Trisha E. O`Hehir, RDH, BS
Although a frequently used medical term, it wasn`t until 1994 that the word, debridement, first appeared in dental-hygiene literature in Irene Woodall`s textbook, Comprehensive Dental Hygiene Care. I was honored to be part of the team responsible for Chapter 25, "Periodontal Debridement," along with Irene Woodall and Nancy Young. Together, we developed the debridement-therapy concept, reviewed the periodontal literature, and presented a new view of dental-hygiene instrumentation. Despite many articles and continuing-education courses since the writing of Chapter 25, the concept of debridement still seems to create confusion.
Scaling and root-planing are familiar terms to all of us. What then is the difference between root-planing and debridement? That`s simple - debridement is more than root-planing! Two primary distinctions should be remembered: 1) debridement goes beyond the root surfaces and 2) it is measured objectively.
Root-planing focuses only on the root surfaces. Removing hard and soft deposits from the root surfaces has been accomplished primarily through the use of curettes. The goal always has been to achieve smooth, glassy surfaces. Based on the assumption that bacterial endotoxins were cementum-bound, the goal of root-planing remains to remove cementum. More research has revealed that endotoxins are not, in fact, bound to cementum, but easily removed with power scalers. Today, complete cementum removal to eliminate endotoxins, although effective, is considered overtreatment. Some studies actually demonstrate the potential for endodontic problems resulting from aggressive root-planing to remove cementum. Cementum removal leaves open dentinal tubules which allows pathogens to travel between the periodontal pocket and the pulp.
Debridement takes into account more than just the root surfaces. In addition to treatment of the root surface, it encompasses the pocket space, the pocket wall, underlying tissues, and even takes into account the immune response of the patient. The focus of debridement therapy is the control of a bacterial infection as opposed to simply removing deposits from root surfaces.
Identification of highly pathogenic, free-floating bacteria within the pocket have broadened the treatment focus to include the space between the root surface and pocket wall. Power-scaler lavage flushes out bacteria, as well as calculus deposits, removed by mechancial vibration. The use of antimicrobials as the lavage in the power scalers provides adjunctive antibacterial effects.
Another important distinction between root-planing and debridement is that debridement relies on objective measures of tissue response, as opposed to the subjective measure of root-surface smoothness associated with root-planing. The goal of debridement therapy is to stop disease progress and re-establish periodontal health. The goal of debridement therapy goes beyond the root surfaces to the oral health of the patient.
Based on these findings, the terms "scaling" and "root-planing" actually constitute outdated overtreatment. Debridement therapy deals with the control of a bacterial infection, rather than the narrow focus of root-surface smoothness.
In Chapter 25 of the Comprehensive Dental Hygiene Care textbook, we changed the focus from root-surface smoothness to tissue response. We also shifted the instrument focus from curettes to power scalers. Before this time, ultrasonic scalers were used primarily for gross scaling. Seeing a link between debridement therapy and power scalers, some people jumped to the conclusion that debridement was nothing more than gross scaling. Some think debridement is limited to the use of power scalers. Those conclusions are wrong and were not the message presented in Chapter 25.
Debridement is not simply gross scaling. In fact, it is more involved than root-planing. The goal of debridement therapy is not only calculus removal, but to stop disease progress and achieve an outcome of tissue health. This is accomplished without the aggressive removal of cementum and the subsequent root sensitivity.
What about insurance codes? Insurance codes are a means of communicating services for payment. Insurance codes are not based on the latest scientific evidence and, therefore, take a long time to catch up with scientific terminology. Our goal with insurance codes is to communicate with the insurance company. We must use the available codes to communicate the services our patients have received. Since scientific evidence has demonstrated the superiority of debridement therapy over root-planing, that should be how we treat our patients. Code 4341, Scaling and Root-Planing by Quadrant, is the only code which applies to conservative periodontal therapy and is, therefore, the only choice.
Debridement is the approach taken to control a bacterial infection in the periodontal tissues. The code that best describes that is root-planing, even though scientific evidence suggests removing root-surface cementum may be detrimental. Although not entirely accurate, it is the best, as well as the only, choice currently available. Remember that the goal for our patients is periodontal health, and the goal with insurance companies is communication.
Trisha E. O`Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics. The Web site for Perio Reports is www.perioreports.com. Her e-mail address is trisha@perioreports. com.