Is periodontal therapy required?
Lance Timmerman, DMD, MAGD, FICOI
A dental office’s production is a combination of restorative dentistry and soft tissue care, and a typical practice can include a lot of “cleanings.” Dentists hope these “cleanings” lead to other dental restorative needs. Most patients have few hesitations when it comes to getting their teeth cleaned, often because insurance pays for it, either entirely or with very little out-of-pocket expense. But as soon as a routine visit leads to a significant out-of-pocket expense, the conversation can turn.
Our desire to help people may lead to what Mac Lee, DDS, describes as “approval addiction.”1 Since dentists are often verbally beaten down with greetings such as “I hate dentists,” or “I hate it here,” our self-worth can decline. Our skin may wear thin, and it’s not unusual to pick our battles and save our confrontational energy for fillings and crowns.
A common area to let things slide is in the hygiene department. “It’s just a cleaning” is a common description for what takes place when we bill for a D1110, but it’s our fault if that’s all the appointment is. I have employed dental hygienists who had worked in practices that billed such low fees that, unfortunately, the only way to justify their wages was from volume. Some of them routinely churned out three patients per hour, with an assistant of course.
When I worked with these hygienists, it was not uncommon for me to tell them that a full 60 minutes with a single patient meant they could accomplish more, use more than just a dab of prophy paste, and not be done with the appointment so quickly.
Treating or ‘watching’ periodontal disease
I am not a lawyer, so I can’t give legal advice. But I do have experience dealing with the legal aspect of our profession. Over the years, attorneys have sought my opinion on cases, and I’ve tried to help them when I could. My stance is to defend the dentist when possible or encourage a settlement when the dentist clearly was partially wrong in a situation.
A case recently came across my desk that surprised me. Unfortunately, many details must be left out due to privacy issues, but I can share some generalities. I was taught to present the diagnosis to the patient and let the person decide what to do. I was taught to document informed consent and do as requested. If I treated people well, they would have no reason to complain (to the dental board or to an attorney). This case made everything a bit more complicated.
A patient visited a clinic as a new patient and had a history of periodontal disease. The person presented with bleeding tissues that was more pronounced around some newer crowns on Nos. 14 and 15. The new dentist, in what appeared to be an attempt to avoid conflict, suggested D4910, a periodontal maintenance visit for the patient’s first treatment. The dentist decided to evaluate the patient again at his next recare visit. The patient agreed and was happy with the care.
The definition of D4910 is: “This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site-specific scaling and root planing where indicated, and polishing the teeth. If new or continuing periodontal disease appears, additional diagnostic and treatment procedures must be considered.”2
A short time later, the patient visited a new dental office that referred him to a periodontist, as the margins of the crowns on Nos. 14 and 15 were near bone, thus violating biologic width. The periodontist had a reputation of turf protection and could be aggressive reacting to care done in a general practice. He submitted a complaint to the state board. The issue was not that diagnosis of periodontal disease was missed. The issue was that periodontal disease was active, so a treatment and code of D4341, periodontal therapy, should have been performed.
D4341 is defined as: “This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft-tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of presurgical procedures in others.”3
In this case, maintenance was the wrong procedure, and the disease was active. Biologic width had been violated and not explained to the patient.
We hurt ourselves
One takeaway is that the complaint came from a colleague. The belief that as long as our patients like us, we won’t face litigation or any trouble with the state board is not true; our peers can be dangerous too. That’s not to say we shouldn’t police ourselves. There are dentists who operate below the standard of care and should be rehabilitated.
But how did we get to the point that we tear one another down? Some dentists believe that by speaking poorly of another dentist, patients will trust them more or feel like they’ve found a superior dentist. My experience has been the opposite of this. I’ve found that when speaking poorly to a patient about his or her past dental care, it reflects poorly on all dentists, and the patient is not likely to remain in the practice.
All of this could have been prevented if the original dentist had simply performed proper treatment. The patient had periodontal disease and his gingiva bled. But to be “nice,” the dentist ignored the disease and “cleaned up” the teeth, and ultimately lost. Some dentists go so far as to have a patient sign a form that states, “The patient has been informed that they have periodontal disease and decline treating it and elect to just clean the teeth.” These forms have been shown not to hold up to scrutiny in the legal realm, which renders these waivers useless.
For years there has been talk about the importance of periodontal treatment, its relationship to other diseases, the causation versus correlation argument, and more. These subjects are for another article, but the fact remains that when disease is present, it should be treated.
I have been told that idealism or running a practice with only the ideal in mind without compromises can lead to financial hardships, perhaps even destroying a practice. If the standard of care is too “ideal,” it’s time for a long look in the mirror. This is health care. This is not a retail space, where let’s make a deal is the name of the game. In my office, I treatment plan to the ideal, and if a compromise is due, it must still be a minimum standard of care. If you lack the spine to treat disease when it is present because you want your patients to like you, perhaps a different field would be a better fit for you.
1. Stop Caring with Mac Lee: Howard Speaks Podcast #115. Dental Town website. https://www.dentaltown.com/blog/post/2726/stop-caring-with-mac-lee-howard-speaks-podcast-115. Published August 7, 2015.
2. Glasscoe Watterson D. D1110 and D4910. RDHmag website. https://www.rdhmag.com/articles/print/volume-31/issue-4/features/d110-and-d4910.html. Published April 1, 2011.
3. Glasscoe Watterson D. Prophy vs. perio maintenance. RDHmag website. https://www.rdhmag.com/articles/print/volume-22/issue-9/columns/staff-rx/prophy-vs-perio-maintenance.html. Published September 1, 2002.
Lance Timmerman, DMD, MAGD, FICoi, graduated from the Oregon Health Sciences University School of Dental Medicine in 1998 and practices in Seattle, Washington. He is a diplomate of the American Board of Dental Sleep Medicine, a fellow in the International Congress for Oral Implantology, and a master in the Academy of General Dentistry. He is coauthor of the book, A Cup of Coffee with 10 of the Top Cosmetic Dentists in the United States: Valuable Insights You Should Know Before You Have Cosmetic Dental Work Done.