Treating, Reporting and Managing Periodontal Diseases: A Dental Hygienist's Perspective
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Treating, Reporting and Managing
Periodontal Diseases:
A Dental Hygienist’s Perspective
Presenter: Kathy S. Forbes, RDH, BS
June 23, 2018
12:30-3:30
• Periodontal Disease Diagnosis
Case Types I-V and
AAP Classifications I-VIII
• Chart Documentation
Risk Management Issues
• Dental “Insurance”
Not really insurance . . .
Really!
1
• Treatment Planning for
*Non-surgical Dental Hygiene
Procedures/Procedure Code
Selection
*Evaluations
*Adult/Child Prophylaxis
*Scaling and Root Planing
*”Gingivitis” Procedure
*Periodontal Maintenance
Concerns?
There are dental hygienists who
provide periodontal procedures
(SRP, PM) but document
preventive procedures (AP).
There are business staff who bill for
adult prophylaxis when the
hygienist has provided periodontal
procedures.
2
Concerns?
Both scenarios cause the
practice to lose money.
Both scenarios would be
considered risk management
issues.
Classification/Case Types
of Periodontal Diseases
(Based on 1989 World Workshop in Periodontics)
Formerly AAP Classification System
Case Type I – Early/Chronic Gingivitis
Case Type II – Established
Gingivitis/Early Periodontitis
Case Type III –
Moderate/Chronic Periodontitis
Case Type IV – Advanced Periodontitis
Case Type V – Refractory Periodontitis
3
General Guidelines
Extent Severity
Localized = 30% or less Slight =
of sites are involved LOA/CAL 1-2 mm
Generalized = more than Moderate =
30% of sites are involved LOA/CAL 3-4 mm
Severe =
LOA/CAL 5+ mm
LOA = Loss of Attachment
CAL = Clinical Attachment Loss
Case Types I-V
(recognized by most “Insurance” Companies)
Case Type Status Defined Loss of Attachment/
Clinical Attachment
Loss
Type 0 Clinically healthy No LOA/CAL
Type I Early/Chronic Gingivitis No LOA/CAL
Pseudopocketing
possible
Type II Established Gingivitis/Early Slight LOA/CAL =
Periodontitis 1-2 mm
Type III Moderate Periodontitis/ Moderate LOA/CAL =
Chronic Periodontitis 3-4 mm
Type IV Advanced Periodontitis Severe LOA/CAL =
5+ mm
Type V Refractory Periodontitis
4
Development of a Classification System
for Periodontal Diseases and Conditions
Annals of
Periodontology
December, 1999
www.perio.org
AAP Classification of Periodontal
Diseases and Conditions
(Based on 1999 International Workshop)
Gingival Diseases
Chronic Periodontitis
Aggressive Periodontitis
Periodontitis as a Manifestation of
Systemic Diseases
Necrotizing Periodontal Diseases
Abscesses of the Periodontium
Periodontitis Associated with
Endodontic Lesions
Developmental or Acquired
Deformities and Conditions
5
Gingival A. Plaque 1. Associated
Diseases induced with dental
plaque only
2. Modified by
systemic
factors
3. Modified by
medications
4. Modified by
malnutrition
B. Non-plaque 1. Bacterial,
induced viral, fungal,
allergic,
genetic, etc.
Chronic A. 1. Modified by
Periodontitis Localized systemic factors
≤ 30% 2. Modified by
medications
3. Modified by
malnutrition
B. 1. Modified by
Generalized systemic factors
≥ 30% 2. Modified by
medications
3. Modified by
malnutrition
6
Update will
commence in 2017
to review:
• Attachment level
• Chronic versus
aggressive
periodontitis
• Localized versus
generalized
periodontitis
AAP Disease Classification/Diagnosis
– Use descriptive words:
Generalized chronic periodontitis
Localized plaque-induced gingivitis
with generalized slight chronic
periodontitis
Localized chronic periodontitis - stable
Billing Class/Case Type/Code
– Use Roman numerals (I-IV)
– May use description title also:
IV: Moderate chronic periodontitis
7
Fee for Service PPO (20% discount)
$100 procedure $80 procedure
- $60 overhead - $60 overhead
$40 profit
$20 profit
Insurance:
Protection against the
occurrence of an
infrequent, catastrophic
event.
8
Dentistry:
Involves the frequent
occurrence of
non-catastrophic
events.
Dental “Insurance”
Not really insurance but a
Dental Benefit
or
Healthcare Financing
9
Dental “Insurance” 1972
Most plans paid by incentive:
– First year: paid 70% of dentist’s fees
– Second year: paid 80% of dentist’s fees
– Third year: paid 90% of dentist’s fees
– Fourth year and beyond: paid 100%
Maximum benefit?
Dental “Insurance” 2018
Paid according to negotiated contract
between employer and insurance
company
Varying rates of reimbursement
– Some based on % of UCR computed
by insurance company
– Some rely on “evidence-based”
research
– Some based on “who knows what”
Maximum benefit?
10Documentation
Top Two Areas of Claim Frequency:
#1: Failure to diagnose periodontal
disease.
#2: Failure to diagnose oral cancer
#3: Legal considerations, poor record
keeping, and a lack of informed
consent.
Also note #9:
Failure to refer or referring too late.
Avoid personal shorthand that others
cannot understand and non-relevant
comments that could prove
embarrassing if read in court.
Allow adequate time to complete
the treatment record to avoid poor
documentation and frustration.
Document all data immediately;
delays lead to inaccuracies.
11RDH Magazine
November 2013
Top Reasons Hygienists Are Sued
Strategies for Avoiding Malpractice Claims
Author:
Dianne Glasscoe Watterson, RDH, BS, MBA
Informed Consent defined:
The patient’s agreement that he or
she has had a thorough discussion
with the doctor (dentist),
understanding the recommended
treatment or procedure, its
alternatives, risks and consequences,
and desires the dental procedure to
be preformed.
12Informed Consent defined:
Informed consent is more than
simply getting a patient to sign a
written consent form. It is a
process of communication
between a patient and physician
(dentist) that results in the patient’s
authorization or agreement to
undergo a specific medical (dental)
intervention.
Revised Code of Washington
RCW 7.70.060
Consent form – contents –
prima facie evidence – failure
to use.
13(1) A description, in language the patient could
reasonably be expected to understand, of:
(a) The nature and character of the
proposed treatment;
(b) The anticipated results of the
proposed treatment;
(c) The recognized possible alternative
forms of treatment; and
(d) The recognized serious possible risks,
complications, and anticipated
benefits involved in the treatment and
in the recognized possible alternative
forms of treatment, including non-
treatment;
INFORMED REFUSAL
Periodontal Scaling and Root
Planing
Periodontal Maintenance
X-ray Consent Withheld
14Examples of Fraud
Billing for services not performed.
Altering dates of service.
The American Dental Association’s
Code of Ethics (5.B.4) states: A dentist
who submits a claim form to a third party
reporting incorrect treatment dates for the
purpose of assisting a patient in obtaining
benefits under a dental plan, which
benefits would otherwise be disallowed, is
engaged in making an unethical, false or
misleading representation to such third
party.
Examples of Fraud
Misrepresenting patient identities
Not disclosing existence of primary
coverage
Not informing dental carrier you’ve
billed medical carrier also
15Examples of Fraud
Up coding (now referred to as
remapping), for example:
Billing Scaling and Root Planing
when you provided Periodontal
Maintenance.
Billing a night guard or fluoride
trays when you’ve only provided
whitening trays.
Example of Fraud
Waiver of co-payments and/or
deductibles
The insurance plan is a contract between
the patient’s employer and the insurance
company. The dentist is not a party to
that contract. As such, dentists
cannot accept payments from
insurance companies as payment in
full when a co-payment is
contractually required.
16Example of Fraud
Unbundling Codes – separating dental
procedures so the benefits of the
component parts total more than the
procedures as defined would normally be
reimbursed.
Procedure Codes
designated for
dental hygiene/periodontal
diagnosis and therapy
17How many codes are available
to hygienists in Washington
State?
Where do we start?
18Clinical Oral Evaluations
(Not Exams)
Periodic Oral Evaluation –
established patient
CDT 2018, p. 5: D0120
An evaluation performed on a patient of
record to determine any changes in the
patient’s dental and medical health status
since a previous comprehensive or periodic
evaluation. This includes an oral cancer
evaluation and periodontal screening where
indicated and may require interpretation of
information acquired through additional
diagnostic procedures.
19What is the definition of a
“Periodontal Screening” ?
Many hygienists and dentists
consider a periodontal screening to
include nothing more than spot
probing
BUT…
The American Academy of
Periodontology states that a
charting containing only six points
per tooth pocket depths is a
Periodontal Screening.
Comprehensive Oral Evaluation –
New or Established Patient
CDT 2018, p. 6: D0150
Typically used by a general dentist and/or
specialist when evaluating a patient
comprehensively. This applies to
• new patients;
• established patients who have had a
significant change in health
conditions or other unusual
circumstances, by report, or
• established patients who have been
absent from active treatment for three or
more years. > > >>>>>
20Comprehensive Oral Evaluation –
New or Established Patient
Evaluate and record:
An evaluation for oral cancer where
indicated
Extra-oral and intra-oral hard and soft
tissues
Dental history
Medical history
A general health assessment
>>>>>>>
Comprehensive Oral Evaluation –
New or Established Patient
Dental caries, missing or unerupted teeth
Restorations
Existing prostheses
Occlusal relationships
Periodontal conditions, including
periodontal screening and/or periodontal
charting
Hard and soft tissue anomalies
21What is the definition of a
“Periodontal Charting” ?
The American Academy of Periodontology states
that a complete periodontal charting, including a
description of periodontal conditions, includes
– six points per tooth pocket depths,
– recession,
– furcations,
– mobilities,
– bleeding points,
– minimal attached gingiva notations,
– AAP diagnosis, etc.
Re-evaluation – post-operative
office visit
CDT 2018, p. 7: D0171
No specific definition included in CDT 2016
or 2017 but October 2014 issue of Insurance
Solutions Newsletter states:
“May be used to document the re-
evaluation of a patient four to six weeks
after periodontal scaling and root planing.
However, most payers include follow-up
evaluations in the global procedure fee.”
22Comprehensive Periodontal Evaluation
– New or Established Patient
CDT 2018, p. 7: D0180
This procedure is indicated for patients showing
signs or symptoms of periodontal disease and for
patients with risk factors such as smoking or
diabetes. It includes evaluation of periodontal
conditions, probing and charting, evaluation and
recording of the patient’s dental and medical
history and general health assessment. It may
include the evaluation and recording of dental
caries, missing or unerupted teeth, restorations,
occlusal relationships and oral cancer evaluation.
What is the difference in the definitions?
Comprehensive Oral Evaluation Comprehensive Perio Evaluation
Evaluation of oral cancer Oral cancer evaluation
Extra-oral/intra-oral hard/soft tissues NOT INCLUDED
Dental history Dental history
Medical history Medical history
General health assessment General health assessment
Dental caries, missing or unerupted Dental caries, missing or unerupted
teeth teeth
Restorations Restorations
Existing prosthesis NOT INCLUDED
Occlusal relationships Occlusal relationships
Periodontal conditions including Periodontal conditions including
periodontal screening and/or periodontal charting
charting
Hard and soft tissue anomalies NOT INCLUDED
23Oral evaluation for a patient under three
years of age and counseling
with primary caregiver
CDT 2018, p. 5: D0145
Diagnostic services performed for a
child under the age of three,
preferably within the first
six months of the eruption of the
first primary tooth, including
recording the . . .
Oral evaluation for a patient under three
years of age and counseling
with primary caregiver
• Oral and physical health history,
• Evaluation of caries susceptibility,
• Development of an appropriate
preventive oral health regime,
• Communication with and counseling
of the child’s parent, legal guardian
and/or primary caregiver.
24Pre-diagnostic Services
…. and other individuals
may report any of the listed
CDT Codes as long as they
are acting within the scope
of their state law.
Screening of a Patient
CDT 2018, p. 7: D0190
A screening, including state or federally
mandated screenings, to determine an
individual’s need to be seen by a dentist
for diagnosis
25Assessment of a Patient
CDT 2018, p. 7: D0191
A limited clinical inspection that is
performed to identify possible signs of
oral or systemic disease, malformation,
or injury, and the potential need for
referral for diagnosis and treatment.
Diagnostic Codes
(related to caries risk)
26Caries risk assessment and documentation, with a
finding of low risk.
Using recognized assessment tools
CDT 2018, p. 11: D0601
Caries risk assessment and documentation, with a
finding of moderate risk.
Using recognized assessment tools
CDT 2018, p. 11: D0602
Caries risk assessment and documentation, with a
finding of high risk.
Using recognized assessment tools
CDT 2018, p. 11: D0603
“Evaluation of caries susceptibility”
Caries Risk Assessment Forms for
–Age 0 to 6 years and
–>6 years
www.ada.org
Search, enter:
“caries risk assessment forms”
27Preventive Services
Other than Prophylaxis or
Periodontal Procedures
Fluoride Treatment
(Office Procedure)
Prescription strength
fluoride product designed
solely for use in the dental
office, delivered to the
dentition under the direct
supervision of a dental
professional. Fluoride must
be applied separately from
prophylaxis paste.
28*Factors increasing risk for caries may
include but are not limited to:
High level of caries experience or
demineralization
History of recurrent caries
High titers of cariogenic bacteria
Existing restoration(s) of poor
quality
Poor oral hygiene
Inadequate fluoride exposure
Prolonged nursing (bottle or breast)
Poor family dental health >>>>>>>
*Factors increasing risk for caries may
include but are not limited to:
Developmental or acquired
enamel defects
Developmental or acquired
disability
Xerostomia
Genetic abnormality of teeth
Many multisurface
restorations
Chemo/radiation therapy
Eating disorders
Drug/alcohol abuse *ADA Guidelines
Irregular dental care July 2004
29Topical application of fluoride varnish
CDT 2018, p. 15: D1206
Topical application of fluoride –
excluding varnish
CDT 2018, p. 15: D1208
Interim caries arresting medicament
application – per tooth
CDT 2018, p. 16: D1354
30Documentation for Radiographs
Guidelines for Prescribing
Dental Radiographs
From: American Dental Association and
U.S. Food & Drug Administration
2004, then Updated 2012
www.ada/org/prof/resources/topics/radiography.asp
www.fda.gov/cdrh/radhlth/adaxray.html
Guidelines for Prescribing
Dental Radiography, 2012
Page 3 of Report
Radiographic screening for the purpose
of detecting disease before clinical
examination should not be performed.
A thorough clinical examination,
consideration of the patient history,
review of any prior radiographs, caries
risk assessment and consideration of
both the dental and the general health
needs of the patient should precede
radiographic examination.
31ADA Clinical Indicators
for Dental Radiographs
A. Positive Historical Findings
1. Previous periodontal or
endodontic therapy.
2. History of pain or trauma.
3. Family history of dental
anomalies.
4. Postoperative evaluation of
healing.
5. Remineralization monitoring
6. Presence of implants or evaluation
of implant placement.
ADA Clinical Indicators
for Dental Radiographs
B. Positive Clinical Signs and Symptoms
1. Clinical evidence of periodontal 13. Evidence of foreign objects
disease 14. Pain and/or dysfunction of the
2. Large or deep restorations TMJ
3. Deep carious lesions 15. Facial asymmetry
4. Malposed or clinically impacted
teeth 16. Abutment teeth for fixed or
5. Swelling removable partial prosthesis
6. Evidence of dental/facial trauma 17. Unexplained bleeding
7. Mobility of teeth 18. Unexplained sensitivity of
8. Sinus tract (“fistula”) teeth.
9. Clinically suspected sinus 19. Unusual eruption, spacing or
pathology migration of teeth
10. Growth abnormalities 20. Unusual tooth morphology,
11. Oral involvement in known or calcification or color
suspected systemic disease 21. Missing teeth with unknown
12. Positive neurologic findings in reason
the head and neck 22. Clinical erosion
32“Cleaning” Codes
Prophylaxis – Child
CDT 2018, p. 15: D1120
Removal of plaque, calculus and stains
from the tooth structures in the primary
and transitional dentition. It is intended
to control local and irritational factors.
Prophylaxis – Adult
CDT 2018, p. 15: D1110
Removal of plaque, calculus and stains
from the tooth structures in the
permanent and transitional dentition.
It is intended to control local and
irritational factors.
33Scaling in the presence of
generalized moderate or severe
gingival inflammation – full mouth,
after oral evaluation.
CDT 2018, p. 39: D4346
The removal of plaque, calculus and stains from supra-
and sub-gingival tooth surfaces when there is
generalized moderate or severe gingival inflammation
in the absence of periodontitis. It is indicated for
patients who have swollen, inflamed gingiva,
generalized suprabony pockets and moderate to severe
bleeding on probing. Should not be reported in
conjunction with prophylaxis, scaling and root
planning, or debridement procedures.
www.ada.org
CDT 2018
pp. 288-298
34Full mouth debridement to enable
comprehensive evaluation
and diagnosis on a subsequent visit
CDT 2018, p. 39: D4355
Full mouth debridement involves the preliminary
removal of plaque and calculus that interferes
with the ability of the dentist to perform a
comprehensive oral evaluation. Not to be
completed on the same day as D0150, D0160,or
D0180.
Full mouth debridement to enable
comprehensive evaluation
and diagnosis
Narrative needed describing:
● why debridement necessary
● description of tissues, bleeding,
amounts of plaque and calculus, etc.
● length of time since last “cleaning”
● x-rays and/or photos showing calculus
deposits and degree of gum infection
35When is Initial Periodontal Therapy
(Scaling and Root Planing) Indicated?
When there is evidence of
active disease
bleeding on probing
Increased pocket depth
Continued attachment loss
(i.e. recession)
Increased tooth mobility
Purulent (pus) discharge/suppuration
Sequential radiographic change of
crestal bone
Comprehensive Periodontal Therapy:
A Statement by the American Academy
of Periodontology
• Health Professionals
• Clinical/Scientific Resources
• Scroll to Academy
Statements
• Comp Perio Therapy
(from jop, July 2011)
36Report sets forth the scope, objective and
procedures that constitute periodontal
therapy:
Scope of Periodontal Therapy
Periodontal Evaluation
Establishing a Diagnosis, Prognosis and
Treatment Plan
Informed Consent and Patient Records
Treatment Procedures
Evaluation of Therapy
Factors Modifying Results
Periodontal Maintenance Therapy
Our responsibility to our patients:
We inform.
We document.
We all share the same culture in
the office.
We all have the same “Standard
of Care”.
We have a team on board serving
the patients’ perio and restorative
treatment needs.
37Scaling and Root Planing
CDT 2016, p. 36-37: D4341/D4342
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/or as a part of
pre-surgical procedures in others.
Periodontal Periodontal
Scaling and Root Scaling and Root
Planing – Planing –
four or more one to three
teeth, per teeth, per
quadrant quadrant
CDT 2018, p. 39: D4341 CDT 2018, p. 39: D4342
38Periodontal Maintenance Procedures
CDT 2016, p. 37: D4910
This procedure is instituted following
periodontal therapy and continues at
varying intervals determined by the clinical
evaluation of the dentist,
for the life of the dentition or any implant
replacements. It includes removal of
bacterial plaque and calculus from
supragingival and subgingival regions, site
specific scaling and root planing where
indicated, and polishing the teeth.
If new or recurring periodontal disease
appears, additional diagnostic and treatment
procedures must be considered.
Example:
“If benefits unavailable or
exhausted for Periodontal
Maintenance, please consider
an alternate benefit for Adult
Prophylaxis.”
39RDH Magazine
February, 2014
Site Specific
Scaling & Root Planing
What code to use?
40RDH Magazine
November,
2014
After active periodontal
therapy and a period of
maintenance, is it ever
appropriate to report code
D1110 (prophylaxis) for
recall visits?
What does the American
Dental Association say?
41Response . . .
“This is a matter of clinical judgment by the
treating dentist. Follow-up patients who
have received active periodontal therapy
(surgical or non-surgical) are
appropriately reported using the
periodontal maintenance code D4910.
However, if the treating dentist determines
that a patient’s oral conditions can be
treated with a routine prophylaxis, delivery
of this service and reporting with code
D1110 may be appropriate.”
From CDT 2016, p. 103
Other Procedures
Which may be necessary for
patients requiring
periodontal therapy
42Implant maintenance procedure when
prostheses are removed and reinserted,
including cleansing of prostheses and
abutments.
CDT 2018, p. 63: D6080
This procedure includes active debriding of the
implant(s) and examination of all aspect of the
implant system(s), including occlusion and stability
of the superstructure. The patient is also
instructed in thorough daily cleansing of the
implant(s). This is not a per implant code and is
indicated for implant supported fixed prostheses.
Scaling and debridement in the presence of
inflammation or mucositis of a single
implant, including cleaning of the implant
surfaces, without flap entry and closure
CDT 2018, p. 63: D6081
This procedure is not performed in conjunction
with D1110, D4910 or D4346.
43Debridement of a peri-implant defect or
defects surrounding a single implant, and
surface cleaning of the exposed implant
surfaces, including flap entry and closure.
CDT 2018, p. 58: D6101
No descriptor; however, at the Code Maintenance
Committee meeting in March 2018, a submission suggesting
a new code for “disruption of subgingival biofilm using air
and water pressure combined with a low-abrasive powder on
Tooth surfaces and implants” was rejected because
“The CMC determined that this action request is
for a technique that is appropriately reported with
CDT code D6101 ….”
Local Anesthesia Codes
“Local anesthesia is usually considered to
be part of Restorative, Endodontic,
Periodontal, Removable Prosthodontic,
Implant Services, Fixed Prosthodontic and
Oral and Maxillofacial Surgical Procedures”
Local anesthesia CDT 2018, p. 87: D9215
Local anesthesia not in conjunction with
operative or surgical procedures
CDT 2018, p. 87: D9210
44Oraqix™
(Lidocaine and Prilocaine)
Kovanaze™
(Tetracaine HCl and Oxymetazoline HCl)
FDA approved as of June 29, 2016
• Regional anesthesia
(#4 - #13)
• Pre-filled, single-use
sprayer
• 2 sprays (0.2 ml per spray)
4-5 minutes apart.
www.st-renatus.com
45OraVerse®
(Phentolamine Mesylate)
• Local Anesthetic reversal agent
• Accelerates the reversal of lingering
numbness
• Takes ½ the time
www.septodontusa.com
Cleaning and Inspection of a
removable appliance
CDT 2018, p. 91
This procedure does not include any
required adjustments.
Cleaning and inspection of removable complete
denture, maxillary D9932
Cleaning and inspection of removable complete
denture, mandibular D9933
Cleaning and inspection of removable partial
denture, maxillary D9934
Cleaning and inspection of removable partial
denture, maxillary D9935
46Localized delivery of antimicrobial agents via
controlled release vehicle into diseased
crevicular tissue, per tooth
CDT 2018, p. 40: D4381
FDA approved subgingival delivery devices
containing antimicrobial medication(s) are
inserted into periodontal pockets to suppress
The pathogenic microbiota. These devises
Slowly release the pharmacological agents so
they can remain at the intended site of
action in a therapeutic concentration for a
sufficient length of time.
Gingival irrigation – per quadrant
CDT 2018, p. 40: D4921
Irrigation of gingival pockets with
medicinal agent. Not to be used to
report use of mouth rinses or non-
invasive chemical debridement.
47Fluoride gel carrier
CDT 2018, p. 56: D5986
Synonymous terminology: fluoride
applicator
A prosthesis, which covers the teeth in
either dental arch and is used to apply
topical fluoride in close proximity to tooth
enamel and dentin for several minutes daily.
Periodontal medicament carrier with
peripheral seal – laboratory processed
CDT 2018, p. 56: D5994
A custom fabricated, laboratory processed
carrier that covers the teeth and alveolar
mucosa. Used as a vehicle to deliver
prescribed medicaments for sustained
contact with the gingiva, alveolar mucosa,
and into the periodontal sulcus or pocket.
48Adjunctive General Services
Application of desensitizing medicament
CDT 2018, p. 90: D9910
Includes in-office treatment for root sensitivity. Typically
reported on a “per visit” basis for application of topical
fluoride. This code is not to be used for bases, liners or
adhesives used under restorations.
Application of desensitizing resin for cervical
and/or root surface, per tooth
CDT 2018, p. 90: D9911
Typically reported on a “per tooth” basis for
application of adhesive resins. This code is not to be
used for bases, liners or adhesives under
restorations.
Contact Information:
Kathy S. Forbes, RDH, BS
Phone: 253-670-3704
FAX: 866-669-9308
Email:
prodentseminars@gmail.com
Professional Dental Seminars, Inc.
1702 Valley Oak Ct
Castle Rock, CO 80104
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