Mr. Z. was my patient today. He is a 58-year-old male who presented for a recare appointment. He is currently taking cholesterol and oral diabetes medications. I had seen him previously one time only at his initial appointment in the practice. At that time, he was diagnosed with moderate, generalized chronic periodontitis. His radiographs revealed moderate bone loss in the posteriors, with pocket depths ranging from 3-6 mm generally. There was heavy subgingival calculus evident on radiographs.
At the time of the initial appointment, I treatment planned Mr. Z. for four quadrants of scaling and root planning with anesthesia. These were scheduled with the dentist, because he had the time available to get the treatment accomplished sooner. (The doctor takes an active role in nonsurgical periodontal treatment as needed, and is very capable!)
Fast forward to today, 18 months later. I noted on the record that Mr. Z. had opted out of a formal re-evaluation appointment. Today’s visit was his first time back at our office since his quadrant debridement. He informed me that he does not take care of his teeth as recommended, and that we would most likely need to “start again from scratch.”
As I re-evaluated his soft tissue, I could see that the deep scalings had been effective in minimization of most pocketing. However, there was still a fair amount of bleeding with new calculus present in the lower anteriors, as well as generalized biofilm and debris. I asked him if he had changed any of his self care after the quadrant debridement visits? His response was, “No.” He reported that he was still brushing his teeth twice a day “some of the time,” and that he was not using any means to clean his teeth interproximally.
I struggled with how to reach this man? I wanted so much to understand his perspective.
At first, he was listening to a real estate motivational tape with a bud in his left ear during treatment. When I began asking questions as I worked, he stopped and gave me his attention. He told me that he keeps up with other aspects of his overall health care in that he sees the eye doctor, as well as a PA so as to stay on top of any changes in his diabetes control. It was her recommendation that he see his eye doctor regularly so that any potential vision changes could be recognized.
He said, “You know, when I come in here to the dentist, you guys find a bunch of things wrong with me. It costs me money, time, and aggravation. I have no problems, and nothing is bothering me. So I just don’t feel like dealing with it. Plus, when I go to see them, nothing that they do hurts me. I can’t say the same for here.”
I put down my instruments and asked Mr. Z. if I was hurting him? (At that point, I had debrided his entire mouth with the ultrasonic, using a thin tip, and had moved on to fine scaling with hand instrumentation.) He replied, “No, honestly, you are not hurting me. The noise was annoying, and the water sometimes makes me feel like I’m going to choke, but I have to say it really does not hurt.”
As I tried to understand his perspective, I talked about how I feel when I go to the dealer to get an isolated car problem situated, and I’m offered a “complimentary analysis.” Before I can say Jiminy Cricket, I have 10 other things that need to be addressed, and they all cost me money. Total frustration, because I had no awareness of any of this, and I am mistrusting of the dealership. Was the examination at our office like that for him? I told him he was a better person than many for keeping up with the consistent medical checkups that others avoid because they don’t want new “discovery.”
At this point, it seemed it was my opportunity to try to reach him via the oral systemic link.
I asked him if he knew that research links oral inflammation with potential challenges in blood sugar controls? I shared with him the true story of our patient who had struggled with this. Once her periodontal disease was treated and being maintained, her sugars had magically stabilized. At this point, I could see that Mr. Z. was really listening. His ear bud had fallen on the floor, and he gave it no heed. I wondered, is this my breakthrough moment?
Author’s note: I cannot help but wonder why the physician assistant, who made certain she raised awareness regarding prioritization of regular eye exams did not emphasize the importance of minimizing oral inflammation? My thought was to possibly send a cooperative care letter to the PA that would summarize the visit today, noting the periodontal condition and inflammation, and asking for her assistance in the reinforcement of the oral systemic link in her appointments with him. This could be designed like the cooperative care letters sent to our general dental practice from the periodontist.
Mr. Z. thanked me at the close of his appointment, and scheduled a four-month recare visit with me. Will he follow through, as months pass, and quoting him, “Nothing is bothering me?” Will the story that I told him about the other uncontrolled diabetic patient resonate with him as he is driving from our parking lot? Only time will tell.
I leave you with a three-fold message to consider. First, for those of you who are skeptical, there are general dentists out there who can scale and root plane effectively. Secondly, devising strategies to reach unmotivated patients remains the hygienists’ greatest challenge; using storytelling and anecdotes can go a long way. Finally, how can we continue to raise awareness in the medical community (Mr. Z’s PA) as to the significance of the oral systemic link? Onward we go; it is in our hearts’ core.
EILEEN MORRISSEY, RDH, MS, is a practicing clinician, speaker, and writer. She is an adjunct dental hygiene faculty member at Rowan College at Burlington County. 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.