Redefining conservative: Explaining the need for perio treatment to patients

April 14, 2015
Explaining the need for perio treatment to patients

Explaining the need for perio treatment to patients

BY Andrea Kowalczyk, RDH, BS

It's late Thursday afternoon, and the last patient of the day is Mr. Jones, a 64-year-old gentleman who is in the practice for a new-patient exam. Mary, the hygienist, tells Mr. Jones she will record pocket depth measurements before the doctor comes in to perform a full examination. Mr. Jones has recently retired to the area and has not seen a dentist in four years. As Mary probes, she notices that Mr. Jones has generalized bleeding and 4 mm pockets; two 5 mm pockets on tooth No. 31; and one 6 mm pocket on tooth No. 29. The radiographs indicate slight bone loss in that area.

Mary informs the doctor of her findings. The doctor states that because Mr. Jones has "just a few pockets and has not had a cleaning in several years," Mary should "complete a prophy for Mr. Jones today and reevaluate the pockets in six months."

This scenario gets played out daily in countless dental practices around the country - so much so, that some of you reading this may not notice what went wrong here.

Conservative approach?

In today's competitive dental marketplace, we may be reluctant to inform patients with isolated disease that they need more hygiene treatment than just their "free cleaning" for fear of losing them to another practice. To justify this, we often rationalize that we are "conservative" in our approach to diagnosing and treating periodontal disease. However, given what we know today about periodontal disease and its destructive effects on tissue, coupled with the systemic ramifications, could it be time we challenged this common thought process on what we consider to be conservative treatment?


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Webster defines the word conservative as "marked by moderation or caution." In medicine, catching and treating disease early, and before surgical intervention becomes necessary, is considered conservative. In dentistry, we know that the purpose of subgingival scaling is to remove bacterial toxins and arrest periodontal disease at its earliest stages. According to the American Academy of Periodontology: "Untreated gingivitis can advance to periodontitis. Toxins stimulate a chronic inflammatory response in which the body in essence turns on itself, and the tissues and bone that support the teeth are broken down and destroyed. As the disease progresses, more gum tissue and bone are destroyed" (perio.org).

In the case of Mr. Jones, we shouldn't wait until he has lost more gum and bone tissue to treat his disease. If he ultimately needs full-mouth scaling and root planing, or surgery with the associated injections and longer healing time, would that be considered cautious? Wouldn't treating Mr. Jones' disease while it is limited to only a couple of teeth be the most conservative approach?

It should not be overlooked that most hygienists would perform localized scaling for Mr. Jones during the prophy, yet not bill out a 4342. In our efforts to "help" the patient financially, we inadvertently create several problems for both ourselves and the patient when we do not properly code for services rendered:

1. The patient may not be fully aware of his or her condition, causing early home-care interventions to be neglected.
2. We provide a service for which we are not paid.
3. If disease progresses, we must explain why we did not treat it earlier, an awkward conversation at best. We see this often in patients with moderate to advanced gum disease who have had years of preventive prophies in another practice. It is likely that the original treating office thought they would help the patient save money initially. Then, as the disease progressed, it became increasingly difficult to reverse course for fear of angering or confusing the patient. In this case, the neglect began with good intentions.

Focusing on the treatment

To prevent this from happening in your practice, you will need verbiage tools you can employ to ensure the patient understands his or her condition and accepts treatment. Once the doctor has confirmed that your recommendations are appropriate for the patient, the key is to communicate those findings to the patient in a way that is relevant and relatable to the individual.

Note this example of what not to say: "Mr. Jones, gum disease can cause tooth loss if not treated early. We need to perform a scaling and root planing when we find periodontal disease."

Where does this verbiage go wrong? The information may be correct, but it is not presented in a way that feels relevant to Mr. Jones. This verbiage is focused on the treatment, not the patient and his personal situation and concerns.

A better way to present the treatment sounds something like this:

"Mr. Jones, you have an active infection around the tooth that anchors your bridge. Gum disease can cause you to lose that tooth if not treated early. We would hate to see you lose the investment you have made in your bridge. Treating the tooth with scaling and root planing is the best way to prevent that."

Now, the information is correct and relevant to Mr. Jones.

In addition to helping the patient relate to your recommendations, you need to ensure he understands them. Too much dental lingo will prevent patients from being able to truly own their condition. The example below illustrates this point: "Mr. Jones, you have periodontal disease. We need to perform a localized scaling and root planing and then put you on periodontal maintenance every three months. Additionally, we will place some Arestin in the pockets over 5 mm."

Mr. Jones is thinking: "What?!"

More effective verbiage looks like this: "Mr. Jones, you have an active infection around the bone that holds your teeth in place. We need to clean out that infection so you do not lose any bone. Losing bone can cause you to lose your teeth and your bridge. Infection can also weaken your immune system. Since you are a diabetic, we need to get your mouth as healthy as possible. After we have removed the germs that cause the infection, we will place some antibiotics in the most involved areas to kill any remaining germs. Does this make sense?"

This example illustrates that when the condition is explained in plain language, the patient can truly grasp the urgency in undergoing the treatment.

It may be of comfort to know that in my clinical experience, when patients are thoroughly educated, they almost always accept localized scaling and happily return to the office. They are usually relieved it was caught early. With the use of an intraoral camera and helpful websites, education on isolated periodontal disease is easier to provide than ever before. We are truly helping our patients when we give them full, understandable disclosure of our findings, and provide treatment while it is still relatively painless and affordable. Halting a progressive disease at its earliest stages allows us to be truly conservative in our approach. RDH

ANDREA KOWALCZYK, RDH, BS, works as a senior hygiene performance coach with Enhanced Hygiene. She obtained a bachelor's degree from O'Hehir University and a post-graduate certification in mentoring. She speaks nationally on hygiene topics, including on how hygienists can avoid career stagnation. She resides in Houston with her husband and son. She can be contacted at [email protected].