Let Your Hygienist Shine!

PERIODONTICS Let your hygienist

Gemma Langford* explains how periodontal cases can be handled successfully by dental hygienists within the general dental practice.

Should initial/non-surgical I certainly would manage most initial therapy CASE STUDY periodontal therapy be dealt in-house; you will find that if referred to a A 50-year-old gentleman attended for a new with in practice or referred to periodontist your patient will most likely only patient assessment in November 2010. The a periodontist? have initial therapy with their hygienist patient had not visited a hygienist for four This is a question that every dental hygienist first anyway. years and his most recent dental exam was should ask themselves. How many patients have If you are a general dental practitioner one year ago by his previous GDP. He disclosed you referred out of practice because you were (GDP) and confident you have a highly skilled he was a heavy smoker (20 cigarettes a day) too afraid to treat them/do not have the time/ hygienist, why would you refer out for this type but had no other relevant medical history. are not paid enough? I would like to see more of treatment? If the patient still has areas that The referring GDP gave the patient a straightforward periodontal cases handled by need attention after initial therapy then seek BPE score of 444/444 and a diagnosis of dental hygienists, after all, that is that what we referral to a periodontal specialist. chronic periodontitis. are trained for. In this article I will attempt to Many GDPs would argue that their dental The patient presented with generalised deep show the practising dental hygienist how to hygienists do not have the time to provide a pocketing >6 mm in all sextants with heavy successfully handle periodontal cases in-house periodontal service in general practice or that sub and supra gingival calculus deposits. The and also gain fair remuneration for this service. their patients do not understand periodontal hygienist also noted heavy staining and marked disease – this can all be solved with a halitosis. An OPG taken by the referring GDP The hygienist is a highly periodontal consultation and report in-house. showed generalised moderate/severe horizontal qualified professional If the dental hygienist takes the time to bone loss. As a dental hygienist that deals with complex discuss, make the patient aware of their The patient was aware he had ‘gum disease’ treatment every day, I feel it is certainly problem and send them a report (the treatment but had never been offered treatment by his possible to successfully manage patients with plan must be developed by the GDP with previous dentist. straightforward periodontal issues without the the dental hygienist’s expertise or checked At this appointment I discussed the need to refer to a periodontal specialist. and countersigned by the registered GDP if severity of his periodontal disease and advised consultation is with the hygienist) this gives I would need a further session to collect data the patient trust in your abilities as a clinician. for the referring clinician (I advised the patient Would a GDP start complex restorative there would be a charge for this appointment), treatment without a report? I should hope who would decide a treatment plan for not, so it should not be any different with the patient. perio. It is very feasible to charge for this time – the hygienist (if you use her/him for this Appointment 1 (30 mins) consultation) is a highly qualified professional In-depth discussion again regarding the patient’s person and there is nothing wrong with perio status and causes of periodontal disease. charging for the time taken for the consultation Smoking cessation advice given, patient given and to formulate a report. This way the patient leaflets and advised to seek GP support. A 6ppd has an informed choice and you are still paid for chart, mobility and BOP recorded (Fig. 1). your sessional time. Formulation of treatment plan with GDP, 4 x 1 GDPs should discuss with their dental hour RSD appointments under local anaesthetic Gemma Langford hygienist a fair rate for providing initial and 1 x 20 minute post-treatment review eight * Gemma is a dental hygienist originally therapy/non-surgical perio - after all s/he will weeks after RSD completed. Periodontal report from Manchester but now living be providing a highly skilled and specialised formulated and signed by referring GDP. The in Southport, Merseyside. Gemma service. GDPs also need to charge patients qualified with a Diploma of Dental GDP also took pre-operative photographs (Fig. Hygiene from the Liverpool School of adequately for the hygienist’s time. Compare 2). A periodontal report was sent to the patient Dental Hygiene in 2006. your rates with a periodontist providing non- with periodontal consent forms, including all surgical therapy in your area and go from there. costings for initial treatment (Fig. 3).

17/11/10

Dear Mr,

Thank you for making yourself available for your Hygienist consultation on Wednesday 17th November 2010. During this consultation I gathered important information relating to the health of your gums in the form of a 6-point periodontal pocket chart, a chart that indicated the presence of bleeding relating to your gums and a chart that recorded any mobility of your teeth.

I also had a discussion with you regarding the causes and consequences of gum (periodontal) disease and I would like to take this opportunity to reiterate this. Periodontal disease affects the gums, bone and other supporting tissues of the teeth.

All gum disease is caused by plaque. Plaque is a film of bacteria, which forms on the surface of teeth and gums everyday. Many of the bacteria in plaque are completely harmless, but there are some that have been shown to be the main cause of gum disease. This bacteria irritates the gum causing what is called a periodontal pocket. If left untreated, these pockets get deeper and more difficult to clean. As the disease gets worse the bone anchoring the teeth in the jaw is lost, making the teeth loose. If this is not treated, the teeth may eventually fall out.

Based on the charts I gathered at your consultation appointment and the full mouth x-ray that was taken, Dr Dodd has come to the diagnosis of chronic periodontitis, which has resulted in moderate/severe bone loss around all of your teeth.

Your presenting gum problems are as follows: ■ Chronic periodontitis, generalised interproximal pocketing >5mm. ■ Moderate/severe bone loss. ■ Supra-gingival calculus deposits (tartar above the gum-line) and Sub-gingival calculus deposits (tartar below the gum-line). ■ Generalised staining. Fig. 1 Pre-treatment charts ■ Generalised bleeding coming from the deeper periodontal pockets. ■ Halitosis. Treatment options: Option One – No treatment at all (unadvisable, will lead to further progression of periodontal disease and tooth loss). Root surface debridement under local anaesthetic with myself. Option Two – £380 Option Three – Referral to Periodontal Specialist (a consultation currently costs and £69 for any x-rays needed. The Periodontist will discuss treatment prices with you at his consultation).

Option Two – Treatment provided by myself: For option two – This will initially consist of four 60-minute appointments for initial root surface debridement (deep cleaning) under local anaesthetic. This is to remove all tartar and plaque deposits and for oral hygiene instruction.

I will then need to see you for a review appointment 8 weeks post treatment to review your progress. If all is well you will then be put on a maintenance plan of 3 monthly appointments.

Fig. 2 Pre-operative photographs of Option Two – Treatment costs: the patient £560.00 for root surface debridement over four 60-minute appointments.

£26.39 for a 20-minute review appointment 8 weeks post treatment with the Hygienist.

I need to stress to you that the outcome for any treatment you undertake for your gums will Appointment 2 (60 mins) be directly affected by your oral hygiene routine and cigarette consumption, and failure to comply with instructions will reduce treatment success. Periodontal consent form returned by patient. UPPER LEFT quadrant local anaesthetic given Whilst the success rate of periodontal treatment is not 100%, with the correct oral hygiene regime and treatment planning, I feel confident that there will be an overall improvement by buccal infiltration. ULQ RSD with Cavitron to your gum health. You must be aware however, that additional appointments maybe Ultrasonic scaler (thinsert used to flush deep required for further treatment, should the treatment not be entirely successful, at additional cost. I will advise you accordingly at your post - treatment review appointment. pockets) and LM curettes. Toothbrushing instruction with patient’s Oral-B electric Please note that any sundry items needed for oral hygiene instruction are not included toothbrush, bass technique stressed and patient in your initial appointment fee but I will make you aware of what you will need during your appointments. advised to brush 2 x daily. Interdental cleaning I trust that you will take the time to consider the contents of this report, and I look forward instruction given with Tepes and Vision brushes; to seeing you again. these were charted for the patient to take home (Fig. 4). It was stressed to the patient that he Yours sincerely, Dr S. Dodd BDS MJDF RCS (Eng) must use the interdental brushes 1 x daily; Gemma Langford RDH the patient was reassured regarding initial bleeding when toothbrushing and using interdental toothbrushes. The patient was Fig. 3 Extract from the Patient Periodontal Report (also included were ‘facts about gum disease’, given post-operative instructions regarding detailed information about gingivitis and periodontitis, consent forms and the late cancellation/ local anaesthetic. failed appointment policy) www.nature.com/vital vital 25 © 2011 Macmillan Publishers Limited. All rights reserved. PERIODONTICS

UPPER RIGHT quadrant local anaesthetic the necessary skills to perform initial therapy given by buccal infiltration. URQ RSD with and recognise when they need to refer to a Cavitron Ultrasonic (thinsert used to flush periodontist but I would urge them not to make deep pockets) and LM curettes. Tepes and a ‘knee jerk’ reaction, but take the time to think vision brushes charted and demonstrated to about each individual case they encounter. After patient. POIG. all, we have been trained to an exceptionally high standard: let’s use our skills. I for one would Appointment 4 (60 mins) not want to become a ‘scaling machine’. Upper arch checked, I noted that the tissues Moreover, as periodontal negligence claims were healing well. The patient informed me are on the rise in the UK, it is the dental Fig. 4 Interdental cleaning instructions there was much less bleeding when using the hygienist as well as the patient’s GDP that will interdental brushes. LOWER LEFT quadrant come under scrutiny if a negligence claim goes local anaesthetic given by inferior dental ahead. It is the dental hygienist’s responsibility block. LLQ RSD with Cavitron Ultrasonic to inform patients regarding their periodontal (thinsert used to flush deep pockets) and LM status and to work in the best interests of that curettes. Tepes and vision brushes charted and patient. Does this mean an automatic referral demonstrated to patient. POIG. to a periodontist before an initial therapy phase of treatment is offered to the patient? I suppose Appointment 5 (60 mins) that is open to debate, but it is important to take LOWER RIGHT quadrant local anaesthetic each clinical case on an individual basis and it given by inferior dental block. LRQ RSD with is for the dental hygienist and referring GDP to Cavitron Ultrasonic (thinsert used to flush deep decide when it is appropriate to refer. pockets) and LM curettes. Tepes and Vision brushes charted and demonstrated to patient. Further reading POIG. Initial treatment completed, I stressed ■ British Society of Periodontology. to the patient the importance of interdental Periodontology in general dental practice in the cleaning and toothbrushing. I informed the United Kingdom: a policy statement. March patient he would need an eight-week review 2001. Available at: www.bsperio.org.uk/ to re-pocket chart and check for non- members/policy.pdf responsive sites. ■ British Society of Periodontology. Referral Policy and Parameters of Care. Available at: Appointment 6 (8 weeks post-op http://www.bsperio.org.uk/members/ review 20 mins) referral.htm Patient attended for review appointment. I ■ American Academy of Periodontology. Index noted that there was slight reformed calculus on of AAP Clinical and Scientific Papers (dealing Fig. 5 Post-treatment charts the lower anteriors on the lingual surface but no with the aetiology, pathogenesis or treatment other calculus had reformed. The patient had of periodontal diseases). Available at: http:// been using Tepes and Vision brushes daily and www.perio.org/resources-products/ brushing 2 x daily with his electric toothbrush. posppr2.html 6ppd chart recorded; most sites had significantly ■ Axelsson P (ed). Minimally invasive treatment, reduced in pocket depth with little BOP. Two arrest and control of periodontal diseases. pockets >5 mm remained UR6 distal and LR5 Quintessence, 2009. distal (Fig. 5). The patient informed me he ■ Lindhe J, Lang N P, Karring T. Clinical had noticed a significant improvement in his periodontology and implant dentistry, 5th ed. oral health with no BOB and no halitosis. I Wiley-Blackwell, 2008. referred the patient back to the GDP for post-op ■ Wilkins E M. Clinical practice of the dental photographs (Fig. 6) and for a treatment plan hygienist, 9th ed. Lippincott Williams & regarding UR6 and LR5 which would probably Wilkins, 2005. involve a future referral to a periodontist. I advised the GDP the patient would need GLOSSARY a maintenance plan of three-monthly Fig. 6 Post-operative photographs of BPE = Basic Periodontal Examination the patient hygienist visits. 6ppd = six point pocket depth

Let’s use our skills BOP = bleeding on probing The total initial therapy treatment cost for this RSD = root surface debridement Appointment 3 (60 mins) patient was £586.39 and I received a percentage ULQ RSD = upper left quadrant root surface Firstly I checked the ULQ completed at the last of total treatment costs. debridement appointment; it was noted that the tissues were As you can see from this case study, it is POIG = post-operative instructions given healing well and inflammation was resolving. possible to treat patients with significantly deep BOB = bleeding on brushing The patient informed me he had been brushing pockets in general practice. It is important for and using interdental brushes as requested. the dental hygienist to be confident they have