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Perio Program Series: Step 5: Reflect on the Program

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Reflecting on Your Perio Program

This is the fifth installment of our five part series on implementing a perio program in your practice. The first installment focused on assessing the periodontal health of 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. In the third installment it was time to create the plan for your perio program. Once the plan was ready, the focus was implementation. The fourth installment provided ideas for presenting the perio program to patients to gain their acceptance and full participation. In this final installment, our clinical experts provide reflections on the implementation and acceptance of the perio program and helpful suggestions for measuring success and identifying areas needing improvement.

Diane Brucato Thomas, RDH, EF, BS, FAADH, OMT, BBP:

Valuable feedback to evaluate the success of your perio program can come from everyone involved. The doctor may notice a need to refer fewer clients to the periodontist as one positive result of the periodontal program. In addition, production numbers should increase significantly.

The front desk personnel are often the ones who receive direct reports from the clients regarding their feelings about the services they receive. Maintaining good, open-minded, non-defensive communications with these co-workers can only improve your service as a clinician. This feedback provides the opportunity to grow and excel.

The scheduling experts can report the percentage of clients who actually schedule for recommended periodontal treatment, while those collecting fees can report on collection success. Those team members can offer suggestions as well as feedback. For example, despite making every effort to convey a client’s responsibility to pay at time of service, one day I had a client who had spent the entire day with me in treatment, then claimed he wasn’t expecting to have to pay that day. To avoid this in the future, the front desk team solved this problem by performing collections when clients walk in the door, before I take them back into the operatory. They explain by saying, “We have found that when clients come in for long procedures, it is easier for them to complete business transactions while they are fresh, beforehand. This way, when you are done, you can just go home and rest.”

The clinician can take advantage of the re-evaluation appointment after treatment is completed and healing is well underway to evaluate the success of the periodontal program. The re-evaluation appointment should include a complete periodontal charting of probing scores, bleeding points, purulence and tissue description. I cannot say it enough: L earn to read the tissues! If you were completely thorough removing sub gingival calculus or if you missed something, the tissues will not lie. Healthy tissue is pink, not red or cyanotic, and it does not bleed. Do not be afraid to reinstrument and re-evaluate to achieve optimal tissue health. If an area does not resolve, it may be necessary to refer the client to a periodontist.

In performing thorough re-evaluations and reading the tissues, you may discover you have a weakness pattern. For example, there was a time when I consistently missed the disto-lingual line angles of mandibular bicuspids. B y paying attention to that, I was able to identify an area where I needed to improve my skills and push myself to overcome that weakness. In that process, I became a better clinician.

An important evaluation instrument that my clients and I love is the perio-data form, because it offers boxes to add and compare probing scores and bleeding points by sextant at each visit. It also tracks total pocket and bleeding scores for each appointment. The differences from appointment to appointment are visibly obvious and quantifiable. Reductions in the total numbers of pockets and bleeding points provides great overall cause for celebration. Areas in need of improvement are obvious to the clients and they then know where they need to be more thorough with their daily oral hygiene.

Data tracking is a fun way to track the success of your periodontal program. Keep track of how many 4mm, 5-7mm, 8mm+ pockets, and bleeding points are recorded pre-treatment compared with post-treatment figures. You can calculate your success in closing pockets and reducing bleeding scores with these numbers. This can be very impressive and encouraging.

Finally, take advantage of the re-evaluation appointment to ask each client directly how they felt about the program. Ask them what changes they noticed in their mouth since treatment. Ask them if the treatment met their expectations. Ask if they felt they received a good value — was it worth the financial investment? You can even ask them what you could have done to make their experience better. As you listen with an open mind and open heart, any directions for necessary change will become clear. One last thing, be creative and celebrate every success with your clients. Periodontal disease is a lifestyle disease. It doesn’t happen overnight and it doesn’t heal overnight. Changes in lifestyle take time and effort. Our clients really appreciate when they are recognized for that. A gold star on a lapel for lack of bleeding is fun, especially when they forget it is there and the grocery clerk takes notice.

You will know your periodontal program is successful when your clients send their best friends and loved ones to you for their periodontal care.

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

There’s nothing more frustrating than spending a ton of time and energy discussing, planning and implementing a new service or technology only to look back after six months and realize you’re right back where you started.

This scenario happens all the time with dental teams. I can’t tell you the number of times I’ve spoken to dentists and hygienists who say, “ We used to have a perio program in place. I don’t know what happened.” Sometimes it’s a change in staff but most of the time it’s a series of seemingly small events that lead to the disintegration of the program. It’s unrealistic to think you won’t at some point encounter a patient who declines your treatment recommendations or experiences challenges with insurance benefits.

Go back to your why

It’s important to ask yourself how your perio program fits into the vision of your practice. Why did you implement it in the first place? How does the program serve your patients first and foremost?

If the primary focus of any new service is to increase production, the motivation to keep it going forward will often fade. Sometimes there is a disconnect between the pressure to sell treatment and a strong belief that the treatment being recommended is truly in the patients best interest.

Having a strong belief system that perio therapy will have a whole-body impact on your patients is key to keeping your perio program active and a permanent part of your practice philosophy — even when you face obstacles. If the entire team doesn’t share this belief, things can fall apart quickly.

Tracking is key

How do you know if your plan is working? While production and numbers aren’t your primary driving force, they are in fact a valuable measuring tool. Measuring frequency of perio procedures and production are a gauge to the amount of value you’re delivering to your patients.

Numbers provide a quantitative look at how well you’re implementing the program and are often indicators to celebrate and to focus on areas that still need some work.

Here are a few things you’ll want to track:
  • Perio percentage. Every consultant has a slightly different way of measuring this. Whether it’s based on procedures or production, this number is very telling of how well you’ve implemented your perio plan. For an easy-to-use tool to calculate your perio percentage and track it month to month, go to InspiredHygiene.com/Periotool.
  • Quads of therapy compared to new patients. If you are completing about the same number of quads of SRP per month as the number of adult comprehensive exams, this is a good indicator that most of the therapy is being performed on new patients. This will give you a hint as to how well you’re evaluating existing patients for active infection.
  • Perio case acceptance. Compare how many quads of therapy each hygienist is presenting and how many are being completed. If you aren’t enrolling at least 7 0 percent of the patients presented with treatment, ask yourself these questions:
    • Are you providing enough evidence of active disease for the patient to feel the need to move forward?
    • Has the admin team had the opportunity to be educated on the oral-systemic link and do they believe strongly in the value of perio treatment?
    • Is there time on the schedule for patients to schedule treatment within one to two weeks of diagnosis?
    • Are dentists and hygienists backing each other up when treatment is presented?
    • Are flexible financial options being reviewed for every patient who is presented with a treatment plan?
    • Is there accurate and complete documentation to support insurance claims on perio procedures?

When faced with a challenging situation, team members sometimes make decisions based on assumptions rather than facts. One example is assuming since one plan rejected a claim for perio therapy for a patient with beginning periodontal disease that all plans will respond the same. Instead of first reviewing the quality of the perio documentation provided or other information that would support the claim, one person talks to another and before you know it, the commitments you made and the standards that were set are no longer being followed. If no one is tracking the procedures, it can be months or years before this decline is noticed.

An obstacle that is not quickly addressed can lead to the complete disintegration of the program and all the work you’ve put into it. If you notice perio numbers are declining, sit down as a team and review your standard of care. Reviewing this agreement will more often then not reveal one of the obstacles to case acceptance (and presentation) listed above and give you the chance to resolve it.

Sarah Cottingham, RDH, CEO BCS Leadership, LLC:

With your new or revised perio program it is important to monitor the effectiveness of the implementation by consistently looking at a few metrics within the practice. These metrics are important, not just for the doctor or the hygienist, but for the entire team. In a previous installment of this series, it was discussed how to calculate your mix of services over one year. Understanding the baseline starting point or baseline metrics, provides a point of comparison. From the new monthly and quarterly numbers the practice can gauge the effectiveness of the implementation of the program.

Your mix of services including periodontal appointments should be 30/30/30/10: prophylaxis, perio maintenance, perio therapy and other procedures. Calculate these numbers now that your perio program has been implemented and compare to where you were before. Are you closer to the 30/30/30/10 mix of hygiene services?

Monitoring these numbers on a monthly, quarterly and yearly basis will result in the entire team being aware of what is working and what may still need additional enhancement. Determine the total number of hygiene visits per month and then totals for prophylaxis, perio therapy, perio maintenance and other visits. To determine percentages, simply divide the total number of hygiene visits by the number of specific services. This will give you an indication of the effectiveness of the current month. Another metric to calculate is the acceptance rate for your periodontal treatment plans. Determine the total number of patients who were presented a periodontal treatment plan and what the acceptance rate was for those treatment plans. Did everyone accept treatment? If not, how many did accept treatment and how many declined or wanted to wait for treatment. This figure will give you your treatment acceptance rate.

In addition to monitoring these metrics, it is important that each team regularly review their periodontal maintenance visits for effectiveness. Are the patients periodontally healthy? Do they need more sub gingival instrumentation? Are the three- and four-month patients returning to the practice as scheduled? Monitoring and understanding compliance with scheduled periodontal maintenance visits is vital to the success of any perio program.

On a monthly basis, it is also important for each provider in the practice to understand their contribution to the bottom line. Having a monthly meeting that revolves around the metrics of the practice is imperative to the team understanding what is working and what areas of the perio program might need additional attention.

Several items to consider are:
  • Production per hour
  • Collections on behalf of the provider per month
  • Amount of hours available to see clients
  • Hours worked with client
  • Amount of hours clocked
  • Number of hours canceled or no-shows
  • Total number of each service provided

There are many other numbers that we have our clients monitor on a regular basis by using a software program that allows them to understand their data. It is important to put the information into a format that the team will understand. Routinely reviewing this information will let you know if the new perio program is improving over time, holding stable or diminishing. In order to understand how the practice is doing, the benchmark metrics must be clearly laid out and reviewed on a very consistent basis. This allows the entire team to reflection the effectiveness and acceptance of your new or updated perio program.
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