March 17, 2021
by Gabriele Maycher, CEO, GEM Dental Experts Inc. BSc, PID, dip DH, RDH
When you stabilize your internal economy, your practice can weather the most volatile economic storms.
The Canadian Dental Hygiene Association (CDHA) con-ducted a nation-wide survey in the fall of 2020 to evaluate the impact of Covid-19 on its members and found that one-third of the nearly 3,600 respondents had seen a reduction in their working hours, some reporting cuts as high as 50%. Hygienists cited “patients’ general fear, anxiety of returning, concerns about infection control practises, loss of insurance coverage, affordability, and limited appointment times” for the decline in business. However, this same study also tells us that 31% of hygienists reported their clients had no concerns, and in fact, a number of respondents mentioned that “they’ve never been busier.” What sets these hygienists apart from the rest? How are their practices thriving when others are barely surviving?
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Your Reality Check
If you’re blaming the lagging economy for a drop in appointment scheduling, a reduction in work hours, and an unstable job situation, then consider this: Every business is impacted by what I call an “external economy” and an “internal economy.” The external economy is influenced by national and global markets that we have little control of. And the 2020 Covid environment is a perfect example of that. In the mid to late 70s it was the global HIV/AIDS epidemic. Although only a few sporadic cases were documented at that time, by the early 80s it had already spread to five continents and 300,000 people. It was an unsettled time for our profession because we were struggling to understand this new emerging disease and characterize the risk of infection. Just as with COVID-19, we weren’t sure about the necessary safety protocols, splatter consequences, infection rates and modes of transmission. When I graduated, I was one of the first hygienists to wear safety glasses, gloves and a mask. Can you image how startled patients were to see me for the first time donning personal protective equipment at a time when unmasked faces and bare hands were the norm? And then there were those patients who were nervous about coming in for treatment because they knew we treated HIV/AIDS patients, and they were afraid we could transmit it to them by simply being near them.
So, if it isn’t COVID or AIDS, it will always be something. How about the runaway inflation of the 80s, which was responsible for 21% interest rates? And yet a lot of practices were their busiest and thriving, including the practices I worked in and managed. Remember the early 2010s when hygienists were in a surplus, getting offered a fraction of the wage they were worth? Like I said, there will always be external economic factors threatening your security as a healthcare provider, so how do we build an internal economy that can thrive regardless of what’s happening in the world around us?
Building From the Inside Out
You have great influence over the internal economy of your hygiene practice, those factors that you can control, like systems, process, protocols, procedures and most, importantly, treatment philosophy. Hygienists who report they’ve never been busier in 2020 are thriving because they are focused on optimizing their internal economy, which allows them to continue practising dentistry just as if there wasn’t a global pandemic knocking at their door, draining patient retention, limiting working hours and convincing patients that maintaining their oral health isn’t really an essential service.
These thrivers have a different treatment philosophy than their cohorts who are struggling just to get by. And it comes down to how they deliver basic care, shifting their focus from six-month “cleanings” to providing more comprehensive nonsurgical periodontal therapy for the treatment of gum disease. The American Academy of Periodontogy (AAP) reports that 86% of practices don’t provide the standard of care to treat periodontal disease. That means there’s a lot of room for improving our competencies and providing patients with better outcomes. The remaining 14% of practices that are effectively treating periodontal disease are the busy ones, delivering comprehensive therapy and vital long-term treatment to meet the standard of care set out by the AAP and their college.
Let’s Define ‘Cleaning’
My blood pressure hits the roof whenever I hear dental professionals and patients refer to their visits as a “basic cleaning” and checkup appointment. It infuriates me because there is nothing “basic” about a patient’s cleaning appointment since 80% of patients have some level of periodontal disease according to the American Dental Association, requiring nonsurgical periodontal therapy to get them to optimal health. How often do you as a professional use this term–a term that’s not even recognized in the dental literature?
Despite my best efforts, I know that dental professionals will continue to use this term. So rather than trying to eliminate it, why don’t we give it a definition to help us distinguish the difference between a basic “cleaning” and “nonsurgical periodontal therapy,” especially when speaking with our patients. Here is my definition: a “basic cleaning” is maintenance treatment we do for patients with “healthy gums,” (which is only 20% of patients in your practice) and “health” is defined in the literature as, <3mm sulcus or pocket depths and <10% bleeding on probing. If you have pocket depths >3mm and/or > 10% bleeding on probing you have “unhealthy gums” or periodontal disease, which requires nonsurgical periodontal therapy to get your gums back to health. This typically means your treatment may involve up to six appointments, plus a post-care appointment for initial therapy and/or more frequent maintenance appointments until such a time we establish health.
Darby and Walsh’s definition of nonsurgical periodontal therapy (NSPT) is “therapy that encompasses the control of oral biofilm through self-care and professional periodontal debridement, supplemented by adjunctive therapy with antimicrobial or host modulation agents as needed for the treatment of periodontal diseases involving natural teeth and implant replacements.” With 80% of your patients having some level of periodontal disease, most will need more than just a basic “cleaning.”
A Breakdown in Basic Care
Before we discuss how to implement NSPT 80% of the time, let’s discuss the clinical breakdowns holding back most hygienists from developing that highly perio focused practice. As a consultant, there are three clinical breakdowns I typically find during the chart audit process that you need to fix and become laser focused on if you want to create this change, and those areas are the comprehensive oral exam (COE), the number and type of radiographs exposed for a dental hygiene diagnosis, and using best practices in the treatment of periodontal disease.
Comprehensive oral exam– Conducting a COE requires fundamental hygiene skills and provides a vital service to our patients. So why do I see so many common mistakes as I conduct chart audits in practices across Canada? Here’s what I see most often.
COE not being done at all. There seems to be an assumption that minimal assessments are required if you only bill for a new patient (NP) exam. In fact, sometimes only a caries assessment is performed. The practice should worry less about billing protocols and more about meeting the expectations of their college or practice standards. Whether you are performing a specific exam, NP exam, comprehensive exam or recall exam, you are liable to the requirements of your college’s standard of care, not the fee guide’s interpretation of the standard of care.
COE being done once per lifetime. According to the AAP, a COE should be done once a year. Whether or not you decide to bill for it has nothing to do with whether it should be done.
COE billed but all the assessments not completed according to requirements. A COE isn’t just caries and or probing assessments. If you’re unsure of the requirements that constitute a COE, consult your college and do not rely on just your fee guide’s interpretation of requirements.
When sufficient time is given at the patient’s initial appointment and these required assessments are done comprehensively, a quick review at followup appointments is all that’s needed for most of them. Some assessments like medical dental history review, intraoral exam, vitals, probing, bleeding on probing, and recommended and accepted treatment will need to be updated at each appointment or annually as per college standards or patient-specific needs, which shouldn’t require any substantial additional time. In most of my practices, we provide more time every third year to establish a new baseline of assessments and ensure accuracy. At this appointment, patients are once again billed for a COE fee.
All COE assessments are done, but they do not translate into a comprehensive treatment plan. Instead of treatment planning for nonsurgical periodontal therapy, I often see that a basic “cleaning” is the only treatment planned. It’s as if there is a breakdown in the interpretation of the assessments collected and/or a misunderstanding about how they should translate into treatment. Or, perhaps, limiting beliefs about what a patient will and will not pay for gets in the way of the clinician discussing the recommended treatment and associated costs. Most of the time it is a combination of all these factors.
The number and type of radiographs exposed – Exposing the correct radiographs is as fundamental as telling patients to “say aah”. Here are the breakdowns I have encountered.
Radiographs focus on a dental diagnosis only. I know this to be true because typically only horizontal radiographs are taken. With horizontal radiographs, 50% of the time you cannot see the crestal bone levels either on the mandible or maxilla. So how can these radiographs be conducive for a dental hygiene diagnosis? They can’t.
No dental hygiene radiographic interpretation documented. Well what can I say about this? If it ain’t documented, it didn’t happen.
Hygienist and or dentist is unaware of the hygienist’s scope of practice. In some provinces it is in the hygienist’s scope of practice to initiate or expose radiographs for a dental hygiene diagnosis. In other provinces only the dentist can prescribe radiographs. Regardless, it is important to know where the responsibility lies and make sure it happens and an interpretation gets documented. And perhaps vertical bite wings are a better choice for viewing both caries and crestal bone levels to evaluated for a dental hygiene diagnosis?
Dentist not allowing RDH to work within their scope of practice. This happens more often than you know mainly because either the dentist is unaware of the hygienists’ scope or the hygienists themselves are unaware as they move from province to province. Another possibility is that the practice owner is just more focused on restorative than preventative care, thinking patients won’t value more than a basic “cleaning.”
Team is not aligned to a periodontal classification. With each clinician in the practice boasting different years of clinical experience and educational training, there is no doubt the team is not aligned on a common periodontal classification and, therefore, not aligning on what radiographs are required to screen for all periodontal conditions. Everyone should be using and aligned to the new global 2018 AAP Periodontal Classification when it comes to the type and number of radiographs needed.
Not using best practices in treating periodontal disease – If you are providing a basic “cleaning” for most of your patients, then there is a good chance you’re not providing the standard of care to treat periodontal disease. And if you’re not up to date with the new global 2018 AAP Periodontal Classification, then this is doubly true.
When treating periodontal disease, there are six phases to treatment that can’t possibly be done in one basic “cleaning” appointment, according to Foundations of Periodontics for the Dental Hygienist (Nield-Gehrig and Willmann, 5th Edition, 2019). The treatment phases are as follows:
Assessment and Preliminary Therapy Phase (assessment, diagnosis, planning). Depending on the level of periodontal disease, this could take an entire appointment. Not only do all the assessments need to be gathered but hygienists need to interpret and discuss their findings with the patient to establish a logical and accepted treatment plan, including discussion of fees. This phase also includes prescribing, exposing, and interpreting radiographs to determine an accurate dental hygiene diagnosis. Education on periodontal disease and prognosis is an important part of this phase. All of this takes time.
Phase I Nonsurgical Periodontal Therapy Phase (implementation, evaluation). Initial therapy could take up to six appointments and include an additional post-care appointment to reevaluate.
Phase II Surgical Therapy. This may include periodontal surgery, endodontic surgery, and/or dental implant placement. Although these procedures are not within our scope, they need to be discussed collaboratively with the dentist to get the patient to health.
Phase III Restorative Therapy. Dental restorations, fixed and removable prostheses and reevaluation of overall response to treatment. Again, not in our scope, but all these conditions affecting the periodontium (predisposing factors) need to be identified and addressed to get the patient to health.
Phase IV Periodontal Maintenance. Appropriate maintenance intervals need to be determined and scheduled to maintain oral health and stability.
According to the CDHA survey, one of the benefits of COVID-19 was increased time with patients. Why do we need COVID as an excuse to take more time with patients when the standard of care set out by our college and literature already states that we need more time than we are taking? Has there ever been a dentist who has only diagnosed four cavities because he or she was afraid the patient wouldn’t accept or pay for treatment of eight diagnosed cavities? Never, but still, we try to treat patients with periodontal disease in one appointment versus what’s needed.
The truth is, the hygienists who reported that they had never been busier are the ones performing comprehensive oral exams, taking the appropriate type and number of radiographs to screen for all periodontal conditions that may exist, and treatment planning the appropriate amount of time to get their patients back to health. When patients routinely experience this level of care, they don’t have to be convinced about the value to their oral and overall health.
The good news is that you currently have everything in place to become a practice that can thrive in the face of any global economic and health crisis. By leveraging your hygiene department and putting a laser focus on patient outcomes, you can not only recover your lost 2020 revenue, but also set yourself up for unprecedented growth moving forward as we continue toward a return to normalcy. But just as important, you’ll be prepared when that next crisis comes knocking.
- Covid-19 Member Impact Survey Results, September 8th & 22nd, 2020. https://www.cdha.ca/…/COVID-19_Surveys/…/CDHA_COVID-19_member_ impact_survey.aspx?…
- Prevalence of periodontitis in adults in the United States: 2009 and 2010 P I Eke 1 , B A Dye, L Wei, G O Thornton-Evans, R J Genco, CDC 2012 Oct;91(10):914-20. Journal of Dental Research.
- Chapple ILC, Mealey BL et al. Periodontal. Health and gingival disease and conditions on an intact and a reduced periodontium: Consensus report workgroup 1 of 2017 World Workshop on the Classification of Periodontal and Peri-Implant Health. J Clin Periodontol. 2018;45(Suppl 20): S68-S77. https://doi.org/10.111/jcpe.12940
- Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology July 2011, American Academy of Periodontology.
- Foundations of Periodontics for the Dental Hygienist, Nield-Gehrig and Willmann, 5th Edition, 2019. Chapter 10, pg. 195, Table 10-4, Phases in the Management of Periodontal Disease.
- Darby and Walsh Dental Hygiene Theory and Practice, 5th Edition, 2015. Denise M. Bowen & Jennifer A. Pieren. 2020. Pg. 519
- American Academy of Periodontology: Perio.org https://www.perio.org/consumer/perio-evaluation.htm?