Mission Impossible

Nov. 1, 2004
Remember those exhausting and sometimes grueling clinical sessions in dental school and your relationships with various clinical instructors?

By Lynne H. Slim, RDH, BSDH, MSDH

Remember those exhausting and sometimes grueling clinical sessions in dental school and your relationships with various clinical instructors? The well-respected clinical faculty encouraged professional growth in a way that kept your independent spirit intact while teaching you not to be indifferent to the needs of your clients. Dentists are autonomous based on a well-deserved educational status in society, but they also are public servants whose clients trust them to knowingly do no harm. Clients want desperately to trust their dentists; they're not always looking for the techie-dentist with all the fancy gadgets; rather, they are seeking a professional to whom they can turn, then say to themselves, "Yes, I trust this person to do what is in my best interest."

Public trust of dentists' treatment plans is beginning to erode. To our dismay, even Hollywood pokes fun at the dental profession from time to time. In the 2003 movie "The Secret Lives of Dentists," one of the opening scenes is telling. A dentist examines a new adult client and comments on a migrating wisdom tooth. "It better be cheap, that's all I can say," says the client. The dentist then asks, "Why is that?" to which the client responds, "Because five years from now some other guy is going to have to re-do all of your work."

Clients, who are more insurance-driven than ever, are skeptical of expensive treatment plans, especially those that include nonsurgical periodontal treatment. After all, periodontal care is subject to a deductible and a co-payment, and many times a client's insurance allotment for a calendar year is used up with scaling and root planing alone. It is only right and ethical to perform a comprehensive clinical assessment on each new adult client as long as "comprehensive" is meaningful, and a resulting diagnosis and appropriate treatment plan are included.

Nonsurgical periodontal treatment has emerged as the treatment of choice for the majority of clients who present with periodontitis. Increasingly, the use of anti-infective or host-modulating pharmacological agents or both as adjuncts to nonsurgical therapy is enhancing the outcome of such therapy, making surgery a poor second choice. Moreover, there now exists evidence showing strong links between systemic and periodontal health — that systemic health depends on periodontal health. These reasons make a more compelling argument for a definitive periodontal diagnosis and treatment plan.

What can you offer your clients in response to the ethical challenges that surround our profession? Besides "gold standard" restorative treatment and service, why not make definitive periodontal diagnosis a top priority? Add to your mission statement a sentence or two about a moral obligation to emphasize total health through the promotion of oral health and wellness. Here's an example of a mission statement that incorporates this philosophy: We believe that a client's oral wellness contributes to his quality of life and, therefore, we value comprehensive care for all of our clients.

Here's another one that is effective, but has a slightly different emphasis: Our mission is to provide world-class dental care that includes an anti-infective approach to the prevention and treatment of dental caries and periodontal diseases.

Initial client assessment

In too many general practices, a clinical periodontal assessment consists of a set of horizontal bitewing radiographs, a panoramic film, and full-mouth probing. Perhaps, in your defense, this is what you and your team have been trained to do as part of a soft-tissue management program. Companies that provide soft-tissue management training may be interested more in a profit motive than in supporting individualized and synthesized data collection. What does a comprehensive clinical assessment include? At a minimum, it involves a detailed medical and dental history that includes asking relevant questions, a full set of periapical radiographs and vertical bitewings, full-mouth, circumferential probing along with a determination of clinical attachment loss and an assessment of mobility, furcation involvement, bleeding on probing, and recession. Trauma from occlusion, pathologic migration of teeth, and functional occlusal relationships also play important roles. The list presented here is not compulsory and should be customized. A new diagnostic tool called the PreViser Risk Calculator is an affordable periodontal disease risk indicator that can be added to your diagnostic armamentarium. The PreViser Risk Calculator creates an easy-to-use risk analysis report for individual clients that can be sent home with clients along with a computer-generated periodontal chart.

Don't let the new adult client leave your office without making a periodontal diagnosis. An easy way to combine periodontal screening and the more definitive comprehensive exam is to incorporate the screening exam into the D0150 comprehensive exam. If a preliminary diagnosis of periodontitis is made, the client can be re-scheduled with the dental hygienist or dentist for a D0180 comprehensive periodontal exam. After the preliminary diagnosis, send the new adult client home with a pre-printed kit called a periodontal screening kit and include a brochure on periodontal diseases, information about nonsurgical treatment, and anything else you think might be appropriate. Delegate the development of the pre-printed packet to your dental hygienist. A well-educated, motivated hygienist will appreciate the challenge.

In recent years, the concept of dental hygiene profit centers has emerged. The notion of creating dental hygiene profit centers is repugnant to many dental professionals and smacks of the American obsession with commercialism that is sometimes inappropriately applied to the delivery of oral health care services. Let's remove this distasteful and unethical term and re-focus on the delivery of client-centered needs instead. Yes, general dental practices need to be profitable and must merge the values of the new with values of the old. Nevertheless, if accomplished in an ethical manner, solid profits and consistent growth of the practice will prevail.

Dr. L.D. Pankey, founder of the Pankey Institute, wrote in 1952 that financial success in dental practice would surely follow if dentists provided high-quality, optimal, and ethical treatment. Even more important, Pankey, who based his practice philosophy on Aristotle's teachings, emphasized living a happy, well-balanced life. Dental hygiene profit centers, as a practice goal, represent the antithesis of the Pankey philosophy and to the notion of giving one's best in a caring, comprehensive manner.

Develop a client-centered hygiene department

How does one begin to create a client-centered dental hygiene department? In addition to a comprehensive clinical assessment, the dentist/hygienist/assistant team must understand the significance of evidence-based decision making. Evidence-based periodontics requires a scientific basis for treatment. Decisions are based on a compilation of scientific findings, and not on the successful marketing hype of pharmaceutical companies. In developing an evidence-based approach to the assessment and treatment planning of gingival and periodontal diseases, it is essential for the clinical team to:

1) Make a commitment to take continuing-education courses in periodontics together, and stay abreast of current philosophy procedures, products, and techniques in periodontics. When attending a seminar, don't always accept a speaker's word as gospel. Pay attention to whether the speaker is unbiased and credentialed and that sponsorships and other relationships with private industry are fully disclosed.

2) Read the American Academy of Periodontology, or AAP, position papers and parameters of care on important issues and apply these parameters to your practice.

3) Consider a subscription to Perio Reports, a bi-monthly newsletter that provides summaries of relevant periodontal and preventive dentistry research.

4) Make sure the entire team has a complete understanding of what evidence-based dentistry is and is not. Read about evidence-based dentistry online and include your referring periodontist and members of a local study club in this particular discussion.

5) Read ADA's Guide to Dental Therapeutics, which gives an evidence-based rationale for using new and current drugs.

6) Teach yourselves to critically analyze dental literature so you can learn to separate fact from fiction.

7) Get to know your local periodontist and make him or her an important part of your team. Ask your referring periodontist to assist you in developing your non-surgical periodontal therapy protocol, including the appropriate use of local and systemic chemotherapeutic agents.

8) If you have more than one choice for a periodontist who will become part of your team support system, choose a periodontist who:

a) matches your practice philosophy and supports the level of non-surgical periodontal care you prefer to treat before considering a referral;

b) communicates fully and faxes you relevant client information including charting and treatment plans;

c) insists on three-month alternating recall beginning at the time of referral.

Criteria for referral to a periodontist

Here's another stinging patient encounter: "Doctor, I appreciate your telling me that I have a serious gum infection, but I am not going to see a specialist. I don't want to have my gums cut, and I can't afford it anyway." How do you respond to your client's statement? Do you pat him on the back and give in, or do you do all you can to persuade the client to see a periodontist, especially in light of advanced infection?

In pondering this question, I recently asked my personal internist about referring clients to a specialist when the need arises. "Lynne," she said in her distinctive Irish brogue, "how could I not? My patients trust me to keep them healthy." This particular health professional believes in "doing the right thing" by her clients and individualizes her treatment recommendations.

Referral to a periodontist in today's competitive dental practice environment is tricky. Perhaps partly as a result of the 1997 "Reader's Digest" article titled "How Honest are Dentists?" clients are more cautious about treatment recommendations and worry that dentists are always trying to sell unnecessary treatment. To that end, it behooves all dentist/hygienist teams to have a written protocol for nonsurgical periodontal therapy based on disease type and another document titled "Consultation and Criteria for Referral to a Periodontist." The writing of this particular referral document can become a creative team exercise that can be developed with input from the entire team. The table at right contains a sample referral protocol that was developed jointly by a large group dental practice team in consultation with a local periodontist.

What if your patient refuses to see a periodontist? Should you lose sleep over Mr. Smith's tooth No. 8 with severe periodontitis and deepening probing depths who wants to adopt the wait-and-see attitude until he gets his next bonus check (which may not be for another five years)? In this instance, document in writing your referral and include a localized diagnosis in your treatment notes.

The dentist/hygienist/assistant team can mimic Dr. Phil and "get real" about other aspects of care that clients care deeply about. Educating your clients about oral cancer and dental caries prevention are equally important to total wellness, and there are many creative avenues available to you to build unequalled client confidence and respect.

More than 2,500 years ago, the dentist's first responsibility was spelled out clearly in the form of the Hippocratic Oath of the Greek Physician: primum non nucere — "Above all, do no harm."

Develop a client-centered dental hygiene department that includes diagnosing and treating early to moderate periodontitis nonsurgically and referring clients to a periodontist according to a given set of criteria.

These valuable priorities will enhance your professional status and earn your clients' trust. Let your conscience be your guide, refer when appropriate, and keep your moral compass intact.

& Referral Criteria:

The following criteria are not exhaustive. The dentist's professional judgment is always required in any decision requiring a consultation from a specialist.

1) Atypical, non-plaque induced gingival lesions in which a definitive, differential diagnosis and treatment regimen are required.
2) Clients with chronic periodontitis who are experiencing periods of rapid attachment loss and bone destruction. (Includes clients with dental implants.)
3) Clients with chronic periodontitis with detect-able (radiographic and clinical) furcation involvement.
4) Clients with aggressive periodontitis (adults and children) in which there is rapid attachment loss and bone destruction.
5) Clients with known systemic and immune dysfunction who present with necrotizing ulcerative periodontitis.
6) Clients who present with frequent periodontal abscesses.
7) Perio/endo lesions in which an endodontic lesion has been ruled out.
8) Mucogingival deformities

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