Case acceptance means hanging in there until a positive outcome is achieved
BYJamie Collins, RDH, CDA
Some patients who appear on the schedule elicit a groan in the back of our minds. You know who they are. They are in desperate need of periodontal therapy, for example, and decline treatment despite your best efforts. If you have practiced for any amount of time, you have met more than one of these patients who have early to advanced periodontal disease and only want to do "what insurance pays for." At what point are we able to convince this type of patient about the risks, if left untreated, in addition to the benefits that treatment can provide?
According to the American Dental Association, periodontal disease affects nearly two-thirds of Americans over the age of 65, and nearly 47% of Americans over the age of 30. Periodontal disease is often referred to as a "silent" disease. Many individuals are not aware there is a problem affecting their oral health since nothing hurts. I have experienced a multitude of patients who think that, if nothing hurts, then it is not a pressing issue to treat (and they will deal with it once it hurts). What many don't realize is that the bleeding gums and bad breath are warning signs of periodontal disease.
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There is a fine line between educating and preaching to the patient. Once the latter happens, the conversation often ends with the patient feeling frustrated and not receptive to any recommendations. "Carl" serves as an example. He had seen a few hygienists over the years for a "cleaning only." However, periodontal therapy had been recommended for years.
The first time I saw him clinically he presented with advanced periodontal pockets ranging from 3 mm to 7 mm with significant bone loss and subgingival calculus with heavy bleeding. Previous hygienists had tried to recommend periodontal therapy but Carl simply did not comply.
I took the extra time to educate him, as well as show and explain the radiographs, with the added benefit of intraoral photos. He then understood the reasoning behind the recommendation and promptly scheduled for treatment. For the past four years, I have been seeing Carl every three months, and his periodontal condition and home-care compliance have improved greatly since first meeting him. He is now invested in his own oral care and asks questions each time about how he is doing and what he can do to improve. He values any suggestions I have made and is now willing to try any oral care aids that I recommend. He expressed the feeling of being "talked down to" from previous hygienists and therefore he had little interest in what was recommended.
Understanding how treatment can cut costs
There are many different ways to educate and inform patients about periodontal disease, increasing case acceptance. You have to be able to "read" the patient. Some are better at understanding conversations and statistics. Others need to see a visual representation showing the destruction going on within the mouth. All patients, though, need to be able to see that the value of periodontal health is in their own best interest for overall health. Some patients are more receptive than others initially, but repetition at each visit is a must.
A patient may have exhibited "borderline" probing depths for years. Suddenly, though, those pockets exhibit progression to 5 to 6 mm pockets. The patient can't understand why he or she is suddenly suffering from periodontal disease and needs extra therapy, at an increased cost. Has the patient's health changed? Taking new medications? Or has this individual changed any habits?
As we have been taught, the oral cavity can be a window to the overall health of an individual. The prevalence of diabetes in America, both diagnosed and undiagnosed, is astounding. Multiple studies have been published to exhibit a significant decrease in glucose levels once periodontal treatment has been completed and the disease is controlled. Diabetes increases the risk of periodontal disease, and uncontrolled periodontal disease has been proven to make diabetes harder to control, thus creating an ongoing cycle of destruction. By treating the periodontal disease, the inflammation can be reduced, creating stability in glucose levels.
Many other health conditions present in the oral cavity prior to the patient exhibiting outward symptoms. The other oral-systemic links are numerous. For many patients, these links represent the needed push to move forward with recommended treatment.
United Concordia published a study exhibiting the decrease in health-care costs of those individuals who were treated and maintained periodontal disease vs. individuals who did not receive needed periodontal therapy. The annual savings for chronic diseases were on average $2,840 (40.2%) for diabetics, $1,090 (10.7%) for heart disease, and a significant difference of $5,681 (40.9%) for those who had suffered a stroke.
In turn, treatment also reduced hospital admissions related to diabetes by 39.4%, stroke by 21.2%, and heart disease by 28.6%. The annual medical cost savings are drastically different for those patients who were treated for periodontal disease vs. untreated active periodontal disease. When the patient complains of the cost of periodontal therapy, remember the potential cost savings in overall health costs.
Putting disease in writing
Sometimes we can tell our patients what we see, but many need to see it in writing. Utilizing a software system that shows the changes in bone levels on the periodontal chart - in combination with recession and furcation involvement - has proven to be very resourceful in my practice. The visually pleasing graphs as well as patient education resources have been informative and easy for patients to understand. It also presents a way for the science to "show" the information to patients since it is presented through a computer program.
The data is part of the patient's health history, and it is calculated within the program. I currently use a voice recognition system where I speak into the headset and it records the numbers to the corresponding tooth surface. The patient hears those numbers and the alarm that sounds when a 4 mm or above pocket is noted. The chart notations show up in red, catching the attention of the patient. It spurs the questions from the patient often before the charting is completed. After completing the periodontal chart, if additional treatment is recommended, sit the patient up before making any recommendations. The additional few seconds allows your patient to look you in the face while upright, strengthening the conversation and allowing the patient to feel like an involved party vs. being lectured to.
Whether the patient is new or an established patient and periodontal treatment is needed, compile the necessary resources. A complete periodontal chart includes recession, furcation, and bleeding points. Explain to a patient that a prophylaxis (D1110) treats only above the gum line, and will not treat the underlying subgingival involvement. If periodontal conditions are left untreated, they will progress, possibly leading to pain and eventual tooth loss.
An up-close intraoral photograph displayed on the computer monitor allows the patient to see what you see. To see what is on their teeth and the inflammation in the gingiva can be astounding for the patient. For many, the visual picture of the large chunk of calculus and resulting inflammation is all they need to accept recommended therapy. In contrast, we have all had those patients who have declined treatment and we have completed a "bloody" prophy. The key is to educate and convert the way these patients value our services and put value on their long-term oral and overall health.
A wealth of patient education materials is available for in-office and take-home use. You can find everything from videos to be played in the operatory that explain the disease process and treatment options to take-home materials. Have relevant brochures for the patient to take home to read at their leisure.
Many people will have questions about the recommended treatment once they leave the office. I have given many patients the information along with the invitation to call me with any questions that may arise. You would be surprised to know how many call me directly with questions or concerns and then promptly schedule therapy appointments. Making yourself available instills confidence in the patients' minds as well as allows them to realize your recommendations are for their overall health, not just for the added income to the practice.
Stay in touch
If the patient does not immediately comply with recommended treatment, do not give up each time you see them. You don't always know the family or financial situations. For many people, whether they have insurance coverage or not, the unexpected expense of periodontal therapy can present a financial burden. If patients see the value of the needed procedures, they are often willing to plan and find a way for treatment, even if it takes a few months before they are able to schedule treatment.
Have the office manager or patient coordinator available to discuss payment or financial options with the patient. There are many outside financing options to offer patients the ability to complete needed treatment quickly without having to provide their full patient portion up front. Repetition and consistency is the key, if the patient is not able or willing to complete treatment after the first recommendation.
Compassion and sensitivity for the patients' concerns will also play into the willingness to accept treatment. Many individuals in need of perio therapy have stayed away from dental offices out of fear or past bad experiences. Those patients often come to see us after years away and are nervous just walking into the office.
Many are there now due to pain or discomfort. The fear of injections for treatment is foremost in the minds of many. Reassure the patient that there are things we can do to minimize the "pinch," and offer alternate suggestions if applicable. For some patients, the alternative option of anesthetics such as Cetacaine Topical Anesthetic Liquid (Cetylite) or Oraqix (Dentsply) placed into the base of the pockets is sufficient for pain control. I will often give the option of either pain control method to the patient with the understanding that if they choose to have an infiltration or block due to discomfort, we can administer it at any time. The ability to choose often allows the patient to have a little control over the situation and increases the willingness of case acceptance.
Whether the patient is new or established, young or elderly, we see all walks of life. Periodontal disease does not discriminate and neither does the need for treatment. By understanding the patient's needs and concerns, we are able to make recommendations best suited for each individual. By establishing confidence in our abilities and value in treatment, the patient will be much more willing to accept suggested treatment. In turn, the potential oral and overall health and wellness will be positively impacted for years to come. RDH
Jamie Collins, RDH, CDA, resides in Idaho with her husband, Cory, and their four children. She currently works as a full-time hygienist as well as an educator at the College of Western Idaho. In addition, she acts as a content expert and contributor in multiple upcoming textbooks. She can be contacted at [email protected].