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Practice Quality

In January, 1997, Bob Levoy, management consultant for almost 3 decades, will have published a new text on practice development. It is one of his precepts for today’s practices that to stand out in the marketplace the individual practitioner must communicate an image of quality by demonstrating to patients that his or her practice has a sophisticated awareness of periodontal disease. It is this quality image which distinguishes practices in patients’ eyes and we hope this newsletter can serve as a guideline for your practice as you strive to stand out by the quality of your periodontal awareness to them.

Although your patients may seldom mention to you their wonders about their own periodontal condition they are constantly being bombarded with product advertisements for agents to help prevent periodontal disease. Periodontal disease is portrayed as the same threat to the mouth that aliens are to humans in a science fiction movie. Market surveys show a rising awareness of periodontal disease among the population and feelings of risk marked by increased product sales, the ultimate bottom line for manufacturers. Often this translates for dental practices into dealing with increase anxiety among patients which causes actions running the gamut from avoiding the subject to being paranoid about the problem. Patients are silently looking for information about their own periodontal condition. They hope they don’t have periodontal disease, but if they do they want to feel assured that their doctor will find it and intercede successfully to resolve it.

The most trust-producing approach to people’s unasked questions about periodontal disease is to demonstrate an attentiveness to it, even before they ask. Since people gauge attentiveness in dental practices by the time spent and intensity (thoroughness) of the process a consistent, multileveled approach to periodontal diagnosis and treatment will not only be most productive, but will also have the largest personal impact on patients.

A multileveled approach to communicating practice quality through periodontal awareness would include:
Periodontal disease screening for all new patients and those recall patients who have previously been found to be free of disease.

A comprehensive periodontal examination for those patients showing periodontal disease screening scores which indicate the presence of periodontitis. This includes both new patients and recall patients who have not previously had a full periodontal charting.

In-office initial preparation (if your office has chosen to provide these services), a specific visit for evaluation of your in-office initial preparation results, and referral criteria established and applied to patients who show active periodontal disease.

A tiered approach to periodontal supportive therapy which distinguishes between those who require only prophylaxis, those who require supportive therapy for stable periodontal conditions and those who need more intensive supportive care when compromised periodontal conditions cannot be more fully treated.


1. Demonstrate your awareness off periodontal threats to dental health by screening all patients for periodontal involvement before they ask for it.
2. Provide comprehensive periodontal evaluation to all patients with pockets over 4mm in more than one quadrant of the mouth.
3. Establish a tiered approach to periodontal care and maintenance with objectives, time commitments and fees understood by all staff.
4. Predetermine levels of disease which will be referred if unresponsive to your care. Advise patients of this before beginning treatment.
5. Watch for patient questions, the more effective your program the more people will want to know about their conditions and solutions.
6. Reinforce patients good decisions about care, as well as their success in home care and treatment.

Seeing this tiered approach to care, patients grasp the practice’s dedication to people’s periodontal needs. They view the practice as capable of providing valuable information and just the right solutions for them. What creates the image of quality is, in addition to this tiered approach, the way in which the visits are conducted. When new patients being received into the practice, maintenance patients without prior periodontal chartings, or maintenance patients without a history of periodontal disease are seen, a screening examination should be first used to rapidly determine the level of need for additional periodontal care. In many practices the hygienist will assume responsibility for this task with new patients, but the screening process should be explained to each patient as it’s performed. The American Academy of Periodontology has a complete screening system which recommends tracing each tooth to find pockets, but only recording a single number for each segment of the mouth which indicates the deepest pocketing found in the segment. We would be happy to assist you in using this system. Regardless of the system used, periodontal examination, including full periodontal charting, should be employed with patients whose pocket depths exceed 4mm in more than one quadrant.

The full periodontal examination can be completed as part of a comprehensive examination or be separated to be provided as an individual service. Many practices recommend a full new patient examination for patients of record who have a periodontal need and have not had a comprehensive examination in the past five years.

To further convey to patients the image of quality, the examination should be both detailed and systematic. The practitioner and his/her assistant should utilize a repeatable sequence of examination which allows the practitioner to report findings to the assistant and to have the assistant code the findings in a central location in the patient’s record. When patients both see and hear doctor and assistant efforts, they know each fulfills a role highly focused on discovery of information. The patient gains confidence in the process and the office. They themselves become focused on the information being gathered with the result that they are more inquisitive about their own mouth. When patient’s begin to question you it is a prime indication that they have become involved in seeking a solution and that trust is being developed.

Here is a sequence of clinical examination incorporating several levels which insures that no periodontal impact will be overlooked during examination:

  • Oral Pathology Level – screen for soft tissue lesions
  • Pre-restorative Level – record missing teeth, existing restorations, open contacts, extrusions and rotations of teeth.
  • Periodontal Status Level – test mobility, check for furcation involvement, subgingival calculus, overhangs on restorations, root grooves and level of gingival inflammation. This portion of the exam is often best done by tracing the sulcus base around each tooth with an explorer.
  • Support Recording and Disease Activity Level – record six probing depths on each tooth and indicate those measurements which bleed by circling the probing depth. The process is often facilitated by recording all the facial or lingual pocket depths in one arch (including recession areas), circling those areas which bleed upon probing, then repeating the process on the opposite surface of the same arch before switching arches.
  • Interarch Relations and Occlusal Function Level – record occlusal function, TMJ-status and arch relationships which impact restorative or orthodontic needs.
  • Radiological Review Level – confirm clinical findings with radiographs. This assessment may be performed prior to the clinical steps if films are available.

For the practice which performs initial preparation procedures, it is important to decide what levels of periodontal disease will be referred initially and what post-initial periodontal preparation conditions will be recommended for advanced care. When levels of disease have been established for referring advanced care, patients can be advised of this potential by all staff members providing treatment. This insures that patients will receive a consistent message. In addition the practitioner has less difficulty presenting other forms of care when an ideal result isn’t obtained with initial treatment or trial maintenance. This consistency of standards builds integrity with patients which is a basis for belief in the office’s treatment recommendations, periodontal or otherwise.

For a long time, the dental profession had an all or nothing approach to periodontal care, often placing those patients who had advanced problems but refused specialist care into the maintenance program. Hygiene care for those patients was much more difficult when pockets needed to be cleaned out in addition to prophylaxis completed. This was a burden to the hygiene staff and often patients assumed they were okay. Evolving now in the periodontal community is a tiered approach to care. One where prophylaxis is provided to patients with minimal periodontal involvement, periodontal supportive therapy to patients who have been treated for periodontal disease and their involvement is stable even if residual deformities remain, and compromise supportive periodontal therapy for those whose disease is still active. At each of these levels the focus of care is different. The prophylaxis patient will be screened for periodontal involvement, but the primary emphasis will be home care and coronal debridement. The periodontal supportive therapy patient will be monitored for deepening or residual stable pocket areas, the subgingival regions debrided as a primary focus, home care and coronal debridement effected. The intensive supportive therapy patient receives assessment, perhaps anesthesia, subgingival pocket debridement including smoothing of root surfaces, and counseling regarding actions and potential outcomes of additional care. Since actions by the dentist and his team require greater skill and effort as the care becomes more intensive, both fees and time regimens as well as recall intervals may be changed for these different patient groups. In this manner each patient becomes aware of their status at each recall. Those who are struggling become aware of it and are less likely to be overlooked in the day to day activity of busy practices, popping up with advanced problems at a later date.

When your patients see a consistent program in which their periodontal status is a primary consideration and care is tailored to their individual situation they will assign a higher image of practice quality to your practice. Helping patients to openly communicate their wonders and fears makes for good decisions on your patient’s part. And lastly, reinforcing their good decisions help them see a potential for successfully saving their teeth. This leads to a higher level of trust in other practice recommendations as well.

If you would like to further refine your in-office periodontal awareness program we would welcome the opportunity to provide assistance.
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