All throughout the day, we treat them one by one. Each individual patient is treated in a different way. This is our standard of care. Will you agree with this statement? If you don’t agree, then let’s make a “Red Letter Day”- – today!
What is the difference between a Prophy and a Periodontal Maintenance?
Are you scaling more than twenty minutes during a regular continuing care appointment? If you are then it is probably more than just a Prophy.
When a patient completes phase one treatment for non-surgical periodontal therapy, they are now and forever considered a “Periodontal Patient”. If you have Diabetes or high blood pressure, you will always be evaluated by your doctor to prevent progression of the disease. A patient diagnosed with cancer, high blood pressure and/ or Diabetes, doesn’t just get treated and then never see their doctor for regular preventive measures. This is the same protocol for patients diagnosed with Periodontal Disease.
One reason hygienists may choose to eliminate the periodontal maintenance appointment is for financial reasons. In the United States and other countries a billing code is used and more money is charged for the service. In the United States code D4910 (Periodontal Maintenance after scaling and root planing has been completed.) is a much higher fee than the fee for code D1110 (Prophylaxis. This means no disease is present.) The other reason dental professionals do not provide the periodontal maintenance appointment or bill appropriately is that many third-party payers do not cover the periodontal maintenance appointment at frequent intervals. (Example: Less than six months interval.)
When we understand the research regarding periodontal pathogens we will understand how to communicate to our patients “Why” they need to return in most likely twelve weeks. The research, the science, reports that periodontal pathogens will repopulate a healthy and recently scaled sulcus as early as nine to twelve weeks, post maintenance.1 A patient can brush and floss all day long and this may not be enough to remove the periodontal pathogens. These pathogens are what will cause tooth loss in periodontal patients.
Following a 10-year study, researchers found that patients who received regular periodontal maintenance had significantly reduced probing depths and lost fewer teeth than patients who did not have periodontal maintenance procedures. Here are the arguments to use regarding regular twelve week periodontal maintenance for your periodontal patients. This is the information to communicate to patients. It is our role as a healthcare provider to read the research, know the science, and share it with everyone who needs to know.
It still happens each day in many dental hygiene treatment rooms throughout the world. No matter how much time is spent removing plaque and calculus, the office still charges the same fee for what are actually a different procedure and a different diagnosis. The problem that is seen most likely is that the hygienist is not individually assessing patients for periodontal disease. The other problem is that the hygienist will do an assessment but there may be a lot more calculus present than is considered a regular prophylaxis procedure. If it has been awhile and if you live in the United States, look at the CDT Codes and read the description for D1110. No matter where you live, review the billing code description. Exactly what type of plaque and calculus does this billing code refer to? Does the code say this is a procedure for a preventive or a disease state? Read this description and see for yourself that (For example, in the United States) CDT Code D1110 refers to a healthy dentition, small amounts of plaque and calculus. If you are spending more than twenty minutes scaling, then you are not adequately treating this patient. Scaling calculus for more than twenty minutes is not the description of a prophylaxis. In the presence of moderate to heavy calculus you have more than a CDT Code D1110. (The Prophylaxis code for insurance billing purposes in the United States.)
No one wants to spend more money! People will pay for what they want not always what they need. It is our job as a healthcare professional to be an advocate for prevention. We need to share the research and the science behind the disease and how to prevent it, with our patients. We are the experts and we want to be an advocate of optimal oral health for our patients. We have a responsibility to spread the word that without good oral health a person will not have a healthy body.
“Working as a team of healthcare professionals, we can conquer the disease process. Together we can make a difference in our world!
Can you effectively explain to your patients why they need to return for non-surgical periodontal treatment? Do you know what to say when a patient returns with heavy calculus? What do you say when the patient had scaling and root planing last year and returned today with a 6-mm pocket? That pocket was there prior to scaling and root planing a year ago but what do you say when it occurs again at the periodontal maintenance appointment?
Tell then the truth!
You told your patient about the research and science behind the disease and you also need to tell them that periodontal disease is episodic. The disease process can and will most likely return at some point. This is why your patients need to continue coming back every twelve weeks, (or at frequent and the appropriate intervals.) even if they seem healthy for many years after the scaling and root planing is completed.
As mentioned previously, when a patient has Diabetes or high blood pressure, the doctor will ask the patient to be examined frequently because the disease is likely to return. Today, it is all about prevention. Prevention needs to be your message to the patient. When there is a new area of bleeding upon probing (BOP) or a new 5-mm pocket, now is the time to sit the patient upright in the chair and discuss early intervention. This will most likely mean prevention in the future. In dentistry today, during the twenty first century, we no longer “wait and watch”. Waiting is not the standard of care. What are your “waiting” for?
Periodontal Maintenance vs. Prophylaxis
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 patient’s 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 Colgate’s 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.
Communicate the difference
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 they’re 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.
- .www.perio.org September 2003 Issue