Periodontal Disease, an A1c of 9.8, and a Patient Who Does Not Want a Lecture
A 58-year-old man is in for a recall. His chart shows 5–7 mm pockets in all four posterior sextants, bleeding on probing at 62% of sites, and heavy calculus. He has type 2 diabetes with a recent A1c of 9.8%, smokes about half a pack a day, and takes aspirin daily. He was referred for scaling and root planing six months ago and never scheduled; he says it is "too expensive and it's just gums." He brushes once a day, does not floss, and mentions that his mother lost all her teeth at 60. He is pleasant but is clearly expecting a quick visit, and the dentist has asked you to "go over oral hygiene" before he leaves.
1. You have maybe six minutes. What one or two messages do you choose, and what do you deliberately leave out?
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Leave out flossing. He does not floss, he has heard about flossing, and leading with it confirms his expectation that this is a lecture. It is also not the biggest lever here.
Message 1 - the link runs both ways. His gums are infected and his blood sugar is running high; poorly controlled diabetes makes periodontal disease worse, and treating the periodontal infection can help with glucose control. That reframes scaling from "just gums" to something connected to the disease he already takes seriously. Say it in one sentence and stop.
Message 2 - the trajectory. His mother lost her teeth at 60 and he is 58 with 7 mm pockets. That is a fact he volunteered, so it lands without you moralizing. Do not use it as a scare tactic; use it as his own reason.
Then stop talking. Six minutes of your voice is worth less than two minutes of his. The goal of this appointment is not perfect hygiene - it is that he schedules the scaling he has been avoiding for six months. Pick the outcome, not the curriculum.
2. Show how you would open the conversation so that he does not shut down, and what you would do if he says "I can't afford it."
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Opening - ask permission and ask a question: "I want to show you two things I saw today and then hear what you think - is that all right? ... Last time we talked about deep cleaning and it didn't happen. What got in the way?" That puts the reason on the table instead of assuming it is motivation. If he says cost, believe him.
Responding to cost - solve the actual problem:
- Ask what his insurance covers and what a realistic monthly amount is; ask the front office to price it out in quadrants rather than as one number.
- Offer a quadrant-by-quadrant plan across several visits - smaller payments, and it starts sooner.
- Find out whether an HSA/FSA, a payment plan, or a community clinic referral fits.
- Connect it to money he may already be spending: "the reason I push this is that the alternative is implants and dentures, and you've watched what that cost your mother."
What not to do: do not repeat "it's important" louder, do not imply he does not care about his health, and do not promise a specific outcome. Reflect back what he said ("so it's not that you don't want it, it's that the number doesn't work") and then work the number.
3. What medical and safety factors do you flag before he leaves, and who is responsible for each?
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Daily aspirin: he should not stop it on his own for a cleaning, and you should not tell him to. Flag it so the dentist can decide whether to coordinate with his prescriber before scaling; note it in the chart. Responsibility: dentist decides, physician advises, you surface it.
A1c 9.8%: this is uncontrolled diabetes. The dentist should know before any surgical or extensive periodontal care, both for healing and for appointment planning. Consider a medical referral or a note to his physician, with his consent - the periodontal treatment and the glucose management work better together. Responsibility: dentist refers, you make sure the value was actually seen and recorded.
Smoking: brief, non-judgemental, permission-based - "Would it be useful if I told you what quitting would do for your gums?" One sentence, an offer of a quitline, then move on. Responsibility: shared, but never a condition of treatment.
In-office screening and scheduling: confirm current blood pressure if the office screens, and note that long appointments late in the day with a patient who may be hypo- or hyperglycemic carry risk - suggest he eat and take his medication normally before visits.
You are not diagnosing or prescribing. You are making sure the dentist walks into the operatory knowing what the patient's body is doing.