Periodontal treatment or prophy?

May 1, 2012
been a dental hygienist for 12 years, and I have worked in my current office for the last four years. The doctor does excellent ...

Dear Dianne,

I’ve been a dental hygienist for 12 years, and I have worked in my current office for the last four years. The doctor does excellent restorative work, and I have great faith in his skills. However, recently he has been on my case, telling me that I’m not doing enough periodontal treatment. He went to a course and heard a statistic that 33% of treatment codes coming out of the hygiene department should be periodontal codes. When we ran the statistics for our office, we found that only 7% of our codes were periodontal codes. I feel bad about this, but what am I supposed to do? Am I supposed to start calling every little 4 mm reading periodontal disease? I’m very conflicted over this supposed problem. For the most part, I see the same patients over and over at their six-month visits. The vast majority of them are healthy and stable. I feel like I’m being asked to solve a problem that (1) doesn’t exist, and (2) is out of my control. I don’t like having my competency challenged. Do you have any tips to help me resolve this issue?

Annie, RDH

Dear Annie,

The statistic your boss heard is a benchmark that has been bandied about for some time. I don’t know where it originated, but I do not believe this benchmark is applicable to every office situation. For example, if your practice has a very low number of new patients, it may be unrealistic to expect 33% of procedures to fall in the periodontal category. Another consideration is if the practice is a high-end cosmetic practice. Again, new patient numbers are typically lower in those practices. If the practice has a large number of children, periodontal procedure codes will probably not be 33% of total codes.

However, if the practice is a typical “bread and butter” practice, 7% seems inordinately low. I’m not pointing fingers, but many hygienists become complacent over time. It is easy to settle into a basic routine of doing the same thing over and over. Further, if the hygienist is pressed for time, it’s very easy to delay probing or do what I call a “drive-by probing.” This type of probing is a quick in-and-out, here-and-there probing with no numbers recorded and a little chart note like this: PP – WNL. This is supposed to be an acronym for “periodontal probing – within normal limits.” My friend and fellow speaker, Patti DiGangi, RDH, says it really means “we never looked.” Funny as it sounds, it is the unfortunate truth in some situations. What I’m saying is this: if you aren’t looking for periodontal problems, I doubt you will find them.

The problem in some practices is that the hygienist does not have sufficient time to do a thorough periodontal evaluation. It takes the average solo hygienist 10 to 15 minutes to do a full-mouth, six-point probing with all numbers recorded, along with bleeding points, recession, furcations, and mobility. If the hygienist sees nine to 10 adult patients in an average day, multiply the number of patients by the time needed to perform a thorough periodontal evaluation. Does anyone have an extra 90 minutes per day? With an assistant, the time needed to perform that all-important periodontal evaluation and recording is reduced to half or less. That’s why I tell doctors over and over: if you want hygienists performing thorough periodontal evaluations, make it part of someone’s job description to assist with recording the readings. If doctors remove the barriers to periodontal evaluations — i.e., time and assistance — hygienists will discover periodontal problems that have been overlooked in the past. The minimum standard is that every adult patient should have a full-mouth, six-point probing and recording once a year.

Let’s take the discussion a little further. How deep do the readings need to be to indicate that definitive periodontal therapy is needed? Do a few 4 mm readings with slight bleeding require root planing and scaling? Does all gingivitis progress into periodontal disease if not controlled? What if the patient is generally healthy but has a couple of isolated 5 mm readings?

In most cases, periodontal breakdown occurs slowly over time. The pathogens that cause problems start in shallow sulci. Even a seemingly healthy sulcus can contain small numbers of microbes that can increase in numbers large enough to lead to breakdown if they are not disrupted and removed. It is widely held that there has to be a sufficient number of pathogens before breakdown occurs. By the time we discover numerous pockets over 6 mm, we are late to the game and much damage has already occurred. After all, a pocket is nothing more than a scar in the bone that is left over from disease processes that may or may not still be active. A phase contrast microscope allows the clinician to look for the presence of certain microbes, such as spirochetes and motile rods, and white blood cells. Even if no bone loss has occurred, the presence of white blood cells indicates a disease process is at work. Certainly, early intervention can avert worse problems later.

Root planing and scaling are indicated when there is bone loss, since it is not possible to instrument root surfaces that are covered with bone. In the absence of recession, a 4 mm reading on a probe typically indicates inflammation associated with gingivitis, not periodontitis. However, keep in mind that a 4 mm pocket can be the start of a disease process involving bone loss. So when you find 4 mm readings, do not minimize what this could become if not treated appropriately.

Readings above 4 mm usually indicate bone loss. These situations call for more definitive scaling and careful monitoring to ensure that pockets do not progress to deeper bone loss. Even an isolated 5 mm reading deserves site-specific scaling, possibly with anesthesia. The code for such a procedure is D4342, root planing and scaling for 1-3 teeth.

Bleeding is not always associated with gingivitis or periodontal disease. Bleeding can also be associated with certain medications, hormonal fluctuations, trauma, capillary fragility, and systemic disease. However, in the absence of outside factors, healthy gingiva should not bleed. When it does, the clinician must assume that a disease process is at work and develop a treatment plan that addresses the problem.

It would be unethical to manufacture periodontal problems where none exist. It is also unethical to minimize or “watch” small problems become big problems. I challenge you to guard against complacency and start performing thorough periodontal evaluations if you have not been doing so. When you start looking, I have no doubt that you will find areas that need more treatment than a regular prophy. Also, after your patient has been treated with definitive periodontal scaling, make sure these same patients are kept in periodontal maintenance for as long as necessary. While you may never hit the 33% benchmark for periodontal procedures, you have room for improvement.

Best wishes,

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 [email protected]. Visit her website at

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