Nonsurgical Periodontal Therapy
I treated a new patient who had not seen a dentist for 30 years. He showed signs of bone loss but not as bad as you would think. His calculus was subgingival and supragingival with heavy bleeding and high levels of sensitivity. I did not probe or perform debridement. I did not use the 4355 code. I scheduled him back for nonsurgical periodontal therapy and told him that I would either charge out localized or two quadrants of periodontal therapy. After scaling, I took pocket depths ranging from depths of 2 mm to 5 mm. I realized I should have performed periodontal debridement, then reevaluated him in 3 weeks to 4 weeks, and performed localized periodontal therapy. Was I unethical in my decision to probe after?
You asked about ethical considerations for probing following treatment vs prior. This makes me believe you view nonsurgical periodontal treatment as more of a mechanical debridement that needs to take place irrespective of probing depths or other considerations, such as nutritional status. bleeding indices, medical considerations, and behavioral issues, that could impact oral/overall health. All of these factors, along with probing depths, help determine a diagnosis for appropriate treatment. While it is true that both hard and soft deposits must be removed to successfully arrest disease, I have treated numerous patients with “normal” probing depths but with significant hemorrhaging and generalized gingivitis, or minimal hemorrhage, but excessive probing depths and risk factors that compromise outcomes. You did not mention the tissue response/or bleeding, which are classic indications of the body’s inflammatory response to pathogenic biofilm. Likewise, you did not mention other risk assessments. Reduction or elimination of risk factors is a component of successful nonsurgical periodontal therapy. This patient received a mechanical treatment, which will likely temporarily improve his clinical status, but it sounds like he may have missed understanding the complicated process of managing periodontal disease over his lifetime. This starts with understanding his diagnosis and connecting that to his overall health. Otherwise, it might be another 10, 20, or 30 years before he seeks dental hygiene care again.
The fact that you asked this question tells me you have some level of discomfort with your treatment approach. In my opinion, unethical clinicians are those who never question their protocols, or rely on nonevidence-based approaches steeped in “traditions,” not science. I applaud you for inquiring. I see this as an opportunity for growth, so the next time you examine a patient, it won’t matter how long it has been since his or her last visit. Probing depths will be one component of the data necessary to develop a comprehensive treatment plan based on diagnosis. That, in my opinion, is an ethical approach to care.