To Root Plane or Not to Root Plane
What exactly needs to be root planed? This of course is a clinical decision that needs to be made by the health care provider, not the insurance company.
However, the decision to root plane or not to root plane needs to be made based on the individual needs of the patient. Setting a policy that anybody 4 mm and above need to be root planed will help your patient retention to decrease rather quickly. Otherwise the patient is being treated as a number and not the individual that they are.
Whether the patient is a new patient or a patient of record that has been treated in your office by your hygiene department for years, the clinician should be doing a thorough review of not only the health history at every visit, but also their dental history. Even if it is a matter of looking back over the past three to five years in the patient’s record in order to see where the patient was and where they are now. This also applies to the new patient.
The reviewing of the new patient’s past dental history is imperative in order to determine what treatment may be recommended. Some of the questions that you may want to ask:
When was your last dental visit?
Once you have completed charting existing restorative conditions and you are starting to look at what needs to be done, if there is an existing crown that needs to be replaced, this is an excellent time to ask the patient, “Mr. Jones, this tooth is going to need this crown replaced. Do you know when the crown that is currently on it was done?” This will help the front office when it comes to going over the financials with the patient that has insurance. This is also a good time to ask the patient who has missing teeth how long ago the tooth was extracted. Of course they will be more than likely be giving you an estimated amount of time. However, the more information that is provided to you and your staff about existing treatment will help in providing the most accurate information when the financials and treatment plan are gone over.
Another time to ask questions is once the radiographs are developed and you have completed the periodontal charting with the patient who is actively participating in the co-diagnosis. If the patient has 4 millimeter pocketing or more, it is important to know if they have ever been root planed before and if so, when. If it has been less than two to three years, some insurances will not cover root planing and it is important for the patient to know prior to treatment what estimated cost will be coming out of their own pocket.
Now, when it actually comes to the need for root planing, we all know that pocketing alone is not the only diagnostic tool that we should use when treatment planning root planing. We also will want to evaluate bleeding upon probing, bleeding during instrumentation, radiographic bone height, tissue color, shape, and attachment loss.
Medical history is also important.
When this patient presents himself or herself to you for their dental healthcare needs they are coming as an entire package. Medical, dental, personal lives, stress levels etcetera. They are not only coming as a 4-millimeter pocket.
What if Mr. Jones had root planing in another office and there is no bleeding upon probing, bleeding upon instrumentation, and the tissue color is pink and firm, does not have any medical concerns, the patient flosses daily effectively, brushes after every meal, but has 4 millimeter pocketing? Is this a patient that needs root planing?
This is just an example of how a patient with a 4 millimeter pocket may actually be maintaining it, and should be continuously monitored at their periodontal maintenance appointment rather than jumping in with root planing because they have 4 millimeter pocketing.
Take the example of Mr. Smith that has been seen in your practice every 3 months for years and they are diabetic, flosses on occasion, and has two 4-millimeter pockets in the maxillary and mandibular right and left quadrants. With heavy generalized bleeding during instrumentation, but no bleeding upon probing. Is this a patient that needs root planing?
Now, Mr. Smith is another story, and he is a patient of record and wants to know why he needs it now even though none of his pockets have changed. One way to explain this to the patient is, “Mr. Smith, we have been able to slow down the periodontal disease process for many years now. However, with your history of being a diabetic, not flossing on a regular basis, and the heavy bleeding that is present at this time indicates to me that you are losing ground when it comes to the health of your mouth. When there is bleeding present, this is not healthy. We need to be more aggressive in order to slow down the disease before the probing depths get deeper, and root planing is the most conservative approach at this time. In the future if we do not see your health improving we may want to refer you to a periodontist.”
This is an example of a verbiage that may be used or modified at your office when working with patients of record. This patient will now become a periodontal maintenance appointment every 3 months. Unless the health of their mouth improves so much that there is no periodontal disease then they become a prophylaxis.
So, in order to determine if root planing is needed, it is recommended to ask questions verbally in addition to reviewing the medical and dental history, evaluate bleeding upon probing and instrumentation, radiographic evidence of bone loss, and the shape and color of the tissue.
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