Perio-loading the daily schedule

I once overheard a dental receptionist tell a dental assistant to overload the dentist’s schedule with periodontal procedures because his daily schedule was light and full of holes. What bothered me most about the statement was my impression that this periodontal treatment (scaling and root planing (SRP) with and without adjuncts) was now being viewed as a revenue-generating source. It didn’t bother me that patients would be placed on the schedule who were already diagnosed and treatment planned for a nonsurgical periodontal procedure. Instead, what concerned me was the possibility that this particular periodontal procedure was being viewed by staff as a proprietary service that can be used to increase daily profit. Ethical patient care decisions must always come first before commerce, so perhaps we need to review professional integrity as it relates to the delivery of certain periodontal procedures in a general dental practice.

There is no doubt that nonsurgical periodontal therapy, if performed according to evidence-based clinical guidelines and based on a diagnosis of periodontitis, should be considered first-line therapy. These recommendations are supported by evidence with a moderate or high level of certainty.¹ Clinical guidelines also suggest that hand and ultrasonic instruments in combination improve performance of SRP in locations where access is poor.¹

In 2015, a panel of experts selected by the American Dental Association (ADA) Council on Scientific Affairs published an evidence-based clinical practice guideline and systematic review (SR) on nonsurgical treatment of patients (SRP) with chronic periodontitis with and without various adjuncts.²  

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SRP shows a moderate benefit, and benefits seem to outweigh potential adverse effects like damaging the root surface or tooth/root sensitivity. ² For patients with moderate to severe periodontitis, systemic subantimicrobial doxycycline (20 mg twice a day) for 3-9 months may be used as an adjunct to SRP and clinicians should expect a small net benefit. ² Systemic antimicrobials studied, including amoxicillin and metronidazole, metronidazole, azithromycin, clarithromycin, moxifloxacin, and tetracyclines (including doxycycline at an antimicrobial dose of 100 mg or greater a day) should provide a small net benefit for patients with moderate to severe periodontitis but potential adverse effects require pretreatment screening for allergy and patients need to be closely monitored during therapy. ²

The strength of evidence for chlorhexidine chips and photodynamic therapy with a diode laser are weak. In considering doxycycline hyclate gel or minocycline microspheres (local antimicrobials), evidence to support their use is unclear but experts on the committee recommend their use. The nonsurgical use of other lasers as SRP adjuncts are not recommended by the experts because there was uncertainty regarding their clinical benefits and benefit-to-adverse effects balance. ²

Has dental hygiene and dentistry embraced evidence-based practice (EBD) initiatives throughout its system in the same way that medicine/nursing has done? Are we making evidence-based care decisions for our patients based on strength of evidence, clinical expertise, and patient need or preferences? Or are we basing our decisions on profitability quotas? 

I read a ton of dental hygiene blogs and what practicing hygienists complain a lot about is being weary and frustrated because they are expected to work an unrealistic schedule and one that cheats patients of quality care. They are frequently rushed and expected to perform services with substandard equipment and in a way that pushes them beyond their professional limits. For example, I read about hygienists who are expected to work two columns of patients instead of one and some employers are pushing them to “sell” services to patients, whether they need them or not. SRP is viewed as a way to increase daily productivity and the emphasis is on profitability quotas instead of improved periodontal and overall health. Professional oral irrigation as an SRP adjunct with various oral irrigants like chlorhexidine gluconate is also being added to the SRP treatment plan despite a lack of evidence to recommend it.

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If you find yourself working in a toxic dental practice environment where profitability quotas are king and there’s little regard for ethical, patient-centered care, what can a dental hygiene provider do? 

• Review ethics and commit to being a provider of service, not a commodity. Recognize that you might be misplaced in a particular practice. As professionals, our obligation to patients requires a more beneficent posture and our priority is not the profit motive of a retail shop.⁴

• Learn the new 2017 classification system for periodontitis and apply it to diagnosis and treatment planning.⁵ Recognize limitations of initial therapy (SRP) and refer patients to a periodontist if the patient has unresolved inflammation, or continued bone or clinical attachment loss. Make a list of other reasons to refer a patient to a periodontist and don’t suggest to the patient that your practice can manage their condition. Let the patient make that decision based on a specialist’s assessment. The law looks unfavorably upon the following lapses of judgment by a dental provider:
• failure to diagnose and failure to inform the patient of the diagnosis

• failure to inform a patient of the availability of treatment

• failure to inform patient of limitation of various treatment modalities

• failure to inform patient of consequences of not receiving treatment

• failure to treat a disease in a timely and appropriate manner or within the standard of care

• failure to refer the patient for treatment when possible and when deemed necessary⁶

• Assume ownership for a way of practicing that integrates best available evidence, clinical expertise, and patient preferences. Expanding your view and approach to patient care requires education in evidence-based dentistry. Just the thought of learning anything involving research scares a lot of people, but it gets easier once you decide to learn it. Start with the ADA Center for Evidence-Based Dentistry and sign up for workshops that are taught by EBD leaders in dentistry. You will gain firsthand experience by incorporating the latest scientific research into practice. Become familiar with the Cochrane organization, a highly respected authority of evidence-based dentistry and read the Journal of Evidence-Based Dental Practice.

• Lastly, when a patient thanks you for your professionalism and attention to detail, remember what you did to earn it. Professionalism is a lot more than wearing scrubs and being polite. It implies a set of values like fairness, integrity, honesty, service beyond oneself, respect for the human dignity of everyone, a passion for quality, and a commitment to excellence.⁷

If you find you cannot negotiate a more ethical and less toxic work environment, update your resume and understand that you and your patients are worthy of more.

References:

1. https://www.ncbi.nlm.nih.gov/books/NBK401542/
2. https://ebd.ada.org/en/evidence/guidelines/nonsurgical-treatment-of-chronic-periodontitis
3. https://www.theatlantic.com/magazine/archive/2019/05/the-trouble-with-dentistry/586039/
4. https://www.cda.org/portals/0/journal/journal_072013.pdf
5. https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.18-0006
6. Cobb CM, Callan DP. Flash point in periodontics: patient referral. Triage 2005. 1(2): 12-16.
7. https://www.cda.org/portals/0/journal/journal_072013.pd