The Clinical Edge — A 12-part series — Part 7: Perio and beyond!

by Tammy L. Carullo, RDH, PC, PS

While avoiding clinical complacency is essential for all aspects of dentistry and dental hygiene, it is most important to avoid becoming complacent about care issues involving periodontal disease. Periodontics is constantly changing and treatment is evolving. New products, easier administration of local delivery systems, and profoundly important information linking systemic diseases to periodontal disease all have a crucial bearing on what we need to know, why we need to know it, and how we can implement it to better help our patients.

Prevention is the very cornerstone of care for the periodontal patient. Unfortunately, we have gotten so wrapped up in treating perio that we have become complacent about preventing the disease before it gets out of control.

Before we can venture beyond the scope of traditional periodontal therapy, we first need to review some pertinent information. According to recent surveys, only 42 percent of general dental practices conduct a structured soft-tissue management program. That figure has dramatically declined from 58 percent during the past two years. Why are these percentages so important to us? What is the reason behind the drop-off of this essential therapy?

The percentages show us just how far off the beaten path of treatment and prevention we have wandered. This sudden decline is not due to an increase in prevention or patient health. In fact, quite the contrary is occurring in rapid succession. The oral health of our dental patients is in a state of decline. Two of the main reasons for this decline are time and finances.

A soft-tissue management program takes time and commitment on the part of the dental practice. Some practices still operate under a 30-minute recare schedule. Unbelievable! To actually think that high quality care can be completed in that amount of time is simply foreign to me.

You need to step back and honestly examine the information regarding proper care for your patients. Here is a basic breakdown of time that should be spent on each procedure for each patient.

  • 10 minutes for the preliminary assessment, which includes comprehensive medical history review, vitals (blood pressure, pulse, respirations), and extraoral and intraoral (cancer) exams
  • Five minutes for the periodontal assessment
  • Five minutes for radiographs
  • 20-plus minutes for scaling with a recheck of work
  • Five minutes for the prophy
  • Four minutes for fluoride application (always recommended for perio patients)
  • Six minutes for local deliveries or desensitizing
  • 10 minutes for structured, formal patient education

These procedures add up to 65 minutes — the estimated amount of time needed for an appointment. However, if you operate like the majority of dental practices, you tend to adhere to a schedule of 45 minutes per adult.

But let's take another look at why you need to spend more time on each of the aforementioned procedures. In addition to improving the quality of care, all of the procedures increase case acceptance as well. Some hygienists have asked me why case acceptance should matter to them. After all, they do not own the practice, nor do they have a vested interest in it.

Without a high percentage of case acceptance, the bottom line will ultimately suffer. A low bottom line means not having enough income to support an otherwise thriving hygiene department.

The 30-minute time crunch
The reason why 30-minute appointments don't work is because they don't provide the time needed to develop nurturing relationships. In fact, surveys indicate that patients are more likely to accept treatment — periodontal therapy, in particular — if they feel comfortable with, and trusting of, the particular practice and team.

Yet, it still amazes me to see the number of practices that simply do not get this! Recently, a seminar participant approached me regarding the 30-minute issue. She was a hygienist with more than 30 years of experience. She was not happy with the suggestion that a routine 30-minute schedule was less than ideal. She was very comfortable in her role within this practice and took my views on the one-hour appointment as an insult. In no way did I intend to insult her or any of you.

But be honest with yourself and examine the time allotment for procedures. You do the math. If you are eliminating even one of the essential components of care, your patient is not getting the maximum benefit of his or her dental visit. That is a simple fact.

For any skeptics out there, let's look closely at these components of care, and then you can be the judge of the level of importance each bears.

We begin with the preliminary assessment, which includes the comprehensive medical history review. This is more than just asking, "Are there any medical history changes?" Believe it or not, I have heard that inquiry more times than I care to count. It simply is not adequate. Many patients will omit medications on their forms, simply because they do not deem them relevant to their dental treatment. They will omit prescription drugs, vitamins, minerals, and herbals — all of which can have an impact on oral health.

It can be a serious health risk to proceed with treating a patient without knowing with absolute certainty the specifics regarding their medication. Further investigation into specific side effects of prescription and/or over-the-counter medications, interactions, and potential oral complications that you should be watching for are paramount for the long-term health of your patients.

Let's take a hypothetical case in point. A patient presents as the perfect picture of oral health. Gingivae is pink, firm, stippled, probing indicative of 2-3mm, and no bleeding. This same patient, a mere six months later, suddenly presents with 4-5 mm generalized bone loss, Class III bleeding upon gentle probing, as well as an active and seemingly aggressive state of periodontal disease. Upon review of the medical history (medications, more specifically), it is revealed that the only change is that the patient was put on Zoloft by her family physician.

While you would never remove a patient from a medication, this may be the perfect opportunity to communicate your findings to her physician as there are other alternatives to treating depression without the oral complication of peridontal breakdown.

If you move forward with conventional periodontal therapy without investigating the potential cause of the sudden onset, your efforts may be in vain. If this patient began taking a medication that you are unaware of, and you proceed to treat him, the destruction will only continue. You have treated this patient from a purely symptomatic standpoint instead addressing the source of the problem.

A comprehensive medical history review — where you question your patients on specific medications — is not an option for elimination as a routine procedure. Scientific research confirms that what goes on within the body systemically has a definite effect on what happens within the oral cavity. To be blind to this connection is unadulterated ignorance!

Vital information
Many dental practices do not take vitals on every patient. This issue can be summed with the very simple question: Would you, as a dental professional, treat a patient who presents with a blood pressure of 180/110? Most of you would reply: Absolutely not. How do you know if you are not taking your patients' blood pressure?

The extraoral and intraoral examinations are essential cancer screenings. To eliminate these exams is nothing short of malpractice. Palpating the lymph nodes of the head and neck can reveal early warning signs of lymphomas. If you fail to do an adequate screening and a month later that patient is diagnosed with lymphoma, you could be held liable since the head and neck fall under the jurisdiction of dentistry.

An intraoral exam is so much more than simply "looking" in the mouth with a mouth mirror. Even pulling the tongue from side to side is not sufficient. We need to go in and actually palpate the tissues. Many pathologies are not visible but can be detected upon simple palpation.

During the periodontal assessment, probing, gingival appearance, bleeding, attachment, recession, mobility, and classification all need to be conducted on a routine basis and compared to your baseline evaluation. You need to note any deviations from that baseline.

Then you have X-rays. Without them, you cannot see beneath the oral tissues and restorations, and you cannot make an adequate assessment or diagnosis of the patient's condition. Finally, you get to the actual implementation part of the appointment. It's crucial that you not only get the job done, but recheck your work. The prophy is next, but it does not need to take up more than five minutes of your time. Fluoride for all perio patients is a given as well as any local deliveries and desensitizing.

The final step is patient education. Take the time to show your patients the how-tos of proper hygiene; give them some floss and make certain that they know how to use it! How many of us actually spend adequate time on this very crucial component of care? Patients need to understand fully how to use any products you recommend and their purpose. If they don't, they will get frustrated and quit.

Now, after carefully examining the reasons why each of these components of care are essential to well-balanced treatment, which ones would you eliminate from the list for the sake of time? Don't forget about the doctor's examination and the housekeeping required for your next patient. One can clearly see that time can add up very quickly. If you're very proficient, you may be able to save a minute here and there. But what happens if you have a patient who simply takes longer on the instrumentation aspect?

The financial issue is more of an establishment of quality for your patient. When you provide quality care, you have less of an issue about what it will cost. Unfortunately, we are getting so buried under the mountain of insurance issues now that we have lost sight of this goal. Too many times, we are faced with the dilemma of patients' stating, "If my insurance won't cover it, I don't want it." We have created the monsters that exist within the dental practice; now we need to make a concerted effort to establish quality as a focal point rather than finances.

The bottom line is that the more time you spend with your patients, the better. You have ample time not only to get everything on the list completed, but, perhaps more importantly, to develop a trusting relationship with your patients that will lead to better compliance, improved case acceptance, and a happier, healthier patient.

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 jtncar@redrose.net or phone (717) 867-5325. For more information about her company, visit www.practiceby design.com.

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