Approved by the ADHA Board of Trustees
April 29, 1998
The American Dental Hygienists' Association
takes the following positions regarding the oral prophylaxis:
There is evidence that supragingival (above
the gumline) scaling alone can be detrimental to the total health of
an individual. There is no evidence that supragingival scaling and coronal
polishing have any therapeutic value.
The oral prophylaxis should consist of supragingival
and subgingival (below the gumline) removal of plaque, calculus, and
stain.
Only a licensed dental hygienist or dentist
is qualified to determine the need for and perform the oral prophylaxis.
The dental hygiene process (assessment, diagnosis.,
planning, implementation, evaluation) should be employed when delivering
the oral prophylaxis.
Insurance codes should be revised to more accurately
reflect current delivery of dental hygiene services.
Background
The profession of dental hygiene had its modern beginnings in the early
1900s when Dr. Alfred C. Fones determined that properly trained individuals
could provide oral health education and prophylactic care to patients
(Motley 1983). Since that time, the focus of dental hygiene services
has been, and remains to be, the oral prophylaxis Included in this area
are therapeutic scaling and root planing, and periodontal maintenance
care.
There are a number of existing definitions for
"oral prophylaxis" (see Appendix A). A common element in these definitions
is the removal of deposits from the tooth surfaces Most of these definitions
only address deposit removal from coronal tooth surfaces and the clinical
crowns of the teeth (supragingival). The American Academy of Periodontology
presents the most comprehensive definition of the oral prophylaxis as
the "removal of plaque, calculus and stain from exposed and unexposed
surfaces of the teeth by scaling and polishing as a preventive measure
for the control of local irritational factors." Darby and Walsh (1993)
suggest that the components of the routine prophylaxis should include,
but not limited to, patient/client education, supra- and subgingival
scaling, and polishing as appropriate.
Though many existing definitions of the prophylaxis
address removal of deposits above the gumline, in reality, very few
patients require only supragingival deposit removal. The National Institute
of Dental Research (NIDR) reports that close to 90% of individuals examined
in a study exhibited some calculus while 23% had supragingival calculus
(Brown, Brunelle, Kingman 1996). Sixty-seven percent (67%) of the NIDR
study participants had some subgingival calculus with or without accompanying
supragingival calculus. Additionally, the prevalence rate of calculus
was found to be 74% in persons aged 13-17 and over 90% in all older
age groups. Most notably, only 10% of specific sites examined had _only_
supragingival calculus.
Current definitions indicate that the oral prophylaxis
is performed on patients/clients with normal, healthy mouths to maintain
health and prevent the initiation of dental diseases. However, according
to the same NIDR study, over 90% of persons 13 or older experienced
some form of periodontal disease. This shows, again, that the reality
is most Americans do not have disease-free mouths. It should be emphasized
that, though calculus is not the cause of periodontal diseases, conditions
can be exacerbated by its presence. The real cause of these diseases
is bacterial plaque. Like calculus, bacterial plaque is present above
and below the gumline. However, the most virulent plaque is found below
the gumline. In order to obtain any therapeutic value, it is necessary
to remove subgingival plaque and calculus.
When periodontal disease is present, removal
of deposits on the teeth is no longer a preventive service. In the presence
of periodontal disease, periodontal debridement (therapeutic scaling
and/or root planing, also known as nonsurgical periodontal therapy)
is indicated. Often the administration of local anesthesia is required
for pain control at this level of care. These procedures can be the
definitive treatment for gingivitis or early periodontal disease, or
can be a pre-surgical treatment when disease is more advanced. Once
periodontal therapy, either surgical or nonsurgical, is complete, supportive
periodontal maintenance care is implemented. This includes continuing
care visits where the patient's oral health is monitored and debridement
procedures are performed to prevent the return to a disease state. Other
components of nonsurgical periodontal therapy and supportive periodontal
maintenance care could include subgingival antimicrobial irrigation
and treatment for dentinal hypersensitivity.
The range of dental hygiene professional services
includes all three levels of care: the preventive oral prophylaxis,
therapeutic scaling and root planing, and supportive periodontal maintenance
care. This clearly indicates the need for dental hygienists to have
assessment skills before providing any service to the patient/client.
Dental hygienists receive extensive education in this area as mandated
by the _Accreditation Standards for Dental Hygiene Education Programs_.
As stated in Standard 5.3.4, "the curriculum *must* include content
designed to prepare the student to assess, plan, implement, and evaluate
dental hygiene services as an integral member of the health team" (Commission
on Dental Accreditation 1992a). It is important to recognize that dental
hygiene education also includes an average of 600 hours of supervised
preclinical and clinical education (Commission on Dental Accreditation
1992b).
Oral health care delivered by the dental hygienist
directly involves the teeth and their supporting structures (the periodontium).
Therefore, the dental hygienist is in an ideal position to collect and
assess data on the periodontal tissues, recognize periodontal disease,
collaborate with the dentist and patient/client to determine a treatment
plan, discuss findings with the patient/client and participate in all
levels of care for periodontal disease (Darby and Walsh 1993).
The dental hygiene process of care is an important
component of dental hygiene practice. The ADHA policy 18-96 describes
the dental hygiene process of care as
Assessment: The systematic collection and analysis
of data in order to identify clients needs.
(In the Dental Hygiene Process, client may refer
to individuals, families, groups or communities as defined in the _ADHA
Framework for Theory Development_.)
Diagnosis: The identification of client strengths
and oral health problems that dental hygiene interventions can improve.
Planning: The establishment of realistic goals
and the selection of dental hygiene interventions that can move the
client closer to optimal health.
Implementation: The act of carrying out the
dental hygiene plan of care.
Evaluation: The measurement of the extent of
which the client has achieved the goals as specified in the plan. Judgement
to continue, discontinue, or modify the dental hygiene plan of care.
Periodontal disease has recently become a renewed
focus for dental researchers because of the possible links to other
conditions such as cardiovascular disease (Loesche 1994, Herzberg and
Meyer 1996, Loesche et al 1998), low birth weight infants and premature
births (Slavkin 1997). These studies are increasing the awareness of
the link between oral health and total health. Because dental hygienists
provide treatment for periodontal disease, they can contribute to a
patient's/client's overall health. Dental hygienists provide a valuable
service to the public when their skills are appropriately utilized.
Not only do they provide therapy and education to patients/clients,
but they can be instrumental in detecting oral symptoms for other diseases
such as diabetes, HIV/AIDS and oral cancer.
Another issue of importance is the use of untrained
personnel to perform coronal polishing procedures (including rubber
cup and air polishing). Polishing procedures are considered cosmetic
in nature and have no therapeutic value (Woodall 1993; Walsh 1995).
With regard to the pedodontic oral prophylaxis, it is false to assume
that coronal polishing alone constitutes preventive oral health care.
As previously cited, three quarters of children aged 13-17 have calculus
(Brown, Brunelle, Kingman 1996). Additionally, in this study the prevalence
of gingival bleeding was highest among individuals 13-17 years of age.
It is negligent practice for a dental hygienist or dentist to provide,
supervise or charge for the delivery of stand-alone polishing services
while having patients/clients believe that they are receiving a thorough
oral prophylaxis. When performed by untrained personnel, polishing procedures
can have harmful effects and may produce morphological changes in the
teeth, removal of the outer layer of enamel containing protective fluoride,
and damage to restorative materials. For a more complete discussion
of polishing procedures, refer to the 1997 _ADHA Position Paper on Polishing
Procedures_.
Insurance Issues
Insurance coverage for dental hygiene services does not accurately reflect
dental hygiene practice. The American Dental Association (ADA) _Current
Dental Terminology_, second edition (CDT-2) insurance code 01110 states
that the adult prophylaxis is "performed on transitional or permanent
dentition which includes scaling and polishing procedures to remove
coronal plaque, calculus and stains." It is intended for use on the
patient/client without periodontal disease. As previously mentioned,
the 1996 study by Brown, Brunelle, Kingman indicates there is limited
need for the adult prophylaxis code 01110 due to the limited number
of patients who have only supragingival calculus. It is unreasonable
to expect that this code corresponds to the needs of most patients/clients
since a small percentage of patients fit into this "healthy" category.
A major finding of the study is that moderate periodontal disease is
common among adult Americans. Thirty percent (30%) of individuals ages
25-34 exhibited periodontal disease and this percentage increased to
over 80% in individuals 65 or older. More advanced disease was reported
in 20% of persons under 45 years of age. In those over 45 years old,
the percentage increased until over 40% of those over 65 exhibited advanced
disease.
The ADA CDT-2 code 04910 applies only to those
patients/clients who have had active periodontal therapy and are now
in the maintenance phase. There is a large pool of patients/clients
who do not fit into any of the existing code categories for preventive
or nonsurgical periodontal services (See Appendix B). There is no accommodation
in the existing codes for the large number of patients/clients who present
with early to moderate periodontal disease, supra- and subgingival deposits,
but have yet to receive active periodontal therapy and do not require
quadrant scaling. Because the codes do not include this situation, the
propensity for insurance fraud exists. Patients/clients who require
the 04910 code are frequently seen on a three or four month interval
rather than every six months. Insurance companies often refuse coverage
for patients who require more than the "customary" two oral prophylaxis
appointments per year. In order to accommodate these patients/clients,
practitioners alternate the 04910 and 01110 codes to obtain coverage
for these individuals. Using the 01110 code for periodontal maintenance
is incorrect and may constitute insurance fraud. It is ADHA's position
that the existing insurance codes be revised. A solution to this problem
could be establishment of a series of codes that correspond to the American
Academy of Periodontology's classification of periodontal diseases.
According to the US Department of Health and
Human Services (1990), "health promotion and disease prevention comprise
perhaps our best opportunity to reduce the ever-increasing portion of
our resources that we spend to treat preventable illness and functional
impairment." Insurance companies have long supported preventive health
services. Comprehensive dental hygiene care results in the prevention
of disease and subsequent expensive treatment. Preventive services provided
by dental hygienists should be sufficiently covered by insurance companies
to motivate patients/clients to obtain preventive care on a regular
basis. This will result in savings to both the public and the insurance
companies as we know dental diseases to be nearly 100% preventable.
Legislative and Practice Issues
Currently, the removal of calculus deposits is limited by statutory
law or administrative rules to dental hygienists and dentists. The ADA
insurance code manual states that removal of supragingival plaque and
calculus is an adult prophylaxis. The earlier discussion distinguishing
between the oral prophylaxis and periodontal therapy is an important
one because of the attempts by some state legislatures and dental boards
to change the state laws and rules to allow unlicensed, untrained personnel
to perform the "oral prophylaxis". As previously mentioned, very few
patients exhibit the conditions that warrant the type of services that
correspond to the ADA CDT-2 classification of adult prophylaxis (01110).
It is essential that each patient/client be assessed for their individual
needs prior to being treated. Untrained or unlicensed personnel are
not qualified to perform this assessment.
Another consideration when distinguishing between
the oral prophylaxis and periodontal therapy is that periodontal disease
can be either generalized or localized. In other words, a patient/client
could have a few areas with disease and an otherwise healthy periodontium.
It is questionable that an untrained or unlicensed individual will be
able to determine which areas need the oral prophylaxis and which need
therapeutic scaling and root planing. The oral prophylaxis is an integral
part of comprehensive dental hygiene care. The dental hygienist must
enact the dental hygiene process of care (assessment, diagnosis, planning,
implementation, and evaluation) in the context of delivering a thorough
oral prophylaxis. Therefore, the oral prophylaxis should not be provided
by anyone other than a licensed dental hygienist or dentist who has
the ability to employ all components of the dental hygiene process.
By allowing unlicensed and untrained personnel to perform dental hygiene
services, the public is at risk for poor oral health care.
Conclusion
Dental hygienists are licensed preventive oral health professionals
educated to perform educational, clinical, and therapeutic services
to the public. Central to dental hygiene practice is the oral prophylaxis
that includes removal of supra- and subgingival deposits from the tooth
surfaces in order to restore and maintain oral health. Dental hygiene
is a profession of complex competencies requiring the practitioner to
apply knowledge and skills in making decisions about patient care. The
dental hygienist receives extensive education and must pass a national
cognitive examination and a state or regional clinical board in order
to become licensed. In most states, dental hygienists must meet mandatory
continuing education requirements for relicensure. Allowing unlicensed
individuals to perform dental hygiene services is placing the health
of the public at risk.
The insurance codes for dental hygiene services
do not accurately reflect delivery of dental hygiene services. Fraudulent
insurance claims and inadequate coverage for patients/clients' are problems
inherent in the existing ADA CDT-2 code structure. Additionally, inadequate
coverage may lead to patients/clients choosing to forego needed care
because their policy will not cover additional therapeutic services.
Ultimately, this leads to increased cost for more extensive treatment
due to the lack of maintenance care. Reevaluation and restructuring
of the current insurance codes is necessary in order to insure that
patients/clients receive the comprehensive care they need. Restructuring
the ADA CDT-2 codes will assist the oral health care provider to meet
the needs of the patient/client while reducing cost to insurance companies.
Appendix A
Existing Definitions for Oral Prophylaxis*
The removal of plaque, calculus, and stains from the exposed and unexposed
surfaces of the teeth by scaling and polishing as a preventive measure
for the control of local irritants (American Academy of Periodontology,
1992).
The oral prophylaxis means those specific treatment
procedures aimed at removing local irritants to the gingiva, including
complete calculus removal with bacterial debridement (Wilkins 1994).
A series of procedures whereby calculus and
other accretions are removed from the clinical crowns of the teeth,
and the clinical crowns are polished (Zwemer 1993).
* This is not a comprehensive list of definitions
for oral prophylaxis. ADHA acknowledges there may be other existing
definitions.
Appendix B
Insurance Codes Relating to Preventive and Nonsurgical Periodontal Services
01110 prophylaxis--adult A dental prophylaxis
performed on transitional or permanent dentition which includes scaling
and polishing procedures to remove coronal plaque, calculus and stains.
Some patients may require more than one appointment or one extended
appointment to complete a prophylaxis. Document need for additional
time or appointments.
01120-prophylaxis--child Refers to routine dental
prophylaxis performed on primary or transitional dentition only.
04341--periodontal scaling and root planing,
per quadrant This procedure involves instrumentation of the crown and
root surfaces of the teeth to remove plaque and calculus from these
surfaces. It is indicated for patients with periodontal disease and
is therapeutic, not prophylactic in nature. Root planing is the definitive
procedure designed for the removal of cementum and dentin that is rough,
and/or permeated by calculus or contaminated with toxins or microorganisms.
Some soft tissue removal occurs. This procedure may be used as a definitive
treatment in some stages of periodontal disease and as a part of pre-surgical
procedures in others.
04355--full mouth debridement to enable comprehensive
periodontal evaluation and diagnosis The removal of subgingival and/or
supragingival plaque and calculus that obstructs the ability to perform
an oral evaluation. This is a preliminary procedure and does not preclude
the need for other procedures.
04910--periodontal maintenance procedures (following
active therapy) This procedure is for patients who have completed periodontal
treatment (surgical and adjunctive periodontal therapies exclusive of
04355) and includes removal of the bacterial flora form crevicular and
pocket areas, scaling and polishing of the teeth, and a review of the
patient's plaque control efficiency. Typically, an interval of three
months between appointments results in an effective treatment schedule,
but this can vary depending on the clinical judgment of the dentist.
When new or recurring periodontal disease appears, additional diagnostic
and treatment procedures must be considered. Periodic maintenance treatment
following periodontal therapy is not synonymous with a prophylaxis.
Source: American Dental Association _Current
Dental Terminology_, Second Edition, 1 995.
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