Supportive perio therapy

Our patients are an essential cog in the wheel of successful periodontal treatment. Without their active participation, stability is not an option.

by Annette Ashley Linder, BS, RDH

We have a problem with Code 4910 — supportive periodontal therapy (SPT) — in our office. Patients complain and then cancel the three-month, perio-maintenance appointment because "insurance will only pay for two cleanings a year."

Many of these patients completed active periodontal treatment four years ago, but are now back with full-blown, active periodontal infection all over again. What do I say and do? My insurance coordinator is upset because insurance isn't reimbursing for treatment and patients are complaining to her. How do we get insurance to pay? How do I help my patients see that this appointment is different from a three-month prophy ... and what makes it different? Should we charge for an exam? Can we alternate with the prophy (0110) code?

If these are questions that you and your team are asking, please know you are not alone! They are among the most frequently asked at lectures and when consulting with dental practices. Managing three-month periodontal maintenance appointments is a real and valid frustration for the dental team.

The three-month interval of care (supportive periodontal maintenance therapy) following active periodontal treatment is well established in research as critical and key to long-term periodontal stability. Patients treated for periodontitis who comply with suggested SPT intervals experience less tooth loss and attachment loss than patients who do not comply. Because the progression of the disease is unpredictable, SPT protocols allow for close monitoring, as well as professional procedures. In other words, ongoing and supportive periodontal maintenance is an integral part of the treatment plan. (Visit www.AAP.org to learn more about the research.) The challenge is how to get this message across to the patient. While there is no single solution to the problem, there are some steps you can take to change the pattern.

Patients don't get it!

A major contributing factor for low SPT compliance that I routinely observe is the "unilateral" enrollment of the patient in periodontal treatment. What does this mean? In many dental practices, patients are simply told that they have a "gum problem" and they need to have "quadrants of scaling and root-planing to remove the calculus from below the gum line." Patients are told that the treatment will "require three-to-six appointments and the cost will be around $900. Insurance may pay for a good portion of the treatment — perhaps one-half to three-fourths of the cost." Patients may accept the recommended treatment, but are they really participating in their treatment?

It is a set-up for another compliance battle with the patient and a no-win scenario. A successful periodontal therapeutic outcome depends on what patients do when they leave the dental chair. You can scale and root-plane until you are blue in the face ... but if the patient isn't participating — i.e., performing thorough daily bacterial-plaque removal and maintaining appropriate professional care appointments — chances are slim for ongoing perio stability. Patients who accept periodontal treatment "because the hygienist or the dentist said to do it" are the patients that cancel appointments, don't comply with home care, complain about money, and fail to keep the needed three- month, supportive-care appointments because "insurance only pays for two cleanings a year!" Periodontal therapy is a partnership between therapist and patient. The goal is to allow patients to take ownership of their health — periodontal or otherwise — and coach them to be informed and pro-active health-care clients. Here are some ways to do that!

Beyond the roots

One solution starts at the beginning, during the assessment and treatment-proposal phase. Ideally, we would like everyone to say "yes" to treatment. But in the real world and for a variety of reasons, that is not likely. Trying to talk a patient that says "no" into treatment leads to more frustration. When and if they return for care, these patients often present with active disease again and require retreatment. That means back to ground zero for the hygienist, who assumes all the blame and struggles to give an explanation to the patient. Talk about stress and burn-out! This is not fair to the hygienist, the dentist, or the team.

There are better and easier ways to do this. Hygienists are continually educating and discussing oral health-care needs with patients. Existing health conditions, medications the patient takes, and the patient's personal history all have an impact on each individual's periodontal status. These interrelating areas should be discussed with the patient.

Have research articles, office newsletters, and other patient information sheets available in the reception area and treatment rooms. Periodontal disease is a complex, multifaceted condition. Contributing factors include genetics, local and environmental influences, and immuno-inflammatory responses of the host. Periodontal disease is episodic and incurable, but it also is controllable. Controlling it is the goal of interceptive therapy. In other words, it is more than just bacterial plaque!

Updated histories are an important part of data collection. Audit patient records to make sure health histories are complete and current. Discuss with patients the significance of their current health status, medications they take, life changes and stressors and their relationship to chronic infections such as periodontal disease. What follows are two examples of how you might lead into a discussion of contributing factors:

"John, you have indicated that you have been diagnosed with diabetes. We have a lot of new research information that demonstrates a link between diabetes and periodontal infections. Please allow me to share that information with you."

"Mary, you have indicated that you smoke. The latest research shows that smokers have the greatest risk for periodontal infections and tooth loss, and I would like to discuss some of this information with you."

A periodontal evaluation should be a part of every dental hygiene appointment and documented in the patient's record. Create an open environment of co-examination and codiscovery to involve the patient in the diagnostic process so that he or she will be more likely to say yes to necessary treatment. Prior to beginning the periodontal exam, remind patients of clinical signs that they can understand. These might include bleeding, pocket depths, bacteria found deeper in the bone and connective tissue creating infection, inflammation, and bone loss. Offer patients a mirror so they can view the exam process. Proceed through the periodontal exam calling out the numbers, bleeding points, and other clinical signs. With a team member recording the data, it becomes time-efficient to complete the full-mouth examination. Some patients will watch; others will not. The important part is to allow the patient to hear the hygienist report clinical signs of periodontal infection. Use the examination to educate and motivate. At the completion of the exam, most patients want to know "What does this mean and what do we do to fix it?" This is your opportunity to explain to patients why they need more than a routine professional prophylaxis and to present an appropriate periodontal-treatment plan that emphasizes the importance of three-month maintenance-therapy appointments.

At each of these appointments, the patient should leave with some form of written patient-education information. This may be a professional pamphlet, a research fact sheet, or your own perio-office information forms. At each appointment, focus on the patient's progress and continuing perio needs, and make sure the patient is involved every step of the way. Utilizing visual tools, the intraoral camera, or a hand held mirror gives the patient the opportunity to "see" the difference between healthy tissue and infected tissue. (Sample SPT letters can be found at AnnetteLinder.com.)

What is the difference?

SPT requires a periodontal appointment and is part of periodontal treatment. It is not a three-month prophy. It is more than a routine supragingival scaling and polishing. Depending on how the patient presents, the appointment may include site-specific scaling, root-planing, pocket debridement, and placement of antimicrobials and medicaments. The definition of supportive periodontal therapy, according to the AAP and the ADA, includes the following:

"This procedure is for patients who have completed periodontal treatment (surgical and/or nonsurgical therapies, exclusive of Code 4355), and includes medical-history review, evaluation of periodontal status (charting), removal of bacterial flora from crevicular and pocket areas (i.e., scaling, root-planing, debridement), scaling and polishing of teeth, periodontal evaluation, and a review of the patient's plaque-control efficiency. Typically, an interval of three months between appointments results in an effective treatment schedule, but this can vary depending on the clinical judgment of the dentist. When new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered. Periodic maintenance treatment following periodontal therapy is not synonymous with a prophylaxis."

Determining an appropriate interval of care is an extremely important clinical decision based on current research and protocols, the patient's clinical presentation and risk factors, and the dentist's clinical judgment as to the best standard of care. Developing comfortable, professional communications — combined with a partnership approach to patient care — helps to eliminate the frustration of "I only want what insurance covers" and ensures better patient commitment to three-month maintenance protocols.


Don't hesitate!

• to resubmit claims with letters of explanation, charts, pictures, and documenting research
• to tell patients to call their insurance companies to find out why a claim has not been paid
• to always charge out for the services you render, knowing that it is correct
• to retreat active periodontal infection as needed and site-specifically
Example: A patient completed active therapy (Code 4341) several years ago and has not maintained three-month supportive therapy. The patient presents needing retreatment. Changes in the patient's medical history, stress factors, and poor compliance all contribute to the need for retreatment. Because periodontal disease is a chronic infection, it is not unusual to have to retreat with quadrant/s of mechanical and chemical therapy. Most carriers do not define Code 4341 treatment as a once-in-a-lifetime procedure, so many will reimburse the patient for 4341 treatment procedures following an appropriate time interval (typically after 24 to 36 months).


Submitting an insurance claim for supportive periodontal therapy

Once patients have received periodontal treatment (4341), they become 4910 patients. Only submit a claim for Code 4910 after utilization of Code 4341.

1) The procedure is billed four times per year under Code 4910. Many insurance carriers will pay for two "cleanings" a year and include 4910 treatment in this category. These insurance companies are going to pay twice a year and that is it. Some will pay for Code 4910 treatment four times a year, and some contracts cover Code 4910 twice a year, and then modify the other visits to the 0110 prophy code. As with many ADA codes, the insurance carrier will only reimburse for "what is covered by the contract." The contract is between the employer, the patient and the insurance company. Patients who commit to periodontal treatment because they value good health (and wish to rid their bodies of infection) understand the reality of dental insurance. Realistically speaking, we are not talking about the cost of open heart surgery. If patients who value their periodontal health have to pay out-of-pocket for two visits per year, it usually is not a big deal to them.

2) Examination and radiographic analysis are charged separately. Code 4910 includes a periodontal-records update, not a periodic examination. Therefore, the periodic exam, Code 0120, is performed and charged out separately, usually at six-month intervals. The same is true for necessary radiographic evaluations.

3) Use of a narrative may help patients gain insurance payment. A sample narrative might say: "Patient completed active periodontal therapy (Code 4341) on date of [insert date here] and is now receiving periodic and ongoing periodontal treatment."

4) Along with periodontal claim submission, dental offices are reporting a better success rate when they include any or all of the following: intraoral photos of bleeding, pus, and exudate; swollen, inflamed tissue; periodontal examination chart depicting progression of the disease; definition of the 4910 code from current ADA, CDT, and research regarding the correlation between systemic health and periodontal disease.

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