Shame on us: the 3% problem and periodontal disease

July 19, 2012
Statistically in the U.S., 3% of the hygienists’ production is in the 4000 codes.

Statistically in the U.S., 3% of the hygienists’ production is in the 4000 codes. Based on the new AAP guidelines and recommendations to “get there early,” is this good enough? If not, what is? The answer depends partly on the practice location. Rural Montana has more periodontal need than some areas of Washington, D.C. Another part of the answer depends on the philosophy of the doctor and his or her diagnostic tendencies. The age of your practice can matter also, especially if you already have a strong periodontal program with patients in a maintenance program and you’re receiving few new patients. For practices located in a college town with a younger, more disease-resistant population, there may be a lower periodontal percentage.

Perhaps it’s time to look at your statistics. Run a report titled “Production by Procedure (individual ADA codes) by Provider.” Ask your hygienists to total up all of his or her production in the 4000 codes (periodontal scaling and root planing, periodontal maintenance, and any adjunct services such as antibiotic therapy or OralDNA testing). If your practice is progressive with periodontal services, we typically see 33% of hygiene production fall into this category. Quite frankly, I’d be thrilled if it was at least 20%.

I'm hearing the arguments right now:

  • But it’s not our fault that the patient doesn’t accept treatment!
  • They cancel and fail their appointments.
  • It’s the economy!
  • They don’t think they need treatment.

Yes, I agree – times four. But here’s my rebuttal:

  • Are you diagnosing the disease process?
  • Have you trained your team with great verbal skills?
  • Do you have an established periodontal protocol that everyone is held accountable for?
  • Do your office team members routinely use the intraoral camera for education?
  • Do you have an excellent model – an unforgettable visual aid that will be seared into the patient’s mind?

(Check out my new DVD series Got Perio? I Just Want My Teeth Cleaned here.)

Research indicates that we’re not getting there early enough with diagnosis or treatment. I also know, from our research with Miles Global, that many hygienists are treating periodontal disease and billing it as a normal, healthy prophylaxis.

If we ask a hygienist, “How would you rate your periodontal program, on a scale of one to 10, with 10 being the best?” The answers will be:

  • “Our periodontal program is non-existent,”(if they know their statistics)
  • “We’re working on it,” or
  • “Eight out of 10.”

And yet, based upon the practice management software reports, we find that the level of periodontal services, compared to the overall hygiene production, is often less than 1% – not anywhere close to 33%.

This isn’t about the money. That’s another argument I hear. Ironically, the money does follow. It’s about the diagnosis and recommendations, plus doing whatever we can as a health care provider to make certain the patient understands the “why.” I understand there’s a fine line between nagging and passion, from the patient’s perspective. This article will present some tools that can help create value, improve the patient’s understanding and leave a visual and clinical picture in your patient’s mind. With this information, your periodontal patient will never say, “Why can’t I have a normal cleaning again?”

How do you evaluate your periodontal protocol? Ask yourself these starter questions:

  • Are you doing routine periodontal probing and complete charting annually? Does your hygienist note furcation involvement, bleeding points, purulence, mobility and recession?
  • Does your hygienist have time to set the stage for case acceptance? To revisit treatment recommended but not completed? Does she routinely use the intraoral camera and the soft tissue model? Do you build in ADA codes (a zero-cost service) to track usage? Does your hygienist verbally let you know about her time spent educating the patient when you walk into the operatory? (Yes to all? A huge gold star and high five!)
  • During your new patient exam, do you set the stage for periodontal disease by at least doing a spot probing and assessing the health of the tissue?
  • Do you look at your hygiene production? If you have a strong periodontal program, 33% of your hygienist’s production will be in the 4000 codes: periodontal scaling and root planing, periodontal maintenance and adjunct services. This percentage does vary demographically; a more educated population can have a higher level of health.
  • Are most of your hygiene services in 1110 codes for a normal healthy adult?
  • Do your patients have bloody bibs?
  • Are your hygienists doing “the best they can in the time they’ve got” and charging for a prophy?
  • Do you have most adult patients scheduled in a 45- to 50-minute time slot?
  • Is your hygiene production lower than one-third of your overall production?
  • Are your hygienists current and capable of scaling and root planing?
  • Look at your recall/reactivation process. How effective are you?
  • Do you have the tools/instrumentation available that are needed to provide definitive periodontal care?
  • Is your practice current with full mouth X-rays?

How do you incorporate a solid hygiene program into your practice? Go to the American Academy of Periodontology website and download the latest AAP guidelines. As a team, the doctor(s) and hygiene department need to create a consistent periodontal protocol for the practice.

The easy diagnosis is patients with a pocket depth of 1 mm to 3 mm and a clean healthy mouth. The easy ones to diagnose are also those patients with severe periodontal disease — 7 mm to 12 mm plus probing depths. The tougher diagnosis is those patients with 4 mm to 6 mm pocket depths, with or without calculus buildup or recession, with or without fremitus or furcation involvement.

Develop a periodontal protocol

The hygienist(s) and doctor(s) need tosit down as a team and talk about diagnosis. Practice on each other! What are your personal standards? Determine and come to consensus regarding the type of type of periodontal probe that’s preferred and provides the most accurate readings. Also discuss and be on the same page regarding the location of the probe, the angle of the probe and the proper amount of pressure on the probe. For a sample of a periodontal protocol, email me at [email protected].

The examination

The dental assistant can begin gathering information and also begin to set the stage for case acceptance. He or she can do the following:

  • Review the health history
  • Take the necessary X-rays
  • Ask the patient questions:
    • 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 for the rest of your life?
  • In addition, she can take a blood pressure screening and chart existing restorations.
  • She can also use the intraoral camera 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 temperature or sweet sensitivity there? Bite sensitivity?
    • Does food get wedged in between your teeth?
  • She can chart missing, crowded, rotated, yellow teeth.

The doctor comes in and, after connecting with the patient, does the complete examination, looking at every single tooth as well as the soft tissues and bone. The doctor does the oral cancer screening examination also and does a spot probe of the tissues, setting the stage for case acceptance in the hygiene chair.

X-rays are a large part of the diagnostic process

If a patient says on the phone that they want a cleaning but no X-rays (and have no current X-rays), the patient is waving a huge red flag! In many states, it is malpractice to attempt to diagnose oral conditions without X-rays. Patients cannot consent to malpractice! Even if you have the patient sign a consent/release form refusing X-rays, you will still be liable. If you agree and skip the X-rays, do restorative treatment on No. 14 but fail to diagnose significant bones loss between Nos. 14 and 15, you will be liable. Create an X-ray protocol for your team. This would include the interval, age of the patient, caries index, periodontal status, and OralDNA testing if periodontal disease is present.

Should the doctor do the periodontal charting?

At the new patient examination, the doctor should at least spot probe and have a sense of the periodontal status of the new patient. I prefer the healthcare provider that is going to provide hygiene services complete with the full probing. Even with a standardized protocol, different providers will have different probe readings. The doctor’s role is to set the stage for treatment of periodontal disease, to be concise.

Informed consent

Your patient says, “I don’t care about gum disease. I just want a regular cleaning.” What do you do? There are two options. One is to say, “Well, I don’t get fired by my physician because I’m overweight or because I smoke!” True, but also realize again that a patient cannot consent to malpractice. Even if you have a patient sign a form that states they realize they have gum disease, the same patient can come back later and say, “I didn’t know what I was signing.” The malpractice case would then be one of “supervised neglect.” However, if you’ve made the diagnosis, documented well, referred to a periodontist (for resistant patients to receive a second opinion) and documented refusal to see a specialist, you’ve done your homework.

It’s time we, as dental professionals, take charge. When was the last time a physician looked into a patient’s mouth and said, “Man – you’ve got gum disease! When was the last time you saw your dentist?” Do you refer to the patient’s physician if they have a questionable periodontal status, uncontrolled periodontal disease, high blood pressure, a history of cholesterol issues, are overweight, or are a smoker? Do you refer for a C-reactive protein test?

If not, why not?


Kilgore International soft tissue periodontal model (it’s more real to patients than the clear tissue model): The model demonstrates healthy gum and bone, moderate periodontitis, and severe periodontitis.

OralDNA: Test with 4-5 mm pocket depth. My advice: Don’t wait until your patient reaches the 6-7 mm mark. If I can help, drop me a line. It’s time we get there sooner, and if we don’t ... Shame on us! If you’re using OralDNA, I recommend you reevaluate at the one-year mark. Give the patient a scorecard. Much like cholesterol testing, we need to motivate the patient by continually reinforcing the need to change.


Read Dr. Savage's recent article on solutions to conflict in the office here.