Case Studies




Hygienists often ask how I would treat certain patients or what kind of recommendations I would make for specific conditions.  Recently, we held a forum where hygienists could anonymously ask the expert any question and I would give my honest and best answer.  We separated the questions by topic.  Now you have a chance to see what hygienists want to know.  Who knows maybe your question can be answered too.

Please feel free to contact me at Robin@OkPerioImplant.com with your questions.  I will be happy to answer you directly, but it may also be posted here for others to see.

Treating Periodontal Disease- Scaling/Root Planing (SRP)
Patient Compliance/Treatment Planning

Professional Products


Health History/Medicine

Home Care Products
Auxiliary Periodontal Procedures

Meth/Recreational drug use


Treating Periodontal Disease- Scaling/Root Planing (SRP)

Q: How do you get rid of the inflammation on patients that have chronic hemorrhaging, edema and redness around PFM crowns, and this is in mouths of patients with above average home care? - Val W.

A: It’s simple really...First we have to identify what the actual problem is.  The list can include, true metal allergy or biologic width encroachment.  Most of the time it is an invasion of the biologic width, that dimension of soft tissue that must be present in all cases for proper health.  Biologic width issues can also occur around any restoration type, even full porcelain crowns.  Once this occurs the only way to fix this is to do a crown lengthening procedure to recreate the proper biologic width.  As a review, the biologic width is the 3—4 mm dimension that must be present from the crest of the bone to the margin of the restoration.  It is very rare to have this type of reaction for a true metal allergy.  If it is really an allergy, then the procedure is still the same, crown lengthening and then non-metal restorations.

 Q:  How often would you repeat Scaling and Root Planing?

A: Well, technically you should never have to repeat SRP if it is done correctly.  Let’s use an example.  A patient comes in after an absence for about 3 years with 5 mm probing depths and bleeding throughout.  Subgingival calculus is everywhere and they need SRP.  If you do the SRP thoroughly, reevaluate and they now have normal pocketing you should keep them on 3 months for the next year.  If they can maintain a good home care routine and comply with regular recalls, then they should be fine forever.  If they skip steps, or slack off then SRP will need to be repeated.

 Q: Do you think SRP should be performed before any surgery is done?

A: SRP should be done prior to any type of surgery almost 100% of the time, simply because you want to reduce the bacterial load throughout a mouth before surgery so that the procedure has a better outcome.  There are only a few exceptions to this, but you really can’t go wrong by doing SRP prior to any type of surgery.

Q: Once a patient has gone through SRP (1-3 teeth in 1 quad) should they be considered perio maintenance (4910) from now on? Can you alternate codes 1110 and 4910? Is 4910 only billable at the perio office?

A: The general rule of insurance coding is that once you use a perio code for a patient in their care, then you must use 4910 as the continuation code.  You cannot mix the codes based on coverage of what the patient wants or the benefits that they have because that is insurance fraud and you will get in trouble.  Only occasionally, in very specific cases can you switch someone from a 4910 to a 1110, and it depends on the patient’s insurance carrier.  4910 code is applicable at any office and not just a perio office.

Q:  What is the best way for managing the stubborn smoker with progressive perio that doesn't respond to SRP and refuses referral or recommendation to a periodontist?

A: The toughest patient’s are like this.  First, try to get to the real reason why they don’t want to go.  If they just refuse then you need to cover your butt by having them sign a refusal letter and tell them that at the rate they are losing ground they will lose their teeth, and in a lot of cases, most won’t have enough bone for implants or dentures.  But cover your backside is the main key.

Q: Why do smokers after SRP not have ideal results? Even after the best care and proper follow up appointments?

A: Smokers or any kind of tobacco users will always have a poorer response than non-smokers simply because the body cannot fight the healing process through all of the nicotine and by-products that are in tobacco.  One thing you should notice is that most smokers will have much less bleeding than non-smokers, but will have deeper pockets because the blood vessels that help fight periodontal disease are too constricted so that is another reason why their disease is more severe.  You will also notice that people who have recently stopped smoking will initially bleed more until their body gets used to things again because of the blood vessel dilation.  Not to worry, it will calm down.

 Q: What is the best way for a patient to control root sensitivity following SRP?

A:  Fluoride is the best way.  It is important to remineralize the root surface and occlude the dentinal tubules to obstruct fluid exchange which causes sensitivity problems.  Different types of fluorides and products work differently for each patient, sometimes it is trial and error to find the right one.

 Q: Can a patient have periodontal disease if infection is not present?

A:  The simple answer is yes, but that question is loaded.  The definition of periodontal disease is measurable attachment loss and infection does not need to be present to have attachment loss.  However, 99% of the time there is infection or inflammation present to assist in the attachment loss.  Think of the patient with immaculate home care with generalized recession and thin tissue.  That patient is contributing to the attachment loss, but the biofilm that is present is more damaging because of the recession and thin tissue present than if the tissue was thick.  So technically infection is present.

 Q: My dad wears an upper Valplast partial and has moderate periodontal disease.  He swears he has these “episodes” where his gums get inflamed, then recede, then back to normal.  He says this even happens in the edentulous area (#12-15).  Will the bacteria still attack the tissue where there are no teeth?  He has excellent home care and of course the edentulous area does not recede, but it gets sore and inflamed along with the rest of his mouth during an “episode”.

A:  Traditionally, bacteria will not have much affect on an edentulous area, but the partial can harbor additional bacteria and fungus that can cause irritations.  This irritation may cause localized swelling.  It is most likely that he might be getting gingival abscesses periodically which leads to an inflammatory response.

 Q: Does instrumentation in the pocket alter or improve the negativeness of the subgingival micro flora?

A:  Not quite sure what you mean about negativeness, but instrumentation in the pocket alters the biofilm thus allowing for an improvement in the ratio of good and bad bacteria.  Disruption of the biofilm is paramount for health of the tissues and teeth.

 Q: What do you think the most valuable contribution diode lasers bring to Periodontics and dental hygiene and what are their limitations?  Any comments on other types of lasers and their applications.

A:  Lasers in general are a good tool to have, but I caution those who use it without additional specialized training…it is a must.  Simply, lasers are like a curette or scalpel because they remove tissue.  Lasers generate heat and can burn hard and soft tissue. They have a higher affinity for pigmented areas, so for diseased areas, diode lasers work well to get rid of granulated tissue which improves access for traditional therapy.  Laser treatment should be combined with conventional therapy.  The limitations include education, knowledge, and experience.   It is very important to have these or serious damage will occur.

 Q: We have a laser that we use in our office to treat periodontal disease.  I was wondering what you thought about lasers used in dentistry.  I was at the Hygiene Expo but I did not think about this question until it was too late!  If you do not mind I was curious at to what you thought! Thanks – Darcie

A:  I personally have multiple lasers and use them almost daily.  Some of it to control disease and some of it to treat the disease, but my methods would be different from hygienists because I am allowed to do much more than you.  I do feel that lasers have a great place in dentistry and will be around more and more.  I think that the biggest issue with lasers is from the training side of things.  You must be trained properly and you must use them correctly.  Without training and the proper use, you will cause some problems.

 Q: At what point should a patient be referred to a Periodontist and what should be the limitations of the general dentist practice?

A:  I don’t like to put limitations on any practice because there are so many differences in offices.  My blanket answer is that you should do what you are technically capable of and what your comfort level is.  Once you are out of your league or comfort zone then that is when the patient should be reserved to be scheduled with the specialist.  Hygienists will run into trouble because the GD will want you to keep everything in the office even if you feel that you cannot handle the case.  That is a whole different set of issues that you’ll have to deal with.


 Patient Compliance/Treatment Planning

 Q: What information do you need when a hygienist refers a patient to you?

A:  Any information is a blessing but the ideal information would be full mouth radiographs, full mouth perio charting and any extra information, like “the patient likes nitrous”, or “the patient is afraid of losing their teeth”.  Anything to help out the process and relationship with the patient.

 Q: I have had patients that I feel should be referred to a periodontist, but my general dentist did not back me up. How do we battle this? – Concerned RDH

A:  This is probably one of the biggest practice management issues that hygienists deal with.  It basically boils down to greed of the dentist thinking that they are going to lose the extra $100 dollars.  But what really happens is that the patients that are referred are much more appreciative of the dentist when they are sent because they get better treated.  If your doctor is one that will not relinquish control over patients and what you can do, and this goes against your philosophy, then you need to convert them to your control or leave.  The hygienist must have complete control over their group of patients.

 Q: I am a dental hygienist in a general dentistry practice.  My question is about mouth-breathers.  Several of my patients present with excellent dental hygiene and healthy tissues until I touch the maxillary anterior sextant.  If I look at and/or touch this area it gushes blood!  I know that it is due to the mouth-breathing, but is there any way to correct this issue short of duct taping their mouths shut when they sleep:) Summer H.

A: Great question and not really.  The only way that you could do something to help this area would be to protect it while they are sleeping.  A simple overextended fluoride tray with a bit of fluoride would help.  Many spouses would pay double though for the duct tape


 Professional Products 

Q: What ultrasonic scaler do you recommend for a hygiene practice that performs about 65 to 70% perio treatment or is there a difference in the units? – Desperate Hygienists  (This is really a question for a hygienist so I let one of my hygienists answer.)

A:  There are so many great brands but it varies depending on your style.  Just as we all make different scaler and curette choices based on preference and ability, I think the same goes for Ultrasonics.  I find the Magnetostrictive is the most accommodating because every surface of the tip is active, unlike the Piezo.  I like the control of the manual tune versus the auto tune units, much more control for me and the patient.  Only with manual control can you use the thinnest tips designed – like an explorer.  I suggest comparison shop and go to hands on courses before committing to a particular brand.  There is a lot of really good information and courses about ultrasonics out there.

 Q: Do you recommend a certain brand of subgingival bacteria testing kit for a general office?

A:  I don’t do bacterial testing because it really doesn’t matter all that much as far as the type of bacteria that you have.  The treatment will be the same or very similar regardless of the bacteria type.  The most important issue is that you get 100% of the bacteria off at all times, the type is immaterial.

 Q: How does the Perio Protect system work?  How does the “gel” get to the bottom of the pocket?

A:  Perio Protect is a system with custom made trays that deliver a variety of medicines to the tissues to get the desired outcome.  These are not “bleaching trays” or something similar, but specifically FDA approved materials Bleaching trays and other do-it-yourself type may cause patient harm.  Basically, it works on a positive pressure system.  A vacuum seal is created with the trays and tissues so the medicaments are forced to the base of the pockets.  I would have you defer to the website, there is a wealth of information there.  Go to www.perioprotect.com.

 Q: How often are you using Perio Protect on your patients?

A:  Pretty much all the time.  Even on a patient who has good home care, the additional benefit will keep them healthier.  The most effective use is for patients with bleeding 4 and 5 mm pockets throughout their mouth and on 3 month recalls.  The added benefit of the Perio Protect system really boosts their overall care.



 Q: Can you talk about how the implant overcomes (or does it) the nature of the biological width?

A:  An implant doesn’t overcome the biologic width, it resets it.  The biologic width is going to be present whether there is a tooth present or an implant.  The body has to set up this relationship in order to preserve the health and integrity of the mouth.  The biologic width of an implant is altered because there are different non-living components to factor in, but it is present.  You will typically find deeper pocketing around implants because of the biologic width, and it depends on the implant fixture platform placement as it is related to adjacent teeth.

 Q: Implants, to probe or not to probe?  That is the question…

A:  You must probe around implants like you would natural teeth because you need to know the health of the tissues holding the implant in place.  If you don’t know what the tissue is doing, then you won’t know how to treat the patient.

 Q: Our office recently purchased the “Gold” scalers for implants. Do you feel these are good/safe instruments?

A:  There are a lot of questions about how to clean implants.  I have a very simple way of thinking about the cleanliness of implants.  It is very difficult to damage an implant surface and if you are getting to the surface of the implant and not just the crown, then there is a bigger problem than a little bit of plaque.  Implant surfaces also don’t collect much in the way of debris anyway because of the surface smoothness.  The bottom line that I would recommend is to use what you have and when you get around an implant, just be a bit more careful, but don’t be afraid of them.

 Q: When cleaning implants what instruments are you recommending?

A:  Same as above

 Q: What is the best way to clean implants? My doctor wants me to Prophy Jet.

A:  Same as above


Health History/Medicine

 Q: What are the problems associated with Bisphosphonates (Fosomax, Actonel, etc.)? Should women be taking them?

A:  These groups of medicines used to treat bone density issues are very important medicines with great benefits and side effects.  People should only take a bone density medicine when necessary.  Taking them because it could help is a big problem.  Osteonecrosis of the jaw is a very serious issue that is only coming to the surface with bisphosphonates.  This condition causes a dying of the bone of the jaw, and unlike osteoradionecrosis, which occurs during radiation to a jaw after cancer, bisphosphonate induced osteonecrosis has no treatment.

 Q: Are there any contraindications to taking Periostat indefinitely? Have any of your Periostat patients reported improvement in arthritis joints since being on Periostat?

A:  There really isn’t any downside to taking Periostat constantly.  Because of the dosage involved, there are no real problems.  Also because of the mechanisms of how the medication works, you can have improvement throughout the body with all systems that work on an anticollagenase basis.  Joint pain is only one of the many benefits of Periostat.  Others include better skin condition and obviously better oral health.

 Q: I have a patient with burning mouth syndrome?  Lidex gel does not help, really nothing has helped.  He is on a lot of medications, has changed some that cause BMS, and still nothing has worked to relieve his mouth pain.  Any suggestions?

A:  Unfortunately, that is a problem.  Nothing seems to help and there are so many different triggers for each person which causes this problem.  Everyone seems to respond well to some things, while others do not.  Occasionally, I have had luck with simple peroxide, or even a soothing effect with Pepto Bismol.  Some of the topical anesthetic rinses will work temporarily, but nothing is a magic cure.  One main emphasis is to keep the area as clean as possible and free from bacteria and fungus which increases their problem, which is why hydrogen peroxide seems to work.


Home Care Products

 Q: I worked for a Periodontist for 9 years and he is a big believer in Listerine. Do you?

A:  My simple philosophy is that patients should use any home care product that is going to get them doing a better job.  Listerine is a great product because of the alcohol content.  It definitely kills bugs, but it has very little substantivity, just like all the mouth rinses.  The problem with mouth rinses and irrigants is that there is no way for the agent to stay for long.  After the saliva processes through, then the bugs come back, and you’re at square one.

 Q: How do you feel about Water Piks?

A:  Same as above

 Q: Does hydrogen peroxide use eventually cause brown, hairy tongue?  We learned in dental hygiene school that it causes the papilla on the tongue to grow and trap debris and bacteria.

A:  Sometimes, but for a short term.  If you think about it, with chronic antibiotic or antimicrobial therapy that is initiated in a patient, the balance of bacteria and fungi are set.  When you start the therapy the balance is altered and a proliferation of fungi occurs.  Until the body can reset the balance, hairy tongue may occur. Time will fix things or an antifungal rinse may be used.

 Q: Besides staining, why do you recommend Prevention over Peridex? Do you dispense prescription strength or OTC?

A:  I like Prevention mainly because of the staining aspect.  Studies have shown that it doesn’t really matter what agent you use as a mouth rinse, because they all work about the same.  I like Prevention because of the zinc component to promote healing as well as the hydrogen peroxide as a simple agent to kill off bacteria.  I use the prescription strength because of the more concentrated hydrogen peroxide component.

 Q: Do you have patients on any special supplements (vitamins) when undergoing any treatment including implants?

A:  I do not routinely have people on any supplements, but I do encourage them to increase their vitamins and calcium, especially B vitamins and vitamin D.

 Q: What toothpaste do you recommend for hypersensitive patients?

A: Whatever works for the patient and their sensitivity.  Most patients do well with Sensodyne because of the action of the Potassium Nitrate.  I have some patients who do well with home fluoride.  More toothpaste companies are combining the two products for even better sensitivity control.


Auxiliary Periodontal Procedures

 Q: When doing a gingival graft, do you get better results when using the patients own tissue or cadaver tissue?  Which method do you use on a regular basis?

A:  I use both methods equally.  It depends on the type of graft needed and what needs to be accomplished.  If the tissue is thin and fragile, the palatal tissue works best, but if you have thick enough tissue and just recession, then donor tissue works just fine.  I try to use donor tissue when possible because patients appreciate the easier healing.  Donor tissue techniques are much more difficult and not as forgiving, so some clinicians choose not use it.



Q: I’ve seen dental assistants posing as hygienists without education, illegal but dentists are not afraid of being caught. What is a hygienist worth to you?

A:  Hygienists are an invaluable part to any properly run office.  There are a lot of offices that run assistants as hygienists and skirt the law, but my feeling is that it is only a matter of time before they are caught and it’s not worth it.  Most offices think of hygienists and the hygiene department as a pain to deal with, but where they are missing the boat is that the hygiene department can be a significant asset and income generating part of an office.  My feeling is that dentists need to take off their power hats and give up control of the hygiene department to the office and go on with normal dentistry.  The office will be much happier and much more productive.

Q: A patient refused phase I therapy and just wanted a “cleaning”.  The dentist made me just polish his teeth and said it wasn’t supervised neglect since I thoroughly educated him on the risks.  Is he right?

A:  Only if the patient signed a waiver saying that he understood there was subgingival disease and the only way to thoroughly get rid of the problem is with scaling and root planing.  Once a patient signs something stating their problems will worsen if they choose not to do what you recommend, then they are more apt to do what is needed.


Meth/Recreational drug useanswered by Noel Kelsch, RDH

Q: At what age do you recommend talking to children about Meth use?

A: Talking to children about drug abuse should start as soon as the child is old enough to understand the concept. The Partnership for a Drug Free America has a program that starts in 1st grade. I do not think that is too soon. The youngest child I have seen that tested positive for Meth was 11. He needed the information before then. Our children are our greatest asset and we need to give them information on protecting themselves as young as we can. The prime case that confirmed this for me was the case last year in LA County where a 2nd grader reported her mother who was sharing her drug with her infant to keep the child from crying. We teach our small children to never talk to strangers and to never run in the street. Teaching them to avoid the perils of drugs at a young age is just as vital.

 Q: If a patient admits to recreational drug use to the clinician but refuses to discuss with the parent, do you have patient/doctor confidentiality, especially if the patient is a minor?  Or over 18?

A: As we discussed in the class in the state of Oklahoma you must discuss the issue with the person that is the minor’s guardian or other health care provider who will follow through with treatment. The easiest solution to this is to not ask the child if you are hesitant to report to the parent. Instead explain the finding to the parents (sever decay, dry mouth, weight loss, infection, etc) set up a referral to the child's MD the same day, (remember the half life is 12 hours) We are not psychologists or social workers so many times the delivery of the information is essential to involve other health care providers and have interaction between those providers. The important thing that must happen is that you must get that child to a doctor for evaluation immediately. Confidentiality is a must if they are not a minor and they are not harming themselves, putting others at risk or threatening anyone. Many times you will have to make a phone call if they are driving or there are children involved.  

Q: Why are the lower anteriors last affected by the damage pattern of meth use?

A: We really do not know yet. The pattern is apparent but this issue has not been studied. It is hypothesized that because that area tends to stay dry when the patient is breathing through the mouth and has severe xerostomia. The bathing of the teeth with saliva that is very acidic is thought to create the decay pattern. It is also hypothesized that is why a cuspid can have severe decay on the entire tooth except the tip of the cusp. The decayed area is constantly being bathed with saliva that is extremely acidic and the tip is free from the exposure.



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