Why don’t my patients perceive a difference?
By Shanalee Ackerman
Why don’t patients understand the difference between periodontal maintenance and a prophy? In many instances patients state that the “cleanings” feel the same, but cost more. The complication arises in our own understanding of the clinical differences between a prophy and a periodontal maintenance appointment, the struggle to develop the proper verbal skills to discuss these significant differences, and helping patients feel the difference.
The dental prophy is intended for people who do not exhibit any of the signs or symptoms of periodontal disease. Symptoms of periodontal disease include:
- Bone loss,
- Exudate, and
- Recession with or without furcation involvement.
A prophy is a preventive procedure for patients who do not have periodontal disease and should only be used with patients who are periodontally healthy. The CDT-14 book of dental codes published by the ADA defines a prophy: “Dental Prophylaxis – D1110 – Removal of plaque, calculus and stains from the tooth structure in the permanent and transitional dentition. It is intended to control local irritational factors.” A prophy, therefore, is for healthy patients and is intended to help keep them that way.
Periodontal Maintenance Defined
In contrast, periodontal maintenance, D4910, is defined in the CDT-14 book as follows: “This procedure is instituted following periodontal therapy and continues at varying intervals. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planning where indicated, and polishing of teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.”
By definition, periodontal procedures are subgingival in nature. Periodontal scaling requires additional skill and expertise when compared to a routine prophy. Patients with periodontal disease, regardless if it is active or currently maintained, have the scars associated with the periodontal disease, including bone loss, recession and pocketing. Periodontal disease is a bacterial infection that overwhelms the body’s immune system and results in the individual’s own immune system to initiate a breakdown of supporting tooth structures. Periodontal disease can also be episodic. The mouth can get re-infected and the body’s immune system can reinitiate the breakdown of supporting tooth structure. Destructive episodes can occur with no knowledge of the patient and can be triggered by stress, disease, or other systemic and localized problems. Therefore, when a patient has experienced periodontal disease in the past, more diligence is required on the part of the practitioner to monitor for signs of active disease long after the disease has been brought under control through good periodontal therapy.
According to the above description, a true periodontal maintenance visit will follow active periodontal therapy, such as scaling and root planning. With active therapy the hygienist’s goal is to remove as much subgingival debris as possible and disrupt and destroy the bacterial proliferation below the gumline. Following active therapy, the purpose of periodontal maintenance is to debride the sulcular areas of attached and non-attached plaque pathogens in a frequency that will allow the body’s own immune system to overcome and battle the periodontal pathogens, and keep the bacterial levels under the threshold of infection.
Helping Patients Understand the Difference
To be successful in ensuring that patients are able to distinguish between a prophy and a periodontal maintenance visit, it is essential that they understand that you are managing and controlling a disease resulting from a bacterial infection. That disease is controlled though proactive periodontal maintenance visits. With this understanding you will be able to discuss the benefits of therapy with the patient, ultimately resulting in greater patient compliance and understanding of their treatment needs.
The benefits of periodontal maintenance treatment primarily include what the patient wants which is to:
- Save money,
- Maintain or improve appearance,
- Save time
- Maintain comfort or
- Improve health.
Patients invest in their treatment based on their reasons, not your clinical knowledge. When discussing the treatment needs with the patient, you will achieve greater success when you discuss it in terms of what the patient said he or she wants to achieve, not what you will give him or her. Furthermore, utilizing a sense of urgency will convey the seriousness of the disease and the necessity of ongoing care. Convey to patients that you are concerned about the condition and strongly recommend said therapy and maintenance visits to help them achieve what it was they said they wanted.
Finally, ask patients open-ended questions such as, “What do you see as the importance of your perio maintenance visits in helping you achieve your health goals?” Or, “What do you see as the biggest difference between the routine cleanings you have received in the past and the perio maintenance visits you will have in the future?” Asking open-ended questions allows patients to verbalize their understanding and gives you the opportunity to clarify before scheduling their treatment. When your patients understand the benefits of the periodontal maintenance visit, in terms of what they want, they are more apt to comply with recommendations because they have developed a relationship and rapport with you as their provider, and they will trust your recommendation.
Helping Patients Feel the Difference
In building value for periodontal maintenance for the patient, there must be a perceived difference in the treatment performed. A prophy should be “coronal” in nature. Many hygienists do subgingival scaling on patients who are not periodontal patients. The true definition of a prophy implies that the patient would exhibit healthy gingival tissue, does not bleed upon probing, and has no pocketing greater than 4mm. A prophy should not feel like a “deep” cleaning because there should be no areas to debride subgingivally. A prophy should be a simple procedure, often times without the use of the ultrasonic scaler, on a patient that does not have significant subgingival deposits or periodontal pocketing. In contrast, a periodontal maintenance visit should include scaling supragingival and subgingivally as well as using the ultrasonic for at least 75 percent of the scaling in a periodontal maintenance visit.
Ultrasonics are more effective at debriding pathogens than hand scaling, largely because of the lavage and the acoustics created by the tip. It is advisable to make several trips around the mouth, making sure you visit and revisit all sulcular areas. The purpose of periodontal maintenance is to actively disrupt pockets of pathogens that may trigger an immune response. Consistent irrigation and disinfection of the pockets, possible soft tissue curettage, and subgingival scaling is critical in the maintenance of gingival health.
So the next time a patient complains about the cost or necessity of a perio maintenance appointment, remember the following. When patients:
- Understand the difference between a prophy and a perio maintenance,
- Can articulate the difference,
- See the personal benefit, and
- Can feel the difference between the two,
they will have a greater tendency to show up for their appointments consistently, pay for those visits, and refer others to your practice. It starts with your own understanding, verbal skills and delivery of the proper clinical treatment.
Shanalee Ackerman, RDH, MBA is a practicing dental hygienist and Practice Advisor for the Total Patient Service Institute. Working with hundreds of dental teams across the US, Shanalee is credited with increasing their production, productivity, and profitability through the implementation of proven clinical and case acceptance systems.