The Perfect Board Patient

By Paul A. Levi, Jr., D.M.D.

friendly doctor and pacient

Recently, in the predoctoral clinic at Tufts University School of Dental Medicine, the students were preparing to take the Northeast Regional Board examination. A student excitedly came to me and said, “Please evaluate my patient for the periodontal part of the NERB examination. I believe that she is perfect.” The patient must have 12 surfaces of very discernible subgingival calculus and at least two pockets deeper than 4mm. As we were walking to the operatory, the student further remarked that one year ago four quadrants of scaling and root planing had been completed for this patient. I remarked that, should this patient qualify as a Board patient, we as dentists have failed. The student appeared to be shocked at this remark.

Unfortunately, on examining the patient, she qualified. Somehow we did not motivate this patient sufficiently to take care of herself, and although we provided the patient a service of calculus removal last year, we did not provide the service of health. The patient explained that since the student said, “I completed the scaling,” her periodontal treatment was completed, and now she could get her fillings done and her dental therapy would be finished.

I discussed with my student that the procedure of scaling and root planing is not just the mechanical act of taking calculus off of the teeth and smoothing roots, but is educating the patient to understand that it is her responsibility to remove the plaque/biofilm thoroughly on a daily basis. Since biofilm is invisible to the patient they must concentrate on their techniques and be seen for professional hygiene at regular intervals consistent with their needs.

The student then asked, “How frequently should a patient be seen for hygiene maintenance therapy? The sacred cow of dentistry is every six months. This began many years ago when it was said that it takes six months to develop caries, and thus we should see our patients to prevent the caries from becoming large and significantly compromising the tooth. Prevention today, especially with fluoride and sealants does not mean preventing the caries from becoming too deep. It means preventing caries from initiating and preventing periodontal diseases including gingivitis. The latter taking only a few days to occur.1

I suggested that in determining a hygiene interval for our patients, we look at the hygiene status at the time of the maintenance appointment as well as their susceptibility to dental caries and/or periodontal diseases. A hygiene maintenance interval of six months is appropriate for patients with no caries experience and no gingival/periodontal diseases; however, those who present with susceptibility and presently excellent plaque control would do best on a four month interval rather than six months shortening the interval by two months. As humans our lives change and other concerns can affect our routines, thus we may change our hygiene thoroughness. If seen that one time more during the year, we are likely to intervene before dental disease occurs and truly be preventive.


1. Loe, Harold, Else Theilade, and S. Borglum Jensen. “Experimental Gingivitis in Man.” Journal of Periodontology. 36.3 (1965): 177-187. Web. 24 Feb. 2012



Dr. Levi was born and raised in Newton, MA. He attended Hebron Academy, then St. Lawrence University, where he decided to study dentistry after graduating from SLU.  He attended dental school at Tufts University School of Dental Medicine after which he accepted a residency in general dentistry in Burlington, VT.  He joined the Navy as a dental officer and served in Great Lakes, IL for two years.  Following that he earned a certificate in Periodontics from Tufts School of Dental Medicine after which he and his family moved to Burlington, VT to open his practice in Periodontics in 1971.  Among the many positions that he has held are Treasurer of VT State Dental Society, AAP Board of Periodontics, AAP Board of Dental Examiners and is now an officer as well as an examiner, and president of the AAP Foundation.  He has taught at the UVM School of Dental Hygiene and is presently on the faculties of Harvard University and Tufts School of Dental Medicine  and Universidad International de Catalunya.


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