Skip to content
Back to Blog

Episode #614: 50 Shades Of Grey: Strategies For Co-Diagnosis, Early Treatment, And Patient Engagement Of Periodontal Disease, With Angela Heathman

No one suddenly has a seven-millimeter pocket. It happens gradually, often without patients knowing it! Once you identify and diagnose periodontal disease, you also need to communicate it to your patients. To help you follow through with that responsibility, Kirk Behrendt brings back Angela Heathman, one of ACT’s amazing coaches, with strategies to facilitate co-diagnosis and getting them into the schedule. To start prescribing treatment for better health and a better life, listen to Episode 614 of The Best Practices Show!

Episode Resources:

Links Mentioned in This Episode:

Register for Katrina Sanders’s workshop (October 5-6, 2023)

Main Takeaways:

Have a common language for talking about periodontal disease.

Understand what co-diagnosis is and how to do it with patients.

Tell patients what to expect before their periodontal screening.

You have a responsibility to tell patients what you’re seeing.

Don’t wait for patients to have a seven-millimeter pocket!


“It’s really important, I think, to start with figuring out the language you guys are going to use when you’re talking about periodontal disease. Everybody needs to be using the same language, using the same visuals, understanding that we’re going to go through a co-diagnosis with the patient, doing intraoral photos. We have to really figure out how we’re going to diagnose and talk to our patients before we start talking about treatment at all.” (5:44—6:11)

“It’s funny, sometimes I talk about the mouth, and then the patient. It’s really easy to diagnose the mouth, and then it gets a little bit more complicated when the patient comes into it. And then, we have to think about, ‘How are we going to communicate? How are we going to explain? How are we going to diagnose?’ and everything. But you’re right, Kirk. First, we have to think about if this mouth walked in, what would the appropriate care be for this pocketing, this bone loss, everything that we’re seeing? So, if we can get really clear on that using staging and grading and very objective criteria, then we go into the second part, working with the patient, a little bit easier if we’re completely aligned on that part.” (6:46—7:28)

“The first part is having everybody in the office figure out how to co-diagnose with their patients. When I say co-diagnose, I don’t want to be telling the patient after I’ve done a perio exam that they have periodontal disease. I want to let them in on the signs, symptoms, things that I am looking for when I’m looking in their mouth to check for periodontal disease. So, I’m taking X-rays, I’m taking intraoral photos, I’m doing a periodontal screening, and I’m saying the numbers out loud. So, if I can include the patient in that, then they already know that we’re going to have a more serious conversation when I set their chair up.” (9:15—9:55)

“[Saying pocket numbers out loud] makes people sometimes feel awkward. When I say people, I mean hygienists, at heart. We might all agree like, ‘Oh, yeah. Definitely, patients should be involved in this diagnosis.’ But then, when it comes to like, we’re going to have to say these numbers out loud, we’re going to feel silly when we’re calling out the numbers — we have to get over that, and we have to agree this is the best thing for the patient, and this is going to help their understanding of their disease. Because I’ve been in offices too where we talk and we agree, ‘This is the way we’re going to do it. We’re going to say it out loud.’ And then, we go to patient care and it’s like, ‘Oh. Well, I didn’t want to say the numbers out loud this time because I didn’t have an assistant to write them down for me,’ or, ‘I didn’t have any voice-activated software or anything like that.’ It’s like, no — that’s not the reason why you do it. You do it for the patient. So, it’s not silly to do that.” (11:03—12:00)

“It saves a ton of time for the hygienist too if they tell the patient what they’re going to be looking for before they start the periodontal screening. So, I would always say to my patients — and this is while I have the chair up, ‘You’re going to hear me call out numbers. I’m going to say one, two, or three is healthy. Four is borderline. Five, six, or seven is a sign of infection.’ And I’m using the word infection because that’s what it is. I’m not saying “is a concern” or anything like that. No. Five, six, seven-millimeter pockets is a sign of infection.” (12:02—12:40)

“Also, I would say, ‘If you hear me say the word bleeding, then that’s also a sign of infection.’ And so, if I would explain to the patient what I was going to be looking for before I would see them, then as I’m going along doing my perio chart, even if I’m saying them out loud — I know it seems like it’s to myself, but really, it’s to them. And it’s three, two, three; three, two, three; three, two, four; five, two, five. Then, I’m going through the whole mouth, and then I’m sitting the patient up at the end, and they’re the ones asking me, ‘Oh my gosh. What do I do about that?’ So, that’s how it saves me time. Even though it might seem like it takes a little bit longer, it really saves me time at the end.” (12:41—13:25)

“I would even go as far as explaining, ‘I’m going to use a small ruler. I’m going to measure this space,’ because if you don’t explain those things to the patient beforehand and you try to do it the opposite where you’re telling them afterwards, then they’re going to say, ‘Well, of course I’m bleeding. You were poking me.’ So, I think it’s really important to set the stage from that standpoint too.” (14:07—14:33)

“Sometimes, patients come into our chair thinking that they’re going to get a routine prophylaxis. And mostly, that’s because that’s what they scheduled for, and that’s what we’ve done the last ten years. But that doesn’t mean if what we’re seeing today is different that we have to go through with that plan. The plan can change. If we’re seeing that gum disease, periodontal disease is progressing, we can stop, pause, and have that conversation with patients. And that’s what I see a lot when I’m working with hygienists — and I’ve been guilty of this myself. I’ve done it a hundred times where it’s really easy to not mention it. It’s so easy to stay on schedule and not upset the patient and not upset the admin team that I’m throwing more services in if I do what is on my schedule. That’s super easy, and we all do it. But that’s not the best thing for the patient’s health. And so, that’s what we have to focus on is, we might have to shift that appointment. It might not be a preventative prophylaxis anymore. We may need to enter treatment, or therapy, or whatever you want to call your periodontal treatment. We might have to shift into a different mode and stop and talk to the patient about that. And if the patient understands, then the best thing that we can do is to start treating that today.” (14:54—16:27)

“In the office that I worked at for many years, our admin team did an excellent job at setting that stage from the initial phone call that [a cleaning is] not the type of appointment that they were scheduling. They did a really good job at explaining that the doctor was going to do a thorough, comprehensive exam. We were going to take a full set of X-rays. And then, we may or may not get to this piece of it. There were still folks, though, that came into my chair with the, ‘Well, I just want my teeth cleaned’ attitude, even though they had already been told, and they got through our gatekeeper and ended up on our schedule. So, that would absolutely happen. But I could diffuse that pretty easily by saying to the patient, ‘This is all the stuff I’m planning on doing today.’ And then, I would broach the subject before they would. I would say, ‘I know that you told Judy upfront that you wanted to get your teeth cleaned. However, if I find during my assessment that we need to spend time talking about any disease, cracked teeth, or things like that, is it okay with you that we spend our time addressing those things?’ And the patient is like, ‘Well, yeah. Of course!’ I trail off and wait for their response. Every once in a while, like one out of a hundred, there would be like, ‘No, I just want my teeth cleaned.’ But usually, when you led it like that, they were very cool like, ‘Well, yeah. That makes sense. We need to spend time talking about disease or fractured teeth. For sure, we should do that.’ And then, the one out of a hundred or whatever, I would say, ‘Okay. Tell me a little bit more why this is so urgent that you want to have your teeth cleaned today.’” (17:57—20:03)

“I remember this one lady in particular that had really bad perio. She had a wedding that weekend, and she said, ‘The reason why I came in is I don’t like this stain. I don’t want people to see that my teeth are brown.’ I’m like, ‘Oh, okay. Well, I can polish that off.’ So, I polish that off. And then, a few days later, she came back. We did — it was quite a series, four quads of scaling and root planing. So, sometimes, a no isn’t that they don’t want the service. They just might have something else that they’re thinking is most important. It’s very rare that someone says no to rescheduling the prophy part, if that’s really what they came in for.” (20:10—20:58)

“That’s the problem, is that we don’t even always offer [treatment]. Sometimes, we just go, ‘Okay, this is what they’re scheduled for, so this is what I’ll do,’ and we don’t pause and really talk to them about like, ‘Gosh, I’m starting to see changes that are not positive changes. I’m seeing things that I’m not liking here.’” (21:27—21:46)

“You have a responsibility to let [patients] know what you’re seeing. So, back to that co-diagnosis part, assuming they are part of that and are understanding, then we have a fork in the road. We have to decide, are we going to treat this today in the patient’s best interest? That’s what we should do. Or are they on the fence, and for some reason they can’t do it today — they need to maybe have a little bit better understanding of what’s going to happen if they don’t treat this, and things like that. That’s what I call delayed treatment. But I’m really big on still putting that treatment into the treatment plan and planning on, ‘That’s our next visit.’” (22:18—23:09)

“[Clinicians will] kind of threaten the patient, for lack of a better word, with, ‘Okay. Well, if you don’t want to do this today, you need to go home and floss better, and use all these interproximal aids.’ And then, they’ll say, ‘Next time, we’ll recheck it.’ And I want to argue, well, what are you going to be rechecking? They haven’t been flossing in ten years. Like, all of a sudden, we’re threatening them, and then we’re going to recheck. What we’re going to find is they’re going to look exactly like they did today. And so, I like to put that into the treatment plan because if we plan on it, then we can move into that type of appointment really easily next time. But if I don’t, if I just schedule them next time for a “prophy” to “check” and see what they look like, I’m going to discover that they look the same. And then, I’m going to be complicating the appointment with needing to grab the admin team to go over financials. I probably don’t have enough time in my schedule today.” (23:12—24:13)

“I like to plan ahead. If they’re not looking like they’re going to do it today, I want to plan and assume that that’s what we’ll do next time. So, I might be scheduling 90 minutes for their next appointment, and I’m going to have the admin team go over financials so that when they’re in my chair in three months — and I said three months because I always see that also too, like, ‘Oh. Well, we’ll just keep you on six months.’ Like, no! You just told them they have periodontal disease. They need to come back! Today is best, but second best is three months from now. So, I want them to have that expectation so that next time, in three months when they come on my schedule and I check to see what things look like and they look the same, then I can go right into that procedure that I was planning on doing, and they’re already prepared financially. They’re already prepared with the time, and it’s really easy to transition those patients.” (24:14—25:19)

“What we do is very serious. It’s not “just a cleaning”. And it’s really interesting when I go into the offices that we coach because I’ll have a room full of hygienists, assistants, administrators, and I’ll ask, ‘How many of your patients look like this?’ Or I’ll ask them, ‘What does a healthy patient look like?’ And then, they’ll give me all the words, and then I’ll switch and say, ‘Okay. How many of your patients looked like that yesterday?’ And they’ll say, ‘Oh, I don’t know. One, maybe. We had that kid who was home from college. He was healthy.’ And that blows the admin team away because then they’re sitting there thinking, ‘Well, wait. I charged out prophys on everybody. And now, I’m hearing today that the hygienists are saying that they weren’t actually healthy?’ So, I think that that’s really interesting.” (26:59—28:01)

“It’s so important that we realize that we are treating the patients’ infections and we’re keeping their mouths healthy. It’s not just that we’re cleaning their teeth. Especially — you mentioned Katrina [Sanders]. She talks a lot in her course about systemic health, risks, and complications, and we play a really important role in that. I think that we have to remember that sometimes.” (28:10—28:40)

“No one comes in and gains 30 pounds in a year — well, maybe some people. But it’s the same thing for perio. Nobody goes from a three-millimeter pocket to a seven-millimeter pocket. Maybe with a crack or something like that. But, for the most part, it happens very gradually. I feel like that’s the way weight gain happens too. It’s a pound this year, a pound next year, a pound the year after that. But if our physicians don’t recognize like, ‘Hey, Ange. You’re 10 pounds heavier than you were ten years ago when I first started seeing you,’ and she never has that conversation with me then, all of a sudden, I’m going to be 50 pounds bigger. Same thing with perio. If we aren’t telling the patient like, ‘I’m noticing that this three-millimeter pocket is bleeding. I’m noticing that now it’s a four. Now, it’s a five.’ If we aren’t talking about these small, incremental changes that we’re seeing and, ‘Oh, now you have a three-millimeter pocket that’s bleeding, but now you’re diagnosed with diabetes,’ if we aren’t talking about these slight changes that we’re seeing every time they come in and we’re just waiting for them to have a six or seven-millimeter pocket, then we’re doing a disservice to our patients.” (29:47—31:04)


0:00 Introduction.

2:18 Why this is an important topic.

3:52 Use common language when talking about perio.

6:12 Have clarity around staging and grading.

8:55 Know how to co-diagnose with patients.

9:57 Provide examples of co-diagnosis to your team.

11:02 Get over the awkwardness of calling out numbers.

12:01 Co-diagnosis saves your hygienists some time.

14:07 Explain your process to patients in advance.

14:46 Start treating it today.

16:29 Use the word “healthy”.

17:57 How to navigate the “I only want my teeth cleaned” patients.

22:01 Put it into the treatment plan.

26:19 Prescription for treatment, explained.

31:49 About Katrina Sanders’s upcoming course.

Angela Heathman, MS, RDH Bio:

Angela Heathman is a Lead Practice Coach who works with dentists and their teams to help them accomplish their goals. She believes the hard work you do on your practice is just as important as the work you do in your practice!

Angela has over 20 years of clinical dental hygiene, dental sales, and practice coaching experience. When she transitioned from her role as a clinician to her role as a sales account manager, she realized both her passion for education and practice development. Angela holds a master’s degree in dental hygiene education from the University of Missouri-Kansas City.

Kirk Behrendt

Kirk Behrendt is a renowned consultant and speaker in the dental industry, known for his expertise in helping dentists create better practices and better lives. With over 30 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry. Kirk has been a featured speaker at every major dental meeting in the United States. His company, ACT Dental, has consistently been ranked as one of the top dental consultants in Dentistry Today's annual rankings for the past 10 years. In addition, ACT Dental was named one of the fastest-growing companies in the United States by Inc Magazine, appearing on their Inc 5000 list. Kirk's motivational skills are widely recognized in the dental industry. Dr. Peter Dawson of The Dawson Academy has referred to Kirk as "THE best motivator I have ever heard." Kirk has also assembled a trusted team of advisor experts who work with dentists to customize individual solutions that meet their unique needs. When he's not motivating dentists and their teams, Kirk enjoys coaching his children's sports teams and spending time with his amazing wife, Sarah, and their four children, Kinzie, Lily, Zoe, and Bo.