Part Two: Hygiene and the Sedation Patient – Scheduling, Treatment & Billing

Once you’ve discovered the extent of the disease, you can plan a level of care the patient is comfortable with and plan out periodontal maintenance that incorporates the use of sedation for better results and patient satisfaction.

By Constance P. Fadigan RDH, BA

This article is a continuation of our first article, focusing on diagnosis.

Once you know the extent of the disease, you’ll need to work the care plan into an allowable schedule. Root debridement therapy can be scheduled in 40-minute increments while the patient is sedated. Always schedule hygiene treatment before restorative because:

  • The hygienist is more likely to stay on schedule. In the neglected mouth, restorative may be riddled with surprises.
  • This will prevent the use of cavitrons, chemotherapeutics, and other irrigators from allowing aerosols into the extraction sites, which are often an initial treatment phase.
  • Allow 20 minutes for full mouth probing at the first sedated visit, as well as measurements that were not accessible at the initial exam (bleeding, clinical attachment, furcation, recession, mobility, plaque score).

For example: Jane Smith – you recognize 4 quadrants and FMP (full mouth probing) is incomplete.

40 min. x 4 = 2 2/3 hrs. + 20 minutes to complete FMP

Building rapport with a patient happens while the patient is awake, and it’s the only way they’ll remember what home care needs to be done and how. Schedule periodontal monitoring appointments as needed. These twenty-minute appointments are completed while the patient is awake and reviews the home care regimen and education.

Periodontal Maintenance Scheduling

Schedule periodontal maintenance (treatment code: 4910) visits four weeks post-RDT to evaluate periodontal healing (FMP), supragingival scaling, polish, and home care instructions review. For offices utilizing lasers, additional sites may be treated at this time. This may be coordinated with restorative treatment for sedation. Recall/supportive periodontal therapy should be scheduled as you would any periodontal patient (6 weeks, 8 weeks, 3 months). Of particular importance for the high-fear patient is the scheduling of alternating sedation visits. The three-month interval is considered the standard of care for moderate and severe periodontitis.

The first recare visit should be at the patient’s comfort level, usually sedated. Some practices choose to adjust the sedation fee for this shorter visit. Anxiolytic protocols are useful here. Provide comprehensive, thorough care. Alternating visits may be scheduled while the patient is awake using topical anesthetic.

Adjust for patient’s comfort. Some will feel they can have complete care without sedation, others will prefer to always be sedated.

Provide Patient and Hygienist Breaks

A few more things to consider when scheduling for long hygiene visits are scheduled breaks in conjunction with appropriate ergonomics. The average burnout for a hygienist in practice is six years, so let’s not rush it. Breaks should refresh the mind and strengthen the body. Approximately every ninety-minute stretch, take a short walk, refocus the eyes and obtain nutrients. These breaks can coincide with the need for additional local anesthesia in states where the hygienist cannot administer it.

Providing appropriately for the sedated patient is conducive to a good sedation experience for both patient and practitioner. Allow for bathroom breaks every two hours; nourishment every 1-3 hours, and relaxation for the jaw every 25 minutes for approximately five minutes. NEVER LEAVE THE SEDATED PATIENT ALONE.

Anesthesia and Medication Administration

Local anesthesia should be administered in sections during the course of treatment. In states where the hygienist cannot deliver locally, coordinate with the doctor’s schedule to anesthetize each section at appropriate intervals (approximately 40-80 minutes apart). Consider using topical in areas where no anesthesia is needed and/or for awake visits.

No team member should diagnose the need for additional medication of any kind. You can, however, recognize the symptoms of need and reactions to medications. The need for medication must come from the doctor. In some states, the doctor may direct a team member to deliver oral medications.

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Billing for Care

Be sure to charge for the work you do. Present the entire treatment plan and let the patient decide what they can afford to do. Insurance should not dictate treatment. Consider that their dental benefits may have a lifetime maximum, and may cover only four RDTs, or they may not cover “supportive periodontal therapy” more than two times a year.

Submit for the treatment done and include periodontal charting:

  • Comprehensive Periodontal Eval (treatment code: 0180)
  • Full Mouth Debridement to enable comprehensive eval & diagnosis (treatment code: 4355)
  • 9 RDT/SRPs (treatment code: 4341)
  • RDT/SRP localized (treatment code: 4342)
  • Unspecified Periodontal Procedure (treatment code: 4999)
  • Adult Prophy (treatment code: 01110)
  • Periodontal Maintenance (treatment code: 4910)
  • Localized Delivery of Antimicrobial Agent via a controlled release vehicle (treatment code: 4381)

It’s important to note that once a patient is diagnosed with periodontal disease, this patient is always a periodontal patient.

Narratives Can Be Your Best Friend

Submitting a narrative with your insurance claims can increase the benefits the patient receives.  Here are some samples:

  • For multiple RDTs: “Multiple root debridement therapy (4341) completed at a single visit while patient was sedated due to high-fear/anxiolysis.”
  • For Supportive Periodontal Therapy (with exam) include date of RDT & Case Type: “Exam completed at this visit was clinical in nature and evaluated both soft and hard tissues for disease.”
  • For Definitive Therapy include date of RDT & Case Type: “This procedure includes a complete periodontal evaluation, home care instruction, blood pressure screening, light scale and polish. It’s completed 4-6 weeks post Root Debridement Therapy (4341). Please consider this for benefits.”

In Conclusion

The goal is always for complete care and restoration to a healthy oral cavity. With sedation dentistry, a little flexibility will expand your hygiene practice into new patient relationships, making your practice more profitable and more fun. With advance planning and a thorough treatment plan sedation adds a level of comfort for the patient that will lead to better results and continuation of care.

Author: Currently DOCS Education's Chief of Staff, Connie has been a central figure in its founding, growth, and ongoing development. A former dental hygienist, she’s been an essential resource for founder and president Dr. Michael D. Silverman, as well as the more than 24,000 dentists and dental professionals who have embraced sedation dentistry on behalf of their patients over the past 20 years.

References:

1. Advanced Hygiene Concepts (800) 400-6772

2. Mongardini C, van Steenberghe D, Dekeyser C, Quirymen M. One stage full-versus partial-mouth did infection in the treatment of chronic adult or generalized early-onset periodontitis.  I. Long-term clinical observations. J Periodontol 1999;70:632-645.

3. Trieger, Norman DMD, MD. “Periodontal Infections”.

4. Sweeting, Larry A., DDS; Davis, Karen, RDH, BSDH; Cobb, Charles M., DDS, PhD. Periodontal Treatment Protocol (PTP) for the General Dental Practice. J Dental Hygiene.  2008. Special Supplemental.  Pg 16-26.

5. Wilkins EM. Clinical Practice of the Dental Hygienist, 7th ed.  Philadelphia: Lea& Febiger, 1994.

6. Perry, Beemsterboer, Taggart. Periodontology for the Dental Hygienist, 2nd ed. Philadelphia: WB Saunders Co., 2001. Oral and Maxillofacial Surgery Knowledge Update, Vo1, Part II, 1995.

7. New Patient Packet, LLC. 2011

8. Sweeting, Larry A., DDS; Davis, Karen, RDH, BSDH; Cobb, Charles M., DDS, PhD. Periodontal Treatment Protocol (PTP) for the General Dental Practice. J Dental Hygiene.  Table 2. 2008. Special Supplemental.  Pg 26.

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