Periodontal and Systemic Link – Correlation or Causation? – GF024

Protrusive Dental Podcast

In this episode, we focus on the link between periodontal disease and the systemic effects on the human body. There’s more to oral hygiene than just saving our teeth, so let’s dive into this fascinating episode with Dr Reena Wadia to learn more about the importance of perio and how it is associated with the rest of our health.

https://youtu.be/fldpB_8h2Dc

Watch GF024 on Youtube

Key Takeaways:

• There is a strong link between gum health and systemic health.
• Diabetes and cardiovascular disease are key conditions linked to gum health.
• Understanding correlation vs. causation is crucial in dental practice.
• Effective communication with patients can improve treatment outcomes.
• Treating pregnant patients for periodontal health is safe and beneficial.
• Proper diagnosis is essential for effective dental treatment.
• Patients are often unaware of the links between gum health and overall wellness.
• Motivating patients with health benefits can enhance compliance.
• Evidence-based dentistry is vital for accurate patient information. Add the word diagnosis to templates for clarity.
• Team collaboration (dental and medical practices) enhances patient care effectiveness.
• Screening for conditions like diabetes can save lives.
• Holistic care in dentistry is becoming increasingly important.
• A periodontal protocol is crucial for consistent care.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

• 3:50 Introduction to Dr Reena Wadia
• 7:14 Systemic Link
• 12:24 Under Investigation
• 13:54 Using this with our Patients
• 17:04 Birthweight-related Studies and Pregnancy
• 20:14 Make a Periodontal Diagnosis
• 23:34 Medicine and Dentistry Collaboration
• 26:29 Understanding the Patient
• 29:14 HbA1c Machine
• 32:19 The Perio Handbook

This episode is eligible for 0.5 CE credits via the quiz on Protrusive Guidance.

This episode meets GDC Outcome A, B and D.

AGD Code: 490 PERIODONTICS (Pathophysiology of periodontal disease)

Aim: To enhance dentists’ understanding of the link between periodontal health and systemic diseases, enabling them to integrate evidence-based periodontal care into their clinical practice.

Learning Outcomes:

1. Knowledge and Application: Dentists will gain a thorough understanding of the bi-directional relationship between periodontal disease and systemic conditions such as diabetes and cardiovascular disease, and learn how to apply this knowledge in clinical practice to improve patient outcomes.
2. Patient Education: Dentists will acquire practical strategies for effectively educating patients about the systemic implications of periodontal health, using analogies, visual aids, and evidence-based communication methods.
3. Holistic Treatment Planning: Dentists will learn how to incorporate systemic health considerations, such as screening for diabetes or collaborating with medical professionals, into their periodontal treatment plans to deliver comprehensive care.

Enhance your knowledge with Dr. Reena Wadia’s Perio School and establish a habit of implementing Perio protocols in your practice. Don’t forget to grab a copy of the Perio Handbook by Dr. Reena for valuable insights!

If you enjoyed this episode, check out: Communication Masterclass for Periodontal Disease [B2B] – PDP086

Click below for full episode transcript:

Teaser: When you hear stories like that, it's like, could that have been undiagnosed diabetes, heart attack, et cetera, et cetera. So I feel so privileged being able to have that ability to do that test on our patients. And yeah, it's not the nicest thing to say to someone, you might have diabetes, but actually like that could save someone's life.

Teaser:
The guidelines now are, for example, for diabetics, once they’ve been diagnosed with diabetes, they’re supposed to see their dentist, but they need to push it more, because they definitely push the eye appointments, the foot appointments, but what happens to dental? It’s absolutely fine and safe to treat pregnant patients.

Jaz’s Introduction:
A really great trend we’re seeing is the integration of dentistry back into the body. Because for so many years, since the inception of medicine, dentistry has been like on the sidelines. It’s as though the mouth is not part of the body and how little communication there is between medicine and dentistry.

Now all that is changing, especially when it comes to things like airway, right? Sleep disordered breathing has really started to connect medicine and dentistry, and now with strengthening evidence base of certain dental conditions and how they link to medicine. It’s a very exciting time. Now this episode, we’re focusing on the perio and systemic link.

Hello Protruserati, I’m Jaz Gulati. Welcome back to your favorite Dental Podcast. This one’s called Group Function, but we find out one burning question. Burning question, I want to find out from Dr. Reena Wadia, perio specialist today. Is in a world where there’s so much about correlation versus causation? Just because some things correlate does not mean that one causes the other.

However, when it comes to periodontal disease, do we have enough evidence to suggest that there is a true link between periodontal disease and general health? And which links are those. How can we harness this? How can we motivate our patients and what claims can we make to our patients safely? And actually towards the end of this episode what we develop into is really quite good because what we talk about is the number one error that general dentists make and that is a lack of diagnosis, even a periodontal diagnosis of healthy is still a diagnosis.

And an even bigger overview is, does your practice have a periodontal protocol in place? Are your hygienist and dentist singing from the same hymn sheet? And are you talking about general health and those links? Well, hopefully after this episode, you will be.

This episode is eligible for 0. 5 CE credits. Protrusive Education is a PACE approved provider and those in the UK, the GDC is going to be asking for your CPD anytime soon, every December. We distribute a shed load of certificates, because those Protruserati that have been listening to the podcast, been claiming CPD, are sleeping easy, because they’ve got so much CPD.

If you go back all the way six years to Protrusive Archives, you can collect over 300 hours of CPD just from the podcast episodes. So if you’re not already on our platform, answering our quizzes to validate your learning from these episodes, it’s so easy. Just head to protrusive. app, make an account, choose your plan, as well as gaining CPD or CE credits, you support Team Protrusive and our educational movement.

This month we also launched the sixth lesson of VertiPrep for Plonkers. First five core lessons. I essentially teach you how to place your first ever vertical crown, how to ditch the shoulder and ditch the chamfer for the vertical margin, especially good for teeth with subgingival caries and limited tooth structure because you’re so conservative with a vertical preparation.

Once you go verti, shoulders feel dirty. And in this sixth lesson, I went over a full case in full detail, every little facet of the video. I also talked about quality controlling your lab work and generally revised all the principles for the first five lessons. If you want to check out this mini course as well as all my other mini courses, check out protrusive.co.uk/ultimate. That’s protrusive.co.uk/ultimate. Learn to fall in love with dentistry all over again. Now let’s join Reena for this main episode and I’ll catch you in the outro.

Main Episode:
Dr. Reena Wadia, welcome back again to the Protrusive Dental Podcast. You did such a wonderful job in a crown lengthening tutorial. That was, I don’t know, a couple of years ago. Now I didn’t know, I lost track, but as I mentioned that podcast, you’ve been a true mentor to me, even an inspiration. I’ve been attending your talks and reading your blog since I was a student. Fast forward so many years, I’m the one with the gray beard and you look like you’re still, just freshly qualified. I don’t know how you do it. How are you doing?

[Reena]
I’m good. Thank you. So great to be back. And you’re too kind. I don’t agree with all those points. I’ve got plenty of pages, you just can’t see them.

[Jaz]
Well, I can’t see them on the studio here, but you can announce that since your last appearance, you’re now a mum.

[Reena]
I am.

[Jaz]
You’re a clinic owner and also now an author of a published book as well. We were talking about that? So how do you squeeze it all in, Reena?

[Reena]
I’ve got a great team around me. Team being my family, but also my work team. That’s the key ingredient, I think, that’s made it all happen. So I’m super grateful for them.

[Jaz]
And for those who haven’t heard of you, but living under a rock, tell us about you, the dentist, the family person. Just about you, Reena.

[Reena]
Yeah, sure. So I’m a specialist periodontist and I’m the founder of RW Perio, which is our clinic based at 75 Harley Street. It’s probably the largest Perio clinic now in the UK, because we’ve got six Perio specialists working with us, five hygienists, four chairs.

So it’s quite a big facility as such, but it’s, we’ve got a really brilliant team. I’m also the founder of Perio School, which is our global teaching academy. So we do lots of online courses, in person courses, including crown lengthening. And then, yeah, I’ve just released a book. We’ve also got a product range. So I’m keeping my hands fairly busy. But yeah, as you said, I’m also a mom, which is probably my most important role.

[Jaz]
Absolutely. And how many days clinical are you? Like, obviously, you did your perio training. Now you’re a clinic owner. You wear so many other hats. How much involved are you clinically?

[Reena]
Yeah, usually about two days. So not the full four week, because I also teach a diploma program once a week as well. And then there’s always lots of other things going on, admin, et cetera. So, and I try to spend a little bit of time with my daughter during the week as well, which is quite nice. So yeah, balancing everything so far.

[Jaz]
And what is your favorite procedure to do? I would just, I’d like to know, like, from special, what is your favorite thing to do?

[Reena]
Well, definitely surgery, definitely aesthetic surgery, either crown lengthening like aesthetic crown lengthening or a lot of what we’re doing right now is coverage of recession defects, which has become more and more popular.

Even we’ve had direct patients saying, Oh, I don’t like this two millimeter recession. Can you cover it? And it’s amazing what we can do with mucogingival surgery now. When I was an undergrad, I was taught hardly anything on this. Even in my perio of first year, I had no idea, but then as I developed into the specialty, it’s pretty impressive what you can now do with perio surgery, and I think, like, everyone should know about that.

[Jaz]
Do you think there’s a role in the GDP to do simple cases, like Miller’s Class 1, where you’ve got the papillae and stuff, do a couple of millimetres of root coverage, or do you think there’s very much a domain of the specialists?

[Reena]
I think it really depends on the case. You definitely have to do more training, especially recession surgery. Crown lengthening is great. I think every dentist should build their skills on that. Hence we’ve got the course, but I think recession cover is a little bit more tricky, but if it’s something you enjoy and you’ve done more training on it. For sure. I think it’s so useful to have that skill. And there’s so many people who present with it. So you definitely would be inundated.

[Jaz]
Very good. Well, today’s main theme, like I said, crown lengthening, we talked about last time, so everyone, please do go back and listen to that episode if you haven’t already, but today we’re talking about something much bigger, much more powerful in a way, right? So this is the systemic link periodontal and your general health, which I know you’re very passionate about.

I just want to set the scene a little bit because it is a little bit topical last month. I think it was on Steve Bartlett’s podcast. He covered this with Victoria Sampson, right? And here’s a really interesting thing that happened, right? When I went on the usual dental groups. Okay. Firstly, Victoria, if she’s listened to this, like, well done, you’ve got the message out there is great that we’re talking about dentistry and general health.

It’s great talking about all these, the whereas oral biome and everything super important. But unfortunately some dentists from what I saw had some look at a backlash reaction. And this is I don’t know if you saw this and this is because some very good experience dentists said that there is a danger of confusing correlation and causation.

Okay. So my first question therefore is we know there is a link and I’d like you to, for the dental students, the young people, or just anyone who’s listening to just to familiarize what are the links, but then more importantly, okay, which ones are we a little bit unsure about where we need more research and which ones are a bit more concrete?

[Reena]
Yeah, this is a really, really, really important point to make. And as healthcare professionals, we need to make sure we have we understand the science. And, I mean, evidence based dentistry may not have been everyone’s favorite topic as undergrads, but it’s such an important one, especially when the media try and twist things and exaggerate things.

I think we have a duty of care to our patient to make sure that any information we give them is accurate and doesn’t scare them either. So, yes, you basically hit the nail on the head. There are differences between correlation, causation. There’s also differences between, like, levels and quality of evidence.

So, like, a cohort study or a case study of one person compared to, like, a massive randomized control trial that has done systematic reviews and meta analysis, the level of evidence is completely different. And we can’t be drawing, like, concrete conclusions from poor quality evidence with not the great study, not the best studies.

So we have to be really careful here. So I’ll save my opinions of the podcast, but I think, yeah, I think it’s great Victoria’s got the message out there for sure. I think it’s good that people are paying attention to it, but I think we need to be careful what that message is. And at the moment there is definitely links between gum health and general health.

We know that for sure. The two key conditions we can definitely confidently talk to our patients about in terms of links between gum health and general health is diabetes and cardiovascular disease. Those have the highest quality of evidence, especially diabetes, and with diabetes, it’s a bi directional relationship. With the others, like-

[Jaz]
What does that mean? So just for the students, what does bi directional mean in terms of diabetes and perio?

[Reena]
Right, so with diabetes and perio, bi directional means it has an impact both ways. So, for example, if someone’s got perio, they’re more likely to get diabetes, actually, which is an interesting concept. So if you are healthy, and then you’ve got perio, gum disease, which is really common, you’re more likely to get diabetes. Diabetes also has an impact on someone’s perio, obviously, that’s a more obvious one. So especially when the diabetes is not very well controlled, you’re going to have some more severe pocketing.

Then we’re going to be more susceptible to relapse, all those kinds of things as it affects the healing. But also Perio does impact someone’s ability to control diabetes. And in the same way, getting the gums under control can improve the diabetes control as well. So one of the most quoted studies, it’s a Cochrane review, it said you can improve the HbA1c by 0.4% which, by doing good perio treatment, this doesn’t sound like much, but it’s equivalent to adding another drug to their diabetes regime.

So, which is huge, because I imagine you said to your patient, Mr. Smith, they’re probably not motivated by their gum health, but if you say to them, if we can do some good treatment for you, it means that you might not need that metformin that their GP is potentially considering putting you on. I mean, would you rather have one round, of gum treatment or a lifetime of a medication with side effects, I know which one I would choose. So I think this whole perio systemic thing is a great tool for all of us in general practice to use as motivation for our patients. In a positive way, I think that’s the key thing.

[Jaz]
And with cardiovascular, I mean, what kind of cardiovascular disease talking about heart attack risk or heart failure? Like, what are we talking about?

[Reena]
Yeah, any kind of vascular disease in terms of, especially atherosclerosis. So, what happens with this whole link, it’s two things in terms of how it’s all linked. Bacteria, so direct bacteria have been found in the heart, et cetera, et cetera. So, that’s one link. The second link, which is an important one, is inflammatory.

So, by getting perio, you’re increasing your systemic inflammatory load, so that then triggers off any weak parts of the body, then triggers off other inflammatory events. So, like, things like, as you probably remember from back your first year of university, when we learned about general medicine.

When you have atherosclerosis and there’s a plaque in the artery, more and more inflammation is going to allow that plaque to get bigger and bigger, and then that’s going to cause like a heart attack, or it dislodges and then causes like a stroke or whatever. So, it’s contributing to existing conditions, essentially.

[Jaz]
And this message, which has evidence basis is strong. So we know that diabetes, cardiovascular. What are the ones that are perhaps still under investigation that you would say is worth mentioning to patients, but then we need to be cautious because there may not be a true link just yet. There’s an association. There’s no causation just yet.

[Reena]
Yeah, so I would probably mention Alzheimer’s, but obviously it’s an emerging evidence base. And the other ones, like, there’s other ones like chronic kidney disease, there’s again emerging evidence, but other ones like respiratory, those kind of ones, I mean, I probably wouldn’t bring it into conversation, to be honest, because we want more evidence before we can suggest that.

Things like rheumatoid arthritis, I mean potentially emerging links. But it’s more so because also with arthritis you have to think about it physically if someone it’s the manual dexterity side of things. But there’s with those as well. We have to be very very careful. You can’t say there’s bi directional good quality links there at all and we definitely don’t have anything for cancer and things like that So I think we have to be yeah, I think it’s our job as, we are scientists essentially, to be able to evaluate the evidence and then, understand it and then communicate that with our patient.

There’s a really good book called, Bad Profit for Science, I think it’s called. It’s great, it kind of explains to you how to analyze half the stuff we see in the media is not correct. So it’s just, yeah, it’s interesting.

[Jaz]
You have to be very, very careful what you consume. That’s absolutely true. Now, in terms of like, it’s all good and well, like it’s like studying for an exam and knowing that these links exist, right? Because these are population based. What I’m interested from gaining from you Reena and sharing with Protruserati is, okay, how do we apply this to the patient that’s in front of us? How do we use this as armamentarium to get better periodontal outcomes?

[Reena]
Yeah. So I think it’s all about communication and motivation. So when you’re talking about, we should all be telling our patients what gum disease is as part of like the S3 new guidelines. It is, I mean, it sounds obvious, but maybe not everyone’s doing it.

As we need to be telling our patient, Mr. Smith, you have gum disease. This is how severe it is. This is why you’ve got it. And this is what happens in the condition. And I think as part of that conversation, and I, by the way, normally how I explain it is I’ll just get a pen. I’ll do this, you’ve got a pen, this is your tooth, your teeth are held in place by your bone, essentially your jawbone.

Around the bone you have gum, which is normally nice and tight, seals everything together. And when you get gum disease, you get bacteria that attach to your teeth. The gums don’t like it, so they start bleeding, and then the gum loosens up around the tooth, so you get a space between the tooth and the gum called a pocket.

And the problem with pockets is bacteria go inside the pocket and start attacking your jawbone. And if they attack your jawbone, you get bone loss, pocket gets deeper, and then it’s a bit of a vicious cycle until eventually teeth loosen up and tooth loss. But I’ll also say to them that once these pockets open up, then basically the bacteria can travel to the rest of your body, it can have an impact on your general health, as well as your general well being.

So you kind of, I bring it in as part of that conversation, and interestingly, I’m going slightly off topic here, but we ran a patient forum for the first time in our practice, which I was so insightful. We got to a group of random patients together from our practice. So not, we didn’t like particularly pick them, so we got a group to, and all of them were talking about this particular link.

They all said, I wish I knew more about this. I wish my general dentist had told me about the links. I had no idea. So it’s something that patients want us to talk about. I would integrate it as part of, like, the wellness conversation. Like, gum health is a part of your general wellness. Because people are interested in wellness, so spending hundreds and thousands of pounds on all these random treatments to help their general well being. So I think it’s all about-

[Jaz]
Like infusions of vitamins and Westfield and all that kind of stuff.

[Reena]
Exactly. So, why can’t they then just brush their teeth and be better at the oral hygiene because that’s like the portals of the rest of their body. So, I think it’s bring it in the conversation there, and then I would use it as a motivational tool.

So, like I said earlier, like, say you’ve got a patient who’s diabetic, tell them that, look, we can improve your diabetes by doing some gum treatment. Or, if you don’t have a patient with any general health conditions, you can say, look, by looking after your mouth, and treating this and getting your oral hygiene intact, we’re going to reduce the chances of you having general health issues.

So, yeah, I think, and then use analogies that patients can relate to. And I’m sure you’ve all heard of the one that, if you’ve got peritonitis, the size and also the size of your palm on your body, right? You wouldn’t just leave that. You would treat that. You wouldn’t feel better until it’s treated.

So I think make it into a language the patient can understand and then try to use that positively with the patient. The other one that we didn’t talk about is the links between, because I was thinking about patients getting worried, etc. It’s pregnancy outcomes and gum health and things like that. And that’s often talked about.

[Jaz]
So this is like, low birth weight babies from remembering, but from evidence based, I remember that there was a study or a few studies claiming that those who had periodontal disease, those pregnant women, they would have lower weight babies, right?

[Reena]
Yes, exactly. So there’s actually quite a few studies on this, but there’s quite a disparity in those studies. So again, try to use it positively, and I would say something like it’s safer to treat your gums now than not treat it. So you’re reassuring them that look we can safely do periodontal treatment because some of them are scared of even having any treatment. And say to them actually it’s safer to treat it now than not treat it. So I think, I honestly think it’s all about putting things in a positive mindset for our patients. That’s how you’ll get the best results.

[Jaz]
Just spend a minute just to detour here. Not quite detour, but it’s relevant. People, dentists are nervous about treating pregnant women. It’s true, okay? And then pregnant women are also nervous being treated.

So often we make a truce. Like, you know what? I’ll see you postpartum. Let’s just delay everything. Just delay everything. And the pregnant woman is also very, very happy to delay it unless it’s like an urgent pain, right? So let’s try and help periodontal outcomes. Okay, so obviously we want to encourage them when I say it’s good to get your period treated. It’s good for your overall health is good for baby. All right, so that makes sense. But let’s say we’re doing periodontal therapy. Let’s say we’re doing what’s the posh term for root surface debridement nowadays PMPR? Is that what it is?

[Reena]
Yeah.

[Jaz]
For those who have older generation PMPR stands for?

[Reena]
Professional Mechanical Plaque Removal. I don’t know why they use plaque because plaque is like an old school word. It should be biofilm. But anyway, that’s a whole lot of conversation.

[Jaz]
So when you get that ultrasonic, you take it deep in the pocket, you clean it out. Sometimes under LA, usually under LA, I would always do it under LA personally. Are you happy for LA and all those facets of treatment, or do you alter it for pregnant women in any way?

[Reena]
Yeah, actually, like, non surgical treatment is completely fine. As long as you’re not using that anesthetic with, like, felypressin and it’s going to cause problems at the end of birth. But, main thing is, if the patient’s comfortable, they’re in a comfortable position, if they’ve got periodontitis, you can treat it under local anesthetic.

There’s no problems about that. The only thing you’d probably avoid is like surgery. So if someone had like a pregnancy epulis, you may wait till post partum until they’ve actually, you know, had their baby and then address it surgically. Though I have to say, I did have a case probably like a year ago and she, her epulis was massive.

She couldn’t even bite down. It was going on occlusion. So I had to remove it surgically. She was absolutely fine. So I think all these things are guidelines and you have to sort of see what’s best for your patient, but it’s absolutely like fine and safe to treat pregnant patients. The EFP which is the European Federation of Perio have an excellent resources on their website. And there’s lots of leaflets for and videos for patients who are pregnant that you can send to them to reassure them and things like that. So it’s worth looking at.

[Jaz]
Brilliant. I’ll be sure to put those in the blog notes so people can reference those. That’s great. The other thing to just clarify is with patients with periodontal disease, right, we’re motivating them, we’re talking about the general health, we’re talking to try and get that health message across to them. I think the reason that dentists in the past have not discussed it.

And for example, your cohort of perio patients, right, that came in and you got that golden feedback from them that actually, I wish my dentist talked about it. Let’s just delve into that. I think this is what happening. I know you’ll have a great insight to this because when I was attending back in your days in central London, he says to FYP talks, I think that that was amazing.

So I remember you used to teach me some of this stuff, but the reason I think it happens is because dentists they don’t make a diagnosis in their notes. They don’t even just write gingivitis. If you just formalize it, if you actually give it a name, and then therefore you discuss it, and then you assure them and explain, we have a duty even just to discuss the basic gingivitis. And that is what gets the conversation going. So I personally think that’s why we got in this scenario. What do you think?

[Reena]
A hundred percent. And actually the new guidelines, they literally emphasize you need to put a diagnosis in your notes. And the number of people who don’t I’m now involved in some medical legal stuff I’m an expert advisor on the bda indemnity board as well. And it’s so surprising the number of clinicians who don’t write the diagnosis and remember the diagnosis can also be periodontally healthy, periodontal health, gingivitis, periodontitis.

So even healthy, you need to acknowledge that. So it shows that you’ve actually checked everything. So I think, yeah, if you don’t write a diagnosis, you’re then not going to be talking to your patients about it either. So I think it’s really basic, but I get why it’s sometimes missed because you’re back to back with patients, 10 minute appointments.

You’re just quickly trying to do as much as you can. It’s not easy, I completely get that. But I think it’s fundamental that you cannot forget. It’s a bit like going to the GP and they prescribe you something. And they still have this medication, but they don’t tell you what diagnosis you have.

They would never do that. They have to put a diagnosis to prescribe treatment. So it’s the same thing for us. I think that you’re right. It’s a really important fundamental that we need to make sure we don’t forget.

[Jaz]
Most centres listen to this, they’re already doing this, but there are some that, you know what? They mean to do it, but just because their template doesn’t have the word diagnosis in it. They’re just years of just bad habits, unfortunately. And then you just go with it. So simple thing to do. If you’re not already doing it, add the word diagnosis, even add a periodontal diagnosis, right? And you can write healthy.

You can write basic information. You can have a few things templated if you’d like, just be careful with templates. Also risk category, perio risk, caries risk, TMJ risk, all those risks, basically. I know these things are almost impossible when you’ve just only got 10 minutes, for example, which that’s a whole different conversation.

You’ve got to be in the right environment, but you have to then do like a basic core essential thing. And I think having a periodontal diagnosis is an essential thing. That’s why I just wanted to just mention it. How else can we harness the power of this message of the health link and perio link to our patients?

So you’re already having these one to one conversations. Looks like you had a focus group as well. This is something that I think we can easily say that, all practices have like a newsletter they send to their patients. We can talk about it there. What other ideas have you got for the practices to start doing?

[Reena]
Yeah, I definitely think newsletter, have things, if you’ve got a screen in your waiting room, have things playing on there, which, and again, the EFP have got loads of videos on diabetes, gum health, all that kind of stuff. Have things playing in the background that’s going to make them, you think about the importance of it as well.

But I think the one, like, everyone in the team, a one team approach is really important. So like, whether it’s a dentist or a hygienist, make sure everyone’s on the same page. So if you’ve listened to this podcast and you’re excited about it, maybe do like a lunchtime CPD session for your team.

Make sure everyone’s on the same page. And then, we’re all singing from the same hymn book because it’s much more powerful that way, rather than just like, for example, the hygienist talking about it. The other things you can do, I think, is, I mean, all of this is linked with a more holistic care, is if you’re in like a local area, community, which most of you will be, link with get to know the GP, get to know the local practice, and because there might be cross links there, sometimes you have diabetes, not very well controlled, you might want to send a letter to the GP, they might be on certain medications that you need to adjust.

So getting that cross connection is really useful. We did also do a GP forum. Obviously, Harley Street is a bit different. It’s not like a local area set up. But there’s lots of GPs in the area and we brought them together because I was interested to see if they even knew about the links. And most of them didn’t even know.

They didn’t get taught about. I mean, I think there’s like one lecture on dentistry. It’s nothing. Yeah, so they were saying they wanted to know more about it. They would definitely be keen on cross collaborating. And the guidelines now are, for example, for diabetics, once they’ve been diagnosed with diabetes, they’re supposed to see their dentist.

But, yeah, I mean, they need to push it more because they definitely push the eye appointments, the foot appointments, but what happens to dental? So, I think things are changing. But we also need to be proactive in our approach and I do think patients then appreciate it more when we’re all working together.

I think some of the problem lies in the fact that dentistry and medicine are seen as separate specialties and therefore like all the learning is done very very differently and dentistry is not even seen as a part of medicine. But if you take a step back, of course the mouth is a part of the body, like, it’s not a surprise. It should just be all linked together. So I think it’s just because, traditionally, of the way it’s learnt as well, that we’re in that also mindset of dentistry separate to medicine.

[Jaz]
I think what we can take a lesson from is the direction that the airway is heading in. So for example, now with the new guidelines, dentists are able to do so much more in terms of mandibular advancing appliances and then involving the GP.

And now when I speak to a GP, they’re happy to send me patients and it’s bi directional. I get to talk about health and wellbeing and them having more energy. And it’s amazing. Now that I’ve made some appliances, my patients, they come back and they’re saying they’re having dreams again. So they’re actually entering the REM part of sleep because they’re able to actually have a fuller better sleep. They’re feeling more energy, right?

And it’s the same thing that we need to do for perio. So I really think that’s a great what you’ve done there with that with the GP’s. Because those patients all those patients with diabetes they got a huge list of patients with diabetes. Have they seen a dentist? You’re right. They get the foot check the eye check, but they probably don’t get the dental care. So it’s about unless another thing that we should be doing from this podcast, if you’re not already is maybe involving a dentist your greater community, your community GP, your local GP practices. And I think they would love that.

[Reena]
Definitely. And I think it makes it fun as well, like you’re collaborating with other specialties. We’re even, obviously, ours is a different style of clinic but we’ve always been thinking about like nutritionists, like it’s other specialties that can kind of link with us with dental. At the end of the day, the main aim is to improve the patient’s well being and oral health and general health. So, yeah, it’s a great way of putting it.

[Jaz]
What else are you doing, Reena, in this field? Because one thing that you probably are doing already, but I think it’s a good idea, is I know some periodontists and those who place implants, they are big proponents of suggesting vitamin D, because they know that, okay, if they do this random blood test people, people are going to be low on vitamin D, and that’s going to adversely affect their surgery outcomes, their implant outcomes. Is that something that you practice as well?

[Reena]
Yeah, we don’t place implants here, actually, but I do agree with that. You want to get, like, a good idea for the patient’s general health, their bloods, everything is in a good place. Because yeah, you’ll be surprised, nutrition has a massive impact. Even in perio, probably implants as well, I don’t know the field as well, but it’s all linked together.

It’s all to do with healing. One thing we do going back to diabetes is actually, most of our patients, we’ve actually invested in a HbA1c finger prick test, which is what they use at the GPs. I’m not suggesting this is done in general practice, if, I mean, it’d be amazing if it is. But it’s about funding, et cetera.

But what it does show us, cause our patients are pretty much all severe perio, is if that patient has got a potential high HbA1c indicating they may have diabetes. And it’s really interesting in the last kind of six months to a year, we’ve found at least, 20 or so patients with undiagnosed diabetes.

And it’s been crazy. And most of them had no family history, no risk factors. One of them was my husband’s best friend. And he just came for an appointment, come for an appointment. So he came for an appointment with a hygienist, had severe perio. We didn’t even know he had perio. Had severe perio, and then we were like, okay, what’s going on here?

Saw one of the specialists for full assessment, did a  HbA1c through the roof. I couldn’t believe it, we did it again, because I was like, it’s the machine broken, and it was through the roof. He went to see his GP, and they did the same, they did a proper blood test. And they were like, you need to go on urgent medication.

The same guy we treated his perio and it’s completely reversed his diabetes. And interestingly, something which is quite sad is his father, a few years back suddenly passed away. And when you hear stories like that, it’s like, could that have been undiagnosed diabetes, heart attack, et cetera, et cetera.

So, by being able to, I feel so privileged being able to have that ability to do that test on our patients. And yeah, it’s not the nicest thing to say to someone, you might have diabetes, but actually, like, that could save someone’s life. So, it’s the positive is that you can improve that now, and you can potentially even reverse it. So, yeah.

[Jaz]
I love this Reena because the same thing that I’ve been doing in my clinic now is I use an AcuPebble for sleep tests, right? And I get my sleep clinician to report on it. And the amount of patients come back with severe sleep apnea. And then and it’s like amazing. They’re so thankful because they understand that actually this is stealing 10 quality years from their life, for example.

But that’s a slow burner. These are all bigger things, slow burners, but they’re so, so important. So how easy is it for, do you think, for, or expensive is it otherwise for general dentists to start? Because I think this is wonderful. We have a clear link between diabetes and perio. Why aren’t more clinics? I’ve never heard of this, by the way, of dentists doing this. So well done. Tell us more about it.

[Reena]
Yeah, more people are doing it now. It’s obviously not common, but we use a DCA Vantage machine and it’s, I think it’s like six, seven thousand pounds. And then obviously you have to pay for each of the cartridges. And the nurses, our nurses do fingerprint tests. It’s really easy. You just do a quick fingerprint.

[Jaz]
Do you charge the patients additional or is just part of your included package? Yeah. Okay. Makes sense.

[Reena]
Part of it, but there’s no reason why you couldn’t do a minimal charge to cover some of your expenses. And what you’d probably do in general practice as well is make sure you. If you do it according to risk, so you wouldn’t do it for every patient. If certain patients fit a certain criteria, make like a risk criteria, you’d be like, okay, let’s check this just in case. And we can’t, I think one thing to highlight is we can’t, as dental professionals, give a diagnosis of you have diabetes. We’re not allowed to do that.

[Jaz]
Same with sleep apnea. We can’t say you’ve got sleep apnea. I need my sleep condition to write that off.

[Reena]
Right. So, but we can say there is a high chance and you need further investigations. So then they go on.

[Jaz]
You’re screening.

[Reena]
You’re screening. Yeah, basically. So yeah, I think it’s definitely not a bad idea if you’re able and you want to invest and if that’s your clinic is set up with that type of holistic care.

I think out of any of the other extra things that are out there right now, I think this could be a great investment for sure. I think people in, they think perio, sometimes, perio feels like, oh, it’s a boring specialty, all we do is check the gums and clean, do deep cleaning, which I hate that word.

But there’s so much more that you can do with perio, like, whether it’s screening for diabetes and holistic care, whether it’s aesthetic surgery. I think, I really do think, at an undergraduate level, unfortunately, perio isn’t portrayed in the way it is, there’s so much to it. And I think when people realize that, and more and more people are now, they want to do more on it.

I mean, our perio diploma is full for like two years, because, and I’d never imagined that, because perio is not like the best, it’s not the most popular specialty, but I honestly think it is becoming more and more, so if it interests you a little bit, I would say it’s a great one to take further, because there’s not enough of us, to be honest, so.

Yeah. The other thing we do, even like invisalign, we use iTero scans to do a scan for recession. And then we use the time lapse function on the iTero, six months, you can see if there’s changes in recession. So yeah, I think try to see perio’s fitting part of those things and use the tools that we have in different ways.

[Jaz]
I feel really stupid right now because I’ve been using this time lapse function for years, right? I monitor crowding, I monitor wear, okay? But I didn’t think, I don’t know why, because it makes so much sense, you can actually totally monitor recession. Recently I did a time lapse on someone 18 months apart, we’re monitoring wear because he’s got these cupping lesions on his molars from acid erosion.

And so, surprise, surprise, those are the areas that came out red, everything else was good. So I said, okay, let’s bring you back, let’s stick some flowable composite inside, that will reduce the damage. That’s all you need, you don’t need to have this rehab just yet, you’re just in your late thirties, let’s keep monitoring.

But one interesting thing was the second premolar just winged out. Like just, it was just fascinating thing. Just winged out. So these changes are fascinating and recession. You’re right. Another application guys. Good to remember. Now, all of this ties in very nicely cause you’re talking about holistic care.

You’re talking about how dentists are more interested in perio. Is that why you released the Perio Handbook? What is it designed to be? Is it like a textbook? Is it like a guide to help motivate your patients? Is it for patients? Is it for dentists? Tell me more.

[Reena]
So, the Perio Handbook, I have it in my hands here. This was released actually just a few days before we were recording this. So, it’s meant to be for dental professionals, whether you’re a dentist, hygienist, therapist, student. Anyone dental and it is meant to be a summary of everything you need to know. It’s taken me like three years to write. It’s been one of my this is like my second baby, I guess and it’s literally everything you need to know and it’s referenced, but it’s like, it’s comprehensive, but it’s not like a boring, heavy textbook that no one has time to read in general practice. So it’s about 200-

[Jaz]
Can you read out some chapter titles? Give us some flavor of what it’s like.

[Reena]
Yeah. So there are 17 chapters and the way it’s laid out is it’s like the patient journey, basically. So we start off with the foundations. So the periodontium and beyond. So we do a little bit of anatomy, but like in an interesting way.

Of course, we talk about PerioSystemic. And then it goes straight on to like your patient journey. So the second chapter is called, think like a detective. So I say to everyone in perio, like, you have to be a detective. And so this part is all about history taking, finding those risk factors that we’ve been talking about as to why does my patient have perio.

When your patient sits in the chair, they have something called a causal pie above their head. One of those slices is, yes, maybe they’re not brushing their teeth properly, but the conversation has changed. It’s more also now about, okay, are you stressed? Do you have undiagnosed diabetes? What’s your nutrition like?

Et cetera, et cetera. So, it’s genetics, et cetera. So, we talk about that, and then we go straight on to the clinical examination, BP, six point pocket chart, assessment of dental implants, because I feel like some people are not so confident with that. And then special investigations, diagnosis, not just for gingivitis, periodontitis, but also perio implant diseases as well.

And then chapter 6 is prognosis, and then we go on to treatment planning. There’s a whole section on educating and empowering patients, because one of my favorite things is communication. I packed it with tons of really fun analogies that you can use with your patients.

[Jaz]
I mean, all periodontists are coaches. All periodontists are coaches.

[Reena]
Yeah, for sure, for sure. Absolutely. And then we, yeah, go on to the treatment side. So non surgical things, acute, like perio emergencies as such. And then we talk about some more complex things like pocket reduction, gingival recession, and also crown lengthening. So it honestly is, obviously I’m biased, but from the reviews we’ve had so far, everyone’s absolutely loving it.

[Jaz]
I would recommend this. I would recommend this, right? I would recommend that, you know how you people have like book clubs, right? Yeah, I think as a practice, right? If everyone did book club one week and just read that book and here’s why and look, you know Reena, I’m a fan of you and I want to always promote what you do. But the main reason I’m suggesting this to Protruserati is the following, right?

We had someone in my community on Protrusive Guidance on the app recently say the following she posted something she’s so sweet, right and she said I’ve started a Denplan practice recently. Yeah, I don’t know if I should be treating the perio or should I be referring to the hygienist? Okay, and so I said to her, look, actually, what you need to do is the same thing that we had a few years back in my practice, which also has a Denplan contract.

And I said, you need a periodontal protocol in the practice that everyone sings in the same hymn sheet. You have the same examination, same metrics. And then based on those codes, you know what the hygiene is doing, what you’re doing, when do you refer? And unless your team has sat down and mapped this out, you’re really suffering the periodontal outcomes moving forward.

And so what your book offers is yes, I mean, it’s edutainment. It’s got information, but it can be a catalyst for all practices to be a little bit more serious about their flow charts and protocols.

[Reena]
A hundred percent. I think once you’ve got, you literally hit the nail on the head, you need a period protocol in your practice. Cause a lot of the medical legal issues we find is that everyone’s doing their own thing. And then the patient picks up that, oh, something’s not quite right. Not seen from the same hymn book. That’s where complaints start. That’s where people start getting into trouble. So yeah, that will really bring things together. And it’s for the best for the team and the patient.

[Jaz]
Wonderful. Well, I’m going to put a link. Is it on Amazon, right?

[Reena]
Amazon now. So you can get a physical version or physical book. And let me know what you think. I’ll be really interested to hear your thoughts.

[Jaz]
And Instagram is?

[Reena]
My Instagram is Reena Wadia, but this is all part of our Perio School project, which is @perio_school.

[Jaz]
Amazing. Well, I’ll put both those links in the show notes. So Reena, thanks so much for giving an overview of the link between Systemic and Perio and to talk about your book, which I think is, will make a great stocking filler. So try and get this episode out before Christmas. So at the last minute, gifts to your hygienists and bi directional hygienists to dentists.

Everyone should really just go all in, in a Perio protocol. If you already have a Perio protocol in place. Amazing. But I bet that most practices don’t. And therefore this is a great opportunity. Okay. As we enter 2025 to make it on your to do list to have a perio protocol. I think your book would be great for that. Reena, thank you so much. You’re always a welcome guest on Protrusive. I appreciate your time.

[Reena]
Thank you so much.

Jaz’s Outro:
Well there we have it guys. Thank you so much for listening all the way to the end. It’s almost Christmas if you’re listening in December 2024. We’re almost there. I have got a few more episodes between now and Christmas and I get a little bit reflective at this time.

So on our Instagram we’ve been sharing a lot more reels summarizing some of the best content we’ve created over the past few years. So if you’re not already following us on Instagram, please do. It’s @protrusivedental. Don’t forget that on Protrusive Guidance on Android, iOS, or your web browser, protrusive. app, you can get CE credits for all these episodes.

You’ve done the hard work. You’ve listened all the way. It’s so easy just to get certificates by answering our quiz. I want to thank my guest Reena once again. I’m going to put in the show notes all the links that she promised and a link to buy her Perio handbook, which I think is essential reading because I want every practice to have a protocol in place.

And so nice to have something really current, really up to date and really digestible from Reena Wadia herself. Thanks again for making it to the end. I’ll catch you same time, same place next week. Bye for now.