A look at modern periodontics for the 21st century patient, with hygienist Sarah Holslag
The profession of periodontics is constantly changing, adapting to new technological advances and new information. Not only has the profession changed, but so have patients’ perspectives. Today’s patients are armed with information from the internet and they typically have much higher expectations than in the past. They ask questions, expect an up-to-date practice, both clinically and administratively, and are involved in the decision making process of their treatment. In order to serve the 21st-century patient, dental hygienists need to stay abreast of the changes that affect the provision of care in today’s environment.
Kill the frustration
We’ve all been there. Frustrated! It seems as though the periodontal treatment presentation portion of the hygiene visit often lends itself to increased stress. Tirelessly we try desperately to consider the patients current health status and identify risk factors, educate the patient, modify behaviour, scale supra and sub gingival calculus, remove all stain and plaque, perform and record periodontal evaluations, update radiographs, apply fluoride, identify restorative concerns, and so on, all in one appointment that lasts 40 to 60 minutes, if you get started on time! While there is not an easy fix to the common frustrations, there really are keys to make the partnership in diagnosis and case acceptance more valuable and less stressful for all concerned. Warning, however, some of these concepts may take you out of your comfort zone, and some may require practice, in order to go smoothly and feel natural [see box, far right].
Partnership in discovery and co-diagnosis
Patients must desire health – it cannot be forced upon them. The good news is that the vast majority of our patients really do desire and value health. Our role is to be a facilitator of discovery. It is the patient’s job to decide what level of health they choose for themselves. The most eloquent verbal, communication, and persuasive skills on our part are no substitute for a genuine desire on the patient’s part for the services we provide. We can involve the patient intellectually, as they carefully consider advantages and disadvantages of pursuing optimal periodontal, restorative and aesthetic health and they take ownership for their decisions. Emotionally, the patient becomes a partner, as they truly desire what we provide, and take necessary steps to obtain it. While clinical diagnosis is a critical element for achieving optimal clinical results, it is imperative that we not stop at the point of diagnosis, but rather be deliberate about involving the patient in their own discovery.
Most of us in the dental profession are here because we care about assisting others with achieving health. However, it is tragic if our patients lack the desire and motivation to take advantage of what can assist them in restoring teeth to ideal form and function, getting periodontal disease under control, and creating dramatic, beautiful smiles! Creating a partnership in discovery and co-diagnosis opens the door for patients to choose optimal dental health for themselves.
Don’t wait until the last five minutes!
Time management is a challenge in any service industry where you are taking care of patient’s health needs, answering their legitimate questions, and providing treatments within a wide range of clinical conditions. In most busy dental practices, waiting until the hygienist is completely finished before notifying the patient of their findings is almost a guarantee of running behind, as the patient is bound to questions and you will feel rushed to answer them. The end-result? Everybody waits, and soon a domino effect takes place within the schedule. A comprehensive periodontal examination was often considered the simple recording of pocket depths around teeth. Many times, this consisted of a cursory examination with a periodontal probe without actual pocket depths being recorded. Todays evaluation should be more comprehensive and on top of recording pocket depths, furcations, width of keratinised tissue, gingival recession, attachment levels, presence of plaque/biofilms, calculus, gingival inflammation, bleeding on probing and suppuration, it should also consider a patients current health status, including the presence or absence of a multitude of risk factors that are related to periodontal disease as well as a radiographic evaluation
Dental hygienists hold the key to a successful treatment plan in their hands. Many times, the patients first contact with actual therapy is with the dental hygienist. Dental hygienists gain knowledge from conversations with patients that contributes to the success of treatment, reduces apprehension, and helps develop trust. Dental hygienists are integral to periodontal maintenance programs developed after active treatment, which should include ongoing re-evaluation.
Don’t be wordy
Patients will understand and retain information significantly better if audible and visual learning takes place together. Instead of us doing all of the talking (while working on the patient) and them doing all the listening, we should intentionally let the pictures speak 1000 words for us. Dental professionals have a tendency to use terms that are too technical and describe more detail than most patients really need when relying on our own verbal skills to explain the need for treatment. Intraoral pictures, before and after pictures, educational pamphlets, radiographic pictures, etc, all assist in the co-discovery process.
Sit the patient upright
If ever you have been the patient in the dental chair you know what an uncomfortable position that is to carry on a conversation with someone who is seated above you. In fact, communication experts agree that as apprehension rises (as a result of someone with sharp instruments working in your mouth while lying on your back), listening ability diminishes. If you are willing to pause, sit the patient upright to describe conditions, discuss possible treatment, focus on the benefits to build value and use visuals, you will find you actually have to say less, because their ability to hear and retain information is significantly greater with the use of good eye contact and body positioning.
A prophylaxis appointment is not all the patient needs!
Ever wonder why the majority of adults have periodontal disease, yet the most common procedure provided in the hygiene department is still a prophylaxis? Perhaps it is because too often we are attempting to do too much in too little time, short of an actual diagnosis for what the patient really needs.
Prophy and periodontal maintenance are very different procedures for very different patient types that should be thoroughly understood so the appropriate procedure is provided.
Failure to do so can prevent optimal treatment outcomes and reduce the longevity of favourable results. Prophy is only provided for patients without periodontitis. It is primarily a supragingival procedure and is provided at six-month intervals.
Periodontal maintenance (PM) is distinctly different than prophy and is most commonly used for patients who have had active perio treatment. It is ongoing treatment for periodontitis, which is a chronic and non-curable bacterial infection. The objective of PM is to keep the disease under control. Any type of periodontal treatment is ineffective in the long term without an effective PM regimen.
Treatment should be dictated by the needs of the patient and the assessment by the practitioner. Many patients assume that periodontal therapy means surgical treatment, but advances in technology and a better understanding of the etiology of periodontal diseases have broadened the number of treatment approaches and modalities. Many of these procedures fall under the umbrella of dental hygiene.
Patient education, oral hygiene training, and counselling of risk factors such as stress, medical status and smoking are effectively handled and reinforced through conversations with patients.
Removal of supra and sub gingival bacterial plaque and biofilm and calculus through comprehensive, meticulous periodontal scaling and root planning is the primary responsibility of the dental hygienist.
• References available on request
A full version of this article is available in the May issue of Dental Hygiene & Therapy and is worth 1 hour of verifiable CPD. To subscribe, call Olivia on 01923 851735
Sarah Holslag is a dental hygienist and educational consultant with Hu-Friedy. A graduate of Tafe SA in South Australia with an Advanced Diploma of Oral Health (Dental Hygiene), she is embarking on the task of advanced education in dental hygiene, being the first Australian to be accepted into a Bachelor Programme in the USA. Sarah works in a high-tech cosmetic dental practice where she practises the management of complex periodontal cases, aesthetics, implants and the clinical application of lasers in soft tissue management.