We are often asked by the patient and their dentist if supportive care can be provided off-site. The information presented here is to show you the structured and detailed nature of our hygienist appointments for periodontal maintenance at PerioCARE.
If possible, encourage your patient to schedule a 60min session to allow for sufficient time for homecare review and periodontal charting. Shorter appointments are more suitable for patients who are not susceptible and had not experienced periodontitis.
It is our experience that if you work efficiently, quickly yet gently and carefully, most patients will not have an issue if you advise them that they require more time due to their presenting condition. If your patient is very resistant to having additional time for supportive care, this will be biologically obvious at their next re-evaluation visit with Dr. Lingfeng Soo or at their periodic check ups with the family dentist or prosthodontist. This will be discussed and managed as part of their new treatment plan.
Before the appointment
- Understand the overall treatment direction.
- Do not instrument teeth scheduled for extraction.
- Make a note of any dental implants and the type of prosthesis.
The first 5 min at the beginning of the appointment
- Collect an update of the patient's medical, dental and recent smoking history. Make a note of any new crown and bridge work so that you can check that the patient is making the appropriate adaptations to their homecare.
- Screening soft tissue check.
- Quick assessment of the amount of plaque and debris present. Do a quick probe around all sites on all teeth. Walk the probe around each tooth.
- Inform your patient up front first if they require more chair time for a thorough clean. Preferably schedule the additional visit within 1-2 weeks. If the patient is resistant suggest a longer appointment or multiple appointments for the next recall cycle, if this is clinically appropriate.
- Inform your patient at the beginning of the appointment if they have severe disease that requires a referral to the dentist or periodontist for treatment planning. In which case the goal of today's appointment is a gross debridement and introduction of concepts such as the Bass technique and interdental cleaning.
- Probe around all implants and document bleeding sites and probing depths.
- Obtain bleeding scores and record sites of 4mm or more probing depths. Note areas of active break down. The goal is to maintain bleeding scores of 10% or less and probing depths measurements of 4mm or less. Pus or suppuration should not be present. (You may not have sufficient time to do this if the patient has many diseased sites or if it's a 40min visit. Do the best you can, inform the patient and make recommendations for a proper assessment with the dentist or periodontist. Document this in the patient's clinical notes. Ensure that you spend the majority of the appointment on the debridement process.)
The majority of the appointment
- Teeth: Ultrasonic cleaning of the root surface using a fine or slim tips. Curved tips will be helpful. Start with the most posteriorly located tooth, the distal lingual or distal palatal sites. Finish the session at the incisors. Set the power setting at low power if the newly accumulated deposits are soft. If the patient hasn't attended for care for some time, you may need to just do the best you can and adjust the power setting and administer local anaesthetics. Clean one tooth at a time systematically before you move to the next site and next tooth.
- Dental implants: Clean the implant shoulder and abutment with a rubber cup and brushes. Use brushes that will fit. Try the Tepe interdental brushes, the Tepe compact tuft and the Tepe implant care brushes. If there is bleeding, dip the brushes in some Curasept gel first. Remove hard deposits carefully and as thoroughly as you can.
- Re-treatment: Do the best you can.
- Administer local anaesthesia as required.
- Clean as much as you can and as thoroughly as you can for that particular appointment. For the typical patient, spend 2/3 to 3/4 of your time around the molars and premolars.
- Removal of stains.
After maintenance debridement take 5min for the following
- If your patient has alot of debris, defer this part of care until the next visit.
- Revise brushing and flossing techniques in the mouth. Take intra-oral photos to show patient the distal lingual sites of the lower posterior teeth or the upper molars. Or the lingual aspects of the lower anteriors.
- Make recommendations for oral hygiene aids and products. Make it as simple as possible, tell them what to buy and where to buy. Check with your patient that they have sufficient stock of supplies at home.
- Create daily routines with the patient.
- Encourage your patient to clean their teeth at the same time each day and use the same sequence of brushing each time. (We found that doing it once a day thoroughly and really well is more effective than twice a day not so thoroughly. Many patients find it difficult to keep up a labourious routine twice a day.)
- Apply re-mineralizing pastes and fluoride to the teeth. Do this last before the patient gets up from the chair.
The last 5min of the appointment
- Together with your patient read the periodontist's treatment plan and check whether the patient is still on track. Discuss with the patient their clinical targets for the next visit.
- Arrange a re-evaluation with the periodontist if there are persistent deep sites of 5mm or more.
- Arrange a referral to the dentist/prosthodontist if there are any anomalies or concerns such as signs consistent with caries or root canal issues.
- Manage peri-implant problems pro-actively. Notify the periodontist/ prosthodontist/dentist when you observe hard deposits and/or probing depths of 5mm or more with bleeding spots around the dental implant. Notify the dental team if there's persistent bleeding sites around the implant. Adjust the recall to 3/12 never put the patient on 12/12 recall.
Checking out at the end of the appointment
- Remind your patient to arrange a check-up or examination with the dentist particularly if it has been more than 12 months since their previous check-up.
- Remind your patient to arrange a full mouth re-assessment with the periodontist to update their treatment plan if it has been more than 24 months since their last visit.
- Set the recall cycle, encourage your patient to schedule the next visit on checking out at reception.
At PerioCARE we assign a chair-side assistant for supportive care. For collection of periodontal charting as well as suctioning and doing changeover after each patient. This means that our patient has the full appointment with our hygienist for clinical management and this is reflected in the patient fee. For most patients this represents excellent value, the alternative is supportive care visits with Dr. Lingfeng Soo with associated fee.
Review of toothbrushing techniques within 2 weeks
We offer a 20min 'aftercare' oral hygiene check at no additional fee. We ask the patient to bring their toothbrushes and often we find that the patient is more receptive to homecare recommendations as that's the only task for that particular appointment. Outside of the two week period, there will be a separate fee for oral hygiene review.
Final note for clinicians
Over the years we've found that this system works well for the high risk and highly susceptible patient. Patients who have been under our care for a while understand this concept and will automatically book two sessions one week apart or bring forward their SPT recall appointment if they have been taking short-cuts with their homecare.
This protocol forms the basis of the job description for our hygienists. Should you choose to integrate this system at your practice, please contact us and we will be able to assist you with specific information. Click here to take you to the AAP's statement on what constitutes supportive/maintenance care.
The information presented here is for information gathering purposes only. It is not a substitute for clinical advice.