Patient Conversations 

As thought leaders, we must consider a more state-of-the-art methodology to manage periodontal disease. In other words, we must combine traditional diagnostic modalities with SalivalScore. Accordingly, it is essential to understand that often there may be an apparent “mismatch” between the classic diagnostic approach and what is taking place on a cellular level which may seem confusing. We must “re-think” periodontics to understand how this all “fits together.” When combining traditional diagnostics with testing, there are several clinical possibilities. The following examples will provide a more comprehensive understanding as well as simple patient scripts: 

Basis of Script for Patient Communication:
In all cases, we must present the patient with a diagnosis (which cannot be determined by aMMP-8 analysis), a treatment plan, and SalivaScore. The key to this process is to communicate with the patient regarding their number, and if the test is positive (>20ng/ml), let them know that we need to recommend treatment and then retest. Testing without retesting is meaningless. 

For example, “Today, your SalivaScore is very high (>70ng/ml), indicating active tissue destruction. So, the recommended treatment plan is simple non-surgical periodontal therapy and waiting three months to retest so we can get the number down. We must wait three months for the body to heal, so we should not test sooner. Let’s get started and see how you make out. Our target number for health is 19ng/ml or below, so let’s see how you do, as we need to get going. Do you have any questions?”
NOTE: We want to develop a mindset where patients ask for their numbers after understanding the process. 

Patient Scenario 1:  

Periodontal Health with a Very High SalivaScore without Any Systemic Disease 

Note to Clinician: Even though they appear healthy today using traditional criteria, there needs to be a match between what we see and what occurs on a cellular or sub-clinical level. Accordingly, we need to shorten the re-care time and retest after today's prophylaxis. No other periodontal treatment is indicated. 

Treatment Recommendation: Modify the prophylaxis treatment regimen from six to three months. At the three-month re-care visit, they should be retested. NOTE: Make the appointment before the patient leaves the office to be sure this happens. If the numbers do not improve significantly (19ng/ml after three months), referral to a physician may be indicated. 

Patient Script: “Although your gums “visibly appear” healthy, there is an elevated level of inflammation and collagen breakdown on a sub-clinical level, which is invisible without testing. So, to prevent future loss of tissue and bone, let us get you back in three months for a follow-up session, and we can retest you and see what your new numbers look like. This is all about disease prevention and avoiding future potential expensive interventions after bone and tissue loss have already occurred.” 

Case Presentation:  

Patient JC presented for routine prophylaxis. Clinical and radiographic examinations were uneventful. The patient had not had a prophylaxis for two years because of the COVID pandemic. The SalivaScore was 86. Prophylaxis and a review of oral hygiene techniques were performed. The patient returned in 3 months for a retest, and his SalivaScore was 21.  

Patient Scenario 2:  

Periodontal Health with a Very High SalivaScore with Other Systemic Diseases
Note to Clinician: Even though the patient may look healthy on a clinical level, we need to shorten the re-care time and retest. No other periodontal treatment is indicated. Especially in these cases, we must do everything possible to improve the numbers. We need to explain to these patients the mouth-body connection and our need to avoid bacteria in the mouth spreading throughout the body. If, after several attempts, the number is still high or has not improved, we need to suggest a medical evaluation based on their current medical history (i.e., diabetes mellitus, CV disease). When a referral to a physician is indicated, a form letter will be provided. 

Treatment Recommendation: Simple prophylaxis treatment and retest in 3 months. If the number is improving but is still high at that time, a second prophylaxis is recommended, and the patient should be tested three months later. However, if the numbers do not improve significantly after three months, referral to a physician is indicated. 

Patient Script: “Although your gums look healthy, there is an elevated level of inflammation and collagen breakdown on a sub-clinical level, meaning we cannot see this without a test. So, to prevent future loss of tissue and bone, let’s get you back in 3 months for a follow-up session, and we can retest you and see what your new numbers look like. This is especially important with your medical history and our desire to avoid the spread of bacteria from your mouth into the bloodstream. So, let’s get your numbers down, and then we can go from there.” 

Case Presentation:  

Patient TM presented for a routine prophylaxis. Before seeing the hygienist, an assistant administered the SalivaScore test and reported a value of 204. Clinical findings were in the healthy range, and the patient’s oral hygiene was good. The patient reported a history of diabetes. Routine prophylaxis was performed, and oral hygiene techniques were reviewed. Three months later, at the next visit, the SalivaScore was 197. Oral hygiene was still good, and the gingival tissues exhibited relative health. The patient was then referred to her physician with communication. The physician reported that the HbA1c level was 6.8%, and treatment ensued. When the patient returned for the subsequent prophylaxis, the SalivaScore was 24.  

Patient Scenario 3:  

Periodontal Health with a Low SalivaScore
Note to Clinician: There is an ideal balance between the patient’s immune system functioning correctly and dental health on “this particular day.” 

Treatment Recommendation: Continue with current protocols. 

Patient Script: “Your overall dental health is excellent, and your numbers are perfectly normal. You are doing great with your oral hygiene, so let’s continue monitoring your score at your next visit. Our focus here is to continue testing as the body is always in flux and to focus on disease prevention.” 

Case Presentation: 

Patient CL had a clinical examination that showed generally healthy tissues, no inflammation, and good oral hygiene. The SalivaScore was 19. Routine prophylaxis and oral hygiene review were performed. The patient asked to be retested at the patient’s next periodic regular prophylaxis appointment at six months. The SalivaScore was 15. 

Patient Scenario 4:  

Periodontal Disease with a High SalivaScore 

Note to Clinician: These patients demonstrate active breakdown on both a clinical and sub-clinical level and represent the highest risk for continued disease progression. In other words, they have shown a history of periodontal disease combined with testing that prognosticates additional tissue destruction. In this case, positive testing numbers are coincidental with a clinical presentation.However, despite their clinical presentation (bleeding on probing, bone loss), they often present without pain, making it challenging to accept treatment. Explaining the need to reduce aMMP-8 numbers will be an excellent communication tool to enhance patient understanding of their disease process and dramatically improve case acceptance. 

Treatment Recommendation: 

a) Provide the patient with a definitive periodontal diagnosis based on the current classification system (i.e., Stage I-IV Periodontitis). 

b) Provide the patient with grading (A, B, C) and an actual letter before the start of treatment. In this case, Grade C. 

c) Recommend a specific treatment plan with fees (four quadrants scaling and root planning, laser therapy, irrigation, etc. This category of patients can greatly benefit from a referral to a partner periodontist. 

d) Discuss the need for a shortened recare schedule and the need for retesting. 

Clinical Script: “Based on our clinical examination and testing, you are currently experiencing active bone and tissue loss. Your diagnosis is Stage III periodontitis, and more importantly, your SalivaScore suggests rapid disease progression (Grade C). This puts you in the highest risk category. That is the bad news. The good news is that the treatment is non-surgical, inexpensive, and highly effective. The goal is to minimize inflammation and improve oral hygiene, then retest in three months. Do you have any questions? 

Case Presentation: 

NS presented as a new patient. The dental assistant performed the SalivaScore test upon seating the patient. The SalivaScore was 173. Clinical examination revealed moderate to severe periodontal destruction characterized by probing depths in the 6 mm to 8 mm range with radiographic evidence of significant bone loss. Mobility was mild. Extensive periodontal therapy was performed (by the periodontist) and at the first of the regular three-month post-treatment recare visit, the SalivaScore was 23.  

Patient Scenario 5:  

Periodontal Disease with a Low OralFitness Score 

Note to Clinician: These patients demonstrate active breakdown based on clinical examination, yet the testing numbers are low, which may confuse most clinicians. In this case, testing numbers are not coincidental with a clinical presentation. You will see this occasionally, which can be the most confusing of all situations! This means real-time tissue breakdown is low today, and the patient’s immune system is functioning well. Please remember that periodontal disease and a patient’s immune resistance are episodic. The clinical findings are a summation of what has “already occurred,” and the SalivaScore testing is a summation of what is happening on a cellular level on a particular day! We must differentiate what has already occurred from what is happening in real time. This scenario also suggests that this is an ideal time for treatment because the patient’s immune system is functioning well and will respond favorably. 

Clinical Guidelines: 

a) Provide the patient with a definitive periodontal diagnosis based on the most current classification system (i.e., Stage III periodontitis). 

b) Provide the patient with grading (A, B, C) and an actual number before the start of treatment. In this case, Grade A. 

c) Recommend a specific treatment plan with fees (four quadrants of SRP, Laser therapy, irrigation and or referral to the periodontist. 

d) Discuss the need for a shortened recare schedule and the need for retesting. 

Clinical Script: “Based on our clinical examination, you present with generalized inflammation and bone loss, and that information leads us to a diagnosis of Stage III Periodontitis. However, your test numbers suggest your immune system is functioning well today. In terms of disease progression, you present with Grade A (which means you may not experience disease progression in the near term). The good news is that this is easy to treat; the approach is non-surgical (deep cleanings). In addition, because your low SalivaScore means your immune system is functioning well, we should expect an excellent result. The goal is to minimize inflammation and improve oral hygiene, and we can retest in three months. The prognosis is expected to be excellent. Do you have any questions?” 

Case Presentation:   

Patient RJ presented with generalized 5 mm to 8mm pocketing and approximately 1/3 of generalized bone loss, especially in the posterior regions, with moderate furcation involvement and minimal mobility. Bleeding was evident upon probing into the deeper pockets. The SalivaScore was 26. The patient accepted treatment which consisted of scaling and root planing followed by some surgical pocket elimination and then entered a three-month recare program. RJ had an overall SalivaScore of 18 at his first post-treatment three-month recare appointment.  

Overall PCDM (Premier Care Dental Management) Treatment Philosophy  

Being a thought leader and “being among the first” is not easy. Modifying a traditional approach to patient care is not easy, but we must maintain the idea that we are always “trying to do better.” To confidently embrace this technology, we first need to “open our minds” and think forward with the understanding of achieving the following prerequisites: 

a) We must trust the science. As providers of evidence-based high-quality care, we first need to understand that this technology is supported by extensive peer-reviewed scientific literature for over two decades with more than 1000 papers in medicine and dentistry. The Science has been validated. 

b) We must “re-think” how we manage periodontal and peri-implant disease. The advent of personalized dental care and the molecular era of dentistry suggests we must enhance our understanding and management of periodontal and implant care. This technology is not designed to replace classic principles but rather to provide additional information to prevent and predict disease activity in a previously unimaginable manner. We need to combine the “old and the new.” 

c) New Clinical Protocols. We must develop time-efficient clinical protocols that fit seamlessly into our busy daily schedules. These protocols have already been completed. 

d) Mouth-Body Connection. With SalivaScore aMMP-8 biomarker testing, the critical link between oral inflammatory conditions and other systemic diseases has been established. 

e) Overall Improved Patient Care. Acting as an early adapter, more people can benefit from this technology at an earlier point in time. We can offer more patients, more value. We need to seize the moment in dentistry from a historical perspective as our profession advances to cellular dental-medicine, where we can definitively improve patient care and quality of life outcomes.