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Perio Program Feature: Creating a Perio Program for your Practice by Trisha E. O’Hehir, RDH, MS

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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.

  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
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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