Choices in the tool box

After reading Trisha O`Hehir`s column, "Debridement = scaling and root planing plus" (May 1999 issue), one might conclude that ultrasonic and sonic debridement should be the only choice of treatment for periodontal disease. The 4341 code for such services was proposed as the appropriate billing. Most of my 12 years as a dental hygienist has been specifically in periodontal therapy, and I am convinced that "one size does not fit all." Much of what the author says is true, but periodontal initial

Dear RDH,

After reading Trisha O`Hehir`s column, "Debridement = scaling and root planing plus" (May 1999 issue), one might conclude that ultrasonic and sonic debridement should be the only choice of treatment for periodontal disease. The 4341 code for such services was proposed as the appropriate billing. Most of my 12 years as a dental hygienist has been specifically in periodontal therapy, and I am convinced that "one size does not fit all." Much of what the author says is true, but periodontal initial therapy must be personalized to each and every patient`s mouth by a knowledgeable and skilled clinician. If insurance companies do not recognize debridement as a root planing procedure, another code - which better describes what was actually done - might be more appropriate for billing purposes.

Each person has an oral cavity and immune system unique to only them. Certain anatomy, restorations, bacterial count, deposits, tissue, and saliva can only be found in a particular mouth. Therefore, the periodontal hygienist must evaluate the mouth very carefully, and then use the best course of action that personally fits that person`s needs.

A healthy mouth should be the goal. This is accomplished by using a whole host of assessments, skills, products, and equipment. First and foremost is patients` home care. Patients should be able to care for their mouths so well that they rarely need the hygienist to clean their teeth. Let me share with you what I typically see in a dental office, and how I addressed these particular individual needs of patients.

William has not had his teeth cleaned for 10 years. He anxiously awaits his turn to see me. He has already had an initial exam with treatment planning. Someone has told him that I am the one who will be "digging deep" into his gums. I sense his apprehension and ask if he understands what I will be doing for him. He tries his best to explain what he thinks will be happening and then blurts out that he`s had some nasty experiences in the dental chair and that`s why he didn`t come in until now. He asks if I am going to hurt him.

I visit with him about his concerns and the goals he has for his mouth. I note his eye, skin, and hair color. I review his health history and look closely at his full-mouth radiographs for deposits, bone loss, tooth and bone anatomy, cortical bone integrity, and exisiting restorations. I review his initial exam information and periodontal charting. I use colored visual charts to explain why I will need to do more than just "clean his teeth" in order to establish health. I ask what he is doing to clean his mouth now and what his eating habits are. He tells me that he should be flossing more often. I explain that I don`t care what he is doing to clean his mouth as long as he is able to maintain it in a healthy state. I then tell William that I must first evaluate what is happening in his mouth and will inform him of what I find, what I can do for him, and what he will need to do for me, as we work together as a team. Then, he can decide what he wants to do.

As I use the light, mirror, periodontal explorer and probe, I evaluate soft tissue, hard tissue, and deposits. All of this information tells me that William has American Academy of Periodontics Classification III, chronic, generalized periodontal disease. I then formulate in my mind what my course of action will be, as well as what he will need to do, to return his mouth to health.

I tell William what I plan to do, and he agrees to have it done. In his case, I will be using the sonic scaler, periodontal files, curettes, chlorhexidine irrigation, extensive home care instructions in the use of brush, floss and interdental aids, and another evaluation at four weeks. According to what I know about this patient, I have chosen these modalities, and this particular treatment sequence. I have many reasons for my choices.

The first hour I spend using the sonic scaler throughout the mouth and going over home care. The next two appointments are used to scale and root plane the upper and lower arches. Everything I do and how I do it has a specific purpose. I know that I will be successful. I bill these procedures according to what I found in the mouth and what I actually did. In William`s case, I billed out three 4341 quadrant procedures. When he returns, I will bill out the fourth.

My next patient is Mary. She is a meticulous person who is well aware of her past periodontal condition. Three months ago, she came to me with all the areas of her mouth severely diseased. Periodontal readings ranged from 5mm to 9mm. She was initially evaluated followed by periodontal initial therapy performed in six visits.

At this three-month recall appointment, her periodontal charting demonstrates all probe readings are in the normal range except a 9mm pocket on the lingual of #10. Feeling with the periodontal explorer and probe, the root surface feels smooth, but I know what I must do to return this area to health. I anesthetize the area and spend most of the appointment time root planing the area with periodontal files and follow up with tetracyline irrigation. I recommend hot salt water rinse for four days post-op and give home care instructions for using the end-tuft toothbrush.

At her next three-month recall, I measured the area as I performed periodontal charting. I felt a strong tissue attachment on the lingual of #10 with a 3mm reading. The area continues to remain healthy. The initial therapy was billed as palliative, four-quadrant scale and periodontal maintenance. The root planing appointment was billed as a periodontal maintenance, as was her next recall visit.

Both of these patients had periodontal involvement when they were seen. Skilled and personalized treatment and followup was needed to establish health. It was not necessary to numb William`s mouth and use extensive root planing. For Mary, it was essential. In her case, the sonic scaler was not the modality of choice and would not have been successful.

Much can be written about what should happen when a certain procedure is recommended. But when a hygienist is "in the trenches" what does happen is more important. Simply using a particular tool, such as the ultrasonic, that someone says is supposed to accomplish everything does not make it so. The hygienist`s training, knowledge, expertise, and desire to help the patient - coupled with the patient`s cooperation, and compliance - are the only things that can return the unhealthy mouth to a healthy condition. Insurance companies have no problem paying for appropriate procedures that enable the hygienist to reach that goal.

The concept is simple. There`s something on the tooth that the skin doesn`t like, be it bacteria, calculus, or poor restorations. How a particular body deals with this condition is another factor. The hygienist must remove that "something" to the degree that the skin can heal. She or he must then be sure the patient`s health and habits are satisfactory and that the patient can clean the area adequately for the long term.

In my experience, using the best of techniques for an hour with ultrasonic or sonic scalers in many cases is not enough. Hand instrumentation is still necessary. In other cases, sonic debridement will suffice. In still other cases, antibiotic therapy is necessary.

But after using mechanical devices, I always follow up with hand instruments and an explorer. Handpieces do not have the tactile sensitivity that one gets with the explorer. I would never compare root planing with debridement. Root planing is very tedious and specific. When done correctly, the hygienist can picture what the root surface looks like through the hand instrument. That is much harder to do with the ultrasonic handpiece. The ultrasonics are aggressive handpieces and can damage the root surface if used incorrectly. I prefer to use the sonic scaler because it does what I want it to do, but is much more forgiving if my adaptation of the tip is not perfect. Because it has a lower frequency and uses a different mechanism of operation, it is also more comfortable for the patient. If one intentionally rubs the ultrasonic tip on an amalgam restoration while in operation, one will see the scratched appearance it produces. Then imagine the much softer root surface and cementum. There surely would be an adverse effect if used on the root in the same way.

As time goes on, new and exciting modalities for treatment of periodontal disease are being developed. It is up to the clinician to learn about these new products through continuing education and be able to incorporate them appropriately into the treatment sequence. But success of treatment is still dependent upon the skilled hygienist working "in the trenches" with the patient toward a common goal. Ultrasonics certainly have their place, but they are only one of the tools in the dental hygienist`s tool box from which to choose.

Carol Levanen, RDH

Yacolt, Washington

More in Radiology