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Perio Program Series: Create a Plan—Step 3

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This is the third of five installments on the topic of implementing a perio program in your practice. The first installment focused on assessing the periodontal health in your practice, asking, “how healthy are your patients and how healthy do you want them to be?” Answers to these questions provided the foundation for the second installment, focused on getting the conversation going between dentists and hygienists on their philosophies of periodontal treatment and prevention. With those concepts identified, it is now time to create the plan for your perio program. Is it a cookie-cutter plan or individualized for each patient? Our clinical experts provide their perspectives on creating the plan.

Diane Brucato-Thomas, RDH, EF, BS, FAADH:
The first step in creating your plan is determining who will gather the periodontal data, treatment plan and present the case. This varies from practice to practice. In many practices, the dentist will perform these duties. However, more than thirty-one years of practice limited to periodontal therapy in general practice, the dentists I worked with only performed preliminary periodontal screenings (like PST) for initial diagnosis of periodontal disease at their examination appointment (complete series of radiographs taken). Then the doctor schedules the patient with me for a full periodontal evaluation and gathering of data.

Before looking in a client’s mouth, a thorough review of their health history is complete. It is extremely important to know systemic diseases or drugs that may affect the periodontal and gingival tissues. For periodontal evaluation appointments (and maintenance), I negotiated to be provided an assistant to record on a perio data chart, maintaining infection control and saving time. Missing teeth, mobility, furcation involvement, probe scores, bleeding, purulence, recession, protective gingiva, tooth positioning, occlusion, tissue description, case type, oral habits, risk factors and oral hygiene habits are all recorded.

Once I have the data coupled with the patients’ health history, the rest of that appointment is spent on education specific to that patient’s situation, reviewing possible options of care, and facilitating their decisions to accommodate the level of commitment and health that they choose for themselves. In this way, potential treatment plans are developed. They may or may not include block anesthesia; they may or may not involve using the endoscope. Everything is individualized to the clients desires and needs. My dentist usually pops his head in to concur with findings and support the treatment plan. It is up to me to determine and present fees for services.

In other practices, the dentist may do all of the above and all you have to do is implement his treatment plan. In this case, you should work together to calibrate. Make sure you agree where to draw the line and how much time you need to provide a service. Some people have bionic hands and can treat a quadrant in 45 minutes. I am s-l-o-w. It generally takes me up to two hours per quadrant. The doctor needs to respect your expertise in determining how much time you want to be scheduled and set fees to accommodate. After all, you do not tell him he can do a crown prep in the amount of time it takes to do a two surface filling. The same goes for scheduling your post-treatment supportive periodontal therapy appointments. A client with recession has a lot more tooth surface to cover than a client with healthy gums up to their CEJs, and it takes more time to be thorough.

In the case of patients who are scheduled with you for maintenance, make it a habit to pick up your probe before you scale, because the moment you pick up that curette/scaler, the message is: “All is well and this is routine.” Additionally, learn to effectively read the tissue. Besides bleeding, look for purulence, color, texture and/or swelling of the tissues.

To simplify, if you are new at this, divide findings into one of three groups:
  1. 1-3mm, no bleeding healthy routine prophy 1-3mm, with bleeding and/or purulence gingivitis treatment
  2. 4mm with bleeding and/or purulence gingivitis or mild periodontitis treatment varies depending on degree of difficulty
  3. 5mm or above with bleeding and/or purulence moderate up to severe periodontitis treatment or refer depending on expertise/level of comfort

If the patient falls within a treatment category, sit them up and tell them, “I’m sorry, I don’t feel comfortable ‘cleaning’ your teeth, because I see infection that needs treatment. I believe ‘cleaning’ your teeth today would be a disservice.”

You can explain the disease process and show their chart, complete with visuals—i.e., red bleeding points and yellow purulence, etc.—then offer the appropriate treatment plan that works for you. It may involve two simple debridement appointments and local antimicrobial delivery; or DNA or saliva testing for more information, followed by several more advanced treatment appointments; or it may simply involve referral to a periodontist. The important points are to recognize disease, communicate your findings and know your limitations.

Sarah Cottingham, RDH, CEO of BCS Leadership, LLC:
In creating a treatment plan for periodontal therapy it is vital to take into consideration the actual patient. There is no “cookiecutter approach” to treating periodontal disease. A patient’s immune system, age, level of oral hygiene and degree of disease present must be taken into consideration prior to putting together the complete treatment plan.

The codes that we are given in the CPT 2013 coding book are quite limited in regard to providing complete care for every type of periodontal disease scenario that is seen in the dental practice.

With that said, there are many codes that are available for use that sometimes fall to the wayside. Beginning with diagnosing the situation the code D0180, comprehensive periodontal evaluation is a significantly underutilized code. This is a comprehensive code that can be used on an existing patient when periodontal disease has been identified and a comprehensive exam is completed. After the initial diagnosis has been made a plan of attack should be put together that will allow for the patient to have the disease treated to a point of stability.

The additional codes that we have available for use that are significantly underutilized are the codes for testing procedures (salivary diagnostics, oral DNA testing, oral hygiene instruction, nutritional counseling, smoking cessation and many others).

There are many schools of thought in regard to how to schedule for active periodontal treatment. This is where regular team meetings and discussing your periodontal philosophy will have a huge impact. Generally there are schools of thought for full-mouth disinfection versus quadrant or half mouth therapy. If the office is doing two quadrants per visit, generally the appropriate amount of time is one-and-a-half hours per side. Utilizing timesaving techniques such as compounded topical anesthetics that are available will be instrumental in keeping the timeline contained.

Additionally, the practice should begin looking at the amount of time using ultrasonic scalers versus hand instrumentation. There is evidence to support that each has its place and that the utilization of ultrasonic scalers for a larger majority of the time can have a significant impact on biofilm and bacterial load reduction. The goal is to get a biologically acceptable root surface in an efficient amount of time with as little hand fatigue as possible, all while keeping the patient comfortable.

When it comes to setting up a patient for success, many offices find value in creating a “convenience area” where patients can purchase items that have been recommended. Generally patients would rather pick up the suggested items at the dental office, rather then tracking down any specialty items recommended. Many offices carry items that can only be obtained from a professional, therefore carrying some of the items is necessary. To assist in making sure that the patient has everything he or she needs to succeed, we find that the most successful practices will send the patients home with literature that supports the home care regimen that was recommended, while supplementing this with an “oral health report card” at each supportive periodontal therapy appointment.

Rachel Wall, RDH, BS, Owner of Inspired Hygiene:
Over the past 10 years, working with hundreds of practices, we’ve found that even the best dental teams often have some hidden obstacles. They have some inefficiencies or beliefs that hold them back from fully implementing a progressive perio diagnosis and treatment program.

Most teams have some type of perio system in place and yet there is always room for refinement. When creating your perio plan, here are a few obstacles to look out for and overcome. When you proactively identify and clear these obstacles, you are setting yourself up for success in implementing a perio program.

Of course your perio plan should include a written Standard of Care identifying the disease threshold at which you will recommend treatment for your patients, the proper procedure codes to use, fees for treatment and so on. But there are other pieces of the plan that might not be as obvious, but are just as important to have in place.

Schedule: As we’ve analyzed the hygiene department of hundreds of practices, we often see the hygiene schedule as a primary roadblock to implementing a proactive perio program. The time allowed for the recare appointment is a key factor in perio diagnosis and treatment enrollment. If there’s no time for a thorough periodontal exam, disease will often not be detected until later stages. With additional time comes additional expectations. Be sure your perio plan includes a specific checklist for the hygiene exam including how and when the perio exam is completed. And how that information is presented to the patient, including powerful and consistent enrollment language.

Setting aside or ‘blocking’ time in the hygiene schedule for perio therapy is a major factor in implementing your perio plan. An interesting thing happens in the mind of a hygienist when the schedule is so full, there’s no available hygiene appointments for four to six weeks. Even if that hygienist recognizes active infection, if there’s no time to bring the patient back for treatment, he/she may think, “Even if I present treatment, there’s no where on the schedule for them to come back so I’m just going to do the best I can today and check it in three months.” And so the cycle of undertreatment continues. It’s not intentional, it is a function of the framework (the schedule) in which that hygienist works.

Once time is set aside for active perio therapy, it’s amazing how the perio plan is implemented. Even in a hygiene schedule with open time, having blocks reminds the hygienist to be very diligent in his/her examination of the patients’ soft and hard tissues. When disease is present, the sense of urgency is met with a timely visit to treat the infection.

Finances: The teams that are the most successful at implementing a perio plan are those that have a confident and well-trained administrative team. When your admin team is confident and excited about the payment options offered, the clinical team is free from the worry about money and whether their patients can afford what they are recommending.

We have as an industry motto that “insurance should not dictate the treatment.” We all believe it, but how well we follow this belief varies widely. Yes, insurance and finances are a real part of the treatment process and we must be practical in our approach. I believe we must be creative in finding ways to make it easy for our patients to pay for their dental care. There are options with long-term financing, short-term in-office financing and in-house savings plans. Be sure everyone on your team is familiar with what you offer. Have the admin team present the financial portion of the perio plan with confidence and coordination with the clinical treatment options.

The Team: While hygienists and dentists play the biggest clinical role in executing a perio plan, it takes every person on the team to make it a success. When we help teams create their perio diagnosis and treatment program, it is done in a full-team workshop. Everyone is able to voice questions, concerns and excitement about taking perio care to the next level. The cornerstone of any perio program is the belief that optimal care is in your patients’ best interest. Educating the entire team on specific oral-systemic connections is crucial to building a strong belief. Presenting optimal care may require you and your team to step out of your comfort zone. Developing a strong conviction that you can’t not tell your patients when they have active infection will help you on those days when the words don’t come out right or you’re running behind and want to skip perio charting. It will help your admin and operative teams to confidently answer the patient when they ask, “Do I really need to do this?”

Arm your entire team with the knowledge that developing a clear, consistent, science-based perio program is the foundation for success for both the patients and the practice.

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