Disease- Scaling/Root Planing (SRP)
Q: How do you get rid of the inflammation
on patients that have chronic hemorrhaging, edema and
redness around PFM crowns, and this is in mouths of
patients with above average home care? - Val W.
A: It’s simple really...First we have to
identify what the actual problem is. The list can
include, true metal allergy or biologic width
encroachment. Most of the time it is an invasion of the
biologic width, that dimension of soft tissue that must
be present in all cases for proper health. Biologic
width issues can also occur around any restoration type,
even full porcelain crowns. Once this occurs the only
way to fix this is to do a crown lengthening procedure
to recreate the proper biologic width. As a review, the
biologic width is the 3—4 mm dimension that must be
present from the crest of the bone to the margin of the
restoration. It is very rare to have this type of
reaction for a true metal allergy. If it is really an
allergy, then the procedure is still the same, crown
lengthening and then non-metal restorations.
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
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
Q: Once a patient has gone through SRP (1-3 teeth in 1
quad) should they be considered 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
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
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?
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. 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 is
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, it will calm down.
Q: What is the best way
for a patient to control root sensitivity following SRP?
A: Fluoride is the best
way. It is important to remineralize the root surface
and occlude the dentinal tubules to obstruct fluid
exchange which causes sensitivity problems. Different
types of fluorides and products work differently for
each patient, sometimes it is trial and error to find
the right one.
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 measurable attachment loss and infection does
not need to be 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 with
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 present than if the tissue was
thick. So technically infection is present.
Q: My dad wears an upper
Valplast partial and has moderate periodontal disease.
He swears he has these “episodes” where his gums get
inflamed, then recede, then back to normal. He says
this even happens in the edentulous area (#12-15). Will
the bacteria still attack the tissue where there are no
teeth? He has excellent home care and of course the
edentulous area does not recede, but it gets sore and
inflamed along with the rest of his mouth during an
A: Traditionally, bacteria
will not have much affect on an edentulous area, but the
partial can harbor additional bacteria and fungus that
can cause irritations. This irritation may cause
localized swelling. It is most likely that he might be
getting gingival abscesses periodically which leads to
an inflammatory response.
Q: Does instrumentation
in the pocket alter or improve the negativeness of the
subgingival micro flora?
A: Not quite sure what you
mean about negativeness, but instrumentation in the
pocket alters the biofilm thus allowing for an
improvement in the ratio of good and bad bacteria.
Disruption of the biofilm is paramount for health of the
tissues and teeth.
Q: What do you think the
most valuable contribution diode lasers bring to
Periodontics and dental hygiene and what are their
limitations? Any comments on other types of lasers and
A: Lasers in general are a
good tool to have, but I caution those who use it
without additional specialized training…it is a must.
Simply, lasers are like a curette or scalpel because
they remove tissue. Lasers generate heat and can burn
hard and soft tissue. They have a higher affinity for
pigmented areas, so for diseased areas, diode lasers
work well to get rid of granulated tissue which improves
access for traditional therapy. Laser treatment should
be combined with conventional therapy. The limitations
include education, knowledge, and experience. It is
very important to have these or serious damage will
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
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 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.
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 relationship with 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? –
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.
Q: I am a
dental hygienist in a
general dentistry practice. My question is about
mouth-breathers. Several of my patients present with
excellent dental hygiene
and healthy tissues until I touch the maxillary anterior
sextant. If I look at and/or touch this area it gushes
blood! I know that it is due to the mouth-breathing,
but is there any way to correct this issue short of duct
taping their mouths shut when they sleep:) Summer H.
A: Great question and not
really. The only way that you could do something to
help this area would be to protect it while they are
sleeping. A simple overextended fluoride tray with a
bit of fluoride would help. Many spouses would pay
double though for the duct tape
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
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
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? How does the “gel” get to the bottom of the
A: Perio Protect is a
system with custom made trays that deliver a variety of
medicines to the tissues to get the desired outcome.
These are not “bleaching trays” or something similar,
but specifically FDA approved materials Bleaching trays
and other do-it-yourself type may cause patient harm.
Basically, it works on a positive pressure system. A
vacuum seal is created with the trays and tissues so the
medicaments are forced to the base of the pockets. I
would have you defer to the website, there is a wealth
of information there. Go to
Q: How often are you
using Perio Protect on your patients?
A: Pretty much all the
time. Even on a patient who has good home care, the
additional benefit will keep them healthier. The most
effective use is for patients with bleeding 4 and 5 mm
pockets throughout their mouth and on 3 month recalls.
The added benefit of the Perio Protect system really
boosts their overall care.
Q: Can you talk about how the implant
overcomes (or does it) the nature of the biological
A: An implant doesn’t
overcome the biologic width, it resets it. The biologic
width is going to be present whether there is a tooth
present or an implant. The body has to set up this
relationship in order to preserve the health and
integrity of the mouth. The biologic width of an
implant is altered because there are different
non-living components to factor in, but it is present.
You will typically find deeper pocketing around implants
because of the biologic width, and it depends on the
implant fixture platform placement as it is related to
Q: Implants, to probe or
not to probe? That is the question…
A: You must probe around
implants like you would natural teeth because you need
to know the health of the tissues holding the implant in
place. If you don’t know what the tissue is doing, then
you won’t know how to treat the patient.
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
Q: What are the problems associated with
Bisphosphonates (Fosomax, Actonel, etc.)? Should women
be taking them?
A: These groups of medicines used to treat
bone density issues are very important medicines with
great benefits and side effects. People should only
take a bone density medicine 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.
Q: I have a patient with
burning mouth syndrome? Lidex gel does not help, really
nothing has helped. He is on a lot of medications, has
changed some that cause BMS, and still nothing has
worked to relieve his mouth pain. Any suggestions?
A: Unfortunately, that is a
problem. Nothing seems to help and there are so many
different triggers for each person which causes this
problem. Everyone seems to respond well to some things,
while others do not. Occasionally, I have had luck with
simple peroxide, or even a soothing effect with Pepto
Bismol. Some of the topical anesthetic rinses will work
temporarily, but nothing is a magic cure. One main
emphasis is to keep the area as clean as possible and
free from bacteria and fungus which increases their
problem, which is why hydrogen peroxide seems to work.
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: Does hydrogen peroxide use eventually
cause brown, hairy tongue? We learned in dental hygiene
school that it causes the papilla on the tongue to grow
and trap debris and bacteria.
A: Sometimes, but for a
short term. If you think about it, with chronic
antibiotic or antimicrobial therapy that is initiated in
a patient, the balance of bacteria and fungi are set.
When you start the therapy the balance is altered and a
proliferation of fungi occurs. Until the body can reset
the balance, hairy tongue may occur. Time will fix
things or an antifungal rinse may be used.
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 mouth rinse,
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
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
What toothpaste do you recommend for hypersensitive
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.
Q: When doing a gingival graft, do you
get better results when using the patients own tissue or
cadaver tissue? Which method do you use on a regular
A: I use both methods equally. It depends
on the type of graft needed and what needs to be
accomplished. If the tissue is thin and fragile, the
palatal tissue works best, but if you have thick enough
tissue and just recession, then donor tissue works just
fine. I try to use donor tissue when possible because
patients appreciate the easier healing. Donor tissue
techniques are much more difficult and not as forgiving,
so some clinicians choose not use it.
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
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: A patient refused
phase I therapy and just wanted a “cleaning”. The
dentist made me just polish his teeth and said it wasn’t
supervised neglect since I thoroughly educated him on
the risks. Is he right?
A: Only if the patient
signed a waiver saying that he understood there was
subgingival disease and the only way to thoroughly get
rid of the problem is with scaling and root planing.
Once a patient signs something stating their problems
will worsen if they choose not to do what you recommend,
then they are more apt to do what is needed.
Meth/Recreational drug use
– answered by Noel Kelsch, RDH
At what age do you recommend talking to children about
Talking to children about
should start as soon as the child is old enough to
understand the concept. The
a Drug Free America has a program that starts in 1st
grade. I do not think that is too soon. The youngest
child I have seen that tested positive for Meth was 11.
He needed the information before then. Our children are
our greatest asset and we need to give them information
on protecting themselves as young as we can. The prime
case that confirmed this for me was the case last year
in LA County where a 2nd grader reported her
mother who was sharing her drug with her infant to keep
the child from crying. We teach our small children to
never talk to strangers and to never run in the street.
Teaching them to avoid the perils of drugs at a young
age is just as vital.
If a patient admits to recreational drug use to the
clinician but refuses to discuss with the parent, do you
have patient/doctor confidentiality, especially if the
patient is a minor? Or over 18?
we discussed in the class in the state of Oklahoma you
must discuss the issue with the person that is the
minor’s guardian or other health care provider who will
follow through with treatment. The easiest solution to
this is to not ask the child if you are hesitant to
report to the parent. Instead explain the finding to the
parents (sever decay, dry mouth, weight loss, infection,
etc) set up a referral to the child's MD the same day,
(remember the half life is 12 hours) We are not
psychologists or social workers so many times the
delivery of the information is essential to involve
other health care providers and have interaction between
those providers. The important thing that must happen is
that you must get that child to a doctor for evaluation
is a must if they are not a minor and they are not
harming themselves, putting others at risk or
threatening anyone. Many times you will have to make a
phone call if they are driving or there are children
Why are the lower anteriors last affected by the damage
pattern of meth use?
We really do
not know yet. The pattern is apparent but this issue has
not been studied. It is hypothesized that because that
area tends to stay dry when the patient is breathing
through the mouth and has severe xerostomia. The bathing
of the teeth with saliva that is very acidic is thought
to create the decay pattern. It is also hypothesized
that is why a cuspid can have severe decay on the entire
tooth except the tip of the cusp. The decayed area is
constantly being bathed with saliva that is extremely
acidic and the tip is free from the exposure.