Making time for the blood gushers

Mary Carotid, age 34, plops down in your operatory chair and announces her gums are bleeding and she doesn’t know why.

by Lynne Slim, RDH, BSDH, MSDH

Consider reading: Spin doctors
http://www.rdhmag.com/articles/print/volume-32/volume-12/columns/spin-doctors.html

Consider reading: Different strokes are used in periodontal instrumentation
http://www.rdhmag.com/articles/print/volume-32/issue-11/columns/different-strokes.html

Consider reading: Perio/Cardio Link Debunked
http://www.rdhmag.com/articles/print/volume-32/issue-7/columns/peridontal-therapy/perio-cardio-link-debunked.html

Mary Carotid, age 34, plops down in your operatory chair and announces her gums are bleeding and she doesn’t know why. Unfortunately, you’re in a dental practice where you only have 40 minutes for adult recare, and you’re already 10 minutes behind. There’s no time for anything other than ultrasonic instrumentation and polishing and you find yourself just going through the motions, mopping up a bloody mess as you go along. It’s splattered all over your lab coat and visor, and you talk to the patient about the importance of flossing while you are racing through the mouth with your ultrasonic insert. In your mind, and to your defense, there’s no time for anything else because you’re in a practice that treats you like a glorified factory worker.

We all know there’s something terribly wrong with this scenario, but some dental hygienists today are faced with less than desirable working conditions and no opportunity to individualize care for patients. I was faced with similar situations years ago when temp work was plentiful, and I remember working a few temp days where I only had 30 minutes per patient. I couldn’t keep up with a schedule like this and care was compromised. In these dental practices, production trumped ethics. In talking to hygienists around the United States, there are plenty of unethical practices (and more popped up in a lousy economy) that are scheduling adult patients every 30 minutes. I’ve even heard of hygienists having to complete a full series of radiographs, perform a prophy, and grab a dentist for a recare exam in the 30-minute time slot!

When will dental practice management consultants and dentist-employers recognize that RDHs are not production and profit centers?

Bloody prophys in adult patients are a reality for dental hygienists everywhere. When presented with one, it’s time to back up and put on your thinking cap. Becoming familiar with a patient’s medical history is a good start because bleeding gums are sometimes related to some medical conditions, as well as prescription, nonprescription drugs, and even herbal supplements. All four have the potential to alter bleeding.1

The U.S. population is aging at a rapid pace, especially 65 years-and-older. The prevalence of periodontitis increases with age and older adults typically take more medications so you will see a lot of bleeding in this particular age group. In addition, as older adults age and when cognitive impairment progresses, oral health generally declines with a greater accumulation of plaque on teeth.2,3

Periodontal disease needs to be integrated with chronic disease prevention and control. Chronic diseases are accelerating globally due to unhealthy diet and poor nutrition, physical inactivity, tobacco use, excessive use of alcohol, and psychosocial stress. Chronic disease and periodontal disease have many of the same risk factors and severe periodontal disease is related to poor oral hygiene and poor general health.4 Four of the most prominent chronic diseases — cardiovascular diseases (CVD), cancer, chronic obstructive pulmonary disease, and type 2 diabetes — are linked by common and preventable biological risk factors, notably high blood pressure, high blood cholesterol, and being overweight.

I am a periodontal patient and see my personal hygienist, Lori Landon Cason, every three months for periodontal maintenance. Because Lori is familiar with my medical history (and everything else, by the way, because we love to gossip during my appointment!), she expects some bleeding (BOP) because I am a mouth breather with a history of asthma. In addition, I take a daily corticosteroid preventive inhaler, and it’s possible that the addition of the inhaler has an effect on gingival bleeding.

A quick search of the literature only found one reference on asthma and periodontal conditions, and it involved children. In this one small study, asthmatic children had more gingivitis than their healthy controls and it probably has a lot to do with mouth breathing.5

My bleeding could be related to mouth breathing, daily inhaler use, or it could even have something to do with an aberrant inflammatory response to biofilm in my mouth. Bleeding prevalence might even be multi-factorial in my case. This doesn’t mean that every time Lori performs a periodontal exam I am scheduled for something other than periodontal maintenance, but it does mean that clinical attachment loss is monitored very carefully because I always present with some low-grade inflammation.

We manage it with excellent self-care and three-month recare, and there have been times when I’ve needed four quadrants of SRP when inflammation was more pronounced. The same is true for my asthma, by the way. My allergist and I manage it with a daily preventive inhaler to reduce/prevent airway swelling and spasms.

Should adults with localized or generalized BOP be treatment planned for a prophy? This is a loaded question, but it’s one I’m asked a lot when I consult in hygiene departments. The absence of BOP represents a reliable indicator of periodontal stability, and those who use Perioscopy can attest to the elimination of BOP once subgingival calculus and biofilm are removed from the roots of teeth.6 In addition, variations in inflammatory response are a major determinant of susceptibility to periodontitis and that certainly includes BOP. This underscores the importance of periodic comprehensive periodontal exams, risk assessment, and customizing preventive periodontal therapy, including recare intervals.

Dental coding for an adult with bleeding might be a prophylaxis (D1110) or even two prophylaxes if needed, gross debridement (D4355), or scaling and root planing (D4342 or D4341). It all depends on an accurate diagnosis and the ability to correctly interpret diagnostic codes. Using improper codes for financial gain is a serious offense; so make sure you study them very carefully. D1110 (prophylaxis) code has an odd descriptor, and it includes the statement to “control local irritational factors.” I think the ADA meant to use the term local or altered gingival inflammatory response instead of “irritation,” but I don’t know. The mind boggles. In the periodontal/dental literature, there is no such thing as an “irritational response” and “irritational” isn’t even a word that is used in the English language. Try googling the word “irritational.” Nothing pops up.

The population 65 and over has increased from 35 million in 2000 to 40 million in 2010 (a 15% increase) and is projected to increase to 55 million in 2020 (a 36% increase for that decade). Add to this aging population explosion the acceleration of chronic diseases, including periodontal disease, and hygienists need to prepare for considerable localized/generalized blood-letting in their operatories in future. RDH

References

1. http://www.adha.org/downloads/JDH_Herbal_Supp.pdf
2. Johnson VB. Oral hygiene care for functionally dependent and cognitively impaired older adults. J of Gerontolog Nurs Nov. 2012; 38(11): 2012.
3. Renvert S, Persson RE, Persson GR. Tooth loss and periodontitis in older individuals. Results from the Swedish national study on aging and care. J Periodontol 2012 Oct 22. (Epub ahead of print).
4. Peterson PE, Ogawa H. The global burden of periodontal disease: towards integration with chronic disease prevention and control. Periodontol 2000 Oct. 2012; 60(1): 15-39.
5. Hyyppa TM, Koivikko A, Paunio KU. Studies on periodontal conditions in asthmatic children. Acta Odontol Scand. 1979; 37(1): 15-20.
6. Checchi L et al. The relationship between bleeding on probing and subgingival deposits. An endoscopical evaluation. The Open Dentistry J 2009; 3: 154-60.

LYNNE SLIM, RDH, BSDH, MSDH, is an awardwinning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodonta therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at periocdent@mindspring.com or www.periocdent.com.

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