Periodontal Potential in Your Hygiene Department: A New Profit Center

How does your hygiene department measure up? Do you know the score? Many offices that I have come in contact with over the years have not yet implemented a standard protocol for diagnosing and treating patients with periodontal disease. Most dental professionals are aware of the current studies and agree that it is important. A comprehensive periodontal program that is systematized in your practice will benefit your patients and maximize the hygiene department, making it highly profitable. 
We now know more about the link between periodontal disease and systemic diseases than ever before. It is the dental team’s ethical responsibility to do all it can to diagnose, educate, and treat patients. The lack of or failure to perform comprehensive and documented periodontal exams regularly leaves you on a legal slippery slope.
If you approach the idea of a periodontal program with much trepidation, then this article will give you the exact steps to do it. I am giving you the blueprint…you just need to remove the barriers in your practice. One very real and common barrier that I often see is the doctor and staff becoming apprehensive about the transition process from “bloody prophy” to providing the correct treatment plan. Situations exist where the patients have been receiving “bloody prophies” and are being charged for a standard prophylaxis. I also see some practices probing and rarely documenting it. Patients are told that there are areas that will need to be watched, and they leave with little or no understanding of what is really going on in their mouths.
When a periodontal program is about to be implemented, I am often asked, “How are we going to tell our patients that they now have periodontal disease when they have been coming to us for years?” or, “How are we going to explain that they need more than what they have been given in the past?” The reality of it is this: you just can’t ignore it and compromise the patient’s health. We now know more about periodontal disease than ever before. There has been a lot of research and new clinical data in recent years. The profession now has the knowledge and the tools to help patients. That is the message you share with them.
The process of evaluating and implementating a periodontal program is organizational and involves setting up system protocols.   You will see that with commitment, an outline of what should take place in the treatment room, staff training, and proper assessment, you will soon be on your way (Table).

Table. Do You Say “Yes” to Any of the Following?

  • Periodontal probing is not consistently done and seldom, if ever, documented.
  • Low production in the hygiene department.
  • Very few patients on periodontal maintenance, code 4910 not being utilized.
  • More than 80% of the hygienist’s procedures are CDT code 1110.
  • Hygienist is not in favor of a periodontal program.
  • Hygienist is performing deep scaling procedures during prophy visits and not charging the patients.
  • Patients with “bloody bibs” are not being educated or treatment planned properly.
  • The practice has few tools in place for patient education.
  • CDT codes not being utilized properly.
  • There are few, if any, risk assessments performed.

    If you say “yes” to any of the above, then re-evaluate your periodontal standard of care.

ATTRIBUTES OF A HYGIENE DEPARTMENT WITH A FULLY IMPLEMENTED PERIODONTAL PROGRAM

• The hygienist sees the benefits and is on board with the idea of the program.        
• Six-point periodontal charting is documented at least once a year on every hygiene patient.
• The hygiene department produces at least 25% to 35% of practice revenues.
• Periodontally related services make up at least 25% of hygiene revenues.
• The practice fully utilizes CDT codes 4341, 4342, 4355, 4910, 4381.
• Pocket depths are called out during probing so that the patient can hear them.
• The majority of “bloody bib” patients are being enrolled in a periodontal program.
• The doctor, along with the hygienist, has defined the office philosophy for treating periodontal disease.
• The hygiene department has an exact protocol in writing for the standard of care it wants to provide.
• Patients and staff are educated about periodontal disease.
• Staff has excellent verbal skills.
• Each adult patient receives 60 minutes for prophy and perio maintenance appointments.
• Once patients have completed nonsurgical therapy to treat periodontal infection, they are maintained through periodontal maintenance instead of prophylaxis, for the life of the dentition.
• Financial policies are in place to make treatment more attainable for the patient.
• Patient educational systems such as CAESY and Consult-Pro are in use, which leads to patients understanding their condition better as well as increased case acceptance (Figure 1).
• If the patient has large amounts of calculus and plaque, then full-mouth debridement is recommended.
• Hygienists and doctors routinely find the need and place locally applied antimicrobials in pockets of 5 mm or more. 
• Time is blocked off in the future to accommodate patients who need to return for treatment.
• Goals are set, and monitors are in place.

CASE STUDY: ACTUAL RESULTS FOR INCOME INCREASE

Figure 1. It’s easier to get the patient to understand the need for treatment with the help of patient educational systems, such as CAESY.

Figure 2. Graph of actual results after implementation of a periodontal
program.

Figure 2 is a graph from an actual practice in a low-fee area of the country. It shows the first 6 months of implementation of the periodontal program. This particular practice has 3 full-time hygienists. The figures represent production for the entire hygiene department. I expect it will level off at $55,000 per month.

CASE STUDY: ACTUAL RESULTS FOR SHIFT IN STANDARD OF CARE

Figure 3a. Before implementation of periodontal program.

Figure 3b. Six months into implementation of periodontal program.

Figure 3c. Conservative goal: 1 year into implementation.

Figures 3a to 3c show the percentage of procedures done in the hygiene department of the office we used for our case study. As you can see in Figure 3a, when the program first began, the majority of treatment was prophylaxis with very little attention paid to periodontal disease. Figure 3b shows the results 6 months later, when the standard of care shifts to a more well-rounded protocol. We expect this trend to continue, as shown in Figure 3c.

LEARN HOW YOUR HYGIENE DEPARTMENT MEASURES UP

The hygienist that does prophies all day is producing a low level of periodontal care. The first step in developing an exact periodontal protocol is to find out where you are now. This is done by procedure code, utilizing your computer software. Generate and print a Procedure Code Summary or Production by Procedure report for the last year. Use the codes listed below. You are looking for the number of procedures, not the dollar amount. After you have determined the number of procedures performed, determine your percentages.

• 1110—prophy
• 4341—periodontal scaling/RP 4 or more teeth
• 4342—periodontal scaling/RP 1 to 3 teeth
• 4355—full-mouth debridement
• 4381—locally applied antimicrobial
• 4910—periodontal maintenance

DEFINE YOUR TREATMENT PHILOSOPHY FOR TREATING PERIODONTAL DISEASE

I recommend that you start with an exact screening protocol for new and existing patients. Can you imagine going to see your physician and never having your blood pressure taken? How about leaving the office without someone telling you what it was? Patients coming to your office should receive full-mouth probing, and it should be documented. They should be educated about periodontal disease and the significance of the numbers as probing is taking place; patient numbers should be called out for them to hear. Patient records should include up-to-date full-mouth x-rays, an updated medical history, a comprehensive risk assessment, and full periodontal charting that is documented.
You should perform a chart audit in your practice to find out how many patients are coming in for a regular checkup and are rarely, if ever, having their periodontal condition fully evaluated. The majority of practices that I have seen are doing just prophies versus doing prophies and limited scaling and root planing on patients who present with isolated periodontal disease. When the former is done, patient care is compromised. Patients put their trust and faith in the dental team each time they come to the office. Don’t accept, “We don’t have patients with periodontal disease in our practice because we are taking such good care of them” from any member of your staff. Look further and you will find it.

OPPORTUNITIES THAT ARE OFTEN MISSED

Every day in dental offices across the country, many opportunities are missed to provide better care to patients and increase revenues. Here are the most common missed opportunities:

• Not utilizing the time in the chair for patient education.
• No standard-of-care protocol.
• No follow-up with patients when they don’t schedule or when they break an appointment.
• Not communicating to the patients on their level of understanding.
• Not utilizing CDT codes to the patient’s advantage.
• Not diagnosing properly.
• No utilization of locally administered antibiotics.

USE OF LOCALLY ADMINISTERED ANTIBIOTICS

Periodontal therapy programs should include treating isolated disease as well as generalized disease. Periodontal therapy programs should also include locally administered antimicrobials. As we implement periodontal programs throughout the country, we see Arestin (Ora-Pharma) as the most commonly used product in periodontal therapy protocols. We have found that through the use of Arestin, the patient’s overall health improves. Arestin enhances the scaling and root planing and provides the longevity for a better state of the patient’s health. Materials for staff training and program implementation are available from the manufacturer.

HOW TO BEGIN THE IMPLEMENTATION PROCESS

Now that you have a vision for your hygiene department, it’s time to take action and make it a reality. You’ll begin the implementation process by examining the results of the reports you generated, using the codes I provided. Once you know where you are and where you want to be, you will need to establish a standard of care. Share it with your staff and put it in writing so they can reference it.
You’ll want to have an office meeting for training and to get everyone on the same page. Educate all staff  members so they can schedule patients and make financial arrangements. They will need to know how to handle patient objections with effective verbal skills. It is important to have all of the staff repeating the same clinical message to patients and communicating the urgency of returning for their next appointment. Refer back to the section on “Attributes of a Hygiene Department With a Fully Implemented Periodontal Program” for the actions that will make your program successful.

ADDING VALUE TO YOUR PRACTICE

Once your implementation process begins, you will soon experience an increase in revenue while providing better treatment options for your periodontal patients. Diagnosis and treatment will en-hance patient care and your bottom line. Besides being the right thing to do, you’ll find the implementation of this program to be personally rewarding for you and your staff.


Ms. Pardue is a nationally recognized lecturer and practice management consultant. She has assisted hundreds of doctors with practice expansion and staff development as director of consulting with Classic Practice Resources. She has been named a Leader in Dental Consulting by Dentistry Today for the past 4 years. She can be reached at (800) 928-9289, extension 10, by e-mailing This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or by visiting classicpractice.com.

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