Board Certified Periodontist

11 – Patient Instructions

We have been talking about the Supportive Periodontal Therapy appointment going through it step by step.

The final step before dismissing the patient is to give some feedback. I have titled this podcast as Patient Instructions.

Before we go there, think back with me to your training and how you gave patient instructions upon graduation. If you were like me, you spent a lot of time on this. Later, our words were briefer. Some think this is because we have lost interest in the subject. I don’t think this is necessarily correct. I think that we learn overtime what works and what doesn’t. It doesn’t work to spend a lot of time talking during an appointment where the patient is scheduled for some form of treatment.

In an SPT appointment, I consider the examination phase an important part of the treatment. Remember, this is the big difference between this type of appointment compared with the adult prophylaxis appointment.

This is common, but the problem is, none of us likes to be lectured to, especially about things we may have been doing wrong. We are defensive for one thing and will be mounting arguments in our heads that will drown out any words someone might be telling us.

Also, I know a lot more at the end of the appointment about their mouth specifically so my feedback can be more customized and effective when given at the end of the visit.

An obvious question at this point you might be thinking is, “Well, if we don’t like to be lectured to, why the lecture here?”

Good question. I think the answer is that what we want to know in a lecture about what we do for a living is very different compared with what patients want know after a supportive periodontal therapy visit.

You and I want to know things that might help us do a better a job. And if we find a few ideas that help us manage our days better, we are all ears. Also, we are more invested.

In contrast, patients want to know just a few things. They first want to know if there are any problems. They want to know if they will keep their teeth. This is very different compared with why or how they will keep their teeth. In other words, they may not be that interested in a lot of detail.

But what if there is more they need to know than they care to know? What if they need some details along the way. This is why I am such a fan of The Story.

If there is a story that explains what periodontal disease is and how it is both treated and managed by patients, then it makes work a lot easier for those involved in the patient’s care over time.

Again, I invite you to listen to my story that is found on the front page of my website. It is called A Tooth Has Four Parts or ATH4P for short.

If the patient has been treated by me they are familiar with this story.

If they have been treated by someone else, it is a good idea to know what patients are told.

Once you know what this is, then all you need to do is reinforce the story with a few comments. Recommendations in this context are simply reminders – not new material.

This means your instructions to patients at the end of the SPT visit are reminders.

But let’s take this one step further. What if the story you want to work with is known by others in your office? Then it will remove the burden from you to be the only one who reminds patients what it is they need to know.

Remember, patients often seek validation from others as to whatever it is you told them. Also they are as forgetful as I am at times. If I am your patient and you tell me about a particular toothbrush. It is very possible I might ask about this toothbrush with someone else in the office. Whatever the recommendations are that your office makes, it is helpful that everyone in the office knows what these recommendations are. Everyone in the office should know the story of periodontal disease. For one thing, it is useful information to them as human beings, and as I have already said, then they are in a position to reinforce this information with patients easily.

Finally, don’t forget to review the findings in terms of the two most important numbers the patient should already be tuned into.

First, did the bleeding index go up or down? Is it over or under whatever cutoff you like to set? Mine, again, is 20%. I have already explained why in an earlier podcast.

Second, are there any advanced sites? These are pockets 6 mm and deeper.

Once you have addressed these two numbers the next question is, “What’s next?”

Should they stay on the same interval of care?

Should they return to the periodontist?

Can the interval be stretched?

Finally, always try to put negative information between positive statements.

Begin with a complement. Then provide feedback. And end with a complement or word of encouragement. I don’t think I need to coach you on this. My only point here is to not come off as critical. Find encouragement and limit criticism. Remember, the fact that patients have come back, regardless whether or not they are taking good care of themselves is worthy of the compliment that it is great they are coming in. It’s better than giving up and not returning. 

You are listening to the Perio Hygienist Podcast. A podcast situated at the intersection between the dental specialty of periodontics and the profession of dental hygiene. My name is Dr. Ben Young and I am a periodontist practicing in San Antonio Texas.

The content of this podcast is professional in nature and is intended to provide practical instructions and tips to practicing dental hygienists – especially those of you who see my patients following the active therapy procedure I have performed.

And if you are a student – dental or dental hygiene – welcome, but this will likely not be the complete overview on the subject you may need. Feel free to listen and tuck it away for later.

As for the rest of us, let’s get started.

This is what I call A Payoff Episode. This has the potential of improving your morale significantly.

All the podcasts up to now, and including this one, are going through the normal steps of a routine Supportive Periodontal Therapy, abbreviated SPT or Periodontal Maintenance appointment and now it’s time to get down to cleaning –

  • Something you are good at.
  • Something you know how to do.

But now, I need to put what you may think you need to do into the specific context and need of this particular patient population – in order to rachet down the natural impulse most conscientious dental hygienists have to (air quotes here) “do a good job.”

Now, prepare yourselves. Some of what I will say in this podcast will sound unconventional. I assure you that it makes complete sense, but only if you understand it within a very narrow specific context of care.

There are three important facts about these particular patients that must be undstood when you are thinking about how to accomplish cleaning procedures for them.

Fact #1: These are treated periodontal patients, meaning they have probably recently had extensive root instrumentation.

Fact #2: These are chronic disease patients. This means they have a greater potential to relapse compared with patients who have never had a diagnosis of periodontal disease.

Fact #3: Their interval of care, at least starting out, being every three months places them at greater risk for recession, sensitivity and loss of tooth structure, should they receive the standard prophylaxis cleaning provided to their healthy adult counterparts.

Let me put it this way.

A prophy appointment is a cleaning appointment. That is its emphasis.

A supportive periodontal therapy appointment is an assessment appointment, with a small subgingival procedure I will describe, and a very quick light polish I will also describe in a moment.

Now let me give you an idea on how time is spent in each type of appointment.

The bulk of the prophylaxis appointment is cleaning teeth.

The bulk of the SPT appointment is in assessing conditions along with providing feedback. My cleaning step for these patients is usually under five minutes. You heard me right. And the reason it is so brief is I know exactly what I need to do, and I do just that. It’s quick and simple. And when patients remark that it was fast, I simply tell them what I just did and why within the context of their chronic periodontal condition.

I had a patient in just this past week, and I was recommending to her to return to see the dental hygienist she knows who works in the referring practice’s office.

She doesn’t want to go back. Instead, she wants me to continue to provide her with supportive care because the cleaning she receives at the other office takes 45 minutes and are always intense, meaning uncomfortable. Is this the cleaning she needs?

On the other hand, I have also had patients come to me who tell me that some dental hygienists aren’t any good because they aren’t that intense.

My point is that patients are always trying to understand if what they are receiving is what they need or not. Are they getting their money’s worth?

Unless we take the time to explain to them what we will be doing and why, they will judge our actions against whatever it is they are used to. Sometimes this results in patients seeking and continuing unnecessary treatment. I for one do not wish to aid and abet them in this.

So, let me remind you that your first step with a new patient is to listen and learn from them. What are they expecting? What did they experience with active therapy?

The second step is to review with them what exactly a periodontal supportive therapy appointment really is – and it is an appointment to assess the stability of their periodontal situation and then to gently and lightly intercept areas they cannot reach themselves in order to disrupt the organizing microorganisms.

When you kick over an ant pile, it means the ants have to start over. When you disrupt the subgingival microflora, it means that it will take these organisms additional time in order to become a threat once again. Usually, 5 mm and smaller pockets can be maintained indefinitely on a three-month interval with this kind of subgingival disruption.

What about subgingival antimicrobials? Not really wanting to discuss this now, but I am talking about successful long-term maintenance with subgingival ultrasonic cleaning alone – without any additional measures.

Six-millimeter pockets and deeper, the advanced sites as I call them, are unpredictable at three-month intervals going forward.

Patients need to be reminded of this and patients need to be involved in making decisions as to what it is they wish to do with this problem should they have it.

When we are involved with chronic care, these discussions as to what to do become routine and plans can sometimes be formulated months and even years in advance.

For example, there is no reason not to tell patients when in the future they might need a new full mouth radiographic series, or when in the future we might want to repeat root planing, either generally or specifically in certain areas, or when we might want to repeat a surgery or replace a failing tooth with a dental implant.

And add to this conversation when we might want to remove tobacco stains.

So, what does this routine cleaning within a supportive periodontal therapy visit with a well informed periodontal patient look like?

First, unless there is subgingival calculus not removed during active therapy, hand instruments do more harm than good.

This leaves us with the ultrasonic unit with a thin-tip insert as the instrument of choice, and this instrument’s power setting should be turned down. The way I think about it is that it is the equivalent of a single bristled brush with water flushing that enters the pockets around teeth and disrupts the organisms there. It lightly touches the root in the same way a toothbrush lightly touches a tooth in order to disrupt plaque. It is not intense; it is specific, and it enters areas the patient cannot reach with their daily brushing and flossing.

I explain to patients what I call the toothbrush/flossing line. This line is drawn at 3 mm. Brushes and floss are not intended to go deeper, and when they do, it is likely with some injury to tissues. This is why they need to see someone who can reach these areas for them.

Following this light subgingival deplaquing which also is used to lightly remove supragingival calculus that has formed since the last visit, I use a prophy jet to quickly clean light stains and plaque from around the teeth.

Now here we get into personal preferences. Do you have to use the same instruments I do? Not at all. You can use hand instruments or probes to disrupt subgingival plaque, but do not attempt to root plane. I find ultrasonic flushing easier. Do you have to use a messy prophy jet? Not really, but often times you don’t need the rubber cup and pumice polish either. If your office gives out soft bristle brushes, you can use this and then give it to the patient.

My only points are these:

The cleaning within the context of this particular visit is light and focused on areas patients cannot reach themselves. The general cleaning steps to remove supragingival stains and plaque are gentle steps in order to not cause more wear on teeth.

If the patient continually comes in with heavy stains, then discuss a reasonable interval for more aggressive polishing methods and the risks involved doing these procedures too often.

Next time let’s talk about patient feedback that come at the end of this routine supportive periodontal therapy visit. How do we address patient non-compliance? What exactly do we want them to be doing on a daily basis?

 Thanks for listening.

If you have liked this information and find it useful, I could sure use some ratings of the podcast and comments. Also, I would expect some questions at this point, especially if what I am saying sounds radical or extreme in your experience. I am very happy talking all of this through.

Until next time, keep fighting the good fight. Thanks for listening.