Note from RDH eVillage Director: Because of the complexity of the question below, I asked both Lynne Slim, RDH, and Rachel Wall, RDH, to respond, so please read both responses.
Dear RDH eVillage:
I have been a dental hygienist for 25 years. I truly love what I do, have not gotten burnt out, and am a young-looking 48-year-old. I live in a town where there is a community college with a hygiene program that graduates students yearly, so the competition is fierce as far as jobs are concerned and jobs are far and few between.
I would like to know what is happening to dentistry these days? I know that, since I have been out of school, many advancements and changes have been made. But it seems all of the offices where I have worked at lately are unethical and all they care about is making money and not about the patients' true needs.
My main concern is that this 4941 root plane and scale code (RPS) is truly being overused and overcharged. I can't begin to tell you how many times a patient is sent to my chair with a diagnosis of RPS without being probed. I start probing and may get a few 4's and the patient is diagnosed as four quads of RPS at $200 a quad. Or bone loss is seen on the films and nine out of 10 times it is due to the fact that bone loss is due to grinding and/or clenching, or they have a history of perio disease that is now being maintained in a healthy state. Therefore, there is usually nothing to scale.
I won't do a procedure that I truly feel in my heart is not needed. For one, I can lose my license, and, second, I truly am an ethical, honest person. If I take this to the doctor, they say I am not complying and I must do what they say. This puts me in an uncomfortable position, and I usually end up getting fired over the new graduates who will comply.
I am not against RPS if it is truly needed. But I feel a lot of times the patient needs a gross debridement first and then a fine scale and polish — and they are usually fine. There is no need for anesthetic and to charge so much even when a slight bit of subcalculus (radiographic or not) is present. And what is wrong with just charging one quad of scaling instead of four quads, if there are eight teeth or less involved in the whole mouth?
I just feel that if a person is being charged $200 a quad, there better be some major sub calc and bone loss involved. You cannot RPS without roots. Also, I have been told if a patient has had RPS, they need to be on a perio maintenance code forever. I feel most RPS are misdiagnosed anyway. After all is said and done, they usually have a disease-free mouth and I put them back on a regular prophy 1110 and was told this cannot be done. Meanwhile, they are getting charged so much more for a perio prophy when I am doing nothing more than a 1110.
I currently work one day a week in an office that caters mainly to mentally challenged patients in group homes. If you want to talk RPS, all of them need it. They barely get a toothbrush in their mouth. But unfortunately, because of limited state funding, I must do the best job I can for these patients. Not all dentists and hygienists could deal with these patients on a daily basis, but I wish some of them could experience what I do to truly see what a true RPS is instead of trying to rip off normal patients each day.
As you can tell by now, I am truly fed up and disgusted with how dentistry is being done these days. Everything seems to be based on production, production, production. I know dentists are out to make a profit, but base it on the patients' true needs, not on the needs of your pocketbook.
I was brought up being told that honesty is the best policy and to live by the golden rule — to treat people the way you want to be treated. If more dentists followed this rule, I guess I would have a full-time dream job by now, but my hopes just get diminished.
Dear Troubled Hygienist:
I feel your discomfort and frustration. We recently discussed this particular issue of "profitability" for profitability's sake online in the periotherapist yahoo group. I am just as frustrated as you are and am very disturbed at trends that I, too, am seeing in private practices. Here's my take on the situation for what it's worth and you are welcome to agree or disagree with me. A healthy debate/discussion on this entire issue if very much needed in the dental hygiene community.
Like you, I believe that some hygienists are overtreating their clients in using the 4341 SRP code when a simple debridement will do. It's a clinician's call to make in determining which code to use but there are unethical clinicians (dentists and hygienists) who are diagnosing periodontal diseases when the client presents with gingivitis. I have witnessed periodontists, dentists and hygienists who have treatment planed four quadrants of SRP when a debridement is all that is needed. Why are some (and I hope that it's a minority of dentists, periodontists and hygienists) doing this? Obviously, it's being done to boost production for the dental practice. It's sad but true that there are unethical clinicians out there who don't let their conscience be their guide.
Clinicians don't have to be dishonest to make a good living. Clients and insurance companies are "on" to those clinicians who are out to take advantage of them but, unfortunately, some clients cannot choose who they can go to for care. For those who can choose, they will switch dentists when they understand what is happening, and we can only hope that those dental practices will not fare well in the future. For those dental practices who are ethical and honest, they will always have loyal clients and these clients will refer their friends and family so that these practices will thrive and continue to be profitable.
In an ethical practice, once scaling and root planing has been done, the client should remain on a 4910 periodontal maintenance schedule because the client really does have a periodontal disease that needs to be monitored over a lifetime. In many practices, the 1110 and 4910 procedure fees are similar so it's not a big issue. If the 4910 fee is a lot higher than the 1110 fee, I take issue with that because, personally, I perform periodontal maintenance on all of my adult clients! I perform an oral cancer screening exam, periodontal screening, give oral hygiene instructions as needed and remove biofilm with a thin ultrasonic instrument on low power (combined with hand instruments as needed) and polish.
One way to make sure that risk for periodontal disease (and subsequent treatment planning for non-surgical periodontal therapy) is appropriate is to use the Previser risk assessment tool. If clients are at at moderate to high risk of periodontal diseases, non-surgical therapy and 4910 maintenance procedures are indeed appropriate. You can practice with the Previser risk assessment tool for free online at < www.previser.com. Using the Previser tool adds an additional cost to treatment (the Previser folks charge $6 per client), but I feel that this fee is worth it in the long run. Remember, too, that many clients with periodontal diseases don't have a lot of calculus but they continue to lose attachment and sometimes need periodic scaling and root planing procedures.
I also think it's sad that some clinicians aren't referring certain clients to a periodontist when these clients present with advanced disease and other complications like mucogingival conditions, aggressive periodontitis or significant furcation involvement. Molar teeth are difficult to treat non-surgically, and sometimes it is in a client's best interest to be evaluated by a periodontist, too. Periodontists aren't all "knife happy" as some clients and clinicians like to call them. From a legal point of view, it is very important to refer when you (meaning the dentist/hygienist team) are providing care that is almost exclusively handled by a specialist.
I hope I have answered some of your questions. Please don't hesitate to contact me personally if you would like to discuss these issues further. The dental hygiene profession is lucky to have someone like you who is truly "professional".
Lynne Hollister Slim, RDH, MS, is president of Perio C Dent, Inc. (Perio-Centered Dentistry) in Douglasville, Ga. She is the moderator of periotherapist yahoo group < yahoogroups.com/group/periotherapist and the author of the Periodontal Theraypy column in RDH magazine. She can be contacted at (770) 947-2496 or [email protected]. Her Web site is www.periocdent.com.
Dear Frustrated:
I feel your pain. Having worked as a fill-in hygienist myself, I understand the frustrations when working in an office that uses a protocol I am neither familiar nor comfortable with. Good news! With a little effort on your part, there is light at the end of the tunnel. I also know that you are not alone in your distress. Many other hygienists are feeling the same way and just may not have reached the point crying out for help.
Your letter presents many issues, all of which could be explored in several different articles. With respect to article length and endurance of the reader, I am not able to address all the protocol and treatment issues. I do, however, want to acknowledge you for recognizing that there are many inconsistencies with perio therapy and disease diagnosis. As a consultant, I have found that very few practices have a current perio protocol that is implemented effectively.
Let's look at the core issues that I perceive are causing your frustration. They are as follows:
• Protocol for periodontal examination
• New AAP periodontal disease classification
• Active perio infection vs. past bone loss
• Full quad therapy vs. site specific therapy
• Periodontal therapy fees
• Life-long perio maintenance and the AAP's recommendation on maintenance
• Treating disease and not calculus
• ADA codes
• Communication with dental team when working as a temporary hygienist
• Doctor/hygienist communication
My first piece of advice is to sign up for the most current and comprehensive periodontal continuing education course you can find. RDH magazine posts continuing education course around the country in the back of every issue. In the meantime, go to www.perio.org. This is the official site for the American Academy of Periodontics. On the "Professionals" page, you will see a link to the Clinical and Scientific Papers. Visit that link and print and read as many of the Statement and Position papers that you can stand. The AAP is the current authority on all things perio in the country. This is a very valuable website, offering new guidelines for perio classification, treatment and maintenance. These papers may answer many of your questions regarding what constitutes periodontal disease versus a healthy patient.
With this updated knowledge under your belt, you will be much better armed to participate in collaborative treatment planning when a patient presents with disease. You will also be able to site literature and professional guidelines when faced with a situation in which you are not comfortable treating the patient as prescribed.
Another benefit is to build your resume. In a tough job market, the more you can contribute to a practice, the more valuable you become. This can be in the shape of knowledge of current perio treatment trends, willingness to participate in treatment planning and recognizing that the hygiene department is an integral part in the success of any dental practice.
If you have a good relationship with a periodontist in town, you may want to take him/her out to lunch to discuss some of your concerns. He/she may be just as concerned as you are with the current state of perio therapy in your community. He/she may also be able to make a special introduction on your behalf to a few general dentists that he/she knows are perio-aware. You may want to try temping for a few perio offices for awhile, or selecting a few great offices and expressing your commitment to them as their permanent fill-in hygienist.
The moral of the story is that without the synergy and support of a healthy Doctor/hygienist relationship, it often feels like we are fighting an uphill battle. Creating that synergy is possible.
Just like with your patients, sit knee to knee with your doctor and share your concerns. Keep an open mind and a heart for learning and growing. In order to be a happy and effective hygienist, our professional values must match those of the doctor we are working with.
Rachel Wall, RDH, BS, is an active clinician, speaker, writer, and consultant. During her 14 years as a hygienist, she has enjoyed positions in periodontic and cosmetic practices as well as teaching, consulting, and research. As founder of Inspired Hygiene, Rachel serves as a hygiene consultant whose goal is to inspire dental teams to reach an outstanding level of patient care and performance. For more information, you may contact Rachel at [email protected].
Call for Help. I would like to know what is the general consensus of hygienists using the Florida Probe? I dislike using it intensely and I do not feel it is accurate when I compare my findings with the perio probe. Please respond at [email protected] and I will reprint the feedback in next month's RDH eVillage.
