Written by Janice Cary, RDH, Tuesday, 31 May 2005 19:00
Years ago, a common game involved a group of people sitting in a circle while a sentence was started with one person whispering into the ear of the next. The interesting feature of this game was that the sentence at the end of the circle never remotely resembled the one at the beginning. Over the intervening years, I have learned about “filters, baffles, and frames of reference,” which the brain uses to make sense of what individuals understand. I’m sure you can remember what reading someone else’s notes taken from a missed class is like. We learn in our own way—some through sight, others through sound, and some through repetitive movements. Processing new information takes place around what we have already learned, hence the changes in the story at the end of the circle: the more people that are involved, the more the story changes.
INFORMATION IS KNOWLEDGE
Knowledge is coming faster than wisdom these days, and common sense seems to take third place. It amazes me that professionals can read, understand, and recite the latest information, yet not have any idea of how their information is being received. The worst of it is that at any given time in any given office, patients are at a disadvantage, because information is generally being given in a language foreign to them and in a single manner. The script is the same for every patient regardless of his or her background or education. Caring professionals can’t understand why patients don’t quickly “come up to speed” on the latest information being given to them regarding their care.
Let’s take an example. Recently, I was in an office where the staff had just been to a seminar by a well-known and gifted lecturer—gifted because the information came in easy-to-understand bits and because the examples had merit. More than 200 dentists, hygienists, and auxiliary staff members were in attendance, drawn as much by the dinner as by the information on periodontal disease, its diagnosis, and treatment. Handouts were given for use in each office, and brochures and diagrams were included for each staff member to learn, each in his or her own way. The materials were slick, professional, and easy to understand.
The seminar information covered bacteria, biofilms, systemic implications of periodontal disease, and the fact that periodontal disease is the most common chronic disease in the world. Links were drawn to cardiovascular disease through research at Harvard and other institutions, which indicated that bacteria found in arterial plaques are the same as those in gingival pockets and gingival crevicular fluids.1 Some of this information was new, and some had been published in journals over the last several years. What was interesting was that words such as infection and antibiotics are now prominent in both scientific and consumer journals.
While the actual diagnosis of the disease and its consequences have not changed much over the years, the knowledge of its effect on alveolar bone, tissue, and other parts of the body has swelled to the point where links are being drawn in popular magazine articles and at easy-to-read Web sites, such as perio.org and ColgateProfessional.com. The consumer is the benefactor of this research, and many patients come to the dental office already aware of the basis of the disease.
Many patients make a dental visit easier because when we probe, they already know we are looking for pockets and what the numbers mean. However, the majority of our patients are not aware and do not speak or understand the new language of this disease. We have several challenges awaiting us as dental professionals.
First, are we armed with the latest research on periodontal disease, and are we staying abreast of information that patients may see in the media? Is there a way to introduce terminology to describe the disease process, treatment, and outcomes in a way patients will understand? Can we discuss dentistry as a part of total health and link the head to the rest of the body in easy-to-understand terms? Are your staff members as current as they need to be to answer questions that patients ask of them after the dentist has left the room? Finally, does your practice have a prevailing philosophy of care that can be translated easily to new staff members, serving to erase cases of “in my last office…”?
Do all staff members understand the practice philosophy in your office? Can they speak intelligently about your desire for total wellness of your patients? Can they relate the information they may be learning through continuing education courses, reading scientific journals, and/or from you to your patients and other staff when there are questions? Are they accurate in the use of their terminology? More importantly, as the dentist, have you actively decided on your protocol to treat disease? Or do you “wing it,” as I have found in most practices, based on your perception of the patient, his or her standing in the practice, and any insurance or payment issues? It is the last question that makes policy and protocol difficult to implement.
I understand it’s not easy to take a patient for whom you have been caring for many years and inform them, suddenly and with conviction, that the bleeding gums you have been “watching” for years (with home care instructions to floss, etc) now are indicators of a chronic disease that can affect the body in destructive ways.
What was learned in the evening seminar about periodontal disease and cardiovascular disease may be difficult to share with a patient of long standing who has no knowledge of bacteria, biofilms, and gingival crevicular fluid, and who does, on occasion, actively floss!
I have been witness to many recare appointments where the hygienist has carefully laid the groundwork for the doctor to have an open discussion about bleeding, mobility, recession, etc and watched in dismay as the opportunity was squandered with a wave of the hand and a “try harder, and we’ll see you again in six months.” It’s no wonder the hygienist is frustrated and the patients do not improve. Only when the case is beyond the doctor’s scope of care, when there are bony defects, furcations, and mobility, is the patient referred to the periodontist. This is an unfortunate situation, and unfortunately, it is too common.
Many practices do better with their new patients, since they come with no previous expectations. The new-patient examination initiates treatment for these patients that is more comprehensive. New patients are getting a higher standard of care: full-mouth films, full 6-point periodontal charting, video patient education, etc. The entire dental team knows what to do with a new patient because it has practiced the scenario many times. It is smooth and professional. Patient scripts over the phone prior to the appointment are carefully crafted to elicit as much information about the patient as possible, including health concerns and insurance coverage. Some offices try to identify specific needs quickly so they can be met quickly.
In actuality, your “bread and butter” (recare) patients may now be receiving a lower level of care, all because these patients came before the new information.
WHAT PATIENTS HEAR
I have worked in practices where hygienists in adjacent chairs take different care of their patients. For instance, hygienists who have been trained or retrained in the last couple of years take medical history updates in writing and take blood pressure and full-mouth chartings prior to any care. What must the patients be thinking? Which patient thinks his or her care is better? What message are you sending to your staff and those patients?
I have heard conversations between full-time, temporary, and part-time hygienists who work in the same office discussing how different offices handle probing, charting, and irrigation solutions, about desensitizing after quadrant therapy by using gels or varnishes, about using power toothbrushes, etc. Is that happening in your office? What’s good about it? It may force you to look at and focus on developing a philosophy of practice. Understand that it’s vital for all providers to be on the same page with patient care. If this scene has happened to you, it may be time for you to use the information from that recent seminar you attended and incorporate it into your practice.
The language necessary to educate your patients must be spoken with conviction, and you must be ready to let them know that you have new information. You and your staff must develop a similar speech pattern that enables you to transmit necessary information quickly among yourselves and translate it into easy-to-understand bits. Some patients will want to know “everything,” some will tell you to “just fix it,” and others will “have to think about it.” However, the procedure for an accurate diagnosis and presentation of findings should be the same in every case, regardless of whether the hygienist or the dentist first sees the patient.
HOW TO PROCEED
Starting at the beginning, a full-mouth series of radiographs must be taken. A Panorex and bite-wings are no longer sufficiently diagnostic. Second, a full, 6-point probing on every tooth must be completed and entered into the chart. These 2 pieces of information contain almost everything you need to start the discussion with your patient, whether new or existing. For the long-term patient, a script might include language such as, “We now know much more about periodontal disease than ever before, and we are going to document your status in a way that is different from past visits.” Don’t be defensive about what happened before. You have taken a course, read an article, or gone to a meeting where you learned new things. You are gathering better data than in the past, and the patient will benefit from it. Let the patient know that each member of the office supports comprehensive patient care.
Six-point periodontal probing is a new step in many offices. Let the patient know what you are doing and why. If you involve them in the process by having them listen to the numbers, the discussion that follows will be preframed. The radiographs will add another level of credibility to your discussion, one that the patient can actually see. Intraoral cameras are a great help in the display of bleeding, recession, etc, but they are not mandatory. You have spent years talking about cavities, crowns, and root canals. You can do this the same way.
Patients understand the word infection, so don’t be afraid to use it. Decide at what point antibiotics are to be placed, and reinforce their placement with references to other local or systemic infections that are treated with antibiotic therapy. Patients are not surprised by the word; they just haven’t heard you use it before. Just as some of your patients have to “go home and think about it” when other types of dental treatment are presented, some will have to “think about” antibiotic therapy as well. Be sure to have articles available that will answer their questions and reinforce your diagnosis. If they want a second opinion, reassure them and let them go. When another dentist confirms your diagnosis, they will be back.
Setting a clear standard of care that each staff member recognizes as protocol for your office makes it easy to place patients in the correct treatment category. It also reduces confusion and “hallway-rendered” alternative treatment decisions. If it exists as a standard of care, the patients’ insurance coverage, or any other issue, doesn’t matter. You have new information and are willing to share it with your patients. As always, the decision is up to the patient. The key is this: does the patient understand what you said and what he or she is to do? Is the protocol for the patient as clear as it is for your staff? Take a look at this:
(1) Bleeding gums with no bone loss is indicative of gingivitis; this patient may be returned to health and a healthy-mouth prophy.
(2) A patient with bleeding gums, pocketing of 5 mm, and slight bone loss has periodontal disease, but can be maintained in a stable state with 3-month recare visits and annual probings to gauge the spread of disease. Antibiotics can be placed.
(3) A patient with bleeding gums, pocketing of 6 mm or more, and visible bone loss needs aggressive therapy, thorough home care, and monitoring 4 times a year. Antibiotics should be placed.
(4) A patient with a history of systemic disease should be aware of possible complications from periodontal disease and should be carefully monitored.
Only the patient who is in the aforementioned category No. 1 can be considered as a potential healthy-mouth prophy (1110). When your patients ask you why, a good example to use is that a physician examines a patient with a chronic disease such as diabetes differently than he or she would examine a patient without disease. And further, patients who have systemic disease should more readily understand the implications of an infection on their health. We do the patient a disservice and leave ourselves liable to claims of malpractice if we don’t point this out.
Use the knowledge you and your staff have recently gained to work toward a language that your patients can understand. Have visual aids such as brochures and charts accessible for patients to take with them. If a patient is healthy, congratulate him or her. If he or she is not, then provide all of the information needed in whatever format works best. This provides the patient a better picture of the effects of disease on the rest of the body. Help patients make the connection. They will become healthier, better patients, and you and your staff will also benefit.
1. Goel SN, Bissada N, Deluca DJ, et al. Presence of periodontal pathogens on coronary balloon catheters following angioplasty [abstract 0828]. Presented at: The IADR/AADR/CADR 80th General Session; March 6-9, 2002; San Diego, Calif.
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