Case presentations should note savings of non-surgical treatment
Lynn Miller, RDH
New insurance codes were adopted in January 1996. Are you up-to-date when treating your patients for periodontal disease? Here are some quick tips and definitions to get current.
Most dentists and dental hygienists practice "disease maintenance" when treating periodontally involved patients. This treatment is not based on a lack of care or even lack of knowledge, but rather established modalities that have not, until about five years ago, been questioned. We perform "prophys" and "watch" many areas. We even think we are getting aggressive by doing a "therapeutic scaling" and putting the patient on a three- to four-month recall program.
Before we decide which preventive or periodontal procedure is best for treating our patients, we must first understand what each treatment really means. Carefully read, learn, and study the definitions of the four most common hygiene procedures.
Definition of oral prophylaxis; ADA Code 0110:
Scaling and polishing procedure performed on dental patients in normal or good periodontal health to remove coronal plaque, calculus, and stains to prevent caries and periodontal disease. Since pockets are absent in a completely normal periodontium, scaling and polishing are performed on the anatomic or clinical crown and into very shallow, healthy sulci. (American Academy of Periodontology)
Definition of periodontal scaling performed in presence of gingival inflammation; ADA Code 04345:
Gingivitis can be characterized clinically by marked changes in color, gingival form, position, surface appearance, presence of bleeding, and/or exudate. With no loss of attachment or bone loss, this scaling treatment procedure is more precise in describing therapy for generalized gingivitis and is not meant to be performed on a routine basis. Upon completion of treatment the gingival tissues should be normal and can be maintained by adult prophylaxis on a regular basis. This is a scaling only procedure; it may require single or multiple visits. Should not be reported in conjunction with an adult prophylaxis, or for reporting periodontal scaling performed in conjunction with root planing. (Deleted code 04345 is still a valid payment code in many contracts.)
Definition of scaling and root planing, per quadrant; ADA Code 04341:
Scaling and root planing is a definitive, therapeutic procedure for treatment of some stages of periodontal disease and as a part of pre-surgical procedures in others. Root planing removes cementum and dentin that is rough and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. There must be bone loss and disease. It might need to be performed every one to two years, depending on the patient`s systemic and social factors. (American Academy of Periodontology)
Definition of full mouth debridement; ADA Code 04355:
To enable comprehensive periodontal evaluation and diagnosis ... the removal of sub-gingival and/or supra-gingival plaque and calculus when these obstruct the ability to perform an oral evaluation. This is a preliminary procedure and does not preclude the need for other procedures. Nor should it be used in conjunction with other procedures ... For the patients who have neglected their oral health to the extent that calculus and plaque will not allow for accurate visual and radiographic interpretation. (American Academy of Periodontology)
The cost of disease maintenance
The American Academy of Periodontology was the first to recognize that periodontal disease is a very quick, episodic event. Obviously, this causes a great deal of bone destruction in a very short period of time. The good news is that it is so easy to find - at least in most cases. It is as simple as performing a complete periodontal charting, studying the X-rays, and documenting the bleeding index. The bleeding index is paramount in detecting active disease because when, there is bleeding, there is possible bone loss occurring right before your eyes. Waiting and watching two to three months and then bringing our patients back is practicing disease maintenance.
The patient should not be released from our current treatment until the bleeding has stopped. The tissue should be healthy and firm with the attachment and circular fibers hugging the tooth.
Aside from bleeding and the visual condition of the tissue, most periodontists and hygienists rely heavily on X-rays. A full-mouth X-ray is needed for all periodontal patients.
I highly recommend studying an X-ray before you pick up a probe. I am so used to this procedure that not doing it would be like going on a trip but not knowing the destination. It really helps you to understand the shape and direction of the tooth and if there is any "tight" but diseased tissue (the kind that fools all of us) with a pool of bacteria and bone loss underneath. If you first study the X-ray, you will be able to find the periodontally involved areas.
One of the most important - but, at first, intimidating - things the hygienist needs to do is learn to talk to patients about the fee. I am not asking you to become financial managers, but it is helpful if you mention that this is going to cost about X number of dollars. Round the figure off and tell the patient the office manager will go over the exact dollars with them.
In addition, tell the patient how much time, trouble, and money the scaling and root planing will save, since periodontal surgery can be avoided.
The various cases in dental offices require a different case presentation based on the insurance codes.
Case Type I
The gingivitis (04500) present is shallow - 3 to 4 mm pockets - and no bone loss is noted. The dental office should charge 11/2 to two times the prophylaxis fee. Perform Code 4345 scaling in the presence of gingival inflammation, as well as gross debridement. The treatment will involve two to three visits that are one to two weeks apart.
The first appointment is for 50 to 60 minutes. An initial exam, probing and charting, scaling and irrigation, and oral hygiene instructions are performed.
One to two weeks later, the second appointment is for 40 to 50 minutes. Treatment involves scaling and irrigation, as well as oral hygiene instructions.
The third appointment, one to two weeks after the second one, is for 30 minutes. The intent now is to perform a prophy and re-evaluation, oral hygiene instructions, and appoint for recare appointment in three to six months.
A final observation about ADA Code 4343 is that patients can be kept on six-month recall. You cannot use a 4910 after this procedure.
Case presentations with bone loss
For Case Type II, early periodontitis (04600) is present with pockets ranging from 3, 4, or 5 mm. Bone loss is non-reversible. Take a probe and lay it over the top of the tissue, demonstrating to the patient the difference between 3 mm and 5 mm pockets.
X-rays are not necessarily diagnostic.
Count the number of periodontally involved teeth and divide by four (four teeth make up one quadrant). Example: Janice Smith has 12 periodontally involved teeth; divide by four equals three quadrants of scaling and root planing. Charge 21/2 to three times prophy fee.
The first appointment is for 50 minutes. Treatment includes periodontal probing (0140), full mouth X-rays, the case presentation, oral hygiene instruction, and getting an early start on the scaling and root planing, if possible.
Two to four appointments can then be scheduled based on the need for them, staggered one to two weeks apart. Devote five to seven minutes per tooth. During each appointment, you perform scaling and root planing (one to two quads), as well as irrigation.
At the final appointment, usually the third to fifth one, a 30- to 40-minute prophy is performed. You re-evaluate the OHI as well and appoint for recare appointment in three to four months.
Case Types III and IV
In Case Types III and IV, moderate to severe periodontitis (04700 and 04800) is present with 5, 6, and 7 mm pockets. For these cases, charge at least three times the prophy fee, and code or classify by deepest pocket. X-rays, at this point, are diagnostic.
In addition, evaluate for bruxing guard, consider antibiotic therapy, and determine whether vitamins and irrigation would be helpful as additional therapy. The question on whether the third molars need to be removed should be answered. A referral to a periodontist is recommended.
The first appointment is for 50 minutes and involves periodontal probing (0140), full mouth X-rays, the case presentation, an impression for a bruxing appliance, and oral hygiene instructions, including vitamin and irrigation home therapy.
The second through fourth appointments are for eight to 10 minutes per tooth. The treatment includes scaling and root planing (one quadrant), irrigation, delivering the bruxing appliance, and oral hygiene instructions.
The last appointment is a prophy for 30 to 40 minutes. In addition, re-evaluate the OHI and appoint for recare appointment in the next two to three months.
With Case Types III and IV, refer to a periodontist if:
- Biological width is hurt (crown lengthening is needed).
- Ridge augmentation is needed.
- Vertical defect is noted.
- Furcation involvement is noted.
- Implant placement is indicated.
- Patient refuses general dentist`s therapy.
- Systemic disease is noted.
- Patient is not responding to your treatment.
The correct understanding and application of insurance codes allow for early detection and prevention of periodontal disease, saving our patients time, money, and pain. Early treatment of Class I, II, and III cases saves patients quality time since Class IV or V cases are significantly more maintenance intensive.
We save patients money since periodontal surgery is four to six times the cost of scaling and root planing or adjunctive services.
And we spare patients unnecessary pain from the latter stages of disease and, certainly, periodontal surgery.
The other benefits for our patients are innumerable: prevention of bad breath, keeping the quality and beauty of their smile, and a lifetime of good health.
Being a great hygienist is a never-ending process. Because at least 75 percent of the adult population have some type of periodontal disease, the understanding and use of these codes is a necessity.
Lynn Miller, RDH, is the owner of Lynn Miller & Associates, Inc. in Austin, Texas. The company is a practice management consulting firm. Ms. Miller is a member of the RDH Editorial Board. Please call (800) 435-3830 with questions about this article.