Plan Your Perio Program by Rachel Wall, RDH, BS

Plan Your Perio Program 

Learn how to streamline your perio protocols and increase your treatment acceptance


by Rachel Wall, RDH, BS


Despite the growing evidence of a connection between active periodontal inflammation and numerous life-threatening health conditions, there remains a vast range of awareness and implementation of consistent diagnosis and treatment standards for active periodontal disease, especially in general dental practices.

Over the past 17 years, my company has guided hundreds of dental teams to the successful implementation of a perio care program that fits their clinical philosophies. When Dentaltown asked me to share a plan for a successful perio program, I immediately said yes. The more dental professionals who address chronic periodontal inflammation, the healthier our patients will be. And the more consistently these systems are followed, the sooner our message will be consistent across providers and the sooner consumers will see hygiene teams as a critical piece of overall wellness.

Mindset is where we start

Whether at a white coat ceremony signifying a dental student’s entry into patient care or at a pinning ceremony like I experienced when I completed dental hygiene school 30 years ago, dental professionals take a professional oath.

We promise to:
  • Render the highest level of care possible.
  • Put the health of our patients at the forefront of our treatment decisions and recommendations.
  • Uphold the highest level of professional and personal conduct.
  • Continually improve our knowledge and skills.
I’ve read quite a few oaths from various dental schools and I have not seen, “I promise to share with my patient only the treatment I think they can afford or will accept, or that which is covered by their insurance.”

In my experience, fully implementing and maintaining a periodontal care program in a GP practice requires a few core mindset principles to be shared by the entire team:

  • A belief in our obligation to identify and provide solutions for the treatment of active periodontal inflammation/infection.
  • A belief that treating the inflammation or infection will have a positive impact on the patient’s overall health
  • A belief that implementing an effective perio care system is worth the effort, changes and learning that’s required.
Starting with the large body of evidence pointing to the oral-systemic link helps teams stand firm to standards they’ve committed to. When these beliefs are coupled with clear systems and calibration, there is enormous potential for growth in this area.

Which obstacles are you facing?

While mindset is the first step down the path to developing these systems to address disease in your patients, there will likely be lots of obstacles. I’ve never met a dental team who intentionally neglected their patients’ periodontal health. It’s usually a result of obstacles that prevent a team from fully implementing a program. Once you identify what may get in the way of implementing a solid, consistent perio program, enrollment and treatment protocol are next to come.

When people face obstacles, the path of least resistance is the easiest choice. We’ve all been there, right? Often, avoidance is simply a symptom of wanting to stay in our comfort zone or not knowing the way through the obstacle. We observe this every day with the teams we support.

One of the most common obstacles to a periodontal care program is the schedule itself. Creating a sense of urgency for treating an active infection is easy when you use the communication tips in this article, but that sense of urgency will be lost if the patient discovers it will be eight weeks before that infection can be addressed. If you went to the ER for an infected toenail, would it make sense to wait for eight weeks to debride and treat that infection? Of course not. You’d expect it to be addressed right away.

When there is no time reserved for periodontal care, it reduces the value of care for the patient and the provider. It’s so easy for hygienists to get stuck in the “prophy trap.” It negatively affects their career satisfaction, their productivity and their patients’ health. Hygienists want to deliver care that will improve their patients’ health. If there aren’t systems set up to reserve time for perio care, hygienists will often take matters into their own hands and do the treatment within a prophy. This snowballs into issues like running behind, not meeting profitability goals, and patients and teams who believe everything can be handled with a “good cleaning.”

Other obstacles to look out for:
  • Lack of confidence to present treatment to long-standing patients.
  • Inadequate time in hygiene visits to properly complete periodontal assessment and educate patients on the appropriate care.
  • Insurance limitations and how they affect the team’s willingness to present necessary care.
  • Dentists and hygienists not being calibrated in their philosophy of care.
Clinical calibration

Because they’re the primary providers of care, there must be an agreement between dentists and hygienists on what constitutes health versus disease and when patients move into perio care.

In 2017, the American Academy of Periodontology met with the European Federation of Periodontology for the World Workshop to develop and publish the most recent perio classification system, “staging and grading.” In addition, experts wrote papers on guidelines for diagnosing, classifying and treating periodontal disease.

The paper “Periodontal Health” states that “absence of inflammation associated with gingivitis or periodontitis, as assessed clinically, is a prerequisite for defining periodontal health.”1 The first sign of active perio inflammation is most often bleeding on probing or exploring.

Coupled with the clinical presence of bleeding, the staging and grading guide gives us clear parameters for determining if periodontal disease is active, what level of destruction has occurred and the patient’s risk for disease progression.

Calibration steps

1. Sit down and carefully review the periodontal health paper and the staging and grading guides. Develop a common understanding of what constitutes active periodontal disease, gingivitis and health.

2. Calibrate clinical diagnostic techniques. Ask a few questions and see how close or far apart hygienists and dentists are on these key diagnostic data points:
  • Is bone level routinely visible on X-rays?
  • What does bone loss look like on a radiograph?
  • Are we placing and angling the periodontal probe the same way, resulting in consistent measurements between providers?
  • How do we read the probe?
  • Are we recording bleeding and taking photos to document active infection/inflammation?
3. Using the staging and grading guides with the American Dental Association’s CDT code descriptions, determine at which point you’ll move a patient from a preventive prophy to a therapeutic procedure such as gingivitis therapy or active periodontal therapy, and also when you’ll refer to a periodontist. Create a document that outlines your clinical standards of care and allow the team to give input, ask questions and agree to the standards. Having clinical standards documented helps keep everyone on track and brings new team members up to speed. You can also refer to this document whenever there are disagreements. [Editor’s note: You can download a standard of care template at inspiredhygiene.com/standardofcare.]

4. Develop a flowchart to demonstrate how a patient flows from diagnosis into treatment and through the active periodontal therapy journey into continuing care. Be sure this is clear with specific ADA codes, procedure times, documentation needed, etc.

Communication and the three P’s

There’s no doubt that as modern practitioners, we have to be savvy to the incredible number of factors that are at play in the day-to-day delivery of dental care. As you develop your periodontal care program, consider how to communicate with your patients their current state of health or disease. Once recommendations for care are made, patients must believe in the value of the treatment and understand the investment they’re making in their health and how that can be offset by benefits and financial options. When consistently applied, the “three P’s” include patients in the diagnostic process and allow them to participate in a way that supports discovering their condition and accelerates their acceptance of care.

The three P’s are simple:

PREP. The key here is patient participation. The goal is to pull the patient into the conversation before the exam is completed. “Kate, I’m going to do a thorough exam of your gums and the bone surrounding your teeth. I’m going to call out some numbers, so please listen carefully. A rating between 1 and 3 is typically normal, and healthy gums don’t bleed.”

PERIO ASSESSMENT.
For patients to participate in their own diagnosis, they have to hear those numbers being called out. No matter if the hygienist has an assistant, is using voice-activated charting or works by herself in the operatory, those numbers have to be called out to engage the patient. Be sure bleeding and other inflammation indicators are also communicated to the patient and charted in the patient’s digital chart.

Remember, bleeding is the indicator of active inflammation. If it’s not documented, it didn’t occur. Active therapy is not appropriate care unless there is active inflammation.

PRESENT RECOMMENDATIONS. This is where we present the evidence and a concise message to advocate for perio therapy. A few items are important:

  • Sit the patient up. Whenever we are presenting treatment, patients need to be sitting upright while we sit knee-to-knee with them.
  • Photos. Take a photo of infected, bleeding areas. This helps patients visualize what’s going on and also serves as a strong piece of documentation supporting your diagnosis and treatment plan.
  • Printing. Even if you have a beautiful monitor right in front of your patient, I encourage you to print perio charts in color. Many of our clients purchase an inexpensive printer and put it somewhere near the hygiene room so the charts are easily accessible.
  • Personalization. Patients always want to know how our recommendations apply to them personally. Make sure hygienists are highlighting patients’ risk factors, such as diabetes, autoimmune conditions, high cholesterol, certain medications, rheumatoid arthritis, a family history of heart disease, or a history of cancer or stroke. Any of these issues can create a risk factor related to periodontal disease.
A common communication obstacle presents itself among long-standing patients who have been diagnosed with active periodontal disease after years of healthy preventive prophies. Often, hygienists are reluctant to present treatment because they fear patients will think they’ve been neglecting this issue. The reality is that people see their medical doctors and dentists every day with new health issues; a physical today could reveal high blood pressure that wasn’t present a year ago.

The advice we give our dental practice clients is to investigate what’s been documented in the chart regarding the patient’s perio status. Very often, there have been past recommendations to improve oral hygiene, visit the hygienist more often and so on. Build on those past conversations and share with the patient that the chronic inflammation has not resolved and a new approach to care is necessary.

“Jane, in your chart I see that we’ve discussed this bleeding the past few visits and we’ve tried a very conservative approach. However, this infection in your gums and the bone surrounding your teeth has not resolved. Your body has not responded as we’d hoped and this inflammation has become a chronic problem. It’s time to do something different to assist your body in healing and eliminating this infection.”

Measure to move forward

The time spent developing a perio care program is valuable. Tracking results will help you know if the new commitments and standards are staying in place and if there are obstacles that have not yet been resolved. It will also help you acknowledge and celebrate your success.

Guiding teams to successfully develop and implement a clear, consistent periodontal diagnosis, enrollment and treatment system has been a huge part of our work and mission over the past 17 years. We believe in the power of the dental health care provider to make an incredible impact on patients’ lives in so many ways.


References
1. Periodontal Health by AAP/EFP https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.16-0517
2. UNC Whitecoat Ceremony https://dentistry.unc.edu/2009/03/white-coat-ceremony-focuses-onbeginnings/
3. Univ of Louisville Dental Professional’s Pledge https://louisville.edu/dentistry/pledge
4. Dental Hygiene Oath https://dimensionsofdentalhygiene.com/amp/article/ethical-decision-making-dental-hygiene/
5. AAP/EFP World Workshop website, Including Staging & Grading Classification System https://www.perio.org/2017wwdc


Author Bio
Rachel_Wall Rachel Wall, RDH, BS, is CEO and founder of Inspired Hygiene, a coaching firm focused on elevating hygiene services, systems and profits. Inspired Hygiene strives to help dental teams achieve a triple win with healthier patients, empowered, engaged hygienists and a profitable practice. Wall has spent the past 30 years as a clinical hygienist and hygiene productivity coach. An award-winning educator, she is the author of the book “Return on Hygiene.”
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