Scheduling dilemma

July 10, 2015
How should the severity of disease be factored into scheduling?

How should the severity of disease be factored into scheduling?


Dear Dianne,

I always love your column with your spot-on, no-nonsense approach to dilemmas of dental hygiene. So here's my dilemma.

The dentist and office manager with whom I work have a one-size-fits-all approach to periodontal scaling/root planing (SRP). I am allowed one hour to periodontally scale two quadrants-no matter the pocket depths and amount of calculus and inflammation present. To make matters worse, the office manager schedules three SRP patients back-to-back on a routine basis!

HELP! The emotional and physical toll is next to impossible to bear for much longer.

Also, the dentist tells me that insurance companies only accept vertical bone loss when deciding whether or not to pay an SRP claim. Is this correct?

Thank you,

Western RDH

Dear Western,

First of all, thanks for your good words about the column. Did you know that this is the 17th year for "Staff Rx"? My excellent editor, Mark Hartley, deserves thanks as well. He's the "wind beneath my wings."

Not considering the severity of the periodontal case makes about as much sense as not considering how many teeth need restorations. Just give them all one hour indeed. I'd bet a pizza the doctor doesn't schedule his patients that way. Would he give a patient needing one restoration the same amount of time as someone needing four restorations? Not a chance.

Evidently, the doctor is not knowledgeable about classifications related to severity, or maybe he just doesn't respect what you do. One doctor said to me, "Well, you have easy prophies and difficult prophies. How hard can that be?" He was so far behind current treatment protocols that I don't think he even realized that treating periodontal disease requires something other than a mere prophy. As his consultant, I remember thinking, "This is not going to be easy."

Determining the patient's level of periodontal disease is foundational to developing a proper treatment plan. In fact, the ADA gave dental professionals some guidelines related to classifications way back in 1969:

Type I-Gingivitis-Characterized by inflammation due to accumulation of gingival plaque and calculus-no bone loss. Pockets < 4 mm.

Type II-Early periodontitis-Progression of the gingival inflammation into the deeper periodontal structures and alveolar bone crest with slight bone loss-no mobility or furcations. Pockets 4 mm to 6 mm.

Type III-Moderate periodontitis-A more advanced state of the above condition with increased destruction of the periodontal structures and noticeable loss of bone support, possibly accompanied by an increase in tooth mobility. Pockets 6 mm to 7 mm.

Type IV-Advanced periodontitis-A more advanced state of the previous class with pronounced mobility and furcation involvement. Pockets 8 mm or more.

Type V-Refractory progressive periodontitis-Pocketing varies, but the disease is progressive in spite of treatment.

Even with these guidelines, selecting a case type is not always easy, but at least we have some basic criteria with which to make a distinction related to case severity. Does an advanced case of periodontitis take the same amount of time to treat as an early periodontitis case? Emphatically, no.

Even gingivitis can be challenging. I've seen severities all along the spectrum from mild to severe. The more severe cases usually require two visits to complete, especially considering the time needed to help the patient ramp up his or her home care. After all, what good have we done if all we do is remove the debris from the patient's teeth but neglect to teach him or her how to take care of his or her teeth at home?

It seems plausible that an early periodontitis case could be treated using the half-mouth, one-hour approach. However, moderate to advanced cases require intensive instrumentation (both hand and power scaling). To complete two quadrants is likely to take one-and-a-half to two hours. In my clinical experience, advanced cases should be completed using either single quadrants or even sextants in the most severe cases. If you are being asked to treat such cases doing two quadrants in one hour, the quality of care is surely going to suffer.

Since periodontal debridement procedures are typically intense, it would be reasonable to request that the office schedule no more than two of these procedures back-to-back. The work is physically and mentally demanding, and business assistants may not be aware of the stress this causes.

One thing I know and teach is this: The quality of the professional care that the patient receives in any dental practice is more important than anything he or she can do at home for himself or herself. It puts a serious responsibility on dental professionals to make sure they are delivering high-quality care that meets or exceeds the standards. High-quality care goes beyond merely scraping debris off the teeth. It also involves developing a customized home-care plan, considering medical conditions, reinforcing and reexamining home-care routines, choosing appropriate adjunctive medicaments, and teaching the use of power brushes and interdental cleaning tools. It takes time to do this well, but it does not appear that your boss understands what high-quality dental hygiene care means. This is your challenge.

You need to initiate a discussion about treatment planning and periodontal severities. I would start with a question: Would you use the same amount of time to do one crown as you would to do three crowns? Then go from there. I would also bring up the quality-of-care issue and let the doctor know that it is physically impossible to treat a moderate to advanced case appropriately with the current protocol. Say, "These are your patients, and I feel it is my responsibility as an employee here to give them high-quality care. You would want the same if you were the patient."

Your second question was related to bone loss and insurance approval of periodontal claims. I am not aware that the bone loss has to be vertical in nature. However, third-party payers want to see evidence of bone loss to compensate periodontal scaling. Dr. Charles Blair's "Coding with Confidence" manual states: "A diagnosis of early, moderate, or advanced chronic periodontitis will include some level of clinical attachment loss (CAL). CAL may not be apparent from pocket depth measurements. CAL involves the loss of alveolar bone support and gingival attachment as the periodontal fibers migrate apically from the CEJ due to periodontal toxins in plaque."

Clinical attachment loss is defined as the sum of the sulcus depth plus any recession. It is measured from the CEJ to the base of the pocket. One suggestion is to include an intraoral picture with the claim to bolster the need for definitive periodontal therapy.

The challenge for you is to gently and discreetly help the doctor understand the need for variable treatment times depending on case severity. The best argument will be to compare your work to his work and be allowed some flexibility in order to deliver high-quality care. I wish you much success, because I believe your career longevity could be shortened if you continue to work under the current adverse conditions. RDH

All the best,


DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an awards winning speaker, author, and consultant. She has published hundreds of articles, numerous textbook chapters, an instructional video on instrument sharpening, and two books. For information about upcoming speaking engagements or products, visit her website Dianne may be contacted at (336)472-3515 or by email [email protected].