It's up to the dentist and dental hygienist to determine each patient's periodontal status at the time of visit.
I just returned from spending five glorious days in Cancun, Mexico, at an all-inclusive resort. Having never experienced an all-inclusive vacation before, I was like a kid in a candy shop. On the first day, Perry and I tried to do it all: pools, ocean, cocktails, restaurants, hot tub, you name it. I was so eager to frolic in the ocean that I rushed in and ended up stubbing my toe really badly. Day one in paradise was windy and we couldn’t see the rocks mixed in with the sand on the ocean’s floor. While I was away, I did my best to forget about the realities of daily life, but there’s a topic I kept revisiting in my mind.
Out of the blue, just before I left to go on vacation, my good friend and co-author of a few magazine and journal feature articles, Suzanne Newkirk, RDH, emailed me. The email topic was the minutes from a September 2018 Georgia Board of Dentistry (GA BOD) rules committee meeting in which a GA BOD member invited the president of the GA Society of Periodontists to weigh in on the possibility of GA dental hygienists performing periodontal maintenance under general supervision. A prepared statement from the department of periodontics at the Dental College of Georgia was also presented to the committee.
Georgia was one of only five states in the U.S. where general supervision legislation hadn’t passed until a couple of years ago, thanks to the leadership of Ms. Newkirk as president of the GDHA and many other leaders and members who came before her. Suzanne and I coined the term “laggards” for these states, and in 2014 we wrote about the consequences of these restrictive practice acts on the public at large, particularly the underserved.1
The 2017 GA HB 154 authorizes a supervising Georgia dentist to delegate preventive dental services under general supervision to dental hygienists working in a private dental practice setting or in any of the alternative practice facilities defined in the bill. These settings include hospitals, nursing homes, long-term care facilities, rural health clinics, federally qualified health centers, hospices, family violence shelters and free health clinics.
Prior to the passage of HB 154, the restriction of dental hygiene practice acts in Georgia created a hardship for many low-income clinics that had to rely on volunteer dentists to be present in the treatment facility for dental hygiene services to be provided. The intent of the bill was to increase access to dental care for the state’s most vulnerable citizens, many of whom live in areas with few dentists.
After the bill became effective on Jan. 1, 2018, Georgia dental practitioners wrote to the board requesting periodontal maintenance be included as a delegated duty under general supervision for stable patients following active periodontal therapy. According to the September rules meeting minutes, the purpose of the discussion that day was to gather more information on this topic.
In her statement to the rules committee, Dr. Langston, a periodontist and current president of the GA Society of Periodontists, expressed concern on behalf of society members should the request be granted. Dr. Langston read the summary definition of periodontal maintenance as defined by the American Academy of Periodontology (AAP) to the committee and stated, “She feels strongly that periodontal maintenance should be monitored by the dentist because the patient is at risk.” She further stated, “A lot could happen in three months such as a patient could go under stress or they may change their medications.” She added that if a particular patient isn’t at risk, then you would code the patient as an oral prophylaxis code D1110. She stated, If you feel they are at risk and code them as perio, then they are at risk enough to require active monitoring.”
In their written statement to the committee, the Department of Periodontics at the Dental College of Georgia in Augusta wrote that the points mentioned in the GA Society statement aren’t just their opinions alone but are consistent with the position of the American Academy of Periodontology, of which they’re all members, and the American Board of Periodontology, of which they’re all diplomates.
Their statement reads, “While there is no problem with the performance of routine prophylaxis by hygienists under general supervision, we are very concerned about the health consequences if this new request is granted; namely, that it will have significant and deleterious long-term consequences for the oral health of citizens of
Georgia, for the reasons stipulated below.” (You can read the entire document2 online here.)
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To address the statements by the aforementioned Georgia groups, Suzanne contacted several experts in their respective fields. According to the American Dental Association (ADA), the purpose of the Code on Dental Procedures and Nomenclature (known as the CDT Code) is to achieve uniformity, consistency and specificity in accurately documenting dental services in order to receive reimbursement from third-party payers. CDT Code 4910 is the procedure code used for billing following active periodontal therapy (either surgical or nonsurgical). Nowhere in the code description is there a requirement for the treating clinician to include information on the clinical state of the patient in order to receive reimbursement of services.
Suzanne, a periodontal co-therapist, speaker, author and KOL in periodontal endoscopy, said, “Many patients in general and periodontal specialty practices that have undergone treatment for periodontal disease clinically present at their continuing care appointments with normal probing depths and show no evidence of ongoing loss of attachment.” She feels that these patients are typically categorized as “having a reduced but stable periodontium” and feels that “although they are stable does not mean that they should be coded as an oral prophylaxis, CDT code D1110, nor does the fact that they have a positive history for ‘risk’ make them diseased or mean that they should be coded as a CDT 4910,” as was stated by Dr. Langston. In fact, CDT 2013 indicates that how our supervising dentists choose to code a patient with a stable periodontium following active periodontal therapy "is a matter of clinical judgment by the treating dentist.”
To address the statement provided by the department of periodontics at the Dental College of Georgia, Suzanne looked at the AAP website page on nonsurgical periodontal treatment and found nothing to suggest that patients seen under general supervision for periodontal maintenance will have “significant and deleterious long-term consequences,” nor did she find any scientific evidence to support the statement. The AAP website does state, however, that “most periodontists agree that many patients do not require any further active treatment following scaling and root planing” other than ongoing maintenance.
Difference between CDT Code 1110 and CDT Code 4910
It never hurts to review the difference between prophylaxis (D1110) and periodontal maintenance (D4910) as procedural codes that are defined to provide uniformity in determining third-party payer reimbursement. Besides consulting with Suzanne, who wrote to the GA BOD president about these code differences, I contacted Dianne Watterson, RDH, MBA, a speaker, author and consultant with more than four decades of experience in dentistry. Dianne was willing to review code differences and here are her responses to my questions:
1. What’s the difference between CDT Code 1110 (prophy) and CDT Code 4910 (periodontal maintenance) in terms of actual procedure?
The descriptor for code D1110 says, “Removal of plaque, calculus and stains from the tooth structures in the permanent or transitional dentition. It is intended to control local irritational factors.” We consider it a preventive code since it falls in the “preventive” category of codes (D1000-D1999). The periodontal maintenance code, D4910, descriptor states, “…removal of bacterial plaque and calculus from supragingival and subgingival regions, scaling and root planing where indicated, and polishing the teeth.” D1110 is considered a component of D4910 by third-party payers. The difference is D4910 is considered therapeutic in bringing active disease under control. But in terms of actual procedure, both codes specify removal of plaque, calculus and stains.
2. Should a dental hygienist be given more time to perform periodontal maintenance?
It depends on the patient and his/her needs, severity of disease and number of teeth.
3. Is it illegal for a dental practice to downgrade periodontal maintenance to a prophy at the patient’s request?
Dental practices should charge for what they do. If the patient has ongoing signs/symptoms of disease activity and the hygienist has to continue to provide active treatment in an effort to bring disease under control, the code should be D4910. However, third-party payers may “remap” the D4910 code to D1110 due to plan limitations.
4. Does the performance of periodontal maintenance mean that the patient is at greater risk of future periodontal breakdown?
Dental hygienists who provide high-quality care should always be diligent about assessing for disease activity for the life of the dentition. But we have to acknowledge that there is wide variability among our patients with regard to their response to active therapy. Some patients achieve a level of oral health consistent with disease control and good health, while some never get to that point. Stability and continual improvement over a period of time, typically one to two years, should be a good indication to the clinician of whether or not the disease is stopped. Further, we know that host immunity plays a large role in health versus disease. Changes in host immunity can open the door for disease as well as patients becoming re-infected, especially if they exchange saliva with infected individuals. All patients do not carry the same risk level for future periodontal breakdown.
5. Can you clear up confusion on the part of those who think registered dental hygienists aren’t qualified to perform periodontal maintenance (supportive periodontal care) in a variety of settings?
Dental hygienists are educated under the same set of rigid criteria and must pass a board examination in order to be licensed in every state (except Alabama, which allows preceptor training). Hygienists work in a variety of work settings and are prepared through the educational process to provide thorough, consistent care, regardless of the setting.
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Code for what you do
Dr. Charles Blair is always telling audiences to code for what they do. He also reiterates in his lectures NOT to alternate between periodontal maintenance and a prophy. Periodontal maintenance (D4910) is a procedure code for ongoing management of periodontitis. Patients may present with a periodontium that’s stable or unstable, and it’s up to the dentist and dental hygienist to determine the individual’s periodontal status at the time of the maintenance visit.
Dental and dental hygiene practitioners are educated about risk factors for periodontitis and to recognize the need for periodic reassessment and site-specific scaling and root planing where indicated as a requirement for supportive maintenance care. A comprehensive periodontal exam includes probing depths, bleeding on probing, clinical attachment loss (CAL), mobility and furcation involvement, along with a complete dental medical and dental history and periodic radiographs. It also requires careful monitoring of a patient’s self-care, including disclosing solutions to determine adequate or inadequate biofilm disruption at home. Taking time to teach patients how to disrupt biofilm along an unstable or reduced periodontium takes time and commitment on the part of the practitioner.
Supportive periodontal treatment also includes appropriate recare intervals. Many dentists today delegate supportive periodontal treatment to the dental hygienist who’s educated to perform this function. Periodontitis patients who continue to lose clinical attachment and who are unstable over time should be referred by the dentist and dental hygienist to a periodontist. With periodontitis, there’s an episodic pattern of tissue destruction, and it’s a lot like the metabolic syndrome, diabetes. Diabetes is managed, just like periodontitis, and patients need to be monitored over a lifetime to prevent life-threatening complications. Certified Diabetes Educators (CDEs) are health professionals who possess comprehensive knowledge of and experience in diabetes prevention, prediabetes and diabetes management. The CDE educates, supports and advocates for people affected by diabetes, addressing the stages of diabetes throughout a person’s lifespan. CDEs and RDHs, like RNs and RDHs, share a lot of similarities in their educational requirements for licensure.
What does periodontal maintenance mean to me as a practitioner and what is my take on Georgia’s general supervision battle?
Periodontal maintenance to me means occasionally fighting for enough time to be thorough and doing battle with the front desk staff member who wants to slip a perio maintenance patient into a 40- to 50-minute appointment slot with no assistance in periodontal charting. Many third-party payers only cover perio maintenance twice a year and patients with periodontitis require three- to four-month ongoing supportive care management. Getting patients to comply with three- to four-month ongoing care is difficult for patients on a fixed budget, especially patients over the age of 65. Most of the time, dentists delegate periodontal maintenance to the RDH because we are just as qualified, if not more so, than general dentists in periodontal assessment and instrumentation.
RDHs, like me, enjoy the challenge of managing a patient’s periodontitis, given adequate time and resources. I enjoy nothing more than periodontal charting, assessment and patient education. Instrumentation can be more time-consuming, but it varies according to patient presentation. Hygienists are ideally suited to pamper the periodontal maintenance patient, and it takes a unique ability to develop and maintain a long-term relationship with these patients. Keeping periodontitis patients stable requires trust, good communication skills and compliance with our recommendations.
Georgia’s new battle about whether or not RDHs should be permitted to perform periodontal maintenance under general supervision comes across as a petty turf battle in which dental hygienists are being used as pawns in a game of control and fear of lost wages by dentists. Patients miss out when the RDH isn’t allowed to use his/her clinical skills in community health settings. Furthermore, there are no documented cases of licensed hygienists causing harm to patients in these settings.
The whole point of general supervision legislation is to expand access to care in a variety of settings. RDHs are very capable of being primary care practitioners and they’re capable of doing this without a dentist standing over them. For both dentists and RDHs, periodontal assessment isn’t easy and takes adequate time and commitment. A majority of geriatric patients in assisted living homes and other settings need preventive dental care, including periodontal maintenance. Many of these older adults will present with moderate to severe chronic inflammation and poor oral hygiene.
The world’s population is aging and the ever-expanding number of adults who have retained teeth, complex medical histories and need for preventive care will increase way beyond the ability of the “dentist” as a sole provider to care for them. Clinical supervision may evolve into peer professional support and learning where RDHs are assisted in developing their skills through regular discussion and experienced colleagues as is done in nursing. Does the Georgia board or other boards of dentistry in remaining laggard states really want to deny the compassionate care of an RDH?