Periodontal (gum) disease is a very common enemy of the astute dentist, and we now know that is can have very serious implications to those who suffer from it. Gum disease is linked to diabetes, low birth weight infants, heart disease, high blood pressure, and it is the major cause of tooth loss in adults today. This relationship now has an official term: the oral/systemic connection. Essentially, the process of untreated gum disease is as follows:
· Germs form plaque
· Plaque turns into tartar that is filled with germs
· The body sends in blood cells to kill the germs (red, bleeding and puffy gums)
· Bone is destroyed by the overactive blood cells sent to kill the germs
· Eventually the tooth is lost
In order for gum disease (periodontitis) to be diagnosed, there has to be a loss of bone. Soft tissue inflammation may or may not be true periodontitis, where bone has been destroyed, but it is usually an early warning sign that periodontitis may be around the corner. Dentists take x-rays to determine obvious bone changes, and we measure the cuff of gum tissue around each tooth. Each tooth should have a cuff of healthy gum tissue that is between 1 and 3 mm in depth, and no bleeding should occur with light measurement of this cuff. However, in the case of gingivitis and gum disease, these measurements can be anywhere from 4-12mm, and usually bleeding occurs as a result of unhealthy gum tissues. Healthy gums simply do not bleed. (However, the absence of bleeding does not necessarily mean that periodontal disease is not active—especially in the case of smokers.) Usually, the dentist measures 6 places on each tooth with the “stick”, call a periodontal probe, but some may just “spot-check” problematic areas occasionally. It is generally accepted and expected that a complete periodontal exam, including at least 6 measurements on each tooth, amounts of recession, etc., is conducted at least once a year for patients who have signs, symptoms, or a history of periodontal disease. Otherwise, at least some type of periodontal screening should be done regularly to rule out periodontal disease. Periodontal probing is as important of a diagnostic test as dental x-rays, which also should be done when indicated.
The periodontal probe is a thin, blunt ruler that has hash marks representing millimeter measurements; it can be made of plastic or of surgical-grade metal. The dentist or hygienists usually start on one side of the mouth and calls out each measuring point for someone to record. A thorough examination of the gums also includes bleeding points, recession measurements, and mobility measurements of each tooth. Depending on the situation, more frequent x-rays may also be needed to confirm or support the physical examination findings. The test is usually painless, unless the tissues are very unhealthy. However, periodontal measurements are subject to human error. Sound research tells us that there can be a difference of up to 2 millimeters in measurements from one clinician to another, and most dentists are trained to read periodontal records with this in mind. There are some digital calibration and recording systems that utilize special probes to convert electrical impulses into measurements; however, to date they have not shown a great deal of promise except in research settings.
Today, it is well understood and accepted that a “cleaning” no longer is an appropriate procedure. Dentists and hygienists should be treating according to appropriate diagnoses based on periodontal examination findings. Healthy patients with no gingival inflammation and little or no tartar require less therapy than do patients with gingivitis or severe periodontal disease, and patients with gum disease limited to one or two teeth require less therapy than patients with generalized gum disease. Therefore, fees charged should be appropriate for the level of therapy provided. In fact, insurance billing codes established by the American Dental Association now reflect this. Periodontal probing and appropriate dental x-rays to support accurate diagnoses are essential for fair coding and billing for the “cleaning” that you may need.