Building a periodontal-therapy program
Dru Halverson, RDH, BS
Developing a periodontal-therapy program in your hygiene department will create three positive benefits for your practice:
(1) An increase in case acceptance of restorative and aesthetic treatment
(2) An increase in production
(3) Patients with healthy mouths
Research indicates that at least 80 percent of the adult population has some form of periodontal disease. Unfortunately, only 10 percent are being treated in general practices today. There is an urgent need to rectify and heal the state of the average American`s oral health. Since 1985, research and the American Academy of Periodontology have shown that periodontal disease is:
x- Episodic in nature
x- When treated early has the best chance of reversal back to health - and the general dentist has the early opportunity!
So, why do hygiene departments still have voids in the schedule, why don`t hygienists probe and perform scaling and root-planing procedures, and why don`t patients accept periodontal treatment that has been diagnosed?
Let`s look at five ways to develop the periodontal aspect of the hygiene department to make certain that periodontal disease is diagnosed, that treatment is accepted and performed, and that payment is received.
Work toward the same vision
Hiring a dental hygienist is a big step. You can make better use of your time by consistently delegating responsibilities for the hygiene procedures to the hygienist and focusing your efforts on the higher income-producing services. However, this will not occur if the dentist and hygienist have not developed a close relationship and a clear vision. Together, you should build a program that will allow each patient to achieve optimal oral heath.
If you feel confident about the hygienist`s techniques, you will be more willing to relinquish the hygiene procedures. Ensure that your hygiene team is dedicated to the practice and its patients by including them in team meetings and continuing education courses and making certain that they feel a part of the well-oiled machine that is your practice.
All patients, existing or new, should be thoroughly evaluated, classified, and informed about the state of their periodontal health. It is easy to tell patients that are healthy about their excellent oral health and to compliment them on their current home-care regime. However, it is a lot more difficult to tell patients that have been coming in on a regular basis that something has changed and that the treatment done in the past at a preventive or maintenance level will not take care of them any more.
Many times, a small infection is ignored or treated without telling the patient during the "superhuman prophy." Why? Because the dentist views the infection as an admission of failure concerning the earlier treatment provided this patient. Instead, the dentist should explain the episodic nature of periodontal disease and the factors that play a role in the immune system`s efficiency. This helps the patient understand why conditions have changed in his or her mouth. Patients should be informed of even the slightest change in the health of their mouth.
The clinical criteria for periodontal-disease classification include:
x- Probe readings or pocket depth
x- Bleeding upon probing and suppuration upon probing (These require the use of a periodontal probe. Many different types are on the market, and one of them will be just right for you. Remember that an effective probe is one that is actually used!)
x- Severity of the bleeding
x- Furcation involvement
x- Recession from the CEJ
x- Bone loss (recession plus pocket depth)
x- Attachment loss
x- Mucogingival health
Treatments include scaling, root-planing, and curettaging all of the toxins from the infected sites, or referring the patient to a specialist. The hygiene team must develop a treatment plan for any and all infections found in each patient`s mouth. I suggest that you have each patient sign an acceptance of treatment form or a refusal of treatment form. This does not necessarily protect you in a legal sense, but signing the form makes the patient feel more responsible for the decision that has been made. The ultimate goal is to get a commitment from the patient and, to do this, we must create a sense of urgency for the need for treatment. We have to make the patient want the needed treatment.
The hygiene team must realize the nonsurgical limitations of the general practice. Refer the patient to a specialist when the case falls into an area that you, as a general dentist, can no longer treat and achieve ideal health.
Rediagnosing at each appointment is a must. Time must be allowed in each hygiene appointment for this to happen. If the hygienist is rushed, the probing will be done poorly, improperly, or not at all.
Probing is the number one diagnostic tool available to all clinicians. Radiographs showing the crestal bone and lamina dura follow a close second. You need to be able to refer to diagnostic radiographs throughout the treatment - i.e., initially at diagnosis, through the series of active therapy appointments, and during the maintenance appointments.
So, what constitutes acceptable radiographs for the diagnosis of periodontal disease?
* Be clear, high quality films
* Have no overlaps, cone cuts, foreshortening, or elongation
* Show open contacts between each area
* Clear crestal bone
* Show defined lamina dura
* Show a clear, defined apex on each root of each tooth
* Have good contrast
* Have no artifacts on any film
Develop a strong hygiene department that strives to achieve continuity in the diagnosis, treatment, and re-evaluation process for patients.
We always are striving to improve our communication skills, so that we can communicate more effectively with our patients. We want our patients to be happy, both during and after each appointment, as well as healthy throughout their lifetimes. To achieve this, we must communicate in terms that will enhance that conversation, whether we are communicating with the patient in the office or by telephone. The goal is for patients to see the need for treatment and to want to come in for their appointments.
Communication gurus tell us that 80 percent of communication is through body language, facial expression, and tone of voice. The remaining 20 percent is communicated via the actual words that we say. We must use effective body language and facial expressions. Here are a few important things to remember in this vital area:
(1) When patients are in the dental chair, raise them to at least a 45-degree angle. If patients are lying back, they are not in control. As a result, they will have a difficult time listening to you and concentrating on what you are saying. Sit the patient up for more effective communication.
(2) Get the patient eye-to-eye, knee-to-knee. In the clinical area, many dental professionals talk to their patients from the "mystery zone" - namely, behind the chair - while mixing up materials or completing paperwork. Patients will try to "find" the dentist to help them focus on what he or she is trying to communicate. By the time they do, the important bit of information will have been said and the patient will have missed out on hearing it.
Ensure that you are positioned in front of your patients, and adjust the height of the chair to reach their eye level. This will allow you both to be in a comfortable, win-win situation for great communications. This body position also holds true when the patient is outside the clinical area, such as when the front-office staff is collecting money for services rendered, scheduling appointments, or reviewing needed treatment and financial responsibilities at a consultation.
(3) Take off the mask and the glasses or visor. If patients cannot see your mouth as you are talking, they will not be able to focus on what you are attempting to convey.
In addition to using good body language and facial expressions, have patients demonstrate the skills they are expected to perform at home. Give them a sample of the tool(s) that they are to use - i.e., toothbrush, floss, etc. If they have to purchase a piece of equipment for their home, give them a brochure to show them what to look for.
At the end oF each hygiene appointment, provide written communication in the form of professional brochures and home-care instructions that are developed especially for your practice. Make certain that the information is placed together in an easy-to-handle sack or bag.
Improve verbal skills
While nonverbal communication is important, it does not mean that dentists don`t have to worry about what they say - the verbal communication. We always should be trying to improve our verbal skills during patient care, including broadening our verbal repertoire. We are engaged in a constant battle to educate our patients. We must clear road blocks due to words and phrases in dentistry that have developed negative connotations for our patients, and thus closed the road to great communication.
The list in Figure 1 will give you some idea of the words that dental professionals should steer clear of and the words that we must attempt to adopt in our everyday communication with patients. When reviewing treatment or making financial arrangements for treatment, use a private consultation room. This can be a great benefit because some patients need more time to ask questions about the proposed treatment. Instead of rushing the patient through or running late with the next patient on the schedule, place these patients in the consultation room or book them for a separate consultation appointment.
Keep in mind that some patients prefer to have a support person with them prior to saying "yes" to a treatment plan. Other patients will need extensive financial arrangements. That will take time and require input from a dental-team member who feels comfortable discussing the patient`s financial responsibility. Use the nonclinical consultation areas as much as possible to achieve maximum case acceptance.
Many practices provide nonsurgical periodontal therapy and call these procedures "adult prophys." Do not shortchange yourself - you are providing care that will help a patient move from a diseased state to a healthy state. Call the treatment what it is, take the time necessary to perform it, schedule the necessary number of appointments, and charge the appropriate fee. Know that patients who have clinically been diagnosed as having periodontal diseases are not in a healthy mode. They are in a diseased state. The treatment for these patients is entirely different than for healthy patients who are coming in for preventive appointments or "adult prophylaxes."
Set production goalS
Several dentists have told me they know they need a hygiene department, but they feel the department costs more than it earns for the practice. Expenses for salaries, equipment, and supplies are high enough for these dentists to consider doing the hygiene themselves. That`s a big mistake in my book. Dentists should not move from restorative dentistry to hygiene just to make the hygiene department profitable.
At the same time, I see many hygiene practices that may be good, but not profitable - and ultimately, they are not as good as they could or should be.
The department`s challenge is to help patients achieve and maintain healthy mouths and to generate a healthy profit margin for the practice. The hygienist should be producing at least three times her salary. The schedule should be preblocked for approximately half of the production goal, and those "preblocks" should be held for primary procedures. Preblock the hygienist for at least six months or preferably one year if you are advance-or pre-scheduling. Pri-mary procedures for a hygienist include any periodontal appointments, sealants, and appointments that include a full-mouth series of radiographs or a panoramic radiograph.
Spend the time and money necessary to become current with the latest in nonsurgical periodontal therapy ? i.e., how to diagnose, prepare, and present treatment plans; file insurance, overcome objections, and treat the disease. If you let your hygienist maximize the incredible talent and expertise that he or she has developed, your patients will benefit by becoming and staying healthier than ever before. The benefits to your practice are numerous: the personal satisfaction from helping your patients access this optimum health; the hygienist?s loyalty because she is trusted to use the clinical expertise and talent she possesses; and a healthier practice financially because a quadrant of root-planing and scaling is equal to two prophylaxis appointments in most practices.