Periodontal Cleaning

Periodontitis is a form of gum disease. It is a chronic infection of the gums which is characterized by a loss of attachment between the tooth and the jawbone. It is the leading cause of tooth loss among adults in the United States.

 Teeth are attached to the jaw by a series of very strong ligaments. The gums are also connected to the tooth by a complex series of microscopic fibers; and the gums lay over the tooth-bone attachment like a protective cover. Periodontitis begins in the shallow pocket where the tooth and gum meets, usually as a milder form of gum infection known as gingivitis.Bacteria can grow in this pocket, usually due to inadequate oral hygiene. The gum begins to pull away from the tooth deepening the pocket, making it harder to clean and encouraging the formation of tenacious tartar deposits belowthe gumline.

Bone is lost as the infection progresses down the root and pockets form

Over time this infection can cause inflammation in the bone, causing it to slowly disappear, undermining the attachment to the tooth. This loss of bone is what distinguishes periodontitis from gingivitis, where no bone loss occurs. After many years this can lead to tooth loss.

 

Diagnosis

 Periodontal disease is diagnosed with a thorough periodontal exam. A small, blunt probe is used to measure the depth of the gum pockets around every tooth in the mouth. Measurements are taken at six sites on each tooth. This depth gives an objective gauge of the health of the gums. If the pockets bleed easily during probing this is noted as well. This bleeding is a sign of inflammation of the pocket. The appearance of the gums is noted; infected gums appear red and puffy.

The amount of tartar, or calculus, is determined. The mobility of all teeth is checked and the bite is evaluated. X-rays of all teeth are needed to evaluate the condition of the bone around each tooth and show calculus deposits below the gumline.

Treatment

 It is important to realize that periodontitis ischronic, insidious, and episodicin nature....

Chronic- Periodontitis is typically a slow moving condition, taking many months or even years to develop. Once the disease develops and is diagnosed, it is never really cured. Instead it is managed, much like other chronic conditions like high blood pressure or diabetes.

Insidious- Periodontitis is usually silent until its later stages. That is, patients typically have no symptoms until the disease has progressed very far. It must be diagnosed through a thorough periodontal exam. Symptoms which do occur late in the disease are bleeding gums, sore or itchy gums, loose teeth, change in bite, bad breath, and acute gum abscesses.

Episodic- The actual disease activity of infection causing bone loss does not occur at all times in all places in the mouth. Instead, the active stages occur in an on/off fashion at various locations in the mouth. This can only be determined by accurate exams initially and at recall.

    These above factors are important to understand the treatment of periodontitis. The goal is to control the current active infection and then closely monitor for signs of disease activity on a regular basis. Once susceptible to this disease it must be monitored for the rest of the patient's life. The ultimate goal is to prevent further bone loss and keep the teeth involved for as long as possible.

Treatment regimens are determined on an individualize basis. Most traditional treatments follow the same basic pattern. First the infection is disrupted by thorough cleaning below the gumline by the doctor or hygienist. This cleaning is called "scaling an root planing" and may take one to four or more appointments. Local anesthesia is often used for patient comfort. The goal is to remove the tartar and bacteria from the root surfaces to allow healing and reattachment of the gums. An individualized home care regimen is devised for the patient to control plaque. Plaque contains the bacteria which cause the disease and plaque hardens to become tartar. Controlling plaque levels through proper home care is critical to the success of the treatment.

The gums are given time to heal once scaling is done(2-4 weeks) and the mouth is reexamined to evaluate the success of the treatment and determine the need for further care. At this point laser treatmentscan be used to reduce localized pocketing. Laser treatments of pockets kills many of the offending bacteria, removes diseased tissue, and encourages gum reattachment to the teeth. This can often be done without scalpels, sutures, or the discomfort associated with traditional periodontal treatments.

A recall interval is determined. Regular recall visits are crucial for managing this disease over the long term. Frequent recall allows regular, early removal of tartar accumulations, disruption of bacteria in deeper pockets, and close monitoring of disease activity throughout the mouth. Any further treatment needs can be addressed as soon as possible.

 

Why do I need to come back in 3-4 months?  My insurance only covers two cleanings a year.
You have a chronic bacterial infection called periodontal disease. By measuring the pockets surrounding your teeth, evaluating the gum tissue, and reviewing your x-rays, your dentist and hygienist have discovered the infection in your gums.

As your dentist and hygienist mentioned, 1-3mm pockets without bleeding and recession are typically considered healthy. 4mm pockets with bleeding may indicate gingivitis or even early periodontitis. 5mm+ pockets with multiple bleeding sites strongly indicate the presence of a bacterial infection called periodontal disease. The infected areas are not accessible by brushing and flossing and require your dentist or hygienist to manually remove the bacterial toxins with special instruments. The infection must be removed every 90-120 days to prevent further bone loss. With-out adequate bone support tooth loss occurs.

Concerning your insurance benefits, it is true that most dental plans allow two cleanings per year  for healthy patients. For patients with periodontal disease, however, you have separate benefits aimed at arresting the bacterial infections and preventing additional bone loss. Depending on the premiums paid by you and/or your employer, periodontal benefits usually range from 30-80 percent. A deductible may also apply.

Once you have been diagnosed with periodontal disease, we are obligated to provide your dental plan with the appropriate billing codes, a copy of your periodontal measurements, and sometimes x-rays. Legally and ethically, as your dental care team, we cannot ignore the infection in your mouth. Be assured that we will do our best to see that you receive the dental benefits provided by your employer.

Will my insurance cover periodontal visits?
To give you an accurate estimate of your dental benefits, we must first see a copy of your dental plan. If you bring in a copy of your dental plan, our business staff will gladly interpret it for you. Most dental plans expect patients to pay a portion of their periodontal visits. As a general rule, periodontal patients should expect  to pay at least 30-50 percent of their treatment needs over the course of the year since most dental plans require a deductible and a  copayment on periodontal services.

As you know, our goal is to provide excellent dental care to all of our patients. In good conscience, we cannot ignore a bacterial infection simply because of insurance limitations. With periodontal disease, the risk is too great. If left untreated, periodontal disease not only leads to tooth loss, it may also place you at risk for heart disease, respiratory disease, diabetes, and , if pregnant, a preterm low birth weight baby.

Why haven’t I been told about Periodontal Disease before?
This is an understandable question. Quite simply, our bodies change. Bacterial plaque can cause decay in our teeth or cause an infection in our gums called periodontal disease. When you come in for your cleaning and exam, the dentist evaluates both the health of your teeth and the health of your gums and bone support. Just as you may have developed a cavity since your last appointment, you may have also developed an infection in your gums which may be the beginning stages of periodontal disease.

There are many risk factors  affecting the onset of periodontal disease, including: smoking, diabetes, heart disease, respiratory disease, pregnancy, osteoporosis, stress, radiation, chemotherapy, medications, inadequate home care, hereditary predisposition, etc. Our goal is to protect your oral health which is essential to your overall health.

Can’t you just change the code?
I wish it were that easy. However there are very serious consequences for doing so.

The Health Care False Claim Act states: “No person shall knowingly make a false statement or false representation of a material fact to a health care payer for use in determining rights to a health care payment. Each claim that violates this subsection shall constitute a separate violation.”

Dentists and Hygienists have a legal responsibility to select the dental code that most accurately reflects the treatment rendered.  To manipulate a code to obtain better benefits for a patient is a violation of the Health Care False Claim Act and draws the attention of the F.B.I. and U.S. Postal Inspectors because false claims sent via the U.S. Postal Service constitute mail fraud.

Dental insurance phone representatives often tell patients the benefits available under their dental plans. While a phone representative may  know the details of a patient’s dental plan, he/she often does not understand the legal responsibilities of the dental office. A dental representative may tell a patient what code(s) will be paid under the terms of his/her contract, not realizing the dentist and/or hygienist can lose his/her license if he/she manipulates treatment codes in order to obtain those benefits.

Changing a code is not the answer to dealing with denied dental services. The plan purchaser, usually ones employer, must agree to increase benefits when negotiating the dental contract.