Ease into a periodontal program, so patients can mentally adjust to new approach

Every general dental office has a periodontal program, whether by design or by default. Whether written or improvised, decisions are made every day regarding nonsurgical therapy and concerning referrals to the periodontist. Having the clinical skills to comfortably and predictably provide nonsurgical perio therapy is essential, but implementing the perfect perio program may be harder than debriding an 8 millimeter pocket.

Jul 1st, 1998

Trisha E. O`Hehir, RDH, BS

Every general dental office has a periodontal program, whether by design or by default. Whether written or improvised, decisions are made every day regarding nonsurgical therapy and concerning referrals to the periodontist. Having the clinical skills to comfortably and predictably provide nonsurgical perio therapy is essential, but implementing the perfect perio program may be harder than debriding an 8 millimeter pocket.

Besides refining our clinical skills and establishing criteria for providing periodontal therapy, we must know what we hope to accomplish. It is not enough to tell people they have periodontal disease and they need nonsurgical therapy. More importantly, what can we predictably accomplish with our treatment? What does successful, non-surgical therapy look like? What benefits should the patient expect? When we look at a patients` periodontal condition, can we see what they will look like after treatment? This is often easier to do with restorative work. Unless patients understand and desire the results, they won`t accept periodontal treatment.

It`s easy to create a periodontal program on paper. Using textbook definitions to set our standards, we may find ourselves treating every patient in the practice! According to some definitions, bleeding and probing depths 4 millimeters and greater are considered in need of treatment. The great majority of our patients actually may fit the categorical description of periodontal disease - either gingivitis or periodontitis. Setting up a program to treat pocket depths rather than patients can lead to problems.

You all have heard stories of dental offices implementing a perio program, only to find all the regular recall patients being told they now need expensive, nonsurgical periodontal therapy that looks to them like what they were getting every six months already. They`re in the same room, with the same hygienist, who uses the same instruments. Their first question is, "Did the dentist just buy a new car or a boat or something?"

Rather than implementing your program across the board with all patients in the practice, start with new patients. This gives you time to develop and perfect your perio program with patients you haven`t already given free periodontal care. It also gives you a chance to see the results of your clinical efforts. Providing nonsurgical therapy is one thing, but predicting your success rate is another skill entirely. It requires practice and experience.

You may feel confident providing optimal periodontal care to new patients, but lack that same confidence with long-time recall patients. If you have some patients who have been coming in regularly and could still benefit from more focused therapy, suggest treating a single quadrant in a longer visit at each recall, rather than feeling the need to treat the whole mouth within a couple of weeks. If their periodontal disease is slow-moving, as most is, no harm will be done by stretching out the treatment. When they feel the difference between the first treated area and the untreated areas, they may choose to go ahead with the treatment rather than spreading it out. It is better to spread out treatment than to secretly do a little bit of perio therapy each recall without telling the patient.

If your office has been giving away perio therapy freely for years, abruptly changing things will be difficult for both hygienists and patients. Start by gathering good data on all patients, explaining their periodontal condition to them, and discussing options such as nonsurgical and surgical therapy. Tell them about the new findings linking periodontal disease and systemic conditions like heart disease and low birth-weight babies. Ask them what they want for their mouths.

If you find yourself still giving away perio therapy, at least record on the bill what periodontal therapy was provided, what the fee should be, and then mark it "no charge." At least that way your patients see the dollar value of the therapy they would otherwise take for granted.

If a patient has one or two areas that need subgingival instrumentation and you can comfortably treat those areas in today`s appointment, go ahead and do it. But, first, explain to the patient what you will be doing and why. Just because there may not be an extra charge for this doesn`t mean you should keep a secret from the patient. If you don`t have time to both explain and do the treatment, spend the time educating the patient and offer the therapy to the patient for consideration. Then offer to schedule it another day.

If you are new to a practice, take time to evaluate the situation. Don`t immediately jump to the conclusion that periodontal disease is being ignored by your new employer and the hygienist who has been there for years. Find out the current approach to periodontal therapy. Does the practice have an established perio program, or did the current hygienist inherit the "silent" program? The silent program is where you provide periodontal therapy, but you don`t tell the patient. Because you don`t tell, you don`t charge either. A couple of things can happen with a silent perio program, either the patients think you are a very thorough dental hygienist or they think you`re just rough and slow! Whatever the case, talk to both the dentist and the other dental hygienist to see what has been tried, what has failed, and what their goals are for the perio program.

You may also find that patients with what appears to be active disease have actually been monitored for several years with no disease progression. Assume the best before proclaiming the eminent loss of many teeth in the practice. Steamrolling your ideas through a new practice does nothing for your position as a team player.

Hygienists who have been with the practice for a number of years need to look at each patient with a fresh view. If this were my mouth, what would I change? Knowing what I know today, how can I improve the periodontal health of my patients? It is easy to get caught in the routine of what was inherited. We need to step back every once in a while and reevaluate our approach to patient care.

Every structured perio program needs a separate set of rules for implementation. The way a perio program is integrated into a practice is essential to its success.

Trisha E. O`Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.The Web site for Perio Reports is www.perioreports.com. Her e-mail address is trisha @perioreports.com.

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