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Assessment Phase - Perio

This is also when you do :

  • Comprehensive history
  • Radiography Extra-oral, intra oral periodontal examination
  • Periodontal Diagnosis
  • Periodontal Risk Assessment

Codes

  • 221 Clinical Periodontal Analysis and Recording

Perio Acute Phase/ Step 0 Emergency Care phase

  • Address any Acute Conditions Causing pain/ or infection
  • This may include acute periodontal abscess, necrotizing periodontal disease or irreversible pulptitis

Warning

  • The patient has none of these

ADA codes considered

ADA codesDescription
013Oral examination limited
213Treatment of acute periodontal infection – per appointment
419Extirpation of pulp or debridement of root canal(s)
311/324 etcExtraction of teeth associated with acute pain/infection

Perio Systemic Phase / Step 1 Phase

  • Risk Factor control Falls here while the biolfilm and OHI fall under disease control
      • Aim to guide behavioural change by motivating patient
    • Dietary Analysis
    • Diabetes
    • Tobacco smoking (Ask,Advice,Help, quitline )

Codes considered

131 - Dietary Analysis and Advice 142 - Tobacco sussation advice

Perio Disease Control Phase / Step 1 & 2A Systemic Phase and Cause related therapy phase & Step 2B Re-Evaluation

Step 1 portion

  • Removal of supragingival biofilm:
    • Oral hygiene practices are established here and reinforced at all stages of treatment
    • Professional mechanical plaque removal and control of plaque retentive factors

ADA codes considered

ADA codesDescription
111Removal of plaque or stain
113Recontouring and polishing pre-existing restoration – per tooth
114Removal of calculus – first appointment
115Removal of calculus – subsequent appointment (where extent or degree of calculus cannot be corrected in first 114 appointment)
131Dietary analysis and advice
141Oral hygiene instructions
142Tobacco counselling
311/324 etcExtraction of asymptomatic hopeless teeth
Smoking Cessation Model QR code

All periodontal patients receive non-surgical instrumentation to reduce/eliminate subgingival biofilm and calculus deposits.

  • This may be completed with either hand or powered instruments, either alone or in combination.
  • Non-surgical treatment may be performed with either traditional quadrant-wise or full mouth delivery.
  • Chlorhexidine mouthrinse may be considered for limited time periods as an adjunct to instrumentation.
  • Gross caries control and initiation of endodontic procedures.
  • Management of peri-implant disease requires referral to Periodontal department.

ADA codes considered

ADA codesDescription
222Periodontal debridement per tooth
250Active non-surgical periodontal therapy per quadrant (at least 3 teeth in quadrant CAL ≥ 3mm or PD ≥ 4mm).

Step 2b Revaluation portion

After 8 weeks the patient is re-evaluated.

If the following endpoints are met, the therapy is deemed successful and the patient may be enrolled in supportive periodontal care maintenance program and proceed with subsequent restorative/prosthetic therapy:

  • No pockets ≥ 5mm with BOP
  • No pockets ≥ 6mm
  • Full mouth bleeding score ≤ 20%

ADA codes considered

ADA codesDescription
221Clinical periodontal analysis and recording
022Intraoral radiograph per exposure
Any applicable codes from Step 1
graph TD
    A[Start] --> B{Endpoints achieved?};
    B -- Endpoints achieved --> D[STEP 4 - SUPPORTIVE PERIODONTAL CARE];
    B -- Endpoints not achieved --> C[STEP 3 - CORRECTIVE PHASE];

Perio Definitive Treatment Phase/ Step 3 Corrective phase

Only if the clincal endpoints are not achieved!

STEP 3 - CORRECTIVE PHASE

Endpoints not achieved

  • Residual pockets 4-5mm should have repeated non-surgical instrumentation.
  • Residual pockets ≥ 6mm are indicated for surgical therapy, with referral made to Periodontal department.
  • Localised residual pockets (<30% sites) may be re-instrumented by DMD, generalised (>30% sites) must be referred to Periodontal department.
  • If persistent deep periodontal pockets are present and the student is unable to determine the underlying cause, they should not simply re-instrument these sites or defer management by referring the case to incoming students in the following year. Referral must be made to the Periodontal department for specialist evaluation and management.
  • Management of peri-implant disease requires referral to Periodontal department.

ADA codes considered

ADA codesDescription
222Periodontal debridement per tooth
250Active non-surgical periodontal therapy per quadrant (at least 3 teeth in quadrant CAL ≥ 3mm or PD ≥ 4mm).
019Referral

Perio Definitive Phase / Step 4 - Supportive Periodontal Care

Endpoints achieved

  • SPC intervals between 3 & 12 months, patient dependent based on risk assessment tool https://www.perio-tools.com/pra/en/
  • Professional mechanical plaque removal
  • Repeated individually tailored oral hygiene instructions

ADA codes considered

Any applicable codes from Step 1

ImageTechniqueImageTechniqueImageRisk assessment tool
Flossing Technique QR codeFlossing TechniqueBrushing Technique QR codeBrushing TechniqueRisk assessment tool QR codehttps://www.perio-tools.com/pra/en/