By Rhonda R. Savage, DDS
Consultant / Philips Oral Healthcare, makers of Sonicare and ZOOM!

Do you place your patients’ best interests first? If you do, you lower your risk of engaging in malpractice and are likely increasing your income. But most important, your patients receive the care they deserve and expect.

As you’re probably aware, the majority of research indicates that periodontal disease is linked to or has an association with cardiovascular disease, diabetes, low-birth-weight babies, hormonal changes, obesity, metabolic syndrome, smoking, nutritional deficiency and autoimmune diseases. How do you evaluate your periodontal protocol?

The following are questions you should consider:

  1. Are you doing routine periodontal probing and complete periodontal charting annually?
  2. During a new-patient exam, do you set the stage for periodontal disease by performing only minimal spot probing and assessments of tissue health?
  3. Is your hygiene production lower than one third of your overall production? If you have a strong periodontal program, on average, 33% of your hygienist’s production will fall under the 4000 codes: periodontal scaling and root planing, periodontal maintenance and adjunct services.
  4. Do most of your hygiene services fall under the adult scaling and prophy code?
  5. Do your patients have bloody bibs? (A bloody bib does not mean a prophy was provided.)
  6. Are your hygienists doing “the best they can in the time they’ve got” and charging for a prophy?
  7. Do you have most adult patients scheduled in a 45-50 minute time slot?
  8. Are your hygienists current in technique, providing excellent scaling and root planing services?
  9. Look at your recall/reactivation process. How effective is it? Are you at risk of being sued for abandonment?
  10. Do you have the tools/instrumentation needed to provide definitive periodontal care?

Is it time to re-evaluate your standard of care for periodontal disease? Missed or monitored neglect is one of the top causes of litigation. Proper examinations, diagnostic x-rays, charting, patient informed consent, proper timely referrals or treatment are important for your practice and the care of your patients.

Following are traits of practices with highly-effective periodontal protocols.

They have a written periodontal protocol.

Hygienist and doctor need to sit down as a team and talk about diagnosis. What are your standards? Reach a consensus regarding the type of periodontal probe that’s preferred and provides the most accurate readings. Also be on the same page regarding the proper location and angle of the probe, and amount of pressure on the probe. Practice on each other!

The dental assistant prefaces the doctor’s exam with an oral evaluation—at the doctor’s second chair.

The total new-patient examination time is 45-60 minutes and can be dovetailed into the schedule, prior to an hour of hygiene time. Some doctors do the entire examination. However, having the dental assistant gather information at the doctor’s second chair is ideal. Fees for the patient’s cleaning can be estimated properly.
The assistant can begin gathering information by doing the following:

  • Connect with the patient
  • Review a patient’s health history
  • Take a baseline blood pressure reading
  • Chart existing restorations
  • Take necessary x-rays
  • Use the intraoral camera; chart missing, crowded, rotated, yellow teeth; and ask the patient:
    • Has anyone explained the importance of replacing this missing tooth?
    • [Your gums look red and irritated, and you have a lot of tartar build up.] Do your gums bleed when you brush? Has anyone ever talked with you about gum disease?
    • [This filling has been there a long time and it’s done a good job for you. It looks like it’s wearing down along the edges.] Do you have any sensitivity to temperature or sweets there? Bite sensitivity?
    • Does food get wedged in between your teeth?
  • Ask the patient:
    • What brought you to our practice?
    • If there was one thing you would change about your smile, what might it be?
    • How do you feel about keeping your teeth the rest of your life?
    • [You have a nice smile!] Have you ever been interested in whitening your teeth? We have the Zoom WhiteSpeed in our office and it’s amazing!

An assistant can be invaluable in connecting with a new patient and—once trained—setting the stage for case acceptance. Case acceptance often increases when an assistant is involved in the exam process, because as laypersons, patients often relate well with them. Patients hear what you say differently when it comes from a team member.

The assistant can also present information about products that can help a patient become healthier or more satisfied with his smile. This is an ideal time to present a new electric brush, for example. Though team members might think whitening is old news, patients still want whiter, straighter teeth. Case acceptance is directly proportional to the enthusiasm of the presenter.

X-rays are a large part of the diagnostic process.

If a patient dictates on the phone that he wants a cleaning, does not want x-rays and has no current x-rays, he’s waving a huge red flag. In many states, it is malpractice to attempt to diagnose oral conditions without x-rays. Even if you have the patient sign a consent/release form refusing x-rays, you can still be liable. If you agree and skip the x-rays, do restorative treatment on #14 but fail to diagnose significant bones loss between #14 and #15, you will be liable. The patient cannot sign away his consent to the standard of care. Create a written
x-ray protocol for your team. This would include the interval, age of the patient, caries index and periodontal status.

The doctor conducts a thorough examination.

The doctor’s examination is typically 10-15 minutes during a new-patient appointment.
She ideally first sees a new patient in her chair. After connecting with the patient, she does a complete exam, looking at every tooth, as well as soft tissues and bone. Then she conducts an oral cancer screening.

Some doctors are too quick and don’t connect with the patient. Others take too much time and “talk the patient to death.” The goal of the case-acceptance process is to gauge a patient’s need for communication through his questions. Most patients don’t want or need a lengthy discussion regarding treatment. If the needs are significant, consider offering the patient a complimentary consultation.

The doctor makes the periodontal diagnosis.

At the new-patient exam, the doctor should at minimum conduct a spot probe of the tissues and have a sense of the periodontal status of the patient. I prefer the full probing be completed by the health care provider that’s going to provide the hygiene services. (The hygienist may be able to complete this.) Even with a standardized protocol, different providers will have different probe readings.

The doctor’s role is to help the patient understand the need for the recommended periodontal treatment. The doctor should use layman terms, and be simple and clear when providing explanations.

“Fred, you have signs of gum disease. Gum disease is caused by bacteria that cause an infection. It’s often called a silent disease because it’s not always painful.
Most people know there’s something wrong when their gums bleed when they brush. If you had an infection in your eye like you do in your mouth, you’d see it and rush to the eye doctor. We need to get you with our hygienist who can help your gums be healthy and give you tools to take care of them.”

The hygienist’s role is to go into more detail with regard to the etiology and the doctor’s treatment protocol. If you end up with a very clean and healthy patient, and the hygienist’s services didn’t warrant an hour, the hygienist can help with other responsibilities such as clean up and set up, instrument sterilization, and recall and reactivation calls.

The seven stages of treatment planning are routinely followed.

You know the 7 stages of treatment planning; unfortunately, I often see doctors and team members jump from step 1 to step 5 without considering the ramifications:

  1. Comprehensive Evaluation
  2. Diagnosis and Treatment Planning
  3. Treatment Consultation
  4. Preventive and Periodontal treatment
  5. Restorative Dentistry
  6. Cosmetic Dentistry
  7. Maintenance

To prevent engaging in malpractice, and to treat your patients with their best interests in mind first, we need to be attentive to each phase of dentistry. Refine your hygiene services with a written periodontal protocol. Keep in mind that the diagnosis is key. Know when to refer.

Also consider tapping into the talents of your dental assistant. Economically, having the majority of the examination time be allocated to an assistant is more affordable for the practice. The more the assistant does, the more the doctor can have a drill in his hands, doing things only a doctor can do.

The same is true for hygienists. Moving a new patient exam to the assistant’s chair creates more time for the hygienist to provide services only she can.

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Rhonda Savage, DDS is an author and lecturer, and CEO of Miles Global, an international dental training and consulting firm. She is a Past President of Washington State Dental Society, an Affiliate Faculty Member of University of Washington School of Dentistry, and a member of the Pierre Fauchard Academy, American College of Dentists, and International College of Dentists.