a notation
of WNL is commonly made—an abbreviation for “within normal limits.” But does
this standard visual examination truly mean that a thorough evaluation was made
such that it can be accurately concluded that the patient does not have any
pathology or conditions requiring intervention?