Periodontal Triage (The flow of perio patients through your office)-DoctorSpiller.com

Periodontal disease page 12345678

The term Triage means the process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. It is generally applied to battlefield or disaster scenarios in which priorities for limited resources are decided based on various criteria such as one patient’s need for immediate lifesaving treatment versus a recognition that another will die no matter what the rescue personnel do. This decision must be balanced against the need to get a lightly injured soldier back into battle as soon as possible.

In dentistry, every patient will receive some sort of periodontal treatment, whether it be a simple prophylaxis or complex periodontal procedures ranging from root planing to osseous surgery with bone grafting. The criteria a dentist uses to decide on the periodontal treatment plan for any given patient is a form of triage. Given the changing nature of periodontal treatment modalities over the last few years, this page discusses my own “periodontal flow chart” for patient triage.

Periodontal Triage

Patients are broken down into six groups according to their initial periodontal diagnosis when entering the practice for routine dental treatment.  Each diagnosis is handled in a different way.  Since the treatment regimen for each diagnosis is always the same, the hygienists can tell the patient exactly what the steps are and how much the total periodontal treatment plan will cost.

Since any periodontal case must be well documented, all patients who fall into any periodontal classification except the first one (the periodontally “clean” patient) must have a full series of radiographs and a periodontal probing on the first visit.  In the case of “gingivitis” (debridement patients), the periodontal probing is deferred to a second visit, along with the oral examination and treatment plan.

1. The periodontally healthy patient

A vast majority of your patients will fall into this category.  These patients present with 1-3 mm sulcus depth, minimal calculus and  minimal bleeding on probing.  Their periodontal treatment consists of an initial prophylaxis and scheduled regular recall prophys:

First visit

  • Exam (0150)
  • x-rays
    • FMX (0210)–Patients  over the age of 30 and any patient with extensive dental work, extensive caries or extensive missing teeth.
    • 4 horizontal BWX (0274) –Patients 12-30 with selective periapicals if there are individual teeth with suspected periapical pathology.
    • 4 horizontal BWX (0274) and a panorex –Patients under 30 with unerupted wisdom teeth, congenitally missing teeth or other suspected pathology.
    • 2 horizontal BWX (0274)–Patients under 12 without erupted 2nd molars.
  • Prophylaxis (1110)

Recall visits

  • Recall Exam (0120)
  • Appropriate BWX once every year or two depending on need
  • Recall prophy (1110)

2. Healthy patients with minor isolated pockets

These patients present in a state of reasonable periodontal health, but with minor isolated pocketing and bleeding that probably will require further periodontal treatment.  This includes patients with overall good periodontal health, but having one or two specific areas in which the pockets will require enough deep scaling to need anesthesia.

First visit

  • Exam (0150)
  • FMX (0210)
  • Pocket Probing
  • Prophy (1110)– only if the site specific needs are minimal.  In this case, the third visit would be skipped.

Second Visit

  • Localized scale and root planing 1-3 teeth/area(4342) — billed per site
  • Isolated Arestin (4381) — billed per site

Third visit–Only if no prophy was performed at first visit.

  • Fine scale Prophy (1110)–Short visit to complete the prophy in the areas unscaled in the second visit.

3. The “Gingivitis” patient (The full mouth debridement patient)

“Gingivitis” is a misnomer, but stands as a diagnosis acceptable to insurance companies.  These patients present with 1-4 mm pockets, extensive calculus and/or serious bleeding and pain on probing.  These conditions make it very difficult get accurate probing depths, and hide the true long term classification of the patient’s periodontal condition.

“Gingivitis” patients do not receive a standard prophy or billable oral examination at their first visit, although the overall condition and any serious problems should be noted and treated immediately if necessary.  There are two reasons for deferring the examination until a later visit.

Insurance companies will not approve an examination on the same visit as a full mouth debridement.

It is difficult to assess the true periodontal condition until some healing has taken place.

In reality, many patients with more serious periodontal disease will initially be classified as gingivitis patients if probing is difficult or impossible due to heavy calculus, bleeding or pain on probing.  Two to three weeks after a debridement, oral examination becomes much easier, and classification of the patient’s periodontal condition becomes more accurate.

First visit

  • FMX (0210)
  • Pocket probing
  • Full Mouth Debridement (FMD) (4355)

Second visit

  • Exam (0150)
  • Pocket probing
  • Evaluate for root planing and appoint for appropriate root planing appointments.
  • Fine scale (1110) — Only if the the periodontal condition has improved.  In this case, the patient is reclassified as a periodontally healthy patient and placed on a regular recall schedule.

4. Early periodontitis

Patients in this category present with numerous 4-5 mm pocketing and bleeding on probing.  These patients may require a full mouth debridement on their first visit, after which they will enter immediately upon their root planing visits.  Many patients in this category do not have enough calculus to justify a FMD, in which case the following regimen is followed.

First visit

  • Exam (0150) or Comprehensive perio exam (0180)
  • FMX (0210)
  • Spend the time explaining to the patient why they need special (and more expensive) periodontal treatment with anesthesia at subsequent visits.  The appoint for two visits of root planing.

Second visit

  • 2 quads of scaling and root planing (4341) billed per quadrant
  • Arestin placement (4381) billed per site maximum 3 sites per quad

Third visit

  • 2 quads of scaling and root planing (4341) billed per quadrant
  • Arestin placement (4381) billed per site maximum 3 sites per quad

Fourth visit (2 – 3 weeks later–no charge)

  • Post-op check and prophy touch-up. At this visit, the patient is evaluated as to outcome of the treatment.  Early periodontal disease often clears quite well if the patient is willing to spend the time cleaning interproximally (I recommend Stimudents).  If the condition heals to a state of health, future recalls may be regular prophys (1110) twice a year.  If not, the patient may require a higher frequency schedule of perio maintenance recalls (4910)

5. Moderate Periodontitis

Patients in this category present with numerous 5-7 mm pockets and moderate to severe bleeding on probing.   These patients may require a full mouth debridement on their first visit, after which they will enter immediately upon their root planing visits.  Many patients in this category do not have enough calculus to justify a FMD, in which case the following regimen is followed.

First visit

  • Exam (0150) or Comprehensive perio exam (0180)
  • FMX (0210)
  • Spend the time explaining to the patient why they need special (and more expensive) periodontal treatment with anesthesia at subsequent visits.  The appoint for four visits of root planing.

Visits 2, 3, 4 and 5

  • Because of the depth of the pockets and the wide expanse of root surface above the periodontal attachment, any given quadrant will require more time to thoroughly root plane.   Trying to do more than one quad at a time on these patients will tax the resources of both the patient and the hygienist.
    • 1 quad of scaling and root planing (4341) billed per quadrant
    • Arestin placement (4381) billed per site maximum 3 sites per quad

Recall visit in 3 months, and at 3 or 4 month intervals after the first recall depending on the outcome of the initial treatment.

  • Exam and perio maintenance cleaning(4910) — This is a combined fee, including both the exam and the “perio prophy”.  The patient should be made aware that his or her bill for future cleanings will be higher than that charged for a regular prophy due to the wider expanse of tooth structure that must be scaled.
  • Vertical BWX (0274) once a year at perio maintenance recalls.

6. Severe Periodontitis

Patients in this category present with numerous pockets of 7 mm and greater, severe bleeding on probing and 2+ or higher mobility.

When patients in this condition want desperately to keep their natural teeth, we do not attempt to treat their periodontal condition in our own office.  These patients receive the following:

  • Exam
  • FMX
  • referral to a periodontist.

More frequently, these patients choose a treatment plan that includes keeping the teeth with a good prognosis, extracting the teeth with the poorest prognosis, replacement of the missing teeth with implants or removable prosthetics, and referral to a periodontist for treatment of their periodontal condition.

Periodontal disease page 12345678