On a syndicated television Fox News story in 2006, a reporter presented a program examining the link between oral and systemic health. She did a great job reporting the potential links between periodontal disease and cardiovascular disease. Any consumer watching would have walked away well informed about the mouth-body connection of periodontal disease. However, six years later, the last statement the reporter made on that program still warrants careful consideration by dental professionals. The reporter said, “Next time you visit your dentist, if you don’t hear them calling out your numbers ... find another dentist!”
That statement alone indicates she got it. After her investigation into oral and systemic health, she understood that the crux of the matter goes back to an early and accurate diagnosis of periodontal infection. She understood that the larger the numbers, the greater the likelihood periodontal infection has to adversely impact overall health.
What I don’t think she even considered is the reality that plays itself out daily during dental hygiene visits. The patient may indeed receive a periodontal screening complete with pocket measurements. But due to the fact that the screening occurs in silence, the patient does not have the advantage of listening to their own pocket depths and correlating what they are hearing with the health, or lack of, inside their own mouth.
What a missed opportunity! Listening to the numbers could directly impact patient “ownership” of an infection that generally has no symptoms. Patients should be given an opportunity to hear their own numbers as the data is collected, as well as see evidence of active infection by looking in the mirror to see tissue that bleeds readily during measurements.
Consider the difference. In many cases patients are informed of the findings after data collection takes place in silence. For example, “Mary, you had some 4 and 5 mm pockets especially around the back teeth.”
It is hard to imagine what significance the knowledge of a few deeper pockets might have to patients who just came to get their teeth cleaned. They might simply think, “Well, nothing’s bothering me.”
In contrast to the scenario of recording numbers and reporting on it after the fact, consider the impact if, prior to any measurements being taken, the patient is given the following instructions, “Mary, as I measure the spaces around your teeth, I will be examining where the bone and gum tissue attach to the tooth. The space should be shallow, about 1 to 3 mm, and keep in mind that healthy tissue does not bleed during measurement. I want you to listen for any spaces measuring deeper than 3mm, or for any area where bleeding is detected. Either can be signs of an infection developing in the gum tissue and surrounding bone that can affect your teeth and your health.”
Immediately, the patient is involved in the process of early detection as they listen to each space being measured, with or without bleeding accompanying it. One piece of our armamentarium that should be present in every treatment room is a hand mirror for patients to view concerns in their own mouths as they are discovered. Obviously, use of the intraoral camera is a powerful adjunct to hand mirrors to increase visibility.
The two steps of asking the patient to listen to numbers as they are being collected, and seeing tissue that bleeds or hemorrhages easily upon probing are what I refer to as “periodontal game changers.” Frequently, upon completion of a periodontal screening as patients have listened to their own numbers, or seen tissue that bleeds upon measurement in their own mouth, they ask one of two questions: “How bad is it?” or “What do I need to do next?”
When dental hygienists have patients asking those questions, gaining case acceptance to treat periodontal infection becomes so much easier than when the patient is left thinking, “I just need to floss more.” Or, “Oh well, nothing’s bothering me.” Both are common when a synopsis of findings is delivered after the fact, and the patient missed hearing and seeing the evidence of disease as it is discovered.
The objection from many dental hygienists who continue to probe in silence is that they can record the data faster if not saying it out loud. Time management is one of the biggest challenges dental hygienists face. But consider how much more time must be spent after the fact trying to build value for what the numbers mean to the patient vs. a scenario where they participate in data collection, hearing each pocket, and seeing bleeding. Patient participation in data collection literally saves time in enrollment for subsequent treatment, or in delivering personalized disease control instructions.
The D0180 Examination
In cases where time management constraints for performing a detailed periodontal evaluation may not be realistic to include with the patient’s regularly scheduled visit, it is wise to consider whether use of the D0180 examination is appropriate.
D0180 is the ADA code for “Comprehensive Periodontal Evaluation – New or Established Patient.” This procedure code is not describing a simple periodontal probing, but rather a much more extensive and comprehensive evaluation of a patient’s overall periodontal condition along with accompanying risk factors such as tobacco use or diabetes.
From a time management perspective, dental hygienists often see patients during routine visits who require more time to complete a thorough periodontal evaluation, particularly if a significant amount of attachment loss is present and/or the patient has multiple risk factors. Use of the D0180 examination as a substitution for the scheduled prophylaxis or periodontal maintenance could be provided. Or, in many cases, identification of the need for a comprehensive periodontal evaluation during the dental hygiene visit would warrant the patient’s return for a separate visit to complete the D0180 examination.
Since this procedure is diagnostic in nature, it must include the dentist for evaluation of the data and to confirm a diagnosis and treatment plan; however, often it is advantageous to schedule the patient with the dental hygienist for data collection, recording, and patient education, having the dentist examine the patient during the visit.
Irrespective of performing a simple periodontal screening or a comprehensive periodontal evaluation, and irrespective of manual probing or using automated probing systems, the priority has to be the experience for the patient.
In the Fox News reporter’s effort to emphasize the value of patients understanding their periodontal status, she made a bold statement. “If you don’t hear them calling out your numbers, find another dentist.”
I’ll make a bold statement too. “If you don’t allow patients to hear their own numbers, who benefits?” If the answer is you, then it is time to include your patient in the answer!
- Prior to any periodontal data collection, remind patients of the ranges of normal probing measurements, and that healthy tissue doesn’t bleed with measurements.
- Ask patients to listen as numbers are being measured and recorded to identify sites deeper than normal that could indicate disease.
- Allow patients to see unhealthy tissue that bleeds easily with probing.
Karen Davis, RDH, BSDH, is the founder of Cutting Edge Concepts, an international continuing education company, and practices dental hygiene in Dallas, Texas. She is an independent consultant to the Philips Corp. and serves on the review board for entalantioxidants.com. She can be reached at [email protected].
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