Actively searching for periodontal disease
by JANET HAGERMAN, RDH, BSDH
I had spent the summer filling in as a temp for a hygienist on pregnancy leave. As always, I first cleared my periodontal philosophy with the dentist to be sure our protocols were congruent, and then proceeded to look for, find, and treat the patients who presented clinically with various levels of periodontal disease.
Apparently this did not suit the permanent hygienist who occupied the adjoining treatment room. One morning I walked into the office to hear her loudly complaining to the dentist about me and the amount of time I spent on periodontal therapy, compared to her "prophy machine." When the doctor defended my use of periodontal therapy as clinically documented and indicated, she lamented, in a tone of exasperation, "But she's looking for it!"
Yes, of course I'm looking for it -- and you should be too! Today, more than ever, it is imperative to use your detective skills to search for, discover, and treat the periodontal disease you find.
We now know that the mouth is the portal to the entire body. With strong evidence suggesting, and indeed revealing daily, oral links to heart disease, diabetes, obesity, low-birth-weight babies, and more, it has become glaringly obvious and imperative that the dental office be more than a cleaning and filling station. The dental practice of today -- and of the future -- must be a center for wellness and prevention. It must be a screening, diagnostic, and treatment center for a plethora of conditions that affect oral and whole body health. The ideal place to direct these energies is the preventive-oriented hygiene department.
"Looking" for periodontal disease requires a different mindset than that of a prophy model. It requires us to actively search for signs of periodontal disease before you ever pick up a scaler. You must determine whether the patient either has a level of periodontal disease that must be identified and treated, or is free of periodontal disease and therefore a viable candidate for a prophylaxis. All too often, hygienists rush in to perform a prophy, only to discover halfway through that their scaler drops off into a bleeding pocket (is it 5 mm or 6 mm?), and then upon probing, learns that the patient has even more pockets. Now this hygienist has a dilemma. How do you tell your patient halfway through a "cleaning" that you now see periodontal disease and that you need to perform a different treatment for this? It is no wonder that patients would feel confused and overwhelmed at being confronted with information in this manner, and they may be reluctant to comply with a midstream treatment plan change. This type of situation can undermine your patients' confidence in you as well as in your treatment recommendations.
We must "look for" periodontal disease right from the start in order to properly diagnose and treat it. Sophocles said, "Look and you will find it -- what is unsought will go undetected." Certainly this is true of periodontal disease. Hygienists who are not looking have been proving this for years, by not looking, not finding, and not performing periodontal therapy on unsuspecting, sick patients who carry within them a disease that affects their oral and systemic health. We can no longer tolerate this supervised neglect. In today's health-care environment, discovering and treating a patient's periodontal disease is a game changer, and may indeed be a lifesaver!
Looking for periodontal disease requires a congruent philosophy of all team members, not just the hygienist. From the doctor to the assistant to the administrative team, all staff members need to understand, believe in, and support an agreed-upon periodontal protocol for the practice. All team members must be committed to "looking for clues" to periodontal disease. Here are some prioritized strategies for success.
Periodontal protocol planning meeting with doctor and hygienist -- This is the opportunity to get on the same page with your dentist. What are you and your dentist's core beliefs about periodontal disease -- i.e., how you find it and when and how you treat it? Your protocol should be written and include your overall periodontal philosophy and description with current clinical support, your office core values, and treatment commitments to your patients. Simply stated, your periodontal protocol should affirm how you plan to "look for it," identify it, and treat it. (For example: All of our patients will have a full six-point periodontal screening performed and documented initially and annually). This protocol will become the foundation that you will commit to for every patient, every time, and the agreements that will ensure doctor/hygiene mutual support on behalf of your patients.
Staff meeting to solidify your periodontal protocol -- This meeting creates the opportunity to inform and educate the rest of the team about the periodontal protocol draft by the doctor and hygienist. It is also the forum to invite discussion, feedback, and contributions from the whole team. Their feedback will be vital to the implementation of your new program. Invite their opinions about how each team position can and will support your periodontal program. (Examples of this could include how assistants can help with the probing process or how the administrative team can adjust and block appointment scheduling to accommodate timely SRP appointments.) As a team, create scripts to assist all staff members in presenting the same congruent periodontal message to all patients.
The team needs to open patient dialogue in a way that gently invites interactive discussion about periodontal disease, rather than just "educating" or talking to the patient. This can be accomplished with, among other things, good open-ended questions, transformational vocabulary, and positive patient preparation. All of these can be crafted into simple scripts that team members will be comfortable using. Here are examples all staff members can use to "collect clues" to look for and find periodontal disease:
- "Mr. Jones, tell me, what do you know about periodontal disease?" This open-ended question is a great way to introduce the topic and get true feedback from your patient. Do not ask, "Do you know about periodontal disease?" This is a closed-ended question and will not supply useful patient information.
- Abolish the outdated, obsolete, and clinically incorrect term "deep cleaning" and replace this with appropriate clinical terminology -- e.g., periodontal therapy, periodontal treatment, treating your infection, etc. This transformational vocabulary will go far in eliminating patient confusion about periodontal treatment and encouraging treatment acceptance.
- "Ms. Jones, we now know periodontal disease has major implications with many other systemic conditions, such as heart disease and diabetes, and our office is committed to screening for this at the earliest opportunity. Today we will start your appointment with a screening in order to determine what treatment you actually need."
The list is endless and the point is for all team members to contribute their own ideas about how everyone can support your periodontal program in their own way. Each team member can be a sleuth who collects his or her own patient clues in order to make your periodontal program work smoothly and successfully for all patients. When all team members have helped to create your practice's periodontal protocol, there will be associated personal accountability for the implementation of your program.
Support materials -- Reinforce your periodontal program and message with third-party support material. Good sources are the American Dental Association, American Academy of Periodontology, and American Association of Oral Systemic Health. Also, practically all vendors of periodontally associated products and services provide excellent patient education materials, usually complimentary. Most people are visual learners and vastly benefit from written and take-home materials (customized for your practice). Perform your own research and be able to recommend online information and helpful websites for your patients.
Are you actively looking for periodontal disease? Does the sleuth in you come out searching for clues? Where and how do you actively seek signs to support evidence of periodontal disease? While probing depths, BOP, and radiographic bone loss are important, indeed imperative determinators, this criteria is only the start -- the bare basics. What other clues may be lurking in your patients' medical histories, lifestyle information, and conversations?
What other signs and clues can you detect from careful observation of your patients? In the words of Sophocles, "Look and you will find it." Don't let periodontal disease remain undetected in your treatment room. Be the sleuth, look for clues, find the periodontal disease, and treat it. RDH
Look for signs in all the right places:
- Has your patient (new or patient-of-record) missed preventive dental appointments for extended periods of time?
- Does your patient or patient's family have any history of heart disease or conditions?
- Does your patient or patient's family have any history of diabetes?
- Is your patient pregnant?
- Is your patient planning to become pregnant or in a situation that may be considered pre-pregnant?
- Does your patient smoke?
- Does your patient or patient's family have any history of past periodontal disease or conditions?
- Does your patient's spouse/partner have any history of past periodontal disease or conditions?
- Has your patient undergone any lifestyle changes (e.g., divorce, job change or loss, financial stress, family stress, etc.) that would contribute to stress in their life?
- Does your patient exhibit radiographic bone loss? Do your radiographs clearly show bone levels around every tooth? Often this not apparent with a panoramic and bitewings. Check to see if an FMX (18 single PAs) is necessary.
- Have your patient's probing depths been identified and recorded regularly?
- Are all bleeding sites always documented?
- What does your patient know about periodontal disease? Ask him or her. This is the perfect opportunity to uncover the patient's beliefs, which you can then guide. Their answers will provide valuable clues to help you enroll them in appropriate treatment.
Janet Hagerman, RDH, BSDH, is an author, international speaker, advisory board member, and consultant. A graduate of the Medical College of Georgia, her focus on communication and leadership empowers health professionals nationwide. To learn more, visit Janet's website at www.janethagerman.com or contact her at firstname.lastname@example.org.
Consider reading: Bringing in more of your "ideal" patients
Consider reading: What Can We Say To Our Patients?
Consider reading: When should a dental office refer to a periodontist?
Past RDH Issues