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Dental Hygiene Time Management for the New Year by Trisha O’Hehir, RDH, MS Editorial Director, Hygienetown

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Introduction

No more bloody prophies in 2013! How many bloody prophies did you see last week? One is too many, but chances are, you struggle with several each day. Despite repeated toothbrushing and flossing instructions, subgingival instrumentation finds calculus and bleeding on many patients. If this is the case in your dental hygiene department, it's time for a change that will positively impact your time management of bloody prophy appointments.

A "prophylaxis" is a procedure performed on periodontally healthy patients to keep them healthy. Gingivitis and periodontitis are specific infections, like dental caries, to be diagnosed and treated differently than a prophylaxis. Removing subgingival calculus from interproximal areas where the tissue is puffy, swollen and bleeds easily is actually providing periodontal therapy. It is no longer a prophylaxis. Just because it frequently happens doesn't make it right. A prophylaxis appointment doesn't allow time for periodontal therapy so taking the time to treat localized periodontitis is bound to put you behind schedule. Patients don't appreciate the "free skilled therapy" you're providing, as evidenced by their comments suggesting you may be the "rough" hygienist. The patient's perception and that of the insurance companies is that a prophylaxis consists of polishing the clinical crowns of the teeth. Removing subgingival calculus from infected interproximal surfaces constitutes scaling and root planing for which you are not charging. It adds time to your appointment and the patients don't like it. Yes, they need it, but they don't like it and it's not technically part of a prophylaxis. Besides, it's what stresses you out, takes more time and often puts you behind schedule.

Removing supragingival calculus from the linguals of the anterior teeth is also time consuming and not the most comfortable for patients either. This also adds unnecessary time to the dental hygiene visit. Believe me; patients would love to come in just for polishing and no scraping with sharp pointed instruments.

By changing two things you do at each dental hygiene visit you will avoid providing unpaid periodontal therapy and easily stay on schedule. Add two simple requests of your patients and forever change their future DH visits, making them easier and more pleasant for both of you.

A prophylaxis is a procedure done on a healthy patient to keep them healthy. The exact definition: "A dental prophylaxis performed on transitional or permanent dentition, which includes scaling and polishing procedures to remove coronal plaque, calculus and stains." No pockets. No bleeding. No subgingival calculus to remove, only coronal instrumentation, no subgingival instrumentation. Since there is no code for treating gingivitis or early periodontitis, D1110 is often used, inaccurately, for bloody prophies.

Providing periodontal therapy, subgingival calculus removal from interproximal areas, during a prophylaxis visit leads to a bloody prophy. We laugh about these visits, but the truth is, a bloody prophy doesn't help the patient or the hygienist. The patients continue to ignore their responsibility to daily clean the interproximal areas and the next visit is the same as the last. The periodontal instrumentation at each visit adds extra time and stress, often pushing the limits of the schedule. Bloody prophies need to be a thing of the past.

Change just two things in a routine dental hygiene visit and the bloody prophy will be eliminated and the periodontal disease will be diagnosed. First, change your probing technique and second, change when you polish the teeth. These two changes will convert a bloody prophy into a diagnostic visit followed by polishing. After all, patients think a "cleaning" is the polishing! Give them what they want before giving away valuable periodontal scaling and root planing.

First Change - Recognize Interproximal Disease

Periodontal disease often goes undiagnosed due to faulty probing technique introduced by researchers and followed by dental hygiene educators. To be fair, not all educators follow the researchers. Instructors with clinical practice experience realize the importance of probing the mid-interproximal surfaces. Basic probing instructions suggest holding the tip of the probe in constant contact with the root surface, holding the probe parallel to the long axis of the tooth and walking the probe around the surface from line angle to line angle. Researchers wanted their probing to be reproducible, so rather than angling the probe to reach the mid-interproximal surface and find any crater development, they kept the probe parallel to the long axis of the tooth for all measurements. While being easily reproducible, this technique will not detect any mid-interproximal pockets and therefore significantly underestimates periodontal disease. When probing an interproximal site, hold the side of the probe against the contact area and aim the tip of the probe to the midpoint of the interproximal surface. This will ensure more accurate probing.

To focus more acutely on the interproximal surfaces, try probing according to Dr. Howard Farran. He suggests separating the brushing surfaces from the flossing surfaces as a way to educate patients while probing. It's really very simple and so much fun. Simply separate facial and lingual surfaces from interproximal surfaces, making two passes with the probe. First, probe all the brushing surfaces - facials and linguals. Tell patients you are doing a new test for gum disease and you will say the measurements out loud so they can hear them. The numbers should be one to three, anything four or higher is disease and any bleeding points are a sign of infection. After probing the brushing surfaces, tell patients you are now going to check for infection on their flossing surfaces. The same rules apply regarding the numbers one to three being healthy, anything four or higher is disease. After you finish probing according to Dr. Howard Farran, sit patients up and ask them what they think. They will know exactly which surfaces they are missing and where the disease is.

The bloody prophy patients are the ones who do no interproximal oral hygiene. They profess to brush like crazy, but they do nothing to clean between their teeth. The message these patients need to hear is "skip brushing and start cleaning in between." If they have time for only one thing, it has to be to clean between the teeth.

It makes no sense to talk flossing to patients qualifying as a bloody prophy. It's been done before and you've probably gone over flossing with them at least a half dozen times already. Tell them they no longer have to floss. It won't hurt to say this as it's clear they aren't flossing now. These patients need other options. Let go of your allegiance to floss. That was something they brainwashed us with in school. The scientific evidence shows that despite the dental profession's commitment to floss, very few people floss and those who do are not very effective at removing plaque from the proximal surface embrasures. It's time for alternatives: picks, sticks and flossing with water. These are easy to do and people like using them. If they clean between their teeth every day, there will no longer be bloody prophies in your schedule in the future. It makes no sense to remove the subgingival interproximal calculus at a prophylaxis appointment when there is no commitment to daily interproximal cleaning.

Patients have three options at this point. Based on the diagnostic probing, they have periodontal disease between their teeth. First, you can schedule them for four sextants/quadrants of periodontal instrumentation with anesthesia. The second option gives them a chance to control the infection themselves with daily cleaning between the teeth with sticks, picks or flossing with water. Find a convenient alternative to dental floss that works for patients. At the next visit it will be clear from the probing if they are cleaning between their teeth. If they are, it will be easy to remove the remaining calculus because the tissue will be much healthier. Wait until cleaning between the teeth becomes a daily habit before removing the subgingival interproximal calculus. It will be much more valuable at that time. The third option is to do nothing. In this case, they will return for their next dental hygiene visit with more subgingival calculus, biofilm and bleeding. The choice is theirs to make. Changing the probing technique to measure brushing surfaces separate from flossing surfaces clearly lets patients know what is missing in their daily oral hygiene.

Second Change - Give Patients What They Want

Probing according to Dr. Howard Farran has identified disease on the "flossing" surfaces of the teeth, giving patients the information they need to realize the value of cleaning between the teeth on a daily basis. Next identify alternatives to floss that will work into their daily schedule. The next step should be to polish. Given a choice, patients likely prefer polishing over instrumentation with sharp instruments. To them, the "prophy" is the polishing. Since that's what people expect, why not give it to them before instrumentation? Polishing first is a strategy to avoid doing subgingival instrumentation during a prophylaxis appointment. Many polish with a rubber cup while some are lucky enough to have an air polisher. With new softer powders, subgingival polishing can be accomplished, blasting out the plaque biofilm.

Polishing provides an opportunity to teach patients what a clean tooth feels like. Have patients feel the plaque biofilm on linguals of the mandibular posterior teeth or the facial surfaces of the maxillary molars before polishing. Before polishing have them remove it with a toothbrush and feel the difference. With this comparison, they will learn how a clean tooth feels to their tongue.

Following polishing and flossing between the teeth, instrumentation should be restricted to supragingival areas. The area with the greatest accumulation of supragingival calculus will be the lingual of the lower anterior teeth. Power scalers and hand instruments will effectively remove these deposits. Time will not allow for full-mouth subgingival instrumentation, which is wrongly included in a prophylaxis visit. Subgingival instrumentation constitutes periodontal therapy and should be scheduled at another visit.

Teaching patients a simple toothbrushing technique will prevent the future accumulation of mandibular lingual calculus. Reducing future lingual calculus will reduce the amount of time needed for supragingival instrumentation.

Toothbrushing instructions and pamphlets teaching toothbrushing most often suggest starting on the facial surfaces of the maxillary anterior teeth. According to the research, the area with the greatest calculus accumulation is the lingual of the lower anterior teeth. The area with the greatest plaque biofilm and bleeding is the lingual of the mandibular right (for right handed brushers, left for left-handed brushers). Based on this scientific information, toothbrushing should begin on the mandibular lingual to prevent calculus formation. Preventing calculus formation will reduce instrumentation time at future dental hygiene visits.

To feel the difference between plaque-covered surfaces and clean tooth surfaces after brushing, toothbrushing is best done without toothpaste. Without toothpaste, toothbrushing will take two minutes instead of 30 seconds, cover all areas of the mouth and most importantly, without the strong flavor of toothpaste the tongue will feel the difference between plaque biofilm covered surfaces and clean tooth surfaces.

Summary

These two changes in your approach to the bloody prophy appointments will focus your efforts and prevent the temptation to provide periodontal instrumentation. Focusing the probing and subsequently the oral hygiene on interproximal areas is bound to create healthier patients and shorter regular dental hygiene visits. Polishing first and teaching patients to dry brush inside bottom teeth first will reduce calculus buildup and cut down on the need for future instrumentation. Start out 2013 with these ideas to streamline your appointments and increase patient health.
Dentaltown Magazine
April 2024
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