Nuts & Bolts of a Productive Soft Tissue Program Joseph P. Trovato, DMD

A leading researcher, Frank A. Scannapieco, DMD, based on his and previous research findings has shown periodontal disease as a potential risk factor for systemic diseases. In addition, he stated “It is conceivable that improved oral health may prevent the progression of Chronic Obstructive Pulmonary Disease. We are all aware of the link between periodontal disease and diabetes.2 It is a known fact that acute bacterial infections increase insulin resistance in diabetics, suggesting that periodontitis is a risk factor for diabetes.3 The Surgeon General’s Report 2000 stated uncontrolled diabetes is a significant factor in the etiology of gum disease.

The American Heart Association stresses the importance of periodontal treatment, stating that periodontal infections may produce bacteremia even in the absence of dental procedures.4 Assuming that all of the above findings prove valid, I believe that in the near future, not doing a complete periodontal charting examination on a patient will be malpractice. A cursory periodontal exam such as a PSR may not be adequate. There can be only a few non suspecting sites in areas other than those done in a PSR examination.

Insurance claims for services involving periodontal treatment should always be submitted with the newly revised accompanying diagnosis that is based on the American Academy of Periodontology’s case types which are as follows:
GINGIVITIS Inflammation of marginal gingival- pocketing of less than 2mm.

CASE TYPE 11
EARLY PERIODONTITIS
Pocketing of 2 to 4mm

CASE TYPE 111
MODERATE PERIODONTITIS
Pocketing of 4 to 6mm with tooth mobility of 1 or 1 + with the start of furcation involvement.

CASE TYPE IV
SEVERE PERLODONTITIS
Pocketing of over 6 mm

CASE TYPE V
REFRACTORY PERIODONTITIS
These sites presumably continue to be infected by periodontal pathogens no matter how frequent or thorough the therapy is provided.

The new case typing is now based on the most periodontally involved area of the mouth. For example you can have a patient with ten 4-mm pockets and only one 6-mm pocket, and be classified as a Type 111.

In order for your hygiene department to be productive the following guidelines should be followed:
Every adult should have a complete periodontal examination which consists of 192 pocket measurements in a mouth having a complete compliment of teeth. In our office we utilize the Florida Probe which is a computerized probing device which measures the patient pocket depths to within 2 tenths of a mm accuracy, by way of using a constant force of 15 grams pressure. This technology is ADA approved and is proven to be highly accurate over manual probing. This allows us to diagnose periodontal disease at the earliest stage.

If the examination indicates periodontal disease we now take a plaque specimen from the patient’s pockets and examine it under a phase contrast microscope to see if the patient has bacteria that is normally associated with periodontal disease. I believe that not using the microscope is like a physician practicing medicine without a stethoscope. Besides being diagnostic it is a great motivator for patients, especially if the slide is inundated with spirochetes and other motile bacteria.

If the patient has bleeding gums even in a few areas they definitely have gum disease. However the patient should be informed that the absence of bleeding gums does not mean there is no disease present.

This is why the microscopic examination is so important. Since periodontal disease many times is asymptomatic, seeing the causative bacteria on the monitor attached to the microscope ads validity to your diagnosis.

A consultation is then given to the patient at which time the fee and procedures are explained and financial arrangements are made. Prior to the appointment dental and medical insurance information should be obtained in order to give the patient their estimated portion.

The few times when a patient refuses treatment for gum disease, you must have the patient sign a release stating he or she was informed.

If the patient refuses to sign then you must document it in the patient’s record. The most common lawsuit against dentists is the failure to diagnose periodontal disease.

Upon acceptance of treatment the patient is then scheduled with the hygienist for the root planning appointments. The patient is then given a prescription for Vioxx (rofecoxib) 50mg and instructed to take one tablet 1 hour before all root planing appointments. We have found that a single 50mg dose of Vioxx produced an analgesic effect, that renders the root planing appointments much more comfortable. In most cases there has not been any post-operative discomfort. Vioxx also reduces the necessity of administering local anesthetics normally required to do root planing procedures, which can be disruptive in a busy practice. Upon completion, an appointment is given with the periodontal therapist who instructs the patient for their customized home care instructions. The use of a periodontal therapist allows the hygienist to be more productive releasing her or him of the important time consuming instructions. Usually at this visit is when I prescribe Periostat which is the first FDA systemic approved delivered collagenase inhibitor. This is used as an adjunct to root planing and scaling. Periostat is not intended to replace traditional periodontal treatment. The dosage is 1 capsule taken twice a day over a 3-month period. Some studies have shown, significant pocket reduction.5

Home care instructions include the use of chlorhexidine provided there is no bleeding, since chlorhexidine has an infinity to hemoglobin rendering it less effective in the presence of blood.6 In such case we will start out with Therasol. Therasol is a highly substantive, bactericidal liquid that does not stain the teeth and is effective in the presence of blood. Electronic brushing techniques, rubber stimulators, and special subgingival irrigators are stressed and customized instructions in their use is given.

Periodontal patients are seen in three months following initial therapy. A full mouth computerized Florida Probe reading is done at this time in order to evaluate the success of treatment. If pockets of 5 mm or more remain, the patient is appointed for laser therapy. We use the Biolase Waterlase to debride the pockets of 5 mm or more. This surgical procedure is well accepted, since I never had to give anesthesia using the Biolase Waterlase.

A plaque sample is obtained at the hygiene appointment and then given to the periodontal therapist, for evaluation. Root planing and scaling is performed followed by a fluoride application to help prevent the recolonization of bacteria and reduce sensitivity.

The hygienist then appoints the patient in three months for periodontal maintenance. Periodontal maintenance is not an option for our patients, it is mandatory. The American Academy of Periodontology recommends periodontal maintenance four times a year: an interval of three months between appointments appears to be an effective treatment schedule7 However, when the patient’s pockets are reduced to an acceptable level, I may reduce the number of perio-maintenance appointments from four to as low as two per year.

Our patients have made a financial investment in their treatment and we want them to protect that investment and their health by keeping the perio-maintenance appointments.

At the maintenance appointment, the periodontal therapist views the plaque sample with the patient under the microscope and the findings are recorded. Home-care instructions are then reviewed.

We have found the above protocol to be successful and effective in treating periodontal disease.

References
1.-2. SCANNAPIECO FA.ETAL: PERIODONTAL DISEASE AS APOTENTIAL RISK FACTOR FOR SYSTEMIC DISEASES (POSITION PAPER)

3. MENLEY BI DIABETES AND PERIODONTAL DISEASE. TWO SIDES OF A COIN COMPEND CONT EDUC DENT 2000; 21 (11): 943-954

4. CHEITLIN MD, ALPERT JS, ARMSTRONG WF, ET AL.ACC/AHA GUIDELINES FOR THE CLINICAL APPLICATION OF ECHOCARDIOGRAPHY: A REPORT OF THE AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART TASK FORCE ON PRACTICE GUIDELINES 1997; 1686-1744.

5. CATJ. CIANCIO 5, CROUTR,HEFTI A, POISON A. ADJUNCTIVE USE OF SUB ANTIMICROBIAL DOXYCYCLINE THERAPY FOR PERIODONTITIS. J DENT

6. CLINICAL PERIODONTOLOGY 8TH EDITION P. 519 CARRANZA MIKI NEUMAN

7. AMERICAN ACADEMY OF PERIODONTOLOGY STATEMENT ON PERIODONTAL MAINTENANCE PROCEDURES 6 TH EDITION CURRENT PROCEDURAL TERMINOLOGY FOR PERIODONTICS PAGE 46

Curriculum Vitae
Joseph P. Trovato received his DMD from the University of Medicine and dentistry of New Jersey in 1990. He has since been practicing general dentistry at 445 Beigrove Drive Keamy, N.J. 07032.

Dr Trovato is a: Diplomat of the American Academy for Pain Management

Fellow in the Academy of General Dentistry

Fellow in the International Congress of Oral Implantology

Associate Fellow American Society of Osseointegration

Associate Fellow College of Oral Implantology

Fellow in the American Society of Dentistry for Children

Member of the American Association of Functional Orthodontics

Member of the International Association for Orthodontics

Member of the American Dental Association

Dr. Trovato is published in the Functional Orthodontist, and holds a devise and method patent on a technique for the treatment of TMD, orthodontics, and full mouth reconstruction. In addition, Dr. Trovato also lectures on Orthodontics/TMJ, lasers, air abrasion, and the treatment of periodontal disease (gum disease)

Dr. Trovato hosts a weekly radio show “Tomorrow’s Dentistry Today.” on WMCA., covering the N.Y. metropolitan area. The show airs Tuesday evenings at 7:30, and discusses current trends in dentistry. You can contact Dr. Trovato at: (201) 991-0177