Clashing paradigms

Jan. 1, 2003
For some time now, I have been trying to develop a soft-tissue management program in my office. However, I am becoming increasingly frustrated!

Dear Dianne,
For some time now, I have been trying to develop a soft-tissue management program in my office. However, I am becoming increasingly frustrated!

I am the full-time hygienist in a small practice with a doctor who has the philosophy that all periodontal disease should be treated with a "prophy." There are several patients with generalized 6-7 mm pockets or greater who refuse referral to a periodontist. It is extremely difficult to instrument these patients without anesthesia. Recently, one of these patients came in for an extraction on a molar with 7-8 mm pockets. I was mortified to see all the calculus that I had missed on the root surfaces.

I feel like a failure! It seems like I am expected to get periodontally involved teeth calculus free with a prophy, and I know that is not possible. I recommend root planing with anesthetic for many of the difficult new patients, but I do not feel like my doctor supports me.

All other things considered, I am happy in this practice. Do you have any suggestions?
Frustrated Flossie

Dear Frustrated,
What I see here is clashing paradigms. Obviously, your doctor is not up to speed on current periodontal therapy protocols. My guess is that the doctor is one who has been in practice for 20-plus years, and/or maybe he is ultra-conservative. However, he needs to understand that he is not helping his patients or his practice by minimizing the periodontal needs of his patients.

I believe it is next-to-impossible to scale deeply and thoroughly on a patient with calculus deposits of 6mm or more without some kind of anesthesia. Hygienists who work in this fashion become so accustomed to 'tiptoeing' around the sulcus that they are likely to miss subgingival deposits. Further, it is extremely difficult to remove some deposits, even when the patient is anesthetized. If the patient is not anesthetized, the odds increase greatly that calculus will be missed.

It is indeed a humbling experience to see an extracted tooth after it has been scaled. Two examples are shown in the photographs above.

Since I am one of the old-timers (1978 dental hygiene graduate), I remember when the phrase "soft tissue management" came into focus. My doctor/boss and I traveled to Chapel Hill, N.C., to attend a seminar on treating periodontal disease in the general practice. The speaker talked about anesthetizing one quadrant and working only in that area for the whole appointment. It was a novel and even radical idea, and we were anxious to try it. I remember the feeling of "freedom" at not having to worry about hurting my patient, of being able to scale aggressively and deeply as I had never been able to do before. What a learning experience that was! Further, the results I achieved with many of my patients were nothing short of phenomenal. My boss and I were excited to learn how to help our patients in a substantial way.

Later, we attended a course sponsored by Pro-Dentec that put the whole treatment protocol into a logical sequence, based on the severity of the patient. We began using their protocol and incorporated the Rotadent® into our treatment regimen. Our patients seemed to benefit even more when we incorporated a power brush into their therapy regimen.

Having consulted with both general and periodontal practices, I have observed that the greatest difference in the hygiene department is the use of anesthesia. It is common for nearly every patient on the hygienist's schedule in a periodontal practice to receive anesthesia, especially in areas of deep pocketing. They seem to understand that the hygienist's ability to effectively reach and remove deep subgingival deposits, sans anesthesia, is severely hampered.

This entire subject gets me up on my soapbox about hygienists giving local anesthesia. My feeling is that hygienists in every state should be taught to administer local anesthesia. According to the ADHA, hygienists in 31 states can administer local anesthesia. Every year, a few more states are added. This skill should be taught nationwide in all dental hygiene schools. What a travesty it is for a hygienist to be properly certified in an anesthesia state, then move to a non-anesthesia state. Suddenly, she or he can't anesthetize patients because it is not legal, although the hygienist has been anesthetizing patients successfully for years!

Doctors in non-anesthesia states should lobby their state dental boards to allow anesthesia certification for hygienists, as it would relieve the stress of having to leave a procedure to anesthetize a hygiene patient. Patients would benefit from more thorough scaling, as hygienists often do not want to bother the doctor from his/her procedures to anesthetize a hygiene patient.

The discovery and subsequent treatment of periodontal disease is an important part of any comprehensive treatment plan. Providing a healthy foundation on which to build future restorative and/or cosmetic dentistry is essential. However, communicating the existence and severity of the disease presents a problem for many clinicians.

What I observe in many offices is that doctors have difficulty communicating their findings, especially for periodontal disease. Here are some examples of actual statements I have heard:

• The Minimizer — "Mrs. Jones, it looks like you have a little gum problem that we need to attend to." No explanation is made of bleeding, pocket depths, quadrant scalings or fees. The problem has been minimized in the minds of patients, and they don't understand why a little problem will take five appointments and $800 to correct.

• The Unrealistic — "Mrs. Jones, you have a lot of build-up on your teeth, and you will need to come in four times to get your teeth cleaned." Periodontal therapy is called a cleaning, which denotes a simple procedure to a patient. There is no mention of disease or infection. I can just imagine what thoughts could be going through this patient's mind: "Four visits to get my teeth cleaned — ridiculous! They're just after my money!" It's little wonder these patients often break appointments. They haven't been convinced that there is anything seriously wrong.

• The Intellectual — "Mrs. Jones, I have found that there is periodontal destruction present with readings from 4mm to 7mm. The alveolar breakdown will eventually lead to tooth mobility. We will attempt a therapeutic, nonsurgical approach for resolution of this problem." After the doctor leaves the room, the patient turns to the assistant and says, "What did he say?" This doctor has not learned to communicate on the patient's level by using words that are easily understood. From the patient's standpoint, the doctor was speaking in a foreign language.

Part of the problem is that doctors sometimes do not know how to convey to a patient that she or he has periodontal disease, because the doctor does not understand disease classification and protocol for treatment.

The doctor's primary responsibility is to diagnose periodontal disease by thorough examination of the patient. A complete intraoral examination of soft tissues should be carried out with an assistant recording the doctor's observations regarding tone, texture, bleeding, mobility, exudate, recession, and probing depths — all within the patient's hearing. The patient should be allowed to see areas of gross calculus and deep periodontal pocketing. In addition, existing restorations, restorative, and/or cosmetic needs should be recorded. The patient should be given the appropriate periodontal classification, and the necessary radiographs should be taken.

Here's an example of what the doctor might say: "Mrs. Jones, I have determined from the examination of your gums that there are some problems that need to be addressed before we can begin repairing your teeth. You have a periodontal infection that is causing the bone to deteriorate in several areas of your mouth. Let me show you what I mean."

Then give the patient a mirror and let her see the probe disappear under the sulcus. Show the patient the calculus and swelling. Also, use your X-rays and intraoral camera (if you have one) to educate the patient about her problem.

The doctor then continues the conversation: "However, the good news is that I think we can help you by treating this problem in a conservative, nonsurgical way. My hygienist, Flossie, has good success in most cases with this therapy. She will be spending some time helping you to understand the disease process and how to control it, as well as providing your gum treatment. Your periodontal therapy will take X appointments, and the fee will be Y. Do you have any questions you'd like to ask me? Is there any reason not to get started as soon as possible?" If there are financial concerns, refer those questions to your financial coordinator.

The problem I see in many offices is that the doctor does not take the time to "drive the point home," to educate the patient sufficiently, or to give the patient hope. We often overestimate the understanding level of the patient and do not attempt to talk on his/her level. In other words, we do not give patients a chance to take possession of their problem.

If new patients are seen in hygiene first, the hygienist must inform the doctor before she or he sits down to exam the patient of the findings and patient periodontal classification.

Treating periodontal disease should be a major part of any profitable and effective hygiene department. Therefore, it is your challenge to help your doctor understand that a prophy is for healthy patients, that patients with periodontal pockets deserve more definitive therapy. Anything less is supervised neglect.

To help the two of you "get on the same page," I recommend that you attend a good course together on conservative periodontal therapy. I talk about all the issues of protocol and communication in my courses across the country. In addition, Pro-Dentec still gives its courses across the country. Here's the Web site:

In the absence of attending a course together, I recommend you write down what you would like to see implemented for your hygiene department. Set up a meeting with your doctor and discuss with him how you would like to start managing those periodontal patients in the practice.

Tell him exactly what you have told me about feeling like a failure and not being able to scale thoroughly without anesthesia. If the doctor understands that your major concern is the well-being of the patients, he will be willing to make the necessary changes.

I commend you for your pursuit of excellence and desire to help your patients by offering them thorough treatment.

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Lexington, N.C. To contact Glasscoe for speaking or consulting, call (336) 472-3515, fax (336) 472-5567, or email [email protected]. Visit her Web site at www.profession