In January, 1997, Bob Levoy, management
consultant for almost 3 decades, will have published a new text on practice development.
It is one of his precepts for today’s practices that to stand out in the marketplace
the individual practitioner must communicate an image of quality by demonstrating to
patients that his or her practice has a sophisticated awareness of periodontal disease. It
is this quality image which distinguishes practices in patients’ eyes and we hope
this newsletter can serve as a guideline for your practice as you strive to stand out by
the quality of your periodontal awareness to them.
Although your patients may seldom mention to
you their wonders about their own periodontal condition they are constantly being
bombarded with product advertisements for agents to help prevent periodontal disease.
Periodontal disease is portrayed as the same threat to the mouth that aliens are to humans
in a science fiction movie. Market surveys show a rising awareness of periodontal disease
among the population and feelings of risk marked by increased product sales, the ultimate
bottom line for manufacturers. Often this translates for dental practices into dealing
with increase anxiety among patients which causes actions running the gamut from avoiding
the subject to being paranoid about the problem. Patients are silently looking for
information about their own periodontal condition. They hope they don’t have
periodontal disease, but if they do they want to feel assured that their doctor will find
it and intercede successfully to resolve it.
The most trust-producing approach to
people’s unasked questions about periodontal disease is to demonstrate an
attentiveness to it, even before they ask. Since people gauge attentiveness in
dental practices by the time spent and intensity (thoroughness) of the process a
consistent, multileveled approach to periodontal diagnosis and treatment will not only be
most productive, but will also have the largest personal impact on patients.
A multileveled approach to communicating
practice quality through periodontal awareness would include:
Periodontal disease screening for all new patients and those recall patients who have
previously been found to be free of disease.
A comprehensive periodontal examination for those patients showing periodontal disease
screening scores which indicate the presence of periodontitis. This includes both new
patients and recall patients who have not previously had a full periodontal charting.
In-office initial preparation (if your office has chosen to provide these services), a
specific visit for evaluation of your in-office initial preparation results, and referral
criteria established and applied to patients who show active periodontal disease.
A tiered approach to periodontal supportive therapy which distinguishes between those
who require only prophylaxis, those who require supportive therapy for stable periodontal
conditions and those who need more intensive supportive care when compromised periodontal
conditions cannot be more fully treated.
Seeing this tiered approach to care,
patients grasp the practice’s dedication to people’s periodontal needs. They
view the practice as capable of providing valuable information and just the right
solutions for them. What creates the image of quality is, in addition to this tiered
approach, the way in which the visits are conducted. When new patients being received into
the practice, maintenance patients without prior periodontal chartings, or maintenance
patients without a history of periodontal disease are seen, a screening examination should
be first used to rapidly determine the level of need for additional periodontal care. In
many practices the hygienist will assume responsibility for this task with new patients,
but the screening process should be explained to each patient as it’s performed. The
American Academy of Periodontology has a complete screening system which recommends
tracing each tooth to find pockets, but only recording a single number for each segment of
the mouth which indicates the deepest pocketing found in the segment. We would be happy to
assist you in using this system. Regardless of the system used, periodontal examination,
including full periodontal charting, should be employed with patients whose pocket depths
exceed 4mm in more than one quadrant.
The full periodontal examination can be
completed as part of a comprehensive examination or be separated to be provided as an
individual service. Many practices recommend a full new patient examination for patients
of record who have a periodontal need and have not had a comprehensive examination in the
past five years.
To further convey to patients the image of
quality, the examination should be both detailed and systematic. The practitioner and
his/her assistant should utilize a repeatable sequence of examination which allows the
practitioner to report findings to the assistant and to have the assistant code the
findings in a central location in the patient’s record. When patients both see and
hear doctor and assistant efforts, they know each fulfills a role highly focused on
discovery of information. The patient gains confidence in the process and the office. They
themselves become focused on the information being gathered with the result that they are
more inquisitive about their own mouth. When patient’s begin to question you it is a
prime indication that they have become involved in seeking a solution and that trust is
being developed.
Here is a sequence of clinical examination
incorporating several levels which insures that no periodontal impact will be overlooked
during examination:
Oral Pathology Level – screen for soft tissue lesions
Pre-restorative Level – record missing teeth, existing restorations, open
contacts, extrusions and rotations of teeth.
Periodontal Status Level – test mobility, check for furcation involvement,
subgingival calculus, overhangs on restorations, root grooves and level of gingival
inflammation. This portion of the exam is often best done by tracing the sulcus base
around each tooth with an explorer.
Support Recording and Disease Activity Level – record six probing depths on each
tooth and indicate those measurements which bleed by circling the probing depth. The
process is often facilitated by recording all the facial or lingual pocket depths in one
arch (including recession areas), circling those areas which bleed upon probing, then
repeating the process on the opposite surface of the same arch before switching arches.
Interarch Relations and Occlusal Function Level – record occlusal function,
TMJ-status and arch relationships which impact restorative or orthodontic needs.
Radiological Review Level – confirm clinical findings with radiographs. This
assessment may be performed prior to the clinical steps if films are available.
For the practice which performs initial
preparation procedures, it is important to decide what levels of periodontal disease will
be referred initially and what post-initial periodontal preparation conditions will be
recommended for advanced care. When levels of disease have been established for referring
advanced care, patients can be advised of this potential by all staff members providing
treatment. This insures that patients will receive a consistent message. In addition the
practitioner has less difficulty presenting other forms of care when an ideal result
isn’t obtained with initial treatment or trial maintenance. This consistency of
standards builds integrity with patients which is a basis for belief in the office’s
treatment recommendations, periodontal or otherwise.
For a long time, the dental profession had
an all or nothing approach to periodontal care, often placing those patients who had
advanced problems but refused specialist care into the maintenance program. Hygiene care
for those patients was much more difficult when pockets needed to be cleaned out in
addition to prophylaxis completed. This was a burden to the hygiene staff and often
patients assumed they were okay. Evolving now in the periodontal community is a tiered
approach to care. One where prophylaxis is provided to patients with minimal periodontal
involvement, periodontal supportive therapy to patients who have been treated for
periodontal disease and their involvement is stable even if residual deformities remain,
and compromise supportive periodontal therapy for those whose disease is still active. At
each of these levels the focus of care is different. The prophylaxis patient will be
screened for periodontal involvement, but the primary emphasis will be home care and
coronal debridement. The periodontal supportive therapy patient will be monitored for
deepening or residual stable pocket areas, the subgingival regions debrided as a primary
focus, home care and coronal debridement effected. The intensive supportive therapy
patient receives assessment, perhaps anesthesia, subgingival pocket debridement including
smoothing of root surfaces, and counseling regarding actions and potential outcomes of
additional care. Since actions by the dentist and his team require greater skill and
effort as the care becomes more intensive, both fees and time regimens as well as recall
intervals may be changed for these different patient groups. In this manner each patient
becomes aware of their status at each recall. Those who are struggling become aware of it
and are less likely to be overlooked in the day to day activity of busy practices, popping
up with advanced problems at a later date.
When your patients see a consistent program
in which their periodontal status is a primary consideration and care is tailored to their
individual situation they will assign a higher image of practice quality to your practice.
Helping patients to openly communicate their wonders and fears makes for good decisions on
your patient’s part. And lastly, reinforcing their good decisions help them see a
potential for successfully saving their teeth. This leads to a higher level of trust in
other practice recommendations as well.
If you would like to further refine your
in-office periodontal awareness program we would welcome the opportunity to provide
assistance.
