My love affair with periodontal disease

Oct. 1, 1999
One of the most professionally rewarding aspects of clinical hygiene is the treatment of periodontal disease. Taking a patient from a diseased state to a state of good health over a series of appointments gives a hygienist the feeling of success that cannot be achieved by just performing routine prophylaxis duties. In fact, I`ll go a step further and say that if I didn`t ever get to tackle any tough periodontal cases, I`d probably be bored silly.

The challenge of treatment can spark a true romance.

Dianne Glasscoe, RDH, BS

One of the most professionally rewarding aspects of clinical hygiene is the treatment of periodontal disease. Taking a patient from a diseased state to a state of good health over a series of appointments gives a hygienist the feeling of success that cannot be achieved by just performing routine prophylaxis duties. In fact, I`ll go a step further and say that if I didn`t ever get to tackle any tough periodontal cases, I`d probably be bored silly.

How I love the challenge of a Class III or IV patient! Call me weird, but all that calculus and bleeding just gives me a thrill, because I know that, when I`m finished with this patient, he will be different. He will be better. He will understand the disease process at work in his mouth. Through a joint coalition that he and I form, we will fight the battle together to control the disease that seeks to rob him of his teeth.

It only takes one successful periodontal experience to make a hygienist feel like I do. When you witness the gradual turnaround in the condition of the tissue from diseased to healthy - and your patient can actually see and feel the difference treatment makes - the success is intoxicating. You want more successes. And with each success, you become a better hygienist.

So, what does it take to have periodontal successes? Basically, it takes three things:

* a comprehensive periodontal therapy treatment program

* a motivated, enthusiastic hygienist

* an astute, motivated doctor

Many general dentistry offices do not have an organized periodontal treatment protocol. Patients often are judged at face value. No periodontal charting or comprehensive exams by the doctor are conducted. New patients are scheduled with the hygienist, and the idea is that they are going to get their teeth "cleaned."

But what happens when patients present with periodontal disease? A routine prophylaxis is not the best treatment for these patients. In fact, it can be detrimental in several ways. First, if only gross calculus is removed, the tissue response will be a tightening of the tissues at the gingival margin, creating a "pressure cooker" of pathogens deeper in the pocket. This is an open invitation for a periodontal abscess.

Second, if patients are unaware of the disease process at work in their mouths and the hygienist is not able to fulfill the patients` expectations (a cleaning in one visit), the patient may feel the hygienist is not a competent clinician.

Third, if periodontal treatment is initiated without the patient being fully aware of the disease process and the implications of postponing or avoiding treatment, the patient may feel the doctor is only after financial gain and not really interested in him as a patient. The patient most probably will fail to understand why his bill for that day was $120 for a quadrant scaling.

Any of these scenarios is reason enough for having an organized method of identifying periodontal disease, classifying severity, and treating the disease based upon established protocol.

The identification process of the periodontal patient begins during the first phone call received by the front desk.

Patient: "This is Jean Smith. I`d like to make an appointment to get my teeth cleaned."

Business assistant: (not recognizing this patient`s name) "Could you tell me when you last visited our office?" Notice, the business assistant doesn`t say, "Are you a patient here?" With so many patients to remember, it is easy to forget someone, especially someone who has not been in for awhile. However, patients do not want to feel they have been forgotten. If I were a patient who visited the practice during the past year, I would be offended if I was asked this question. After all, I`ve given them lots of my hard-earned money! The least they can do is remember me.

Upon determining that this is a new patient, the assistant is ready to ask the next question.

Business assistant: "Could you tell me when you last visited a dentist?" If patients say that they had a dental visit less than nine months ago, it is "fairly" safe to assume patients have had regular care. Patients sometimes will volunteer information regarding routine care. If patients indicate that several years have elapsed since their last visit, they need to see the doctor first for a comprehensive exam.

Business assistant: "Are you having any dental problems at this time?" Of course, if the person is in pain, the problems have to be addressed first. If no problems are stated, it may be appropriate to schedule the patient first with the hygienist. The idea is to discover if patients have had regular care and are just switching dentists or if they are dental cripples (or phobics) with lots of dental needs.

The hygienist`s role

It is my feeling that all new adult patients should be scheduled first with the doctor. It is, after all, the doctor`s obligation to diagnose any dental disease that may be present. It is truly wonderful when the patient has been thoroughly assessed, charted, and classified before being sent to the hygiene department. The radiographs have already been taken and the patient is fully aware that she is in the hygienist`s chair to begin periodontal therapy. All the hygienist has to do is begin the education and therapy.

However, many doctors` schedules do not allow time for new patient exams. Indeed, the schedule may be booked solid for two to four months in advance. Out of necessity, new patients are scheduled first with the hygienist.

So what do most hygienists do when they get a new patient with lots of debris and periodontal problems? Without any further ado, they grab the ultrasonic scaler and proceed "off to the races!" Gotta work fast, not much time, gotta get this stuff off, hurry, hurry, hurry! Finally, when the doctor comes in to do the little two-minute quickie exam, the hygienist is patting herself on the back for getting so much done in such a short time! Wrong, wrong, wrong!

Here`s what I recommend if you are a hygienist in an office that places new patients in hygiene first.

* Seat patient, review medical history, inquire about concerns.

* Before reclining patient, take a quick tour of the mouth. If heavy debris is obvious, proceed with FMX. If not, take four vertical bite-wing films.

* While films are developing, do full perio charting, if possible. If the debris is so heavy that probing is difficult, delay further probing until anesthesia is given at quadrant scaling appointments. However, do attempt to classify this patient.

* Go and ask doctor to come and confirm your findings. The doctor can announce the diagnosis of periodontal disease. At this point, the doctor may want to talk to the patient or further discussion can be left completely up to the hygienist. The patient should also be charted for restorative needs at this time.

* If restorative needs are great, a separate consultation appointment will be needed. However, patients must understand that restorative concerns cannot be addressed until their periodontal disease is treated and brought under control. No one but a foolish person would build a building on a crumbling foundation.

I have been in the awkward situation of seeing a new patient who presents with periodontal disease. Here`s the conversation: "Mrs. Jones, from what I see and from what the X-rays show, there are some concerns about your gums that I want the doctor to see first."

I push back from the chair and get the doctor. After the doctor has made the diagnosis, you may begin to educate your patient about the disease process. "Mrs. Jones, have you ever heard of pyorrhea? It is a bacterial infection in your gums that attacks the bone around your teeth. If left untreated, the bone deteriorates so much that the teeth become loose. Most people are unaware that this disease is present, because it is usually not painful until the later stages of the disease.

"A regular cleaning will not help you. In fact, it could cause quite a bit of discomfort. This disease is treatable, though, so I think we will be able to help you."

Patients may then ask you what causes the disease or if they are going to lose their teeth. I`ve had patients ask me why the disease was not diagnosed earlier, especially if they were active in another office. These are all legitimate concerns. You must answer their questions to the best of your ability, but never disparage another health professional to your patients.

"The disease itself is not inherited, but sometimes the tendency can be present in families. The good news is that periodontal disease is usually slow-moving and quite treatable. We are here to help you keep your teeth for as long as you need them!" You become patients` best ally in attacking their disease.

Notice I said `their` disease. Until patients take ownership of the problem, they will take no action. In a previously discussed scenario when the hygienist quickly goes to work scaling, patients are not given an opportunity to take possession of their problem. They have brought the problem to you, the hygienist, and you quickly took possession. But when patients take possession, they see you in a different light. Patients who understand the ramifications of the disease are anxious to get started with treatment and rarely miss appointments.

"The deposits (called tartar) that have built up on the root surfaces of your teeth are quite hard and tenacious. These deposits are like a coral reef in the ocean where marine life hides and lives. All kinds of nasty bacteria live and hide in and around this tartar. Our therapy will involve getting rid of all those deposits, thereby eliminating hiding places and breeding ground for bacteria.

"Throughout the course of our therapy, I will ask you to do some things concerning your home care that you haven`t done in the past. If you will do what I ask of you, our chances of success are great. However, if you don`t, we will not be able to achieve the result that we hope for and the disease will not be controlled.

"Periodontal disease is a little like diabetes, in that we don`t use the word `cured.` We attempt to bring the disease under control and stop the progression of bone loss. With treatment, many people are able to stop the disease and save their teeth."

When periodontitis is present, I always tell them, "Each patient is different. Some get better results than others. If we find that your gums are not responding to our treatment, it may be necessary to refer you to a gum specialist called a periodontist for further treatment."

Home care protocol should be based on the individual patient. We have all kinds of tools at our disposal: interdental brushes, floss, various interdental picks, power brushes, and chemical agents. However, it is never wise to overwhelm patients with too much information or too many tasks at one time.

One of my goals in periodontal therapy is to get the patient to use some type of interdental cleaner on a daily basis. While dental floss is the standard, it is not always the best choice. For patients who have wide embrasures, interdental brushes are far superior. If you need proof, just disclose the plaque and try to remove it with floss. You will find that the brush works better. If I decide that floss is the best choice, I only teach one quadrant at a time. If I scale the maxillary right quadrant first, I instruct the patient to floss only that quadrant. Then, on successive appointments, I add a quadrant and check their technique.

People with limited dexterity or large hands may find floss too difficult. For these patients, interdental picks work better.

In addition, I have had good success using power brushes. I find patients are a little more willing to spend time with their brushing with a power brush than with a manual brush, not to mention that they remove more plaque. To be successful, the brush should be dispensed from the office, and the hygienist should teach patients how to use it. Patients should be instructed to bring the brush with them on successive visits during periodontal therapy for review and reinforcement.

Most Type III and IV patients are quite phobic about dental offices. Their fears have caused them to shun any treatment for long periods of time, thereby exacerbating their periodontal condition. It is the hygienist`s responsibility to treat these people with the utmost care and as pain-free as is humanly possible. Use whatever it takes: nitrous, local anesthesia, topicals (especially those that you can squirt into the sulcus), stereo headphones, a warm blanket, and frequent breaks. If patients know that you care for them as a person, as well as a patient, you will win them over. That patient will become a good, compliant patient. And, by all means, call your perio patients at home after you have seen them that day just to check on them. Your patients will appreciate this act of kindness.

The doctor`s role

To have a successful program, the doctor must recognize the value of periodontal therapy as opposed to routine scaling. A different mindset must evolve regarding how periodontal disease is approached and subsequently treated. Old habits are hard to break! Even though many doctors desire to have a comprehensive periodontal treatment program, they are not willing to put forth the necessary effort to change their own routine. Just getting some busy doctors to slow down long enough to diagnose the disease can be a major undertaking!

Doctors need to see their hygienists as "co-therapists" in patient treatment. After all, establishing a firm foundation on which to build future restorative or cosmetic dentistry is a necessity for long-term success. What I see all too often is a hygienist on a prophy treadmill with little or no time allotted for serious periodontal therapy - therapy that places as much emphasis on education and behavioral change as periodontal scaling and root planing.

The doctor`s primary responsibility is to diagnose periodontal disease through 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. Also, existing restorations and 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. However, the good news is that I think we can help you by treating this problem in a conservative, non-surgical way. Our hygienist, _______, has good success in most cases with this therapy. (He/she) will be spending some time helping you understand the disease process and how to control it, as well as providing your gum treatment. Your periodontal therapy will take _____ appointments, and the fee will be _______. Do you have any questions you`d like to ask me? Is there any reason not to get started as soon as possible?"

Financial concerns are then referred to the financial coordinator. For the doctor and hygienist, please remember to set the chair in an upright position and look at the patient eye-to-eye when talking about dental concerns. Do not talk with your back to the patient, and do not talk to the chart. Your tone of voice should be friendly and controlled, not curt and rushed.

For a successful periodontal program to be carried out in any dental office, the doctor and hygienist must be "on the same page" with regard to protocol. Take some time to discuss what changes will be needed to institute this type of patient treatment in your practice. You will find that the financial and professional rewards are well worth the extra effort!

Dianne Glasscoe, RDH, BS, is an adjunct clinical hygiene instructor at Guilford Technical Community College. She holds a bachelor`s degree in human resource management and is a practice management consultant, writer, and speaker. She may be contacted by e-mail at [email protected], phone at (336) 472-3515, or by fax at (336) 472-5567.

Classifying the patient

The American Academy of Periodontology classification system should be the standard in any general practice. By categorizing patients, a clear understanding can be drawn as to severity, number of appointments needed for treatment, and cost of treatment. This provides the doctor, the hygienist, and the patient with a "road map" for the treatment journey.

Here are the categories and my recommendations for treatment:

Type I - Healthy

Tissue is firm, pink, and stippled, and no probings record deeper than 3 mm. One appointment (Code 1110).

Type 2 - Gingivitis

The disease is characterized by inflammation due to an accumulation of gingival plaque and calculus - no bone loss.

First appointment: Disclose; TBI; floss instructions; educate about problems associated with plaque; stress importance of good home care; and full debridement with Cavitron. Forty minutes (Code 4355)

Second appointment: Disclose; review any home care procedure that is not demonstrated properly; fine scaling, polish; and establish appropriate recare. Forty minutes (Code 1110).

(Optional approach, depending upon disease severity)

First appointment: Disclose; TBI; floss instruction; educate about problems associated with plaque; stress importance of good home care; and right-side scaling complete. Fifty minutes (Code 4341).

Second appointment: Disclose; review any home care procedure that is not demonstrated properly; and left-side scaling complete. Fifty minutes (Code 4341, but adjust fee since no local was used).

Type 3 - Early Periodontitis

The progression of the gingival inflammation has moved into the deeper periodontal structures and alveolar bone crest with slight bone loss.

First appointment: Disclose; TBI; educate about progression of disease; right-side scaling with or without anesthesia (may be able to use topical in sulcus); and irrigate with chlorhexidine. Also, if bitewings were taken on exam, finish out with periapicals to make a FMS (Code 330). Sixty minutes (Code 4341).

Second appointment: Disclose; reinforce home care; left-side scaling (anesthesia as needed); and irrigate with chlorhexidine. Sixty minutes (Code 4341).

Third appointment: Disclose; check scaling; polish; and establish appropriate recare interval (recare should be coded 4910). Forty minutes (Code 1110).

Type 4 - Moderate/Severe Periodontitis

A more advanced state of the Type 3 condition, increased destruction of the periodontal structures has occurred, as well as a noticeable loss of bone support - possibly accompanied by an increase in tooth mobility.

First appointment: Take FMS (14 periapicals to add to bitewings taken at exam). If the patient has a full complement of teeth, no scaling should be done at this appointment. However, if there is a quadrant that has few teeth, this quadrant may be scaled at this appointment with anesthesia. Disclose; TBI; and educate about disease process. Sixty minutes (Code 4341).

Second appointment: Disclose; review home care; quadrant scaling with anesthesia; and flossing instructions or interdental aids in scaled quadrants. Only 60 minutes (Code 4341).

Third appointment: Disclose; review home care; and quadrant scaling with anesthesia. Sixty minutes (Code 4341).

Fourth appointment: Disclose; review home care; and quadrant scaling with anesthesia. Sixty minutes (Code 4341).

Fifth appointment: Final check and polish; and establish appropriate recare (recare should be coded 4910). Forty minutes (Code 1110).

Please keep in mind that these are my recommendations only. Each patient should have treatment planned according to specific needs. However, this program is used quite successfully in a number of general dental practices for classifying and treating periodontal disease.