The Rythym of Dentistry
About 2/3 of the work we do at Hofmeister Family Dentistry is focused on preventative dentistry.
In the industry, this is called a Periodic Oral Evaluation (POE). There are variations on this theme (e.g., patients on periodontal maintenance schedules, people that get cleanings more frequently for personal reasons, etc.). But the vast majority of our patients receive standard POEs twice a year. If you’d like to read some of the scientific literature behind this paradigm, here’s a link to a NIH study reviewing the clinical evidence and cost effectiveness of bi-annual POEs. There’s broad consensus between the clinical community, patient community, and insurer community that semi-annual POEs is a good mechanism to manage oral health (despite the fact that different insurers have very different definitions of “semi-annual” - e.g., (1) twice a calendar year; (2) once every 6 months; and (3) twice every 12 months - which makes scheduling more complex than it needs to be).
At a periodic oral evaluation, you can broadly expect some combination of the following activities to take place:
Medical history update (e.g., medication updates, surgeries, medical appliances)
X-ray updates (i.e., bitewing x-rays, localized periapical x-rays, panoramic x-rays, full mouth x-rays)
Periodontal charting
Cleaning (done by the hygienist using manual scalers or an ultrasonic machine called a cavitron)
Exam (done by the dentist using a probe and a mirror)
Treatment planning (done by the dentist if additional dental work is required)
Polishing (done by the hygienist)
Each step is important in its own right and they all work together to result in good oral health outcomes.
We ask for medical history updates in order to understand the interaction between the work we do at the dental practice and the stuff going on outside of it. Patients with recent joint replacements may need to pre-medicate with an antibiotic before cleanings (at the direction of their orthopedic surgeon). Patients with an infection elsewhere in the body may need to delay dental treatment for a period of time until the infection subsides. Patients taking blood thinners may need to hold the medication prior to a dental cleaning in order to avoid bleeding as a result of a cleaning. Patients receiving IV-Bisphosphonate treatment for bone diseases may not be able to receive certain dental treatments as a result of how the medication impacts bone growth and how long the medication stays in the body. This is a critical information gathering phase of the appointment that helps inform all the following steps.
X-rays come next and functionally serve as another information gathering phase. We can glean a lot of insights from the patient telling us what’s going in their mouth as well just looking and poking around. But those methods only go so far. We take x-rays in order to see what’s going on beneath the gums, between the teeth, and inside the tooth. If you’re interested, we wrote a blog on x-rays already. Take a look! We take bitewing x-rays once a year. We take periapical x-rays as needed. And we take panoramic x-rays or full-mouth x-rays every 3 - 5 years. We do our best to strictly adhere to clinical guidelines as well as patient preferences. So don’t be surprised when we tell you it’s time to take some x-rays.
Periodontal charting comes next. We typically alternate periodontal charting with x-rays. That means that if you have two dental appointments a year, you’ll get x-rays during one appointment and periodontal charting during the other appointment. What is periodontal charting? It’s where we use a very thin probe to measure the distance between the gingival margin and the bottom of periodontal pocket. So what the hell does that mean? It’s the distance between the top of your gums and where your gums attach to your teeth. It’s measured in millimeters. The smaller the number the better (I like to say it’s like golf). If you’re on the receiving end of this process, you may here a bunch of numbers being said out loud (e.g., 3-2-3, 3-2-3, 2-1-2, 2-1-2, etc.). Those numbers are the distance between the top of the gums and where the gum attaches to the tooth. The deeper the number, the more likely it is that something wonky is going on. To be more specific, we’re hoping for measurements between 0 mm - 3 mm. This means that the patient has good oral hygiene and the gums are happy, healthy, and effectively attached to the tooth and bone. Measurements above 3 mm are the sign of things going on, including: (1) gingivitis; (2) periodontal disease; (3) soft or hard tissue damage; (4) bone loss. The results of the periodontal charting give the hygienist and the dentist the information they need to figure out if any additional care is needed (e.g., more frequent cleanings, deeper cleanings, laser therapy, osseous surgery, or guided tissue regeneration). We can do some of these procedures at our dental practice. But sometimes we need to coordinate with a specialist (i.e., a periodontist) to help mitigate the underlying issues.
Once we’ve gathered all the necessary information in the form of medical history updates, x-rays, and periodontal charting, we start the cleaning. The hygienist works their way around the mouth cleaning each surface of each tooth to ensure that all the gunk that’s built up over time is removed. That gunk can be a couple different things. It can be food. It can be a combination of bacteria, saliva, and food (i.e., plaque). Or it can be calculus (a.k.a. tartar). Calculus is the hardened version of plaque and is really hard to get off. We want to get the gunk off because - in addition to irritating the gums - the gunk creates acid that dissolves tooth enamel (i.e. the outer surface protecting the tooth). Once the enamel is penetrated, bacteria can make it’s way to the inside of the tooth and start wreaking havoc. We don’t want havoc so we clean off the gunk. Hygienists use hand scalers to scrape off the gunk. And sometimes they use ultrasonic scalers (a.k.a. cavitrons) to speed up the process. The cavitron can be a shock for first-timers as it uses a lot of water and it emits a high-pitched noise (both of which can be a little disorienting). The upside of the cavitron is that it speeds up the process of removing stubborn plaque and tartar. If you’re a weirdo like me, you have to watch some videos of deep cleanings. Calculus removal is oddly satisfying.
Now that the teeth are clean, the dentist comes in to put everything together. They review medical history updates with the patient and hygienist, they take a look at the x-rays, they review periodontal charting (with a focus on areas of concern), and they explore the mouth to find potential areas of decay. With all that information, they provide insight as to next steps. If the patient passes the test, they come back in 6-months to try again. If there’s a cavity, the patient comes back for a filling. If there’s a really big cavity, the patient comes back for a crown. If the patient is grinding their teeth because they’re really stressed out, we make them a nightguard. If there’s sufficient decay such that the cavity has made it’s way into the root of the tooth, we send the patient to an endodontist for a root canal. If the periodontal charting shows really deep pockets, we send the patient to a periodontist to explore options to help manage/treat the periodontal disease. If the tooth is bombed out, we send the patient to an oral surgeon to extract the tooth. When a tooth is pulled, we work with the patient to explore restoration options (e.g., implants, bridges, partial dentures, full dentures). The dentist has to navigate this complex ecosystem and walk the patient through the entire process. It’s complex.
The hygienist finishes things up by polishing the teeth, running floss to make sure they cleaned out all the gunk, and providing instructions as to how to optimize home health care (because what you do everyday matters way more than what we do every 6-months). My favorite polishing flavor is Mint Mojito. It’s a nice combination of citrus and mint.
At Hofmeister Family Dentistry, we do our best to make sure that we set the patient’s expectation as they come into the office. Medical history updates, x-rays, periodontal charting, cleaning, exam, treatment planning, polishing, and then scheduling the return visit. The combination of those steps hopefully results in good oral hygiene.