Perio/Hygiene for the 21st Century

Parts 1 and 2 of this series reviewed today's approach to Non-Surgical Perio Therapy in the 21st Century general practice.

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by Dr. Steven Gutter, MBA
Part 3: Financial Considerations

Parts 1 and 2 of this series reviewed today’s approach to Non-Surgical Perio Therapy in the 21st Century general practice. Many clinical guidelines to treatment were presented in “The 21st Century Perio/Hygiene Treatment Protocol” (Table 1). This final chapter of the three-part series discusses the financial aspects of perio therapy in the general practice.


A practice’s policy of patient finances enhances the patients’ behavior modification. Generally, people believe that they get what they pay for, and that something for nothing means nothing. The degree to which a patient pays for treatment, in dollars, time, energy, or discomfort, is the degree to which the care received is valued. When people pay for a product or service, they are aligned in the outcomes received for their investment. It is said, “Unpaid-for dentures don’t fit.” Paying for dental care reinforces patients’ contribution to their co-therapy.

The doctor and/or hygienist explain to the patient about the co-therapy approach, and that what the patient does in bacterial control at home is as important to the long-term outcome as what is done in the office. The dentist may say, “Mrs. Jones, this is part of your contribution to our success. Your compliance with your daily bacterial control will help protect your investment. Working together, I see no reason why we wouldn’t have a favorable result. And you will want to keep in mind that there is nothing we can do which will overcome what you don’t do. Do you know anything that would prevent you from doing your part in our cotherapy? Your commitment to compliance is the key to your long-term health.”

Non-itemized fee approach

Some offices present perio treatment as a package with fees in the range of about $300, such as $900 to $1,200, or $1,500 to $1,800, depending on the complexity of the case. Other offices itemize a case at its outset or at its end, which will be discussed later. Suggested fee ranges for treatment of different levels of disease are displayed in Table 2. The non-itemized fee approach, also known as the front-end loaded fee plan, affords the practice the option of giving extra appointments or providing extra Arestintreatments without “nickel and diming” the patient. One fee also saves offices from the necessity of reselling the patient on every visit. The fees include diagnosis, behavior modification, home-care recommendations (power toothbrush, tongue scraper, interproximal aid, chlorhexidine, chlorine dioxide, irrigator), active therapies (SRP and Arestin), and re-evaluation and retreatment visits. Patients are pleased to hear there are no further charges for future visits. A comprehensive, non-itemized fee, along with its convenient, affordable financial arrangements, is the easiest way for the patient and the office. If dental benefits are being used, the upper end of the fee range quoted is charged out to the carrier. A listing of the treatment codes and their fees that add up to the higher end of the fee range is submitted. Click here to view Table 1.

An example of a non-itemized fee approach for case presentation to patients follows. “The fee covers the disinfection and medications in initial therapy with two or three re-evaluations and retreatments. Home-care tools, devices, training, and initial SRP/maintenance therapy are also included in the fee. Should healing be compromised, additional antibiotics and/or enzyme-suppressant pills (Periostat) may be prescribed. Referral to a specialist may become indicated. The fee covers the entire five-to-six months of therapy plus all related aids that control the bacterial infection. This medical/dental approach yields the best nonsurgical outcomes available. Does this sound like the way you would like to care for your mouth?”

A non-itemized fee range of $1,300 to $1,600, with all the extra value and treatments included, seems very reasonable to patients who have bought into their disease state for this conservative, nonsurgical approach to care. Patients deem that any fee in excess of $100 is expensive. Itemizing the fee necessitates posting six-to-eight charges, each over $100, which seems like a greater investment than presenting the patient with one all-inclusive amount. Table 2, “Case Fees,” gives guidelines of suggested fees.

Itemized fee approach

Using the itemized fee approach, the financial coordinator must understand that patients are inclined to concentrate on “How much is my insurance going to pay?” The itemized approach may elicit resistance to the fees for re-evaluations, retreatment of unresolved areas, recommended home-care aids, etc., and hinder compliance to a comprehensive approach.

The 21st Century Perio/Hygiene Department uses an insurance-friendly model in which a practice may or may not accept assignment of benefits. The office vision is patient-centered, relationship-driven, and values-dominated. Doctor and staff effectively communicate with patients by posing needs-development questions and listening to patient responses. This occurs through doctor and staff training on communication skills, focusing on what to say and how to say it, centering on the practice vision.

Today’s employers’ dental benefits are only an aid, not a “pay-all.” Patients no longer sign over all bills to the dental plan and escape payment-free. The following dialogue may be used for patients fortunate enough to have dental coverage. “This office is committed to a comprehensive, nonsurgical approach to treating gum infection. The initial Gross Debridement (Code 4355) fee is $100 and allows for some healing while affording us an accurate assessment of the extent of infection after the initial removal of deposits. Each quadrant is then treated with scaling and root planing (SRP) with an ultrasonic scaler with anti-infective medicines to lavage the tissue. SRP fee is $175 per quadrant, or $700. The sites with pockets >5 mm will then be treated with a controlled-release antibiotic called Arestin at $19 per site. Each re-evaluation and retreatment visit every six weeks after the SRP of unresolved areas is $100 per visit. A power electric toothbrush is $100, and there is a fee of $20 each for two different antibacterial mouth rinses for home use.”

So, the above example would have itemized fees as follows:

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Sometimes an itemized presentation encourages the patient to consider the money instead of the benefits of the care. The offices that master the fee presentation move the patient toward buying into the desired successful outcome after the patient buys into having this disease. The value is recognized in being disease-free, looking good, feeling good, having fresh-smelling breath, and understanding the ongoing process of keeping ahead of the bacterial proliferation through home care, professional treatment, and judicious use of newly available drugs.

Both approaches to fee presentation work; however, the non-itemized fee approach tends to focus on the benefits of care, the long-term value of the treatment, and affordable and convenient financial arrangements. Outside financing is often used to close the case. Successful patient financial arrangements support the success of clinical outcomes.

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Trish O’Hehir, RDH, editor of Perio Reports, tells doctors to consider a fee for one crown for the Type II early perio case, a fee for two crowns for the Type III moderate perio case, and a fee for three crowns for the Type IV advanced perio case. This way of non-itemizing takes into consideration the degree of difficulty of the case; the time invested; and the care, skill, and judgment of the dentist/hygienist team. The most defensible strategy in today’s litigious society is to refer furcation-involved Case Type III or Case Type IV patients for a specialty consult rather than having the general dentist take full responsibility for the case.

Financial arrangements

Financial arrangements for the higher fee in the range are finalized. If a credit remains after treatment is done, a refund is generated. If the patient has dental benefits from his employer, estimate the amount of the coverage. Make arrangements to finance with Care Credit, Dental Fee Plan, or a similar patient financing program and/or collect the patient portion upfront. Emphasize the benefits of “convenient, affordable payments that fit into the patient’s budget.”


The ADA procedure codes are indicated in the left-hand column of Table 1 of the “21st Century Perio/Hygiene Protocol.” Table 3 lists relevant code narratives, i.e., D4355 - Gross debridement, D4341 - Quadrant scaling and root planing, D9630 - Drugs and medicaments (used with narrative for the in-office antibacterial subgingival irrigation), D4381 - Controlled release antimicrobial (used with narrative for Arestin, Atridox, and/or PerioChip), D0180 - Periodontal re-evaluation, and D4910 - Periodontal maintenance. The new code 4342 Scaling and root planing (SRP) for three teeth or less is a good descriptor for site-specific treatments and/or retreatments of recurrent periodontally involved sites.

Patient discussions

Whether treatment fees are itemized as in Table 1 - Insurance Column, or nonitemized with a case fee as in Table 2, value is the subjective matter to develop with the patient. Some doctors give patients a one-year fee emphasizing the chronic nature of perio disease and the anticipated need for its ongoing control. When the patient understands the nature of the disease and has trust and confidence that his or her best interest is at heart, the cost becomes a secondary issue. The more operative decision becomes when to have the work done.

The dentist must be comfortable with the value for perio treatment, and cannot give away perio treatment as “super-prophys.” As a powerful revenue producer, an arbitrary target is between $200 and $400 per hour per hygienist performing “21st Century Perio/Hygiene Therapy,” depending on the comprehensiveness of treatment; the care, skill, and judgment of the dentist/hygienist; and the patients’ perceived value for the service.

The most important thing to sell the patient is the disease, and its possible ramifications. Reporting the probing depths aloud to a recording assistant informs the patient that the numbers on the chart are signaling infection and past destruction. The patient codiscovers disease after hearing probing depths of >4mm and/or bleeding on probing. A future article will discuss in more detail compliance for perio case presentation.


Two inviolable rules of commerce are as follows:

1)The business cannot bill for excellence and deliver mediocrity (customers will realize they didn’t get their money’s worth and will stop coming); and

2) The business cannot bill for mediocrity and deliver excellence (cost of doing business becomes too great to sustain and it makes little, if any, profit). In either case, the business goes broke.

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The solution to these rules is to charge a fair fee for a fair service. Dr. L.D. Pankey said, “A fair fee is that fee which the doctor is willing to receive and the patient is willing to pay, without economic hardship, with appreciation and gratitude by all.” “Without economic hardship” necessitates the central aspect of Dr. Pankey’s philosophy, “Know your patient.” The phrase, “with appreciation and gratitude,” places the major responsibility on the doctor as the teacher and educator, and further liability on staff members as facilitators to impart the inherent value of dental services to the patients.

An enlightened patient will appreciate the care, and ultimately pay the fees with a feeling of gratitude. How the office handles the finances enhances the patient behavior modification and value of services.

The value of saving a mouth for a lifetime compared to the value of replacing one tooth with a bridge or an implant is clear. However, the time involved in the procedures varies greatly. The nonsurgical perio treatment is performed in about six-to-nine visits over five or six months, whereas a bridge is usually placed within two visits in a total treatment time of about three hours in two weeks. Implant surgery, conventional and/or immediate fixture placement, and crown procedures average a total treatment time of three to six hours in a six-month period. The perio treatment works to save an entire mouth, and the other services replace a selected tooth or teeth, begging the question, “What’s it worth?” Could these treatments have similar fees? Could the value of these treatments be comparable?


Providing exceptional care in nonsurgical periodontal services can profoundly impact the bottom line of a dental practice. Patients and dental offices should recognize the perceived value for comprehensive nonsurgical perio treatment. Initial periodontal therapy in the general practice is the “excellence-in-care” relationship builder that leads to long-term restorative and cosmetic dentistry. Health and wealth are not mutually exclusive - they go hand-in-hand!

Dr. Steven Gutter, MBA, has been a national consultant and speaker in the dental profession for over 20 years. He practiced in San Francisco for 10 years. He has successfully educated over 11,000 GP offices in his more than 600 presentations and consultations on Perio/Hygiene implementation, practice management, dental insurance, and dental office fee analysis. He is on the Board of Directors for The Speaking/Consulting Network (SCN), founded by Linda Miles, and is an instructor at University of Miami/Jackson Memorial Hospital’s Dental GP Residency. He can be reached at (800) 433-4907 or at

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