Periodontics for Beginners – PS008

Protrusive Dental Podcast

How are periodontal diseases managed in general practice?

Join us for an engaging conversation with Emma Hutchison, our Protrusive student, as we explore Periodontology (Perio) in the real world.

This conversation delves deep into the practical protocols, patient communication strategies, and real-life scenarios every dental student and practicing dentist should be aware of.

https://youtu.be/X5ahZ9bzsc4

Watch PS008 on Youtube

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

Highlights of this Episode:

• 0:37 Emma’s Dental School Experience: Special Care Dentistry
• 03:02 Emma’s Denture Adjustment Case
• 06:11 Periodontics Month
• 06:54 Communicating with Patients about Gum Disease
• 10:15 Managing Non-Engaging Patients
• 15:04 The Psychology of Habits
• 17:13 Referral Protocols in Dental Practice
• 20:00 Risk Factors in Periodontal Treatment
• 25:03 Genetic Factors in Periodontal Disease

Don’t miss the special notes on An Introduction to Periodontal Diseases available exclusively in the Protrusive Guidance app!

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, be sure to recap PS007 – Basics of Indirection Restorations Part 2 – The Crown Fit

Click below for full episode transcript:

Jaz's Introduction: Welcome to another episode of Protrusive Students. We're joined by Emma Hutchison, our Protrusive Student, to talk about Perio. Look, I'm no periodontist. I'm no specialist, but I can share a few pearls of wisdom for treating Perio in the real world.

[Jaz]
Emma had some absolutely fantastic questions about protocols, communication, and what to do if you have a non engaging patient. Because let’s face it, that’s what happens in the real world. Our patients don’t floss and they don’t brush how well we want them to. So how do you manage that? Here at Protrusive Students we try and cover the themes just for you guys. And of course, if you’re a dentist watching this, then it’s also relevant to you. We just go back to basics. Let’s get to the main part of the interview and I’ll catch you in the outro.

Main Episode:
Emma Hutchison, our Protrusive Student. It’s now perio month, so it’s great to have you back. Just give us an update, basically, in terms of what new things have you learned at dental school? What are the interesting experiences that you’ve had? Any ups or downs that you’d like to share with us?

[Emma]
So, I’ve only seen one patient in the last week, because I’ve had a few no shows last week and it was for a denture ease, so it wasn’t anything too tricky, which was fine for me. But, yeah, it was good, just a wee denture ease. The elderly gentleman was very happy, so that made me happy. In terms of lectures, lots of special care dentistry at the moment. We’re very heavy with special care dentistry in our second half of third year at Glasgow.

[Jaz]
I know in some countries they don’t have that as a speciality. Can you explain to everyone listening and watching what special care dentistry is?

[Emma]
Yeah, so I suppose special care dentistry, a lot of patients that have very complex medical histories. I mean, this week we were doing people with mental health problems, schizophrenia. We’ve been doing cardiology, oncology, patients with very learning disabilities as well. Patients that I suppose you could consider a bit more medically compromised or that can be a bit more trickier to treat. So we’re very heavy on that in our third year at Glasgow.

[Jaz]
So if you can treat those medically compromised patients and you can treat anyone, right. It really tests us in terms of what medicines are on, which antibiotics you can and can’t give, what the guidelines are in terms of when it’s safe to treat, when it’s not safe to treat, all those things.

[Emma]
Yeah, definitely. And a lot of it is refer to the BNF and all your drug interactions. But no, it’s good. It’s really interesting to learn all about these medically compromised patients. And it’s amazing how much you need to change of your regular dental routine to suit these patients, I suppose, and make accommodations for them as well.

[Jaz]
Interesting thing to reflect on based on a couple of things you said is one, the slow pace of dental school in terms of when you have some DNAs, which happens a lot, unfortunately, in dental school, just the nature of the beast. And then how do you fill your time to make sure you’re actually doing something productive?

I felt like a lot of time when I was studying dentistry, patient wouldn’t turn up and then you’re just there doing suctioning for someone else or nothing. You’re having like an impromptu tutorial or something, which is good, but sometimes you kind of be there. Like looking out the window. And so it’s really important to make sure you’re not doing that.

So I’m hoping everyone’s going to have their productive student notes ready, reading them, taking them with them. So if a patient doesn’t show up, they can have that. So this is just the nature of the beast. The other reflection I have is denture ease. What do you think caused this patient to have an area that needed adjustment for this denture?

[Emma]
So I had delivered this denture, it was a wee while ago, the patient was, had unfortunately been in hospital for a wee while, so I had planned to see him two weeks after the denture delivery, just as standard protocol to see if there was anything wrong with it. He was in hospital for a month, so it had been a while. And when we fitted that denture, it was perfect. It was like a glove. And then he said, when he went home obviously, it’s a brand new denture, it’s going to take some time to get used to, but when he started eating, that’s when he noticed it was painful and it was really digging into his freedom down there, but it was easy enough to see he had a huge ulcer there, the poor man, and pressure indicating paste, showed me exactly where to adjust it as well.

So it is quite tricky with those things because it can take a wee while for it to almost heal start hurting these new dentures. It’s tricky as well. I’ve seen a patient before who hadn’t been wearing the denture because it was sore. And then it’s a bit more trickier to see where the pain is actually coming from because you’ve not got redness or something like that.

[Jaz] So it’s a couple of lessons to share then based on that. Just so I don’t forget is, always warn your patient that this is normal. Like you should say to your patient. It’s like you said, like a glove. That’s exactly it. It’s like a brand new pair of tight shoes, right? You’re going to get some foot blisters on your feet, right? It’s normal and to adjust it. And when they come in and it’s like the ulcers there, you could use pressure spot indicator paste. But do you guys have Dycal in your clinic?

[Emma]
We do have Dycal, but not on our Prosth clinic. I don’t think-

[Jaz]
It’s something I was taught by Mark Bishop to use just on the ulcer, just the base, actually, not even the Dycal, just the base on the ulcer and then put the denture on and then see and pick it up. It’s like anything that will just mark because what you’re testing for pressure is where it’s actually too much pressure. But for the ulcer, you just wanted to rub off on exactly where to adjust the denture. So you can actually use anything that marks off onto the denture. So that’s a good thing to use.

We actually had an episode with Mark Bishop, I think it’s episode 28 of the podcast. So anyone who’s new to dentures, check out that episode with Mark Bishop. We talked about the use of pressure spot indicator, the use of the Dycal in that way. And it really talks you through everything. Now, one thing to bear in mind, like your one is obvious because it was like overextended probably in that frenum area.

But number one thing before you do an adjustment on the teeth on the actual chewing surface of teeth themselves is before you adjust anywhere on the inside of the denture, check the occlusion because it could be the fact that the patient bites together, it actually is hitting on an incline and the entire denture is then moving and then the teeth bite together. And so you need to make sure it’s got a nice, clear, easy, repeatable bite. Because if it isn’t, it’s actually the bite that’s the problem, not the fact that it’s overextended anywhere. Do you know about that?

[Emma]
Yeah. No, I’ve never actually really thought about it like that to check the occlusion first. Because then I suppose nothing’s going to get much better if you don’t address that.

[Jaz]
Because imagine the denture itself is actually perfectly flush to the tissues, but it’s the bite being off and then the pressure gets on that’s causing it. So really good top tip is to check the occlusion first in those areas. But anyway, we digress. It’s Perio Month. Thanks for sharing your experiences with us, always gives us a few things to talk about there. Tell, ask us your student based perio questions. How much experience have you had of treating periodontal, or managing should I say, periodontal disease in your student clinic so far?

[Emma]
We don’t get on to our perio clinic until fourth year, so we’ve had a lot of teaching on periodontal diseases, but I’ve not seen any perio patients at all yet.

[Jaz]
You haven’t seen any perio patients yet, but I bet you’ve studied all the, I bet you can name all the bacteria.

[Emma]
Yeah, yeah.

[Jaz]
Well, this month’s notes, revision notes in crush your exam section will be your perio notes. So it’ll be good to have all that. But now that you know you’re going to be treating more and more and managing this next year and whatnot. So what kind of questions have you got then?

[Emma]
So the first question that I have almost stems from my nursing career, I suppose, where many clinicians you would never actually say the words gum disease to a patient, you could talk about bone loss or you’ve got inflammation, but when you start to say the words gum disease, the patient sort of freaks out.

Why didn’t you mention this to me before, X, Y, Z. So is that something that you would avoid saying? Is it something you would actually encourage saying the words gum disease? And what would you do personally in that situation?

[Jaz]
Okay, well, firstly, I’m going to direct everyone to the episode, the fantastic episode I did with Ian Dunn on communicating periodontal disease, okay, really fundamental episode. I want you to watch it, Emma, before you go on clinics. It’s fantastic. Ian’s way of explaining perio is phenomenal. But in the same way that if you see a lesion on a patient and you suspect that, oh, this needs an urgent referral, this could be cancer kind of thing, do you use the C word?

Do you say it’s cancer to the patient in the same way? Not in the same way, but I think if you discuss this scenario, and recently I asked this to Amanda, Dr. Amanda Phu Nguyen from Australia, and we’ve got an Oral Med episode coming soon. But essentially, she said that for some patients who are extremely anxious, you probably don’t want to use a C word, but you want to say that it’s really important to get checked out.

We don’t know. It could be something suspicious, but it’s really important to get checked out and that’s enough for them. For some people who are really blase and they really need the kick up the butt, then maybe for that individual, right? Who’s not going to have sleepless nights for it from it. You should say actually, this could be the C word.

It’s really important you go to this appointment because otherwise they won’t be bothered towards the appointment. So let’s take the patient’s personality type. If they are someone who’s highly anxious stuff, then maybe you want to explain it in other, other ways. But as long as they understand that there is a bacteria, there’s plaque, there is inflammation and swelling of the gums.

Okay. And this is either reversible or irreversible and talk about that. And then eventually you can then bring in the whole gum disease. But if you feel as though that that’s too strong of a word, I get that. But in some patients you need to actually really spell it out that this is gum disease.

You could lose your teeth because these are the patients who perhaps are really not taking their oral hygiene seriously. They’re not engaging. So I would say it depends on the individual, but I would drive out everyone to listen to that episode because to talk about whole 45 minutes on this, that Ian Dunn episode will be fantastic. So thank you Emma. We will link that in the show notes because Ian does a far better job than I could ever do.

[Emma]
Yeah, no, that’s good. I think a lot of things in dentistry, very patient centred depends on the patient. So I think that’s another situation there for you need to figure out a bit more about your patient first, which can actually be quite a difficult skill to have. Tailoring your communication, I suppose, to the patient, I think that can be quite difficult. Probably takes a wee while to develop that skill.

[Jaz]
This is all the realms of emotional intelligence, right? Really figuring out who it is in front of you and speaking in their language. is what sets apart a good communicator to an excellent communicator.

[Emma]
Yeah, yeah, and I think as dentists, often as very academic people, sometimes we’re maybe not the best with emotional intelligence, but it is something that you can work on definitely. But that also sort of ties into my second question. When it comes to patients who just aren’t really motivated, what implications does this have on future treatment? Is it enough just to say to this patient, if we don’t do this, then we can’t do this, you know?

[Jaz]
Yeah, totally. It’s a fantastic question. And now every country has their own guidelines and the British periodontal guidelines, I know, I think are good. And I will make that available for those who want to see it in the show notes to look at.

But I love the term they use, which is engaging and non engaging patients. And there’s different pathways of how you manage these and a non engaging patients that you’ve tried everything. You’ve spent the time, the due diligence to really explain the issue to them, teach them the tools, give them the tools to be able to improve the oral hygiene.

But they’re just not engaging, they’re not putting the hard work in. So is it fair that we give these patients the full blown periodontal treatment, because a day later it’s going to be covered in plaque again? And plaque is the source of the disease. So really, what we need to do is, just like you wouldn’t do complex crown bridge work on someone who’s got poor oral hygiene, then maybe we shouldn’t be doing the actual root planing and actual hands on stuff until the patient has mastered the delicate skills of really good, high quality oral hygiene.

So I would say that every patient deserves your best firstly, every patient deserves a chance and give them the chance to try and communicate in their own language in a way that works best for them. This could be drawing on a whiteboard. This could be make sure you show them in a mirror exactly how to clean, get them to demonstrate in front of you.

And when they come back, we can’t just rely on subjective. We need objective data. Let’s look at plaque scores, because maybe their plaque score is 50% and next time they come back, it’s 30%. Now, it could be better, but at least we’re seeing improvement, right? And then, okay, you’re going to help this patient.

But if you’re seeing 50%, 50%, 70%, 50%, and the patient is just lying, and you know that the level of hygiene isn’t good enough, then for that patient, they don’t progress through a flowchart. You just go back to base one. There’s no point spending any more time and money on doing periodontal therapy with scaling, root planing, root surface debridement, whatever they call it, whatever the cool kids call it nowadays.

But we need to make sure we get the foundations correct, which is excellent oral hygiene. So base it on your patient, give everyone a fair chance, but quickly recognize who is following what you’re saying and who is not. And I’m not saying don’t give them your best, but they can’t then move to the next stage if they’re not getting the foundations right.

[Emma]
Yeah, definitely. And I think, again, that’s another thing that can be hard to communicate to your patient, especially, if they’re saying that they’re brushing, they’re brushing, but there’s been no improvement. It’s hard to sort of communicate that.

[Jaz]
So tough, Emma. Like, I don’t want to hurt my patient’s feelings either. So what I tend to do, is I firstly find out, okay, what are you using to clean in between your teeth? And I wait for them to say something and you say, oh, I’m using the little brushes. Okay. That’s great. How often are you doing it? Okay. Now at this point I say, yeah, you know what? Not as often as I should.

That then gives me permission to say, okay, you know what? I think it’d be great if we did it more frequent. I just see things a bit slipping and I want to make sure that we’re set up for success in the future. So how about we do a bit more and that’d be great. But then sometimes I say, yeah, I do it every day.

And I have a look and the oral hygiene is horrendous. That’s an opportunity for me to discuss technique. Well, firstly, you’re already doing better than most of my patients because you’re actually doing it. And you’re doing it, once, twice a day. This is amazing. But strangely, when someone says they’re doing it a few times a day, usually I should see like no plaque.

But in your case, I’m seeing this hidden bacteria in between the teeth, like in your blind spots. Is it okay if I can show you? Then I’ll show them in the mirror exactly where it is. I pick it up my probes. Ah, I think this is a technique issue. I think you’re doing it like you said, but it’s a technique issue.

Let me go through the technique. And so with an interdental brush, I show them how to insert it and actually really massage it into the gum. And sometimes it’s just making sure they’re using the correct size. Right? It’s got to be big enough, snug enough that it’s going to actually brush the sides of both the teeth, adjacent teeth, and they need to also massage it into the gum and into the sides of the teeth. So it’s not just a matter of going in and out. So this is an opportunity to educate them on the technique aspect, I find.

[Emma]
Yeah, you saying that actually, that’s a good sort of pathway into oral hygiene instruction and things like that as well. I’ve never really- it’s all about taking that as an opportunity to then try to like educate them on their oral hygiene and things as well. No, that’s good. That’s good.

[Jaz]
We want to be non-judgmental, but we want to make sure that they’re doing it. So I have found that works for me in practice at the moment. I don’t want to make them feel bad. So I just ask questions and based on what they say, I’ll then show them or just encourage them to do it more frequently.

And I often offer, you’re seeing the hygienist next, should we go over the right color brushes for you? What I mean is technique, but sometimes they just want an excuse. Oh yeah, you know what? It’d be nice to see which brushes to use again. And then they get a demo again. And sometimes, life gets busy.

People got kids, people got ill parents, people got pets, people got all these things in life, busy work, life, stress, all that kind of stuff. And sometimes it’s not your highest priority. Now, one thing I make a big deal of nowadays, my own lessons is out of sight, out of mind. Meaning that if the teepee brushes are not there by your washbasin right in front of you, like to use, they’re not going to get used.

It’s just a thing to realize. Now, for example, it’s human psychology, it’s human nature, whereby if there’s a step, if there’s an extra step involved to doing something, It will much, much less likely to get done. So it reduces the chance of something getting done massively if there’s one extra step. Let me give you an example.

Recently, we had this system whereby we’re changing the way that we give antibiotics to our patients in our practice. So before the antibiotics, the nurse knows where it lives. Zoe, can you get me some amoxicillin, please? Right. And she’ll go, she’ll get the amoxicillin. We just fill in the log and we give it and we prescribe it.

Now, we have to use a key to open a lock, get the antibiotics out in the right order, and then go open an Excel sheet and insert it, okay? There’s no audit done yet. I have a feeling that the percentage of I’m just being very real, honestly. I’m making myself vulnerable. As a practice, okay, our numbers of antibiotics has gone down.

And so I think every practice in the world should do this, right? Making the kind of habits that we want to discourage make it more difficult, but the kind of habits that we want to encourage make it easier. Same with dental photography. Those dentists who have their camera out and ready. The lens is ready.

The flash is ready. The retractor is there. It’s all ready to go. They will take photos. For those who have to now, they’ve got a patient. They want to take a photo. Now they have to go to a different room, get the kit, attach the lens to the body, charge the battery, whatever. It’s not going to happen. So, it’s just human nature to make the habits that you want, those healthy habits that you want to foster, make it easier. And it’s the same with Perio.

[Emma]
Okay, so yeah, have your teepee brushes out in front of you.

[Jaz]
It’s got to be there. It makes a big difference to me anyway.

[Emma]
Yeah, I worked in a practice as well at some point where the answer was like drawer was locked and you had to write it in a wee notebook and then you had to put it on an excel sheet and just no one ever really prescribed them anymore.

[Jaz]
So true.

[Emma]
Yeah. So my next question for you, Jaz, is about referrals. I know you’ve got periodontal specialists out there, hygienists and therapists. What warrants a referral and to whom?

[Jaz]
Okay, fine. So firstly, there should be a every practice should have a perio protocol, right? Every practice should have a perio protocol. Like this practice, this is how we treat perio. And it really is a good, because it involves the hygienist, and the dentist to really have dialogue and have meetings and talk about this. And so everyone does things a set way. So everyone gets good quality care. So everyone has a staging and a grading.

So diagnosis is covered by everyone. We have set intervals where we make sure we do a basic periodontal exam. And then based on those scores, we have some guidelines, right? And so a lot of times it’ll be, okay, off you go to the hygienist and you’re low risk, or if you’re high risk, then we’re a bit more prescriptive with the hygienist.

And sometimes if it’s refractory, they come back to and then if we find that the patient is engaging and doing their best and we’re still not getting the right results because we’ve been really good at record keeping. We’ve got the six point pocket depth charts and whatnot. At that point, we have to consider, okay, perhaps this patient needs a specialist.

And the funny thing is, right, working with specialists, I feel as though they do the same thing that we do. The patient’s paying a lot more money and suddenly they start getting the results. Because now you value what you pay for and suddenly they’re paying all this money back. I better start TePe brushing kind of thing.

And so sometimes it’s that and sometimes it is the skill and the diagnosis and sometimes a surgery is needed basically. So I would say there’s a lot we can do with Perio when it comes to doing it in house because a lot of it is reliant on excellent, the foundations, the pillars of excellent oral hygiene and working in tandem with your hygienist therapist and seeing those scores come down is a beautiful thing as a practice.

But we need to also feed our specialists with those refractory cases and following a protocol or a guideline, whether it’s the one in your practice or a nationally recognized protocol. So whichever country you’re in, follow your local periodontal societies guidelines.

[Emma]
Yeah. Yeah. I think we’ve got the SDCEP guidelines in Scotland. What is it in England that you use?

[Jaz]
The BSP, the British Society of Periodontology.

[Emma]
Yeah, that’s a wee bit tricky one for us because we learn some SDCEP and some BSP and they’re mix and match a wee bit.

[Jaz]
Look, Scotland’s still in Britain, that’s how much it’s so good.

[Emma]
Well, yeah, sorry, sorry. Scotland, England. The British ones, the Scottish ones. So we learn a wee bit of both, but mainly SDCEP and the dental hospital.

[Jaz]
You know what, honestly, like as long as you’re following a system and you know that system well. I think they all have good intentions and are backed by evidence and I think that’s the best thing to do.

[Emma]
Yeah. Okay. Cool. And then my last question that I had for you, Jaz, was what sort of risk factors and things need to be addressed or controlled before you start with perio treatment?

[Jaz]
Okay. So defining periodontal treatment, treatment is like when you’re actually picking something up and you’re carrying, scaling biomechanical plaque removal, introducing a scaler subgingivally, that kind of stuff.

So what kind of risk factors? Well, things we look out for is smokers right now. Smoking is a tough topic because we’d love for our patients to all quit smoking once they’ve diagnosed a perio, but that’s not how it happens. Okay. It doesn’t happen in the real world, but even just by quitting by half, like Instead of 20, have 10.

That’s a sign that someone is an engaging patient. And so maybe that will have a better impact. So we need to first ask the question. Are you smoking? Did you know there’s a link? Medical, legally, we need to inform them, did you know there’s a link? This is actually causing, it’s making your gum condition much, much worse.

Have you ever considered smoking? If they say, yes, I’ve considered it. Okay, maybe now you can help them. There’s local pathways and guidelines, NHS, et cetera, in the UK, for example, to help them to quit smoking. If they say, you know what, I’m not interested in quitting smoking at all. And therefore they’re showing like a poor attitude.

It’s a tough one because we still need to help them. So we still need to perhaps give the best we can in terms of oral hygiene, instruction, and oral hygiene education. And then once they’ve mastered that, then proceed to biomechanical plaque removal. The thing is, if it’s someone who doesn’t have the right attitude towards smoking, and they don’t have the right attitude towards their oral hygiene, then that’s a non-engaging patient.

But sometimes, smoking, they can’t give up, but they then overcompensate by doing really well with oral hygiene and that’s going to help them a lot anyway. I sometimes emphasize, look, because you’re a smoker, whilst I get most of my patients to spend four to five minutes a day in front of the mirror, you have to spend 15 minutes a day in front of the mirror.

And that’s why I say to them, so they have to kind of make up for it. So that’s my view on smokers and not to dismiss them entirely, give them the best shot. But I want to see that they’re really working the oral hygiene, if they’re not going to be reducing smoking. The other one is diabetes to look at.

And we want to make sure we work with the GP to make sure that diabetes is controlled. Sometimes they’re an undiagnosed diabetic and if their perio scores are continually getting worse and they’ve got a history of diabetes, maybe. And so you ask the patient, when was the last time you had a blood test?

It’d be really good for you to get checked out. And of course, if they’re already a known diabetic, we could keep asking, look, how’s your control? Is your GP happy? Is your healthcare team happy about how you’re doing it? And there’s a relationship whereby if you improve the perio, you improve the diabetes. You improve the diabetes, you improve the perio. Did you know that?

[Emma]
Yeah. What sort of a relationship is that again?

[Jaz]
I want to say symbiotic, but I’m not sure if that’s a more of a bacterial thing. But yeah, so diabetes is really important. Smoking as we addressed the other risk factors is stress, actually stress, obesity, all these things, but stress is a big one.

Make sure that patients are directed towards getting help for stress and just making them aware that look, we need to focus on the stress because that’s important as well. Occlusal things aren’t as much recognized. So let’s not go there. But I do think that if someone is a, there was a study done and I’ll reference it whereby they had these patients and they follow them up and they see whose perio got worse and whose didn’t.

And if they had active periodontal disease and they were a Bruxist, and if they didn’t wear an occlusal appliance to manage the Bruxism forces, then they actually had worse periodontal outcomes. So perio plus Bruxism, you can imagine the occlusal trauma. The jiggling forces on the teeth. So I’m not saying for a second that bruxism or occlusal considerations cause periodontal disease.

No, but they can exacerbate it. They can induce jiggling forces. They can have a role in accelerating it. So managing those as well. Are there any that you have in mind that haven’t covered yet based on your perio lectures?

[Emma]
Not at the moment. I know the two main ones, smoking, uncontrolled diabetes, definitely. It wasn’t until a few weeks ago in an ortho lecture that I came across, jiggling forces, bruxism and perio and how that can all be linked together, so.

[Jaz]
Did you know about the stress one?

[Emma]
No, I don’t think I did. I don’t think I’d really learned about stress. I wonder why that is. There’s some science behind it, definitely.

[Jaz]
I think it’s the effect on your immune system.

[Emma]
Yeah, yeah.

[Jaz]
It is an immune condition in a way. When we look at periodontal disease, it’s inflammation. So we have to really step back and be a real healthcare practitioner overall. And look at your patient and give them that advice. I think it’s good to point that out to them.

And it’s difficult sometimes to be the main helper. But as someone who treats and manages a lot of TMD, I often recommend an app called Balance to do meditation. If they’re having a real crisis to speak to a GP and not to stay quiet and have that conversation. And sometimes that’s all they need. They just need someone to care for them, look out for them and say, look, it’d be really good for you to take this next step.

[Emma]
Yeah. I suppose fundamentally, the more you can control the risk factors before you start perio treatment, the better the outcome you’re probably going to have from your treatment as well. So yeah.

[Jaz]
Very good. Now, I wanted to say one last reflection for students. Perio is one of those things where there is such a huge genetic component. I have patients in their seventies and eighties who will look me in the eyes and say, Jaz, you’re I’ve never flossed in my life, and I’m not going to start now. All right. And you know what, yes they’ve had caries, crowns, root canals, but you look at their bone levels and they’re winning. On the other side, I’ve got patients who, if they don’t floss three or four times a day, they’ll be in big trouble by the time they’re 40.

So there’s a huge genetic element when it comes to periodontal disease and to be mindful of that. And then, I know we should treat everyone the same in a way, but when it comes to healthcare, we should be specific to the individual. So if you’re noticing that your patient is, scores are getting worse and there’s more inflammation, then we need to coach our patients that, look, I’m seeing something here where in you, you can’t follow the blanket advice of brush two minutes a day and use some floss. That’s not enough for you. And have that very customized approach to healthcare when it comes to Perio.

[Emma]
Yeah, I think a common theme is dentistry is it’s very customizable towards your patient. But a lot of this, that you were talking about your gene expression, your family history, all of that, there’ll be a good deal of that in the notes as well.

And Perio is something that I really quite struggled with last year. Going through the lectures. All the pathology of it, what goes on at an immune level, that’s something that I really quite struggled with and it took me a while to go through these lectures and translate that into my notes, which makes sense to me. So yeah, I’ve spent a lot of time on those perio notes and something that I’ve really struggled with. So hopefully these notes will include all the things.

[Jaz]
I’m sure they will go right in the crusher exam section. Thanks to Emma Hutchison always. And we’re so grateful to have your notes. And I think it’s going to help a lot of students all over the world. So guys, if you’re not already on protrusive. app, remember the email to email is [e-mail] and therefore you send in your proof that you’re a student and you get added to the area and you get access to Protrusive Vault as well. But Emma, we’re going to see you at the same time next week, but obviously we’re trying to film all these now because you’re going to get busy with your exams and I want to make sure that you do really well.

So we’re trying to record these now. It’s funny that we discuss some denture stuff today and hoping that’s going to spark some ideas for you in terms of coming up with some good questions. We’re going for removable prosth, like I am no expert when it comes to removal pros, but as someone who’s been practicing a little while now, I think I have enough to offer in terms of guidance for students. So come up with any questions and remember, if I don’t know the answers, there’s probably an episode I can direct you to that’s covered it, or I know some clever people that can help us.

[Emma]
Yep, perfect. Next week, Removable Prosth.

[Jaz]
Amazing. Thanks so much, Emma.

[Emma]
Thank you.

[Jaz]
Well, there we have it, guys. Thank you so much for listening all the way to the end. Remember, you can download Protrusive Notes. So Emma works really hard on these fantastic notes. And for all students, this is absolutely free. All you have to do is sign up to Protrusive Guidance. It’s completely free. And when you email [e-mail], your student ID or proof of being a student, we give you access to a few secret exclusive areas just to help you guys out.

Now, please do share this with your student colleagues. Why keep it a secret? They’re going to find out anyway. Be the one to share this with them. Share the revision notes. Sharing is caring, and especially comes to education. Always adopt an abundance growth mindset. There’s totally more than enough to go around for everyone, and everyone can benefit. If you’re a fan of the show, then hopefully you are our tribe. You are our Protruserati. You are our selfless. You are sharing.

You are caring. So let’s foster those values, And share away. Thanks so much for listening all the way to the end. I’ll catch you same time, same place next week. Bye for now.