Presenting Your Case

May 1, 1997
Case presentation ...dentists attend course after course to learn how to master it. Yet hygienists are never taught it. Case presentations are not a mystery. They are simply the art of allowing the patient to hear and to understand their problem, as well as how we can fix it (or control it). A case presentation puts the control back in your hands and gives the very best care possible to patients.

Solid verbal skills lay out the facts for periodontal treatment

Lynn Miller, RDH

Case presentation ...dentists attend course after course to learn how to master it. Yet hygienists are never taught it. Case presentations are not a mystery. They are simply the art of allowing the patient to hear and to understand their problem, as well as how we can fix it (or control it). A case presentation puts the control back in your hands and gives the very best care possible to patients.

Case presentations are much like properly sharpened instruments. Sharpened verbal skills expedite treatment plans and ensure the patients will really understand why they need the treatment that we are proposing. Instead of "thinking about it," patients dismiss the fears of pain, money, and ambiguity. They really understand what they need and ask for it.

If we don`t use sharpened verbal skills, 20 to 40 percent "think about it" and promise to call back later.

The process of presenting a case can take only 10 minutes or as long as 40 minutes, depending on the patient. So it is important to "classify" patients first, obtaining a "feel" for how much time will be required. As you practice and get more comfortable, the average time will be about 10 minutes.

Ten steps to case acceptance

Education and communication are the most vital stage of allowing our patients to completely understand their periodontal needs, as well as what treatment modalities are successful or unsuccessful. The process takes 10 to 15 minutes and should include:

- After taking 4 BWX (established patients should already have an FMX) and/or an FMX for new patients, show the patient the bone loss on the film. Study the film carefully before any probing is started. X-rays show what bone loss has already occurred and should be used to get a visual picture of what potential problems the patient has had.

- Explain pockets. Use the ADA`s "Don`t Wait Till it Hurts" brochure. Tell the patient to listen for "two" and "three" depths as being healthy, "three" and "four" as being pockets with bleeding (gingivitis), "four" and "five" as pockets with bleeding, infection, and bone loss. Then probe the entire mouth starting with the upper right disto-buccal.

- Classify the patient. Show the patients with a mirror, which areas are bleeding, the condition of the tissue, and any areas that have purulence or exudate.

- Always chart recession after probing. This is the only true way to get an accurate reading of the pocket. For example, if you have 2 mm of recession plus a 3 mm pocket, this equals 5 mm loss of attachment.

- Open the ADA`s pamphlet, "Don`t Wait Till it Hurts," go to page four, advising the patients of systemic and local factors contributing to periodontal disease. Examples are bruxing, hormonal changes, stress, hereditary factors, oral hygiene care, and dietary factors.

- Show the patient the phases of periodontal disease and explain to them which phase they are in. Explain to the patient what needs to be done to "arrest" the disease so that their bone loss does not get any worse.

- Always get the patient to sign the release form on the back of the periodontal probe sheet. Be sure they understand that what you are doing is not a prophy - or anything like it.

- Plant seeds of thought. If this is the first time the patient has heard that they have a periodontal infection, they need to know about the three- to four-month recall after the initial series of scaling and root planings. In addition, they might need a scaling and root planing again next year, as well as the three- to four-month recall. You can control the disease but you can`t cure it.

- Explain about how deep flossing gets into the sulcus (no more than 1 to 2 mm). Reiterate how thorough the scalings are. The scalings and root planing are necessary to ensure their pockets do not get any deeper. Their home care is an important adjunct to your scalings. Let the patient own the disease!

- Tell the patients three to four times (once to them, once to the doctor, and once when you walk the patient up to the front desk) about their disease and what will be necessary to get them on a maintenance program so that they are not losing any more bone.

Case Presentations

Learning to communicate effectively is the greatest skill a hygienist can possess. Practice your communication skills so that they become easy and comfortable when you are discussing periodontal disease, defective restorations, bruxing habits, or any other problems the patient might be having.

Let`s take a case where the patient has had bleeding and some problems in the past. The patient has four 6 mm pockets, and five 5 mm pockets with bleeding and spongy tissue.

You might say, for example, "Ms. Jones, I am finding that you have several infected areas in your mouth." (Hold up a mirror and show her the bleeding and edematous tissue.)

"What these pocket depths and bleeding are telling me is that you have bacteria in your pockets that is destroying more bone. This is why our parents and grandparents used to lose their teeth because we thought it was a natural occurrence. Today we know how to stop it, but I need to do a deep scaling, in this area. It will then be necessary for you to come back three more times for the other areas. Each time I will re-probe and possibly do some fine scaling on the last area. This is what we call non-surgical treatment.

"The procedures costs somewhere around $600. Our office manager will discuss that with you. My primary goal is to immediately stop this infection so that you do not lose any more bone. Periodontal surgery is much more expensive than $600 - it usually starts around $4,000 and that is what we are hopefully going to prevent if you begin therapy, do your brushing and flossing, and continue coming in. Periodontal disease is a lot like high blood pressure. You can get it under control, but it is never totally cured."

The patient may ask, "Why didn`t you ever tell me about this before?" It is important to allow the patient to own the disease - yet not make it your problem. Show them the ADA pamphlet, "Don`t Wait Till it Hurts," and explain exactly what stage the patient is in by the photographs. The contributing factors of periodontal disease on another page in the brochure. On yet other pages, explanations are provided for scaling and root planing. Give the brochure to the patient to take home with them.

You can add for dramatic emphasis, "When your gums are healthy, they hug the tooth like a rubber band to protect the underlying bone and root structure from invading bacteria, food debris, and toxins in your mouth. When your gums get infected, they no longer hug your tooth, and lose the elasticity. You have a barrier of tartar and bacteria on the roots of your teeth and gums. Your gums will not attach back to your teeth and get their healthy tone back until we remove this barrier of tartar and bacteria.

"I want you to know I have been watching this area for some time. I have recorded the depths of your pockets and documented them. I was concerned during the last several visits about your bleeding in this area. The bleeding shows us there is an active infection. I have been trying to be conservative in my treatment, hoping the infection would clear up. I know now that we need to take a more aggressive approach. Periodontal disease is a progressive disease caused by a bacterial invasion."

"I want to make sure your pockets do not get any deeper, that we stop the bacterial invasion and the bleeding. What we need to do is a scaling and root planing to complete the treatment. Would you like to get started today?

"In addition to what we are going to do today in the office, I would like to start you on 1,000 mg. of Vitamin C with Rose Hips. Vitamin C helps connective tissue heal, and this is what your gum tissue is made of. It will help your gums hug back to the tooth and help keep it healthier. Rose Hips help Vitamin C get into your system more easily. Vitamin C is a water-soluble vitamin and, without the Rose Hips, you can lose a lot of the Vitamin C.

"I am also giving you a sheet of home care instructions, which includes the Vitamin C. A lot of the healing process depends on if you floss before bedtime and brush at least three times a day."

If a periodontal scaling and root planing is started, call the patient before leaving the office to ask how they are feeling. Also ask if they have any questions concerning the periodontal program you have put them on.

What about the case where the patient has never had any serious problems, but is now bleeding? The patient may very well ask, "What has happened to me that I am getting this?"

After going over the ADA Brochure and charting, say, "Gum tissue can change and become infected in short periods of time. Your record doesn`t indicate gum disease present at your last visit. Have you been under stress? (Everyone always answers `yes` to this one) Sick? Change in hormones? Medication? Biting or grinding habits?" In this case, you might need to do only a therapeutic scaling and root planing (Code 4345). This code, though, needs a narrative before reimbursement.

Depending on the severity, bring the patient back for a prophy or re-evaluation for 10 minutes in two weeks. Go over all the educational information outlined in the first case above, including placing the patient on Vitamin C, and establish a three- to four-month recall, depending on the severity of the pockets and bleeding.

In another scenario, you note that the patient seems to be distressed at your recommendation. In response, go over the explanation described about the Vitamin C and home care.

You can add, "Some recent scientific studies show that these subtle signs are more serious than we thought and require immediate attention in order to stop you from losing any more bone around your teeth. I am concerned because you have an infection in your bone and gum tissue. I would like to start a scaling and root planing today. Would you rather wait?" ( I have never had a patient say, "Yes, I would rather wait.") Many times they seem distressed at you but they are just frightened about the disease."

A patient may also ask, "Why didn`t my previous dentist tell me about this?" In which case, you can respond, "Did the dentist or hygienist ever take the measurements of the pockets around your teeth that we just did? Well, if I hadn`t done those measurements, I wouldn`t have known either."

Or you may want to explain by saying, "Sometimes gum disease can be hard to diagnose. Dr. Jones tries to be very alert for early diagnosis. There is also a high probability this wasn`t here a couple of years ago. Dr. Smith is an excellent dentist. I am sure he would have told you if you had periodontal problems.

"Periodontal disease can progress very rapidly. I recommend that we watch these areas for a couple of weeks. Can you come back in two to three weeks? I just want to probe the pocket depths again to make sure the infection has cleared up. It won`t take but 10 minutes of your time. Then to make sure it does not get any worse, I would like to see you in three months." Always name the month. For example: "I would like to see you in November."

New hygienists in a practice may experience problems with established patients. A patient may ask, "Why didn`t Doris (the previous hygienist) tell me about this? She was very good, and I really trust her."

You can respond by stating, "Doris is an excellent hygienist, and these problems were noted at your last cleaning. But periodontal disease is a cyclical infection process, and I am sure the infection was not active at your last cleaning. I am very concerned because the heavy bleeding and pus I am getting today tells me you are losing the bone around your teeth. I am concerned about your health. I would like to have Dr. Jones look at this so we can determine a treatment plan to clear this infection up."

Note how many times the words "infection" or "losing bone around your teeth" were said. Do not use words like periodontal treatment, a little red, a little bleeding, etc. It`s important to "wake the patient up!"

Lynn Miller, RDH, is the owner of Lynn Miller & Associates, Inc., in Austin, Texas. The company is a practice management consulting firm. Ms. Miller is a member of the RDH editorial board. Please call (800) 435-3830 with questions about this article.

Protocol for hygiene case presentations

Step 1: Indices

After studying the patient`s x-rays, thoroughly examine and record on the periodontal probe sheet the following:

A. Bleeding Sites = Bleeding Index (B.I.)

B. Gingival Inflammation = Gingival Index (G.I.)

C. Plaque Scores = Plaque Index (P.I.)

Step 2: Periodontal

Do a complete periodontal charting. On the back of the periodontal probe sheet is a legend of how to chart each finding and recording information.

A. Record all pocket depths, including 1 - 3 mm.

B. Chart all gingival recession sites. Add the # of millimeters of gingival recession to the pocket depth. This equals the true attachment loss.

C. Record all bleeding sites found during periodontal probing by circling the pocket depth in red where the bleeding occurs.

D. Check and record all mobility.

E. Record any purulence or exudate (exudate can be found when scaling a deep pocket. Look for the little white streams or white "balls" in the blood. This is exudate.)

F. Check the x-rays (4 BWX should be taken every six months to one year) Is there vertical or horizontal bone loss or a bony defect on the x-rays? Is there involvement that shows up on the x-ray? Are there any changes since the last x-rays were taken? Does the bone level on the x-rays correlate with your periodontal probings today?

Step 3: Restorative and fissure sealants

Thoroughly examine the patient`s teeth for caries, overhanging margins, defects under crowns, root caries, leaking amalgams, or leaking composites while you are scaling. Also check for virgin teeth that need fissure sealants.

A. Always tell the patient what you are finding and note on the Treatment Summary Sheet.

B. Any suspicious areas should be brought up by the hygienist first. It is very difficult for a dentist to thoroughly examine a patient`s mouth during a periodic exam in the hygiene room. When done by the hygienist first, it is a win-win-win. The patient gets the best care, the dentist saves time, and the hygienist does not run behind!

C. Fissure Seal the teeth that need it today! If a tooth has a deep fissure, pit, or cingulum, suggest to the patient and the dentist that we put a fissure sealant in the tooth. Do not watch virgin teeth decay!

Step 4: Night guards and home whitening

Check teeth and gingivae for incisal wear and recession due to bruxing or clenching.

Look for wear facets on the cuspids, molars, or the upper and lower anterior teeth. If these are apparent, the patient needs a night guard. (Bruxing can contribute to periodontal disease, headaches, neck aches, and TMJ problems.)

A. Bruxing has now been found to cause or contribute to recession and periodontal disease.

B. Check for thickening of the lamina dura on the x-rays, which is a sign of bruxing or grinding.

C. Ask the patient if they ever wake up with headaches, neck aches, or ear aches.

D. Ask the patient if they grind or clench (most patients will say "no") but remember that 75 percent of all adults grind.

E. If bruxing is present, a hard splint should be made. If the patient is whitening, a soft suck-down night guard can be made to hold the whitening material in at night.

F. Take a shade guide of all patients. If the patient wants to bleach their teeth, make a soft suck-down night guard during bleaching procedures (two weeks only).

Step 5: Medication and Stress

Ask the patient if there is any medication they are taking that could dehydrate their mouth or contribute to their periodontal disease.

A. Antihistamines dehydrate the tissue. They slow the normal bodies defense from producing saliva and crevicular fluids.

B. Anti-depressants dehydrate the tissue. In addition, when a person is under stress, or depressed, they normally do not take care of themselves like they normally would. Stress has also been shown to stop the bodies natural absorption of vitamins and food by upsetting the gastro-intestinal tract.

C. High Blood Pressure Medications act as a diuretic, thinning the blood and alter the natural defense mechanisms in the red and white blood cells.

D. Dilantin or anti-seizure medications cause hypoplasia in the gingivae.

E. Birth control pills, or Hormones; any hormonal changes; puberty, pregnancy, changes of life, or nursing can contribute to gingivitis.

F. Diabetic patients: Diabetes impairs the bodies natural defense against anaerobic bacteria. Diabetes decreases the circulation to the extremities of the body, which lowers the defense mechanism against periodontal disease.

Golden Rules of Case Presentation

1. Love your patients` health more than they love themselves! Inform before you perform.

2. Integrity. Understand your material and then stand on what you believe and know to be the truth.

3. Honesty. "The truth shall set you free."

4. Educate and communicate!

5. Answer their questions and thank them for asking them.

6. Close the treatment plan with urgency and a question: "Would you like to get started today?"