Follow-up after definitive therapy

By Dianne Glasscoe Watterson, RDH, BS, MBA

Dear Dianne,
My first question is about patients who have completed root planing/scaling and the follow-up visit before definitive maintenance begins. I like to see my periodontal patients following definitive therapy three to six weeks after the last root planing visit, since I believe it is important to evaluate their progress. Our office manager (who is in charge of billing to insurance companies) wants to know if this is important to do or if this visit is optional, because there is no code to bill to insurance companies. She also questions how much we should charge for this visit, or if we can even charge for that visit at all.

My second question is what do you feel is the best protocol to follow for the periodontal maintenance visit? How often should we be doing full-mouth charting?

I really do appreciate your help!
Mary, RDH

Dear Mary,
Like you, I believe it is important to monitor the periodontal patient's progress closely after completing definitive root planing/scaling, and waiting three months (when definitive maintenance begins) seems too far into the future. The "interim visit" can be pivotal in correcting inadequacies in the patient's home-care routine, and it is also an opportune time to remove any residual calculus that may become evident after some healing has occurred and to polish the patient's teeth. Most patients look forward to having their teeth polished. You can even say to the patient after completing the RPS, "Next time I see you, I will be evaluating your progress, and I'll also polish your teeth." Believe it or not, many patients feel you have not "cleaned" their teeth until they are polished.

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Your office manager is correct in stating that there is not a specific code to report the "interim visit" before the three-month definitive maintenance. However, you do have some options as to how to obtain reimbursement for this visit. First, let's look at a code descriptor as it is written in the ADA Current Dental Terminology:

Did you notice there is not one word in the dD1110 -- Prophylaxis -- Adult: Removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.escription that states the patient needs to be periodontally healthy to use this code? In the past, we felt it was only appropriate to use this code with patients who had no signs or symptoms of disease. (It is noteworthy that this descriptor has been rewritten several times over past years.) Given the current descriptor, there is nothing to prevent us from using this code for the interim visit we are discussing. Of course, when you begin the definitive periodontal maintenance phase, the appropriate code would be D4910.

Another way to make provision for this interim evaluation visit is to provide the visit at no additional separate charge to the patient. The cost of the visit could be included in the cost of the RPS and become a planned component of treatment, much like denture adjustments or dressing changes with dry socket treatment.

The definitive periodontal maintenance visit -- D4910 -- is a therapeutic visit aimed at controlling pathogen repopulation in addition to the removal of any stains, calculus, and plaque from supragingival and subgingival regions. This visit includes any root planing that is indicated as well as polishing the teeth. This code does not include the doctor's examination.

The accepted standard of care for full-mouth periodontal probing and recording is once per year for all adult patients. If the patient is a new or established patient with signs or symptoms of periodontitis or a history of periodontitis, the examination code is D0180. Here is the CDT descriptor:

This procedure is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patient's dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, and oral cancer evaluation.

Most offices perform two examinations per year on periodontal patients -- a D0120 periodic exam and a D0180 periodontal evaluation. Some hygienists perform a full periodontal evaluation at each visit but only do "spot probing" on problem areas. That is acceptable as long as the full six-point probing and recording is performed once per year. It is customary to charge a higher fee for the D0180, as it requires the full periodontal evaluation as described above. Please understand that the D0180 code is not appropriate to use when performing periodontal screening and recording (PSR).

You inquired about a protocol for the periodontal maintenance visit. This visit should contain many, if not all, of the components listed here:

  • An update of the patient's medical history, oral cancer exam, and blood pressure screening.
  • An evaluation of the patient's home care and customization of methods to fit the patient's needs, including power brushes, interdental cleaners, and antimicrobials.
  • A microbial evaluation through phase contrast microscopy, BANA, or DNA microbial analysis.
  • An evaluation of tissue condition and probing as needed.
  • A focused effort at removing pathogens that have repopulated, with heavy emphasis on power scaling with thin tips that allow for deep access.
  • Hand scaling as needed and polishing.
  • Doctor examination as needed.
  • Reappoint for next visit.

One point I would like to emphasize is that teaching the periodontal patient to floss may not be useful or even appropriate, especially if the patient has lost the interdental papilla to the ravages of periodontitis. It is estimated that only 3% to 5% of patients floss daily, and of those who do floss, many do not use floss correctly. In a systematic review published in 2008, it was demonstrated that dental floss provided no benefit over toothbrushing alone. (Berchier C, Slot D, Haps S, Van der Weijden G. The efficacy of dental floss in addition to a toothbrush on plaque and parameters of gingival inflammation: a systematic review. Int J Dent Hygiene. 2008;6:265-279.) Interdental brushes have proven to be far better at removing interdental plaque than floss. Further, water irrigation devices such as Waterpik provide great benefits in removing microbes. Years ago, we erroneously believed that plaque could only be removed through mechanical friction. We now know through the work of Costerton and others that plaque can indeed be removed with a dental water jet. (Gorur A, Lyle D, Schaudinn C, Costerton J. Biofilm removal with a dental water jet. Compend Contin Educ Dent. Mar. 2009;30(1):1-6.) For the majority of people, using a Waterpik is easier than flossing and more efficacious to boot. You should spend time helping your patient become proficient using any technology you recommend, including power brushes and water jet devices.

The other maintenance aspect that may be difficult to implement is monitoring for the presence of microbes. Phase contrast microscopy is an excellent way to monitor for the presence of white blood cells, spirochetes, motile rods, other problematic microbes, and is very motivating for the patient. If your office does not have this technology, other options include OralDNA (www.oraldna.com) and BANA testing (https://www.oratec.net/product.asp?product_id=87).
All the best, Dianne

DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the  United States. Dianne’s new book, “The Consummate Dental Hygienist: Solutions for Challenging Workplace Issues,” is now available on her website. To contact her for speaking or consulting, call (301) 874-5240 or email dglass coe@northstate.net. Visit her website at www.professionaldentalmgmt.com.

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