Scaling and arrestin for 4mm pockets?

I recently went for my regular 6mo cleaning. I am new to the area I am a new patient to this practice. They were running a "special" for new patients, x-rays, exam and cleaning for $49.00, excluding any perio issues. My hygienist found 7 4mm and two 5mm pockets, all non-bleeding. (All were 1-3 at my last visit). She wants to do a scaling and place Arrestin in all of the pockets. Does this seem excessive? My husband had a few 5mm pockets , which were bleeding, they were reducedd to 3mm with a regular cleaning and rinsing with Chlorhexidine. I will do what I need to in order to maintain good oral health, as I am a monster grinder and worry about developing periodontal disease. I have had moderate pocketing (4mm)in the past, which my Dentist said was do do the bruxism. After having my teeth cleaned and a night guard made, they returned to normal (1-3). I can't help but to feel that at $125 per quadrant, and $50.00 per Arrestin, that this treatment may be more about money. I would appreciate any feedback. Thanks!

chris in Moreno Valley, California said: I recently went for my regular 6mo cleaning. I am new to the area I am a new patient to this practice. They were running a "special" for new patients, x-rays, exam and cleaning for $49.00, excluding any perio issues. My hygienist found 7 4mm and two 5mm pockets, all non-bleeding. (All were 1-3 at my last visit). She wants to do a scaling and place Arrestin in all of the pockets. Does this seem excessive? My husband had a few 5mm pockets , which were bleeding, they were reducedd to 3mm with a regular cleaning and rinsing with Chlorhexidine. I will do what I need to in order to maintain good oral health, as I am a monster grinder and worry about developing periodontal disease. I have had moderate pocketing (4mm)in the past, which my Dentist said was do do the bruxism. After having my teeth cleaned and a night guard made, they returned to normal (1-3). I can't help but to feel that at $125 per quadrant, and $50.00 per Arrestin, that this treatment may be more about money. I would appreciate any feedback. Thanks!

Hi, I am going to agree with you, i am a hygienist and find that if the hygienist that finds all of this stuff is working on a commission type of job, alot of unnecessary stuff is diagnosed. If your pockets are not bleeding, it is an indication of it being stable and more frequent recare appts are warranted, if they are bleeding it means unstable pockets and further treatment may be needed.

Thank you so much for the quick response. I thought it was a little much- but as I am overly cautious with my oral hygiene, I have made an appointment with the Periodontist. Better to be safe than sorry. The dental world needs more honest people like you!

chris in Moreno Valley, California said: I recently went for my regular 6mo cleaning. I am new to the area I am a new patient to this practice. They were running a "special" for new patients, x-rays, exam and cleaning for $49.00, excluding any perio issues. My hygienist found 7 4mm and two 5mm pockets, all non-bleeding. (All were 1-3 at my last visit). She wants to do a scaling and place Arrestin in all of the pockets. Does this seem excessive? My husband had a few 5mm pockets , which were bleeding, they were reducedd to 3mm with a regular cleaning and rinsing with Chlorhexidine. I will do what I need to in order to maintain good oral health, as I am a monster grinder and worry about developing periodontal disease. I have had moderate pocketing (4mm)in the past, which my Dentist said was do do the bruxism. After having my teeth cleaned and a night guard made, they returned to normal (1-3). I can't help but to feel that at $125 per quadrant, and $50.00 per Arrestin, that this treatment may be more about money. I would appreciate any feedback. Thanks!

I am a hygienist and frankly it's hard to tell,but I am leaning toward your gut feeling..arrestin is not all that effective, chlorohexidine is. Been practicing many years and trend is to do quads a lot more frequently than in the past, and some of the more agressive dentists are capitalizing on that.I think it is a little overkill in far too many cases. But the idea is to prevent periodontal disease from progressing, which is good, of course. However that is what I do as a routine cleaning, for someone with 4-5 mm pockets. If the bruxing is the culprit, it is a mechanical loss of bone, not chemical, so antibiotics would not really be necessary, (nor the quad scaling). Hope that helps!

I am a hygienist also, and I have used both arestin and chlorhexidine(CHX) with scaling and root planing (SRP.) I have found both to be effective, but rinsing with CHX will NOT get to the base of a 5mm pocket. I am going to assume that because you do not have bleeding, you do not have any subgingival calculus present. What I have found to be equally effective and will keep your pockets healthy in between professional cleanings is a waterpick. You can use plain water in it for daily use, then a couple of times a week, place about 1 oz of CHX in with the water and irrigate your gums. I have seen more patients' pockets reduced and maintain healthy gums with this method. By the way, if you do have SRP's done, the standard of care to determine if you do need them is 4mm pockets. Besides just the pocket depth, the hygienist should be looking for presence of bleeding/pus, the color of the tissue, the texture of the tissue, and recession to determine the total clinical attachment level. Instead of quad scaling ( 4 or more teeth), they can perform localized scaling on just the individual pockets (1-3 teeth) and charge out per tooth D4342/D4341. Hope that helps, if you need more info, email to sdavisrdh@yahoo.com. Keep wearing the nightguard!

I would to thank everyone for their feedback. I went to see a Periodontist who assured me that I do not need the suggested tx. I do have 2 5mm pockets wihout bleeding. He feels this is probably due to the bruxism. He suggested a routine cleaning, no SRP or Arrestin. He also told me that as long as I keep up with my current home care, I will be fine with a 6mo recall. I'm more comfortable with a 4mo recall, so I think I'll go with that. Again, thanks for the honest advice. Between the people I've met here, and the Periodontist I met with today, my faith in finding honest dental professionals has been restored.

I would be interested in knowing what the office that recommended the Arrestin and quads has to say now that you have seen a periodontist. I am glad you were proactive in your oral health care. I wish more patients were like you.

I have not contacted them. I don't think I would get any type of response. When I told the office manager who went over the cost of treatment with me that I was going to see a Periodontist, she responded by saying, "OK, then we're done here for today". She then got up and left the room. I have an appointment with another general practice this Tuesday,(the perio office does not do cleanings, only surgeries) hopefully I will finally get my teeth cleaned!

Her comment, we're done for today, was abrupt at best. I suggest you share your concerns and why briefly with the dr at the time of the exam when you go for your cleaning and request perio depths at your next check-up to be sure you aren't getting into trouble. If an office knows you are communicating with a periodontist, they will be more apt to be honest. Also just for thought, I have found time and time again if a dr recommends a certain periodontist, you will get a more objectionable opinion if you go to someone he didn't recommend. Get my drift?

I picked my own Periodontist. I am borderline obsessive with my dental care as I am a terrible clencher/grinder, and have had some 4-5mm pockets in the past. After looking at my x-rays he asked "Why were you referred here?" I explained the situation, and that I previously worked as a certified DA. He said I had three 5mm pockets, and that he wouldn't recommend anything more than a routine cleaning. I even asked if a 3 or 4mo recall would be appropriate and he said it was unnecessary as long as I keep up with my home care. I think from this point on, I will go with a 4mo recall just to be safe. Without saying that the other office was looking to generate money, he did say that as "As a former assistant, I'm sure you're aware that in offices where hygienists are offered "incentives" they sometimes have a tendency to "over-treat."

Good for you! I love the tactful way your dr commented on the tendency to "over treat". Hopefully you are on a path of excellent oral health care with qualified staff, and with your background you can see to it! Thanks for sharing the outcome.

I had some 4 and 5 mm pockets that I had root scaling and planing for. After a 6 mo recall, I still have some of these 5 mm pockets. One of them is red and inflamed, but does not bleed when I floss or brush...does this mean it is stable?? I do have some mild bone loss and I plan on going to another dentist that recommended an emdogain treatment. I have researched this and it seems promising. It is better than what the perio wanted to do: fillet my gums open like a fish. Why isn't using a perioscope the standard of care?? Most dentists scrape around the gums blindly...any takes on this??

Tami, Did your hygienist explain that Arrestin is not a guarantee for attachment regrowth? I have used it before, sometimes successful and often not. You should have been evaluated at 1 month post scaling and root planing and then either a 3 or 4 month recall, not 6 months. The fact you still have 5mm pockets is not surprising. The fact that one is red and inflamed is just part of perio disease process. Perio is never stable. It can progress rapidly even if you are doing your part at home and keeping up with a 3 month recall. Every case is different. I don't know what emdogain tx is. Never heard of it. The reason a periodontist wanted to lay a flap is because he knows you have subgingival calculus that cannot be removed any other way. When he lays your gums back he can get to the base of the pocket which promotes regrowth of attachment. As long as there is any calculus you will not get complete healing and there is a very good chance that pocket will get deeper. You can ask for Peridex, a rx to use at home. It helps alot.

I believe Emdogain is a bone-graft material used for bone loss with furcation involvement and tissue regeneration.

Thank-you. I was researching on the internet and you are right!

You're welcome.

some one could tell me if there are any good and honest Periodontist in Broward county or Miami dade in florida thanks a
lot good information here

I recently visited a dentist after not seeing one for three years (due to not having any insurance). In the past I have been told that I had the beginning stages of periodontal disease and to make sure I flossed daily to eliminate more problems. This recent visit (with a new Dentist) it was suggested I have a deep cleaning and was told in advance that there could be extra cost if Arrestin was needed in the pockets. I brush and floss regular 3-4 times a day and do not have bleeding. After my cleaning I was told I had 2-5mm pockets and 12 pockets that were 4mm or below. I asked if these 4 mm pockets would heal on their own with proper brushing and flossing now that the SRP had been done. I was told NO and that I needed Arrestin in all the pockets to kill the bacteria. I was also told that the maximum amount they would place would be 16 pockets so I was very surpised to learn I needed so many. None were placed in any of the front teeth or incisors, would it make sense that 14 needed to be placed in molars?After reading some of the postings on this site I have to wonder if $800 (out of pocket) later more work was done than actually needed. My husband is scheduled for the same cleaning later this month and we would like to know in advance if all this is really necessary.

Hi Linda, Some feel Arestin is good and others think it's not as great as portrayed by Dentist's , etc. I know that in some offices they split the Arestin in 2 and place 1/2 in each pocket. If you find that they are "taking you for a ride" on this...another suggestion might be to schedule prophy's 3x's a year. I would ask if (maybe at no cost to you) that the hygienist could possibly schedule a short appointment in 2 weeks to see what the depths are...? If you're not happy with this office and they "push" items at you , maybe find another office (through friends)...Good Luck 4mm pockets I feel are borderline, so I would also suggest asking about your history of perio (if any).

There is also another method out there called PerioProtect. This is a localized antimicrobial/antibiotic system in which the patient wheres prefabricated mouth trays, usually 2xday for 30mins or as directed depending on the severity of the perio condiditon. This route is still expensive because of the fabrication of the trays but once you have them, the gel and antibiotic (vibromycin) which are used are about $30 which lasts over a couple months. Not all offices offer this procedure as they have to go to a seminar to take a course on this method. The one dentist I work for uses it and I find that it has a higher effective rate than Arestin does because it is constantly killing the pathogenic bacteria at the base of the pocket instead of a once and done treatment.

smiledivaRDH in Schnecksville, Pennsylvania said: There is also another method out there called PerioProtect. This is a localized antimicrobial/antibiotic system in which the patient wheres prefabricated mouth trays, usually 2xday for 30mins or as directed depending on the severity of the perio condiditon. This route is still expensive because of the fabrication of the trays but once you have them, the gel and antibiotic (vibromycin) which are used are about $30 which lasts over a couple months. Not all offices offer this procedure as they have to go to a seminar to take a course on this method. The one dentist I work for uses it and I find that it has a higher effective rate than Arestin does because it is constantly killing the pathogenic bacteria at the base of the pocket instead of a once and done treatment.

Do you find staining a problem to the teeth with this product: perio protect? I find that Chlorohexidine did stain and alot of times its tenacious to scale. Unfortunately, a lot of Dr.'s today (not all) push procedures $$$$. How long has this product been on the market?

I've read some of blogs here and wanted to comment. If you are in doubt about a treatment always get a second opinion. Get a copy of your x-rays and get a consultation. Most offices wont charge you. Legally with insurance you can do scaling when there are 4mm pockets. I personally will have to check xrays to determine if scaling is needed on 4mm pockets. X-rays are your friend for diagnosing perio. As far as Arestin I offer it and tell pts it can help. I have had pts that didn't respond to it. But its cheaper to try that 1st then to have gum surgery. I don't want to step on toes but some are all about the money and scale 4mm pockets when it really was not needed. But majority of us are honest and want what is best for our pts. And when treatment is recommended ask why.

hyg sucks in Richmond, Virginia said: I've read some of blogs here and wanted to comment. If you are in doubt about a treatment always get a second opinion. Get a copy of your x-rays and get a consultation. Most offices wont charge you. Legally with insurance you can do scaling when there are 4mm pockets. I personally will have to check xrays to determine if scaling is needed on 4mm pockets. X-rays are your friend for diagnosing perio. As far as Arestin I offer it and tell pts it can help. I have had pts that didn't respond to it. But its cheaper to try that 1st then to have gum surgery. I don't want to step on toes but some are all about the money and scale 4mm pockets when it really was not needed. But majority of us are honest and want what is best for our pts. And when treatment is recommended ask why.

Hyg Sucks,

I agree with your approach. Although I'm an assistant now, I will be I have had slight exp dealing with perio. I'd love some advice from you on how to make the most of my dental hygiene program which I'm starting in the fall at a dental school in DC. Thanks!

afuturedentist@gmail.com

hyg sucks in Richmond, Virginia said: I've read some of blogs here and wanted to comment. If you are in doubt about a treatment always get a second opinion. Get a copy of your x-rays and get a consultation. Most offices wont charge you. Legally with insurance you can do scaling when there are 4mm pockets. I personally will have to check xrays to determine if scaling is needed on 4mm pockets. X-rays are your friend for diagnosing perio. As far as Arestin I offer it and tell pts it can help. I have had pts that didn't respond to it. But its cheaper to try that 1st then to have gum surgery. I don't want to step on toes but some are all about the money and scale 4mm pockets when it really was not needed. But majority of us are honest and want what is best for our pts. And when treatment is recommended ask why.

Do you do a gross debridement as routine care if a pt hasn't had tx in awhile and only has a few 4mm? I like to and then see how well they are at home care and how the pocket depths are say in a 1 month eval. I have worked for dds before that jump on perio for the $$ when the gums are so swollen you aren't getting accurate probing depths. If it's on the x-rays, I don't have a problem starting with quads, but sometimes I don't think it's necessary right off the bat. I will recommend pt's see a periodontist if they seem uncertain or if most of the mouth is 6mm and deeper. I have encountered dds who flip out when I send "their" pt to a specialist. They want to keep that $$ in their hands.

I would love to do gross debridement more often but insurance co don't want to pay for it. In those cases a just do quads but I will do it if I have no choice. I think 4mm pockets can be speudo pockets and going straight to quads might be costly to the pt. I had pts whose teeth I had to hold to scale and the DDS refused to refer them out. I think as long as we are on the ball our pts when benefit from us and get their perio on track. I am a big reader and love new things. These can be beneficial to our pts.

Arestin placed in pockets of 5mm or more. not 4. all commissioned hygienists do not over sell. Really nice comment. take a course, READ

Everyone should take the time out to read new materials that come out on perio. Most hyg do. I like doing CEs on perio. Not sure what the comment for read was for. Things are always changing it is good to be up to date with your info so you can relay info to pt.

exp in Massachusetts said: Do you find staining a problem to the teeth with this product: perio protect? I find that Chlorohexidine did stain and alot of times its tenacious to scale. Unfortunately, a lot of Dr.'s today (not all) push procedures $$$$. How long has this product been on the market?

This product has been on the market for several years now. I do not notice staining that can be solely contributed by this product. It uses the vibromycin vs. the chlorehexedine. It can be a great tool if the pts are compliant and wearing the guards regularly.

smiledivaRDH in Schnecksville, Pennsylvania said: This product has been on the market for several years now. I do not notice staining that can be solely contributed by this product. It uses the vibromycin vs. the chlorehexedine. It can be a great tool if the pts are compliant and wearing the guards regularly.

Hi Smilediva, Thank you for the above info. regarding perio protect. Can you please inform us on this site more About this product , you mention wearing guards? (and or website...)

Thank you to all for all the valuable information. I am a patient at the beginning stages of determining a plan to control my periodontal problems. I have been advised by a dentist that a full mouth scaling & root planing (SRP)would be highly recommended. I have also been researching the Pero Protect System mentioned in this thread (www.perioprotect.com)
My questions:

1. Should/can SRP's be used in conjunction with the Perio Protect System for more effectiveness?
2. If so, which procedure would be recommended to be performed first - the SRP; or a predetermined time period on Perio Protect first, and then the SRP's?

Thanks again!!

If a SRP was suggested then you should have it done. The tartar and unhealthy bacteria needs to be removed or your condition could get worse. I haven't researched the perio protect but I am going to look into it.

Just read the perio protect info. Like I said I'm not familiar with it. When a pt is perio the 1st step is removing the tartar and bacteria. That is done through SRP and antibacterial med. Most offices have a rinse, some have Rx meds for the pt to take, or antibiotics are placed in the pockets. That office seems to have a tray filled with an antibacterial gel. I believe if you do the SRP in combination with the perio protect it should help with your perio. If the SRP and meds doesn't work then the DDS will refer you out to a specialist.

I have been told that I need root planing by the hygenist at my recent cleaning. She did take x-rays but did not measure the pockets at all. I'm leary about this procedure without pockets being measured. I've been going to this office for a number of years but recently they moved to a new and very upscale location. I'm wondering if costly procedures will help with the rent. Am I being unreasonable?

diane in Batavia, Illinois said: I have been told that I need root planing by the hygenist at my recent cleaning. She did take x-rays but did not measure the pockets at all. I'm leary about this procedure without pockets being measured. I've been going to this office for a number of years but recently they moved to a new and very upscale location. I'm wondering if costly procedures will help with the rent. Am I being unreasonable?

I would ask to have a full-mouth probing: listen for 4 and 5 mm pockets; also , ask why, now , do you need this procedure, and that it was not mentioned in the past? Ask the R.D.H. to look back in the perio charting notes, to see what teeth, and where they are (teeth 1-16 are upper right to upper left, and 17-32 for lower left to lower right), ask which teeth she feels need SRP (scaling and root planning, write them down). Ask the cost,etc. have your questions in hand and take note of "teeth"....GL You may need it and again you may be right in your feeling as to the above.

I'm a hygienist and arestin works only with pt. compliance. You have to floos your teeth properly. If not arestin will not work. I don't like using the arestins but where I work he wants us to sell,sell,sell. If a pt. has 4mm pocket with or without bleeding , he wants them to be on perio. maint and places arestin. I disagree, and as we all know , you NEVER disagree with your boss.

How do you deal with a pt that you feel only needs srp in three quads? do you charge for three quads then just clean the fourth on one of the visits. like today for example one of the other hygienists in the office did the new pt exam and said the pt needed an srp on LL and then clean the rest of the mouth at the same time and they only gave me one hour. I really needed an hour and a half to take BP give anes educate plus do a good job removing calc and stain. sometimes if the pt needs more than just a reg cleaning they charge for one quad. Is that normal? I have only worked about 15 days as a hygienist. I just want to do what is right for the patients. I thought that full mouth debridement was never proper tx as the gum tissue can tighten leaving subging calc plaque and bacteria, possibly causing ging abcess. any advise????

Sometimes by looking at x-rays you can tell a scaling is needed. I personally show the pt their xray and explained why. I don't always do the perio charting then because it is more comfortable to do it when the pt is numb. I can get more accurate readings that way. Some hyg do the readings after they scale so they can get better readings. If a pr only needs srp in three quads you only charge for three quads. Insurance is only going to pay for those three quads. You can't charge for a pt for srp if their 1-3mm readings. That is healthy. You can do a gross debri and have the pt come back for a prophy. I like to have the pt come back for a perio maintenance after a srp. Once you have a srp you are perio and will always be perio and will have to be charge as such. Insurance fraud is committed when you charge a pt for srp and they are not perio. Remember your name is on the line also when that office commits fraud.

hyg sucks in Richmond, Virginia said: Sometimes by looking at x-rays you can tell a scaling is needed. I personally show the pt their xray and explained why. I don't always do the perio charting then because it is more comfortable to do it when the pt is numb. I can get more accurate readings that way. Some hyg do the readings after they scale so they can get better readings. If a pr only needs srp in three quads you only charge for three quads. Insurance is only going to pay for those three quads. You can't charge for a pt for srp if their 1-3mm readings. That is healthy. You can do a gross debri and have the pt come back for a prophy. I like to have the pt come back for a perio maintenance after a srp. Once you have a srp you are perio and will always be perio and will have to be charge as such. Insurance fraud is committed when you charge a pt for srp and they are not perio. Remember your name is on the line also when that office commits fraud.

do you alternate between a pm and pro. after they have gone through sc/rp?

This is all so exciting. Hygienists really play an imp role in oral health:) I'm in my 1st semester of hyg and I'm loving it!

cavitron in Hallandale, Florida said: do you alternate between a pm and pro. after they have gone through sc/rp?

This is no longer allowed with insurance. Once perio always perio. It would be nice if you could because it would save the pt out of pocket expense when they are on a 3 or 4 MRC.

diane in Batavia, Illinois said: I have been told that I need root planing by the hygenist at my recent cleaning. She did take x-rays but did not measure the pockets at all. I'm leary about this procedure without pockets being measured. I've been going to this office for a number of years but recently they moved to a new and very upscale location. I'm wondering if costly procedures will help with the rent. Am I being unreasonable?

No, you are not! Is this the same hygienist you have been seeing? You know she should have measured those pockets so don't be afraid to call the office and ask her why she didn't. Also, if she tells you she can see it on the x-rays, don't buy it. She has to submit those measurements to your insurance for payment. If you don't have insurance, you still need the numbers to know if you are getting anywhere with your treatment or if it's progressing. Don't be afraid to tell her so. Call her on it and see what she says and you will have your answer to the new location and the money. Also, do you know the number one lawsuit in dentistry is from patients who were not diagnosed with perio or after they were did not receive proper referrals or treatment? Ask what your previous numbers were. If you get some answer that another hygienist saw you blah blah, keep in mind and tell her the same dds saw you and he/she is ultimately responsible for you oral health. Afterall, you get charged for an exam EVERY time you get a cleaning. That's why you pay for it. If she tells you she'll have doctor call you, you now have the ball in your court. You may very well need perio treatment, but maybe you needed it before. If they aren't probing (measuring) you have a lawsuit that's winnable. I know, there I go being on the patient's side again. It's what I do best! :)

PS Please let us know what happens! If the dr tells you that you have needed it for sometime, tell him in that case you expect to be getting it done at his expense since it has been their oversight. Afterall, periodontal disease is a life long disease. There is NO cure. The best you can hope to accomplish is to stay on top of it and keep it from progressivly getting worse. Who knows how much trouble you're going to have in the future from poor diagnosing!! You can also ask for referrals to periodontists to corroborate the diagnosis. Personally, I'd go to the one he says to stay away from. The ones they recommend are usually a friend and they often send patients back and forth and cover each other's backs. Good luck.

I work as an RDH and I am not a firm believer in Arestin. Periodontal disease is a chronic disease that is very difficult to treat. You CAN NOT cure periodontal disease, once you have it you have it for life. I am not even really a firm believer in quadrant scaling unless it's 5-6mm pocketing or less. Good luck trying to instrument to the base of a 7mm or > pocket and remove all of the subgingival calculus (can possibly be done by experienced hygienist, but I would say there are few out there). I am a FIRM believer that once a patient has periodontal disease they should be under the CONSISTENT and FREQUENT care of a periodontist...not a general dentist who thinks they know what they are doing. Periodontal disease is with you for life, so investing $1000 at one visit is not going to cure your disease. I see patients that would probably do fine for their whole life with 4-5mm pockets as long as they stay on a routine cleaning schedule (4-6 months). GENETICS plays a HUGE role in periodontal disease. Yes, brushing and flossing help significantly...but I see patients on a daily basis that haven't flossed a day in their life and DO NOT show any signs of periodontal disease (generalized mild to moderate gingivits). I also see patients that floss 2x daily and still cannot reduce the 4,5, and 6 mm pockets. Many factors come into play with periodontal disease....hygiene, genetics, TOOTH POSITIONING, composition of minerals in your saliva (which may allow you to build calculus/tartar quicker). They only perio procedure I would invest time or money in after 5mm is flaps. You cannot be sure the root surfaces is completely debrided unless you see it. That or a subgingival cam/microscope.

Matthew in Brighton, Massachusetts said: I work as an RDH and I am not a firm believer in Arestin. Periodontal disease is a chronic disease that is very difficult to treat. You CAN NOT cure periodontal disease, once you have it you have it for life. I am not even really a firm believer in quadrant scaling unless it's 5-6mm pocketing or less. Good luck trying to instrument to the base of a 7mm or > pocket and remove all of the subgingival calculus (can possibly be done by experienced hygienist, but I would say there are few out there). I am a FIRM believer that once a patient has periodontal disease they should be under the CONSISTENT and FREQUENT care of a periodontist...not a general dentist who thinks they know what they are doing. Periodontal disease is with you for life, so investing $1000 at one visit is not going to cure your disease. I see patients that would probably do fine for their whole life with 4-5mm pockets as long as they stay on a routine cleaning schedule (4-6 months). GENETICS plays a HUGE role in periodontal disease. Yes, brushing and flossing help significantly...but I see patients on a daily basis that haven't flossed a day in their life and DO NOT show any signs of periodontal disease (generalized mild to moderate gingivits). I also see patients that floss 2x daily and still cannot reduce the 4,5, and 6 mm pockets. Many factors come into play with periodontal disease....hygiene, genetics, TOOTH POSITIONING, composition of minerals in your saliva (which may allow you to build calculus/tartar quicker). They only perio procedure I would invest time or money in after 5mm is flaps. You cannot be sure the root surfaces is completely debrided unless you see it. That or a subgingival cam/microscope.

One thing to keep in mind is that in a periodontist's office, most often, it is a hygienist that does the initial SRP and the pmt's. We as trained hygienists are very capable of performing non-surgical periodontal treatment.

Matthew, you may be technically correct - periodontal disease is permanent by definition, BUT the inflammation can be cured. It is merely technically 'diseased' because of attachment loss that will not return. It is the inflammation that is the major concern, and folks who may have some attachment loss but no inflammation can be returned to less intensive 'perio maintenance.' This is especially so after pocket reduction surgery, in my experience, provided the self-care is excellent. In our older practice with mostly older longterm patients (many went to periodontist for surgery and SRP), we have many folks who can do fine with 6 month hygiene appts without a return of inflamm and further attachment loss. If the sulcus is only 3mm, the patient can get their brushes down the sulci, there is no perio lesioning of the firm gingiva and only light calculus building up, how does this justify continued intensive treatment? Sure, plenty need a lot more than that, but having 'periodontitis' isn't the same for everyone.

As for Arestin - I am suspicious, skeptical and open to accept a good argument for it. So far, I am not convinced it is effective and certainly not convinced it is worth the price people are charging for it. Arestin is new to this area where I live, and not commonly used at all. We do have the Periowave, which may be extremely expensive $$$$nake oil, or not. All I know is I recently attended a CE course with a prominent California periodontist, and he is more a fan of systemic antibiotics and surgery, and not a fan of Arestin or other subG antibiotics.

and 4mm pockets needing antibiotics and SRP? Ha. Could be operator error, could be pseudopocketing, could be firm, healthy gums. If doesn't bleed, I worry a LOT more for the 20 yr old with all 3mm gums bleeding like the fountains at Bellagio.

From what I have seen there are very few patients with >5-6mm pockets that respond well to a single quadrant scaling/root planing. I can break it down into 3 groups that most of the pt.'s I see fall in to.
1) scaling and root planing is performed with Arestin placement - pt. is completely non-compliant with home care (generally the reason they have 5-6mm pockets in the first place).
2) scaling and root planing is performed with Arestin placement - pt. does not respond as they are GENETICALLY PREDISPOSED to having periodontal disease
3) pt. responds well if they are absolutely diligent with home care and follow up with perio maintenance every 3 months

I see far too many smoking patients with poor hygiene that are investing thousands of dollars into scaling and root planing with Arestin when it is obvious they are not going to respond. In fact I think a prerequisite to scaling and root planing is quitting smoking. The tissue is not going to reattach to the tooth surface if it is so fibrotic and diseased from the smoking.
Also, I have yet to see any 5mm pockets that do not bleed upon probing (whether it be delayed bleeding, or pouring blood). The only time I ever see this is a malpositioning of teeth where it's basically a pseudo-probing depth due to attachment variation on two adjacent teeth).
I'm just saying pt.s with gen. 4mm pockets should not be investing money in scaling and root planing. Also, patients with severe, advanced periodontal disease should not invest money into scaling and root planing unless they are completely convinced their home care will be immaculate, and they are willing to invest the time and money to keep any achieved results stable for the longterm.

Periodontal disease is just like heart disease, it's a disease and has many factors that come into play. I just see people think of SRP as the "magic bullet" when it is so archaic as far as solid treatment for perio.

hyg sucks in Woodbridge, Virginia said: I would love to do gross debridement more often but insurance co don't want to pay for it. In those cases a just do quads but I will do it if I have no choice. I think 4mm pockets can be speudo pockets and going straight to quads might be costly to the pt. I had pts whose teeth I had to hold to scale and the DDS refused to refer them out. I think as long as we are on the ball our pts when benefit from us and get their perio on track. I am a big reader and love new things. These can be beneficial to our pts.

According to the school I went to, the periodontist I worked for for a few years, the parameters of care issued by the AAP & current literature, gross scaling is not recommended. Quadrant scaling & root planing is the perferred treatment as residual calculus & granulation tiissue promotes the developement of perio abcesses. I have seen poor healing because of gross scaling too many times in the perio office. It's really hard to be diplomatic when recommendin flap surgery or even extractions to patients because of incomplete debridement. Quadrant scaling is the optimal treatment if you cannot complete treatment at 1 time. (or series of appointments)
A non-staining chlorhexidene product is perioplus by oraldent pharma. It comes in 5 formulations. It's worth checking into.