A Two-Part Series: Hygiene for the Sedation Patient – Diagnosing Disease

With preparation and a few adjustments to your normal hygiene protocols, periodontal treatment on patients with dental anxiety can make your practice more profitable and more enjoyable.

By Constance P. Fadigan RDH, BA

Practicing hygiene on sedation patients was one of the greatest pleasures of my clinical career. The work was fun, the results were fantastic, and the patients were happy to have a healthy mouth.

It takes just a few simple tweaks to your normal hygiene protocols to integrate non-surgical periodontal treatment when working on the high fear patient. While you’ll need to adjust your schedule, diagnostics, and insurance billing, these simple adjustments will make your practice more profitable and more enjoyable.

Studies have shown that “non-surgical periodontal therapy” for the whole mouth at a single visit results in a significantly better pocket depth reduction. Of course, the goal of good long-term results is paramount, and specific steps must be taken to help the high-fear patient succeed with a continuing care regiment.

Consider that, “Most new patients and even many existing patients will ultimately be diagnosed with periodontal diseases,” according to the Journal of Dental Hygiene in the Periodontal Treatment Protocol (PTP) article for the General Dental Practice. (2008)

What’s in it For the Patient and Hygienist

Patients will appreciate a better use of their time by coming in for one or two visits, as opposed to repeatedly taking time off work and finding a driver to take them to/from the dentist. Patients will feel like they’ve made a giant leap towards their oral health goals, and are more compliant during treatment, post treatment, home care, and recare.

As a benefit for the hygienist, you’ll enjoy greater access, greater pocket depth reduction, and eliminate cross contamination that may result from intervals of treatment.

Without painting too rosy a picture, there are some issues to consider. Long appointments can be fatiguing on the hygienist and on the patient. You may find patient compliance for continuing care compromised due to lack of relationship building and education time.

Diagnosing disease may have its challenges when an unsedated patient doesn’t want you to probe or use any tools, possibly not even to take X-rays. In this case, you’ll need to have a full arsenal of diagnostics to appropriately recognize areas of involvement. These are normally considered when diagnosing and treating, but in these circumstances they’re more significant until measurements and X-rays can be successfully taken.

Risk Factors

The list of periodontal risk factors is long and includes:

  • Age, gender, and medications.
  • Quantity and distribution of plaque and calculus.
  • Smoking, race, systemic disease; socioeconomic status, and level of education will point you towards the possible extent of the disease.

There are things you can see in the mouth with just a mirror such as:

  • The condition of the teeth.
  • Mobility, obvious caries, and malodor.
  • Obvious furcation involvement.
  • Position in dental arch, and within alveolus, occlusal relationships, and the evidence of trauma.
  • Super eruption or broken teeth and the current condition of restorations.

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A tissue assessment will provide added clarity. The color, contour, consistency, purulence, keratinized and attached tissue; recession and supragingival deposits and biofilm all point at what’s going on with bacteria, infection, and under the gingiva.

Also, carefully consider the time since the patient’s last visit to a dentist for routine care. If the patient will allow, take X-rays so you can see subgingival deposits and bone loss.

Recognizing any of these characteristics in a treatment area (whether you treat by quadrant, sextant, or other philosophy) should designate it as an area of disease. Measurements are used as a definitive diagnosis of disease but are one of many tools used to determine the extent of disease.

Since determining the exact extent of disease may not be possible at the initial visit, a definitive diagnosis will depend on the probe readings taken at a sedated appointment. In this instance, you may wish to use a test appointment to treat an area of pain and complete the initial exam including full mouth probing and full periodontal evaluation (probing, bleeding, clinical attachment, furcation, recession, mobility, plaque score). 

At this point, you will need to bring the patient back for a consultation appointment.

Be sure to check back in the next issue of the Incisor as we conclude the second half of this discussion on the scheduling, treatment, and billing for dental hygiene on the sedation patient.

Author: Currently DOCS Education's Chief of Staff, Coni Fadigan has been a central figure in its founding, growth, and ongoing development. A registered dental hygienist, she’s been an essential resource for founder and president Dr. Michael D. Silverman, as well as the more than 24,000 dentists and dental professionals who have embraced sedation dentistry on behalf of their patients over the past 20 years.

References:

1. Advanced Hygiene Concepts (800) 400-6772

2. Mongardini C, van Steenberghe D, Dekeyser C, Quirymen M. One stage full-versus partial-mouth did infection in the treatment of chronic adult or generalized early onset periodontitis.  I. Long-term clinical observations. J Periodontol 1999;70:632-645.

3. Trieger, Norman DMD, MD. “Periodontal Infections”.

4. Sweeting, Larry A., DDS; Davis, Karen, RDH, BSDH; Cobb, Charles M., DDS, PhD. Periodontal Treatment Protocol (PTP) for the General Dental Practice. J Dental Hygiene.  2008. Special Supplemental.  Pg 16-26.

5. Wilkins EM. Clinical Practice of the Dental Hygienist, 7th ed.  Philadelphia: Lea& Febiger, 1994.

6. Perry, Beemsterboer, Taggart. Periodontology for the Dental Hygienist, 2nd ed. Philadelphia: WB Saunders Co., 2001. Oral and Maxillofacial Surgery Knowledge Update, Vo1, Part II, 1995.

7. New Patient Packet, LLC. 2011

8. Sweeting, Larry A., DDS; Davis, Karen, RDH, BSDH; Cobb, Charles M., DDS, PhD. Periodontal Treatment Protocol (PTP) for the General Dental Practice. J Dental Hygiene.  Table 2. 2008. Special Supplemental.  Pg 26

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