Periodontal maintenance or prophy?

Dianne Watterson, RDH, MBA, weighs in on the case of a hygienist whose practice has a policy of billing the preventive care of any patient with a history of periodontal disease as D4910, regardless of if the disease is active. But is this policy really evidence based? And was the patient right to leave the practice over it? Find out here.

Jan 1st, 2019

Dianne Glasscoe Watterson,MBA, RDH

Dear Dianne,

I work in a solo practice with another full-time hygienist. We both graduated 10 years ago and our doctor is a great guy. We pride ourselves on delivering high-
quality care to our patients and we focus on making sure our patients are happy with their experience.

However, I recently had a new patient in my chair who was definitelynot happy when she left. This nice lady recently moved to our area and was referred to our practice by a neighbor. I seated her and gathered all the preliminary data plus took a full-mouth series of x-rays. Her medical history was uneventful and she had no history of smoking. She indicated that she had experienced some periodontal problems in the past, but as far as she knew, everything was fine now. Her periodontal charting revealed no bleeding on probing and no signs of disease activity. When I did a tour of her mouth, the tissue looked great and I only found one reading at 5 mm and a few areas of recession. Her home care was very good.

The policy in our office is if a patient has periodontal disease, past or present, the code for their preventive care is D4910. So that’s what I marked. But when the patient checked out, she was most unhappy with the charge and the business assistant’s explanation. She said, “I just came in to get a cleaning and I feel like I have been ripped off!” When the business assistant told me about the situation, I decided to send the patient a written explanation through email. I explained while there is no cure for periodontal disease, we try to control it, much like diabetes, and I was following the policies of my office. The patient replied she will never return to our practice.

Needless to say, this is upsetting. I feel responsible for losing a good patient and I certainly do not want this to happen again. Where did I go wrong?

Upset RDH

Dear Upset,

Your post is most interesting, as it brings up several “hot-button” issues. First of all, periodontal disease is a phrase that covers both gingivitis and periodontitis. These are two very different diseases and gingivitis is definitely curable. So to say that periodontal disease is not curable is an erroneous statement.

Whether periodontitis is curable is debatable. There are some who feel the absence of disease following definitive therapy and a season of maintenance fulfills the criteria for curability. Gary Greenstein, DDS, MS, periodontist and researcher, posits:

“Some therapists believe that periodontal diseases are chronic diseases and not curable, rather they are maintainable illnesses. However, this line of reasoning fails to recognize that most patients with periodontal diseases attain periodontal health after therapy at the vast majority of sites. The need for maintenance post-treatment is an important aspect of optimizing long-term success, but recognition of this fact does not justify characterizing periodontal diseases as incurable . . . . The belief that chronic periodontitis is incurable in the presence of health after periodontal therapy seems contradictory. Maintenance may be an extension of active therapy, but the absence of disease after treatment fulfills the criteria for health and curability.”1

In clinical practice, I had patients who I treated with definitive periodontal therapy, then placed them on three-month maintenance for a period of usually two years. Some of those patients showed continual improvement over time and reached a point where they had no symptoms of active disease. Others did not. I had some patients who continued to display bleeding and instability. Often these same patients had mitigating factors such as diabetes, very poor oral home care, or smoking. These patients were never cured.

Secondly, comparing periodontitis to diabetes is not an accurate or fair comparison. Diabetes is an endocrine disease that does not get better nor can it be fully controlled. People with diabetes can continue to have increased atherosclerosis as well as other serious medical complications—even with “successful” treatment. Periodontitis can, however, be stopped and fully controlled. There are genetic issues with some people that allow a high-risk biofilm that may compromise our ability to affect a “cure.”

Also, consider that some people get better with periodontal treatment, then get reinfected, particularly if they live with a spouse or significant other who has periodontal problems. Periodontitis is a microbial disease and the pathogenic microbes can be passed from one person to another. This is not so with diabetes.

The American Dental Association addressed this topic of whether it is appropriate to return people to a regular prophy following definitive perio maintenance. Here is its statement:

“This is a matter of clinical judgment by the treating dentist. Follow-up patients who have received active periodontal therapy (surgical or non-surgical) are appropriately reported using the periodontal maintenance code D4910. However, if the treating dentist determines that a patient’s oral condition can be treated with a routine prophylaxis, delivery of this service and reporting with code D1110 may be appropriate.”2

Let’s get back to your situation. You mentioned this new patient had no signs of disease activity and, in fact, looked very healthy. If she had not mentioned that she had some history with “periodontal problems,” which could mean gingivitis or periodontitis, what would have been the logical treatment? A prophy, of course. So, I’m siding with your patient on this one.

You mentioned the policy in your office is to treat all people with a history of periodontal disease, past or present, as if they still need therapeutic care. My advice is to get rid of this policy. Herein is the crux of the problem: Try putting yourself in the patient’s position. Consider if you had a disease for which your doctor treated you and you got better. Would it be right or fair for your doctor to keep on treating you as if you still had this disease? No, but it is right for your doctor to monitor for disease and to retreat should the disease return.

All this confusion is not your fault, as the code descriptor for D4910 has this vague phrase “for the life of the dentition.” Many interpret this to mean “once perio, always perio.” My interpretation is different. I think it means dental clinicians are to be vigilant and look for disease for the life of the dentition. However, I know this is controversial. Further, patients do not care for our “policies,” especially when those policies seem unfair and hit them in the pocketbook. The phrase “it is our policy” is one of those awful phrases that should never be used with patients.

Periodontal treatment and maintenance decisions require the treating clinician and the patient use sound decision-making. All patients have a right to have a say in their treatment decisions. If an office denied me that right, I’d go to another office.

One last thought: Many hygienists cannot discern the difference between the two services, D1110 and D4910. To clarify, D1110 is “removal of plaque, calculus, and stains from the tooth structures.” (“Tooth structures” includes the root.) The code D4910 applies to the same services, with the added emphasis on periodontal bone loss.

All the best,

Diane Glasscoe Watterson

References

1. Greenstein G. Periodontal diseases are curable.J Periodontol. 2002;73(8):950-953.

2. American Dental Association. A guide to reporting D4346.http://www.ada.org/~/media/ADA/Publications/Files/D4346EducationGuidelines_Final2016May17.pdf?la=en. Published May 17, 2016

DIANNE GLASSCOE WATTERSON, MBA, RDH, is an award-winning author, speaker, and consultant. She has published hundreds of articles, numerous textbook chapters, and three books. Dianne’s new DVD on instrument sharpening is now available on her website at wattersonspeaks.comunder the “Products” tab. Visit her website for information about upcoming speaking engagements. Dianne may be contacted
at (336) 472-3515 or
by email at
diannemba@gmail.com.

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