The following is a guest post by Debbie Seidel-Bittke. If you are interested in guest posting for Dental Heroes, please sign up here.
The following is Part II of yesterdays post by Debbie Siedel-Bittke titled, You Decide: Prophylaxis of Periodontal Maintenance.
The Prophylaxis Appointment (CDT Code D1110 prophylaxis) is only for patients who exhibit healthy gingiva. They have a healthy periodontium. The Prophylaxis (CDT code D1110) definition says the removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.
The Periodontal Maintenance (CDT Code D4910 periodontal maintenance) is a post-therapeutic procedure used to maintain the healthy results of periodontal therapy, not to prevent disease in healthy patients. The Periodontal Maintenance (CDT code 4910) definition states: “It can only be used following periodontal therapy and continues at varying intervals includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site-specific scaling and root planing where indicated, and polishing the teeth.”
The Periodontal Maintenance appointment is to be used following Phase I definitive periodontal therapy and for an indefinite time, determined by the patients progress over time to achieve stability and the absence of the signs and symptoms of disease. Periodontal maintenance patients who have poor oral hygiene, smoke, exhibit bone loss and/or excessive bleeding, have not achieved an acceptable level of stability and in addition, have various immune deficiencies such as Rheumatoid Arthritis, Diabetes, Arteriosclerosis, etc., etc. When these patients continue to return for dental hygiene appointments and these disease challenges persist they will need to be referred for a consultation by a periodontist.
What are the specific differences between a periodontal maintenance procedure and. a regular prophylaxis? Periodontal maintenance procedures include a predominance of power scaling with thin inserts to access and debride the depths of periodontal pockets. Think scaling SMART not hard! Your patient may need localized areas of local anesthesia. The goal of this appointment is thorough debridement of pathogens that have repopulated in the sulcus. Periodontal pathogens reside in the sulcus and on the plaque and calculus. Biofilm is always present on the root in the presence of calculus or no calculus. Annually, a comprehensive periodontal exam is mandatory. (Six-point periodontal probing is necessary in order to reassess changes that have occurred in pocket depths.) A pre-procedural rinse and irrigation post-procedural with an appropriate antimicrobial, such as Povidone-iodine or Chlorhexidine, is the Gold Standard. You may need to apply desensitizing agents, such as Colgates Pro-Relief™, with a rubber cup if your patient has sensitivity and/or exposed root surfaces. If you have a fluoride varnish you can easily apply this for immediate relief from any root sensitivity. There are numerous choices for today’s sensitive dental hygiene patient. Always polish with low-abrasion pumice and/or pastes if your patient has exposed root surfaces. This is often the case for periodontal patients.
One way to explain to patients when they need to understand the difference between Prophy and Periodontal Maintenance is to say this: Your gums are not healthy and this can also affect your total health. Usually, your dental hygiene appointment is only a preventive therapy but today I will need to treat areas of disease. I am recommending that we do something different today. Today I (fill in the blank with your own plan) will let the patient know if you will do a gross debridement, scale and root plan an area, etc.” Ask the patient if they have any questions and find out if they have objections and why. It is at this point in time you will need to address financial issues. For some patients the most challenging part is the finances. It is well known that most people will buy what they want. This is when you have effective communication skills that you can overcome the financial barriers to accepting non-surgical periodontal care. Most people will find the money when they understand they will live a longer and healthier life!
When patients still don’t comprehend the importance of optimal oral health in relationship to their total overall health, try to explain that you are not providing appropriate treatment with only a prophylaxis appointment. Patients also need to understand they are not there to get their teeth “cleaned”. Dental hygienists are in the business of preventing disease.
One more way to communicate the importance of more than a prophylaxis is to show the patient radiographs of their teeth, the surrounding bone and/or intraoral photographs of the diseased areas, bleeding staining, plaque, calculus, etc. Show them actual tooth mobility if it exists. A loose tooth is not a pretty sight to see!
Some computerized patient management software programs, stand-alone devices and programs, such as the DENTRIX periodontal chart where you can color code areas with different colors, (Red for BOP, green for mobility, etc.) Dental R.A.T.® and PerioPal®, also produce impressive probing charts. Even giving the patient a hand mirror and showing him/her how his/her gums are bleeding can be a powerful, emotional tool. The main point here is that the independent authority has to be highly visual and vivid to counter the emotional belief that theyre being cheated. Some patients will believe “It’s all about the almighty dollar”, when in reality we are in the business to provide optimal health.
It is becoming more common to have Physicians gather systemic information with lab tests, and dentists are beginning to use lab tests as well. Four outside labs have periodontal tests: two are culturing services – Oral Microbiology Testing Service (OMTS) and Oral Microbiology Testing Lab (OMTL). The other two are DNA tests: OralDNA Labs® and micro-IDent®plus. All four tests can detect pathogens that are associated with periodontal disease. There is also a third-party statistical test, PreViser™ based on clinical findings that estimate the likelihood of periodontal disease. In addition to these outside tests, there are two microbiological tests that can be used chair side. BANA™ is an enzymatic test for periodontal pathogens, and the other is a video microscopy test called BioScan™.Any of these above listed tests can provide the type of important information dental practices and patients may consider prudent.
The dental hygienist has two important roles. The first role is to determine which type of periodic preventive care is needed, by each individual patient. It is the role of a healthcare provider to educate and communicate to patients exactly what type of care is appropriate for their overall health. Education is the second role.
We are not talking about the almighty dollar. We are concerned about our patients overall health. When you understand and communicate the difference between health and disease. Prevention and treatment, you are providing optimal care.
Disease means Periodontal Maintenance for life. Prophylaxis means the patient is healthy and there is little plaque, calculus and no bleeding.
Sources 1. www.perio.org September 2003 Issue 2. www.perio.org
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