Do I have to do periodontal scalings?

Nov. 1, 2000
We have learned that conservative, nonsurgical dental-hygiene treatment is often as successful as surgery in treating and maintaining patients with periodontal disease.

We have learned that conservative, nonsurgical dental-hygiene treatment is often as successful as surgery in treating and maintaining patients with periodontal disease.

Dianne Glasscoe, RDH, BS

Dear Dianne,

I am a dental hygienist with 30 years of experience. I have been with my present practice for 15 years. Most of our patients have dental insurance.

Recently, my boss decided to bring in another dentist to the practice. Since that decision was made, he has been on a mission to increase the hygiene production. He now is encouraging almost all of my adult patients to have their teeth cleaned every three months, whether insurance covers it or not. He also has decided to subject the patients to deep perio scalings whenever insurance will cover it. For most of our patients, that`s once every three years or so.

Before he started this "big push," I would do a gross scaling if the patient exhibited heavy calculus, and then have the patient back for a fine scaling and polish. Now, the doctor insists that the patient must have quadrant scalings under local anesthesia.

This all feels like a money scam to me. I feel awful doing these unnecessary deep scalings and covering up for him verbally about why they are necessary, followed by three-month recalls. I feel it is merely a way to keep the hygiene schedule filled. I can easily see how quadrant scalings bring a lot of money into the practice, yet my last raise was so miniscule, it was embarrassing.

I would feel much better if he would just refer these patients to the periodontist. I wish I could tell the doctor that it is illegal for hygienists to do periodontal scalings. Can you tell me anything that might make me feel better about this situation?

Heavy-hearted Hygienist

Dear Heavy,

I believe there are several issues brewing here, so I will try to address each one. The first issue I see is that your doctor has decided to make sweeping changes in the hygiene department, without first engaging in a meaningful discussion about why those changes are necessary or helpful to patients. Sometimes, doctors go to meetings and come home with new ideas. They immediately decide that change needs to occur, but neglect to "sell" the staff on those changes.

Sometimes, the change is good; sometimes, it isn`t. Any change can cause turbulence. When the benefits are obvious to us, change is easy to implement. However, if the change is perceived in a negative light, we tend to avoid and even resist it.

Obviously, you view the change the doctor has decided to implement as beneficial only to him in a financial way. You can perceive no benefit to you or your patients. In fact, you see the change as something underhanded and even dishonest.

We have seen many changes in the dental-hygiene profession in the last 15 years. One of those changes is the discontinuance of the old "gross scale/fine scale" protocol. We have learned that when we remove the gross calculus at the gingival margin, the tissue tightens around the margin, creating a "pressure cooker" of pathogens deeper in the sulcus. Various studies have shown that patients experience better tissue response when thorough treatment is initially carried out. Therefore, I would never recommend a gross scale/fine scale treatment sequence.

The task is easier for both the clinician and patient when the patient is anesthetized. We can scale more aggressively to the depths of the sulcus if we do not have to worry about patient comfort. We have learned that conservative, nonsurgical dental-hygiene treatment is often as successful as surgery in treating and maintaining patients with periodontal disease. So, on this point, I believe the doctor is on target with current protocol regarding periodontal treatment. You may need to take some good periodontal courses that reflect the latest in research and protocol. Simply put, the way we do things now is not the way we used to do things.

However, it appears that the doctor is being much more aggressive than in the past regarding diagnosis. The doctor is not allowing you to use the benefit of your 30 years in the profession. This is demoralizing and demeaning. To provide your patients with the best treatment, you both need to be on the same page. Some common ground needs to be established. A good starting place would be the American Association of Periodontology classification system, which allows you to classify patients according to severity. This classification would guide treatment sequencing. You need to work out a system that says, for example, all Class III periodontal patients will need to be seen x number of times and the treatment will be $xxx.

I also believe there is a problem with the doctor allowing the practice to be "insurance-driven." When that is the case, doctors often find ways to ways to gain maximum benefits without first considering what is best for the patient. Overtreatment is just as bad as undertreatment. Both scenarios happen when the practice is insurance-driven.

Another issue is the addition of another doctor in the practice. It would be foolhardy to bring in another doctor, without first considering whether there is sufficient demand for services. Most doctors worry needlessly that they will suddenly not have enough to do once the new person comes on board. Your boss may be trying to ensure that there will be plenty of dentistry for both doctors, since the hygiene department typically drives the rest of the practice.

On the recall issue, several studies have proven that frequent recall is a key factor in helping patients gain control of periodontal disease.

In fact, a study conducted by Axelsson and Lindhe ("The Significance of Maintenance Care in the Treatment of Periodontal Disease," J of Periodontal, 1981, Aug. 8, Vol. 4) proved that if the recall was frequent enough, the patient could maintain with a minimum of home care. That says quite a lot about what we do as hygienists. I believe that every patient who undergoes periodontal therapy should be on a three-month interval for at least a year. If no disease progression is noted during that time, the interval may be gradually increased. Much depends on the patient`s motivation and host immunity.

Some of your resentment regarding the changes in the hygiene department stems from the fact that you feel you are inadequately compensated. Many doctors never consider the fact that a raise can be viewed from a negative perspective, if it`s too small. If your doctor would institute a nice incentive bonus for the whole office, it would boost motivation to work as a team and make the business profitable.

It is easy for hygienists to forget is that the practice is a business. It must be run profitably or it cannot survive. The hygiene department should produce a substantial portion of the total production, usually about 33 percent. Factors influencing this percentage are the number of hygienists in the practice and what is counted as purely hygiene production. The doctor has the burden of fee-setting and diagnosis. Some doctors struggle with these issues. Staff members who are well-compensated generally do not question the doctor`s decisions. However, staff members who are underpaid frequently tend to raise questions about the doctor`s motivations.

Personally, I cannot imagine life as a hygienist if I did not get the opportunity to treat periodontal disease. I believe we all need the challenge of bringing a patient from a state of disease to a state of good health. In my opinion, that is one of the most clinically rewarding things we can do as dental hygienists. Certainly, situations exist where patients need to be referred to the periodontist. However, the general practice can provide initial therapy for most patients if the hygienist is attuned to treating periodontal disease as a true disease. In that capacity, we become more than an average hygienist. We become periodontal therapists.

Is it possible that you do not value what you do for your patients to the extent that your treatment deserves? Sometimes, our jobs become so routine that we fail to see how valuable our treatment is.

Maybe you are not up to the challenge. I encourage you to attend some good courses that will get you "fired up" about periodontal therapy. I also recommend that you and your doctor engage in some dialogue about your anxiety over the changes. Do not assume the worst until you have talked with the doctor. Also, do not discuss your frustrations with other staff members. This is a hygienist/doctor issue only.

I hope I have said some things that will make you reconsider your value to the practice and to your patients. However, I cannot take your burden away or change you. Only you can do this!


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 [email protected], phone (336) 472-3515, or fax (336) 472-5567. Visit her Web site at