The periodontal maintenance patient
I work in a general dentistry practice in the northeast. We have a great team, and I particularly enjoy treating periodontal patients. I get so much professional satisfaction in taking patients from a diseased state to good oral health.
However, we seem to have a problem getting patients to agree to three-to-four month recare visits after periodontal therapy. Most of the time, they don't want to come in until six months or longer. Sometimes, patients will go through the whole process of quadrant scalings and not return for a year or longer. It's so demoralizing for me as a hygienist to see patients regress because of neglect. It makes me feel like all of my hard work was for nothing.
Do you have any ideas for the problem of motivating and educating periodontal patients in the importance of frequent maintenance?
I'm sure many of your fellow hygienists are glad you asked this question. Insufficient and infrequent periodontal maintenance can sabotage the initial results achieved with periodontal therapy.
First, let's discuss the concept of the periodontal maintenance visit. After a patient has completed periodontal therapy and debridement, the tissue enters a healing phase. If the therapy has been thorough, accretions and pathogens have been removed from the sulcular environment. Consequently, there should be a definite improvement in tissue tone and texture. Bleeding should be significantly less. Some pocket reduction may occur as a result of shrinking tissues and reattachment at the base of the pocket. These are all desirable outcomes of good periodontal therapy.
However, these wonderful results can be short-lived, especially in cases where significant bone loss has occurred. Patients generally are not able to cleanse pockets that are 5 mm or greater. Some studies have shown that toothbrushes rarely reach 3 mm into the sulcus and that supragingival plaque control will not alter the subgingival microflora. Patients simply do not have the ability to cleanse pockets as we can, even with thorough instruction. In very little time — depending on the strength of the host's immunity — the pathogens can multiply to the point of overwhelming the host response, and the disease becomes active again.
The periodontal maintenance visit gives the clinician the opportunity to revisit all areas of the sulcular environment and knock out those pathogens that have reappeared. The time interval should not be more than two to three months after the completion of periodontal therapy. There should not be a gross accumulation of calculus subgingivally after only three months, although some patients will develop stain and supragingival deposits. Therefore, vigorous hand scaling is unnecessary and counterproductive. Liberal use of ultrasonics with thin inserts on low power should be the treatment of choice. This allows for maximum pathogen eradication, and the water or antimicrobial lavage cleanses the pocket of free-floating pathogens. The wonderful thin inserts now available allow for better access in deep pockets and furcations than hand instruments.
Another argument for the use of thin-insert ultrasonics is that they are inserted easily into the pocket with minimal distention of the pocket wall away from the tooth. This is especially important where new healing and attachment is occurring at the base of the pocket. Hand instruments typically produce more tissue stretching and can tear the delicate new tissue, which results in slower healing.
The professional maintenance care we deliver to periodontal patients is extremely important in achieving long-term, positive results. The goal is to keep periodontal pathogens at low enough levels so that the host immunity is not overwhelmed and healing can occur. The World Workshop in Clinical Periodontics states, "Maintenance visits on a regular basis seem to be more important in retention of teeth than either the type of active treatment accomplished for oral hygiene practices," and "... supportive maintenance care remains the most dependable measure for disease control in the treated periodontal patient." Knowing this, how do we get patients to understand the importance of these visits?
Patients demand six-month or longer intervals between maintenance visits due to insurance dependence. We've all heard the familiar lament, "I can't come every three months because my insurance won't pay for it." I don't want to rant about insurance companies and coverages, but there are great disparities between insurance plans. Some plans cover regular procedures, while others don't cover even minimal dental procedures adequately.
However, patients are usually unaware of what their insurance will cover. The fact is that periodontal patients require more frequent professional maintenance to control their disease.
When your patients understand the reasons behind frequent professional care, they are more apt to comply. It is for their good, not the financial good of the practice. If you develop a close, professional rapport with your patients throughout the course of their therapy, they will trust your recommendations.
Some patients will fail to comply, no matter what you say. Don't let that bring you down. You are there to help people in any way you can; however, getting appropriate care is ultimately the patient's decision. Keep careful documentation, especially of patient noncompliance. Accept the fact that you can't change people, but you can motivate some to change themselves through your skill, enthusiasm, and caring attitude.
Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Lexington, N.C. To contact Glasscoe for speaking or consulting, call (336) 472-3515, fax (336) 472-5567, or email dglasscoe@ northstate.net. Visit her Web site at www.professionaldentalmgmt.com.
Here is a sample conversation that you may want to adapt to your situation:
Hygienist: Mrs. Jones, we have certainly come a long way in getting your gums healthy again. Together, we have made this happen. However, we are not completely 'out of the woods.' The next 12 months are very critical to your continued progress. Periodontal disease is not curable, but it is controllable, just like diabetes. We have succeeded in bringing those 'bad bugs' that are causing your disease under control. But please be aware that the pathogens can multiply and rise up again, causing more tissue destruction and bone loss. We will need to monitor you closely over the next 12 months to make sure you remain stable and to control the new growth of bacteria. From our experience treating many other patients with periodontal disease, we have learned that maintenance visits should be no more than three months apart.
Patient: But my insurance will only cover two cleanings per year!
Hygienist: I understand your dilemma. You are fortunate to have some dental benefits to help with your dental care. But insurance is designed to cover only basic care. You have received very specialized care to treat your periodontal disease. Our other patients who find themselves in the same dilemma understand that they can receive insurance benefits every other visit and are responsible for payment on alternating visits.
Patient: After a year, then what?
Hygienist: If you continue to improve and your condition stabilizes, we may be able to extend the amount of time between visits. That will certainly be our goal. We will be able to evaluate that better after a year. Over the next year, we hope that our professional care coupled with your good homecare will allow your host immunity to become strong enough to keep the destructive germs under control.