Does anyone in real life refer to perio?

[phremius]

I've been trying to figure this out for a while now, when I was in dental school everything that had like a deep pocket or questionable prognosis got referred for a "PG Perio consult". When I was in residency our perio days where marked by periodontists who came in and performed these pretty simple procedures but with high-falutin suturing nomenclatures. Now that I'm a practicing dentist, I can't figure out when the last time I even talked to one...

Granted, I'm at a bread and butter type of dental practice, but I do enough "big cases" and place a couple of implants here and there, but for the most part I can't ever recall coming across patients or cases that required the services of a local periodontist... my complex implants are referred to oral surgeons, flap debridements are done in-house (and I feel should be a part of dental school curriculum due to how straightforward they are). As for the soft tissue grafts, well, the few instances where they came up the patients all pretty much decided to just deal with the recession or pay for a class V when they sat down with the periodontist and found out what the fees are.

I'm not trying to flame anything, but I just can't figure out how perio figures into the whole equation! Would that specialty even exist if they didn't brand themselves as "implant-specialists"? But somehow it just seems more nature for my OS guys to place the challenging 'plants. Any other practicing dentists have this issue?

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[Streetwolf]

Anything a GP doesn't either (1) want to do or (2) feel they can do at an acceptable level, should be referred to the periodontist. Either you are pretty confident and/or good at the procedures you've had to do or you just haven't run across anything complex enough yet would be my guess.

But also, you mentioned that patients have seen periodontists and been turned off by the fees involved. That means you've made at least some referrals.

 

[charlestweed]

GPs refer to periodontists for:

1. Dental implants and complex implant cases that require bone graft and sinus lift. Not all GPs can place implants. Actually, there is only a small percentage of GPs who know how to place implants.
2. Patients who have advance perio diseases either because of the poor oral hygiene or because of the pt’s GPs who ignore the perio diseases and focus too much on bread and butter procedures such as fillings, crowns and bridges.
3. Perio diseases that were improperly managed by other GPs….use of periochip/periostat is not a proper way to manage the perio disease.
4. Patients with mess up dentition because they have not seen a dentist for a long time. When seeing such case, some inexperienced GPs don’t know where to begin, which teeth can be saved, which teeth need extraction…so they dump the patients to periodontists. GPs refer the patients whom they don’t like to treat (crazy, drug addict, medically compromised) to perio….just like when they refer the crying kids to pedo.
5. Crown lengthening. Sure, the GPs can perform this but the GPs don’t get paid much for doing this if their patients have HMO.
6. Implant cases that were improperly placed and restored by other dentists, perios, or OS.
7. For a 2nd opinion because the OS they refer to charge too much.

 

[phremius]

I know what perio does and why GPs refer to them. I'm starting to not believe in perio as a profession.

1) Patients for the most part do NOT like being referred, and referrals create communications issues and extra burdens for all parties and contribute to the escalating cost of dentistry overall. Net societal detraction.

2) I have yet to see anything that perio does that ONLY requires perio! With maybe the exception of soft tissue graft, which to me is such a miniscule percentage of procedures.

3) Proper management of perio is a matter of training, surgical debridement and osseous recontouring are relatively simple, and can easily be integrated into the repertoir of the general practitioner. Hell add it to the dental school curriculum, sure you're not going to be super proficient at it from the get go, but what are you super proficient at when you first start out? It's all a matter of getting enough patient encounter repetitions under your belt.

4) Everything and all things implants included I feel can be handled by the adequately trained GP, though from a business perspective it might not make sense to keep all the implant/parts/sizes stocked for a GP; or super complex stuff, punt to O/S, whom a GP is already likely to have a relationship with due to referrals for wizzies and etc.

5) As far as dumping patients, ahh the joy of private practice is the dismissal! Nothing makes me happier than telling the PITA patient "I don't think I'm the right dentist for you".

Granted, I've only run my practice for a short while, but I just don't understand how perio is a specialty in itself, rather than something more "niche" like, oral medicine.

 

[Mackchops]

Granted, I'm just a dental student, but from my perspective I think all the dental specialties are super-niche. You mention perio, but what about pros? How often do you refer to pros? How does endo survive with the implant craze these days -- I'm sure they're doing less retreats and apicos now.

I think they all survive and do well. Perio probably would be in a lot more trouble if they hadn't taken up the implant reigns, but even pure pros and endo practices are doing just fine and even thriving!

 

[charlestweed]

I know what perio does and why GPs refer to them. I'm starting to not believe in perio as a profession.

You don't but there are a lot of GPs who strongly believe in perio. Because perio diseases are largely ignored by both patients and many general dentists (and orthodontists too), perio diseases continue to be the leading cause of tooth loss. Many dentists have used implants to replace missing teeth and implant dentistry has become an important part of periodontics.

1) Patients for the most part do NOT like being referred, and referrals create communications issues and extra burdens for all parties and contribute to the escalating cost of dentistry overall. Net societal detraction.

There are patients who like to get all the dental treatments done at one GP office. There are also plenty patients who trust their GPs' recommendation and seek care at another specialty practice.

2) I have yet to see anything that perio does that ONLY requires perio! With maybe the exception of soft tissue graft, which to me is such a miniscule percentage of procedures.

You feel this way because you never regard perio as a specialty.

3) Proper management of perio is a matter of training, surgical debridement and osseous recontouring are relatively simple, and can easily be integrated into the repertoir of the general practitioner. Hell add it to the dental school curriculum, sure you're not going to be super proficient at it from the get go, but what are you super proficient at when you first start out? It's all a matter of getting enough patient encounter repetitions under your belt.

Not every dentist is as proficient as you are. Not every dentist likes to touch the no. 15 blade. Not every dentist wants to deal with emergency calls after business hour. Many GPs are afraid of getting sued for performing the procedures that they are not familiar with. Many GPs hate treating crying kids and this is why many pedos can afford to drive Mercedes Benz. Many GPs hate doing time-consuming molar endo procedures, this is why many endos live in big mansions.

4) Everything and all things implants included I feel can be handled by the adequately trained GP, though from a business perspective it might not make sense to keep all the implant/parts/sizes stocked for a GP; or super complex stuff, punt to O/S, whom a GP is already likely to have a relationship with due to referrals for wizzies and etc.

Many GPs prefer perios to place implants for their patients because perios usually spend more time communicating with the GPs (perio schedule is usually lighter than OS schedule). Many perios are willing to come to the GPs offices to place implants and to teach the GPs how to restore implants. Patients with periodontally involved teeth are usually referred to perio (not to OS); therefore, periodontists have the opportunity to diagnose and tx plan for implant placement and restoration….and the tx recommendation will then be discussed with the referring GPs. The OS usually get the implant cases on patients who already lost their teeth. Both OS and perios are good at implant placement…the one who has better communication with the referring GPs is the one who gets more implant cases.

5) As far as dumping patients, ahh the joy of private practice is the dismissal! Nothing makes me happier than telling the PITA patient "I don't think I'm the right dentist for you".

Periodontists don't just see every PITA patient that is referred to their office. To be seen, the patient must first pay the consultation fee (this fee is usually credited toward the tx fee if the patient accepts the recommended tx). If the patient refuses to pay such consultation fee, then he/she is not very serious about his/her oral health.

 

[mike3kgt]

You don’t but there are a lot of GPs who strongly believe in perio. Because perio diseases are largely ignored by both patients and many general dentists (and orthodontists too), perio diseases continue to be the leading cause of tooth loss. Many dentists have used implants to replace missing teeth and implant dentistry has become an important part of periodontics.

There are patients who like to get all the dental treatments done at one GP office. There are also plenty patients who trust their GPs’ recommendation and seek care at another specialty practice.


You feel this way because you never regard perio as a specialty.


Not every dentist is as proficient as you are. Not every dentist likes to touch the no. 15 blade. Not every dentist wants to deal with emergency calls after business hour. Many GPs are afraid of getting sued for performing the procedures that they are not familiar with. Many GPs hate treating crying kids and this is why many pedos can afford to drive Mercedes Benz. Many GPs hate doing time-consuming molar endo procedures, this is why many endos live in big mansions.


Many GPs prefer perios to place implants for their patients because perios usually spend more time communicating with the GPs (perio schedule is usually lighter than OS schedule). Many perios are willing to come to the GPs offices to place implants and to teach the GPs how to restore implants. Patients with periodontally involved teeth are usually referred to perio (not to OS); therefore, periodontists have the opportunity to diagnose and tx plan for implant placement and restoration….and the tx recommendation will then be discussed with the referring GPs. The OS usually get the implant cases on patients who already lost their teeth. Both OS and perios are good at implant placement…the one who has better communication with the referring GPs is the one who gets more implant cases.

Periodontists don’t just see every PITA patient that is referred to their office. To be seen, the patient must first pay the consultation fee (this fee is usually credited toward the tx fee if the patient accepts the recommended tx). If the patient refuses to pay such consultation fee, then he/she is not very serious about his/her oral health.

Dude, seriously, I love this post. It's a breath of fresh air on this forum... well said!

P.S. I loved working with a great periodontist. I also loved working with a great endodontist. When you're doing restorative dentistry on highly educated, well-off, and demanding patients, are you really going to pick up a 15 blade and do open flap debridement? Are you going to be placing 5 implants in the anterior mandible on the mayor? Maybe, but if you had a serious problem (i.e. you hit the lingual nerve with your 15 blade or have paresthesia from the implant going into the mental nerve canal), don't you think that highly educated patient will seek an attorney? And don't you think that attorney will RIP you apart because you are not as highly trained as a specialist? You bet, and I've seen it happen.

Now on the flip side, in a public health position I was in, I had a patient threaten to sue the practice because we ignored his GINGIVITIS to get really bad. He had 3-4mm pockets and bleeding, nothing more, but he claimed that we should have referred him to a gum specialist. He was funded by an organization that provides free dentistry for the needy and thus paid nothing for himself.

Think about it, seriously. Don't be scared of doing advanced dentistry and surgery, just remember the idiom "Dental school teaches how to do, but not necessarily should you do."