by Beverly Maguire, RDH
As the scope of our professional responsibilities evolve, our clinical focus is still to manage the health and disease of the periodontium. Periodontal health or disease can only be revealed through the results obtained in the periodontal examination.
I can vividly remember the first time I began probing a mouth I had previously assumed to be healthy and then suddenly discovered significant periodontal pockets. In the mid-1980s, I was poking around with my new favorite instrument, the perio probe, on a very healthy looking woman with pink gums and great plaque control. Imagine my shock when the probe sank 7mm on the mesial of tooth #7.
I was horrified! I realized immediately how much periodontal disease I had been missing because I had assumed most patients to be healthy. Once we understand the power of the probe, we know that - in order to effectively proceed with our care for patients - we must probe and chart on a routine basis.
The next dilemma is to implement an efficient system of data collection. Who will record the numbers, and how will they break away from their primary job responsibilities to assist in the process? Do all staff members understand the value of this exam to the overall health of the patient and success of clinical dentistry? Your team must find answers to these questions.
The periodontal exam is not an option! Again, it is a cornerstone of the clinical practice of dental hygiene. It is the compass that reveals the direction in which we will proceed with patient care. Most patients are seen in the general practices of this country, and a great percentage of the patients have some degree of periodontal involvement. We have a responsibility to assess their status accurately and inform them of their options for care.
The complete exam What factors must we evaluate? Five areas must be measured, recorded, and assessed if we are to get the full picture of patients' periodontal status - pocket depth, bleeding points, recession, furcation involvement, and mobility.
Pocket depth.This is the first and most obvious area involved in the periodontal exam. All hygienists are trained to measure pocket depths. However, using only this one criteria will provide, at best, a simplistic view of the periodontal status. Pocket depth can be an indication of inflammation or bone loss, but what about the total amount of attachment loss? Recession is also a factor.
A chart with only pocket numbers is limited as a diagnostic aid. Many other factors must be assessed for a complete and accurate evaluation.
Bleeding. Bleeding on probing is one of our biggest keys to disease activity. Is a 4 or 5mm pocket always in need of treatment? You know better! Many pockets indicate a history of disease activity but currently are stable - not bleeding, inflamed, or infected. If inflammation is present, the bleeding upon probing and upon provocation will be a key factor in determining the status of "active" or "stable" cases. Why don't we see more bleeding points noted on periodontal records in patient charts? What's the total? How does it compare to the last several chartings on the patient? What is the trend? Are there changes in the number of bleeding points?
Recession.We all know that a 4mm pocket can indicate early bone loss, but what about an added 3mm or recession? We are now looking at 7mm of attachment loss. If this is common knowledge, why do so few patient charts indicate any recession notations? Please look at the quality of your own records! Once again, monitoring changes in periodontal chart records requires critical thinking skills and data analysis. Changes in these various parameters we are measuring can indicate disease activity. The sooner we notice and intervene, the better the quality of care received by our patients. The records are the basis of early intervention and treatment.
Furcation involvement. This obviously presents a bacterial challenge in both patient and professional plaque control. Many times, we don't associate the 2mm of recession in the molar areas along with the 4mm pocket as being an indication of furcation involvement. Why let furcations get a stronghold? Spongy, bleeding tissue around molars requires attention. Why wait until the pockets are 5-6mm, along with recession? Managing furcas often is an exercise in monitoring the progression of bone loss leading to tooth loss for many patients.
Mobility.Mobility is one of those areas that reveals surprising information when evaluated routinely. The notation of mobility leads us to questions. Why would teeth be loose? Occlusal trauma or bone loss from periodontal activity are the two most likely factors. Advising the doctor of mobility should lead to further evaluation. Occlusal equilibration, nightguard therapy, or referral is indicated. Only the most judicious of clinicians seem to monitor mobility and inform their doctors of their findings on a routine basis.
Sorting through the information
The proper evaluation of this data is critical. It's not enough to simply collect the data; it must be evaluated! This is where critical thinking skills come into play. Once we gather and assess the data, the doctor must be informed of the findings. An efficient protocol for delivering the information in a concise and timely manner leads to the periodontal diagnosis. Doctors cannot diagnose without adequate information. Dental hygienists provide the key to success by collecting the proper data, evaluating it in the form of a hygiene assessment, and then relaying the information to the doctors for a diagnosis. Patient education and case presentation are the responsibility of the hygienist. The entire process is a collaborative effort, and, when done with predetermined protocols and systems in place, it becomes a standard part of the dental hygiene visit.
The perio exam is too vital to patients' oral health to be left to chance. Those chart notations of "WNL" actually mean "we never looked!" Most patients have 168 sites to evaluate for pocket depth, bleeding, and recession. Mobility and furcation involvement must also be evaluated. The complete periodontal picture cannot be evaluated from partial records. It can be shocking when thorough records are compared with partial records. In the case of inadequate records, it unfortunately will be our patients who will come up short. If we do not see early or recurrent disease activity, our patients will not be accurately diagnosed, informed, or offered care appropriate to their needs.
When proper staff training matches the effort expended toward the periodontal exam, hygienists will be empowered to collect the data in a timely way. A hygienist can complete a thorough periodontal chart in five to seven minutes when assisted by a team member. The ADA has indicated that a complete periodontal exam must be recorded for patients on an annual basis. More periodontal disease will become evident once complete records are a part of the hygiene process of care.
Patients must understand their periodontal status in order to make health-care decisions. All will benefit - the patient, the practice, and the professional - when we practice to the highest standards of our profession. The periodontal exam is not an option; it's the foundation of how we treat patients today to protect their oral health. It leads us to the earliest detection of the periodontal disease process, which is our true calling as preventive oral health-care professionals.
Beverly Maguire, RDH, is a practicing periodontal therapist. She is president and founder of Perio Advocates, a hygiene consulting company based in Littleton, Colo. She can be reached at (303) 730-8529 or by email at [email protected]