Although it is clear that every practice has its own unique “fingerprint,” it is also true that there are many challenges and issues that can be found at some level in almost any office. One of the most significant issues that I have been observing lately is the frustration that our hygienists are having in establishing clear protocols around their patient care. “There isn’t enough time to do everything that is expected in the time allowed. “ And it’s true. The skilled hygienist is being asked to update medical histories, perform oral cancer screenings, check blood pressures, assess both soft and hard tissues, talk about periodontal and restorative possibilities, and provide a thorough “cleaning” while giving oral self care instruction. They are also expected to schedule next visits before they clean their room and set up for the next patient. All this in under an hour? Sound impossible? No wonder our hygienists are so frustrated!

 

One step at a time, we can make decisions that can minimize stress and ultimately provide a higher level of care for each one of our patients. We can create protocols that can set everyone up for success. It all begins with 2 small words…slow down.

 

When I was in hygiene school one of the first things that we needed to learn was how to complete a thorough intra and extra oral exam. OK, so it took us 3 hours before we were ready to actually touch a scaler to a tooth. However, we had performed a thorough assessment! We had determined a case type! We had a plan, and a working order, and a commitment to re-evaluate our patients’ progress after we completed their treatment! We ALWAYS took time to make certain that our patient knew what changes they could make at home in order for treatment to be truly successful. It would have been virtually impossible to compromise any small part of this process when we were in school. I’m not sure what happens when most hygienists graduate, because it makes no sense that so many of us succumb to the pressures of “real world practice.”

 

In the “real world” many of us were told that there is no time for that assessment, no need for the case type, and we had little or no understanding about the mysteries of working with codes and insurance. So many of us learned to do what had always been done: use that 50 minutes or an hour to make sure there are no medical changes, probe pockets and note any areas over 3mm, and clean our patients’ teeth. Even in the “higher end” practices many of the best hygienists are performing what I lovingly refer to as Heroic Prophies. We do far more than we can do in the time allowed and our schedules fall behind. We are working in deep pockets, on root surfaces and oftentimes removing moderate to heavy calculus…all for the fees of a prophy.

 

This is where I really got confused. How could the time allowed, along with the fee for Mrs. Jones (who had generalized 4mm pockets, heavy bleeding, and moderate calculus) be the same as the time and fee for Johnny, a 17 year old fashion model in perfect oral health? After all, they were both a prophy, right?  Not right! If we performed a full assessment and went through the other steps that we had learned in hygiene school, we would have realized that Mrs. Jones had generalized early periodontitis. The most appropriate treatment would be a series of appointments including SRP, oral self care guidance, and nutritional counseling. Then we could perform a re-eval 4-6 weeks following her therapy.  Not only would we have been able to bill appropriately for the services that we performed, her outcomes would have been significantly positively influenced by the number of times we were working with her. Mrs. Jones would have a far better chance of reaching a stable level of her oral health.

 

So here’s the bottom line. There is a different way for us to look at each and every hygiene patient. We can engage each patient in a process of co-discovery. They can see, hear and feel a comprehensive periodontal assessment. The patient can become part of their own diagnosis. Experience has demonstrated to me over and over that when a patient is involved in their own discovery, they will ASK for the best treatment to move them toward a higher level of health. Our job is to give them that opportunity.

 

If I could make one change in every hygiene chair, it would be to create a system whereby every patient would experience this type of assessment. I would have an assistant or administrative team member on standby to consistently help with documentation. We would be doing an intra and extra oral exam, charting all pocket depths, recession, mobility, furcations, bleeding and pus, along with gingival attachment and a gingival assessment of color, contour, and texture. Each patient would experience learning about their own health, or their own disease. They could then make informed choices about future care.

 

Following an assessment, patients would fall into one of 3 categories: Prophy, Active Treatment, or Perio Maint.

 

 

For patients that are either healthy or have gingivitis and no bone loss, they would fall into the Prophy area. If there are heavy deposits and the patient requires SRP, we could put them back into routine Prophy after their re-eval. After all, gingivitis is a reversible condition.  Please notice that in this area you may choose to use PSR (periodontal screening and recording) as a screening tool for periodontal disease. Many offices create a protocol on how they will use PSR in relationship to fully documented charting. As long as PSR is used correctly it can play an important role in your practice.

 

There are many patients that have active disease or moderate to heavy calculus with inflammation, and warrant SRP. They can be seen every 7-14 days for treatment, and fall into the Active Therapy section. Each visit can also offer support for oral self care, along with adjunct treatment such as antimicrobials or irrigation. A re-eval at 4-6 weeks would help us to understand the extent of healing and also guide the appropriate recare interval with the patient.

 

For patients that have had active treatment, have bone loss, and are now in a stable condition, Perio Maint is the appropriate category to be in. Many patients may even present with pocket depths in a healthy range. However, if there has been recession and we are instrumenting on root surfaces, this is the appropriate area. Patients with bone loss have an irreversible condition and will stay in Perio Maint virtually forever.

 

What I love about this model is the red line that separates gum disease from bone disease. This is so easy! All we have to do is to make a clear distinction between the two, and we will have a guide on how to schedule and treat our patients. (And yes, help us to know which insurance codes to use.)

 

When patients are in the appropriate category, we have more than enough time to perform all of the expected tasks of the day. If we are given the flexibility to have sliding fee schedules (yes, this is legal) for all hygiene procedures from prophies to SRP to perio maint, we can bill for the time, care, skill and judgment required for each individual patient. It takes a great deal of courage, and even more dialogue in the office to create agreements about how this can work. What I want you to hear is that IT CAN WORK! All it takes is a desire to break out of the traditional model that has NOT been working.

 

Creating perio protocols can be the answer to reducing stress and frustration in your hygiene department. When you decide you are ready, please remember that this can only work as a slow and easy process. Begin with your new patients, making sure that they are fully assessed, and placed into the level of care that is most appropriate for them. Little by little you can then begin offering existing patients the opportunity to learn more about their level of periodontal health.  Assess, Plan, Implement and Evaluate. Yep, what we learned in hygiene school…this can be the new “real world practice!”