The Group Dentistry Now Show: The Voice Of The DSO Industry

Timothy Donley, DDS MSD is the founder of Wellness Illustrated LLC and www.BeyondTheMouth.com. Dr. Donley discusses periodontal disease on the Group Dentistry Now Show. He focuses on changing the narrative in dentistry in regards to periodontal disease and how it is not just a bone and tooth loss issue, but how oral inflammation effects your whole health. This podcast is supported by OraPharma. Find out more at www.PerioEducationUSA.com

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Our podcast series brings you dental support and emerging dental group practice analysis, conversation, trends, news and events. Listen to leaders in the DSO and emerging dental group space talk about their challenges, successes, and the future of group dentistry. The Group Dentistry Now Show: The Voice of the DSO Industry has listeners across North & South America, Australia, Europe, and Asia. If you like our show, tell a friend or a colleague.

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Full Transcript:

Bill Neumann:

Hi. I’d like to welcome everybody back to the Group Dentistry Now show. I’m Bill Neumann. And first off, thanks everybody for listening in. We’ve had a ton of podcasts. I think we dropped four podcasts last week. We’ve got another three coming up in the next couple of days. And so, without you listening in and watching us, we wouldn’t have a show.

Bill Neumann:

And of course, without great guests like the next one we have, we also wouldn’t have anybody listening or watching. So without further ado, I’d like to introduce Dr. Tim Donley. He’s a periodontist. He is based in Bowling Green, Kentucky. So first off, Tim, welcome to the Group Dentistry Now show. Appreciate you being here.

Dr. Tim Donley:

You bet. I’m excited for this.

Bill Neumann:

Yeah. This is going to be a good conversation. And we’re going to talk about periodontal disease and your thoughts on things. And it’s one of those interesting topics that I don’t think we touch on enough here. Certainly a lot of talk around it, but probably a lot of confusion as well. So little bit of background on Dr. Donley and then, we’ll get into the conversation here.

Bill Neumann:

Again, I mentioned he’s a periodontist. He’s from Bowling Green, Kentucky. And he is the Founder of beyondthemouth.com. So, really cool. I had a chance to check out that website. It had webinars and podcasts and a lot of content. And then, the other thing is he’s really heavily involved in continuing education. So, did I miss anything Dr. Donley?

Dr. Tim Donley:

No, that’s good enough. It sure is.

Bill Neumann:

All right. That sounds good. You want to talk about periodontal disease, so let’s talk a little bit about that. And you’re passionate about trying to change the narrative in dentistry. And as it relates to periodontal disease, let’s talk a little bit about that.

Dr. Tim Donley:

I am passionate. And what that passion is based on is that the realization. Look, for like the last 100 years, we dentists have largely been regarded as the senior member of the oral hygiene police, with the dental hygienist, the loyal foot soldiers in the war against plaque. With the ever expanding information that inflammation of oral origin can contribute to the systemic burden of inflammation, and that has ramifications, I think we’re missing a huge opportunity to really redefine dentistry as being about more than just simply, oral hygiene or making sure patients don’t lose their teeth.

Dr. Tim Donley:

We know now that it’s much more than that. Bacteria collects between the tooth and the gum. If it’s left there long enough, if either the patient isn’t consistently adequate in interrupting it, or if we, the therapist don’t or can’t adequately interrupt the bacteria, we know that it starts to penetrate and go deeper between the soft tissue in the tooth. The body recognizes that as being foreign. It mounts a local inflammatory response. Part and parcel of that response is the release of these inflammatory mediators.

Dr. Tim Donley:

White blood cells and other inflammatory cells are summoned to the area. They start to dump out a variety of mediators of inflammation, among those collagenases, which break down collagen. Now, the reason that’s significant is everything we try and preserve in the periodontal environment, is mostly collagen. The bone is mostly collagen. The periodontal ligament is mostly collagen. That typical response is what leads to pocketing and bone loss.

Dr. Tim Donley:

And up until recently, when we would give our little spiel to patients, we all would culminate at a point and say, if you have periodontal disease and if you don’t do something about it, it chews away at the bone support. If you lose too much bone support, the teeth get loose and the teeth fall out. And we crescendo at the point where we say, periodontal disease is the leading cause of tooth loss in adults. And I guess my whole thing is, I don’t think we should stop there anymore.

Dr. Tim Donley:

I think we absolutely have the opportunity to go further than that and say, we know that inflammation anywhere in the body is bad. Medicine is clear on the fact that systemic inflammation is what drives a lot of the chronic, serious diseases of aging. In that typical periodontal pocket, when in fact, that local inflammatory response occurs, the lining epithelium ulcerates. That allows bacteria, bacterial byproducts, the mediators of inflammation, to daily spill into the bloodstream and contribute to that systemic burden of inflammation.

Dr. Tim Donley:

Clearly, I think we can go beyond telling people, well, do this or you’re going to lose your teeth. I think this is a part of overall wellness, to achieve a preferred level of oral health. And that’s what drives the passion.

Bill Neumann:

Yeah, absolutely. You certainly are passionate about it, and I can hear it from the way you deliver the message. So talk about the significance of this, specifically in dentistry.

Dr. Tim Donley:

Well, I’ll tell you right off the bat, it gives us a lot better message than what we’ve said for the last 100 years; brush and floss or your teeth will fall out. It’s about time that that changes. Well, we have the opportunity really to better motivate and better care for our patients, by educating them. And I think that’s the message. The new message of dentistry is look, inflammation anywhere in the body is bad. The mouth can contribute to the amount of inflammation in your body, if you have untreated disease.

Dr. Tim Donley:

The fact of the matter is, most people that have it don’t even know it. Maybe we’d be better off making sure everyone that comes into the office realizes that chronic inflammatory periodontal disease is a potentially serious disease. Keeping it at bay has the potential to improve yes, not only your oral health, but especially for specific patients, your overall health as well. And I think that packs a bigger wallop than, “Well, you really better brush and floss your teeth.”

Bill Neumann:

Certainly. Well, any specific examples that you use chairside? So, how do you get this message across?

Dr. Tim Donley:

Yeah, great question. From my way of thinking, I think there are a series of patients in whom this is really important. We call those priority patients. And these are patients that have risk factors for periodontal disease. And we all know what those are, that are similar to the risk factors for some of these systemic diseases. There are a lot of those that we have in common in periodontal disease.

Dr. Tim Donley:

So how that plays out clinically, if you stop and think about it, tobacco users come into the office. Well, we all very proudly stand up and say, well, tobacco use is a big risk factor for gum disease. I think we have the opportunity. In fact, you might even say we have the responsibility to make sure tobacco users realize, look, you’re already at increased risk for heart disease. That’s well established.

Dr. Tim Donley:

You’re at increased risk for gum disease. If we don’t aggressively treat the gum disease, that at least has the potential to even further raise your risk for cardiovascular disease as a result. The underlying message is look, we can’t monkey around with this anymore in your case. If you’re a tobacco user yeah, we’d love you to quit. But if you don’t, man, put us on the list. We have to treat you, not just doing the procedure and figuring well, that’s it. We have to treat you till we get the desired outcome.

Dr. Tim Donley:

Because doing so, has the potential to affect your overall health. And there are other patients in this priority category, patients with diabetes. Boy, there’s enough information already that eliminating the burden that oral inflammation puts on blood sugar control, we have the potential to make an impact. Patients that have diabetes are already at increased risk for periodontal disease, if in fact, that goes unchecked.

Dr. Tim Donley:

We know it can at least potentially adverse affect blood sugar control. While a stop in the dental office might not be the first stop in terms of a patient managing their diabetes, man, it sure should be the second. This is something that we can do. And even in our practice, we have internal medicine people who are excited about partnering with us because they know we can help them achieve what’s a really difficult thing for some patients. And that is to get their blood sugar in better control.

Dr. Tim Donley:

This sums it up, and I love this. It’s a direct quote from the published findings that came out of the 2019 Perio-Cardio Workshop. This was a joint meeting between the World Heart Federation and the European Federation of Periodontology. And their conclusion after looking at all of the research suggested quote, “People with cardiovascular disease must be aware that gum disease is a chronic condition which may aggravate their cardiovascular disease. And requires lifelong attention and professional care.”

Dr. Tim Donley:

That’s something we should be shouting to every patient that walks by our office, let alone comes in. This is cardiology saying, man, you have to partner with a dental professional because this is an important part of getting you well. And as I said at the beginning, it’s time to leave brush and floss behind.

Bill Neumann:

Yeah. It sounds like what you’re saying is today’s dentistry is a heck of a lot more, right, than just trying to help people save their teeth?

Dr. Tim Donley:

Well, I think you’re right on the money. And this is admittedly, a little bit more on the philosophical side. But in dentistry, for way too long in my opinion, we focused on the procedure rather than the outcome. And I think that’s a big mistake. We, and many of us still do that, well, we root plane them and insurance only covers it every two years. So we already did it. They must be okay.

Dr. Tim Donley:

My whole deal is for certain patients, because of this potential tie in, man, it’s really important to get the desired outcome. We have to define the outcome. We have to treat them until we get the outcome. Instead of saying, well, we root plane and we can’t do it for another two years, we have to stop and say, did the root planning achieve the outcome that we needed?

Dr. Tim Donley:

And if not, we at least have to offer the patient treatment options that increase the likelihood that we are going to achieve the desired outcome. And I think that desired outcome has to go beyond we help patients keep their teeth. And that’s what we all want done. For too long, we’ve focused on, and we’ll even say it, I laugh as a periodontist, I’ll have referring people call me up and say, “Well, the patient still has their teeth. And we’ve tried really hard and they’ve kept them for about 15 years.”

Dr. Tim Donley:

“But I think the time has come. The patient wants to know if there’s anything else you can do to help them keep their teeth.” I don’t think the goal should be to help patients keep their teeth. I think the goal, I think a preferred level of oral health is a dentition that’s functional, that’s aesthetic, that’s relatively inflammation free and maintainable by the patient. Now, that takes a little bit of reflection from a philosophical standpoint.

Dr. Tim Donley:

And that actually, might be a pretty decent topic for a staff meeting sometime. What is it we’re trying to achieve for patients? I think we at least have to offer patients treatment that gives them a dentition that’s functional, that works, that’s aesthetic. Certainly, that’s an important part of life. That’s relatively inflammation free, and that’s able to be kept that way and to be maintainable.

Dr. Tim Donley:

We encourage patients not to come to us to get their teeth cleaned anymore. We encourage patients to partner with us over their lifespan, because we’re the only ones that can determine oftentimes, if this disease is present. We’re the only ones that can get it to resolve. We tell patients to partner with us as part of their strategy for overall wellness. And clearly, the evidence has continued to strengthen and to support them.

Bill Neumann:

So Dr. Donley, how do you keep periodontal disease at bay?

Dr. Tim Donley:

Well, in my practice, as I said, I really use a priority approach. We’re dealing with a systemic disease that has site-specific presentation. Now, what that really means is that some patients and some sites in those patients, are more likely to show chronic inflammatory periodontal disease. Many other risk factors for chronic inflammatory periodontal disease are also risk factors for the systemic diseases that are associated with periodontal disease.

Dr. Tim Donley:

It sure seems reasonable to me to take a more aggressive approach when managing patients who have an elevated risk profile. We know that persistent gum disease can potentially lead to significant health concerns beyond the mouth. We know that there are certain sites that are more likely to have disease. We treat them, patients and those sites, more aggressively.

Bill Neumann:

So let’s talk a little bit about who these priority patients are.

Dr. Tim Donley:

Yeah. I think that’s a great question, and another one of those things that in an office, everyone has to be up to speed as to what this is. I think tobacco users, patients with diabetes or hyperglycemia, patients over their ideal weight, post-menopausal women, patients that are at high risk or have a diagnosis of sleep apnea, for all of those categories of patients, you can make a case for the fact that inflammation of oral origin is more significant in those patients because of their associated conditions.

Dr. Tim Donley:

For instance, we know being over your ideal weight now, is a significant risk factor for periodontal disease. We understand the mechanism by which that happens. Well, people over their ideal weight are already at increased risk for things like heart disease and diabetes. There are at an increased risk for periodontal disease. If we don’t aggressively treat the periodontal disease in patients that are over their ideal weight, it has the potential to further add to the systemic problems that are being driven by them being overweight. That’s why we put these patients on the priority list.

Bill Neumann:

Let talk a little bit about your opinion on procedure rather than outcome. What are your thoughts on this?

Dr. Tim Donley:

Yeah. Dentistry, as I mentioned briefly earlier, dentistry’s long been focused on the procedure rather than the outcome. My whole message is this. For all patients, but especially priority patients, getting the desired outcome is really important. Yes, we need to provide treatment. But then we need, especially in priority patients, to check to see if the treatment yielded the desired result.

Dr. Tim Donley:

If it didn’t, common sense says you’ve got to try something else. And I guess what I’m trying to say more practically, look, the goal isn’t to simply do a “deep cleaning”. The goal is to get all disease sites in a patient’s mouth back to health, to give them the best chance to get healthy, and then do what’s ever necessary to allow them to remain healthy. Because in priority patients, that at least has the potential to pay dividends beyond the mouth.

Bill Neumann:

So, are you talking about deep pockets?

Dr. Tim Donley:

Well, now, you’re asking all the right questions, because that actually gives me another chance to be a little bit philosophical. If you stop and think about it, pocket depth really is only part of the story. What you’re asking and what most people are asking when they ask about pocket depth is, which sites do you treat and how do you treat them?

Dr. Tim Donley:

Another one of those great topics for everybody in the office, doctor, hygienist, even front desk and chair site people, to be on the same understanding, what is our definition of what a diseased site is and what a health site is? You need to know that to determine if you’ve achieved the outcome. Which sites do you treat?

Dr. Tim Donley:

How do you know if the treatment worked? What do you do if the treatment didn’t work? We all kind of assume. And based on doing the procedure, we don’t necessarily get to the answer to those questions. And I think we have to. To answer those, in a recent World Workshop in periodontics, this is where they get the true experts in the field. They lock them in a room and they don’t let them out until they reach a consensus.

Dr. Tim Donley:

We know what a healthy site is now. A healthy site is quote, “Periodontal disease stability will be defined as a state in which periodontitis has been successfully treated through the control of local and systemic factors, resulting,” and this is what’s important, “resulting in minimum bleeding upon probing, optimal improvements in periodontal probing depth and attachment levels, and a lack of progressive destruction.”

Dr. Tim Donley:

Optimum probing depth, I think really means that the site is maintainable by the patient. And that’s one of the definitions of a preferred level of oral health; relatively free of inflammation, functional, aesthetic, and maintainable. This definition of a healthy site, I think that forms the basis. For the goal of dental therapy, help patients achieve a functional, aesthetic dentition in which all sites are relatively inflammation free, stable, and maintainable by the patient.

Dr. Tim Donley:

Ideally, we want to help patients, especially patients in whom oral inflammation can adversely contribute to their overall health. We want to achieve a dentition that’s stable over time. So let’s bring this to clinical significance. Based on the definition of a healthy site, I think this is what’s a working definition of a problem site. Sites that need treatment are sites at which bleeding upon probing, or other signs of inflammation are noted, sites certainly where the pocketing and the attachment loss has progressed over time.

Dr. Tim Donley:

But then also, sites where your clinical judgment suggests that the site wouldn’t be maintainable by the patient. And this is another point that I think bears clarification. Clinical judgment, by definition, is part of the evidence-based approach. The evidence-based approach means yes, look at what the good and biased evidence says, look at what your specific patient presentation needs are, and then use your clinical judgment to determine the most reasonable path forward.

Dr. Tim Donley:

When I assess the periodontal status of a patient, I’m really asking myself at each site, is there any evidence of inflammation? If there is probing depth, has it gotten worse? But then I’m also saying to myself, look, based on the topography of this site, is it reasonable to expect the patient to be able to maintain the site? Now, we’ve gotten to the point where we do that reflexively because we’ve done it time and time again.

Dr. Tim Donley:

With new hygiene hires, we have this written down, those three criteria. Ask, and encourage them to ask themselves at each site in a patient’s mouth, if there’s any evidence of inflammation as the probing depth gotten worse, does your clinical judgment say whether it’s going to be maintainable or not? And I think the answers help us to determine which sites to treat, taking that priority patient approach.

Bill Neumann:

So then, how do you treat those problems sites? How do you determine that, and what type of treatment?

Dr. Tim Donley:

Yeah, reasonable question. Things have changed dramatically in this area as well. In addition to my private practice, one of the other hats that I wear, I co-authored the first ever comprehensive textbook on periodontal debridement. And based on that experience, I can tell you that some of the old concepts that many of us still deeply believe in, simply are not supported by the science. These are some of the concepts I teach when I do hands-on debridement courses.

Dr. Tim Donley:

Etiology? Look, it has to be about more than calculus. The whole concept of scraping the root until it’s glassy smooth, which I was taught, which many practitioners still do, despite what you might deeply believe that, well, that actually gets the toxins out of the root, that not only is not supported by the evidence. We’ve known for 30 years, that that’s not necessary. We don’t want hardcore cementum removal.

Dr. Tim Donley:

Yeah, we need to remove the calculus, the clinically detectable calculus as much as possible. But we actually want to do it and preserve the cementum. Because we know that the biofilm, the microscopic etiology really is just in the outer 40 microns of the root. Hardcore cementum removal is not only not necessary, it really isn’t prudent. We also know from periodontal regeneration research that preserving the cementum actually has the potential to result in a better level of attachment.

Dr. Tim Donley:

So what that means is indeed, we’ve got to change our whole mindset. We teach yes, you certainly have to remove the clinically detectable plaque. You have to remove any clinically detectable calculus. But you also have to understand that the etiology is microscopic. Yes, biofilm forms plaque, plaque calcifies and forms calculus. Not all microscopic biofilm forms plaque, not all calculus grows to the point where it’s clinically visible.

Dr. Tim Donley:

If you want to maximize the chance for resolution of disease at a site, and we’ve decided that for certain patients, it’s really important to do that, we have to remove any clinically detectable etiology without excessive cementum removal. And then, we have to remove any potential microscopic etiology. How do we know whether it’s there or not? The microscopic etiology? We don’t. We don’t have a way to clinically identify that yet.

Dr. Tim Donley:

We have to assume at sites that meet the definition of being diseased, I think we have to assume that those root surfaces are covered with microscopic etiology, because we don’t know otherwise. The only realistic way for us to maximize the chance for resolution is to remove any clinically detectable etiology and then expose every square millimeter of the effected root surface to a method that has the potential to interrupt any potential microscopic etiology.

Dr. Tim Donley:

In essence, we think of debridement at the microscopic and topographical level. Now, that’s another one of those things that admittedly, that starts to get pretty philosophical. But boy, I think it’s important for everyone in the office to get on the same page with that. What we want to do is have a clear understanding of what the goal of debridement is, because that’s the only way we’re going to get the desired outcome. And I hope that makes sense.

Bill Neumann:

Yeah, it sure does. So, is that it?

Dr. Tim Donley:

Well, that’s never it. No, not quite. The other concept I think that’s really important is that there are some pockets that are actually more difficult to debride. If in fact, we have to expose every square millimeter of the involved root surface, realize whether you’re using hand instrumentation, ultrasonic, whatever method you’re using, things like furcations, root concavity, subgingival restoration margins, certainly as the pocket gets deeper, these are all factors that make it more difficult to get that intimate debridement contact with every square millimeter of the root surface.

Dr. Tim Donley:

I call these debridement difficulty factors. And that’s where I think combination therapies come in. We for too long have been focused on what our favorite method of debridement is. Well, I really liked curettes because I like the way the route feels afterwards. None of that’s valid anymore. Based on the science, we want to interrupt, certainly remove clinically detectable etiology. But then, do it in a way that doesn’t remove excessive cementum and then expose the entire involved surface to a method capable of interrupting any microscopic etiology.

Dr. Tim Donley:

If there are debridement difficulty factors present, we have to consider using multiple overlapping methods to try and figure out how to maximize the chance that we’re going to interrupt any microscopic etiology. Now, I fully understand there’s many practitioners who will admit confusion. We haven’t done a great job in terms of dental education and dental hygiene education, in spelling out the benefits and the downside to different methods of debridement. But suffice it to say, it has to go beyond what you like to use.

Dr. Tim Donley:

You have to keep in mind what the desired outcome is, what the goal of debridement is. And I would love to bring that to better clinical significance. We have chairside guides that we can use to work through, to tell us specifically what is going to give us the best chance to treat sites. Maybe I’ll come back some time and in a second part, present a chairside clinical protocol that can make it easier for dental professionals to solve some of these periodontal mysteries.

Dr. Tim Donley:

But above all, and I think that’s why we’re all here, is to make it more likely that patients can benefit from good periodontal outcome. We can achieve that. There is no mystery to periodontal therapy. It works if in fact, you do it in a way that maximizes the chance to get the desired outcome. And I hope the discussion we have makes it a little bit easier for that to happen.

Bill Neumann:

That’s great. And we would love to have you back for part two of this. This is really important to the clinical staff. We don’t necessarily go into clinical a lot on the Group Dentistry Now show, and we should. So really, creating this clinician’s corner. And Dr. Donley, you’re going to be one of the first to get the message out.

Bill Neumann:

And periodontal disease being as important as it is, we really appreciate you sharing your philosophy that this is much bigger than just dentistry. And then hopefully, a lot of these clinicians could take these back to the groups that they work in and really going to spread that message and improve the patient’s quality of life. Not just their teeth, but their overall health.

Dr. Tim Donley:

Now, I think that’s well said.

Bill Neumann:

Yeah. And again, appreciate it. We definitely want you to come back. So again, I’d like to thank everybody for listening and watching today, on the Group Dentistry Now show.

Bill Neumann:

I’m Bill Neumann. We’ve had the pleasure of listening to Dr. Tim Donley, who is a periodontist. He is also a paid consultant of Auro Pharma. We’d like to thank Auro Pharma for that, and Dr. Donley. And we’ll see you again soon.

Dr. Tim Donley:

I would look forward to it. Thanks.

Bill Neumann:

Wonderful. Until next time, this is the Group Dentistry Now show.