Periodontal charting

Dec. 1, 2010
When you grow up in George Jones country, you learn to tap your feet, get into the beat, and sometimes feel inspired to share an inner thought.

Multitasking when multitasking wasn't cool

by Kimberly Goodson

Singing ...

Yeah, I may take a lot of kiddin',
But soon everbody'll understand.
What we've been tryin' to do ain't good.
We've been multitaskin' and mutitaskin' ain't cool.

When you grow up in George Jones country, you learn to tap your feet, get into the beat, and sometimes feel inspired to share an inner thought. Granted, I shouldn't attempt country music lyrics, but the truth of this quirky message matches the insight I have gained as cofounder of PerioPal, a voice-driven periodontal charting software company. We all recognize periodontal exams are data intense, time intense, clinically limiting, vulnerable to errors, and yes, generate little to no compensation. Even though PerioPal has turned heads and changed opinions in demonstrations at various dental gatherings, it is just as clear today as it was 10 years ago that periodontal charting is still negatively defined by a large majority of dental clinicians and practice owners. Why now with all that we know?

This realization led me to revisit the true nature of the perio exam. Many clinicians neglect the exam or default to inadequate, spot-probing methods of periodontal charting which have failed our standard of care for a long time.

Hugh Doherty, DDS, reported, "Sometimes treatment is begun without proper diagnostic testing and determining the prognosis. This violates the standard of care that should be provided for patients. The No. 1 priority in implementing a comprehensive periodontal program would be to perform full-mouth comprehensive periodontal charting (six readings on each tooth) at least once per year ... When armed with this information, practices can diagnose and manage periodontal patients properly."1

Periodontal charting places incredible demands on the brain's processing system. The breakdown is not a clinician's lack of knowledge or the lack of exposure to the exam process, but the amount of information needed to be held in memory and the lack of time allotted for the exam. In theory, clinicians' training enables them to perform the exam, but in reality the sensory and cognitive tasks required to collect data from the oral cavity and transfer it to the recording log overcomes their training.

The M Generation

The complex nature of periodontal charting has made dental clinicians prolific members of the "M Generation" (that is, the multitasking generation).2 Multitasking is the activity of performing multiple tasks at the same time or in rapid succession, requiring different types and levels of cognitive processing. Data collection in the oral cavity is Task 1; entering into a recording log is Task 2. The exam is characterized by rapidly and repeatedly switching or toggling between Tasks 1 and 2 in order to complete the examination in the allotted amount of time. Each task requires attention to action, which means task initiation, execution, and termination involving well-learned perceptual-motor and cognitive skills.

The switch is the important point. The switch causes a change in the clinician's attention and focus. Research on multitasking shows that constant and continuous task switching leads to increased stress levels, process losses, and lower performance results. There is a need for processing and changes in attention/focus when switching between tasks.

Jordan Grafman, chief of the cognitive neuroscience section at the National Institute of Neurological Disorders and Stroke (NINDS), states: "Although many aspects of the brain remain uncharted, there is substantial literature on how the brain handles multitasking. And basically it doesn't."3

So how does this tie into periodontal charting?

Periodontal exams are data intense.

Consider recording a complete and adequate exam with 32 teeth documenting six probing sites per tooth with three to five additional clinical observations at each probing site. We can easily record at least 600 possible notations at warp speed; and we wonder why it feels stressful? (Think for a moment, what other health-care professional does this?)

A study in Bristol, England, found that trying to process attention-rich input in a multitasking manner causes an increase in cortisol, a stress hormone.4 Cortisol helps us deal with emergencies and deadlines but when it is constantly being released into our bodies, as with multitasking, it compromises functions of the prefrontal cortex – known as the "executive center" of the brain – causing individuals to become stressed, scattered, and unable to focus.

Periodontal exams are time intense.

Switching between tasks requires a certain amount of time to cognitively "switch gears." The neurology needed for the execution of Task 2 is delayed until use of the neurological pathways from Task 1 is complete. Neuroscientists refer to this as the "time switching cost." This "cognitive queueing," or bottleneck, is a few tenths of a second per switch, but it can add up to a significant amount of time when individuals are continuously switching between tasks.

One study found that shifting repeatedly between tasks can cost as much as 40% of an individual's productive time. There is an extra time cost if the task is complex rather than automatic, and cha-ching, cha-ching, there is an additional time cost if there is an environmental demand for speed and accuracy.5,6

Periodontal exams are vulnerable to error.

Research indicates the quality of output deteriorates when rapid switching or toggling occurs between tasks. Information moves from the sensory organs (sight, touch, smell, and hearing) to the working or short-term memory. It is then rapidly transferred to long-term storage for use or retrieval. Information entering the working memory must be handled appropriately or it is randomly dropped.

There are two critical limitations on handling information in the working memory. First, most adults can retain only up to seven items of information at a time.7 Second, the information has only about two seconds in the working memory before it is rapidly moved to long-term memory.8

The working memory can be compared to a temporary loading zone with only seven parking spaces. The overwhelming input demands of a periodontal exam are likely to increase the margin of error and interfere with the quality of information that is processed within the working memory when attention/focus is repeatedly divided between the oral cavity and the recording log.

Furthermore, there is a relationship between stimulation and performance. When there is too much stimulation and stress, the brain enters an overexcited state that makes it difficult to focus and impairs concentration.9

We've been multitaskin' and multitaskin' ain't cool

The evidence is there. The evidence is mounting. The brain is biologically incapable of processing data-rich tasks, such as the traditional periodontal exam, in a compromised amount of time. Try as we have for decades, our knowledge and skill of the exam process cannot over-reach the sensory and cognitive tasks required to collect large amounts of data from the oral cavity and transfer it to the recording log. The exam triggers a vicious cycle of working hard to collect and document data, taking longer to get it done, feeling stressed and hurried, then compelled to multitask more.

Dr. John Medina, director of the Brain Center for Applied Learning Research at Seattle Pacific University says, "Research shows that we can't multitask." He added, "Taking your sequential brain into a multitasking environment can be like trying to put your right foot into your left shoe."10

Embracing the intelligence of technology

It's time to change our charting notions. Our clinical strength will not be in the collection of data from the mouth to the chart, but in our cognitive processing – thinking, reasoning, and decision-making strategies – that are activated as a result of the exam.

Computer technology relieves the burden of cumbersome periodontal data entry and provides the clinician with powerful resources that shorten the cognitive effort to produce a desired result. Multitasking originated and exists with the greatest of ease in the computer world. Computers have the advantage over humans of performing tasks at the same time as well as switching from one program to another so quickly that it gives the appearance of executing programs at the same time. Computer tools liberate the limitations of the cognitive system and allow users to perform tasks faster and with less effort, extending the reach of human thinking.

Partnerships with technologies are prominent. The simple hand calculator is an example of intelligent technology. It undertakes significant cognitive processing on behalf of the user to reduce the time and complexity required for manual calculations and, therefore, is a partner in "distributed intelligence."11 One can only imagine accountants preparing financial reports or tax returns without the use of a calculator. This sounds absurd and perhaps negligent, yet a large majority of dental practices are cleaving to old methods of periodontal data collection that are just as data intense as calculating financial applications, and which ultimately have a profound impact on the patient's periodontal and systemic health.

Making it all work

Periodontal charting is not the only dental procedure to require multitasking, but it is the only one where the clinician is given little time and no technological support. Computer technology can now assume part of the burden of information processing to accomplish this tedious task. However, it is not the technology alone that creates the shift to periodontal excellence, but all the variables in the mix – technology, activity, goal setting, and applicable thinking strategies that mobilize the change. Consider it a complementary division of labor – technologies liberate the cognitive limitations and activate the clinician's thinking skills and strategies to organize gathered data and enhance clinical performance. It is the joint system, not the technology or clinician alone, that carries out the intellectual task.

Kimberly Goodson, RDH, BS, is president and co-founder of PerioPal periodontal software. Goodson graduated from Caruth School of Dental Hygiene, Baylor College of Dentistry and is responsible for extending the company's Patient Education strategy, managing strategic partnerships, and overseeing legal, sales, financial and business development activities. She resides in Beaumont, Texas, where she is a practicing RDH.


1. Doherty H. A Profitable Hygiene System: Not an Undervalued Practice Resource, Part 2. Dentistry Today. Feb. 2009.

2. Miller P. Multi-tasking: Just an Illusion? Psychology in the News. March 24, 2010; 1.

3 Wallis C. The Multitasking Generation. Time Magazine. March 19, 2006; 4.

4. Miller R. Too Much Multi-tasking. Dallas Morning News. Nov. 19, 2006; 3.

5. Multitasking – Switching Costs. American Psychological Association.March 20, 2006; 1-2.

6. Dzubak C. Multitasking: The Good, the Bad, and the Unknown. Penn State, N.Y.; 6.

7 Forrister K. How Much Can the Brain Really Hold? GTD Times. Dec. 30, 2009; 1.

8. Http://; 1.

9. Wallis C. The Multitasking Generation. Time Magazine. March 19, 2006; 5.

10. Yadav K. The Juggling Act. The Financial Express. April 4, 2010; 1.

11. Salmon, Perkins, Globerson. Partners in Cognition: Extending Human Intelligence with Intelligent Technologies. Education Researcher. April 1991; (20).

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