Part 5: Soft tissue management: A firm commitment

Dec. 1, 2001
Clinical proficiency and the avoidance of complacency are absolute cornerstones in patient care, particularly in reference to soft tissue management and periodontal therapy.

by Tammy L. Carullo, RDH, PC, PS

Clinical proficiency and the avoidance of complacency are absolute cornerstones in patient care, particularly in reference to soft tissue management and periodontal therapy. Since we are in the middle of a technological outburst, an amazing amount of information is available, as well as easier treatments and more complex diagnostic tools such as the Perioscopy system (where a probe equipped with a microscopic camera takes visual accounts of the pocket and root anatomy). The ever-changing world of periodontics keeps us on our toes. However, an equally important low-tech element has direct bearing on the health and well being of dental patients — patient education and communication.

Education begins with communication. The way you perform these duties will determine whether your patients tend to be compliant and accept treatment. Generally, the two categories of dental services that we provide are "want" and "need" services.

Examples of "want" services include cosmetic dentistry and nutritional counseling — basically services that the patient has a definite "no" option. A "want" service is generally elective. While a patient may be in need of a restoration, the need aspect is to eliminate diseased tissue and place a restoration; however, the "want" involves a choice about what material is used during the restoration process.

The "need" category of dental services does truly exist. Emergency appointments where the patient is either in pain or has a badly broken tooth serves as an example. But there is a service that, until now, has been up in the air as far as being a "want" or "need" — periodontal care.

Periodontal care is very much a "need" in dentistry. Yet, far too often, patients interpret the way we present the information to mean that they do not have to follow through with treatment. Our active role in conveying a lack of importance to periodontal care is why treatment is often questioned.

Let me ask this question. What repercussions may occur if a periodontal patient is told that, without treatment, the condition will most inevitably worsen? Are there any repercussions? By agreeing to continue haphazard treatment without actually addressing the periodontal issue is considered supervised neglect.

How does all of this deal with the issue of clinical complacency in soft tissue management? One of the biggest areas of complacency in clinical hygiene is patient education — communication! We seem to have gotten so far removed from the structured patient-education protocol of dental hygiene school. Instead, we practice this art in a very minor capacity.

I began taking polls at our continuing education seminars, searching for the number of hygienists who actually conduct formal patient education. By "formal patient education," I am referring to:

  • Showing the patient how to do what you are asking of them (flossing, for example)
  • Allowing enough time for patients to not only learn the task but become proficient enough to repeat it back to you
  • Repeating the lesson in cases where once is not enough

My informal poll revealed the astonishing result of only 15 percent who actually conduct this type of detail-oriented home care instruction. Fifteen percent! This statistic is shocking! What do we expect patients to do, be clairvoyant and figure it out on their own?

I also recently overheard one hygienist answering a patient's question about how to use a Waterpik after the hygienist's recommendation to do so. Her reply was, "I don't know. Read the instructions on the box when you buy it."

This is absolutely unacceptable! If you don't know how to use something you recommend, develop a good working knowledge of a product before you recommend it. Where is the accountability factor?

We owe it to our patients, as well as ourselves as professionals, to be very aware of the issues regarding patient education, continually moving toward a premier level of communication. Educating the periodontal patient involves more than simply going through the motions of showing how to brush and floss. Periodontal disease is progressive and, in some cases, very aggressive. Speed is of the essence in treating a patient with rapid aggressive periodontitis.

Patients need to be motivated and inspired to say, "Hey, I want to do this because I know it is for my best dental health. You have motivated me through educating me about the need for the care, even if dental insurance won't cover it. So, let's get started!"

Does this sound more like a fantasy than reality? Well, let's suspend reality for one moment and imagine that this scenario is, in fact, how patients truly respond to your treatment. It can happen. If you are committed to being a inspirational chairside presenter, the sky is the limit — for periodontal therapy, in particular. The primary component that creates a low case acceptance with periodontal patients is not what you may think (money). Rather, it's the fear component. Often, patients who are facing the prospect of periodontal therapy are scared. Scaling and root planing can sound pretty ominous to patients unfamiliar with the procedures.

Re-ignite your passion for dentistry, and your STM program will absolutely flourish. Become excited about the treatment you are recommending instead of being caught in a rut when conducting patient education, soft tissue management, and scaling and root planing. STM is so much more than good instrumentation. Keeping current with a more aware and alert patient base will keep you one step ahead of the game. Patients absolutely need to be motivated to accept treatment. Then a continual motivational spiral will propel them throughout their treatment and follow-up.

The future of periodontal therapy depends, and still hinges on, the acceptance component. You will be doing what you need to be doing for your patients now ... and in the future.

Tammy L. Carullo, RDH, PC, PS, is CEO of Practice by Design, Inc. She is a practice-management consultant and continuing-education instructor. She may be contacted by e-mail at [email protected] or phone (717) 867-5325. For more information about her company, visit

The information deluge
The single most important aspect of what we bring to the forefront of patient education is commitment. The patient has only one job in their treatment — commitment. But how do we get the patient committed to periodontal therapy? Believe it or not, the way we present the information during treatment planning and patient education will play a very heavy role in the acceptance level of the cases you and your dental practice present.

The first obstacle is to gain trust by developing a nurturing relationship with patients. Make them feel at ease and comfortable enough so they will ask questions and obtain enough information and facts for an informed decision about their oral health.

The second obstacle is to provide enough information without overwhelming patients. Far too often, dental professionals think that, if we provide every detail, the patient will be more likely to accept the treatment.

However, research indicates that patients who have been informed of just the basic information have a much higher acceptance rate than their counterparts, who need a dental encyclopedia to decipher your explanation.

At one point during my 18-year career, I was definitely of the mindset that more is better. My approach was to provide patients with intricate details of their condition. Only then would they be able to make an appropriate and informed decision regarding their treatment path.

I was sadly mistaken. Most patients do not want all of the information. For one thing, they do not want to be so informed as to see the bacteria that exist within their oral cavity up on a screen from a phase-contrast microscope. They also do not want to walk out of a visit with mounds of information comparable to homework. On a good day, it would take hours to sift through information. Patients want and expect to receive instruction and enough information for making an informed decision.

We provide patients with the essential information. Based on a recent survey of patients, we found four concerns that patients truly want to know about, and they are:

  • What is the quickest/best way to help the situation?
  • Will this hurt?
  • How many appointments will this take?
  • How much will this cost, both covered by insurance and out of pocket?

For years, I believed that a formal consultation in a private room — complete with every piece of dental literature even remotely pertaining to their situation carefully displayed on the table before them — was the way to go. I no longer believe that to be the case. "Keep it simple" is a much better approach. While I do not advocate spending an enormous amount of time gathering information for a lengthy treatment consultation, I do stand behind the fact that the dentist and hygienist both need to play a much more active role in how the information is presented to the patient.