Dianne D. Glasscoe, RDH, BS
Once upon a time, there was a hygienist named Linda. Linda was a very good hygienist. She carefully charted each patient and took great pains to document any disease activity, periodontal or otherwise. Linda showed great concern for her patients by giving them the highest level of care possible. Her clinical skill in calculus detection and removal was quite impressive, and she took pride in each and every patient she treated.
However, there was a problem. Patients were leaving the practice, and it was Linda`s fault. The doctor didn`t have a clue about why his patient-retention rate was so low. He finally ran into one of his former patients at a restaurant one day. The conversation went like this:
Doctor: "Well, hello Bill. It`s great to see you! By the way, I haven`t seen you in the office in a while. I hope everything is all right."
Former Patient: "Well, Doc, it`s good to see you, too. The fact is, I`ve changed dentists. It had nothing to do with you; in fact, I really hated to leave. But your hygienist fussed at me every time I came in until I finally got enough of it."
Doctor: "Well, I certainly am sorry to hear that. We hate to lose good patients like you."
After a few more pleasantries were exchanged, the doctor walked away with a feeling of anxiety and concern. He recalled how another former patient had told him a couple of weeks earlier about switching practices because of Linda`s chastising.
This problem is more common than you might think. According to a survey done by a leading dental publication on why patients leave a particular practice, the third leading cause of patient loss is "hygienist chastisement." People do not like being fussed at!
The heart of the problem
Linda`s problem is one of perfectionism. She expects the same high levels of oral care from her patients that she sets for herself. After all, aren`t we all taught in hygiene school that the oral cavity must be free from every little speck of plaque and calculus to be really clean? Didn`t we get points off of our grades if we left even a minuscule amount of debris? My question is this: Do we transfer this mind-set to patients by "grading" them every time they come in?
Our professional training teaches us to make judgments about our patients` oral hygiene. And, we want them all to be squeaky-clean! But, in the real world, we are indeed fortunate if even 30 percent of our patients are motivated to achieve an excellent level of oral hygiene.
We sometimes talk ourselves blue in the face trying to get patients to improve their home care. Many patients readily will admit that they floss faithfully after their prophy - for about two weeks. Some of my favorite patients (usually elderly) come in for their appointment every recall cycle, looking as if they brushed with a donut. You`ve seen them just as I have.A few of the more obnoxious patients will sit down in the chair and announce: "I don`t need no lecture today!" Have you experienced this?
Or, how about this one: "You`re gonna be mad at me because I haven`t done a good job of taking care of my teeth." This truthful confession always gives me a sinking feeling. Then there are the ones who tell you a bald-faced lie such as they floss every day, when you know there is no way they could and have this much interproximal calculus. These patients feel assured that you are not going to dispute their word, so it looks like the calculus problem is not their fault.
Been down the road a few times
Those of us who have been in a particular office for a number of years may see the same patients every recare cycle for literally years. Some are patients we truly enjoy seeing, and some we dread. In most cases, the ones we dread are those who exhibit a low level of oral hygiene. Somehow, we feel like we`ve failed if this patient doesn`t do exactly what we`ve told them to do.
However, in 25 years in this profession, I`ve learned that you can lead a horse to water, but you can`t make him drink. In other words, you can attempt to educate your patients in the best way you know how, but there`s no guarantee that they will comply. Some people put very little emphasis on good oral hygiene ... period. I even had one man tell me he didn`t floss his teeth because that`s what he paid me to do!
A different paradigm
May I suggest a shift from the old paradigm of nagging and chastising our patients for poor oral hygiene to one of gentle, warm persuasion. The key is assessment. As we assess each case individually, let`s consider the factors that may influence success. Four primary factors are: age, dexterity, attitude, and heredity.
Age: Certainly, the age of the patient is important to understanding the benefits of good home care. Since most young children do not take to heart much of what we say, parents should be encouraged to remind their children to brush, especially at bedtime. Teenagers can be some of our most challenging patients because they generally do not put much emphasis on oral hygiene. Adults often will say they are too busy to do what we ask (it`s tempting to nag in these cases!). Many elders have heard the lecture so many times that it goes in one ear and out the other ear.
Dexterity: Small children and elders often do not possess the dexterity to brush efficiently, much less floss. However, lack of dexterity also can be present in teens and adults. There may be an attitude problem here if some patients demonstrate adequate dexterity in home care, but every time you see them their teeth are covered with plaque, there may be an attitude problem here.
Attitude: If your patient is turned off by your message, no amount of cajoling or browbeating is going to change that individual. We just have to accept the fact that some people are not going to change no matter what - even if they lose their teeth! Certainly, any time we give home-care instructions, documentation should be made in the patient`s chart. If, for example, Bill is a patient-of-record and was given toothbrushing instructions six months ago, it probably is not advantageous to repeat the instructions at his next recare visit, even if he exhibits heavy plaque.
Heredity: Some patients always will have problems with their periodontium because of hereditary factors. I have patients whose tissue bleeds every time I see them, even in the absence of plaque and calculus. It is tempting to berate these people because we think that they just need to do better on their home care. But try as hard as they can, these people still bleed. It usually is counter-productive to continually stress home care to them. Also, many systemic diseases and oral medications can cause capillary fragility, which leads to excessive bleeding.
Sometimes, our best service to our patients is to do a thorough prophylaxis, give a kind word, and be a friend that they look forward to seeing. Always, if you must point out their errors, do it with a hint of regret in your voice and in a gentle manner. It is better not to use "you" statements in a negative message like, "You haven`t been brushing very well in this area." Try to point out the positive first. For example: "You are doing a beautiful job here, here, and here, but here`s an area that needs more attention." In instances where home care is extremely poor and does not improve after several visits, it is best to keep these patients on a short recall schedule, such as every three months.
So far, the patients I have been alluding to are your typical recare patients. However, if you have a soft-tissue management program in place in your office, some other considerations come into play. Let`s examine the differences.
Typically, patients who are classified as Type III or Type IV periodontitis will need more extensive periodontal therapy than just a prophylaxis. These patients often need multiple appointments. They especially need you to aggressively teach them good plaque-control measures. They usually will accept treatment once they have been convinced that they have periodontal disease and understand the damage it can do in the long term if left untreated. The hygienist might explain the treatment to the patient in the following way: "Mrs. Jones, for the next few weeks, we are going to put your gums in `intensive care.` It is essential that you adhere to the instructions that I give you, because your healing depends on it."
Another analogy that works well is this: "The deposits that have built up on your teeth and under your gums are like a coral reef. Have you ever seen how the fish and marine life swim in and out and hide in the coral? Well, the hard deposits on your teeth provide sanctuary for the bacteria causing your gum disease. I`m going to work hard to remove these deposits, but what you do at home is just as important as what I do. We will get a much better result if you keep the area very clean. I will be asking you to do some things that you have not done before to accomplish this objective. But don`t worry, we`ll take this one step at a time."
The partnership between you and the patient in successfully treating the patient`s dental disease needs to be established at the outset. Patients need to realize that this is their disease and that your role is to help them get it under control. Another good analogy to use is to emphasize continuing maintenance. You might say: "Mrs. Jones, periodontal disease is similar to diabetes in that there is no cure. But we can get it under control and stop the bone destruction that is occurring. I want you to realize that after we finish the treatment, we will need to stay a jump ahead by keeping it under control. Until everything is stable, we will want to see you for maintenance visits at three-to-four-month intervals."
Occasionally, patients with dental insurance may mention that their insurance will not pay for them to have their teeth "cleaned" that often. This mind-set often annoys me, and I usually say, "Well, Mrs. Jones, I don`t know a lot about insurance companies, but I do know that they are out to save money.
They often do not have the patient`s best interests at heart when it comes to treatment. Your company purchased a plan that allows for certain procedures, but not necessarily the treatment that is best for you. We like to think that we are giving you the best treatment available, and we will be happy to file your insurance claim for you. But you need to be aware that the insurance may not cover everything that you need to get this disease stopped and under control."
So far, I haven`t had any problems with patients paying out-of-pocket at alternating intervals when they understand that their insurance may not pay for everything. And after a year or so, we frequently are able to move many of these patients back to a regular, six-month recare schedule.
One of the beauties of dental-hygiene treatment is that you can tailor a program that fits just that patient. I have found that floss generally is ineffective with Type III or Type IV perio patients. I have a vast array of adjuncts available, from interdental brushes to power brushes to interdental picks, etc. I decide which would work best for each patient. If I do teach flossing, I start with the quadrant that I first scale and instruct the patient to floss that quadrant only. This eases the patient into flossing and seems to be a more attainable goal.
A final word
The verbal skills we use with patients are so important to treatment success. "Would you mind if I take just a minute to review something that might make your home care easier?" sure sounds better than "You`re not keeping this area very clean - watch this in the mirror."
Ask the patient`s permission.: "Could I show you some ways to replace those missing teeth?" And for heaven`s sake, let`s stop nagging our patients regarding their oral hygiene. Be sensitive to their feelings and limitations. Do your best and then accept the fact that "not very good" is the best that some people can or will do.
Dianne Glasscoe, RDH, BS, is an adjunct instructor in clinical hygiene at Guilford Technical Community College. She holds a bachelor`s degree in human resource management and is a practice management consultant, writer, and speaker. She may be contacted by e-mail at dglass[email protected], phone (336) 472-3515, or fax (336) 472-5567.