Ask Kara RDH: Patient with Severe Sensitivity when Scaling

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I have a patient with extreme thermal and tactile sensitivity but has great probing depths. She qualifies for a prophy but needs to be anesthetized due to her sensitivity. Therefore, we do 1/2 mouth one visit, and the other half another visit. What insurance code would we use to bill this out as? Any suggestions besides local anesthesia to help get this patient through treatment comfortably?

Excellent questions! Both myself and Andrew Johnston, RDH, BS, one of the Today’s RDH Advisory Members and half of the A Tale of Two Hygienists podcast, worked together to answer this for you.

While local anesthetic is an option, it’s not always practical and doesn’t satisfy the reason that the patient needs to be anesthetized in the first place, for which is usually dentinal hypersensitivity. Topical anesthetics do a great job of anesthetizing gingival tissue, but this sounds like this is something different, and topical anesthetic wouldn’t be appropriate or effective for this patient.

Andrew has found a great deal of success in applying fluoride varnish first, at about an 80% success rate. It’s super messy, but effective. Andrew applies fluoride varnish, allows it to sit for five minutes, then begins scaling with an ultrasonic, followed by hand instrumentation. It should be noted that this option isn’t the best for your suction lines. Alcohol wipes will remove varnish from stainless steel instruments. However, alcohol does pose a corrosion risk if used regularly, and I wouldn’t recommend using alcohol wipes on sharpen-free instruments whatsoever.

In addition to the suggestion of applying fluoride varnish first, you can also try polishing first with a desensitizer paste. If exposed dentin is the cause of hypersensitivity, due to gingival recession or perhaps cervical erosion, using a product like a light-cured, resin-based desensitizer on exposed areas can relieve the patient’s sensitivity. For instance, Tokuyama Shield Force Plus is a really easy and effective option for this use. It doesn’t require isolation (i.e., rubber dam) because it doesn’t burn the gingiva upon contact, goes on green to ensure accurate placement and cures clear, takes about 30 seconds to apply, relieves sensitivity for the patient immediately, and under normal circumstances, lasts up to 3 years. While not considered a “sealant,” it is easier than a sealant to apply. If exposed dentin is the cause of hypersensitivity for this patient, this might be an excellent option for relief.

Another suggestion is to make sure you are using proper technique when it comes to scaling. Check your blade adaptation, grasp, and active stroke force. I would also suggest assessing your instruments, making sure your instruments aren’t past their prime and/or dull (depending on many factors, instruments only have a lifespan of 9-18 months). If instruments are worn out and/or dull, it requires you to use more force during your strokes, essentially “scaling harder,” and that’s neither comfortable for you or the patient. Using sharpen-free instruments require a lighter stroke when scaling so less force is needed to scale effectively, making this is a great option for the comfort of the patient and ergonomics of the clinician.

Now to address the coding issue. You can submit for two prophies (D1110), one for each visit, however, certain insurance companies might not reimburse for two at once or so close together, leaving one to be rejected, and the patient will need to pay out-of-pocket. On the other hand, some insurance carriers/plans may cover both prophies because of no “waiting period,” but then may not cover anymore for the rest of the year, again leaving the patient to pay out-of-pocket.

One idea is to book this patient’s appointment for longer, for instance, 90 minutes instead of 60, desensitize first, and maybe only use isolated local anesthesia. This, along with the use of the Unspecified Periodontal Procedure by Report (D4999) to include additional use of anesthetics and adjunct services at a price that your office has pre-determined. D4999 may not be fully covered by insurance if covered at all, and the patient should know they will need to pay out-of-pocket ahead of time for no surprises.

If you really feel you need two appointments, you have a couple of options. You can either tell your patient that due to the complexity of the situation, they can have the insurance pay for the first appointment (D1110) and then the patient can pay out-of-pocket for the second appointment (D1110). Or your office can use D4999 for the second appointment and charge a lesser rate than a full prophy would cost. I would advise that a detailed conversation is had with the dentist/owner to see what they prefer of these two options. Knowing that it is going to take time away from the hygiene production schedule, the dentist will need to be compensated in some way for this so that they aren’t losing money for that time. Don’t forget the second appointment doesn’t need to be nearly as long as the first appointment, and the first appointment doesn’t need to be nearly as long as your normal recare appointments because you’re only doing half of the mouth. Of course, document everything you do!

The last thing I feel should be addressed concerns why this patient so sensitive in the first place? Is it due to recession, clenching, or grinding, all of these in combination, something else? I ask because keeping the patient comfortable while you are scaling is of utmost importance, however, I feel that finding the definitive cause and treating based on that, could provide much-needed relief for this patient. For instance, if clenching is the problem, assessments for airway issues and tongue ties, recommending an occlusal guard, occlusal adjustments, among other treatment modalities, could be of great value to this patient. For other causes of sensitivity, check out Michelle Pielak-Gonzalez’s article found here.

I hope this helps a bit and that your patient can get some relief from her sensitivity!

SEE ALSO: Getting Down to It – Gingival Recession and Sensitivity

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Kara Vavrosky, RDHEP
Kara Vavrosky, RDHEP, is a Co-founder and the Chief Content Officer of Today’s RDH. Kara is a writer of popular articles that share practical advice and tips for hygienists, all in an informative and entertaining way. Beyond light-hearted content, Kara writes researched articles on topics in dental hygiene that educate hygienists on best practices and current protocols.

A graduate of the Oregon Institute of Technology, Kara has a deep passion for spreading knowledge about the importance of oral health and how it relates to the entire body. Kara’s passion extends to helping other hygienists understand the latest protocols, products, and research — all with the goal to push the profession forward.

Kara lives in Vancouver, WA with her fiancé Ben, and their rescued Chihuahua fur-babies, Bug & Lily. Beyond her love of dental hygiene, Kara enjoys spending time with her family, riding the Oregon dunes on her quads, and exploring the beautiful Pacific Northwest and all it has to offer.