I lost a patient last week. She didn’t die. She left the office; angry. I regret that she was upset with me. I did what I was supposed to do, but it wasn’t what she wanted. I’ll attempt to explain the view from in between the rock and the hard place.
You see, she “just wanted a cleaning”. Everybody just wants a cleaning and I don’t blame them. A “cleaning” is a relatively non-invasive procedure that is not uncomfortable for most people and it makes you feel good to have those polished, shiny teeth. The hygienist is usually a good conversationalist and how you all can talk so much during the procedure I’ve never figured out, yet there is an acknowledged social aspect to the visit. Hopefully there is some education imparted, useful information exchanged, maybe some minor improvement to the appearance of your teeth and even a tiny bit of improvement in your oral health. Yes. I said “tiny”. You see, the dental “cleaning” may be one of the most misunderstood and abused procedures in dentistry.
A dental prophylaxis, by definition is a procedure performed for a person who has healthy gums to help keep them healthy. It can involve minor scaling of the teeth and a polish to remove minor stain, all above the gum line. The proactive hygienist will also assess your ability to keep your teeth clean, your gums healthy and teach you about health and prevention technique. That is a “cleaning” and everyone should have as many of those as you want. It’s all good.
Here are some things you may not know about a “cleaning”. A hygienist works under the direction of and by prescription from a dentist who is responsible to perform an examination and make a diagnosis. I need to repeat that. The dentist is responsible for performing an examination and making a diagnosis. Additionally, a “cleaning” is not therapy for gum disease and as many as two-thirds of you have some degree of periodontitis or gum disease even though you may have regular “cleanings”.
A dentist must perform an examination for you once a year to meet standard of care guidelines, at which time he/she would assess the state of health of your teeth, gum tissue, restorations, bone support TMJ condition, oral cancer screening and maybe even a screening for sleep apnea. If the patient is healthy, with no significant inflammation or infection in the gums (bleeding is infection) then a prophylaxis may be prescribed. If, however, gum disease is evident, definitive therapy options should be discussed and will likely involve more treatment than a routing cleaning and you may then accept or decline the recommended treatment.
The prescription for one or more “cleanings” may be in effect for the year to follow and the hygienist may then deliver the service under supervision but without additional examination. The hygienist may also deliver definitive therapy for periodontal disease in the form of root planing, or “deep cleaning”, administer some medicaments, perform laser therapy and other service as prescribed.
So what happened in the unfortunate situation with my patient? The previous examination was fourteen months prior. She wanted “just a cleaning” citing financial concerns. It was explained that if dollars were a concern, the greater health benefit in this circumstance (and the legal standard of care) is the examination, which may include x-ray films if appropriate at the time, and I suggested substituting this for the cleaning. The focus is on health. Delaying the opportunity to make an adequate diagnosis for decay, leaking restorations, gum health issues, etc. creates an unnecessary and unacceptable health risk for this patient and increases liability for both the dentist and the hygienist. “Just a cleaning”, on the other hand, provides little improvement in her health if she is already healthy, yet will not likely improve her health if she has active gum disease and needs an alternative therapy; an inappropriate and/or unnecessary procedure.
I hope this may give you some new perspective and understanding of this situation which we frequently face. My passion is to help people become healthier and suffer less and, in fact, with such emphasis on early diagnosis and prevention it can be construed that dentistry is one profession that works very hard to put itself out of business. We ask only that you give us an opportunity to do it right. Then you may have all of the “cleanings” you want.