Part I: Periodontal Assessment of Your Practice
by Trisha E. O’Hehir, RDH, MS
The dental hygiene department of a dental practice provides
many services, one of which is the periodontal care of the
patients. The dental hygienist is essentially the periodontal therapist
for the practice – diagnosing, treatment planning, providing
care and suggesting referral when indicated. Some offices
have smoothly running programs while others have no perio
program at all. Offices that have no program are simply ignoring
the periodontal disease in their patients. This is evident in
Hygienetown and Dentaltown message boards when new practice
owners ask for advice on how to begin treating perio when
the practice has ignored it for decades.
There seems to be a gap between dentists and hygienists in
some practices on this issue. On one hand there is the dentist
who wants the hygienist to step up and implement a perio program.
On the other hand, there is a hygienist ready and willing
to provide periodontal care but the dentist isn’t open to the idea.
Developing and implementing a perio program in a general
dental practice requires several steps. It’s similar to creating a
treatment plan for a patient, but with this it’s a treatment plan
for the practice. We will break this down into five specific steps
that will be addressed in five articles. The first, this one, will
tackle the problem of assessing the periodontal health of a practice.
Second, getting the conversation going between the dentist
and hygienist and discussing periodontal treatment philosophy.
Third, creating the perio program with details for insurance
codes, treatment options, fees, times and products. Fourth,
implementation of the program with a team approach. And
lastly, the fifth article will be reflecting on the success of the program,
identifying challenges and revising where necessary.
Assessing the Periodontal Health of Your Practice
How healthy are your patients and how healthy do you want
them to be? It’s easy to get caught up providing routine treatment
on a daily basis and not taking time to assess the overall
periodontal health of the practice. There are several ways to
determine just how healthy your practice is. I have invited three
Townies who are dental hygienists to share their insights as we
develop a periodontal program through this series of articles.
Diane Brucato-Thomas works in clinical practice in Hawaii,
Sarah Cottingham and Rachel Wall both own their own consulting
companies, helping dental practices across the country
implement successful periodontal programs.
Three Indicators of Undiagnosed
Periodontal Disease
Diane Brucato-Thomas is practical with her
advice, pointing to three clinical scenarios that provide
valuable information about the health or disease in a dental
practice. Do you recognize yourself in any of these situations?
Diane Brucato-Thomas: Any one of these three scenarios
will tip you off to under-diagnosing periodontal disease. First, if
you find yourself up to your elbows in blood and gore with initial
prophies or routine maintenance appointments, you have
undiagnosed periodontal disease in your practice. Second, if you
frequently run out of time for a routine “cleaning” and have to
reschedule for a second visit, this is a sign of undiagnosed periodontal
disease. The third is making chart entries that you did
your best today and will need to recheck next time. Any or all of
these scenarios mean you have undiagnosed periodontal disease
in your practice and it’s time to assess your periodontal treatment
philosophy.
The “Perio Paradox”
Rachel Wall identifies the lack of assessment of perio as the
“Perio Paradox.” She and her team help dental practices by putting
numbers to the issue and calculating percentages you can
use to evaluate the health of your practice.
Rachel Wall: Depending on what study you read, it’s estimated
that 35-75 pecent of Americans have some form of periodontal
disease. Yet for many practices, perio therapy and
maintenance make up only 5-10 percent of clinical hygiene
services. This is the “Perio Paradox.” I love this term that my
friend, Dr. Chris Bowman, originally coined. It explains what is
happening in so many practices in North America. A lot of
patients have active disease but few are receiving treatment.
Closing this gap begins with discovering where you are in
regards to the level of perio care occurring in your practice. It’s
never the dentist’s or the hygienist’s intention not to treat
perio disease. In fact, many times they are treating the disease
but calling it a “difficult prophy.” Everyone loses in this situation.
The patient loses because they are not made aware of
the disease and its far-reaching effects. The hygienist loses
because he or she is working extremely hard on what should
be a simple prophy. The practice loses because it’s not being
compensated for the work. And the doctor loses because undiagnosed
perio disease is one of the most common reasons for
dental lawsuits.
The first question to ask is, what percentage of new and
recare (adult prophy and perio maintenance) patients have
4mm+ pockets, bleeding and even slight crestal bone loss? These
patients likely have active periodontal infection. If you haven’t
had a clear, written perio protocol in place, it’s not uncommon
for the level of periodontal disease in your practice to be 50 percent
or higher.
Compare this figure with the percentage of procedures
provided in your practice that are periodontal therapy. This
is your perio gap. If you estimate 50 percent of your
patients have active infection yet perio therapy accounts for
only 5 percent of treatment provided, you have a significant
perio gap.
Some of the most common obstacles are:
- No clear, consistent system for perio diagnosis and treatment
- Hygienists are not calibrated (not all on the same page)
- Poor tools/instruments
- No room in the schedule for perio care
- Beliefs about patients’ ability to pay
- Difficulty using technology
- Too much scaling and not enough exam time in the
hygiene appointment
- Fear of presenting to long-term patients
There is a fine line between health and disease. The traditional
prophylaxis code (0110) is designed as a preventive procedure.
It’s not to be used for treatment of gingivitis or
periodontitis. Patients receiving a prophylaxis should have no
gingival bleeding upon probing and no probing depths deeper
than 3mm. If the hygienist is providing subgingival instrumentation
to remove calculus, it crosses the line, becoming periodontal
treatment. No one wins when the treatment is provided
covertly, with no discussion, no charge and no understanding by
the patient of the disease they have developing in their mouth.
Rachel talks about the “Perio Gap,” even offering a Perio
Calculator Tool on her website to calculate the figure.
Calculating the Numbers
Consultant and RDH Sarah Cottingham discusses the mix
of therapy provided by the hygiene department to determine the
health of the practice.
Sarah Cottingham, BCS Leadership: The easiest way to
assess the periodontal health of a practice is to calculate the service
mix within the hygiene department. For a practice that is
diagnosing and treating periodontal disease, the mix is generally
30/30/30/10 for hygiene services. Prophylaxis accounts for 30
percent of patient visits, perio maintenance 30 percent, perio
therapy 30 percent and other procedures account for 10 percent
of visits. This is done by calculating totals for each of four services
for one year and then dividing each procedure total by the
estimated patient visits for that procedure.
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Example |
Total number of D1110 and D1120 is 1146÷2=573 patient visits
Total number of D4910 is 325÷4=81 patient visits
Total number of scaling and root planning is 225÷4=56 patient visits
Total number of FMD is 25 =25 patient visits
573 + 81 + 56 + 25 = 735 patient visits
573 ÷ 735 = 78 percent prophylaxis
81 ÷ 735 = 11 percent periodontal maintenance
56 ÷ 735 = 8 percent active perio treatment
25 ÷ 735 = 3 percent other
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For example, patients are generally seen twice a year for prophylaxis,
four times for both scaling and root planning and perio
maintenance and just once for debridement. Once you have calculated
the patient visits for each service, then add all four numbers
together, which gives you total patient visits. Then to calculate
the percentage for each area of the practice you will take the
individual number of patient visits from each service type
divided by total patient visits, this will give you the percentage
of that service within the practice.
Within this example, the majority of patient visits are for
prophylaxis, with a much smaller percentage accounting for the
periodontal therapy and maintenance. This mix of 78/11/8/3 is
far from the suggested 30/30/30/10 mix and suggests a great
deal of periodontal disease is being overlooked or treated within
a prophylaxis appointment rather than being scheduled as periodontal
therapy. These numbers can be calculated on a monthly,
quarterly or yearly basis. Honestly evaluating the periodontal
health of the practice will provide a starting point for the discussion
of periodontal treatment philosophy.
Summary
There are several ways to assess the periodontal health of
your practice from simply looking at the scenarios Diane outlined
to more in-depth calculations suggested by consultants
Rachel and Sarah. As the periodontal health of your practice is
assessed, our original questions can be revisited. How healthy
are your patients and how healthy do you want them to be?
Answering these questions will provide the basis for discussing
the oral health philosophy of the practice. This will be the focus
of our second in this series of articles on Creating a Perio
Program for Your Practice. Getting the conversation going
between dentist and hygienist is often the hardest step in this
process. Suggestions for getting that conversation going will be
provided. Knowing the periodontal health of the practice will
provide the foundation for a discussion developing the oral
health philosophy for the practice. Dentists and hygienists, what
are your answers to these two questions: How healthy are your
patients and how healthy do you want them to be?
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