Letís Make A Plan
Very few dental offices feel that they are dealing effectively with perio identification and treatment. While we know that a large number of adults have some form of perio disease, the fact is we often see our hygiene schedules full of standard prophys instead of perio scaling and perio maintenance. There are many reasons for this. In my opinion, one major problem is patient resistance. Many patients are reluctant to even entertain the concept that they have a condition that would benefit from more appropriate treatment than a “cleaning.” They have “always” had so-called cleanings, they have not lost any teeth yet, therefore a cleaning is all they need. Added to this may be an underlying mistrust of what the hygienist and/or dentist is telling the patient. Patients may fear that the office “just wants money” or is trying to force them into something they don’t really need (which can be magnified by dental insurance restrictions and coverage limits).
Even patients who have faith in the practice may be resistant to agreeing to more than just a prophy. They may not have any symptoms they can identify themselves, so they chalk up our recommendations to over-zealous diagnosis - just as some people will disparage frequent hand-washing at home or the need for flu shots.
As a hygienist who values appropriate perio diagnosis and treatment, (as well as lots and lots of hand-washing), I struggle with patient resistance myself. An office plan for identifying periodontal disease and corresponding appropriate treatment helps. Following the plan allows the dentists, hygienists, assistants and office staff a way to explain and encourage what patients need.
The American Academy of Periodontology literature provides us with guidance, and using their information and our own guidelines and explanations can help us lead our patients to correct care. Each office should decide what their plan will be. Here is a simple example for perio identification:
While there are many other factors that influence identification of periodontal disease, probing depths and bleeding are easy to demonstrate and explain to patients. Full mouth probing at least once a year for prophy patients monitors how your patients are getting along. When they hear the numbers called out to an assistant, or look at the computer print-out showing their results, tangible evidence is presented. Additionally, bleeding can be shown with an intra-oral camera or simply a hand mirror. One of the quickest and most effective demonstrations that I employ uses a hand mirror and a perio probe. I show the increments on the probe, then show the patient where this probe descends in a pocket while they watch in the mirror.
After the “show and tell” portion of the appointment, my explanation of what is happening and what treatment is recommended can commence. For slight periodontitis, our office has decided to recommend three prophys annually. I explain that insurance will only cover two of these, but that with their increased adherence to the home care routine I present, they will likely find that the tendency to develop a more troubling case of gum disease will be lessened. I explain that if this new routine does not work, isolated areas of scaling and root planing will be needed. For moderate or advancing periodontitis, our office recommends scaling and root planing for the involved teeth and then periodontal maintenance thereafter. This can be 4 or more teeth per quadrant or 1-3 teeth per quadrant as appropriate. I also make it very clear that after this treatment the patient and I will have to be vigilant to prevent the condition from worsening - hence the need for periodontal maintenance three to four times per year. Often I need to take as much as 15-20 minutes to explain what all of this means, with my opinion backed up by the dentist when he comes for his exam.
In practice, this results in a great curtailment of delivering a “prophy” at the appointment, but I am careful to provide some scaling and polishing so that patients do not feel shortchanged. When the patient comes with me to the front desk, the treatment plan is indicated on the routing slip and the treatment coordinator follows up with fees and an insurance estimate. Patients who do not respond to treatment are typically referred to a periodontist.
While this approach does not provide for an initial focus on nutrition, pathogen or DNA testing, irrigation, or prescription meds; these can be incorporated later if appropriate. What this approach does do is identify and help guide patients who need periodontal care to receive that care. And to do it within the restrictive time constraints present in a typical hygiene day.
If patients refuse to pursue perio treatment, do we kick them out of the practice? Of course not. We continue to explain and encourage appropriate care at each and every prophy visit, and we also ask them to sign an informed refusal form so we can document that they have been told about their condition, but have decided not to address it at this time.Identifying and treating periodontal patients is an important task of the dentist and hygienist, and it can also be instrumental in improving practice production. Making a plan to accomplish this is good for everyone involved.
For more information to help with your own plan, check the AAP website.
Carol Tekavec RDH is the Director of Hygiene for McKenzie Management. Carol can improve your hygiene department in just one day of training “in your office.” Interested in knowing more about how to improve your hygiene department? Email email@example.com.Forward this article to a friend
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