message board periodontics

Explaining Therapy A discussion among dental professionals on the message boards of Dentaltown.com. seems relatively easy to understand, but many patients seem to be in denial. Perhaps they have been too well trained to expect a “regular cleaning.” Check out these periodontal presenta- tion methods. Log on today to participate in this discussion and thousands more.

What is it about SRP [scaling and root planing]/deep cleaning that is so difficult Buckeye Greg to communicate to patients? My hygienist is awesome at her job and explaining to Post: 1 of 49 patients what she does. We have CAESY on DVD and I make analogies and answer Posted: 5/16/2007 any questions that the patient has. As soon as my office manager comes in to discuss Total Posts: 1,242 payment of services, it is like the patient suddenly has amnesia and has no clue why this costs more or why it needs to be done. How is everyone going about patient edu- cation for SRP? Are there any pamphlets available that can help? This is becoming a daily nuisance that I would really like to eliminate. ■ Greg

I’m not sure that we do it any different. I guess my suggestion would be to stress IWannaFixIt at every opportunity how it differs from a “regular” cleaning (and you are probably Post: 2 of 49 doing that already). Another thing I think a lot of us do is try to sugarcoat the expla- Posted: 5/16/2007 nations/discussions we have. Maybe someone in the discussion process is doing that? Total Posts: 195 Probably not. We try to use a lot of visual aids (intraoral photos, pointing and play- ing with the digital radiographs, diagrams, etc.) but you are already doing that as well. Frustrating. Sorry I could not be of more help. ■

The worst thing about it is that these people come in and after X-rays, perio Buckeye Greg charting, existing charting and SRP discussion, about 40 minutes have passed and if Post: 4 of 49 they decide not to go ahead with the ideal treatment, that leaves about 10 minutes Posted: 5/16/2007 to go through and do the “regular cleaning,” which they usually leave saying, “That Total Posts: 1,242 was the worst cleaning of my life.” ■ Greg

This is exactly why we stopped doing cleanings at our initial visit unless there is an sdcrog opening in hygiene after the exam/charting visit. It takes time to explain these things Total Posts: 136 correctly. We pretty much insist on a FMX [full-mouth X-ray] at this visit too. We Posted: 5/17/2007 chart existing conditions and start to develop a treatment plan. We had some resist- Post: 5 of 49 ance from the patients at first, but eventually they accepted it. My receptionists are very clear to thest patients that they will not receive a cleaning at this visit. If they don’t like it, they go elsewhere. Too much stress on the docs and staff the other way. The exam fee is $49 or twice that if it is really involved, plus $92 for the FMX. We sched- ule an hour with the doctor for this. Sometimes we are done in 40 minutes, sometimes we could use more time. It is not a profitable visit, but necessary. ■ Steve Crognale

If a patient needs SRP, then he or she is not “eligible” for a regular cleaning. A drnancyjo cleaning is only done in the absence of disease. They should not even be given the Post: 6 of 49 ■ Posted: 5/17/2007 option of a regular cleaning. Explaining that they need to get the disease treated first Total Posts: 6 continued on page 82

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and then they will be on a perio maintenance schedule after that should be explained at the initial visit. We have a very high acceptance rate for perio Tx and I practice in an area where the average per capita income is 26K per year. ■

maclee “Look at the pictures we just took. See the bleeding? The yellow stuff Post: 7 of 49 you see is pus due to the infection in your bone, which is spreading all Posted: 5/17/2007 over your body. We have to do some special procedures to remove the Total Posts: 1,485 infection and special instruction for you to do at home so it will not return. You are on your way to lose some, if not all of your teeth! This is all confirmed by your X-rays. Your bone should be here, but it is way down here. I estimate you have lost 3-4mm of bone. If you don’t treat it, it will continue. My job is to educate you in a way you understand and it is your job to decide what you want to do. All I am doing is being honest with you and I would like to have you to do the same as to why you don’t want to stop the infection. Some people refuse because they are thinking about the possible pain, cost, unnecessary treatment, etc. If you are thinking something like that, please let me know because my job is to overcome your fears or misconceptions.” The team member involved with the diagnosis and treatment planning must be the one who discusses the fee, sets the appointment and collects the money. Once a transfer occurs with an uninvolved team member, patients throw up the road blocks. If a transfer occurs, the one receiving the balk has to tell the patient, “Let me get the doctor to make sure this is the right thing to do.” ■ Mac Lee

Buckeye Greg Very rarely do we have patients Post: 8 of 49 decline the proposed treatment, but it Posted: 5/17/2007 just takes forever to get it through to Total Posts: 1,242 them, it seems. That was my main complaint. When they decline, we tell them that they have all this crap under their and it is going to keep eating away at the bone holding their teeth in. If they want a light scale and polish, then all we are going to do is clean above the gum- line and it isn’t going to do any good for them. Then they sign off in the chart under “declined recommended treat- ment” and that is that. At least they were informed and we have it documented. I do like the word “eligible.” I’m going to work that into my discussion. ■ Greg

d2thdr I’m not sure if you want to go Post: 9 of 49 toward this angle here, but the com- Posted: 5/17/2007 ments about the patient being “eligi- Total Posts: 7,816 ble” for a cleaning got me started. Today, Sam Low from the University of Florida, was here for a CE course titled, “Empowering the Dental Team to Deliver ‘Quality’ continued on page 84

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Periodontal Care.” He addressed many issues of education, primarily the doctor and staff, as a means to communicate with patients. There were absolutely no histologi- cal slides or even much discussion of specific bacteria involved. It was a thoroughly delightful lecture. And, like Mac, he’s a good ol’ boy from Texas, so he doesn’t mess with his words... he just spits it out. Near the end of the lecture he talked about the patient who refuses to be root planed. He said to: 1. Document the refusal. 2. Attempt to establish a rapport through education. 3. Education equals treatment acceptance. 4. Dismiss if they will only allow a “prophy.” Now, first, he’s a periodontist, and doesn’t have to deal with the whole family of the patient. Second, he offered this quote to put in the records for patients with inconsistent recare or who refuse surgery with a specialist: “Patient has been informed of the Dx of severe Periodontitis and the threat of tooth loss. Due to non-compliance with , frequency of recare, refusing to see a spe- cialist, not accepting a surgical treatment plan (pick one or several), patient is placed on a compromised recare treatment plan.” Third, he stated that there has never been a study that showed that polishing has any positive or negative influence on periodontal health. Adding those three together, why is he safer continuing to treat this patient with these steps, instead of insisting on dismissal for this patient also? This is an area that has long bugged me about the conflict of what a patient is willing to do, and how we should legally handle it. Is there a legal precedent either way? What about all the failure to pre-med law suits that should now be overturned with the new guidelines from AHA? How will the courts look at those previous “prece- dents?” I’m so confused. ■ Dennis M. Murphy, DDS

DinoDMD I couldn’t agree more. Post: 13 of 49 OK, so let’s expand the Posted: 5/18/2007 list of why patients refuse Total Posts: 362 periodontal Tx recom- mendations: 1. They do not fully understand their problem. 2. They do not see value, urgency, need or benefit in Tx. 3. Office staff and doc are not on the same page. Anything else? So far, the reasons listed above why patients refuse perio Tx are all linked to communication skills. Effectively communicating perio to patients is no easy task. When patients have pain or a missing or fractured tooth, most already know what they need and will accept Tx with very little convincing. More time is therefore needed in communicating the Tx options than understand- ing the diagnosis since the patients already know the diag- nosis and it’s already obvious to them. Perio on the other hand is not so obvious to them often times. Therefore, with perio, more time needs to be spent in educating them to their problem than what the actual Tx options are. If they do not fully understand their problem, they will not be FREE FACTS, circle 2 on card

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able to accept any Tx option. No one wants a crown, but many know when it’s needed. No one wants perio Tx either, and most do not have anything else to go by other than our words when it comes to understanding the problem and why they need Tx. If we can not effectively communicate the problem in a way that they can relate to and understand, then gaining Tx acceptance will extremely difficult unless your dealing with a long-time patient who trusts the doc implicitly. And even then, it can be diffi- cult at times! With perio, focus more on learning how to better communicate the prob- lem, and watch your case acceptance soar! ■ Donato Napoletano, DMD

I disagree with much that has been written above. While education is saldoc important, it seems that the more I talk and “educate” a patient, the less Post: 16 of 49 likely they will go forward with the treatment. In my experience, people Posted: 5/19/2007 usually seem to be aware if their gums are not healthy: their gums bleed, Total Posts: 2.242 they have a bad taste in their mouth, they haven’t been to the dentist in several years, they never floss, etc. It usually doesn’t seem a total shock that they need SRP. While we don’t do anything too magical, it’s the rare patient that refuses SRP. Most of our patients have insurance so it’s really not too expensive. During my initial “interview” (which just takes a few minutes), one of the questions I ask is, “Do you feel your gums are healthy, do you ever notice them bleeding when you brush or floss?” That’s followed up with, “Have you ever had a deeper cleaning, where you get numb for the cleaning?” Those questions at least plant the seed that there is such a thing as a cleaning where you would get numb first. After I pull my chair back behind them for the exam, we eventually get to the probing. I’ll let the patient know that I’m checking their gums to determine what type of cleaning they need, a regu- lar cleaning or a deeper cleaning. I’ll take a few readings, call off a few numbers, and then tell my assistant (the Kushner talk over technique) what type of cleaning is needed. If they need SRP, I’ll briefly tell the patient that, “Instead of getting your whole mouth cleaned in one visit, it will probably take a couple visits, half at a time, and we usually get you numb so we can thoroughly remove the build-up and keep you comfortable.” And that’s basically it. I think the system works because they were prepped about the possibility from the initial questions, and because the patient is aware of the diagnosis at the time the diagnosis is made. It’s not a collection of data with a presentation at the end (which it would be if the doctor was not the one col- lecting the data). They hear me calling off a few deep readings, noting the bleeding and , and generally accept that something “extra” has to be done to get them back to health. ■ Sal

Sal, great post! Can you explain the list of questions that you do in the “prelimi- tquirt nary interview” with new patients? Thanks. ■ Timbo Post: 17 of 49 ■ Posted: 5/19/2007 ■ Total Posts: 821

Tim, you’ve probably heard them all before, since you’re also into the saldoc “Kushner thing.” But it generally goes like this: Post: 18 of 49 The assistant will leave my chair facing the patient in the op, so I Posted: 5/19/2007 won’t have to drag my chair in front of them as I enter. I’ll sit down, Total Posts: 2,242 introduce myself (just the name, no “doctor”), and usually shake their hand. First question: “What brings you in today?” Most patients have a story they continued on page 86

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want to tell, so I let them tell the story. Their particular story will usually illicit some follow up questions from me. I’ll reaffirm how long it’s been since their last visit (we ask that in our questionnaire), and ask if the last dentist saw anything that needed to get done. Whether or not the last dentist saw three crowns that were needed and not done, or if he thought everything looked perfect six months ago, is good informa- tion for me to know. I’ll occasionally ask why they left their last dentist; I’ll jokingly comment that I don’t want to make the same mistakes that the last guy made. Then, “Are you missing any teeth (they usually forget about the third molars)? Have you ever had braces?” and the perio questions above. At the Productive Dentist Seminar, they encourage you to find three “common bonds” with the patient before you delve into the teeth questions. Bonds like kids, how long you’ve lived in the area, questions about work, etc. I tried that, but it didn’t flow real smoothly for me. I’ve found that people are sitting there ready to tell their teeth story, not their life story, so I start with the teeth. As I roll my chair back to start the clinical exam, I’ll then ask some of the non-dental questions. That’s about it for the interview questions, and then I start the clinical exam. ■ Sal

mjreyn I once heard a speaker say you should never call SRP a “deep cleaning.” The rea- Post: 21 of 49 son being is if a “regular cleaning” costs $60, how much would a patient think a Posted: 5/20/2007 “deep cleaning” should cost? Maybe $120? Certainly not a few hundred dollars a Total Posts: 14 quadrant. I tend to say it a few different ways, but mostly I say it is a more thorough detoxification of the teeth and gums including the root surface, and that the disease present will not be helped by a routine cleaning which is reserved for none diseased tissues. I also try to stress the systemic implications of refusing treatment. You can also say there is new research supporting earlier perio, inter- vention. Also, on the CAESY, there is a print module function where you can print out handouts on just about everything from perio, restorative, systemic implications, etc. One more thing, I believe less is more. We all are pas- sionate about what we do and want to give our patients as much information as possible, but I think I once heard people remember less than 15 percent of what is said, so keep it short and sweet and give them something in writ- ing that they can look at in a less intimidating setting. ■

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