By Trisha O'Hehir
Picture this. Your last patient of the day arrives 10 minutes late. He hasn't been in for a year and has moved to a new home. He has changed jobs and insurance. It's no surprise that he's tied up at the front desk for several more minutes with updating his contact information. When you finally get him into the chair, there are radiographs to take. With that out of the way, the patient announces to you that he "just wants his teeth cleaned." Time is disappearing fast. What to do? It's tempting to pick up the power scaler and blast through a year of buildup, keeping an eye on the clock, hoping to avoid working late yet again.
Here's my suggestion. Take a deep breath, pick up your probe and see just what you are facing. Take your time, no rushing allowed. You'll be tempted to do way too much if you rush. Remember, you are not expected to do "everything" today, even if you quite often do.
Rather than a time-consuming "one extra thing to do," probing may save you time and energy in the long run. It's what you do with the probing that makes all the difference. When you take the time to understand the data, you will use it effectively, making your job a real pleasure. Don't laugh; it's really true!
You know the routine — medical and dental history update, chief concern, and reason for today's visit. Now to the periodontal charting, including six-point probing, recession, mobility, furcations, bleeding points and occlusal screening. The key here is to record all of the data, even if you don't have an assistant every time. Without written data, the periodontal exam has limited value. The numbers are important to you, the patient, and the dentist.
Years ago, I used a tape recorder while probing and then went back later to record the data. Based on that experience, I discourage the tape recorder approach now. It took me forever! I was in the office at least an hour after everyone else left for the day. It should be office protocol for the hygienist to have someone to record probing scores.
Here's a tip for those rare (I hope) times you are stuck without an assistant to record. Following Dr. Farran's suggestion for probing order — start with facial and lingual surfaces, telling the patient you are probing the brushing surfaces. Even though no one is recording for you, be sure to read the numbers out loud for the patient to hear. Facial and lingual numbers will be fairly easy to remember, a quadrant or arch at a time. Then probe the interproximal surfaces, telling the patient you are probing the flossing surfaces.
Involving the patient this way will begin the educational process. Whether you have an assistant or you're going to turn around and record the numbers yourself, saying them out loud includes the patient. You'll be surprised at the increased level of interest exhibited by the patients when they differentiate between brushing and flossing surfaces. You may tell them numbers of one to three are healthy sites and anything four and above marks infection.
Even if you don't give them the guidelines, they are sure to notice a difference if there is one. I guarantee you they will ask if the numbers suddenly go from one and two to five and six. It's a great way to get their attention.
You've got the data; what do you do with it? The first thing is to total the pockets by category: 4 mm, 5-7 mm, and 8+ mm and bleeding points. The pocket totals will give you information about early, moderate, and advanced disease. The bleeding will give you information about areas of infection. These sites are where bacteria have ready access to the circulatory system. Bleeding points are a good tie-in to the perio/systemic link.
Use a charting form that provides monitoring boxes for recording pocket and bleeding point totals. If your chart doesn't have this option, total the numbers anyway for your case presentation to both patient and dentist. What used to be considered "just some fours and bleeding," may actually be 75 pockets and 80 bleeding points or "areas of infection." It's easier for both you and the patient to see why a "cleaning" in the remaining 20 minutes is not going to solve the problem.
Periodontal charting is the best way to differentiate between people who are periodontally healthy and those with periodontal disease. You may not want to look too closely, but you may actually be working in an office with rampant periodontal disease. We've all been there at some point in our careers. Sometimes we get caught in the way things have always been done, and in unrealistic appointment schedules. Actually, an office with short appointments may have an advantage. You definitely can't do any undercover perio when appointments are only 30 minutes. That's just enough time to do a perio charting and inform the patient of their disease status, offer options (nonsurgical therapy with you or surgery with the periodontist), and bring the dentist in. If they're periodontally healthy, the seven minutes you have left after examination and data gathering will be just enough for coronal polishing!
Patients with a few fives should be informed of the extent of their disease. If not, you are simply putting a "watch" on those areas, rather than stopping the disease and preventing further breakdown. Enamel surfaces with a "watch" for caries should at least receive fluoride. There is no recognized treatment for pockets we're watching. It's called "supervised neglect."
Besides checking the periodontal health of your patients, check the periodontal health of your practice. Draw a line down the middle of an index card. Label one side Healthy, the other Disease. Just put a mark in the appropriate column for each patient you see. Healthy means no bleeding and no probing depths over 3 mm. Sure, you can fudge the numbers a bit if you feel it's appropriate. You might have a patient who is healthy in every site except two areas of very slight bleeding. If this is your 3 p.m. patient and you haven't put any marks in the healthy column yet, go ahead and count this one as healthy. However, I wouldn't recommend the old trap of thinking, " It's just a few fours and some bleeding." Count up the number of pockets and the number of bleeding points. When "a few fours and bleeding" is actually 23 pockets with just as many bleeding points, it's clear the patient no longer falls into the "healthy category."
If you haven't been probing regularly, tell patients this is a "new diagnostic test" for gum disease. You can also say this to patients you've seen previously, just to see if they were paying attention. The best response you can get is, "That's not new, you've been doing that for years." In that case, give them a compliment: "That's right, you're very observant to notice that. Today, I'm going to check for disease, first on the brushing surfaces and then on the flossing surfaces. Low numbers are the best; one, two and three are generally healthy and anything four or higher may be infected."
I remember when I made the switch from recording the numbers myself to having an assistant. At the end of the probing, the patient said, "That's new, you've never done that before." I quickly explained that I'd been doing it at every visit. The only difference today was that I said the numbers out loud and the assistant recorded them. I showed him the chart, with full probing scores for all his past visits. He was surprised and said, "I had no idea you were doing a special test for gum disease, I just thought you didn't know where to start and were just poking around a little." I was crushed!
We all know we need to probe at each appointment, and yet, there are days when there just doesn't seem to be enough time. This may sound crazy, but when you don't have time, that's when probing can help you the most. When people come in and say, "I just want my teeth cleaned," probing can save the day for these situations.
Trisha E. O'Hehir, RDH, BS, is a senior consulting editor of RDH. She is also an international speaker, author, instrument designer, inventor, and oral health detective. Her Web sites are www.perioreports.com and www.toothpastesecret.com. She can be reached at (800) 374-4290 or at [email protected].
