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Copyright 2011 Inspired Hygiene and Rachel Wall. All rights reserved.

Host:

Rachel Wall, RDH, BS Founder and Owner of Inspired Hygiene, Inc

Sponsored by

CE credits are provided by Inspired Hygiene. Inspired Hygiene is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 6/1/2010 to 5/31/2014.


Quick Reference Sheet

Session 1: Where are you now? Discovering your Perio Potential with Rachel Wall, RDH

Session 2: The Science of Perio with Dr. Richard Nagelberg

Session 3: The Standard of Care- Diagnosis and Delivery with Rachel Wall, RDH

Session 4: Periodontal Instrumentation and Ultrasonics with Allison Teel, RDH

Session 5: Advanced Diagnostics and the Role of Antibiotics in Perio Therapy with Dr. Richard Nagelberg

Session 6: Periodontal Coding Procedures with Laci Phillips

Session 7: Current Perio Research and Supportive Treatment Services with Trisha O’Hehir, RDH

Session 8: Communication, Enrollment and Handoffs with Rachel Wall, RDH

FAQs Q: How do I view the webinar sessions? A: The webinar sessions consist of power point with recorded narration. You will need to view these on a computer and you will need Windows Media Player. Q: How do we get our CE? A: You will go to http://inspiredhygiene.com/perio2011 to complete the post-test at any time after you’ve listened to the recorded session. You will also need to print your CE certificate on the results page by clicking on “Download your Certificate”. Q: Who do I contact if I have questions about the course? A: Diane Alderson 877-237-7230 [email protected]


Our Goals and Objectives for this Course

• Discover the prevalence of periodontal disease in your practice • Overcome the obstacles that keep you from treating

patients with active periodontal disease • Understand the stages of periodontal disease and how it affects

the entire body • Interrupt the disease in the earliest stage possible • Assist you and your office in creating a periodontal standard of

care guideline • Give you systems to implement immediately to increase

periodontal disease detection, treatment and maintenance • Give you current background on available tools and technology to

diagnose and treat periodontal disease • Provide you with successful enrollment terminology to assist

patients in overcoming their barriers to necessary treatment • Scheduling appropriate time blocks and continuing care intervals • Facilitate proper periodontal coding, including the differences

between an adult prophy and periodontal maintenance procedures • Understanding the value of monitors and tracking your results

Our Commitment to You: We will provide scientific-based and time-tested information that will confirm or shift your core beliefs to directly affect the way you give care to your patients daily. And we will assist you in believing that the periodontal care you provide to your patients truly matters in their overall health care.


About your host:

Rachel Wall, RDH, BS As owner of Inspired Hygiene, Rachel helps dentists tap into the productive potential of their hygiene team. In addition to coaching, Rachel draws from her 20 years of experience as a clinical hygienist and practice administrator to deliver to-the- point articles and speaking programs. Her articles have been published in numerous industry journals including Dental Practice Report, Dentistry Today and Modern Hygiene. Inspired Hygiene’s programs include in-office coaching, a monthly e-zine and the new High Performance Hygiene Mastermind group. Inspired Hygiene is also the preferred hygiene coaching group for the Productive Dentist Academy

and a strategic partner with The Profitable Dentist. Rachel graduated from the University of North Carolina. Rachel can be contacted by email at [email protected].

About our guest speakers:

Special Guest Experts

Dr. Richard Nagelberg

As a full-time clinical dentist for over 25 years and nationally known speaker, Dr. Nagelberg fulfills his passion for educating dental teams as well as his patients about the oral-systemic link. He serves on the J&J Advisory Board and is the founder of PerioConsulting Services. Through his programs “Periodontal Medicine: Medical Manifestations of Periodontal Disease”, “Bacterial Origins of Periodontal Disease” and “Perio/Systemic Links”, Dr. Nagelberg has reached thousands of dental professionals as a professional speaker and author and set himself apart as an expert in the field of periodontal science. He can be reached at [email protected].


Allison Teel, RDH, BS

With over 30 years of experience in dental assisting, dental hygiene and practice management, Allison Teel is a powerful presence in the dental industry. Her clinical skills include a mastery of laser periodontal therapy, ergonomics and ultrasonic therapy. Still active as a clinical hygienist and hygiene instructor in Southern California, Allison incorporates the knowledge brought by her fellowship certification in Diode, Nd:Yag and Erbium lasers along with progressive therapies to get amazing results with non-surgical periodontal treatment. Allison has a passion for educating every patient toward a balance in their total body health. Allison can be contacted at [email protected].

Laci Phillips

While going to college in southern New Mexico to pursue a life of communications, Laci was introduced to her first job in the dental industry as a chair side assistant. Now, 17 years later, she is communicating more than ever through Banta Consulting Group as a dynamic speaker and a technology consultant. Her experience in the dental office as a chair side assistant up through the ranks as an office administrator enable Laci to connect with her audience and her clients. As a staff and software trainer and a team builder, Laci has an effective way of teaching the entire team how to move in the same direction, while working as an individual. Laci is a practice management consultant and speaker for Banta Consulting, Inc. of Grain Valley, MO. Her consulting emphasis is helping dental teams integrate technology in their practices.She can be contacted at [email protected].


Trisha O'Hehir, RDH, BS

Besides clinical dental hygiene practice and several university faculty positions over four decades as an RDH, Trisha is an international speaker, author, instrument designer, inventor, and editorial director for Hygienetown magazine and Perio Reports. She presents thought provoking continuing education programs, combining current research, practical applications, and alternatives for the future. She can be contacted at [email protected].


SESSION ONE Discovering Your Periodontal Potential

Where are you now? Rachel Wall, RDH

Objectives; At the conclusion of this session, attendees should be able: • To determine your periodontal percentage • To create periodontal awareness in your practice • To become aware of the obstacles holding you back • To understand the importance of using the periodontal probe on all patients • To breakdown your hygiene appointment into a manageable time frame

Periodontal Disease Facts

i

However, based on results of a new study published in the Journal of Periodontology, about one in seven 26yearolds already has well established periodontal disease, a major cause of tooth loss in adults. ii

Oral bacteria may spread into the blood stream through ulcerated epithelium in diseased periodontal pockets iii


We estimate that at least 35% of the dentate U.S. adults aged 30

to 90 have Periodontitis, with 21.8% having a mild form and

12.6% having a moderate or severe form. iv

…there are elevated levels of CRP associated with infection with subgingival organisms often associated with periodontal disease… v

These data suggest that the Creactive protein level is a stronger predictor of cardiovascular events than the LDL cholesterol level vi

…men with periodontal disease had a 63% higher risk of developing pancreatic cancer compared to those reporting no periodontal disease. vii


Resources: 1 Albandar JM, Brunelle JA, Kingman A. “Destructive periodontal disease in adults 30 years of age and older in the United States, 1988-1994”. J Periodontol. 1999 Jan;70(1):13-29

1 AAP Public Relations Press Release “Periodontal Disease Isn't Always Your Parents' Disease” January 5, 2001. Referenced article by Thomson WM, Hashim R, Pack A “The Prevalence and Intraoral Distribution of Periodontal Attachment Loss in a Birth Cohort of 26-Year-Olds” Journal of Periodontology December 2000, Vol. 71, No. 12, Pages 1840-1845.

1 Asikainen S, Alaluusua S. “Bacteriology of dental infections” Eur Heart J. 1993 Dec;14 Suppl K:43-50.

1 AAP Position Paper: “Epidemiology of Periodontal Disease” J Perio 2005;76:1406-1419 Accessed from AAP website www.perio.org

1 Noack B, Genco R, et al. “Periodontal Infections Contribute to Elevated Systemic C-Reactive Protein Level” J Perio Sept 2001; Vol. 72, No. 9, Pages 1221-1227

1 Ridker P, Rifai N, et al. “Comparison of C-Reactive Protein and Low- Density Lipoprotein Cholesterol Levels in the Prediction of First Cardiovascular Events” NE J of Med Nov 2002;Volume 347:1557-1565.

1 Imperial College London and Harvard School of Public Health reported in the May 6 online edition of Lancet Oncology (DOI:10.1016/S1470-2045(08)70106-2)

And

ADA A-Z Science in the News on www.ada.org “An evaluation of periodontal disease and pancreatic cancer risk in men”. Accessed Jan 24, 2007.


Periodontal Profile Quiz

1. Do you have a clear periodontal therapy care plan in your office? a. yes b. no c. don’t know

2. Are there clear standards in your office that outline when x-rays are taken? And when periodontal probing is recorded?

A. yes b. no c. don’t know

3. Is your hygiene schedule booked out more than 4-6 weeks? A. yes b. no c. don’t know

4. Are there times in your schedule reserved for periodontal therapy? A. yes b. no c. don’t know

5. What percentage of the patients you see each day for routine preventive Care have moderate to heavy bleeding during scaling?

a. 5-10% b. 30-50% c. 60-100%

6. How often do you complete a full 6-point periodontal charting on each adult patient?

a. once a year b. only when they need it c. once every 2 years

7. Do you currently use local chemotherapeutics, like Arestin, in your office? a. yes b. no

Grade Yourself: #1 a=10 #2 a=10 #3 a=5 #4 a=10 #5 a=10 #6 a=8 #7 a=10

b=4 b=4 b=7 b=5 b=5 b=2 b=5 c=2 c=2 c=2 c=2 c=2 c=5


Score = 17-20 points Take Action Now! Chances are you are performing perio therapy but aren’t identifying it and treatment planning appropriately. Attend a comprehensive perio course and meet with your team to develop a plan of action. Discuss what is holding you back from identifying periodontal disease and delivering non-surgical therapy. Do you feel that there is no time in your schedule for periodontal therapy? Are you so rushed in your hygiene appointments that you are just trying to keep your head above water? If so, take a step back and evaluate what you can do to make things better. Seek the help of a hygiene co

Score = 21-54 Refresh & Renew! Revisit your existing perio treatment protocol. Renew protocol to include latest therapy recommendations, local chemotherapeutics, ultrasonics, lasers. Evaluate the hygiene schedule. Is there time set aside for perio treatment? Attend a workshop, CE course or seek help from a consultant to fine tune and refresh your plan. Be sure all patients receive a comprehensive periodontal exam including recording 6 Point probing at least once a year. This may open your eyes to the periodontal disease hiding in your practice.

Score 55-65 You are flying high! Great work! Continue to attend cutting edge CE courses to keep you on track. Read research and professional journals for updates on the standard of periodontal care. Evaluate your perio care plan each quarter to make sure it matches the current standards.


AAP Periodontal Disease Classification, 1999 Annals of Perio

Accessed from AAP website (www.perio.org) July 6, 2004. Based on “Development of a Classification System for Perio Diseases & Conditions” by Gary Armitage, Dec 1999 Also based on Parameters on Chronic Periodontitis with Advanced Loss of Periodontal Support and Parameters on Chronic Periodontitis with Slight-Moderate Loss of Periodontal Support both by the AAP 2000

Class I Tissue

Pockets

Gingival Disease Inflamed, red, swollen tissue that bleeds upon probing and exploring. Exudate may be present 1-3mm, no bone loss. More than 14 types of gingivitis.

Class II Chronic Periodontitis (formerly Adult Periodontitis)

Bleeding, swelling, redness, suppuration

May be localized or generalized

Beginning-Moderate Loss of Periodontal Support Loss of up to 1/3 of supporting periodontal tissues. If furcation involvement, no more than Class I.

Probing depth up to 5mm with CAL up to 4mm. Radiographic evidence of bone loss and increased mobility may be present.

Advanced Loss of Periodontal Support Loss of greater than 1/3 of supporting periodontal tissues. If furcation involvement, may exceed Class I. Probing depth will be 6mm or greater with CAL greater than 4mm. Radiographic bone loss is evident. Mobility may be present.

Class III Aggressive Periodontal Disease

Rapid rate of progression. Often appears in individuals who otherwise appear healthy. Amounts of microbial deposits may be inconsistent with severity of disease. Disease may be self-arresting.

Class IV Periodontitis as a Manifestation of Systemic Disease

Periodontal disease caused by or worsened by various systemic diseases. There is evidence of several systemic conditions that may cause destruction of supporting periodontal structures.

Class V Necrotizing Periodontal Disease

Acute infection of gingiva that has progressed to include attachment loss. May include ulceration and necrosis of papilla, bright red, painful gingival that bleeds.

Class VI Abscesses of the Periodontium

Gingival, periodontal, periocoronal abscess

Class VII Periodontitis Associated with Endodontic Lesion

Periodontitis associated with an active endodontic lesion.

Class VIII Developmental or Acquired Deformities and Conditions

Localized tooth-related factors Mucogingival deformities and conditions around the teeth Mucogingival deformities and conditions on edentulous ridges Occlusal trauma


Perio Classifications

Class I Gingivitis Bleeding easily on probing and/or exploring on 15+ sites Periodontal probing measurements up to 3mm ___ bone loss evident on radiographs Treatment: Therapeutic Scaling followed by Prophy

Class II Beginning Perio Disease Bleeding easily on probing and exploring Periodontal probing measurements up to and including ____mm _______ bone loss evident on radiographs No furcation involvement Treatment: Localized scaling and root planing, laser therapy

Class II Moderate Perio Disease Bleeding easily on probing and exploring Periodontal probing measurements up to and including ____mm _____________ bone loss evident on radiographs Possible Class I furcation involvement Treatment: Scaling and root planing with antibiotic therapy, laser therapy

Class II Advanced Perio Disease Bleeding easily on probing and exploring Periodontal probing measurements ____mm or greater ____________________ bone loss evident on radiographs Possible Class I, II, III furcation involvement Possible mobility Possible suppuration Treatment: Scaling and root planing with antibiotic therapy, laser therapy, referral to periodontist


Periodontal Charting Protocol You must document annually a comprehensive periodontal exam. Here is what should be included:

§ Pocket depths § Bleeding § Recession § Furcations § Mobility § Mucogingival Defects § Suppuration

This will give you, your patient and third parties the information that is necessary to make informed decisions as to what treatment will be required.

Calibration All hygienists working in the practice must routinely review their method of taking periodontal measurements. All hygienists should use the same periodontal probing instrument and technique to ensure that record taking is consistent and accurate. Technique: The periodontal probe is placed parallel to the long axis of the tooth with exception of the col area. In this case, the probe is angled slightly at the interproximal to measure the sulcus below the contact point of the teeth.

Periodontal probe: Regularly examine periodontal probes to be sure they are not broken or overly worn. The millimeter markings should be easily read. Discuss technique for reading the probe to ensure that all users are aware of the pocket depth that corresponds to each mark on the probe.


Sample Periodontal Probing Script: “Mrs. Jones, next I will be evaluating the health of your gum and bone. I will be using a small round ruler that I place between the tooth and gum to measure the space. Ones, twos and threes are all good numbers. Anything above a three shows disease. The higher the number, the more involved the disease. Bleeding is a sign of active infection. I will be calling the numbers out to my assistant so you will be able to follow along. If you hear me say a number followed by the word recession, that means that there is bone and gum loss on that tooth, in other words the tooth appears longer, because root structure is exposed. Normally this is not an uncomfortable procedure unless the tissue is unhealthy. Please listen carefully so that we can discuss the findings when I am done. Let’s get started.”

Obstacles:

______________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________


Ultimate Hygiene Exam Creating synergy within the dental team takes a strong commitment to consistent, outstanding service. This commitment is best carried out when step-by-step protocols are in place for every procedure. The Ultimate Exam enables the provider to collect all the data necessary to inform patient and Doctor of current oral health conditions and needed treatment. Examination must be completed before picking up a scaler!

• Medical History Review o Comprehensive Medical History Form o Blood pressure screening o Medications and supplements o Pre-Medication o Recent surgeries and/or new diagnoses

• Patient questions and concerns o Cosmetic evaluation-shade guide analysis o Breath Analysis o Discomfort

• Intra and Extra Oral Cancer screening • Periodontal Exam

o Includes 6-point probing, bleeding exam, recording furcation, recession • General intraoral observation

o Calculus detection o Decay examination using Diagnodent o Evaluation of existing restorations o Oral Hygiene Evaluation o Occlusal Analysis

• Radiographs o Decay o Periodontal involvement/bone loss

• Intra Oral Photos or Flash Mouth Tour o Immediate dental needs o Condition of existing restorations o Periodontal conditions and home care review o Review of completed treatment

• Share observations with patient • Request doctor exam now


20:20:20 Hygiene Visit

First 20 minutes: DIAGNOSTIC (data) Dental Interview

HH Radiographs

Cancer Screening Exam Tooth Evaluation

Perio Charting

Middle 20 minutes: TREATMENT Scaling

Polish / Floss

Final 20 minutes: EDUCATION / EXAM Homecare

Pre-diagnosis Doctor’s Exam

What’s Next Pt. Exit

Room Turnover

Session One Action Steps:

1. _________________________________________________ 2. _________________________________________________ 3. _________________________________________________ 4. _________________________________________________ 5. _________________________________________________


CE Post-Test – SESSION ONE To receive CE you must complete the online test at

www.inspiredhygiene.com/perio2011

1. Why is it important to know the percentage of patients in your practice that are receiving periodontal procedures?

A. A tool to evaluate the effectiveness of your practice’s periodontal systems. B. It’s a starting point for a comprehensive plan for outstanding patient care. C. It’s a gauge to let you know if you are coding properly for the services you provide. D. All of the above

2. What is the most important instrument in a periodontal exam? A. Explorer B. Mirror C. Probe D. Curette

3. A complete periodontal charting includes the following: A. Bleeding points, recession, mobility, furcations B. Furcations, suppuration, broken restorations, mobility C. Mobility, bleeding points, recession, existing fillings D. Recession, whitening, furcations, mobility

4. All hygienists working in the practice must routinely review their method of taking periodontal measurements to ensure that record taking is consistent and accurate. This is called:

A. Regulation B. Periodontal Comparison C. Comparison Measurement D. Calibration

5. Recession is measured from the ____ to the ________ _______ with a periodontal probe and recorded in millimeters.

6. Clinical attachment loss is the distance between the ____and the base of the _______.


7. A Nabor’s Probe is used to detect: A. Deep periodontal pockets B. Periodontal Abcesses C. Furcations D. Suppuration

8. How many classifications are there for mobility? A. 1 B. 2 C. 3 D.4

9. Radiographs are an important part of the periodontal exam? A. T B. F

10. The AAP Classification was updated in 1999. How many classifications now exist?

A. 4 B. 8 C. 6 D. 5


SESSION TWO The Science of Perio

Richard H. Nagelberg, DDS [email protected]

www.periofrogz.com

Sponsored by

The objectives of this course are to understand new concepts in periodontics, gingivitis and the oral systemic connection.

Gingivitis and periodontitis Periodontal disease is a chronic, non-curable bacterial infection.

Patients who have undergone successful perio treatment are healed, not cured. Gingivitis is not an early form of periodontitis.

Clinical, immunological and genetic evidence indicate it is the gate keeper to periodontitis. The patient’s DNA must be activated. The inflammatory processes of gingivitis turn on the DNA resulting in changes to the gingival tissue, making it more susceptible to infection by the perio pathogens resulting in periodontitis.

Gum disease cannot develop without both bacteria and the inflammatory response.

If the acute inflammatory response does not resolve the infection, chronic inflammation sets in, which causes the perio tissue destruction. Bacteria are necessary but not capable on their own of producing perio disease.

Is gingivitis truly reversible? Failure to prevent the progression of gingivitis to periodontitis results in a lifetime of disease management for the patient In summary, periodontitis is a bacterial infection, which mobilizes the inflammatory response, which causes hard and soft tissue perio destruction.


C-reactive protein C-reactive protein (CRP) is released by the liver in response to injury, inflammation and infection.

CRP promotes platelet adhesion to endothelial cells, providing a mechanism for the high incidence of cardiovascular events associated with elevated levels of CRP.

Patients with perio disease have elevated levels of CRP. Perio treatment has been shown to significantly lower CRP levels.

Oral systemic connections The same inflammatory mediators released during perio disease, coronary heart disease, rheumatoid arthritis and adverse pregnancy events.

Study shows direct relationship between perio pathogens and hypertension Immunological and pathological responses to periodontitis and rheumatoid arthritis (RA) are nearly identical. There is a strong genetic association between perio disease and RA.

Clinical presentation is very similar. Tissue is red, swollen and tender ultimately leading to bone destruction.

Diabetes is an epidemic in the US.

Medical complications of diabetes: retinopathy, nephropathy, neuropathy, cardiovascular disorders, infections, ulcers, ulcers, cataracts, connective tissue disorders

About 65% of diabetic deaths are due to heart attack and stroke.

The #1 condition that increases susceptibility to perio disease is diabetes.

The #1 condition adversely affected by perio disease is also diabetes.

82% if diabetics with severe perio disease experience the onset of one or more major cardio, cerebro or peripheral vascular events compared to only 21% of diabetics without perio disease.


Key Take-Aways

Oral systemic link mechanisms:

Perio disease increases insulin resistance

Elevated CRP levels increase cardiovascular disease risk

Oral bacteria found in coronary blood vessels.

Same inflammatory mediators in PD, RA, CV and PT/LBW

Total inflammatory burden increases risk for systemic events

Patient dialogue “We now know…” “Gum disease increases the risks for…” “Your gum disease increases inflammation throughout your body. Combining that with your family history of diabetes etc makes it more important to get your gum disease under control.”

There are local and global effects of periodontal diseases. Treating perio disease impacts general as well as oral health.

The most important aspect of perio therapy is proper perio maintenance

The two most important factors determining the longevity of favorable treatment results are biofilm control and perio maintenance at 3 month intervals.

The total inflammatory burden increases the risk for systemic events.

Managing the oral contribution to total inflammation is critical and the responsibility of dental professionals.

Keeping risk factors and patient susceptibility in mind will help us treat the person, not the mouth, and that is what it is all about, the care we provide for every patient, every time.

©2011 Richard H. Nagelberg, DDS


Session Two Action Steps:

1. _________________________________________________ 2. _________________________________________________ 3. _________________________________________________ 4. _________________________________________________ 5. _________________________________________________


CE Post-Test – SESSION TWO To receive CE you must complete the online test at


1 Periodontal disease is:

A. A chronic curable disease B. An acute non-curable disease C. A chronic non-curable bacterial infection D. A chronic curable bacterial infection

2 Gingivitis:

A. Is an early form of periodontitis B. Automatically progresses to periodontitis C. Progresses to periodontitis in every patient D. Is the gate-keeper to periodontitis

3 Periodontal tissue destruction is:

A. Primarily the result of a chronic inflammatory response B. Primarily the result of an acute inflammatory response C. Primarily the result of direct bacterial effects D. All of the above

4 C-reactive protein

A. Is released by the liver in response to injury, inflammation and infection B. Recognizes foreign pathogens C. Is elevated in patients with periodontal disease D. All of the above


5 The most important aspect of perio therapy is

A. Surgical treatment B. Proper perio maintenance C.Non-surgical treatment D.Antibiotics

6 The longevity of favorable perio treatment results is primarily determined by:

A.Home care and maintenance at 3 month intervals B. The active phase of treatment C. Initial therapy D.The perio case type

7 Periodontal disease:

A.Has local effects on the periodontium B. Contributes to the total inflammatory burden C.Affects general health D.All of the above


SESSION THREE The Standard of Care:

Diagnosis and Delivery Rachel Wall, RDH

Objectives; At the conclusion of this session, attendees should understand: • The difference between health, gingivitis and periodontitis • How to develop periodontal standards • The appointment flow for periodontal therapy, re-evaluation, and

periodontal maintenance

Periodontal Distinctions

• A prophylaxis is supra gingival plaque & calculus removal and polishing in the presence of NO disease.

• Gingivitis is periodontal disease. • Complete periodontal probing MUST be done on all new and

existing patients. • The dental hygienist MUST do a thorough periodontal

examination, and take responsibility for establishing a periodontal treatment plan.

• When treating periodontal disease, all treatment plans must include: a. Diagnosis b. Therapeutic Phase c. Maintenance Phase

• Scaling, when performed on patients with periodontal disease, is therapeutic, not prophylactic.

Never assume that the patient is healthy. Always assume disease and prove health.


Periodontal Belief Systems

1. Accurate, written documentation of periodontal condition (including 6 point probing) is the cornerstone of comprehensive care.

2. Risk factors must be identified. 3. Patients must be educated in the distinctions of periodontal disease. 4. Active periodontal disease contributes to the decline of patients’ general health.

Oral bacteria have been linked to heart disease, diabetes, pre-term birth, stroke, and other diseases.

5. It is our responsibility, as health care providers, to enroll patients in their needed care, regardless of their insurance coverage.

6. Early to moderate periodontal disease should be treated aggressively to minimize risk of progression.

7. Repetitive visits offer the opportunity to elevate patient home care and compliance for a lifetime of health.

Periodontal Protocol:

The ADA states that 75-85% of Americans have or will have periodontal disease. What percentage of your patients receives periodontal treatment? ______________. When do you intervene in the disease process?

What % of your patients have 4mm bleeding pockets?

______________________________________________________


Your Standard of Care:

• Gingivitis therapy is recommended when a patient presents with _______ sites of bleeding. The patient returns in _____ months for a follow up prophy. The following medicaments are recommended: _______________________________.

Recommended continuing care interval will depend on evaluation findings at second appointment. 3 mo 4 mo 6 mo

• Localized periodontal therapy (root planing and scaling) is recommended when the patient presents with_______________ pocket(s) with a depth of 4mm or greater, when bone loss is present.

Quadrants with 1-3 teeth that are periodontally involved would require the use of code 4342. Healthy dentition can be cleaned using code 1110 at the first visit.

• Generalized periodontal therapy is recommended when the patient presents with the above conditions but it is more widespread.

Quadrants with 4+ teeth involved would require more extensive treatment and time requirements. Code 4341 is used under these circumstances. (two codes can be combined at one appointment depending on the involvement in specific quadrants.)

• A follow up evaluation appointment is scheduled ________ weeks after the final session of periodontal therapy.

Continuing Care Interval:

• Healthy Periodontium: _________ month • Gingivitis: _________ month • Localized Perio.: _________ month • Generalized Perio.: _________ month • Aggressive Perio.: _________ month or referral


Retreatment: • Patients are transitioned back into active periodontal therapy from maintenance

when the patient presents with _____________ disease and/or ________________involving more than _________ teeth.

Chemotherapeutics: • We recommend site-specific chemotherapeutic therapy or repetitive laser

therapy when the patient presents with pocket readings of ________mm or greater that are advancing and/or bleeding.

Referral: • We refer patients for surgical intervention due to boney defects or for a second

opinion when pockets measure ______ mm and/or when sites are ______________ to non-surgical therapies.

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________

Radiographs: What to take? How often? BWX ___________________________________________________ Vertical BWX ____________________________________________ Periapicals _______________________________________________ PAN ___________________________________________________ FMX ___________________________________________________

What to look for? ______________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________


Periodontal Therapy Protocol The following treatment sheets are utilized as treatment planning tools for active periodontal therapy. Using the table below, identify the level of disease present and choose the appropriate treatment sheet. The number of teeth with infected sites will determine whether a D4341 or D4342 procedure (Scaling and Root Planing) will be performed. In addition, note the sites that will be treated with local antibiotic therapy. The treatment sheet is presented first to the patient and then to the administrator responsible for financial arrangements and scheduling. Then the sheet is stored in the patient chart as documentation of the diagnosis and treatment planning of periodontal therapy.

Gingivitis Beginning Periodontal Disease

Moderate Periodontal Disease

Advanced Periodontal Disease

Signs:

• Bleeding easily upon probing and/or exploring on 15+ points

• Periodontal probing measurements up to and including 3mm

• No bone loss evident on radiographs

Signs:

• Bleeding upon probing and exploring

• Periodontal probing measurements up to and including 4 mm

• Slight bone loss evident on radiographs

Signs:


• Periodontal probing measurements up to and including 5mm

• Slight-moderate bone loss evident on radiographs

• Possible Class I furcation involvement

Signs:


• Periodontal probing measurements including 6mm or greater in any area

• Moderate-severe bone loss evident on radiographs

• Possible Class I, II,III furcation involvement

• Possible suppuration • Possible mobility

Treatment: • Gingivitis Therapy • 12 week recare

Treatment: • Active site-specific

periodontal therapy • 10-12 week

reevaluation


periodontal therapy • Localized antibiotic

therapy • 10-12 week

reevaluation


periodontal therapy • Localized antibiotic

therapy • 10-12 week

reevaluation • Refer to periodontist


PERIODONTAL TREATMENT FLOW CHART

COMPLETE HYGIENE EXAM (D0120, D0150, or D0180)

Healthy Gingivitis Periodontal Disease

1-3mm, no bleeding 1-3mm, bleeding, no bone loss 4+mm, bleeding, bone loss

Prophy (1110) Gingivitis Therapy (4999) + Initial Scaling (1110) + Prophy (1110) 2wks apart SRP 1-3 teeth (4342)

SRP 4+ teeth (4341) Arestin per tooth (4381) Laser Therapy

6 month preventive 12-week reevaluation 10-12 week reevaluation Prophy (1110) Prophy (1110) Perio Maintenance (4910)

Perio Therapy 6 month preventive 12 week Refer (4341/42) Prophy (1110) Perio Maint (4910)


Gingivitis Therapy Enrollment System

¨ Complete Ultimate Hygiene Exam checklist ¨ Print perio chart from computer ¨ Sit patient up and sit knee to knee ¨ Show patient the perio chart

o “You probably heard me call out many areas of bleeding when I was doing the exam. What that means is that you have (moderate, severe) gingivitis. This is a bacterial infection in your gums. The good news is that the infection has not yet spread to the bone surrounding the teeth.” Treatment now can reverse the gingivitis and prevent the infection from spreading.”

o With the chart, show the patient the areas of infection/bleeding o “I’m going to take a minute to complete the plan for treatment here and

then I will review it with you.” ¨ Complete the Gingivitis Treatment sheet

o Include all therapy visits o Include reevaluation in 12 weeks o Include products

¨ Educate patient about gingivitis o Use analogies

§ Fence post § Barrel

o Use CAESY or other patient education system o Educate patient about perio-systemic links o Educate patient about the consequences of no treatment

¨ Show the patient the treatment plan and review the number of visits ¨ Educate patient about perio therapy

o “If you follow the plan for therapy, you will have a great deal of healing and you can stop the progression of the infection.”

o “We include the tools you need to take care of your teeth and gums at home. This is crucial to the success of your treatment. The combination of therapy and home care will give you the best chance of eliminating the infection.”

o Ask patient “How do you feel about what I have shared with you” and listen

¨ Give the patient a high estimate of the cost of therapy if they ask o Let patient know that today’s visit may or may not be covered by

insurance but the second part of therapy usually is covered o Let patient know the exact amount they will be responsible for that day

before proceeding with treatment


¨ Take Gingivitis Treatment sheet to the administrative team o Admin team to complete detailed financial arrangements o Admin to complete Active Perio Therapy Plan sheet to give to patient o Admin to enter specific gingivitis treatment (with codes) into patient’s

treatment plan in computer ¨ Begin Initial phase of gingivitis therapy (D4999)

o Gross Debridement (D4355) is appropriate treatment ONLY if patient has large amounts of calculus that prevent proper perio diagnosis

¨ Doctor confirms diagnosis and treatment plan ¨ Doctor reinforces need for timely treatment ¨ Doctor stresses that gingivitis therapy must be complete before other

restorative treatment (unless possible restorative emergency) ¨ Walk patient to administrative team

o “We have completed the initial phase of gingivitis therapy today. I would like to see Ms. Jones in 2-3 weeks to complete the therapy

o Admin presents financial options and schedules second therapy visit (D1110) and reevaluation (D1110) in 3-6mths

o If the patient chooses not to schedule at that moment, schedule them for a 6mth visit to keep them in the recare loop

o If patient says they do not want to have treatment at that time, schedule them for a 6mth visit and tell them “We will evaluate the progress of the infection at that time”

¨ Include narrative with gingivitis therapy claim “This claim is for gingivitis therapy performed on (date). Patient presented with severe inflammation, heavy bleeding but no bone loss. The treatment was needed to remove hard and soft debris and to allow the gums to begin the healing process.” Include anything specific about the patient such as pregnancy, years since last hygiene visit, any systemic disease, etc.


Gingivitis Treatment Sheet

Name ___________________________________ Date of Diagnosis _________ Clinician _________________________________

Gingivitis Gingivitis is infection of the gingiva that has not yet progressed to the periodontal ligament or the adjacent bone structure. Gingivitis is generally characterized by redness and swelling of the gingival tissues with bleeding readily upon probing and/or exploring. Periodontal pockets are generalized 3mm or less with no loss of crestal bone evident on radiographs.

Signs: Bleeding easily upon probing and/or exploring on 15+ points Periodontal probing measurements up to 3mm No bone loss evident on radiographs

________Number of gingivitis therapy sessions (within 2 weeks)

• D4999 Gingivitis Therapy • D1110 Adult Prophy

Active Therapy will include:

q Therapeutic sub-gingival scaling and disinfection (2 visits)

q Polishing

q Sub-gingival Irrigation

q Laser Therapy

q 12 week post operative evaluation- D1110

q Home care products:_______________________________


Periodontal Therapy Enrollment System

¨ Complete Ultimate Hygiene Exam checklist ¨ Print perio chart from computer ¨ Highlight all areas of periodontal infection (4mm or greater) ¨ Sit patient up and sit knee to knee ¨ Show patient the perio chart

o “You probably heard me call out several 4s (or 5s and 6s) and many areas of bleeding when I was doing the exam. What that means is that you have (beginning, moderate, advanced) gum disease. This is a chronic bacterial infection in your gums and the bone surrounding your teeth.”

o With the chart, show the patient the areas of infection o “I’m going to take a minute to complete the plan for treatment here and

then I will review it with you.” ¨ Complete the Periodontal Treatment sheet

o Include all therapy visits o Include reevaluation in 10-12 weeks o Include products o Include local antibiotic therapy and/or laser therapy

¨ Educate patient about perio disease o Use analogies

§ Fence post § Barrel

o Use CAESY or other patient education system o Educate patient about perio-systemic links o Educate patient about the consequences of no treatment o “Gum disease is chronic and can not be cured. It takes frequent

maintenance to keep the bacteria from reaching a point where they start causing infection in the gums and bone.”

¨ Show the patient the treatment plan and review the number of visits ¨ Educate patient about perio therapy

o “The good news is that we can still treat this non-surgically. In the most infected areas (5mm or greater), we will use an antibiotic directly in the pocket to treat the infection.”

o “If you follow the plan for therapy, you will have a great deal of healing and you can stop the progression of the infection.”

o “We include the tools you need to take care of your teeth and gums at home. This is crucial to the success of your treatment. The combination of therapy and home care will give you the best chance of stopping the disease and eliminating the infection.”


o Ask patient “How do you feel about what I have shared with you” and listen

¨ Give the patient a high estimate of the cost of therapy if they ask ¨ Take Periodontal Treatment sheet to the administrative team

o Admin team to complete detailed financial arrangements o Admin to complete Active Perio Therapy Plan sheet to give to patient o Admin to enter specific perio treatment (with codes) into patient’s

treatment plan in computer ¨ Begin Initial scale of non-infected areas (prophy-1110) ¨ Doctor confirms diagnosis and treatment plan ¨ Doctor reinforces need for timely treatment ¨ Doctor stresses that periodontal therapy must be complete before other

restorative treatment (unless possible restorative emergency) ¨ Walk patient to administrative team

o “Dr. B said it is very important that we find a time very soon for Ms. Jones to return for the periodontal therapy.”

o Admin presents financial options and schedules active therapy and reevaluation appointment

o If the patient chooses not to schedule at that moment, schedule them for a 6mth visit to keep them in the recare loop

o If patient says they do not want to have treatment at that time, schedule them for a 6mth visit and tell them “We will evaluate the progress of the disease at that time”


Periodontal Treatment Sheet

Name ___________________________________ Date of Diagnosis _________ Clinician _________________________________

Active Periodontal Therapy Chronic periodontal disease is infection of the gingiva and loss of periodontal ligament attachment and the adjacent bone structure.

Periodontal Disease Classification:

Beginning Perio Disease Moderate Perio Disease Advanced Perio Disease

Number of teeth with infected sites:

UR______________ D4341 D4342 UL_____________ D4341 D4342

LR______________ D4341 D4342 LL______________ D4341 D4342

_________Number of periodontal therapy sessions (initial scaling, therapy and reevaluation) _________Number of sites of antibiotic therapy (D4381)

Location of antibiotic therapy______________________________________________

_____________________________________________________________________

Initial scaling of healthy areas: q Completed today q To be completed with active therapy

Active Therapy will include:

q Therapeutic sub-gingival scaling and disinfection

q Sub-gingival root planing with anesthesia

q Local antibiotics

q Sub-gingival Irrigation

q Laser Therapy

q 10-12 week post operative evaluation- D4910



Active Periodontal Therapy Plan for (patient’s name) __________

Your periodontal care will require _______ sessions with our hygienist. The total fee of $_________ will include:

q Therapeutic removal of toxins beneath the gums with anesthesia

q Localized antibiotic therapy

q 10-12 week reevaluation

q Laser therapy


q Other __________________________________________

Insurance Estimate $_____________________________

Required Deposit $_______________________________

The final session will be reserved _____ weeks after your last therapy session. This appointment is vital for checking the healing process and your individual tissue response. We will also be reviewing home care techniques and setting up your future 3 month periodontal maintenance schedule. Future visits will always be periodontal in nature. Due to the nature of your disease, and the importance of treating it in a timely manner, we ask that you reserve your appointment times prior to leaving the office today.

Session Dates: 1.____________________________________________

2.____________________________________________

3.____________________________________________

4.____________________________________________

The initial phase of periodontal therapy does not preclude the need for possible future services. You may need site-specific therapy or a referral to a specialist for any non-responsive areas. It is essential that you follow our recommendations and take responsibility for your own dental health.

Signature _________________________________________________________________

If you have any questions about your therapy sessions or financial arrangements please don’t hesitate to call


Treatment Flow Options

Gingivitis: • Initial Gingivitis Therapy (4999) • Prophy (1110) follows initial therapy appointment • All active treatment completed within 2 weeks • Include 3 month follow-up prophy in treatment fee

Beginning-Moderate Periodontitis (pockets 4-6mm): • Initial scaling of healthy teeth (prophy-1110) • 1 Full mouth disinfection appt (2 hours)

o Complete therapy on all infected areas o Topical and/or local anesthesia o Local antibiotics and irrigation

• 2 Partial disinfection sessions (1 - 1 ½ hours each) o Complete therapy on one-two infected areas o Preferably complete one arch at each appt o Topical and/or local anesthesia o Local antibiotics and irrigation

• All active treatment completed within 2-4 weeks • Include 10-12 week Reevaluation (4910) in treatment fee

Advanced Periodontitis (pockets over 6mm): • Initial scaling of healthy teeth (prophy-1110) • 1 Full mouth disinfection appt (3 hours)

o Complete therapy on all infected areas o Topical or local anesthesia o Local antibiotics and irrigation

• 2 Half mouth disinfection appts (2 hours each) o Complete therapy on one-two areas o Preferably complete one arch at each appt o Topical or local anesthesia o Local antibiotics and irrigation

• Several localized disinfection sessions (1 hour each) o Complete therapy on one area o Preferably complete one arch at each appt o Topical or local anesthesia o Local antibiotics and irrigation

• All active treatment completed within 2-4 weeks • Include 10-12 week Reevaluation (4910) in treatment fee


Gingivitis Therapy Session Complete both sessions within 2 wks

Initial Gingivitis Therapy Session –coded as 4999 • Place topical anesthetic if necessary on one quadrant at a time • Review perio readings and X-rays • Explore to detect calculus • Gross scale with ultrasonic using gross debris removal tips • Fine scale with slimline ultrasonic tip and hand instruments • Explore to discover areas that need more attention and complete therapy • Floss and rinse • Irrigate using antimicrobial rinse • Utilize CAESY if necessary • Review OHI, introduce plaque removal aids and anti-microbial products • Make follow-up call the next day to check on patient

Second Gingivitis Therapy Session- coded as 1110 • Place topical anesthetic if necessary on one quadrant at a time • Scale full mouth with slimline ultrasonic tip • Follow up with hand instruments if necessary • Polish to remove stain and plaque • Floss and rinse • Irrigate using antimicrobial rinse • Laser Therapy if indicated • Give written post-op instructions • Utilize CAESY if necessary • Review OHI, introduce plaque removal aids and anti-microbial products • Administer Ibuprofen if appropriate • Make prophy appt in 12 weeks • Review restorative needs and have doctor confirm treatment plan • Schedule first priority restorative needs


Periodontal Therapy Session

Scaling and Root Planing (4341/4342) • Place topical anesthetic in area to be scaled • Administer local anesthesia or locally applied topical • Review perio readings and X-rays • Explore to detect calculus • Note sites that will receive local chemotherapy • Gross scale with ultrasonic using gross debris removal tips • Fine scale with slimline ultrasonic tip and hand instruments • Explore to discover areas that need more attention and complete therapy • Floss and rinse • Irrigate if necessary • Laser Therapy if indicated • Place local chemo agent in all sites >or = 5mm

Completion • Review post-op instructions for scaling and chemo agent with patient • Give written post-op instructions • Utilize CAESY if necessary • Review OHI, introduce plaque removal aids and anti-microbial products • Administer Ibuprofen if appropriate • Make Reevaluation appt in 10-12 weeks • Make first Perio Maint appt if possible 3mths after reevaluation • Make follow-up call the next day to check on patient


Periodontal Therapy Reevaluation Takes place 10-12 weeks after active perio therapy

Coded as 4910

This is the starting point of lifetime periodontal maintenance. This is the last session in active periodontal treatment. Approximately 60 minutes should be allotted for this appointment. This is the perfect time to reinforce the need for on-going supportive maintenance at an interval of 12 weeks. This is also the time to begin discussing recommended restorative treatment.

• Medical History Review • Patient questions and concerns • Intra and Extra Oral Cancer screening • Oral hygiene evaluation

o Utilize plaque disclosing solution o Demo flossing, use of power brush o Demo use of anti-microbial homecare products

• Periodontal Exam o Includes gentle 6-point probing, bleeding exam, mobility

• Digital photos (x-rays if necessary) o Intra Oral Photos if necessary to demonstrate healing o Review restorative needs

• Show patient periodontal healing by using before and after periodontal charting. Tell patient the number of bleeding sites and number of pockets 4mm or deeper before and after therapy

• Light sub and supra gingival scaling with ultrasonics and hand instruments • Retreat localized unresponsive areas • Place local chemotherapeutics where indicated • Cosmetic polish • Review of recommended products (add new products if needed) • Fluoride treatment/ home fluoride therapy • Desensitization therapy • Laser bacterial reduction if possible • Enrollment into lifetime periodontal maintenance program (CAESY) • Review success with Doctor • Treatment plan and schedule proposed restorative treatment • Appoint patient for next periodontal maintenance in 12 weeks


Periodontal Maintenance Takes place every 12 weeks

Coded as 4910

This is the corner stone of lifetime periodontal maintenance. Approximately 60 minutes should be allotted for this appointment. This is the perfect time to reinforce the need for long-term maintenance at an interval of 12 weeks. It is important to distinguish this procedure from a preventive prophy. Identify some services that you will perform at perio maintenance that are different than what you perform at a prophy.

• Medical History Review • Patient questions and concerns • Intra and Extra Oral Cancer screening • Oral hygiene evaluation

o Utilize plaque disclosing solution o Demo flossing, use of power brush, home care products

• Periodontal Exam o Includes 6-point probing, bleeding exam, mobility

• Digital photos (and x-rays if needed) o Intra Oral Photos if necessary tissue health o Review restorative needs

• Reinforce success of perio therapy by telling patient the number of bleeding sites and periodontal pockets 4mm or greater and compare to levels before therapy. Reiterate “this interval is working well to keep your gums and bone healthy, let’s maintain this interval”

• Sub and supra gingival scaling with ultrasonics and hand instruments • Retreat localized re-infected areas • Place local chemotherapeutics where indicated • Cosmetic polish • Fluoride treatment/ home fluoride therapy • Laser bacterial reduction if possible • Desensitization therapy • Sub-gingival Irrigation • Reinforce lifetime periodontal maintenance program (CAESY) • Review success with Doctor • Determine first priority for restorative treatment • Schedule restorative treatment as soon as possible • Appoint patient for next periodontal maintenance in 12 weeks

Recurrent sites of active periodontal disease may be treated at the periodontal maintenance visit. However, once there are over two to three sites of active infection consider re-treatment with site specific scaling and root planing and local antibiotic therapy.


Session Three Action Steps:

1. _________________________________________________ 2._________________________________________________ 3._________________________________________________ 4._________________________________________________ 5._________________________________________________


CE Post-Test – SESSION THREE To receive CE you must complete the online test at


1. Oral bacteria have been linked to the following: A. heart disease and diabetes B. urinary tract infection and macular degeneration C. strokes and pre-term birth D. A and C

2. The ADA states that what percentage of Americans have or will have Periodontal disease?

A. 10-15 % B. 30-40 % C. 70-85 % D. 40-50 %

3. The distinguishing factor between gingivitis and periodontitis is: A. bleeding B. swelling C. plaque deposits D. bone loss

4. Scientific Research suggests that periodontal disease is maintained at what interval?

A. 6 week B. 12 week C. 12 month D. 6 month

5. When treating gingivitis, it is best to complete treatment within what time period?

A. 2 weeks B. 3 days C. 6 weeks D. 12 days


6. Gingivitis Therapy should begin when probing and exploring easily elicits bleeding in _________ sites or more.

A. 5 B. 15 C. 10 D. 25

7. Class II Moderate Periodontitis can involve furcations of what type? A. I B. II C. III D. none of the above


SESSION FOUR Periodontal Instrumentation

And Ultrasonics Allison Teel, RDH

Objectives; At the conclusion of this session, attendees should understand: • How to set up an effective periodontal treatment tray • The difference between Piezo and Magnetostrictive ultrasonic devices and

tip selections • The use of local and topical anesthetics-layering for effectiveness

Tools and Technology

Hygiene Instruments • Periodontal probes with color/black markings 3-6-9-12 • ODU 11/12 explorers • Ultrasonic unit (Piezo or Magnetostrictive) • Slimline and Universal ultrasonic tips • Gracey, Langer , Universal curettes and sickles

Technology • CAESY • Digital Radiography • Computerized clinical charting • Intra or extra oral camera • Early decay detection • FL Probe • Velscope • Laser –Diode, Erbium or Nd:YAG


Products • Hygiene homecare products (chlorine-dioxide, zinc, fluoride) • Power toothbrush (sonic) • Ionic irrigator • Porcelain polishing paste • Locally delivered antibiotics • Locally applied topical anesthetic • Fluoride varnish • Desensitizing agents • Patient education pamphlets

Our goal in instrumentation during any periodontal debridement session is to gain improved tissue health. We will obviously be removing bacteria deposits during instrumentation that will enable the patient’s immune system to handle the level of bacteria within the oral cavity and to gain improved tissue response. This includes reduction in pocket depth and reduced inflammation and bleeding.

Ultrasonics

Piezo: These scaling instruments rely upon linear movement, utilizing aligned ceramic discs to produce the straight micro-movements of the tip. This is achieved through alternating expansion and compression of the ceramic discs when electricity flows over the surfaces of the crystal. Piezo units operate at a frequency ranging from 25 to 50 kHz. Given that the tip moves in a linear fashion the tips two lateral surfaces are the most active. Adaptation to the tooth surface is very important. If it is not correct, the sound will be different against the tooth, letting the clinician know that adaptation needs to be altered. Clinical results are similar to the results with magnetostrictive devices; the limitations of active surfaces make it more technique sensitive.


Magnetostrictive: Elliptical movement of the insert tips is what these ultrasonic devices rely upon. The magnetostrictive stack in the insert converts energy from the handpiece into mechanical oscillations that activate the tip. The electronic system produces small strokes of the insert that are microscopic and delivers from 20,000 to over 42,000 cycles (strokes) per second at the tip. The most active area of the insert’s tip is the point, then the concave face, followed by the convex back, with the lateral surfaces being the least active. The point of the insert should never be directed into the tooth surface. The majority of scaling will be accomplished with the back and lateral surfaces of the insert. The inserts must be meticulously adapted to all areas of the tooth surface.

The length of the active tip area for scaling depends upon the energy output and frequency. Typically, magnetostrictive scalers typically operate at 25 to 30 kHz. At 25 kHz the terminal length of the active tip is 4.3 mm. While at 30 kHz the active tip length is 4.2 mm. A higher frequency of 50 kHz results in an active terminal tip of 2.3 mm.

Insert Frequency Activity at Terminal Tip 25 kHz 4.3 mm 30 kHz 4.2 mm 50 kHz 2.3 mm

Instrumentation Technique Inserts should be activated prior to insertion into a pocket and should be used with a continual overlapping stroking motion. Horizontal vertical and oblique strokes can be used, offering flexibility and choice to the clinician. Lateral pressure should be light and tip angulation should always be maintained against the tooth structure. Grip of the insert should also be light to reduce hand fatigue and facilitate tactile sensitivity.

The cavitational effect of ultrasonic devices aids biofilm removal and the acoustic effects of the water lavage assist in calculus removal.


Ultrasonics: The Clinical Benefits

Clinician and Patient: Modified ultrasonic inserts compared to hand scaling and regular ultrasonic tips produce smoother root surfaces with:

• Least amount of damage • Better access to the bottom of the pocket • Better calculus and bio-film removal • Less operator fatigue • Less repetitive motion for clinician • Increased access to deep pockets • Lavage delivery at time of scaling • No need for sharpening • Ergonomics for the clinician • Lavage-choice of medicament or H2O

NOTES: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________


Ultrasonic Tip and Insert Designs

Insert Tip When to Use Standard Removal of moderat – heavy deposits Standard Triple Bend Aids access for removal of mod-heavy deposits

Beavertail Removal of heavy stain and deposits Supragingival of anterior teeth

Chisel Anterior teeth and premolars, overhangs

Perio Probe Shallow and deep pockets: deposit removal Deep subgingival lavage and calc. detection

Slim Tips Removes deposits in pockets 4+mm Straight Superficial deposit removal Curved and Angulated Aids access and adaptation

Curved Right and Left Aids access and adaptation to root morphology and furcation areas

Right and Left Furcation Removes deposits in root furcation areas Fine Tipped Access in narrow interdental spaces

Diamond Coated Gross deposit removal both surgical and non- surgical access

Endodontic Debridement of canals; Removal of fractured endo instruments

Implant Special disposablesoft plastic tips provided for inserts to debride around implants

*available with different grip sizes and designs, swivel designs and lighted inserts* **Table based on CE course entitled “Efficiency and Effectiveness in Ultrasonic Scaling” written by Betsey Reynolds, RDH, MS

Standard inserts are not designed for use in deep pockets or root adaptation. Utilizing appropriate inserts in the correct sequence and at the appropriate power level ensures good clinical results, patient comfort and clinician comfort.


Sequence: 1. Supragingival calculus deposits: use a standard diameter insert at low to high power depending on the patient’s oral condition. Suitable for pockets up to 3 mm. 2. Debridement of pockets 4mm and greater: use slim tipped inserts at a low power setting. May add hand instruments to enhance debridement. 3. Debridement of furcation areas: use slim tipped right and left instruments adapted to the root surface on a low power setting. 4. Removal of smear layer on root surface: use a slim insert at a low power setting as a final stage of the scaling procedures

Patient Comfort during Periodontal Therapy

Many hygienists are not licensed to give local anesthetic within their scope of legal duties. There are several newer products available to aid in patient comfort during scaling and rootplaning that can be applied topically or into the gingival sulcus.

Topical Anesthetics Gels: Many are available and use whatever you prefer. Our choice is a Triple Topical (sometimes called Profound and Profound Lite) containing lidocaine, prilocaine and tetracaine. This comes in tubes that you can dispense directly onto cotton swabs and place on the gingival margin, or dispense some into syringes with disposable 18 gauge tips for injection directly into the gingival sulcus. Leave in place for 2-3 minutes, then rinse. Within 5 minutes it reaches its peak strength and lasts from 25-30 minutes.

Swish: Dyclone Rinse (0.5% or 1%). Use a compounding pharmacy (such as *Steven’s Pharmacy) for a swish that gives mild anesthetic to gingival tissue and oral mucosa. This is great for generalized, mild sensitivity while scaling early cases.

Subgingival: Oraqix (2.5% lidocaine and 2.5% prilocaine). This anesthetic is applied to the gingival margin of treatment area using the blunt tip applicator. After waiting 30 seconds, it is placed into the sulcus via the applicator in areas that need isolated periodontal therapy and helps with procedural comfort. Onset is 30 seconds and duration is 20 minutes. For maximum effectiveness, the tissue must be dried and isolated. Maximum dosage is 5 cartridges per treatment session.


Cetacaine Liquid Kit with Leur lock syringe. This anesthetic is used in a similar way to Oraqix as described above for localized perio therapy, during the perio exam or perio maintenance. This product works well even when sites are not completely dry and isolated. Onset of anesthesia is 30-60 seconds and it provides 30-60min of comfort. This product is very cost effective and there is little waste as you only use the amount you need. Maximum dosage is .4ml per treatment session.

Local Anesthetic Choices: Blocks and Infiltrations Lidocaine 2%: Most widely used local anesthetic. It has greater vasodilation properties so may have more failures than with other anesthetics.

Mepivacaine 2%, 3%: can purchase with or without a vasoconstrictor. Lower vasodilation properties, less failures, is very safe and comfortable to use due to a higher pH.

Prilocaine 4%: Also available with and without a vasoconstrictor and lower vasodilation properties. Due to the higher concentration of this anesthetic, the maximum dosage per patient is lower than other anesthetics.

Articaine 4%: The newest available local anesthetic and lowest failure rate. It is also metabolized by the body in one third the time of lidocaine. This anesthetic has the ability to diffuse through bone. It is not recommended to use articaine on mandibular blocks, due to a slightly increased risk of paresthesia.

*Steven’s Pharmacy: Costa Mesa, CA 800-352-DRUG or contact a local pharmacy that does compounding.

Session Four Action Steps:

1. _________________________________________________ 2._________________________________________________ 3._________________________________________________ 4._________________________________________________ 5._________________________________________________


CE Post-Test – SESSION FOUR To receive CE you must complete the online test at


1. What is the clinical end result for treatment of periodontal debridement? A. microbial B. surface smoothness C. tissue response D. mechanical

2. To achieve successful debridement, the instrument tip should always be kept in constant motion when adapted to the tooth. A. True B. False

3. Piezo Ultrasonics involve the following: A. elliptical movement of insert tips B. a frequency ranging from 25-50 kHz C. metal stacks that create energy D. all of the above

4. When using an insert with a frequency of 30 kHz, the length of the activity at the terminal tip is:

A. 4.3 mm B. 4.2 mm C. 2.3 mm D. 3.4 mm

5. Which of the following instrumentation factors should be applied during ultrasonic debridement?

A. use of a light grasp B. adapt the active tip area of the insert C. avoid placement of the point of the insert on the tooth D. all of the above

6. Magnetostrictive Ultrasonics generate the following: A. 20-42,000 cycles per second B. elliptical movement C. the most energy is at the end point of the insert tip D. all of the above


7. Triple Topical application involves what three anesthetics: A. prilocaine, benzocaine, mepivicaine B. lidocaine, prilocaine, tetracaine C. bupivicaine, tetracaine, prilocaine D. articaine, lidocaine, tetracaine

8. What anesthetic is marketed as a topical for periodontal pockets? A. lidocaine B. articaine C. Oraqix D. benzocaine


SESSION FIVE Advanced Diagnostics & the Roll Of

Antibiotics in Perio Therapy Richard H. Nagelberg, DDS

[email protected] www.periofrogz.com

Advanced Diagnostics The objectives of this course are to understand and implement leading edge diagnostics and individualized perio care.

Periodontitis is a chronic, non-curable bacterial infection. Patients who have undergone successful perio treatment are healed, not cured.

Comprehensive periodontal evaluation and charting Represents a history of the disease process. It has already happened.

We are observing and documenting events that happened in the past Periodontal evaluation is a damage report.

Two patients present with the same level and extent of periodontal disease Following non-surgical perio therapy, one patient responds favorably, the other does not.

Treat the disease, not the pockets.

Risk Factors for Periodontal Disease Risk factors address underlying biology and behaviors that resulted in the patient’s clinical presentation.

Risk factors for perio disease: heredity, smoking, diabetes, stress, medication, poor nutrition, poor oral hygiene, faulty dentistry, hormonal variations, compromised immune system, connective tissue diseases, past history of active perio disease.


The 2 biggest risk factors for perio disease are diabetes and smoking

Heredity: immune system defects

Smoking: #1 environmental risk factor, antibody suppression, increased bone loss.

Hormonal variations: puberty, menstruation, menopause, oral contraceptives. Progesterone is pro-inflammatory

Stress: Immune system suppression

Risk factors cannot cause gum disease The primary goal of all dental providers is risk reduction Risk factors are exponential, not additive. Diagnosis, causality, risk factors

Salivary diagnostics MyPerioPath; DNA testing for causative bacteria (www.oraldnalabs.com)

PST test; Genetic predisposition to perio disease (www.oraldnalabs.com )

Therapeutic endpoint: clinical improvement, bacterial reduction

Standard of care: mechanical and chemotherapeutics

Mechanical removal of biofilm, SRP, surgical access

Chemotherapeutics: antibiotics, antimicrobials, host modulation

Salivary testing indications: diabetes, history of perio disease (including family Hx), moderate/severe/refractory perio disease, smokers, risk factors for cv disease etc.

Systemic antibiotic regimens: Amoxicillin 500mg X 24, three times per day Metronidazole 500mg X 16, two times per day Clindamycin 150-300mg X 21, three times per day


Locally applied and host modulatory antibiotics:

Arestin® 1.0mg Minocycline

Periostat, sub-antimicrobial dose doxycycline (SDD), 20 mg, two times per day for 3-9 months

Blood testing for dental offices Healthy Heart Dentistry provides blood testing supplies for dental offices (www.healthyheartdentistry.com )

Finger nick collection of 2-3 drops of blood onto a specialized blotter, mailed to lab - C-reactive protein, HbA1c, glucose, HDL, LDL, triglycerides, among others

Indications: Diabetes, elevated risk for cv diseases, rheumatoid arthritis, kidney disease, severe/refractory perio disease.

Richard H. Nagelberg, DDS Email: [email protected] Website: www.periofrogz.com

©2011 Richard H. Nagelberg, DDS

Session Five Action Steps:

1. _________________________________________________ 2._________________________________________________ 3._________________________________________________ 4._________________________________________________ 5._________________________________________________


CE Post-Test – SESSION FIVE To receive CE you must complete the online test at


1 Comprehensive periodontal evaluation and charting:

A. Is the future of the disease process B. Is the history of the disease process C. Indicates disease causality D. None of the above

2 Risk factors for periodontal disease:

A. Are contributing factors for gum disease B. Are exponential C. Indicate underlying biology and behaviors D. All of the above

3 Regarding risk factors:

A. The two biggest risk factors are smoking and heredity B. Risk factors can cause gum disease C. Stress causes immune system suppression D. Primary goal of dental providers is risk factor identification

4 The therapeutic endpoint is:

A. Clinical improvement and bacterial reduction B. Clinical improvement only C. The standard of care D. None of the above


5 The standard of care is:

A. Surgical and non-surgical perio treatment B. Mechanical and chemotherapeutic C. Scaling and root planing D. All of the above

6 Adjunctive antibiotics include:

A. Sub-dose doxycycline B. Locally applied antimicrobials C. Metronidazole D. All of the above

7 Systemic antibiotic regimens include:

A. Amoxicillin 500 mg for 90 days B. Metronidazole 500 mg for 3-9 months C. Sub-dose doxycycline for 3-9months D. Clindamycin 300 mg for 90 days


SESSION SIX Perio Billing and Coding Strategies

That Work! Laci Phillips

Banta Consulting, Inc. 33010 E Pink Hill Rd

Grain Valley, MO 64029 Phone: 816-847-2055

Fax: 816-847-5962 E-mail: [email protected]

Sponsored by

Objectives: • The Employee Dental Benefit Book • Effective Periodontal Coding Techniques • Narratives and Other Secrets • Maximizing insurance reimbursement • Communication Techniques


The Employee Dental Benefit Book 1. Get the proper information from your patient.

2. Periodontal Exclusions, clauses, waiting periods

3. Alternate treatment guidelines and how to get around them

INSURANCE INFORMATION STICKER SAMPLE

Today’s Date Employee Name 2001Banta Consulting, Inc.

Employer SS# Insurance Company Spoke with Maximum Deductible Coverage year %coverage/flat fee Eff date Preventative P Perio Restorative R CT Major X-rays Frequency:Exams Prophy BWX FMS Fluoride

Other Exclusions Sealant Coverage? To what age? Missing tooth clause? NonDup clause? Coord Ben? Wait Periods?

NEW PATIENT INFORMATION STICKER SAMPLE

Name Date Date of Appt Street City State Zip Home Phone Work Phone Cell Phone Appointed for Referred by Previous DDS Phone 2001Banta Consulting, Inc.

Last dental visit X-rays available? Date of request Medical problems Pre Med? Allergies Dental problems DENTAL INSURANCE? Employer & address Carrier & address SS#


Effective Periodontal Coding Techniques

1. CDT periodontal code review

2. Supporting documentation

3. Using the correct code for the procedure

Narratives and other secrets

1. What to write on the periodontal narrative

2. Electronic claims

Perio Narrative Sample

Note: patient exhibits continued pocketing (5mm or greater) in this area, even after past scaling & root planing. This area was scaled & root planed again and a “perio chip”- chemotherapeutic agent was placed in an effort to reduce the sub gingival flora.


Insurance Company Strategies

1. Knowing how the insurance company thinks

2. How to prevent denials and get paid faster

3. How to resubmit a claim for appeal

4. The insurance company “stall” tactics – are they real


Checklist for insurance claims on periodontal procedures:

1. Always submit documentation notes regarding the periodontal classification of patient’s periodontal condition

2. If the patient changes insurance companies, you must submit original documentation of periodontal diagnosis to continue periodontal maintenance benefits.

3. Keep in mind that a diagnostic film is not always 100% conclusive. Your detailed notes of the periodontal condition is crucial in considering a claim for payment

4. Utilize an intra-oral photo or digital photo image to reveal the most detailed evidence of needed periodontal treatment. i.e.; for heavy stain, heavy calculus, deep pocket measurements…take an intra-oral or photographic image of patient’s conditions. A picture is worth a thousand words..

5. Make sure to identify initial date of periodontal scaling and root planing.

6. Submit copy of perio charting for DSRP claims.

7. Remember, the narrative on a claim form must mirror the documentation notes on the treatment rendered page.

Sample Disclaimers: I understand that my insurance is an agreement between me and my insurance company. I also understand that I am responsible for my balance regardless of my insurance.

I understand that I may be charged a 1.5% per month or 18% per year finance charge if my balance goes beyond 90 days.

I assign dental benefit payments to be paid directly to Dr. John Doe from my insurance company.

I give permission for my dentist and his/her clinical team to take any necessary x-rays, photos or study models to enable complete diagnosis and treatment.


Session Six Action Steps:

1. _________________________________________________ 2._________________________________________________ 3._________________________________________________ 4._________________________________________________ 5._________________________________________________


CE Post-Test – SESSION SIX To receive CE you must complete the online test at


1. What attachments are useful in getting a periodontal claim paid? a. Periodontal charting, diagnostic films, narratives b. No attachments c. Photographs d. Panoramic X-ray

2. Which code is used for partial scaling and root planning? a. D4910 b. D4341 c. D4342 d. D4355

3. What is the proper code to submit for periodontal maintenance? a. D1110 b. D4355 c. D4910 d. D4999

4. How would you address a patient’s resistance to scheduling periodontal treatment?

a. Demand they schedule b. Ask leading questions c. Have Doctor talk with patient d. No questions…let patient decide what is best

5. What attachments are helpful in validating a periodontal claim? a. Nothing is helpful b. X-rays c. Charting, detailed notes, photos and diagnostic films d. Study models


6. Fill in the blank: The _______ on the claim form must _______ the ________ _______in the chart.

a. Statement…not be listed…in the notes b. Note…never mirror…pictures c. Narrative…Mirror…Detailed notes

7. Yes or No…A diagnostic film is all you need to validate need for periodontal scaling and root planning.

a. Yes b. No c. Yes and No…it depends on the case


SESSION SEVEN Current Perio Research and Supportive

Treatment Services Trisha E. O’Hehir, RDH, MS

Objectives:

At the conclusion of this session, attendees should understand: • The role VSCs have in allowing toxins to cross the junctional epithelium • How oral probiotics change the balance of periodontal pathogens in the mouth • Why xylitol is not metabolized by Strep mutans • How xylitol reduces plaque biofilm accumulation • When full mouth disinfection may be a valuable treatment option • How to evaluate new products with claims relevant to periodontal care

1. The role of bad breath in perio disease

Volatile sulfur compounds and their smells Methyl mercaptan -- feces Hydrogen sulphide -- rotten eggs Dimethyl sulphide -- cabbage, sulphur, gasoline

Bacteria dump toxic waste into the sulcus

Toxins pass through the junctional epithelium (JE)

JE is made more permeable by VSC

VSC released with breakdown of food, saliva, blood, cells, bacteria

JE turnover rate in health is 2-4 days, in disease increased by 8 fold

VSC are found between teeth and on the tongue

VSC neutralized with zinc and chlorine dioxide


Bad breath is a billion dollar industry in this country.

The public appears to be more easily motivated by bad breath than by the desire for oral health. A study carried out several years ago by the assistant Surgeon General of the United States Army Dental Corps, General Bernier, found army personnel motivated to achieve good plaque control for reasons of “kissability” rather than oral health.

Volatile sulfur compounds of bad breath are not only a result of disease, but seem to contribute to the progression of disease by allowing bacterial by-products to more easily penetrate the crevicular epithelial barrier.

Explaining bad breath to patients

Include question on medical history: Do you ever have bad breath?

Ask what fresh breath products are used - mints, gum, mouthrinse

Teach patients to clean between the teeth and clean the tongue

Recommend products that include xylitol, zinc or chlorine dioxide

2. Oral probiotics

Following conventional periodontal therapy, studies have shown the

long-term success of the therapy correlated with whether or not

streptococcus veridans, including S.oralis and S.uberis, recolonized

the periodontal S. oralis and S. uberis, recolonized the periodontal

sites.

Socransky, S.S. and Haffajee, A.D. The bacterial etiology of destructive periodontal disease: current concepts. J. Periodontal. 63 (4 Suppl): 322-331, 1992.


Introducing good bacteria after daily oral hygiene will allow these strains to colonize tooth surfaces, use up valuable nutrients and thus make the neighborhood no longer desirable for the periodontal pathogens responsible for tipping the balance toward periodontal disease.

Hydrogen peroxide produced by S. uberis KJ2 and S. oralis KJ3 inhibits colonization of many periodontal pathogens, thus reducing pathogenic biofilm on the teeth. By reducing the numbers of periodontal pathogens, the level of volatile sulphur compounds goes down which in turn reduces oral malodor. Hydrogen peroxide released from these bacteria has also been shown to whiten tooth enamel, a nice side effect.

3. How xylitol impacts perio bacteria

Natural, 5 carbon sugar, with a glycemic index of 7

Looks and tastes like “sugar”

Dangerous for dogs, even a small amount, as is chocolate

Eaten in large amounts too quickly, causes gastric upset in humans

Passes through bacterial membrane, but not metabolized

Bacteria must use energy to pump the xylitol molecule out

Bacteria cannot make acids, cannot stick to each other or the teeth

Bacterial communication and biofilm structure is disturbed

Bacteria slide down the digestive track and the nasal track

Plaque levels reduced by 50% with 3 to 5 xylitol exposures daily

Blocks proliferation and endotoxin production by perio pathogen


4. Full mouth disinfection

Both full-mouth and quadrant SRP provide similar clinical outcomes. Decide which is best for your patients based on individual needs and preferences.

Zijnge, V., Meijer, H., Lie, M., Tromp, J., Degener, J., Harmsen, H., Abbas, F.: The

Recolonization Hypothesis in a Full-Mouth or Multiple-Session Treatment Protocol: A

Blinded, Randomized Clinical Trial. J Clin Perio 37: 518-525, 2010.

5. New must-have tools and technologies:

Evaluating new products:

New products for both professional and at home periodontal care are introduced at a rapid rate. Evaluating new products involves reading the research, analyzing claims, and testing the product yourself.

Debacterol

Debacterol (and HybenX for those in Canada and Europe) is a desiccant that pulls water from biofilm and inflamed tissue. When delivered subgingivally the calculus will be easier to remove. Many times this calculus is not felt tactilely by the clinician prior to desiccation. His provides a new option for treating non-responding areas.


Homecare products and medicaments

Xylitol - strive for five exposures each day

Probiotics taken following oral hygiene each day

Oral irrigation is considered flossing with water

Soft Picks provide another alternative to string floss

Dry brushing inside first until the teeth feel clean and taste clean, then add toothpaste

Irrigation following instrumentation

Professional irrigation following debridement therapy does not provide any additional adjunctive benefit beyond that achieved from thorough debridement alone.

Shiloa, J., Patters, M.: DNA Probe Analysis of the Survival of Selected Periodontal Pathogens Following Scaling, Root Planing, and Intra-pocket Irrigation. J of Periodontology 65: 568, 1994.

Disruption of subgingival bacterial biofilm by a single session of instrumentation may require up to three months for the biofilm to reorganize. Researchers showed with monthly professional irrigation, the mechanical action of the needle reaching the probable bottom of the pocket and the introduction of either saline or chlorhexidine was enough to disrupt the delicate balance of the subgingival plaque to a level comparable with instrumentation.

Schlagenhauf, U., Stellway, P., Fiedler, A.: Subgingival Irrigation in the Maintenance Phase of Periodontal Therapy. J of Clinical Periodontology 17: 650, 1990.


Endoscope

The periodontal endoscope provides a magnified (48X) view of

the subgingival area rendering valuable information without the need

for surgery. Researchers compared traditional clinical examination

findings with endoscopic findings in a group of 26 patients with

moderate to severe periodontitis. More than 60% of inflamed pocket

wall sites were seen opposite calculus covered with plaque biofilm as

detected with the endoscope. Less than 30% of inflamed sites were

associated with biofilm alone. Only 5% of inflamed sites were not

associated with either biofilm or calculus covered with biofilm.

Wilson, T., Harrel, S., Nunn, M., Francis, B., Webb, K.: The Relationship Between the Presence of Tooth-Borne Subgingival Deposits and Inflammation Found with a Dental Endoscope. J Perio 79: 2029-2035, 2008.

Wilson, T., Carnio, J., Schenk, R., Myers, G.: Absence of Histologic Signs of Chronic Inflammation Following Closed Subgingival Scaling and Root Planing Using the Dental Endoscope: Human Biopsies - A Pilot Study. J Perio 79: 2036-2041, 2008.

New options for site specific anesthesia

Citoject intraligamental syringe - to anesthetize localized areas for treatment Available from Heraeus Kulzer. J Ir Dent Assoc. 1986 Spring;32(1):13-6

Innovative perio instruments

O’Hehir debridement curettes (available from PDT and Hu-Friedy). These spoon- shaped instruments are designed for both supragingival and subgingival debridement, fitting easily into furcations and deep narrow defects.


Hydrogen peroxide delivery systems - PerioProtect

Perio Protect® is a customized tray to deliver antibiotics and antimicrobials to subgingival spaces to control biofilm. It is used in and at home adjunct following professional care.

The data suggest that the biofilm potential is an accurate indicator of the microbiological health of the sulcus, and further suggest that the efficient delivery of antibacterial oxidants via the Perio Protect system, which uses an oxidative chemical strategy before the physical removal of the biofilms by scaling and root planing (SRP), is an effective treatment for periodontitis.

Schaudinn C, Gorur A, Sedghizadeh P, Costerton J, and Keller D. Manipulation of the microbial ecology of the periodontal pocket. World Dental 2010 Feb-March: 14-18.

6. Tips on how to finally gain team support when implementing new perio technology into clinical practice

Present to the staff first - try on anyone on your team who has perio problems (you’ll be surprised how much untreated perio you’ll find in your TEAM)

Present to practice in reception room information

E-newsletters to the patients

Session Seven Action Steps:

1. _________________________________________________ 2._________________________________________________ 3._________________________________________________ 4._________________________________________________ 5._________________________________________________


CE Post-Test – SESSION SEVEN To receive CE you must complete the online test at


1. Which VSCs are associated with periodontal tissue break down? A. Methyl mercaptan B. Hydrogen sulphide C. Dimethyl sulphide D. Both a and c

2. The turn-over rate of junctional epithelial cells A. Remains the same in health and disease B. Is every 2-4 days in health C. Increases 8 fold in disease D. Both b and c

3. The greatest source of VSCs in the mouth is the A. Dorsum of the tongue B. Smooth tooth surfaces C. Subgingival pocket areas D. Saliva

4. Xylitol is a natural sugar that A. Is easily metabolized by Strep mutans B. Is unsafe for diabetics C. Has a glycemic index of 70 D. Interferes with communication between bacteria

5. With three to five daily exposures to xylitol, plaque is reduced A. 10% B. 25% C. 50% D. 70%


6. Full-mouth disinfection A. Provides similar clinical outcomes to quadrant SRP B. Takes the same amount of time as quadrant SRP C. Provides better clinical outcomes than quadrant SRP D. None of the above

7. According to the research, the periodontal endoscope with magnification of 48X found these findings A. Most subgingival lesions were not associated with calculus B. Most subgingival lesions were associated with calculus

and biofilm C. Most subgingival lesions were not associated with calculus or

biofilm D. None of the above

8. Ways to gain support when implementing new perio technology include: A. Present the information at a staff meeting B. Present to the practice in reception room information C. Communicate with patients using e-newsletters D. All of the above


SESSION EIGHT Communication, Enrollment and Handoffs

Rachel Wall, RDH

Objectives; At the conclusion of this session, attendees should understand: • Communication for periodontal enrollment: scripts and key phrases to

educate and enroll your patients in the care they need and deserve. • The importance of setting goals • The meaning of monitoring and tracking your results

Communication

LINKING: Building a Relationship with Your Patient

ASK Questions LISTEN to responses without interrupting SHARE stories

↓ TRUST once you gain a patient’s trust, you have built a strong relationship


To be a successful health care provider you MUST have the following: • Confidence in your presentation skills

• Belief in what you are recommending

• Excitement about the results

Understanding why patients refuse treatment will go a long way to guiding them to treatment that is in their best interest.

Top 4 Reasons Patients Refuse Treatment TIME FEAR

MONEY CONFUSION

COMMUNICATION: KEY WORDS AND PHRASES

“C” your way to successful enrollment

l I’m CURIOUS l I’m CONCERNED l I’m CONFIDENT l I’m CONVINCED l You’ve made a great CHOICE

• Would you be willing to… • Which would you prefer... dual alternative choice • Is it possible... for you to stay today to get that started? • How would you feel if… you could smile without being... • I appreciate that…I understand • Will that work for you?


• Tell me about…. • Suppose we do this? • Help me understand? • We now know… • “It’s been 3 yrs since your last hygiene visit. That would have

been about 6 visits and we can complete your therapy in just 2.”

ALWAYS, ALWAYS, ALWAYS • Focus on “WHAT’S NEXT” for the patient • Create URGENCY for completing the procedure • SCHEDULE Next Appointment • REAP the rewards of a great appointment while handing off to the next team

player. R: review what you just completed E: educate about what’s next A: acknowledge them for being there P: pre-appoint them for their next visit

New Patient and Existing Patients Script Samples

Perio Examination Script-Pre-frame for Success Hygienist: “Mr. Smith, I will be gathering information together to assess the health of your gums and teeth. I will be measuring the bone level and the soft tissue surround each tooth. You will hear me calling out a series of numbers. Areas that measure one to three with no bleeding are normal and healthy. Any areas that measure four or higher and areas of bleeding indicate infection. The higher the number, the more involved the disease. We will review the readings along with your x-rays when I complete the exam. Do you have any questions before I begin?”


Perio Enrollment Script

Ms. Jones is scheduled to have a simple prophy. The Hygienist has shared the results of current radiographs, perio charting, visual exam and bleeding assessment with Ms Jones. The Hygienist and Doctor then recommend the appropriate level of periodontal treatment for this patient and present the treatment plan.

Ms. Jones: Stacy, I have been coming here for years. You’re telling me now that I need to have $800 worth of treatment. Why is that?

Hygienist: Ms. Jones, I understand your concern. I’m concerned too! As I look in your chart, I have noticed that for several of your last visits, we have noted that you have bleeding and we have attempted to correct this with simple cleaning. Today, we have seen no improvement in your gums. In fact, the level of infection in your mouth has increased in many areas. We must now do something different. Because the evidence now shows that you have active periodontal disease, we must treat this disease appropriately with periodontal therapy in order to stop the infection and bone loss.

Ms. Jones: Why haven’t you told me this before?

Hygienist: Ms. Jones, with current research, we now know that periodontal disease can contribute to heart disease, strokes and other health problems. We are making an effort to educate our patients to this new information and to do everything we can to keep you healthy. We have added additional procedures to make sure we properly diagnose and treat this disease.

Ms. Jones: Well can’t you just clean my teeth today?

Hygienist: Ms. Jones, if your gums were healthy, I would be happy to clean your teeth today. However, they are not. Doing a simple cleaning today would not be appropriate because what we need to do is a very thorough, extensive therapy to eliminate this infection. I would never want to charge for a treatment that was not appropriate.

OR


Hygienist: “Ms. Jones, I am happy to clean your healthy teeth. We will complete that procedure today and schedule another appointment when we can spend time focusing on removing the debris and toxins in the infected pockets in order to begin healing the infection in the sites with periodontal disease.

Hygienist: Tell me, what other questions do you have?

Gingivitis Therapy Script

John presents for a simple hygiene visit. It is discovered with a thorough periodontal examination and radiographs that John has the signs of severe gingivitis. The gingiva is red and there are 15 or more sites of bleeding on probing and there are no pockets that exceed 3mm. There is light calculus and light to moderate plaque accumulation.

Hygienist: “After reviewing your periodontal measurements and your x-rays, it appears that you have a gum infection called gingivitis. This infection is caused by bacteria that are attacking the soft tissues in your mouth and it is the first stage in periodontal disease. The good news is that it has not yet moved into the bone and other supporting structures that surround your teeth. At this point, we recommend a more a therapeutic procedure to stop the infection. This phase of periodontal disease is reversible if addressed with proper care. The therapy includes removal of the hard and soft debris that is present on your teeth and gums. This is a very conservative treatment designed to prevent this infection from spreading to the supporting bone that surrounds your teeth. If nothing is done and the infection is allowed to progress to the next stage it will not be as simple to correct. It will be important for you to follow up with excellent homecare therapy for a successful result. Can you commit to doing your part in the healing process and maintenance of your oral health?”

Periodontal Maintenance Script

After active periodontal therapy is complete, patients are placed in the periodontal maintenance program. Often, patients do not initially understand the difference between periodontal maintenance and “just a cleaning”. It is our job to educate them and support their health with comprehensive perio maintenance care.


Patient: “Can’t you just do a cleaning?” “Why must I come for a cleaning every 3 months?” “My insurance only covers two cleanings each year?”

Hygienist: “John, you have had great success with the periodontal therapy. The acute infection is healing and the gums and bone are much healthier. You have made a significant investment of your time, effort and money to achieve this success. Now it is time to move into the maintenance phase of your periodontal care. Periodontal disease is never cured. It can become active again at any time. Regular maintenance is one way to ensure that any flare ups in the gum infection are found early when we can still treat them conservatively with non surgical therapy. Research has shown that a 12 week interval is effective at keeping the bacteria under control and monitoring the periodontal disease.”

“The fee for perio maintenance is a bit higher than a healthy mouth cleaning because it is a different procedure. Because you have a history of gum disease, we will perform a comprehensive periodontal exam at every visit instead of once a year and we can treat one or two sites of reinfection at this visit for no additional charge. Should you experience sensitivity of the root surfaces, we also treat this at no charge.”

Hygienist: “John, each insurance plan is different, but most insurance companies cover a portion of the periodontal maintenance fee twice each year. You may have to cover one or two visits each year in order to maintain the health of your gums. We will do everything we can do help you get the maximum benefit allowed by your plan.” “I would hate for you to have to go through periodontal therapy again soon because we didn’t keep the bacteria levels down. What you are doing at home and what we can do every 3 months are the best protection against having flare ups in your periodontal disease. It is always possible that you will need to have some level of perio therapy again but if you stay on a very close maintenance program, your chances of a flare up greatly decrease.”


Goal Setting:

Procedure Current Goal Perio % Perio Charting Perio Therapy Priority Blocks (saved) Ultrasonics Arestin Laser Transitioning to Perio Perio Targets Hourly Production Open Time %

OTHER:

Session Eight Action Steps:

1. _________________________________________________ 2._________________________________________________ 3._________________________________________________ 4._________________________________________________ 5._________________________________________________


CE Post-Test – SESSION EIGHT To receive CE you must complete the online test at


1. The difference between a prophylaxis and root planning and scaling is that a prophy is a __________ procedure and rootplaning and scaling is _______ not prophylactic in nature.

A. therapeutic, preventive B. difficult, rewarding C. preventive, therapeutic D. diagnostic, adjunctive

2. The time to enroll the patient in perio maintenance is: A. During the confirmation call B. When they show up for the perio maintenance appointment C. When perio is diagnosed and you’re enrolling the active perio therapy

3. The best way to enroll patients into periodontal therapy is to: A. ask questions B. tell them they have disease C. tell them their insurance probably won’t cover the procedure D. give them free stuff

4. Tracking your results is important for consistency and improvement A. True B. False

6. What is the most important part of building a relationship with patients? A. establishing trust B. knowing who referred them to the practice C. getting accurate contact information D. writing them a thank you note

7. REAP is an acronym to use when? A. Calling to confirm an appointment B. Exiting the patient to the front desk C. Discussing periodontal therapy D. During a new patient call.


RESOURCES

i Albandar JM, Brunelle JA, Kingman A. “Destructive periodontal disease in adults 30 years of age and older in the United States, 1988-1994”. J Periodontol. 1999 Jan;70(1):13-29

ii AAP Public Relations Press Release “Periodontal Disease Isn't Always Your Parents' Disease” January 5, 2001. Referenced article by Thomson WM, Hashim R, Pack A “The Prevalence and Intraoral Distribution of Periodontal Attachment Loss in a Birth Cohort of 26-Year-Olds” Journal of Periodontology December 2000, Vol. 71, No. 12, Pages 1840-1845.

iii Asikainen S, Alaluusua S. “Bacteriology of dental infections” Eur Heart J. 1993 Dec;14 Suppl K:43-50.

iv AAP Position Paper: “Epidemiology of Periodontal Disease” J Perio 2005;76:1406- 1419 Accessed from AAP website www.perio.org

v Noack B, Genco R, et al. “Periodontal Infections Contribute to Elevated Systemic C-Reactive Protein Level” J Perio Sept 2001; Vol. 72, No. 9, Pages 1221-1227

vi Ridker P, Rifai N, et al. “Comparison of C-Reactive Protein and Low- Density Lipoprotein Cholesterol Levels in the Prediction of First Cardiovascular Events” NE J of Med Nov 2002;Volume 347:1557-1565.

vii Imperial College London and Harvard School of Public Health reported in the May 6 online edition of Lancet Oncology (DOI:10.1016/S1470-2045(08)70106-2)

ADA A-Z Science in the News on www.ada.org “An evaluation of periodontal disease and pancreatic cancer risk in men”. Accessed Jan 24, 2007.

Anesthetic Information: “LA Strategies for Success” 2007 CE course provided in Spokane, WA by Art DiMarco, DDS

www.DoctorSpillar.com local and topical anesthetics

Kravitz, “The Use of Compound Topical Anesthetics”, JADA Oct. 2007, Vol. 138


High Performance Perio Evaluation Form

Name: _______________________________________________________ Doctor’s Name: _______________________________________________ Please note that providing your name is optional. If you choose to disclose your name, your comments may be used for marketing materials. Complete this evaluation at www.inspiredhygiene.com/perio2011 ________________________________________________________________________ Course Objectives: Increase awareness and knowledge of periodontal disease process Increase perio diagnosis and treatment in your practice Provide tools to help you create a successful perio care protocol

For each of the statements below, please indicate the extent of your agreement or disagreement

1. The course was related to the above objectives:

a. Strongly Agree b. Agree c. Neutral d. Disagree e. Strongly Disagree

2. The above course objectives were met:


3. The course was a valuable learning experience:


4. You gained new ideas that will help you in your practice and/or patient care:


5. Your questions were heard and answered to your satisfaction:


6. Please share any additional thoughts or feelings about the course as well as additional topics you’d like to see in the future:


Rachel Wall, the copyright holder of the Profitable Perio Online Workshop workbook, authorizes the making of photocopies of the Profitable Perio Online Workshop workbook for each member of your dental team as part of the Profitable Perio Online Workshop.

Thank you,

Rachel Wall, RDH, BS Inspired Hygiene 2706 Hinsdale St Charlotte, NC 28210 8772377230 www.inspiredhygiene.com

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