BY EILEEN MORRISSEY, RDH, MS
You are treating your 50-year-old female patient at her periodontal maintenance visit. She has a history of moderate, generalized chronic periodontitis. She was referred to the periodontist five years prior and had osseous surgery in two of her four quadrants. Her prognosis was considered to be very good. Home care has been consistently better than adequate, and she has maintained an alternating six-month recall frequency for the past five years.
At this visit, "Susan" turns to you and says: "I would really prefer to have my cleanings at your office. Must I continue to go back to the periodontist? Frankly, your cleanings are more thorough, and his are so much more expensive."
How do you respond?
In our practice, there would be no cookie-cutter response to this inquiry, and we take the matter very seriously. I am fortunate to be in an office where my doctor relies heavily on my expertise with regard to the management of the periodontal issues of our patients. Given that Susan has no systemic risk factors, she has maintained very well for five years, she has shown no evidence of recurrent disease, her home care is excellent, and she stays on a regular maintenance schedule at both the general and periodontal practices, I would lean toward responding positively to her request.
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Sidebar: I am bothered by the fact that she states the cleanings in the general practice are "more thorough." That is something my employer is going to explore further, and a column for a different day.
I state to Susan that I will confer with my doctor, and we will decide together if this is an acceptable regimen for her. What I typically do is give him a heads up in advance as to precisely what my patient is going to ask for.
When my doctor comes in for the exam, Susan reiterates her request. He listens, then turns to me and asks me what I think. In Susan's case, I would respond as follows: "I feel comfortable allowing her to keep the same periodontal maintenance schedule in our office only. However, this is with the stipulation that if home care falls short, if she shows any signs of recurrent disease, or if she fails to stay on her three-month cycle, we will immediately refer her back to the periodontist."
My doctor concurs wholeheartedly. Susan happily promises to comply with the stipulations and excitedly leaves the treatment room to make a three-month maintenance visit on my schedule.
In a second scenario, another alternating periodontal maintenance patient, "Lois," makes the same request two weeks later. This is a patient who was diagnosed with severe, chronic generalized periodontitis three years prior. She was treated with quadrant debridement followed by four quadrants of osseous surgery. Her prognosis is fair. Her home care is not what it should be, and she is not consistent with her recare frequency. Despite giving up cigarettes several years ago, she has resumed smoking in the past six months.
When Lois asks if she can forego the periodontal cleaning visits at the office of the specialist, I tell her (as in the previous case) that I will confer with my doctor and we will make our decision based on what is in her best interest. (I again provide him with a heads up in advance).
I feel strongly that it is in Lois's best interest to stay on alternating recall status with the periodontist. She has strong local risk factors that include oral hygiene that is not up to par and inconsistency with staying on a regular recall cycle. The fact that she has resumed smoking is also a huge risk factor with regard to recurrent disease. Nonetheless, my doctor and I are a team. I will wait for him to examine and confer at the exam.
This time, when Lois poses the request to my doctor, he asks me what her status is today, how the home care is, what her periodontal charting shows, and if she currently smokes. (Understand that all of this is for Lois to hear the rationale for the response that is soon to follow.) Finally, he asks me what my thoughts are as to her request. I state that I have concerns based on today's findings. I believe that for the time being, it is in Lois's best interest to maintain an alternating regimen. My doctor concurs.
I appreciate that there are those who may not agree with how we responded to these patients. It is critical that all of us take into consideration the patient's medical and dental history, especially their periodontal history. Compliance, current periodontal status, and home care dedication all need to be carefully weighed in deciding how best to guide the patient.
Onward we go; it is in our hearts' core... RDH
EILEEN MORRISSEY, RDH, MS, is a practicing clinician, speaker, and writer. She is an adjunct dental hygiene faculty member at Burlington County College. Eileen offers CE forums to doctors, hygienists, and their teams. Reach her at [email protected] or 609-259-8008. Visit her website at www.eileenmorrissey.com.