My question concerns new patients. I prefer to have new adult patients scheduled with the hygienist first in order to gather all preliminary data, but questions have arisen about how to handle new patients presenting with periodontitis. My hygienist feels we should not start off with a prophy, but rather go directly to deep cleaning. What do you think?
— Dr. Joe
Dear Dr. Joe,
I understand why you prefer to have new adult patients come through hygiene first because hygienists are very adept at gathering data and making assessments. However, if a new patient presents with periodontal problems that will require definitive periodontal therapy, you should be the one who breaks this news to the patient; i.e., delivers the diagnosis. Let me suggest a strategy.
For our purposes, let’s say that the new patient is a Class III moderate periodontitis case type with pocketing in the 6 mm to 7 mm range. There is moderately heavy supra- and subgingival calculus. There may be furcation involvement and Class I mobility. The patient will require local anesthesia in most areas. Once the hygienist has gathered the data and determined the class type, he or she should say to the patient, “Based on what I see in your mouth and on your x-rays, there appear to be some problems with the bone around some of your teeth. I need the doctor to take a look before I proceed any further.”
At this point, the hygienist will communicate with you outside the patient’s hearing range and inform you of the periodontal problem and case type. You should then come in, meet the patient, look in the mouth, examine the x-rays and periodontal charting, and say, “Based on what I see in your mouth and on the information gathered thus far, you have periodontal disease. It is a chronic infection that, over time, destroys what supports your teeth. The good news is that this is treatable in a nonsurgical way, and we typically get very good results. Our hygienists are specially trained to treat these problems, so I’ll let (hygienist’s name) explain what we’ll need to do to get this infection under control.” Now it’s up to the hygienist to sit down with the patient and explain the treatment sequence. Many doctors perform the comprehensive exam after the periodontal therapy is completed.
The reason it is not appropriate to perform a prophy when periodontitis is present is because a prophy is considered preventive therapy. If a patient already has periodontitis, the appropriate treatment is therapeutic, not preventive. The goal is to treat the disease definitively to bring it under control.
I urge you to discontinue use of the phrase “deep cleaning.” This phrase invokes fear in phobic patients and trivializes the nature of the treatment. Rather, use “advanced hygiene care” or “definitive periodontal care” to describe nonsurgical periodontal therapy. If a patient is insurance dependent, the administrative staff may need to obtain preauthorization of benefits before you proceed with definitive care in some cases.
In a perfect world, it is preferable to have new adult patients see the doctor first for a comprehensive exam, including periodontal assessment, and then move to the hygiene department after the level of hygiene care needed is determined. This gives the doctor an opportunity to meet the patient and perform thorough restorative and periodontal exams in order to guide treatment planning. In more advanced periodontal cases, it may be advisable to refer directly to a periodontist.
All the best,
Dianne Glasscoe Watterson, MBA, RDH, is a consultant, speaker, and author. She helps good practices become better through practical on-site consulting. Please visit Dianne’s website at wattersonspeaks.com. For consulting or speaking inquiries, contact Dianne at email@example.com or call her at (336) 472-3515.