Treating periodontal disease is more than just diagnosing four quadrants of root planing, performing the treatment needed, and then putting the patient on a recall interval.
We were all taught in college that when the disease is limited to the gingiva, the possibility of reversal is considered first when creating a plan of care. On the other hand, chronic periodontitis has slow to moderate rates of progression, but may even have rapid progression. Arresting the progression of periodontitis is done by altering or eliminating the microbial etiology and risk factors that contribute to the disease process. Except, in cases of advanced periodontitis, the need for additional treatment after initial non-surgical interceptive periodontal therapy is rarely possible to predict. In order to do this, we as clinicians are constantly challenged with reassessing the treated tissues every time our patients are in our chairs. Knowing when more or less treatment is required in order to alter or eliminate the microbial etiology is our responsibility to our patients.
Looking back many years ago at the way periodontal disease was treated, we only progressed with treatment if the pockets got deeper. Well, if you think about it, this is like saying we should only have our oil changed in our cars if it breaks down, or do fillings if something hurts. We all know that this is not the best way to prevent break down in the future, and in order to prevent break down you have to stop it before it happens. So, why would we wait for a pocket to get deeper before moving ahead with treatment? Dentistry became preventive oriented years ago when it comes to providing restorative treatment. However, it seems it moved a little slower when it came to the treatment of periodontal disease.
Now instead of waiting for there to be a difference in the pocket depth or radiographic changes for the worse, why not look for changes towards the better. By this I am saying that if the patient has had root planing and has been on a periodontal maintenance interval of 3 months, and the clinician is not seeing any improvement, it may be time to intervene and progress further with treatment.
The next step may be to refer to a Periodontist for surgical intervention. However, many times it may be appropriate to advance with more non-surgical treatment. Some patients may refuse periodontal surgery or cannot undergo these procedures because they are medically compromised or fearful of surgery. These patients may understand treatment has limited success but may be able to prolong retention of their remaining dentition with aggressive non-surgical therapy.
Whenever existing patients are not making progress, or if they are regressing because of their home care, this is the time to intervene. Do not wait for that pocket to get deeper. This is another time your hygiene department may want to come up with a specific protocol. Not only when to refer the patient out to a Periodontist, but when to implement non-surgical therapy for the first, second, or third time.
Below are just a few clinical signs that you may want to utilize when determining if root planing needs to be done again.
- Heavy hemorrhaging during instrumentation
- Sub gingival calculus
- Patient refuses to see Periodontist
- No progression towards better health
- Bleeding upon probing
- You have already shortened the recall interval and there is still no sign that the health of the tissue is improving
- Systemic problems
- Overdue for periodontal therapy and their oral hygiene is less than acceptable
These are just a few of the red flags that may be flying in patients’ mouths that will help in determining if more aggressive care is needed. That is, until the health of their mouth stabilizes allowing their immune system to become strong enough to keep the destructive bacteria under control. Our goal is to help the patient achieve and maintain their oral health.
The care may be anywhere from one quadrant of root planing to four quadrants of root planing, and then possibly a referral to the Periodontist. The patient may also only warrant the use of the code 4342, which is one to three teeth of scaling and root planing instead of a 4341 which is four or more teeth per quadrant of scaling and root planing. Additional therapy may even be site specific to one tooth.
Even in the Parameter of Care Supplement, Parameter on Periodontal Maintenance, in the Journal of Periodontology, Volume 17, Number 5, May 2000 it states, “Despite adequate periodontal maintenance and patient compliance, patients may demonstrate recurrence or progression of periodontal disease. In these patients, additional therapy may be warranted.” Therefore, it is imperative as clinicians that we constantly monitor and evaluate the patient’s condition when it comes to periodontal disease. The challenge of knowing when more or less treatment is required will continue every time we as clinicians have a patient sit in our chairs.
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