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Perio Program Series Step 4: Implement the Plan

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Diane Brucato-Thomas, RDH, EF, BS, FAADH, OMT, BBP:
In the last article of this five-part series, I mentioned educating the client and facilitating their decision to choose from several treatment plan options, based on information and their own desired level of health and commitment to achieve it. Between gathering a plethora of information and spending time on education and facilitation, by now you will have created an impression of thoroughness and caring, and planted the seeds of trust.

Once a treatment plan is decided upon, the fee must be determined and the case presented. Whether the dentist, the hygienist, the receptionist or the financial assistant does this, the first rule of thumb is that the presenting team member must see the value in the fee for service. If he or she feels at all uncomfortable with the fee, the patient will pick up on it and feel like they are being ripped off.

The patient should be sitting up and the clinician should sit facing the patient at eye level. I like to present a complete case fee that is inclusive of every appointment necessary for treatment and follow-up, as well as every possible charge. That way, there are no surprises and I do not come across as "nickel and diming" the patient. If final billing is less for some reason (for instance, if a certain product I thought I would use is not needed), I can always charge less and the client is happy, happy, happy!

One can determine the case fee by first determining the total amount of time that will be required and multiplying that by an hourly fee that varies with degree of difficulty. Supply or product costs are added to that to come up with a total case fee. The case fee can then be divided by the number of treatment appointments and the client is informed how much they will be expected to pay at each visit.

When delivering that all-inclusive case fee, always refrain from blinking. This confirms confidence and value in your treatment and the belief that the fee is reasonable and worth every penny. If your delivery is done in this confident manner, whether a fee is $5 or $5,000, your case acceptance should be in the 90th percentile.

Once the client confirms their commitment to care, it is time to schedule the treatment. In some practices, the clinician does their own scheduling. I have done that, however I find it works better to walk up to the front desk with my client and engage the scheduling expert with a verbal explanation of our treatment plan, the total cost and a breakdown of when fees are expected to be paid. This allows the client to hear the plan and the fees again and ensures we are all on the same page.

Lucky for me, the scheduling experts in our office are also insurance coding experts. Here, any questions about insurance can be answered. They are familiar with every insured client's policy, maximizing clients' benefits to reduce out of pocket costs and pre-authorizing treatment where required. These team members are essential to the success of our periodontal therapy program, making sure the client is scheduled and confirmed, following up on prescription or premedication needs, and receiving payment due at the time of treatment. From the beginning, they set the stage for the success of our periodontal program by telling clients they are in good hands with the dentist and hygienist. Because these team members are the ones who hear the majority of clients' comments, they are the ones who can convey every confidence in the clinicians they represent. Through their words and body language they inspire the clients to "want some of that!"

Rachel Wall, RDH, BS, Founder of Inspired Hygiene, Inc.:

The first step in implementing your perio plan is to present treatment in a way that helps patients say "yes" to the care that will move them toward health. We have a simple system we teach for enrollment. It's called The 3 P's. Some of the steps are so simple that you may shrug them off as common sense, but they are extremely powerful.

Prep

Before doing the periodontal exam, it's important for your patient to know what it is you're doing and what the indicators are for health and disease. It might sound something like this: "Mr. Jones, now I am going to evaluate the health of your gums and the bone surrounding your teeth. I'm going to be taking some measurements and calling out some numbers. The numbers one through three are normal, and healthy gums don't bleed."

Now Mr. Jones knows that if he hears numbers over three or areas of bleeding then something is not normal. Trust me, patients really do listen when you tell them what to listen for.

Perio Exam

Now it's time to perform the periodontal exam. Of course you'll be assessing much more than just pocket depths. You'll also be evaluating:
  • Bleeding
  • Tissue appearance
  • Furcation involvement
  • Mobility
  • Recession
  • Radiographic bone loss
Calling out the information so the patient can hear you allows them to participate in the diagnostic process. Whether you use an automated system like Florida Probe, you have a teammate to record or you're working alone, always call out the data in the perio exam. Let patients know where there is bleeding and show them with a hand mirror or an intra-oral photo. Get them involved.

Present

Now you'll want to share with your patient your observations and the data you collected that will point to whether they are periodontally healthy or if there is active infection. Instead of scripts, key words are very effective at conveying the importance of moving forward with treatment. When the patient presents with active infection and you recommend treatment, be sure to:
  1. Sit the patient up—When patients are lying on their back,
    they are in a very vulnerable position. Help them feel in
    control by sitting them up.
  2. Sit knee-to-knee—When doctors come in to do the exam, I encourage them to immediately sit down so they are on the same eye level as the patient.
  3. Use key words—Some hygienists were offended by the suggestion to change their words, but the truth is, whether it's at home with our families or with our patients and co-workers, we can all continuously refine our verbal and non-verbal communication. A few key words and phrases to use:

    • Infection
    • Significant bleeding
    • You have (instead of I found)
    • Disinfection therapy

  4. Make it personal—Patients don't want to be the victim of the latest new technique or protocol you've learned. They want personalized service and treatment recommendations based on their current dental condition. This requires time spent with the patient on the front end of the visit to discover their medical and dental risk factors and asking some questions to point you toward their dental goals. Making treatment personal means making it relevant and connecting your recommendation to something the patient wants. Do they want to better control their diabetes? Treating their active gum infection will help them get what they want. Do they want to avoid losing teeth or wearing dentures like their parents did? Long-term periodontal maintenance will help them achieve these goals.
But what about my long-term patients?

This is the most common question we get from our coaching clients when they are preparing to implement an improved perio plan. RDHs, in particular, are sensitive to what patients think about them and the care they have delivered over the years. "What will my patients think? Will they think I've neglected them all these years? Will they wonder why I haven't said anything about this infection before?"

Here's the thing. We work with human beings. Our bodies are in a constant state of change. I have never met a hygienist or dentist that has intentionally neglected to tell a patient they have periodontal disease. Even if today is the first time you are presenting a definitive perio treatment plan, this isn't the first time you've mentioned it to your patient.

Think of all the times you've:
  • Told them about their bleeding gums
  • Educated them on home care
  • Shortened their recare interval
  • Mentioned the observed inflammation
  • Shown them plaque and calculus with a hand mirror
  • Documented all of the above in the clinical notes
Every one of those conversations is about periodontal inflammation. Here's the language that we've found works very well when enrolling existing patients into periodontal therapy. "Mr. Jones, we've talked about your bleeding gums for years. We've tried lots of different approaches and your body has not responded the way we had hoped. You still have active infection. It's time to do something different."

And that's really the key to implementing your perio plan. It likely will not all come together over night. You won't suddenly be 100 percent comfortable using new words and new distinctions for when to recommend additional treatment. Committing to taking one small step every day will make a huge impact in your career satisfaction and your patients' health.

Sarah Cottingham, RDH, CEO BCS Leadership, LLC:

When implementing an "optimal oral health program" (periodontal program) into your practice, it is important to verify the level of comprehension of health versus disease with all team members. This should be established by having training or educational meetings with the dental team to discuss and test the level of understanding.

What we find in many practices is that this step is routinely overlooked based on many factors (time, schedules and the money that it costs to set up a team meeting). However, it will cost your practice exponentially more money in the long run if you don't adequately train the team to discuss health versus disease, because this will result in patients not accepting treatment plans. Not adequately training the team to have these conversations has not only a high cost to your practice; it also has a high cost to the patient in the level of health that they will not achieve when they leave your practice in search of a prophy.

This conversation revolves around the team member who will be presenting the case; they have to have a remarkably clear understanding of conservative periodontal treatment and how it can impact a patient's overall health when treatment is performed effectively and in a timely manner.

We have previously discussed the team's role in developing their periodontal philosophy and discussing level of disease tolerance, diagnostic data collection, and most recently, the ADA codes that are available for use. Now is the time to discuss why there is no cookie-cutter approach to treating periodontal disease. Each and every patient who walks through the doors has their own unique situation, including: immune system, level of oral hygiene routine dedication, bacteria levels and so on. This precipitates the need for the hygienist to be a dental disease detective and master of intervention with their tool box of effective intervention treatment options. The tool box that the hygienist is equipped with is determined by the periodontal philosophy of the practice and can include conventional scaling and root planning, use of the endoscope, laser, salivary diagnostics, systemic antibiotics, locally delivered agents, oral irrigating, pH monitoring, probiotics, oral hygiene training appointments and nutritional counseling—to name a few. The contents of your hygiene department's tool box will allow the hygienist to become the master of intervention when it comes to promoting oral and periodontal health. With a variety of tools to choose from, the hygienist is better equipped to plan the care for each patient taking into account the level of disease presentation, the patient's immune system, family history and dental IQ.

We work with many practices that have outlined perio programs for patients, which is a step in the right direction. We caution clinicians about having "programs" for patients. This type of training is great as a guideline but should only be used as a guideline. Each patient's particular situation should be taken into consideration and then the plan of care that is developed should revolve around getting the best result for that patient with the tools that the hygienist deems appropriate.

Hygienists must begin to look at themselves as a frontline oral health-care provider and begin presenting a plan of care based on the patient's needs and not a cookie-cutter periodontal program. When the patient's unique circumstances (systemic health, family history and so on) are included in the development of the plan of care, the results are always remarkable in comparison to the ones that apply the same recipe to every situation. If you were a master baker with a basic recipe, you are likely to get a really good result over and over—yet when outside factors like temperature, humidity and elevation vary, the recipe must be adjusted to account for these factors in order to get the same predictable result. The same is true with individualized care plans.

A team trained to be oral-health detectives and given a variety of tools will far exceed your expectations, both in patient health and revenues that can be generated by an optimal oral health program.

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