Disagreeing about the smoker

I recently saw a 40-year-old female patient who had not had any dental care for four years. Her health history was unremarkable

Sep 1st, 2011

by Dianne Glasscoe Watterson, RDH, BS, MBA
dglasscoe@northstate.net

Dear Dianne,

I recently saw a 40-year-old female patient who had not had any dental care for four years. Her health history was unremarkable. She smokes one pack of cigarettes per day. Since she had not been in for quite a while, the doctor saw her first for an exam. He classified her periodontal condition as a Type II, needing four quadrants of root planing/scaling, and she was scheduled with me.

At the appointment, I saw that the tissue overall looked tight with some redness in the papillae. There was no apparent bone loss on the X-rays. Probing depths on the right side were only 2 mm to 3 mms with one 4 mm on the distobuccal of No. 3 with generalized moderate bleeding. There was no recession or mobility.

Upon scaling, I found that there was light supragingival calculus on lingual lower anterior with generalized moderate/heavy subgingival calculus, tenacious, with moderate bleeding. I was able to complete her right side in the one-hour appointment.

After the patient left, I let my doctor know that I was uncomfortable calling this patient an SRP patient and that she should have been a adult multiple prophy patient. He went over the definitions from the CDT for prophy and SRP:

Adult prophy D1110: Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.

Periodontal scaling and root planing – four or more teeth per quadrant D4341: This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure MAY be used as a definitive treatment in some stages of periodontal disease and/or as part of a presurgical procedure in others.

The doctor determined that this patient needed SRP because she is a periodontal case Type II and needed therapeutic care. If I understood correctly, the doctor felt this patient needed SRP because of the difficulty of the calculus and the amount of time to treat her. My understanding of adult prophy is that there is no attachment loss. I would have typed her as a Class I with no apparent bone loss needing multiple prophies. What is the appropriate classification for this patient? Who is right, me or the doctor?

Confused Over Classification

Dear Confused,

I agree with the doctor on the Type II classification for this patient, but I do not agree that the patient needed four one-hour appointments to treat. Let’s consider the facts.

Fact 1 – This patient is a smoker. Smoking and diabetes are the top two risk factors for periodontal disease; therefore this particular patient’s risk is greatly increased.

Fact 2 – Smoking masks periodontal disease. Smokers often have firm, pale pink gingiva that doesn’t bleed easily. In fact, the tissue can be downright leatherlike (called fibrotic). Being from North Carolina where tobacco is widely grown, I treated lots of smokers. I will even admit to being fooled a couple of times into thinking a particular patient’s tissue was fine since it didn’t bleed and was very firm, until I inserted a periodontal probe – especially at the midlingual areas of maxillary molars – and discovered deep pockets. Facial and lingual bone loss may not be seen on X-rays.

Fact 3 – The amount of bleeding observed (moderate) with this patient indicates therapeutic care is needed. A prophylaxis is intended to control irritation, whereas your patient already had significant irritation as evidenced by bleeding. Therefore, a therapeutic approach is warranted.

Dental hygiene clinical education focuses heavily on calculus removal techniques. Hygienists can become so calculus-focused that they forget they’re fighting a microbial battle. In fact, the former end-point of "glassy smooth root surfaces" has been replaced by debridement with minimal damage to intact cementum. Don’t misunderstand – you need to remove as much calculus as possible. But calculus is not the cause of periodontal problems. Microbes that live in and on the calculus and sulcus area are the real culprits in the initiation and progression of periodontal diseases.

Periodontal diseases are chronic and begin in shallow sulci. Early in the disease process, the patient may not exhibit significant bone loss. In fact, bone loss is a historical marker of the destruction that has already taken place. If you can avert bone destruction by engaging a therapeutic approach early in the process, your patient will benefit greatly.

However, the patient’s smoking habit will greatly increase her risk of future serious periodontal problems. If she is unwilling to quit, then you must treat her with increased awareness and diligence and not allow fibrotic tissue to fool you. After all, if the tissue looks firm and pink – as is often the case with smokers – periodontal disease is probably lurking in the shadows.

The treatment protocol for early periodontitis patients involves a combination of prophylaxis and site-specific periodontal scaling. Here is a description and recommended treatment protocol.

Type II – Early periodontitis. Slight bone loss is detected with some pockets in the 4 mm to 6 mm range. Some areas may need anesthesia to scale thoroughly. However, the disease has not progressed to the point of furcal involvement or mobility. Also, recession must be charted, not only because it shows previous disease, but because it is a more accurate representation of the patient’s periodontal status. Many insurance companies do not pay benefits for root planing unless there is at least 4 mm of attachment loss (not just probing depth). Attachment loss is the addition of the pocket measurement plus recession. Early periodontitis patients will have three or less teeth in the quadrant that are periodontally involved. They will require site-specific periodontal treatment. The remainder of the dentition is appropriately treated with a prophylaxis – D1110.

First visit – prophylaxis for nonperiodontally involved teeth – Code 1110

Second visit – UR/LR periodontal scaling – Code 4342 (specify teeth)

Third visit – UL/LL periodontal scaling – Code 4342 (specify teeth)

Subsequent recare visits can be coded 4910, periodontal maintenance. Please note that for just a few isolated teeth with 4342, the patient may be maintained with prophylaxis in limited circumstances, in the clinical judgment of the dentist. Some insurance payors will not reimburse 4910 after a single or dual 4342 visit. It is highly variable among companies. Also, please note that some payors will allow 4342 on the same day as 1110 and some will not.

I can understand why you did not feel four quadrants of root/planing were warranted for this patient. Most likely, all the periodontally involved teeth can be treated in two visits, with an additional visit for the prophylaxis on the nonperiodontal teeth. Further, the fee should reflect the amount of time, skill, and expertise needed to treat the patient appropriately. With the information I have provided, you and the doctor should feel confident in treating the early periodontitis patient fairly and appropriately.

Best wishes,
Dianne

Dianne Glasscoe Watterson, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe Watterson for speaking or consulting, call (301) 874-5240 or email dglasscoe@northstate.net. Visit her website at www.professionaldentalmgmt.com.

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