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Treating Perio- Scaling/Root Planing
Q: How often would you repeat Scaling and Root
Planing?
A:
Well, technically you should never have to repeat SRP if
it is done correctly. Let’s use an example. A patient
comes in after an absence for about 3 years with 5 mm
probing depths and bleeding throughout. Subgingival
calculus is everywhere and they need SRP. If you do the
SRP thoroughly, reevaluate and they now have
normal pocketing you should keep them on 3 months for
the next year. If they can maintain a good home care
routine and comply with regular recalls, then they
should be fine forever. If they skip steps, or slack
off then SRP will need to be repeated.
Q: Do you think SRP should be performed before any
surgery is done?
A:
SRP should be done prior to any type of surgery almost
100% of the time, simply because you want to reduce the
bacterial load throughout a mouth before surgery so that
the procedure has a better outcome. There are only a
few exceptions to this, but you really can’t go wrong by
doing SRP prior to any type of surgery.
Q: Once a patient has gone through SRP (1-3 teeth in 1
quad) should they be considered a perio maintenance
(4910) from now on? Can you alternate codes 1110 and
4910? Is 4910 only billable at the perio office?
A:
The
general rule of insurance coding is that once you use a
perio code for a patient in their care, then you must
use 4910 as the continuation code. You cannot mix the
codes based on coverage of what the patient wants or the
benefits that they have because that is insurance fraud
and you will get in trouble. Only occasionally, in very
specific cases can you switch someone from a 4910 to a
1110, and it depends on the patient’s insurance
carrier. 4910 code is applicable at any office and not
just a perio office.
Q: What is the best way for managing the stubborn
smoker with progressive perio that doesn't respond to
SRP and refuses referral or recommendation to a
periodontist?
A: The toughest patient’s are like this. First, try to get
to the real reason why they don’t want to go. If they
just refuse then you need to cover your butt by having
them sign a refusal letter and tell them that at the
rate they are losing ground they will lose their teeth,
and in a lot of cases, most won’t have enough bone for
implants or dentures. But cover your backside is the
main key.
Q: Why do smokers after SRP not have ideal results? Even
after the best care and proper follow up appointments?
A: Smokers or any kind of tobacco users will always have a
poorer response than non-smokers simply because the body
cannot fight the healing process through all of the
nicotine and by-products that are in tobacco. Now one
thing you should notice is that most smokers will have
much less bleeding than non-smokers, but will have
deeper pockets because the blood vessels that help fight
periodontal disease are too constricted so that it
another reason why their disease is more severe. You
will also notice that people who have recently stopped
smoking will initially bleed more until their body gets
used to things again because of the blood vessel
dilation. Not to worry as it will calm down.
Q: Can a patient have periodontal disease if
infection is not present?
A: The simple answer is yes, but that question is
loaded. The definition of periodontal disease is called
attachment loss and there does not have to be infection
present to have attachment loss. However, 99% of the
time there is infection or inflammation present to
assist in the attachment loss. Think of the patient
with immaculate home care and has generalized recession
and thin tissue. That patient is contributing to the
attachment loss, but the biofilm that is present is more
damaging because of the recession and thin tissue than
it would be if the tissue was thick. So technically you
have to have infection present.
Q:
We have a laser that we use in our office to treat
periodontal disease. I was wondering what you thought
about lasers used in dentistry. I was at the Hygiene
Expo but I did not think about this question until it
was too late! If you do not mind I was curious at to
what you thought! Thanks – Darcie
A: I
personally have multiple lasers and use them almost
daily. Some of it to control disease and some of it to
treat the disease, but my methods would be different
from a hygienists because I am allowed to do much more
than you. I do feel that lasers have a great place in
dentistry and will be around more and more. I think
that the biggest issue with lasers is from the training
side of things. You must be trained properly and you
must use them correctly. Without training and the
proper use, you will cause some problems.
Q: At what point should a patient be referred to a
Periodontist and what should be the limitations of the
general dentist practice?
A: I don’t like to put limitations on any practice
because there are so many differences in offices. My
blanket answer is that you should do what you are
technically capable of and what your comfort level is.
Once you are out of your league or comfort zone then
that is when the patient should be reserved to be
scheduled with the specialist. Hygienists will run into
trouble because the GD will want you to keep everything
in the office even if you feel that you cannot handle
the case. That is a whole different set of issues
that you’ll have to deal with.
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Professional Products
Q: What ultrasonic scaler do you recommend for a
hygiene practice that performs about 65 to 70% perio
treatment or is there a difference in the units? –
Desperate Hygienists (This is really a question
for a hygienist so I let one of my hygienists answer.)
A: There are so many great brands but it varies
depending on your style. Just as we all make different
scaler and curette choices based on preference and
ability, I think the same goes for Ultrasonics. I find
the Magnetostrictive is the most accommodating because
every surface of the tip is active, unlike the Piezo. I
like the control of the manual tune versus the auto tune
units, much more control for me and the patient. Only
with manual control can you use the thinnest tips
designed – like an explorer. I suggest comparison shop
and go to hands on courses before committing to a
particular brand. There is a lot of really good
information and courses about ultrasonics out there.
Q: Do you recommend a certain brand of subgingival
bacteria testing kit for a general office?
A: I don’t do bacterial testing because it really
doesn’t matter all that much as far as the type of
bacteria that you have. The treatment will be the same
or very similar regardless of the bacteria type. The
most important issue is that you get 100% of the
bacteria off at all times, the type is immaterial.
Q: How does the Perio Protect system work?
A: Perio Protect is a system where you use custom made
trays that can hold a variety of medicines in intimate
proximity to the tissues to get the desired outcome that
you want. These are not “bleaching trays” or something
similar, but specifically FDA approved materials that
have to follow a certain set of guidelines in order to
be useful. Bleaching trays and other do-it-yourself
type things will cause patient harm.
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Practice Management
Q: I’ve seen dental assistants posing as hygienists
without education, illegal but dentists are not afraid
of being caught. What is a hygienist worth to you?
A: Hygienists are an invaluable part to any properly
run office. There are a lot of offices that run
assistants as hygienists and skirt the law, but my
feeling is that it is only a matter of time before they
are caught and it’s not worth it. Most offices think of
hygienists and the hygiene department as a pain to deal
with, but where they are missing the boat is that the
hygiene department can be a significant asset and income
generating part of an office. My feeling is that
dentists need to take off their power hats and give up
control of the hygiene department to the office and go
on with normal dentistry. The office will be much
happier and much more productive.
Q: What information do you need when a hygienist
refers a patient to you?
A: Any information is a blessing but the ideal
information would be full mouth radiographs, full mouth
perio charting and any extra information, like “the
patient likes nitrous”, or “the patient is afraid of
losing their teeth”. Anything to help out the process
and the relationship of the patient.
Q: I have had patients that I feel should be referred
to a periodontist, but my general dentist did not back
me up. How do we battle this? – Concerned RDH
A: This is probably one of the biggest practice
management issues that hygienists deal with. It
basically boils down to greed of the dentist thinking
that they are going to lose the extra $100 dollars. But
what really happens is that the patients that are
referred are much more appreciative of the dentist when
they are sent because they get better treated. If your
doctor is one that will not relinquish control over
patients and what you can do, and this goes against your
philosophy, then you need to convert them to your
control or leave. The hygienist must have complete
control over their group of patients
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Health History/Medicine
Q: What are the problems associated with
Bisphosphonates (Fosomax, Actonel, etc.)? Should women
be taking them?
A: This group of medicines that are used to treat bone
density issues are very important medicines that have
both great benefits and side effects. If people need to
take a bone density medicine they should only take them
when necessary. Taking them because it could help is a
big problem. Osteonecrosis of the jaw is a very serious
issue that is only coming to the surface with
bisphosphonates. This condition causes a dying of the
bone of the jaw, and unlike osteoradionecrosis, which
occurs during radiation to a jaw after cancer,
bisphosphonate induced osteonecrosis has no treatment.
Q: Are there any contraindications to taking
Periostat indefinitely? Have any of your Periostat
patients reported improvement in arthritis joints since
being on Periostat?
A: There really isn’t any downside to taking Periostat
constantly. Because of the dosage involved, there are
no real problems. Also because of the mechanisms of how
the medication works, you can have improvement
throughout the body with all systems that work on an
anticollagenase basis. Joint pain is only one of the
many benefits of Periostat. Others include better skin
condition and obviously better oral health.
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Implants
Q: Our office recently purchased the “Gold” scalers
for implants. Do you feel these are good/safe
instruments?
A: There are a lot of questions about how to clean
implants. I have a very simple way of thinking about
the cleanliness of implants. It is very difficult to
damage an implant surface and if you are getting to the
surface of the implant and not just the crown, then
there is a bigger problem than a little bit of plaque.
Implant surfaces also don’t collect much in the way of
debris anyway because of the surface smoothness. The
bottom line that I would recommend is to use what you
have and when you get around an implant, just be a bit
more careful, but don’t be afraid of them.
Q: When cleaning implants what instruments are you
recommending?
A: Same as above
Q: What is the best way to clean implants? My doctor
wants me to Prophy Jet.
A: Same as above
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Home Care Products
Q: I worked for a Periodontist for 9 years and he is
a big believer in Listerine. Do you?
A: My simple philosophy is that patients should use any
home care product that is going to get them doing a
better job. Listerine is a great product because of the
alcohol content. It definitely kills bugs, but it has
very little substantivity, just like all the mouth
rinses. The problem with mouth rinses and irrigants is
that there is no way for the agent to stay for long.
After the saliva processes through, then the bugs come
back, and you’re at square one.
Q: How do you feel about Water Piks?
A: Same as above
Q: Besides staining, why do you recommend Prevention
over Peridex? Do you dispense prescription strength or
OTC?
A: I like Prevention mainly because of the staining
aspect. Studies have shown that it doesn’t really
matter what agent you use as a mouthrinse, because they
all work about the same. I like Prevention because of
the zinc component to promote healing as well as the
hydrogen peroxide as a simple agent to kill off
bacteria. I use the prescription strength because of
the more concentrated hydrogen peroxide component.
Q: Do you have patients on any special supplements
(vitamins) when undergoing any treatment including
implants?
A: I do not routinely have people on any supplements,
but I do encourage them to increase their vitamins and
calcium, especially B vitamins and vitamin D.
Q: What toothpaste do you recommend for
hypersensitive patients?
A: Whatever works for the patient and their
sensitivity. Most patients do well with Sensodyne
because of the action of the Potassium Nitrate. I have
some patients who do well with home fluoride. More
toothpaste companies are combining the two products for
even better sensitivity control.
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