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Hygienists often ask how I would treat certain patients or what kind of recommendations I would make for specific conditions.  Recently, we held a forum where hygienists could anonymously ask the expert any question and I would give my honest and best answer.  We separated the questions by topic.  Now you have a chance to see what hygienists want to know.  Who knows maybe your question can be answered too.

Please feel free to contact me at Robin@OkPerioImplant.com with your questions.  I will be happy to answer you directly, but it may also be posted here for others to see.

Treating Perio- Scaling/Root Planing
Professional Products
Practice Management
Health History/Medicine
Implants
Home Care Products

 

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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