QUESTION: A patient presented with inflammation around a lower second molar a few days after a prophylactic cleaning. The tooth had a 6 mm pseudo-pocket and was very swollen and tender. The dentist I work for informed the patient that she has an infection because I did not clean deep enough around the tooth. The patient had generalized 2 mm to 4 mm pockets and I am not convinced that the periodontal swelling was caused by “missing a pocket.” Do you think it is appropriate for a dentist to tell a patient that the swelling is a direct result of the dental hygienist not cleaning to the base of the pocket?
ANSWER: When providing patient care, a team effort is essential to obtain positive therapeutic outcomes, as well as a favorable patient perception of the dental treatment rendered. It is critical that a dentist be supportive of his or her staff when interacting with patients to achieve these two goals.
Dealing with any biological system is never completely predictable. In simple terms, no matter how hard we try, our best efforts do not always achieve our desired results. That is why they call it the practice of dentistry. Recognizing this clinical reality comes from experience and careful analysis of various previous therapeutic outcomes.
In my opinion, the dentist could have taken a more constructive approach to diffuse the situation by stating that this can occur in pseudo-pockets (or even in a pocket resulting from attachment loss) in spite of our best efforts. In addition, the dental team would look to resolve the situation and make every effort to ensure the patient was satisfied and comfortable. The dentist could have proposed solutions to resolve the inflammation, such as provide a review of increased subgingival oral hygiene measures, including rubber tipping and the use of a subgingival irrigator. Moreover, re-examining the area to see if any food impaction had occurred—such as a seed or a popcorn hull—would have been beneficial. Also, re-instrumentation with an ultrasonic device at no additional fee to the patient could also have been proposed.
A pseudo-pocket can alternatively be described as delayed or altered passive eruption. In this clinical situation, excess gingival tissue is present and adjacent to enamel. Initially, the excess gingival tissues are attached to the enamel when the tooth has completed eruption and comes in contact with the opposing tooth. Over time, the soft tissue may separate from the adjacent enamel surface. It cannot, however, reattach to the enamel, as gingival tissues can only form reattachment to root surfaces. In other words, debridement in this clinical scenario—no matter how thorough—will not result in the reattachment of detached gingival tissue to enamel. It will continue to exist as a pseudo-pocket collecting subgingival bacteria and requiring careful maintenance. Also, patient self-care is typically less than optimal when cleaning lower second molars, particularly on the lingual aspect. If excess gingival tissue is present, self-care becomes even more difficult.
This information regarding the local periodontal anatomy should be explained to the patient in simple terms so he or she can better understand the problem. In my experience, patients want to be cared for by therapists who communicate, as they work in a unified team effort to help them achieve dental health.
From Dimensions of Dental Hygiene. March 2019;17(3):52.