2020 ‘Get Rid of it Challenge' with Periodontal Disease

Relaxing in my favorite armchair, I glanced at the TV just as a commercial promoting a stannous fluoride toothpaste appeared on the screen. A presenter was complaining about gum “irritation” and the commercial went on to say that bacteria causing gum “irritation” lives below the gum line. Get rid of it is my challenge to those practitioners who are talking about gum “irritation”.

So what’s the difference between irritation and inflammation and what’s the big deal? If you talk in terms of chronic inflammation, your message automatically goes beyond a discussion of sticky goo (biofilm) to keeping chronic body inflammation under control and it’s possible that a patient’s ears might perk up. Managing diet and lifestyle are two great ways to keep chronic inflammation under control and when you tell a patient about bleeding gums, a better message is to focus on ways to reduce inflammation like stepping up oral hygiene, more frequent recare and periodic SRP.¹

A dental prophylaxis is not a “cleaning” and, in my opinion, the more you use this term, the more insurance dependent a practice will become. Charge for what you DIAGNOSE and DO. Patients enter the reception area announcing “I want a regular cleaning (forever prophy) that’s covered by my insurance and not the perio one.” I like Limoli’s way of putting it: “Put the process of appropriate procedure coding in its rightful place. That place, just like the patient’s benefit plan, has to always be last, dead last!”²

Putting on the schedule a note that a new patient had a regular “cleaning” six months ago doesn’t mean that a dental prophylaxis is appropriate. Get rid of it! 

A periodontal exam is much more than 323 323 435 534, etc., probing depths and, just as important, gingival and periodontal diseases require a documented diagnosis. How can you treatment plan a periodontal procedure without a diagnosis? Get rid of this thinking and review the new 2017 classifications. In reviewing the new classifications of gingival and periodontal diseases, I find them complex and difficult to follow so I’ll try to simplify them below for the average dentist and hygienist. Most important, classify the severity/complexity of disease and grade it according to progression and responsiveness. Referral to a periodontist is important and you need to determine criteria for referral. 

You can refer to the severity/grading charts for periodontitis on the American Academy of Periodontology website (www.perio.org) or use the simplified version below. Classifying gingival diseases is different and you can read a synopsis of gingival disease classification here.

When preparing to diagnose periodontitis, laminate a copy of the grading/staging page here. Make a copy for hygienist/dentist providers and review at a staff meeting. 

Staging means determining the severity of disease at presentation and the complexity of disease management.

Stage 1: Initial Periodontitis

Stage 2: Moderate Periodontitis

Stage 3: Severe Periodontitis w/ potential for additional tooth loss

Stage 4: Severe Periodontitis w/ potential for loss of dentition

Extent and distribution of disease should be noted: localized, generalized, molar-incisor distribution. Staging isn’t something that can be determined by recording probing depths only and takes time and critical thinking skills to assess. Several variables need to be carefully evaluated, including clinical attachment loss (CAL), amount and percentage of bone loss, probing depth, presence and extent of angular bony defects and furcation involvement, tooth mobility and tooth loss due to periodontitis. 

Grading includes three levels:

Grade A: Slow rate of progression

Grade B: Moderate rate of progression

Grade C: Rapid rate of progression

When grading a patient, general health status and other exposures, such as smoking and level of metabolic control in diabetes, need to be taken into account to allow comprehensive patient management.

What about the periodontitis patient who never gets a regular prophylaxis? Don’t fret over it, don’t get rid of periodontal maintenance and just code for what you do. If your patient has a documented diagnosis of periodontitis, coding will be obvious and periodontal maintenance will continue indefinitely. Remember that periodontitis is a chronic inflammatory disease and it’s highly unlikely to disappear completely over time. We manage it for a lifetime, just as we would if we were diagnosed with Crohn’s disease or rheumatoid arthritis.³ Staging and grading, if properly documented in writing, will assist you in describing extent, complexity, biological features and risk of further progression. Send this narrative to the insurance companies and stand your ground with patients who want a “simple cleaning”. 

Dental hygiene instrumentation and SRP

The arrival of 2020 gives us the opportunity to make sensible changes in protocols, including nonsurgical periodontal protocols. ‘Out with the Old’, and in with the new instrumentation techniques which mean cutting back on hand instrumentation. Consider replacing a bunch of gracey instruments rattling around on an instrument tray with one or two sharp universal curettes and combine hand instrumentation with ultrasonics, piezo or magnetostrictive technologies. The efficacy of subgingival instrumentation (hand or ultrasonics) for the treatment of periodontitis is the subject of a recent systematic review.⁴

Subgingival instrumentation is an efficacious treatment in reducing inflammation and probing depth and the number of diseased sites with periodontitis in a dentition.⁴ Efficacy is consistent no matter what type of instrumentation is employed (ultrasonics or hand instrumentation) and mode of delivery (quadrant vs full mouth) doesn’t make a difference in outcome either.⁴ In shallow pockets (4-6 mm), a mean difference post instrumentation can expect a 1.5 mm reduction at 6-8 months, and deeper pockets (≥7 mm) can expect a mean probing depth reduction of 2.6 mm. Well-performed nonsurgical periodontal therapy may limit the need for additional treatment procedures which most patients avoid due to higher costs and increased morbidity.⁴

Do not hesitate; start diagnosing and treatment planning but make sure your treatment protocols are well-performed. Don’t rush these procedures and make sure your instruments are working properly. That means no dull hand instruments and ultrasonic inserts that aren’t worn. Why would you choose to diminish your scaling efficacy with a worn tip? Toss worn tips/dull instruments and enter 2020 with clinical excellence.

References:

1. https://www.health.harvard.edu/staying-healthy/playing-with-the-fire-of-inflammation
2. https://www.limoli.com/prophy-vs-perio-maintenance/
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563957/
4. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jcpe.13245