Rejecting treatment recommendation

June 4, 2013
I completed four quadrants of periodontal scaling for a patient who was then referred to the periodontist for an evaluation. She has pockets ranging from five to more than nine millimeters.

by Dianne Glasscoe Watterson, RDH, BS, MBA

Dear Dianne,

I completed four quadrants of periodontal scaling for a patient who was then referred to the periodontist for an evaluation. She has pockets ranging from five to more than nine millimeters. The periodontist recommended treatment that included several extractions, bone grafting, and flaps. The patient never returned to the periodontist for treatment, but continues to return to me for periodontal maintenance visits every three months. How do I help this patient follow through with periodontal treatment? Or what should my next step be? It feels like I am doing SRP at every visit, and I'm out of tricks!

Heidi, RDH

Dear Heidi,

Your letter does not mention how much time elapsed between the completion of the periodontal scaling and the periodontal referral, nor does it mention the periodontal severity. I assume this was a severe case of periodontal disease based on the periodontist's recommendation of several extractions and other extensive periodontal treatment. Without seeing the patient personally, I can only speculate that this patient may have been better served by referring her for a periodontal evaluation prior to SRP. There seems to be no point in thorough periodontal debridement of teeth with a hopeless prognosis outside of removing gross deposits that might become lodged in the socket during extraction.

Evidently, the patient made the choice to refuse the periodontist's treatment recommendations. Informed refusal centers on the right of any competent adult to refuse any or all of the recommended treatment after being informed of the advantages, disadvantages, risks, and alternatives. The reasons for refusal are varied. She may have been intimidated by the scope of the work, the cost, inconvenience, or the fear of discomfort.

Knowing that periodontal disease is a microbial disease in the subgingival crevice, you have to understand that your efforts should be aimed toward microbial control. I believe it is important to underscore this fact, because many hygienists become so calculus-oriented that they forget they are fighting an enemy that cannot be seen by the unaided eye. Calculus does not cause periodontitis. It is secondary in the disease process. It is important to remove as much as possible, but the most important goal should be microbe control. Microbes live in places where calculus doesn't, such as on root surfaces with no calculus, embedded in the nonkeratinized subgingival tissue, and free-floating in the sulcus.

Always remember that periodontal disease begins in shallow sulci. Periodontal probing does not detect disease, and when you find bone loss, the disease is well established. Microbial analysis is the only way to detect disease in its earliest stages before bone destruction occurs.

If this was my patient, the next thing I would recommend would be a microbial analysis to determine which pathogenic microbes are present. Identifying the most putative pathogens helps to guide the selection of a systemic antibiotic or combination of antibiotics. There are several facilities that do this kind of live-microbe analysis:

  • Oral Microbiology Testing Service -- (800) 788-6687 Temple University
  • Oral Microbiology Testing Laboratory -- (213) 740-2012 University of Southern California
  • Oral Microbiology Laboratory -- (919) 966-2002 University of North Carolina
  • University of Pennsylvania -- (215) 898-5915

Another service that identifies microbes through salivary testing is OralDNA Labs ( This service identifies pathogens through DNA analysis and does not need live microbes. The analysis also suggests which antibiotic or antibiotic combination will be most effective against the patient's microbes. If the patient is a smoker, azithromycin has been shown to give better clinical outcomes than treatment without using this adjunct.

Another thing that is extremely important is the patient's homecare. It is imperative that you spend the proper amount of time with her teaching a customized homecare regimen. I would strongly suggest that the patient purchase a Waterpik for daily use. For advanced cases, some periodontists recommend a mixture of a half-teaspoon of common household bleach in a gallon of water for irrigation use. This is a good way to knock out more microbes. It is important for the patient to rinse the Waterpik with clear water after using the bleach mixture to minimize damage to internal tubing.

It has been proven many times in scientific studies that patients remove more biofilm with power brushes than with manual brushes. There are many good power brushes on the market that are available in retail stores, such as the Sonicare, Braun Oral-B, Waterpik Complete Care, and others. Another very good brush that is only distributed through dental offices is the Rotadent by Zila. It is important to have the patient bring her brush with her for her preventive appointment so you can work with her to improve the technique. Some patients have very poor dexterity, so one-on-one instruction is best. For a patient with severe periodontitis, you might need as much as an hour to devote to nothing but homecare in order to properly instruct the patient. After all, how much good have you done if all you did was remove the deposits from her teeth? If she is not clear on what she has to do at home to control her disease, your efforts are pointless.

It is also imperative that your patient learn how to use an interdental brush. Recently, I learned a new way to use a Proxabrush to help with root surface cleansing in deep pocket areas. The brush can be turned vertically and gently wiggled down into the pocket space for thorough cleaning. If you think about it, merely passing the brush horizontally through the interdental space does nothing to cleanse the subgingival root surface. The best interdental brushes for this application are those with the metal handle and replaceable brush.

Following along with your antimicrobial strategy, have your patient use baking soda on her brush instead of toothpaste. Baking soda has been shown to have antimicrobial properties. Also, teach your patient to cleanse her tongue with a tongue cleaner or a spoon, as the tongue harbors many microbes.

The clinical care you deliver should be primarily with power scaling, using an insert with a thin tip. Make sure you debride every square millimeter of the root surface using the side of the instrument. Following debridement, irrigate the sulci with povidone iodine in a small irrigating syringe. Povidone iodine is a potent antimicrobial that has been demonstrated to have about five weeks of efficacy. It has an unpleasant taste so you don't flood the mouth like you would if using chlorhexidine. A little goes a long way. I have also seen a mixture of povidone iodine and water used to cool the tip of the power scaler. This is a very efficient way of delivering the medicament to the base of the pocket.

I hope I've given you a few more tools for your treatment toolbox to use with this difficult periodontal patient. There are no guarantees, but one thing is sure – she must come every three months for professional disease control appointments with you. Otherwise, she is likely to lose her teeth over time. RDH

All the best,

DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. Dianne's new book, "The Consummate Dental Hygienist: Solutions for Challenging Workplace Issues," is now available on her website. To contact her for speaking or consulting, call (301) 874-5240 or email dglass [email protected]. Visit her website at

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