Where did that come from? This article will discuss how we as dental professionals can turn the widely used phrase “It’s just a cleaning” into a thing of the past. We will look at the professional definition of “cleaning,” what treatment is being delivered clinically, and communication between patient and clinician.
Most hygienists agree that a cleaning is scaling and polishing. Some would add routine assessment of perio and restorative issues, a smile evaluation, oral cancer screening, a blood pressure reading, formal risk assessment, and a video tour of the mouth. Other hygienists work with dentists who employ ortho, TMJ, or neuromuscular techniques, and these areas are screened. There is great variation on exactly what is included in a one-hour “cleaning” appointment. If we have so many definitions, just imagine how confused our patients must be. They have no idea what to expect when they see a new hygienist because “All hygienists do it differently.”
In the CDT 2005, the ADA defines an adult prophylaxis as1: “Removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.” The first sentence is very clear. But “It is intended to control local irritational factors” seems to muddy the water a bit.
To really be able to outline a clear definition of a cleaning, let’s look to the language for some definitions. First, we’ll define control: to limit or restrict the occurrence or expression of somebody or something, especially to keep it from appearing, increasing, or spreading. Now the definition of local: typical of, or only found in, a particular area; not covering a wide area or the whole. Irritation(al): a painful reaction, especially an inflammation, caused by an irritant. Factor: something that contributes to or has an influence on the result of something.
Now let’s restate the definition incorporating the definitions of the words themselves. An adult prophy is a procedure that removes plaque, calculus, and stains from the tooth structures for the purpose of limiting the occurrence or spread of periodontal disease in a particular area (not the whole mouth).
What if a patient has generalized disease activity and needs more? What if a patient has several areas of inflammation that are not generalized? What risk factors have to be assessed? What clinical data must be collected? What parameters qualify the patient for the next level of care? What do I do for this patient today if he/she returns for more treatment? These are just some of the questions going through a hygienist’s mind during a routine prophy. In just moments, the hygienist must gather enough data to make a co-diagnostic treatment plan and choose a treatment path. To choose the appropriate treatment path, the hygienist must know the patient’s current periodontal condition as well as risk areas and health history factors. How can this process be made simple and precise?
Five screeenings, 15 minutes
To determine the appropriate treatment path, The JP Institute suggests incorporating five screenings into the first 15 minutes of every recall or continuing care visit and every perio maintenance or supportive periodontal therapy visit. However, before including these screenings with your routine visits, it is critical to ensure that the entire team has a grasp of the benefits of each screening. Also, the hygienist must be able to communicate the value of each screening before providing them for patients. One hygienist who benefited from in-office coaching with The JP Institute says this:
“Hi Sue, it’s great to see you today! Before I get started with your cleaning, I want to let you know that because of the science and research indicating a connection between your mouth and the overall health and wellness of your body, Dr. Brown has asked me to include five screenings today. Let me tell you what they are and how they benefit you. I’ll be doing a health history review and asking a few family history questions, since we know genetics play a role in the mouth-body connection. I’m also going to do a blood pressure screening because the American Medical Association changed the guidelines in 2003. Next I’ll provide you with an oral cancer screening. I will check the outside of your head and neck and the inside of your mouth. I will walk you through each step as I check for abnormalities. I don’t expect to find anything; we rarely do. Then I will do a restorative screening using our intraoral camera to be sure all of your dentistry is serving you well. Finally I’ll do a periodontal screening, where I will measure the pockets. You will remember that 1 to 3 mm is normal, and healthy gums don’t bleed. Keep in mind these screenings are included because research indicates a mouth-body connection. Do you have any questions?” (This entire introduction takes about one minute.)
Two very important things have occurred during this vital introduction. The patient’s paradigm has shifted, and now she is thinking, “Wow, this is not just a cleaning!” Also, the patient has had her first experience with a new paradigm for a cleaning. It is likely that the patient has had these screenings provided before. It is doubtful, however, that she actually perceived the appropriate value for the service, unless the hygienist set the stage by building value, listing each step, and engaging the patient along the way.
By using an introduction, the hygienist lays out a clear plan for the patient. There is no question about what is expected during the visit, why it’s being done, and what the benefits are. Why is this critical for the hygienist? Time management! Adding this step will help the hygienist better control the appointment time. Once the introduction is complete, the hygienist should proceed directly with the screenings. They might go something like this:
“I’m going to start with your blood pressure. Have you had any changes in your health or any serious illness, hospitalization, or surgery? Do you have a family history of cardiovascular diseases such as high blood pressure, stroke or heart attack, or diabetes? How would you rate your stress level? What do you do to decrease stress? Do you use any tobacco products? Are you taking any prescription medications, over-the-counter medications, herbal or nutritional supplements? Are you having problems with any of your teeth, sensitivity to sweets, biting pressure, hot or cold sensitivity? Tell me what you do on a daily basis to take care of your teeth and gums.” (This question gives the patient a chance to brag on what they actually do instead of admitting what they haven’t been doing).
Record the blood pressure on a card with the 2003 guidelines printed on it for the patient’s reference. Each screening should be delivered with a similar narrative. During the oral cancer screening, explain which lymph nodes you are checking and why, what muscles you are palpating and why, and why you are pulling out the tongue. Make each of these steps as important to the patient as they are to you, and they are important since despite aggressive combinations of surgery, radiation therapy, and chemotherapy, the five-year survival rate for oral cancer is poor (African Americans: 35%; Caucasians: 55%)2,3.
Next is the restorative screening. In speaking with dentists all over the country, the number one criticism of their dental hygienist is that they don’t use the intraoral camera and discuss restorative options often enough. Every dentist I know expects his or her hygienist to do a thorough restorative co-diagnosis prior to the recall exam. Using the intraoral camera effectively and quickly begins by being familiar with the equipment. Take the time to ensure proper hands-on training. No team member will pick up a piece of equipment and use it on a patient if he/she is unsure of the equipment. Once people can use it with their “eyes closed,” daily implementation for every patient is a snap. You should tell the patient what you are doing:
“Sue, I’m going to use the intraoral camera so we can see how well all of your existing dentistry is holding up. I am going to place the camera on your lower right molars. You will feel the camera on your lower teeth; however, we’re actually viewing the upper right molars. Can you see the large black filling? Do you see the cracks on the side of the tooth? Do you see the large gap between the tooth and the filling?”
And so it goes as the mouth is toured with the patient’s involvement. Using a four-image format on the monitor, go back and select two of the teeth that show concerns and capture those images. The key is not to tell patients something needs fixing. Let them notice that they have a problem. If the patient asks about a particular tooth, it is appropriate to delay the answer since you have incomplete information and the patient is lying on his/her back. You can say, “That’s a good question. Let me finish the screenings so I can answer that.”
All that remains is the periodontal screening. Engage the patient in the process by telling them, “I’ll be doing your periodontal screening next. I am going to call out some numbers, and remember that 1 to 3 mm is normal. I want you to remember your lowest and highest reading. Also remember that healthy gums won’t bleed and in a healthy mouth this will not hurt.”
The screening includes spot probing and calling the numbers out loud. Next, check the tissue response or gingival index. Esther Wilkins describes it like this. “The col area is not keratinized and is vulnerable to bacterial invasion. Plaque control of the area is of great importance because most gingival and periodontal infection begins in the col area. Use a probe stroke for bleeding evaluation. The probe is inserted a few millimeters and moved along the soft-tissue pocket wall with light pressure in a circumferential direction.”4
This procedure, in addition to probing, is used to assess the severity of disease, if present, based on color, consistency, and bleeding. It is critical to take two intraoral camera pictures of the patient’s tissue. This gives the doctor the opportunity to see the tissue response and gives the hygienist a great visual aid for patient education.
Upon completion of the five screenings, you will have sufficient data to proceed with your dental hygiene diagnosis. The American Dental Hygienists’ Association (ADHA), states: “The formulation of the dental hygiene diagnosis is a vital component of the dental hygiene process of care. Dental hygienists practicing collaboratively with patients and other professional members of interdisciplinary health-care teams are prepared to analyze and synthesize patient assessment data as part of the diagnostic process. The dental hygiene diagnosis provides the foundation for the development, implementation and evaluation of the dental hygiene treatment plan. In order to provide comprehensive quality oral health care, it is the professional obligation of dental hygienists to formulate a dental hygiene diagnosis.”5
In order to quickly and effectively communicate the patient’s current condition and suggested treatment, two things must happen. The patient should be sitting in a good communication position, upright with nothing in the mouth, and the clinician should rid him/herself of barriers such as masks and gloves, and sit eye-to-eye and knee-to-knee with the patient.
Review the screenings, using visual aids, in the order you performed them. Restorative should always be discussed before perio. Restorative always gets talked about before perio; otherwise as hygienists we end up in Perio-land. Don’t laugh, you know it happens! In fact we see it with our doctors everyday. They come in our room for a recall exam and stay 20 minutes in Restorative-land talking about implants or whatever. So don’t disappoint your doctors. Get in the habit of discussing restorative needs first followed by periodontal issues.
Once you have discussed recommended treatment and asked if the patient is interested in treating the problem(s), answer any remaining questions and signal for the doctor exam. Now is the perfect opportunity to help the patient with home care before you recline the chair and clean his/her teeth. Most patients benefit from the use of a power toothbrush, such as Sonicare Elite by Philips Oral Healthcare, since it comes close to reproducing the acoustic turbulence of an ultrasonic scaler.
Including the five screenings consistently in each recall or maintenance visit delivers high-quality professional care while increasing the patients’ perceived value. Keep in mind that implementing new protocols requires clear expectations, procedures, and goals, and should be discussed with the entire team to ensure everyone is on the same page. When we incorporate clinical excellence, clear protocols and good cycles of communication, patients will say, “What a cleaning!” instead of “just a cleaning.”
1 ADA, CDT 4, 2005
2 CDC and the National Institutes of Health. Cancers of the oral cavity and pharynx: a statistics review monograph, 1973-1987. Atlanta: U.S. Department of Health and Human Services, Public Health Service, CDC, 1991.
3 Mashberg A, Samit A. Early diagnosis of asymptomatic oral and oropharyngeal squamous cancers. CA Cancer J Clin 1195; 45:328-51.
4 Wilkins EM. Clinical practice of the dental hygienist, 9th ed. 2004; 212, 337-339.
5 ADHA, Dental Hygiene Diagnosis Position Paper, June 2005.