| Several dentists have written to me asking exactly how I
handle periodontal patient flow in my own office. The
following routine is practiced as a matter of routine by the
hygienists in my practice and represents a fairly healthy
and up-to-date method of patient periodontal triage and
treatment. |
|
Patients are broken down
into six groups according to their initial periodontal diagnosis
when entering the practice for routine dental treatment. Each
diagnosis is handled in a different way. Since the treatment
regimen for each diagnosis is always the same, the hygienists can
tell the patient exactly what the steps are and how much the total
periodontal treatment plan will cost.
Since any periodontal case must be well documented, all patients
who fall into any periodontal classification except the first one
(the periodontally "clean" patient) must have a full series of
radiographs and a periodontal probing on the first visit. In
the case of "gingivitis" (debridement patients), the periodontal
probing is deferred to a second visit, along with the oral
examination and treatment plan.
1. The periodontally healthy patient
A vast majority of your patients will fall into this
category. These patients present with 1-3 mm sulcus depth,
minimal calculus and minimal bleeding on probing.
Their periodontal treatment consists of an initial prophylaxis
and scheduled regular recall prophys:
| First visit |
Exam (0150)
|
x-rays
FMX (0210)--Patients over
the age of 30 and any patient with extensive
dental work, extensive caries or extensive
missing teeth.
|
4 horizontal BWX (0274) --Patients
12-30 with selective periapicals if there
are individual teeth with suspected
periapical pathology.
4 horizontal BWX
(0274) and a panorex (
)--Patients under 30 with unerupted
wisdom teeth, congenitally missing teeth or
other suspected pathology.
2 horizontal BWX (0274)--Patients
under 12 without erupted 2nd molars.
|
Prophylaxis (1110)
Recall visits
Recall Exam (0120)
Appropriate BWX once a year
Recall prophy (1110)
2. Healthy patients with minor isolated pockets
These patients present in a state of reasonable periodontal
health, but with minor isolated pocketing and bleeding that
probably will require further periodontal treatment. This
includes patients with overall good periodontal health, but
having one or two specific areas in which the pockets will
require enough deep scaling to need anesthesia.
First visit
Exam (0150)
FMX (0210)
pocket probing
Prophy (1110)-- only if the site specific needs
are minimal. In this case, the third visit would be
skipped.
Second Visit
Localized scale and root planing 1-3 teeth/area(4342)
-- billed per site
Isolated Arestin (4381) -- billed per site
Third visit--Only if no prophy was performed at first
visit.
Fine scale Prophy (1110)--Short visit to complete
the prophy in the areas unscaled in the second visit.
3. The "Gingivitis" patient (The full mouth debridement
patient)
"Gingivitis" is a misnomer, but stands as a diagnosis
acceptable to insurance companies. These patients present
with 1-4 mm pockets, extensive calculus and/or serious bleeding
and pain on probing. These conditions make it very
difficult get accurate probing depths, and hide the true long
term classification of the patient's periodontal condition.
"Gingivitis" patients do not receive a standard prophy or
billable oral examination at their first visit, although the
overall condition and any serious problems should be noted and
treated immediately if necessary. There are two reasons
for deferring the examination until a later visit.
- Insurance companies will not approve an examination on
the same visit as a full mouth debridement.
- It is difficult to assess the true periodontal condition
until some healing has taken place.
In reality, many patients with more serious periodontal
disease will initially be classified as gingivitis patients if
probing is difficult or impossible due to heavy calculus,
bleeding or pain on probing. Two to three weeks after a
debridement, oral examination becomes much easier, and
classification of the patient's periodontal condition becomes
more accurate.
First visit
FMX (0210)
Pocket probing
Full Mouth Debridement (FMD) (4355)
Second visit
Exam (0150)
Pocket probing
Evaluate for root planing and appoint for
appropriate root planing appointments.
Fine scale (1110) -- Only if the the periodontal
condition has improved. In this case, the patient is
reclassified as a periodontally healthy patient and placed
on a regular recall schedule.
4. Early periodontitis
Patients in this category present with numerous 4-5 mm
pocketing and bleeding on probing. These patients may
require a full mouth debridement on their first visit, after
which they will enter immediately upon their root planing
visits. Many patients in this category do not have enough
calculus to justify a FMD, in which case the following regimen
is followed.
First visit
Exam (0150) or Comprehensive perio exam
(0180)
FMX (0210)
Spend the time explaining to the patient why they
need special (and more expensive) periodontal treatment with
anesthesia at subsequent visits. The appoint for two
visits of root planing.
Second visit
2 quads of scaling and root planing (4341) billed
per quadrant
Arestin placement (4381) billed per site maximum 3
sites per quad
Third visit
2 quads of scaling and root planing (4341) billed
per quadrant
Arestin placement (4381) billed per site maximum 3
sites per quad
Fourth visit (2 - 3 weeks later--no charge)
Post-op check and prophy touch-up. At this visit,
the patient is evaluated as to outcome of the treatment.
Early periodontal disease often clears quite well if the
patient is willing to spend the time cleaning
interproximally (I recommend Stimudents). If the
condition heals to a state of health, future recalls may be
regular prophys (1110) twice a year. If not, the
patient may require a higher frequency schedule of
perio maintenance recalls (4910)
5. Moderate Periodontitis
Patients in this category present with numerous 5-7 mm
pockets and moderate to severe bleeding on probing.
These patients may require a full mouth debridement on their
first visit, after which they will enter immediately upon their
root planing visits. Many patients in this category do not
have enough calculus to justify a FMD, in which case the
following regimen is followed.
First visit
Exam (0150) or Comprehensive perio exam
(0180)
FMX (0210)
Spend the time explaining to the patient why they
need special (and more expensive) periodontal treatment with
anesthesia at subsequent visits. The appoint for four
visits of root planing.
Visits 2, 3, 4 and 5
Because of the depth of the pockets and the wide expanse
of root surface above the periodontal attachment, any given
quadrant will require more time to thoroughly root plane.
Trying to do more than one quad at a time on these patients
will tax the resources of both the patient and the
hygienist.
1 quad of scaling and root planing (4341)
billed per quadrant
Arestin placement (4381) billed per site
maximum 3 sites per quad
Recall visit in 3 months, and at 3 or 4 month
intervals after the first recall depending on the outcome of the
initial treatment.
Exam and perio
maintenance cleaning (4910) -- This is a combined
fee, including both the exam and the "perio prophy".
The patient should be made aware that his or her bill for
future cleanings will be higher than that charged for a
regular prophy due to the wider expanse of tooth structure
that must be scaled.
Vertical BWX (0274) once a year at perio
maintenance recalls
6. Severe Periodontitis
Patients in this category present with numerous pockets of 7
mm and greater, severe bleeding on probing and 2+ or higher
mobility.
When patients in this condition want desperately to keep
their natural teeth, we do not attempt to treat their
periodontal condition in our own office. These patients
receive the following:
Exam
FMX
referral to a periodontist.
More frequently, these patients choose a treatment plan that
includes keeping the teeth with a good prognosis, extracting the
teeth with the poorest prognosis, replacement of the missing
teeth with implants or removable prosthetics, and referral to a
periodontist for treatment of their periodontal condition.
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