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No More Hygiene® NO Cure disease. MORE® Save lives. HYGIENE Grow your practice. Secrets of MODULAR PERIODONTAL® THERAPY NO Dr. Thomas W. Nabors,Cure disease. DDS MOStevenRE J.® AndersonSave lives. HYGIENE Grow your practice. www.TotalPatientService.com | 1-877-399-8677 Modular Periodontal Therapy® No More Hygiene | www.TotalPatientService.com | 1-877-399-8677 2 Non-Surgical Periodontal Therapy Universal Initial Visit Diagnosis Appointment for ALL Modules (60–90 minutes) (this patient could be routine, recall, or new patient) ■ D0180 Comprehensive Periodontal Exam ■ D0210 FMX ■ D0000 Intra-oral Photos ■ D0391 Microscope Slides No More Hygiene | www.TotalPatientService.com | 1-877-399-8677 3 Non-Surgical Periodontal Therapy Module I: Gingival Disease Initiation of Module 1 Therapy (60–90 minutes, ASAP after diagnosis) ■ D0415/17/18 Periodonal Pathogens Testing ■ D4346 Scaling and irrigation in the presence of inflammation *This is a full mouth code ■ D0000 Waterpik ■ D0000 Periodontal Medication CHX (Dispense 3/16 oz bottles) ■ D0000 Maintenance Rinse ■ D0000 Anesthesia (topical numbing gel) ■ D9230 Nitrous Oxide Sedation Continued Module 1 Therapy (30 minutes, 2–3 weeks after initial appointment) ■ D4921 Periodontal Irrigation Upper Right Quadrant ■ D4921 Periodontal Irrigation Upper Left Quadrant ■ D4921 Periodontal Irrigation Lower Right Quadrant ■ D4921 Periodontal Irrigation Lower Left Quadrant ■ D0000 Intra-oral Photos Routine Recare Module 1(3 months) ■ D1110 Prophylaxis ■ D1206 Fluoride Varnish ■ D0000 Maintenance Rinse D0415 No More Hygiene | www.TotalPatientService.com | 1-877-399-8677 4 Module II or III: Mild and Moderate Periodontal Disease Initiation of Module 2 Therapy (60–90 minutes, ASAP after diagnosis) ■ D0415 Periodontal Pathogens Testing ■ D4341 Scaling and Root Planing Upper Right Quadrant ■ D4341 Scaling and Root Planing Lower Right Quadrant ■ D4921 Periodontal Irrigation Upper Left Quadrant ■ D4921 Periodontal Irrigation Lower Left Quadrant ■ D0000 Waterpik ■ D0000 Periodontal Medication CHX (dispense 5/16 oz bottles) ■ D0000 Maintenance Rinse ■ D0000 Anesthesia (topical numbing gel) ■ D9230 Nitrous Oxide Sedation Continued Module 2 Therapy (60–90 minutes, 2–3 weeks after initial appointment) ■ D4341 Scaling and Root Planing Upper Left Quadrant ■ D4341 Scaling and Root Planing Lower Left Quadrant ■ D4921 Periodontal Irrigation Upper Right Quadrant ■ D4921 Periodontal Irrigation Lower Right Quadrant ■ D0000 Intra-oral Photos **Continued Therapy IF Module 3 (60–90 minutes/2–3 weeks after Continued Therapy appt.) ■ D4921 Periodontal Irrigation Upper Right Quadrant ■ D4921 Periodontal Irrigation Lower Right Quadrant ■ D4921 Periodontal Irrigation Upper Left Quadrant ■ D4921 Periodontal Irrigation Lower Left Quadrant ■ D0000 Intra-oral Photos Routine Re-Care Module 2 or 3 (3 months) ■ D4910 Periodontal Maintenance ■ D1206 Fluoride Varnish ■ D0000 Maintenance Rinse No More Hygiene | www.TotalPatientService.com | 1-877-399-8677 5 Special Notes Each Module is a recipe, if you follow it and use the ingredients it calls for, you will have success. To determine what Module your patient needs: Module 1 - AAP staging I - No loss of attachment, 3<mm pockets, bop may be present Module 2 - AAP staging II - 4> teeth, with 4>mm pockets in a quadrant, use code D4342 (1-3 teeth) instead of 4341 for that/those quadrant(s). Module 3 - AAP staging III - Pocket depths 5-7<mm, bop and/or bos Time lines given are a guideline. In office Periodontal Irrigation - use Chlorhexidine In Ultrasonic for Subgingival Irrigation. D0000 is a “dummy code”. No More Hygiene | www.TotalPatientService.com | 1-877-399-8677 6 Your Role in Modular Periodontal Therapy® If you have any questions, please call our office at: (insert office information) Products Instructions Waterpik ■ Fill tank with 200mls of Solution, use until gone ■ Use pik-pocket tip ■ Trace gum line of each tooth for roughly ■ Pressure setting 2 5 seconds, aiming into the gums Chlorhexidine (Three — 16 oz ready to ■ AM – swish, gargle, spit — 30 seconds use bottles) ■ PM – Waterpik — 2 minutes *If you get stain from this product, it will beremoved at your 2 week appointment Maintenance Rinse (use when finished ■ AM – swish, gargle, spit — 30 seconds with Chlorhexidine) ■ PM – Waterpik — 2 minutes Antibiotic (if needed we will call into ■ Use as directed on prescription label pharmacy of your choice.) No More Hygiene | www.TotalPatientService.com | 1-877-399-8677 7 Consent to Periodontal Treatment Patient Name: ______________________________________________ Date: _________________________ This informed consent and authorization is given to Dr. Thomas Nabors, III after receiving a full explanation of the nature of the proposed treatment, as well as alternatives and risks involved. The Doctor has advised me that after a full examination, I have the following periodontal condition: ❑ Gingival Disease. ❑ Mild Periodontal Disease. ❑ Moderate Periodontal Disease. ❑ Advanced Periodontal Disease. ❑ Other __________________. I hereby consent to the following therapeutic measures: ❑ Deep scaling and root debridement with ❑ Oral hygiene instructions for control of local anesthesia. bacterial plaque. ❑ Antibacterial irrigation as needed. ❑ Occlusal bite adjustments. ❑ Systemic antibiotic therapy if needed. ❑ Night grinding appliance. ❑ Pocket specific delivered ❑ Periodic maintenance therapy. antibiotic therapy. ❑ Referral to periodontist for possible surgery. ❑ Home irrigator use. ❑ Extraction of teeth #___________. Risks of Non-Treatment: In making the above recommendations, the Doctor has advised me that the prognosis for non-treatment is usually unfavorable. I have been advised that if my present periodontal condition is not controlled, the risks may include, but are not limited to: gum recession, breath odor, inability to effectively control plaque, abscesses or infections, pain, poor chewing function, tooth sensitivity, drifting of teeth, progressive destruction of supporting bone structure and periodontal tissue, bleeding gums, pus formation, premature loss of teeth, need for dentures and/or dental implants, and increased risk for certain systemic diseases. Treatment Risks: I understand that inherent to any procedure and because of individual variations, certain risks are involved with any therapy that may be used. These include, but are not limited to: minor discomfort, temporary swelling, hot or cold sensitivity, gum shrinkage, abscesses, tissue sloughing, or bleeding. I understand that the proposed treatment implies no guarantee or warranty of success. Due to individual differences, the response to treatment may vary from person to person and cannot be determined prior to therapy. I understand that the results of the proposed treatment may not be to my complete satisfaction, and that my condition may improve, remain the same, or even worsen after treatment. Additionally, I understand that the Doctor may recommend additional and/or alternative measures after completion of the proposed treatment and evaluation of results. I have been given the opportunity to ask questions about my condition and the recommended treatment, and all questions have been answered to my satisfaction. I understand that for periodontal therapy to be successful in the long term, I must commit to the following: maintain excellent oral hygiene, strictly adhere to post-op instructions and prescribed drug regimens, and honor reserved appointments for treatment and periodic maintenance visits. I consent to allow the use of my photographs and other documentation for educational and scientific purposes. Patient Name: ______________________________________________ Date: ____________________ Patient Signature: ___________________________________________ Date: ____________________ Registered Dental Hygienist: __________________________________ Date: ____________________ Doctor: ____________________________________________________ Date: ____________________ No More Hygiene | www.TotalPatientService.com | 1-877-399-8677 8 Refusal of Periodontal Treatment Refusal of Periodontal Treatment I have been diagnosed with periodontal disease and have been informed as to the nature of my I have been diagnosed with periodontal disease and have been informed as to the nature of my condition. condition. I understand that it is the recommendation of Dr. Thomas W. Nabors, III that I receive I understand that it is the recommendation of Dr. Thomas W. Nabors, III that I receive periodontal periodontal treatment. treatment. In making periodontal therapy recommendations, Dr. Nabors, has advised me that the prognosis for In making periodontal therapy recommendations, Dr. Nabors, has advised me that the non-treatment is usually unfavorable. I have been advised that if my present periodontal condition is prognosis for non-treatment is usually unfavorable. I have been advised that if my present not controlled, the risks may include but are not limited to: gum recession, breath odor, inability to effectively control plaque, abscesses or infections, pain, poor chewing function, tooth sensitivity, drifting periodontal condition is not controlled, the risks may include but are not limited to: gum of teeth, progressive destruction of supporting bone structure and periodontal tissue, bleeding gums, pus recession, breath odor, inability to effectively control plaque, abscesses or infections, pain, poor formation, premature loss of teeth, need for dentures and/or dental implants. chewing function, tooth sensitivity, drifting of teeth, progressive destruction of supporting
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