The treatment phase of Supportive Periodontal Therapy generally runs ten minutes or less.
Let that sink in.
Long term care must not involve over-treatment. Over-treatment is where the one performing the therapeutic procedures feels good because she or he is “working hard” to help the patient, and yet the treatment itself is either of no benefit or does harm.
We learn to over-polish and over-scale and root plane while in dental and dental hygiene schools. This is because it is very difficult to detect over-treatment, and every novice quickly learns to identify stains and supragingival calculus associated with under-treatment. Also every procedure has a simple short-term objective, and that is to prove to our instructors that we have acquired the skills to graduate. But over-treatment is also reinforced after graduation. Over-treatment is rewarded in the short-run by increased revenue. Under-treatment might reflect poorly with an employer or it will just bug us because we remember what it felt like when instructors pointed out our deficiencies.
When patients report that procedures are uncomfortable during SPT, this is a clue that over-treatment may be occurring. Keep in mind that we should be managing patients with low inflammation, which should translate into low gingival tenderness, both to probing and light instrumentation. If you pride yourself on doing a good job, but your patient’s consider you a little heavy-handed, I challenge you to rethink what you are doing. Remember, SPT is the management of patients hopefully for years. It involves more assessment and communication than it does instrumentation.
I am very aware of the fact that my position here about brief low impact treatment at SPT visits is not taught, and therefore, likely not practiced by most hygienists and dentists at this time. It can easily be dismissed by concluding that I have low standards of care. This is not the case at all. I do, in fact, believe in a very high standard of care. It’s just that I think many of us are mistakenly using the wrong standards. To illustrate this in a very practical way, let’s discuss pipe smokers in SPT.
Everyone who ever has had to clean the stains of a heavy pipe smoker knows how difficult this can be. Certainly, the therapeutic phase for this group will run more than ten minutes, right? Wrong.
First, let’s not get distracted here as to whether or not it is a good idea for people to smoke pipes. That’s a discussion for another time. Let’s assume that we are dealing with an individual who does not plan to change his behavior. Under hygiene school rules, I grant that this individual will be in the chair a long time, every time. But now consider what will happen to the teeth if this polishing procedure is repeated every three months for ten years. Also recall the majority professional opinion when it comes to patients using smoker’s toothpastes, or any other paste that promises pearly white teeth. Question: If we do not recommend strong abrasive toothpastes, why will we do strong abrasive procedures at tight intervals ourselves?
When a pipe smoker comes for SPT, the purpose is not to deal with the stain – at least not every time. Instead, we need to discuss the problem of over-treatment with our patients and the fact that it is easy to polish away tooth structure that will never grow back. Therefore, we and our patients need to come to an agreement as to how often pipe stains should be removed. My recommendation is usually to remove the stain once a year from all surfaces with the exception of the esthetic zone. It is not my intention to punish the patient by not cleaning to maintain a nice smile. I want him leaving looking good and feeling fine. Aggressively removing the stains on the lingual of his lower central incisor does neither of these. In addition to this, I will provide the subgingival care that is the primary therapeutic reason for his visit. Now if the patient insists that I or a dental hygienist do more to remove the stains in general, then he will sign a waiver acknowledging the long-term risk and also the fact that this service will come with an additional fee.
The objective of the therapeutic phase of SPT is to disrupt bacterial plaque colonies in pockets deeper than 3mm. The power level we will employ is no different than what we recommend to patients when it comes to brushing and flossing. This is best accomplished by an ultrasonic periodontal tip set at moderate to low power. Here and there you might need to use a hand curette or scaler. I generally polish with a prophy jet, but again, the process is brief. Rubber cup polish is fine as well, I just don’t find it gets between the teeth where dentin is exposed as is common with periodontal patients. That’s really all there is to it.
I hope what I have described here has struck you by being profoundly simple. Disruption of plaque where patients can’t reach, taking just a few minutes of your time, is important, but not all that difficult to accomplish.
Remember if the bleeding index rises over 20% or pockets deepen past 5mm, we are no longer talking about SPT. There are times when active therapy measures must be used, like repeat scaling and root planing, but these may need to be scheduled for another time. Scheduling for more definitive procedures may actually end the SPT appointment at this point. The general light instrumentation measures can be accomplished later at the next procedural visit.
If the subgingival cleaning is not performed because other treatment becomes necessary, does this mean that the SPT procedure is incomplete? No, the primary purpose of SPT to detect reversal in periodontal health early has been achieved. The cleaning element is incidental. It can be accomplished at the next visit along with the next therapeutic procedure. My point is that unlike a prophylaxis procedure, cleaning is not the goal or emphasis of SPT.
Is it possible to accomplish the root planing at the SPT appointment? Yes, if you have time to accomplish the task and the patient, after being informed, agrees to the procedure along with the additional cost. Also if the problem was detected by the hygienist, the dentist must become involved before the treatment plan is established and recommended. All of this takes time.
What about subgingival irrigation? There are no long-term beneficial effects to adding subgingival irrigation beyond that used by the ultrasonic tip as described above. This is because plaque is not effectively disrupted subgingivally by water, even at high pressure. Touching plaque with an instrument is more effective by far. But even if you have a medicament that has been shown effective in killing plaque, it is still of little benefit subgingivally long term because there is a steady outward flow in pockets that removes and dilutes these agents. We call this Gingival Crevicular Fluid. Only those medicaments like Arestin that are introduced in a solid state and that linger and dissolve over time show any long-term effect beyond the simple measure of plaque disruption.
But what if patients “expect” to have a certain cleaning during SPT visits? People expect the wrong things when they have not been adequately informed as to what they should expect. We will get more into this later when we discuss how to explain periodontal disease and it’s treatment to new patients. If you have patients who have been coming to you and you have been performing certain procedures that you now consider too aggressive, the best way to approach this is with a conversation. I never try to change my care with patients without informing them of what I am doing and why. This may take more than just a few minutes, but is something easily planned for when you take the long-view of supportive therapy.
Next time I will discuss documentation.
After this, I believe we will be ready to wrap the topic of SPT up and move on to the next subject.
Again, if you would like my white paper on SPT (once I write it, which will follow my final post) then simply let me know. Looking at my schedule, I will likely complete all of this sometime in the middle of January, not by the end of the year as I thought earlier. Oh well. Such is life. Thanks to all of you who are writing me back great comments and observations.
Happy Holidays!