Probing beyond the numbers leaves you fully engaged in the treatment plot
BY Nicole Giesey, RDH, MSPTE
Imagine watching only the first half of an interesting edge-of-your-seat movie, wondering what the ending would be like and being disappointed in not knowing how it ends. You had the chance to know the characters, their background, and their environment. What was next for them? Did you really get to see the whole scenario? What would your reaction have been if other story lines were introduced in the ending that you missed? It's torture knowing only half of the story.
Making sure that the whole picture is nice and clear always makes a situation much easier to understand. This is especially true for dental hygienists. Gathering only probing numbers and not seeing the entire periodontal condition could hinder our diagnosis and treatment of the actual case before us. Having the proper assessment from the beginning is the best practice, with no shortcuts taken.
Perio assessment is taught in every dental hygiene school, and it is intertwined within the didactic and clinical curriculum. Recognition of periodontal disease is one of the cornerstones of our profession. Periodontal disease education, treatment, and maintenance are always hot topics at dental hygiene meetings. We strive to prevent the beginning and progression of the disease. We are periodontal warriors. Like all good warriors, we must know who and what we are fighting. The big perio picture needs to be painted one assessment measurement at a time until the whole picture is complete.
My purpose in this article is to inspire the hygiene community to perform complete periodontal assessments. If dental hygienists are on the same perio-assessment page, we can ultimately improve patient awareness of periodontal conditions through utilization of periodontal assessment for direct patient education.
When probing pockets is completed, the entire periodontal picture is not complete. The assessment of clinical attachment levels (CAL) needs to be completed. By measuring the pocket depth in conjunction with measuring gingival margins from the cementoenamel junction (CEJ), a simple calculation can be made, and the CAL can be determined. The tissue may be coronal to, at, or apical to the CEJ. These scenarios need to be correctly documented.
A protocol that fits the schedule
First and foremost, a protocol to make assessment easy needs to be laid out. Do not try to be a superhero hygienist and tackle both a full-mouth periodontal assessment and a full-mouth series of radiographs on a routine recare appointment. This task is especially hard to complete within the proper time frame if you are in a 45-minute appointment office.
If your day is jam-packed with appointments without a break, you will burn out. Alternating the perio assessment with radiographs at each appointment will spread out the tasks per appointment and provide less fatigue for both the clinician and the patient. This applies to recare appointments. For initial appointments, both the radiographs and perio assessment need to be completed to ensure proper classification of the patient prior to treatment. These initial appointments usually have a greater time allowance.
If you are working in a clinic with no time to even thoroughly clean a patient's teeth let alone charting, patient education, radiographs, and now periodontal assessment, I understand your predicament. Unfortunately, there is no magic solution to that problem. I have worked in that type of environment, and you do the best you can to provide treatment ethically and universally. If you can, try to somehow find the time or make another appointment for a limited exam with radiographs and perio assessment to work in these assessments that are essential not only for the providers but for the patients to understand their own oral health conditions.
Once you get over the hurdle of how to schedule patients, you will need to establish your protocol in the most time-efficient manner.
Set up your station and organize yourself to help the charting process flow easily without becoming an overbearing task. The two methods of gathering perio assessment data are digital charting and paper charting. If you are lucky enough to be employed in a digital office with an awesome periodontal-charting software component, your perio charting will be a breeze.
A hygienist can actually get spoiled in a digital office. It is a very nice feeling coming from a paper office and having the opportunity to transition into digital. It can be a little overwhelming at first, but once you go digital, you will never want to go back to paper.
Periodontal charting software frequently has the ability to automatically calculate the CAL during data gathering. The user can also click on a tooth and add furcation, mobility, plaque/calculus, and bleeding/suppuration points. Also, the software has a soft-tissue component that allows the user to not only perform a perio charting but also a visual/clinical tissue assessment exam. The format prompts the clinician to gather as much documentation as possible to provide tools for an accurate diagnosis. The only other component outside of the charting is the utilization of radiographs for a periodontal confirmation.
An assistant who knows the software and understands the charting process is a real timesaver. Dental assistants and front-desk personnel who can help with charting are truly a gift. Perhaps starting my career as a dental assistant/front-desk person and knowing how hard they work makes me a little biased. The dental office works really well as a team. However, that being said, not having an assistant or front-desk person to help is not an excuse for not completing charting on a patient, especially in a digital office. Utilizing the tips in the sidebar and getting comfortable with the software will help the hygienist be a little more comfortable with performing the task solo.
In fact, there is new cutting edge software on the market that allows the user to wear a headset and speak the perio charting into the headset. The charting is voice activated and will input the information right from the user's headset. This concept has been around for some time, but the perfection of it is now available.
If you are still using paper charting, being organized is key for saving time. A clipboard, the periodontal chart, a pen wrapped in a barrier, and a probe/mirror are all you need. Over-gloves can also be utilized for infection-control precautions.
The first tip is to ensure you are using the right form. There are a many charts with only perio probing on them. If necessary, update the paper chart for complete periodontal assessment. Call various companies and ask for samples to see which one enables you to make a proper assessment with ease.
The second tip is to ensure you have a routine and a consistent pattern while charting. Make sure to incorporate mobility, furcation, plaque/calculus, and especially bleeding/suppuration points to see exactly where there is active bleeding. If you wait until the end of the charting process, the bleeding points may no longer be seen if the bleeding was minimal. After all of the perio pockets, gingival recession, and bleeding points are charted, the assessment of the CAL can be made. Then a complete perio assessment can be made.
The thorough assessment boils down to an accurate diagnosis with the correct information. This accurate diagnosis then allows appropriate patient education and treatment options. The charting can be a direct patient-education tool to visually show the patient the findings, as well as any intraoral camera pictures of tissue and radiographic findings.
Simply probing pocket numbers gives us only the first half of the story. Probing for information beyond the pocket numbers gives us the whole story, and isn't it nice to know how the story ends? RDH
Tips for digital charting
• Make sure all of your dental charting is completed first so that all missing teeth are noted on the chart, as well as any implants that are present. If you skip this step, your perio charting will quickly become a very lengthy process, defeating your time-saving goal.
• Invest in a wireless keyboard and mouse. These are very inexpensive. Remove all instruments with the exception of your probe and mirror and place the keyboard nearby. Make sure to use a barrier over the keyboard to maintain infection-control standards.
• Practice with the software without a patient being present. Ask your employer if the software came with tech support. View YouTube educational videos or the software's website training videos. Once you use it, you will love the results.
• Make sure your software is set up so that you can manually add the gingival margin and that you are not only recording recession but also any readings that are at or above the CEJ. If you do not record the appropriate number for the gingival margin, the software will assume that the margin is at the CEJ. If you have tissue that is 2 mm above the CEJ, your entry for the gingival margin could be -2 mm. All factors as to why the tissue is at the level it is need to be considered.
• Use a flowing and consistent charting pattern. Do not bounce around. Once you input the missing and implant areas prior to the exam, the software will direct you as to where you should go. Depending on the software, you can set up the charting pattern so that the flow preference is the user's choice.
Nicole Giesey, RDH, MSPTE, enjoys researching, writing, and educating on topics related to dental hygiene. She is the dental hygiene product specialist for Maxill. She can be contacted at [email protected].