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Second Opinion: Providing Personalized Care
in Dentistry by Diego Velasquez, DDS, MSD

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Providing Personalized Care in Dentistry
by Diego Velasquez, DDS, MSD
Second opinions are common in health care, whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dental professionals to share their opinions on various topics, providing you with a "second opinion." Perhaps some of these observations will change your mind, while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession.
- Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine

A June 2013 article in The New York Times titled "Rethinking the Twice-Yearly Dentist Visit" challenged a long-held belief about preventive dental visits. The article summarized a study published in the Journal of Dental Research (JDR) that evaluated data from 5,100 patients over 16 years, and concluded that individuals at low risk for periodontal disease do not see a significant difference in tooth loss rates when receiving two preventive dental visits versus one.

Interestingly, the study determined that high-risk patients saw better periodontal health outcomes when receiving preventive care at least twice a year, possibly (and depending on number of risk factors) requiring more than two yearly preventive visits to see the most optimal outcomes.

There are a number of contributing risk factors that elevate a patient to high-risk status. These include the presence of other chronic inflammatory diseases, such as diabetes, poor oral hygiene, smoking, age and genetics. Since periodontal disease impacts more than half the U.S. adult population, according to the American Academy of Periodontology and the Centers for Disease Control and Prevention (CDC), it is likely that many of our patients might benefit from additional preventive care visits.

Have we ever questioned the staple "twice-per-year" protocol put in place by dental insurance companies? Maybe we should. At the very least, I believe we should offer patients more precise and tailored preventive care based on their individual needs and risk factors.

High Risk vs. Low Risk

According to the JDR study, high-risk individuals are classified as high-risk for periodontal disease if they had one or more of three commonly observed risk factors: smoking, diabetes or the interleukin-1 genotype. These patients experienced better periodontal health outcomes when they visited the dentist twice a year. The study also indicated that those who exhibit more than one risk factor might need more than twice-yearly preventive visits.

According to the findings, patients with multiple risk factors had a 50 percent higher likelihood of tooth loss than those with no risk factors or one risk factor. Patients exhibiting two or three risk factors had a 30.1 percent likelihood of tooth loss when receiving only one yearly preventive visit, compared to a 23.5 percent likelihood of tooth loss for those who had at least two preventive visits.

Cumulatively, high-risk patients with two preventive visits annually had a 22.1 percent likelihood of tooth loss, compared to just 13.8 percent for low-risk patients, the study showed. Further, and significantly, two preventive visits for patients with more than one risk factor might be insufficient.

Low-risk patients were characterized as those who do not smoke, have no history of diabetes and are absent of specific genotypes. These patients showed no significant difference in tooth loss whether receiving one of two preventive visits per year.

In my opinion, the study results underscore the importance of regular, preventive care, which includes an assessment of periodontal health and a detailed inventory of any risk factors. For some patients, this once-a-year visit is sufficient. However, patients with increased risk for periodontal disease might warrant additional preventive visits.

Determining Risk Level

To better provide personalized preventive care, each patient should receive an annual comprehensive periodontal evaluation (CPE) that follows guidelines recommended by the American Academy of Periodontology (AAP).

A CPE includes:
  1. Extra- and intra-oral examination to detect non-periodontal oral diseases or conditions.
  2. Examination of teeth and dental implants to evaluate the topography of the gingiva and related structures; to measure probing depths, the width of keratinized tissue, gingival recession and attachment level; to evaluate the health of the subgingival area with measures such as bleeding on probing and suppuration; to assess clinical furcation status; and to detect endodontic–periodontal lesions.
  3. Assessment of the presence, degree and/or distribution of plaque/biofilm, calculus and gingival inflammation.
  4. Dental examination including caries assessment, proximal contact relationships, the status of dental restorations and prosthetic appliances, and other tooth- or implant-related problems.
  5. An occlusal examination that includes, but might not be limited to, determining the degree of mobility of teeth and dental implants, occlusal patterns and discrepancy and determination of fremitus.
  6. Interpretation of current and comprehensive diagnostic-quality radiographs to visualize each tooth and/or implant in its entirety and assess the quality/quantity of bone and establish bone loss patterns.
  7. Evaluation of potential periodontal–systemic inter-relationships.
  8. Assessment of the need for and suitability of dental implants.
  9. Determination and assessment of patient risk factors such as age, diabetes, smoking, cardiovascular disease and other systemic conditions associated with development and/or progression of periodontal disease.
The AAP offers a convenient "Comprehensive Periodontal Evaluation Checklist," available at: www.perio.org/sites/default/files/files/CPE%20Checklist_FINAL%20fillable.pdf. The tool is useful in bringing the entire dental team on board in following a consistent periodontal health exam protocol.

Depending on the outcome of the CPE, patients might require treatment or therapy to reduce or slow disease progression. However, there might be patients who are not showing signs and symptoms of periodontal disease, but can be characterized as high-risk based on other factors such as medical and dental history and lifestyle habits. These are the patients who might benefit from an increased number of preventive care visits.

Team Up

With a reported 65 million adults age 30 and older having some form of chronic inflammatory periodontal disease, dental professionals must take a proactive approach to care. This means thoroughly assessing each patient's risk level and recognizing that each patient requires different and individualized care.

Discussing risk assessment with your patients will help them to better understand why they might be in need of more frequent preventive visits. They will likely appreciate your extra care and attention, especially if it potentially reduces the need for more aggressive periodontal disease treatment in the future and helps preserve their natural dentition.

In working with your high risk patients to manage their periodontal health and multiple risk factors, take a collaborative approach to their care. This means combining the various skills of your dental team and specialists in the area to better meet the needs of each individual patient. This approach also includes conferring with patients' physicians to better convey the impact periodontal health has on the overall health of a patient.

My Approach

I have been a practicing periodontist for 12 years. My practice relies on my close working relationships with local general dentists and hygienists who identify the first signs of periodontal disease in patients.

For us to continually provide the best care for our patients, we must keep an open dialogue about the role of inflammation in periodontal disease, emerging research on the perio-systemic link and the workings of a comprehensive periodontal evaluation.

In considering the increased need for personalized preventive care, oral health-care providers, particularly the dental hygienist or general dentist, must regularly assess patients' risk to determine which patients could benefit from increased preventive visits and possibly specialized care.

For example, when treating a patient who smokes and is also living with diabetes – someone who should certainly be considered high risk – the dental hygienist, general dentist, and periodontist should be in communication on the patient's symptoms, diagnosis and where he or she is in the care continuum. The dental team should also ensure that the patient's medical team has been contacted to make sure the patient is receiving the most appropriate and optimal care.

What to Do Next

Like your patients, your practice is an individualized experience. Consistency for both the patient and practice is important. Implement a protocol that ensures every patient is receiving a comprehensive periodontal evaluation on an annual basis. If you are not the practitioner performing the CPE, have a system in place to check with patients' other dental care providers.

Make sure accurate patient records are kept and that proper patient education is provided. This ensures that each of your valued patients has a complete and more thorough understanding of the various factors that are affecting periodontal health.

With approximately half of your adult patients at risk of periodontal disease, it is important to tailor treatment programs to the correct number of annual preventive visits to suit their unique health-risk situations. Adding a team approach will improve the effectiveness of treatment, and allow you to provide smarter, more efficient care.

A complete abstract of the JDR study is available at: jdr.sagepub.com/content/early/2013/06/05/0022034513492336.abstract.

Disclosure: Dr. Velasquez consults with Interleukin Genetics and conducts clinical research with Geistlich Pharma.

Author's Bio
Dr. Diego Velasquez is trained in both periodontics and prosthodontics and maintains a private practice in Fenton, Michigan. He is a diplomate of the American Board of Periodontology, a member of the Journal of Periodontology's peer review panel, and a consultant for the International Journal of Periodontics and Restorative Dentistry. Dr. Velasquez is an adjunct clinical assistant professor at the University of Michigan School of Dentistry.
Dentaltown Magazine
September 2025
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