What Needs Root Planing?
When do we treatment plan root planing? This is a question that many hygienists are discussing these days. When is the pocket deep enough to warrant root planing? Does there need to be calculus present, bleeding upon probing, radiographic evidence of bone loss?
Unfortunately, there is not a set answer for these questions, which is true when it comes to treatment planning many medical and dental diseases. There are parameters of care provided by our professional organizations and educators. However, every patient has to be treated as the individual they are, this includes not only the disease they present us with, but also the personality, beliefs, values, ethics, and cultural differences they bring with them to our offices.
The first thing recommended when it comes to working with patients from many diverse backgrounds is to keep the mnemonic CARE in mind. This was developed by Myerscough in order to help healthcare professionals remember the skills they should develop.
Second, an accurate and conclusive diagnosis of the patient’s disease must be documented. The American Academy of Periodontology (AAP) has published “Parameters of Care.” on their web page, www.perio.org
The following paragraph is taken directly from, Parameters of Care Supplement, Parameter on Chronic Periodontitis With Slight to Moderate Loss of Periodontal Support, J Periodontal. May 2000, “Slight to moderate destruction is generally characterized by periodontal probing depths up to 6mm with clinical attachment loss of up to 4mm. Radiographic evidence of bone loss and increased tooth mobility may be present. Chronic periodontitis with slight to moderate loss of periodontal supporting tissues may be localized, involving one area of a tooth’s attachment, or more generalized, involving several teeth or the entire dentition. A patient may simultaneously have areas of health and chronic periodontitis with slight, moderate, and advanced destruction.”
With this in mind, how are we going to determine if the patient that presents 4mm pocketing warrants root planing? This is why clinical judgment of the individual healthcare provider becomes so important when it comes to the actual treatment recommended. Many factors, in addition to, clinical attachment loss, bleeding upon probing, radiographic evidence will need to be considered. Such as, systemic health, age, compliance, mental and or physical limitations when it comes to the patients ability to keep their oral cavity plaque free. In addition to these, does the patient need to have their occlusion adjusted; are there restorative needs that will help create a better environment in addition to root planing?
Therefore, when determining if root planing is warranted not only does the individual patient have to be considered, but so does the individual area. Like it was stated earlier in this article, there really is not a set answer to the questions above.
There are times that a patient that is 25 years old, has not had their teeth cleaned in awhile, has 4mm pockets, does not have heavy calculus, has no systemic problems, and has no other limitations, may have great results with a cleaning. The important thing is the reevaluation of the pocketed areas. If at the next visit, this patient in non compliant with plaque control, then root planing needs to be a consideration when it comes to the next phase of their treatment. It is recommended that the patient be informed prior to the second appointment, in the interval set by the clinician, that they may need root planning. If the pocketed area does not improve when the patient comes in for their second appointment, a co-diagnosis should be made when it comes to the next phase of treatment. Office protocol when it comes to interceptive periodontal therapy will determine the next phase of treatment.
Of course there is always the older patient who has 4mm pocketing, has moderate to heavy calculus present, diabetic, and doesn’t have any other limitations. Again the patient will be informed of their disease condition. However, this patient will be treatment planned with needing root planing either using the code D4342 or D4341 depending on the amount of teeth.
Some of you may be asking, why wouldn’t you do a full mouth debridement (D4355) and then a cleaning (D1110)? Well, a 4355 is used when clinical evaluation is not possible. This procedure code is limited to patients that present so much calculus regardless of the pocket depths that there is not any way a comprehensive exam is possible.
If the periodontal condition is resolved, the clinician will have this patient back for periodontal maintenance appointments at the appropriate intervals.
If the periodontal condition is not resolved, then further treatment options will need to be reviewed with the patient. Whether chemotherapeutic products are the next phase or surgery is dependent on the office protocol.
Treatment planning root planing is not “one treatment fits all”. It is a complete, concise diagnosis of the disease with the individual patient’s needs always in the forefront with the healthcare professional supporting the patient in the pursuit of health by educating the patient so they can identify their needs and make well-informed decisions.
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