The most common things patients say to me when they enter my practice for teeth cleaning are
I hate this
It hurt a lot last time
Are you going to use the hooks??
But once we are done with the treatment they are visibly relieved, thank me for being gentle and share their story about the previous dentist/hygienist who did the scaling. The stories are horrendous and it often makes me feel ashamed of my colleagues. Why are they failing in very simple task – managing the pain?
For those who now think that I must not do the scaling very well if it doesn’t hurt:
Me being gentle does not equal me being less thorough with the scaling. I go to those 12 mm deep pockets with my hand scalers and sometimes even without any local anaesthesia. I remove all the subgingival calculus that is possible without surgery – if not on the first visit then on the following visits. And yet the patient thank me for being gentle.
How is this possible? Let me tell you how. If you are a patient, there is information for you at the end of this post.
When I was at dental school I worked as a nurse in private practices (I have written about this period in my life in my previous post). I was a nurse for a young dentist who was performing a scaling for the patient. It was the most unpleasant piece of treatment I have ever witnessed. It was a bloodshed. A complete massacre of the gums.
The patient did not have severe gum disease – just gingivitis. The dentist did not use local anaesthesia and took her sickle and started the scaling (or her interpretation of it). Pieces of interdental papilla were flying around and the mouth was filling up with the blood… I am slightly exaggerating of course, but just slightly.
The patient was wriggling but did the dentist offer local anesthesia? No she didn’t. She carried on with the massacre. All I could do was to place my hand gently on patient’s shoulder as way of comfort in this horrible experience that should never had happened.
In the end of the treatment she had removed all the interdental papillae from patients mouth. Instead of the interdental papillae there were now dark red blood clots. Hands up everyone who knows this should not be done! I hope there are some of you.
Now this was my experience that I witnessed. The rest my patients have told me. The stories do not vary a lot from what you just read.
The Pain Threshold
All the patients are different when it comes to the pain threshold. Some people cannot take any pain and require topical anaesthesia even for probing. Some go through the whole scaling without any complaints and do not want to have a local anaesthesia even when suggested.
But the most important thing with every patient is to tell them about the options for pain relief.
When I see a patient for the first time they are often very sceptical and think they need all the possible pain relief there is. In these cases I suggest that we first try without and if the pain relief is needed it can be applied any time.
The reason I do this is that I have noticed that the fear of the pain is sometimes greater than the actual pain. Once the patients realise this they relax.
Doing It in One Go
This is not how you should do it.
When the gums are inflamed they hurt. As a patient you do not want anyone you just met digging your tender gums with a sharp instrument.
So on the first visit it is important to teach the patient better oral hygiene routines and techniques and get rid of the supragingival calculus (visible calculus) and some of the subgingival (invisible) as well (as much as the patient can take the discomfort).
I rarely use hand instruments on the first visit. I concentrate on very thorough scaling with the sonic scaler (EMS is my favourite). I might still use Mini and Micro Sickle for the lower front area as there is often calculus and stains left after the sonic scaler. Plus the patients loooove to get shiny white smile on the first visit.
Remember to tell the patient that there is (invisible) calculus still to be removed as they might not return for the following visits when the bleeding of the gums stops. It is important to mention that if the calculus is not removed it can result in periodontal abscess and bone loss. Eventually the gums will start bleeding again.
After this I let the gums heal at least for a week. It is much easier for the patient and for me to perform the subgingival scaling when the gums have healed and shrunk. Sometimes they have shrunk that much that not much of the calculus is hidden below the gum line – but this requires the patient to do his share with the oral hygiene at home.
Technique of Scaling
This is where most of the “butchers” fail. They either use wrong tools or right tools but wrong technique.
When I began working in my first surgery abroad and saw the scalers I was supposed to use I declined kindly and persuaded the owner to order me the instruments I preferred. It was a difficult task as the hygienists had used those “instruments for giants” without complaints. I explained that the curettes were far too big for anyone’s teeth. They were clumsy and big and the metal was very “stiff”. Luckily the owner was a wise dentist and I was allowed to order new ones.
The scalers I have by default for all the patients are:
With these I can do simple scale and polish but if there are pockets deeper than 3mm I have curettes at hand in a sterile pouch and I choose them by the location and the shape of the pocket. I have sets of curettes in pouches as listed below:
Please note that I do not get any financial benefit of writing about certain brand of instruments.
Chlorhexidine After Scaling
I always rinse the deep pockets with syringe filled with 0,12% chlorhexidine liquid or gel. It reduces the risk of complications.
Blunt instrument results in slipping of the instrument either to the patients gum or your finger. Neither is good. Blunt instrument also does not remove the calculus – it only polishes it.
It is very important to sharpen the curettes after each use (sickles and syntette do not require sharpening that often). It doesn’t matter if you do it by hand or by sharpening machine. Both of them require skill but the only difference between these two is that the hand sharpening extends the life expectancy of the curette.
I sharpen my instruments in a cycle of hand sharpening two to three times in a row and then machine sharpening once. I sharpen once a week all the instruments that have built up in a week. For you being able to do this you need at least a week’s worth of instruments in the surgery.
Tip: When you sharpen your instruments always check with a test stick first if the instrument is in fact sharp enough. Sometimes if you have used the instrument only for couple of strokes it remains sharp.
Informing the Patient About the Post-Scaling Complications
There will be tender gums after any scaling and polishing. But the patients can take it much better when they are informed about the different kinds of complications that might occur and how they can manage them.
The most common complications and ways of relieving them are:
- tender gums – cold drinks/food, paracetamol/ibuprofen, never aspirin as it might make the gums continue bleeding
- taste of blood in the mouth – normally it is resolved by the next day
- sensitivity to cold – sensitive toothpaste, leaving the toothpaste in mouth after brushing, avoiding acidic food/beverages
It is also good idea to mention the less common complications and the ways of relieving them:
- extreme pain in the gum caused by secondary infection that lasts for many days – salt water rinse, chlorhexidine rinse (alcohol free) or to see your dentist if the symptoms persist
- pain around the partly erupted wisdom teeth – chlorhexidine rinse or to see your dentist if the symptoms get worse despite the rinsing
- periodontal abscess – to see the dentist
If the patient is left untold about these complications and if they do happen it is very likely that the patient blames you. And he will tell this to ten of his mates (marketing rule) even though there was nothing wrong with your scaling skills.
But when explained that you have now disturbed the bacteria balance in the deep pockets by scaling and even though it was necessary and important thing to do the bacteria in the pockets sometimes – in rare cases – do not like it and the situation might get worse, you will have much more satisfied patient even if complications occur. A patient that still trusts you.
Having the teeth cleaned at the dentist should not be painful. Some discomfort is acceptable but it should always match to the patient’s individual pain threshold. And after the scaling the patient’s gums should not look as if Jack the Ripper had done the treatment.
The right technique of the scaling is difficult to master. But once you do, it will be more rewarding for you as you see better healing results with the gums and a happier patient. Here’s one video about hand scaling technique (it’s not ideal video but hopefully you get the idea) but I’m sure hands on courses are available at the dental schools as well.
For the hygienist – please do not accept just any hand scalers. Check out different brands of curettes at the dental show case and order couple of them to try out. If you are unsure with your technique start with the mini-curettes.
For the patient – If you’ve had bad experience at the dentist with the cleaning of the teeth seek another one. Change until you get proper cleaning, relevant info and oral hygiene instructions. Be prepared to have at least two visits.
When you maintain good oral hygiene habits and see your hygienist for regular teeth cleanings (interval decided individually, see my previous post) you will never ever need to go through the same experience again. It takes just one visit to clean your teeth and it is much less painful.
If you do not do your part at home and leave longer period of time than recommended between the cleanings it often takes two visits to do it. And once again it is unpleasant for you.
I worry over the fact that the patient is unable to tell if the scaling was done thoroughly. I have written about this before. It is not until the patient by chance sees somebody who recognises the gum disease and masters the comprehensive treatment for it, when they realise the poor quality of the treatment they were getting in the previous practice.
That, my dear readers simply is not acceptable in the modern dentistry. So revise, revise and revise. Trust the patient’s reaction. If they complain often that it was a horrible experience then something is wrong with your scaling technique, your tools or your chair side manner. Swallow your pride and do something about it.