Maintain, neglect, or over treat - what's a clinician to do?

The age old question of what is the correct recall interval for a periodontal patient has had the magic systematic review treatment and the answer is.....wait for it.......further evidence is required. What a shocker. How many systematic reviewers does it take to change a light bulb? Further evidence required. So there is no evidence that 3/12 recalls for maintenance work for everyone. Anyone who has periodontal recall patients would agree.

What was interesting about this review published in December 2015 in the journal of evidence based dental practice was part of the conclusion which, as well as saying we need more research, mentions "The merits of risk-based recommendations over fixed recall interval regimens should be explored."

And this makes total sense to me. Why have a one size fits all approach. Patient centred care is the way to go, and CQC and NICE say so too.

It points to the need for regular risk assessment and modification of care plans as needs change. We should be completing a risk assessment of a patient every time we see them. But how best to do this?

One worry I have around this published lack of evidence is that the stretching of intervals between Oral Health Assessment and Oral health reviews by NICE were met with some concern. There is potential for supervised failing in both caries and periodontal prevention. A very real issue of achieving health for the patient then stretching the recall sessions until the scores go up again. That is not maintenance, that is supported failure and re-infection.

And when we have a growing body of evidence linking chronic inflammation associated with uncontrolled periodontal disease and systemic illness, is there such a thing as over reviewing when it comes to obtaining and maintaining periodontal and gingival health?

This is another topic for a staff meeting discussion and I suggest at least an annual review of risk assessment  protocols in your practice.

One system that I have supported in its implementation is the oral heath review being carried out  to a certain stage by a trained dental nurse, reducing time in chair with both hygienist and dentist. This working in triage method is incredibly rewarding for the team, efficient in time and economics, and allows a high standard of maintenance of health for patients.

GSK and Corsodyl have packaged a gum care risk assessment pack which you can receive for free and is a good place to start.


Another great tool out there for risk assessment is Previser

PreViser gives dental clinicians a way to objectively analyse their patients' oral disease risk and severity.  These analyses are delivered as personalised reports that improve care planning accuracy and patient acceptance and compliance.
A comprehensive assessment includes assessments for perio, caries, oral cancer and tooth wear. Alternatively individual reports can be generated for perio, caries and oral cancer.
To save time, the patient can be given access on a tablet or computer in reception to complete the non-clinical elements of the assessment.

However you choose to implement risk assessment for recall length, the key thing is to ensure you are attaining and maintaining stability in the patients oral health. And you tend to find those patients who have achieved health are just as keen as you to keep those recall review sessions and maintain the health you helped them achieve.


 

NICE to see you - to see you delivering Oral Health Promotion - are you ready to change?

NICE have brought out fresh guidelines for oral health promotion and patient centered behaviour change and prevention care in December 2015. These will focus the practice on assessment, advice, behaviour change and prevention. 

They sit right along Outcome 1 and 4 from CQC. 

The guidance is for the whole dental team, clinical and non clinical and they are quite clear there are no exceptions. There will be an expectation for the team to base your advise and recommendation on the Delivering better oral health toolkit while tailoring it to the patients individual needs and using NICE Guidelines on behaviour change - recommendation 8 to be precise. This should involve someone who is trained as a behaviour change practitioner. 

The NICE team recognise that not only will this guideline need patient behaviour change but that there will also be a challenge in motivating the motivators who will drive the change in practice to prevention led.

Those who were part of the pilots for the NHS will have a head start. Those who have already worked out that putting prevention and oral care at the core of the practice is the way to go will be thinking what took them so long?!

But for the rest of us, can we honestly say the whole team is delivering patient centered oral health education and behaviour change? And are we able to show this in our protocols, ways of working and notes?

I see this as an opportunity to really rethink how your practice works. Are you still fixing the problems as your first priority? Is oral health education delivered while you wait for the block to work, or over the patient while you work, or as a monologue at the end of the appointment as you herd them out the door? Have you just given up because they never listen anyway? Have you got a practice or company protocol for training, delivery and auditing of oral health advice? 

Maybe you have just found your No. 1 item on the agenda of your next practice meeting. And that can be a good thing.

Change can be hard, and implementing a new way of working in a busy practice a struggle, but the end benefits will outweigh the pain. Motivated patients are more receptive, grateful and switched on to the value of the treatment you provide. Good communication reduces the risk of litigation. And a team that can see their actions producing a result will stay motivated and work well for the practice they are in.

It is good to revisit your protocols regularly, things change. Here is an article I wrote about this a few years back which still rings true and might help you plan that meeting.

Uncomfortable and unreasonable. Those are my strengths.

2016. And I am amazed that I stopped blogging about all things dental pretty much as soon as I started my role with Philips. I must have got comfortable.

I guess it was the focus on one portfolio and brand, and the constrictions that come with that.

I had no idea what I was getting into in 2011. For starters, the company officially announced the Discus acquisition weeks after I started. And so I grew by learning about chemical interactions with the tooth structure and whitening products.

Then I grew my knowledge of governing and legislation in 2012 when the EU 6% law came in to affect. That period was uncomfortable and Safetoothwhitening.org is the product of that growth and I am proud of what it has achieved. Being unreasonable, and working with a team who were also unreasonable, delivered a new product in record time.

2013 and the growth here was a painful lesson that sometimes businesses have to make hard cuts to grow and we lost all of our education funding for our student programmes. As a manger the growth this year was not an easy one. From that pain came the decision to be unreasonable and not give up our website and this has now grown to having over 11000 dental members.

2014 saw my growth as a marketeer, owning the running of the business, it's budget, forecasts and strategy, resetting from the painful cuts to start to regrow in a healthier way. My growth was learning how working in an unhealthy way can impact your family. Not my finest hour. No one needs to be on 24 hours. And it makes you a boring person too.

2015 saw me grow in my understanding of a business on a European and Global level, the painful growth of running Europerio 8 as a Global activity has been valuable. Being unreasonable and working outside my remit with our research team brought valuable insight and allowed us to launch a new product in the most successful way yet. Breaking my arm in August has taught me growth is required in all areas to maintain a balance as a person, and also not to take my health for granted.

And my whole experience at Philips, which is a positive one, taught me you need to be unreasonable to drive change. And that comfortable people do not like you doing it. But I believe there is a way to do it to achieve results when you need others to support your change. It took time and a lot of one to one conversations and interpretations. And that was almost always uncomfortable for me.

And so back to 2016. And a blank page for me. It is daunting to say the least. But I am reminded that painful growth and the discomfort I am experiencing at not knowing my future just yet are exactly what I need.

I got too comfortable, too safe and too set in my mindset. Too willing to settle. A great quote a good friend used today - "The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man." - George Bernard Shaw.

And so I will play to my strengths and embrace the discomfort, and be the unreasonable voice and see what it to come.