Spotting Trouble: Best Practices for Noticing All The Things You Can See In Your Patients

This is the first article in 2-part series on spotting trouble early on during hygiene visits.

Ready, set, go! Retrieve Bob from the waiting room, get him back in the chair, pick and scratch all the tartar, have a great conversation in less than 2 minutes with the dentist, and high-five Bob on the way out. Sound familiar? Dear standard hygiene routine, you are exhausting and unfulfilling! Not to mention missing incredible opportunities to change lives.

The mouth is a treasure trove of information. Yet, when the schedule is tight, it seems quality assessment is the first to go. Perhaps it should be the only thing to stay… Bob does need to ditch the tartar, that simply isn’t the most important part of our time together. Bob might have oral cancer, be struggling with bruxism, or in love with the latest lemon water cleanse craze. In any of those cases, we have bigger fish to fry than Bob’s tartar on his lower anterior linguals, premolar line angles, and buccal of upper molars.

Let’s re-work Bob’s appointment. Rather than calling Bob like a dog from the door to the waiting room, walk right up to him with an outstretched hand and kind greeting. Gather him into our care and have a seat in the operatory. A thorough conversation about Bob’s medical history, current medications, chief concern, and today’s blood pressure reading is the most important part of the entire appointment. How the heck is Bob? We have to know at the beginning!

Today is the day that Bob is due for radiographs. We begin taking the films and decide horizontal bitewings are not going to give us quite enough information about his bone health. We elect 3 vertical bitewings on each side, 2 upper anterior periapicals, and 1 lower. As we are acquiring the films, we cannot settle for less than stellar pictures. Retakes are quick, cheap, and easy. Let’s grab them!

Next up: extra- and intraoral manifestations of trouble. “Bob, we are going to start with an oral cancer screening. Let me know if anything is sensitive or bothers you.” It is best to keep this explanation simple. It is common for hygienists to over-explain what they are doing if it is something new or something that is making us feel uncomfortable. However, our patient, “Bob”, does not care about our rationale behind this part of the appointment. If Bob does care, he will ask. In that case, it is reasonable to say, “I want to make sure that everything looks and feels normal for you. If trouble of any kind arises, catching it early is our best chance for success.”

During the oral cancer screening take note of Bob’s coloring and symmetry, check his lymph nodes and jaw. If Bob's jaw ever hurts, this is an excellent time to brainstorm about what is causing the pain and how to remedy it. Often, a simple 10-to-20-minute walk at the end of every day is helpful enough to relax Bob into a more peaceful state of mind and a more restful night’s sleep. Obviously, that is not the only way to help people with temporal mandibular jaw (TMJ) disorders, but many people just need to chill out so their TMJ will feel better. Also, in our culture taking time to let the amygdala rest, enjoy nature, and move our body is the simplest, most overlooked, highly effective medicine there is. A conversation about going for a walk after work to help Bob's jaw pain is an example of how we know a thing or 2 about whole health and that we care about Bob. Have you ever heard of the adage, “People don't care about how much you know until they know how much you care?” That is exactly why we are taking our time to do a thorough assessment.

We also want to know, how is Bob's thyroid? Out of the estimated 20 million Americans with thyroid disease, 60% of those people are unaware they have trouble, per the American Thyroid Assocation.¹ For many people, we are the only health care professionals palpating their neck. It is typical for men to go decades without a health physical. Depending upon the type of healthcare provider a woman has, her primary care physician might not check her thyroid either. This is further evidence that we (dental professionals) must be making a thorough effort for these patients we love so much.

Once we have observed and palpated Bob’s face, jaw, and neck it is time to lay him back and take a look on the inside. Does he have petechiae on his soft palate? What do the inside of his cheeks look and feel like? Does he have white, lacy, lattice lines on his cheeks? Perhaps Bob has lichen planus that we need to help him address.

Is there anything noteworthy in his vestibule or under his tongue? Speaking of his tongue, how does it look and feel? Is there anything abnormal with the shape, color, and/or texture? Does it appear that his tongue is resting in a place that indicates trouble breathing, eating, or speaking? We are learning that the tongue tells more of the story than we originally thought.

Are Bob’s saliva glands working? How big are his tonsils? Does Bob struggle with strep throat, allergies, or sleep apnea? Maybe myofunctional therapy is the best next step for Bob’s life.

During this visual and tactile exam, we can catch trouble. The earlier the better. It is our sincerest hope that we never have to find cancer. But how would we feel if we were the healthcare professional that missed it for Bob?

Moving on to Bob’s hard tissue. Are his teeth worn down to little nubbins? Does it appear that he has scrubbed his teeth so clean that much of the supporting structure is no longer present? Or how about methamphetamine use? Does Bob have black, bombed out teeth that suggest an addiction to drugs or Mountain Dew? Are the insides of his teeth eroding, indicating GERD or even an eating disorder? And when Bob bites down on his back teeth, does his occlusion look healthy? Personally, I have had many adult patients seek orthodontic care because their occlusion was causing trauma to the hard tissue and devastation to the soft tissue. We can treat perio pockets all day long, but if we never get to the root cause of the issue, such as traumatic occlusion, we will never be successful.

The moment we have all been waiting for: the perio chart! “Hey Bob, 1-3 mm is normal and healthy gums don’t bleed or hurt while I am measuring.” Once the probe depths and bleeding points have been recorded, we need to know about recession and furcations. Does Bob have clinical attachment loss causing mobility? Let’s write that down too. While we gather this information, we must say it all out loud. If we do this, we never have to tell Bob he has periodontitis. He will tell us by the end of assessment.

After we call out the perio chart, we are going to sit Bob up and show him the radiographs. “This thick white line should go up, over, and down between each tooth.” The thick white line is his lamina dura. But Bob doesn’t need a new vocab word; he needs to know if his thick white line is intact or if the spots that were bleeding are also losing bone support. If so, Bob is going to ask us for perio therapy in just a second because bleeding and bone loss are the signs of active periodontal disease. He will tell us that he needs treatment as a prevention activity is no longer appropriate for him. He would like a healthy mouth, body, and better breath.

Super cool note: that “thick, white line” trick also applies to enamel. “Do you see that fuzzy, dark, V-shaped notch? That is where a cavity is starting.” Who knew reading x-rays was such a sinch?!

At this point in our time together, Bob is super impressed. He feels loved and cared for. He is excited to walk after work and is thrilled we can help him heal his periodontitis (that he diagnosed all by himself). In addition to being grateful for incredible care that he has never experienced before, Bob will be loyal to us and to his health. We may not have made it to the tartar picking today, but Bob needs 4 quadrants of scaling and root planing. A bloody prophy would have harmed him more than helped today. Ergo, we saved the day and his future. Congratulations RDH! What an honor to be on the same team.

Quality assessment is the key to fulfilling clinical hygiene days. Now more than ever, our patients need us to get to the root cause of their ailments. They need to believe that we care deeply for them and are here to serve. The brilliant part of quality assessment is that: in health, this whole routine takes less than 20 minutes to complete. All 5 steps of medical history, blood pressure reading, oral cancer screening, radiographs, and full mouth periodontal chart are a breeze. That leaves 25 minutes for calculus removal, polishing, double checking our work, and 15 minutes for the exam. If what Bob needs is a prophylaxis, this system does not make us run late. If Bob needs something else, we now have the data to support the necessity of more time and more involved dental hygiene care. The result will be a healthier patient (Bob), healthier provider (you or me), and a healthier, more profitable practice (our respective clinic). My parting question is: Why not?

Cheers to spotting trouble! May quality assessment bring us all fulfillment and health.

Stay tuned in July for the next part on this 2-part series, where we will learn best practices for spotting trouble beyond the mouth.

Reference

1. American Thyroid Association Press Room. Thyroid.org. Accessed June 1, 2023. https://www.thyroid.org/media-main/press-room/