Periodontics: The joy of long appointments
Anesthetizing the whole mouth is not a problem; we're just not accustomed to it.
Several recent studies show the positive benefits of full-mouth disinfection. The initial reports defined this as full-mouth instrumentation plus extensive use of chlor hexidine. At first, the researchers were convinced that chlorhexidine was an essential part of this approach, but they later compared instrumentation alone to instrumentation plus chlorhexidine and found similar results. The key to their success seems to be completing the instrumentation within 24 hours. The next comparison needs to be full-mouth instrumentation completed in one appointment, compared to full-mouth disinfection done in two separate appointments in a 24-hour period.
The concept of full-mouth disinfection makes sense. Let's look at it graphically. Create a flat image of the infected periodontal tissue in the mouth of someone with gingivitis or early periodontitis. To calculate this, I mea s ured the circumference around several extracted teeth, finding that mandibular central incisors measured about three-quarters of an inch; cuspids, an inch; bicuspids, an inch and a quarter; and molars, an inch and a half. Average those figures out and the measurement is a bit more than an inch and one-eighth per tooth.
Twenty-eight teeth would then measure approximately 33 in ches. Multiply that by an eighth of an inch - the equivalent of 3 millimeters - and you have an area nearly 2 inches square or an area approximately the size of a 2-inch by 2-inch piece of gauze. That's the surface area of the subgingival periodontal infection in someone with an average probing depth of 3 millimeters. That's probably what you see with gingivitis or early periodontitis. In moderate to severe periodontitis, the average pocket depth might be 6 millimeters, enlarging the surface area of infection to nearly a 3-inch square!
If an infection the size of a 2 x 2 were on your forearm, the physician wouldn't suggest debriding just one quarter of it this week, one quarter the next week, and so on. To control the infection, the entire wound would be debrided at one time. Doesn't it make sense to treat a periodontal infection the same way?
It makes perfect sense! However, the first two objections from hygienists about this approach to therapy are: 1) the long appointments and 2) the need for full-mouth anesthesia. Oral surgeons use full-mouth anesthesia all the time. When a person's tongue is completely numb, he or she avoids chewing. Instead, that individual will drink milk- shakes through a straw until the anesthesia wears off and then eat soft cool foods. The same instructions can be given to patients undergoing full-mouth disinfection. Anes thetizing the entire mouth is not a problem; we're just not accustomed to it. Don't just take my word for it - ask an oral surgeon.
The long appointment idea may seem frightening if we picture the intensity of completing one quadrant in an hour, multiplied by four. Or, you might be thinking the patient would have his or her mouth open for the entire time and you would be scaling all that time! That's a frightening thought! Consider, in stead, how much actual instrumentation time you have in a typical one-hour root-planing appointment. If all goes well, you may have 30 minutes, after seating and greeting the patient, evaluating the quadrant treated last week, reviewing oral hygiene, taking blood pressure and vital signs, anesthetizing (or having the dentist anesthetize for you), dismissing the patient, making the chart entry, and turning the room around for the next patient. One single, long appointment instead of four eliminates the set-up, clean-up, meet and greet the patient, blood pressure and vital signs, and chart entry of three visits. That could add up to more than an hour right there! I've found long appointments to be much easier than the rush of an hourly schedule. With more time to devote to a single patient, the quality of care increases and my stress level decreases.
I've also experienced long appointments as a patient and prefer them. In July, I had a full-day appointment to prep 10 teeth (4-14) and another full-day appointment in September to seat nine three-quarter veneers and one post and crown. I'm sure you're wondering how I held my mouth open all day. I didn't! These were the most comfortable dental appointments I've ever had! The key to such comfortable appointments was finding one of the best restorative dentists in the country, Dr. Frank Spear. He knew what he was doing and did it with expertise. There were no wasted motions. He used magnification, the best equipment available, and highly effective assistance. With this approach, time in the mouth was minimized. More time was allowed for discussion of the case and necessary lab work. They were extremely pleasant, day-long appointments for which I gladly paid.
To provide the best possible periodontal care for our patients, we need high-level skills, good equipment, and efficient systems. Rather than providing excellent care, we are too often rushed by the clock to simply "do the best we can." What would you change in your periodontal therapy and patient interaction if you had unlimited time? Interesting thought, isn't it? Next time you're scheduled for a one-hour root planing, ask yourself again - "What would I do differently if I had unlimited time?" Are you currently getting the best possible clinical results? What do you need to do to completely eliminate periodontal disease for this patient?
You've probably had patients ask you to do all their work in one day, but rarely considered it - unless the patients traveled a great distance to the office. Why should distance determine appointment length? Long appointments should be an option for all patients, especially when it makes good sense scientifically.
I'm not suggesting you change your entire system today, but why not try this approach for just one patient? See how you like it; how the patient likes it; what your clinical results are ... and then decide. Our treatment decisions should be based on science, not the traditions that we've always followed. Scaling and root-planing by quadrants is a traditional approach to therapy. Full-mouth debridement and disinfection are supported by scientific research.
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. She can be reached by phone at (800) 374-4290 and by e-mail at email@example.com.