As hygienists, we worked for years doing “bloody” prophies. In many cases, when we were poised to inform patients of their periodontal conditions, the doctors performed their exams and informed the patients that they had excellent oral health. We also had patients already diagnosed for a routine prophy, and we would probe and find 6-mm pockets. From these experiences, we found ourselves in an uncomfortable position. How could we do what we felt was best for our patients while maintaining mutual respect with our doctors? Our concerns were ethical, legal, and professional. In our quest for a solution to this problem, we developed a concept we call Maximum Hygiene, to be implemented in the many group practices that comprise our network.
Although we suspected that our efforts would produce additional revenue for the practice, we had no idea how much more profitable our comprehensive approach to periodontal hygiene would be. In addition, we were accustomed to the hygienist’s role as being somewhat separate from the doctor’s role in dental health. Yet, our experiences over the years nagged at us that something was at least missing—if not wrong—making our contribution underutilized. Furthermore, we sensed that our expertise could be far more complementary to the doctors’ skills and contributory to patient health, but we did not know that the approach we envisioned could revolutionize the hygiene department.
With these many considerations and conflicting thoughts, we spent hours discussing and agonizing over the best way to tell our doctors of our concerns. At last, we presented our diagnosing doctors with a nonconfrontational and nonthreatening proposal that would allow the hygiene department to collect all the probing data. We felt this was the best approach to helping the doctors with periodontal disease classification of our patients.
To our very pleasant surprise, Dr. David Jones, the regional clinical director and our mentor, gave us his full support. Dr. Jones had a similar hygiene program in his private practice. We were fortunate to have a doctor with a similar philosophy and vision for offering the best practices to our patients. Dr. Jones facilitated support from our regional operations director and the other doctors in our large-group practices. Steve Kays, the regional operations director, was instrumental in getting support from the centers’ office managers. It is important in large institutional settings to have strong sponsorship from the general and the operations sides of the business.
GOALS OF MAXIMUM HYGIENE
Mission Statement
The mission of Maximum Hygiene is to probe new and existing patients to establish the appropriate periodontal diagnosis so we can treat periodontal disease early and effect positive changes in our patients’ health. Our core value is to improve the health of patients and offer the same high standard of periodontal care to all.
Short-Term Goal
Our short-term goal is to diagnose and treat all patients with early periodontitis.
Clinical Goal
As hygienists, we want to implement hygiene systems that have a positive effect on the patient. As it turns out, our clinical goal is perfectly compatible with our business goal.
Business Goal
From a business perspective, we want hygiene systems to have a positive impact on the dental practice’s profitability. We aim to establish a hygiene department that yields maximum hygiene revenue.
A VITAL NEED FOR PERIODONTAL DIAGNOSIS AND TREATMENT
The World Health Organization indices for periodontal disease document the severity of the periodontal situation worldwide as follows: 40% of people ages 35 to 44 have pockets of 4 to 5 mm while only 4% have no disease. At ages 65 to 74, 36% have pockets of 4 to 5 mm and only 3% have no disease.1
Within the United States, 75% to 85% of the population has some form of periodontal disease. Furthermore, periodontal disease and dental caries are our most prevalent dental diseases, so it is clear there is vast opportunity and need to diagnose and treat periodontal disease.2
PERIODONTAL DISEASE—A MAJOR SOURCE OF DENTAL MALPRACTICE
One out of every 10 dentists and hygienists will be sued at sometime in his or her career. The majority of those lawsuits will arise as a result of undiagnosed and untreated periodontal disease.2 Therefore, we have a legal responsibility to all of our patients to assist the doctor in rendering the right diagnosis. Similarly, dental practices utilizing the Maximum Hygiene approach take the ethical high road while simultaneously reducing lawsuits and increasing profitability. One could say this is a win-win-win proposition.
MEDICAL LIABILITY AND LOST OPPORTUNITY
If patients have periodontal disease, they are 3 times more likely to have heart disease as patients without periodontal disease,2 so we also have a medical responsibility to inform patients about their periodontal health. If we do not, we are open to medical liability claims. It is vital that a comprehensive periodontal examination is done. The hygiene department can be a valuable tool for collecting the probing data for the periodontal examination.
Patients are reading newspapers and magazine articles about the health links between periodontal disease and systemic diseases, and they are asking why their hygienists do not probe. Indeed, 71% of all dentists do not have a periodontal probe on the new-patient exam tray.2 This means that there is a tremendous lost opportunity to diagnose and treat periodontal disease, a considerable hygiene revenue loss, and an increased medical and legal liability risk.
A PLAN WITH IMMEDIATE AND REMARKABLE RESULTS
Maximum Hygiene has developed a program for soft-tissue management3* that involves probing every patient. This system includes consistent diagnosis, nonsurgical treatment of scaling and root planing, and supportive periodontal therapy.3 The immediate benefits are maximum health for patients, ethical behavior (“doing the right thing”) toward patients, increased doctor production, and increased hygiene production. Maximum Hygiene not only satisfies our minimum standard of periodontal care, this approach also raises our standards far beyond what many would think possible.
The American Academy of Periodontology (AAP) developed parameters for a comprehensive periodontal examination that must include medical history, dental history, restorative examination, periodontal history, periodontal probing, periodontal diagnosis, periodontal treatment, and informed consent.4
The medical history probes heart disease, diabetes, hypertension, pregnancy, smoking, medication use, and substance abuse—all indicators of periodontal disease. The restorative examination considers the missing teeth, conditions of the restorations, caries, tooth mobility, tooth position, occlusal and interdental relationships, parafunctional habits, and pulpal status. Any abnormal findings can also be indicators for periodontal disease.4
CASE TYPES, PATIENT FLOW, AND PROTOCOLS
Chief Complaint and Periodontal History
The results of the comprehensive periodontal examination establish the diagnosis and proposed treatment plan. Results also inform and educate the patient about the disease process, therapeutic alternatives, potential complications, and expected results. With this information, the patient can make an informed decision about treatment and accept responsibility for treatment. The patient is also informed of the consequences of no treatment.4
AAP Periodontal Case Types
AAP Type I: gingivitis. Inflammation of the gingiva, presence of gingival hyperplasia and edema, tissue retractability, gingival pockets, and no bone loss.
AAP Case Type II: early periodontitis. Gingival inflammation into the alveolar crest, early bone loss, pocket depths of 4 to 5 mm, and localized areas of moderate periodontitis.
AAP Case Type III: moderate periodontitis. Increased destruction of periodontal structures, moderate to severe bone loss, pocket depths of 5 to 7 mm, presence of tooth mobility, and localized areas of advanced periodontitis.
AAP Case Type IV: advanced periodontitis. Severe destruction of periodontal structures, increased tooth mobility, pocket depths of 7 mm or greater, and a number of teeth with guarded prognosis.
AAP Case Type V: refractory progressive periodontitis. Periodontitis characterized by rapid or slow bone and attachment loss, associated with inflammation and continued pocket formation, and resistant to normal therapy.4,5
These guidelines are followed consistently so the patient receives the appropriate periodontal disease diagnosis. Based on this diagnosis, we can better educate patients about their disease condition, and they can make better informed decisions about the appropriate treatment they need.
Maximum Hygiene Patient Flow
(1) Doctor reviews medical history.
(2) Doctor determines chief complaint.
(3) Doctor orders x-rays.
(4) Dental assistant charts existing restorations.
(5) Doctor requests hygiene department to collect periodontal probing data.
(6) Hygiene explains to the patient what probing is and why probe.
(7) Dental assistant records periodontal pockets.
(8) Doctor performs restorative exam.
(9) Doctor gives restorative diagnosis and restorative treatment options.
(10) Doctor gives periodontal diagnosis and periodontal treatment options.
(11) Doctor explains the etiology of dental caries and periodontal disease.
(12) Financial counselor presents fees for treatment and doctor’s recommended priority for treatment.
(13) Financial counselor assists patients with financial arrangements to make treatment happen same day or schedule at patient convenience.
(14) The patient is scheduled with the hygiene department first unless the chief complaint is pain.
Patient Periodontal Exam Protocol
(1) Health screening of the medical history for heart murmurs and joint replacements
(2) Dental history and intraoral and extraoral exam for oral cancer
(3) Dental hygiene provisional probing for periodontal disease
(4) Dental hygiene questions for red flags—indicators for periodontal disease:
•When was your last cleaning?
•Do your gums bleed?
•Are your gums sore?
•Do you floss?
•Do you have a bad taste in your mouth?
(5) With the probing, probe depths are called out so patient can hear…patient hearing of his or her periodontal health situation creates urgency and desire to change. Explain that 4 mm and above pockets indicate the presence of gum disease caused by bacteria toxins. Record 4 mm and above in red on the periodontal chart.
(6) Explain the provisional assessment: Tell the patient that a healthy mouth means no pockets above 3 mm, no inflammation, and no bleeding.
Explain active periodontal disease: Type I—gingivitis, pockets 3 to 4 mm with redness and inflammation; Type II—early periodontitis, 4- to 5-mm pockets; Type III—moderate periodontitis, 4- to 6-mm pockets; Type IV—advanced periodontitis, 6- to 8-mm pockets.
When the patient asks what he or she should do to stop the progression of periodontal disease, the doctor’s usual recommendation is nonsurgical periodontal therapy and re-evaluation, but the doctor will make that determination for treatment.
COMPLEMENTARY ROLES OF THE DENTAL TEAM
The Doctor’s Role
The doctor’s role in the Maximum Hygiene approach is to allow the hygiene department to collect the probing data, to preassess the periodontal condition, and to back up the pre-assessment. The doctor has the final decision and judgment regarding the diagnosis. The doctor also maximizes the value of the periodontal diagnosis and periodontal treatment.
Role of the Hygiene Department
The hygiene department’s role is to collect the probing data and to preassess the data for the doctor’s definitive periodontal disease diagnosis. We probe every patient aloud so patients can ask questions. This provides us with a forum to educate the patient about the possibility of periodontal disease and explain treatment that the doctor might propose.
Role of the Staff
Staff involvement includes assistants and front desk members. The staff’s role is to become knowledgeable about periodontal disease so that all are giving the same message. They should be able to explain periodontal disease with value and urgency. Staff also records probe depths, assists hygiene with a full-mouth series of x-rays, presents treatment plans, and schedules patients for hygiene services.
SEQUENCE OF DENTAL HYGIENE TREATMENT BY AAP CASE TYPES4,5
Type I: gingivitis treatment is often completed in one visit. This includes assessment from the periodontal chart, periodontal scaling and debridement, patient education and plaque control instructions, and establishing appropriate recall intervals.
Type II: early periodontitis requires 2 or 3 visits after the assessment, probably more complex plaque control instructions, scaling and periodontal debridement that requires anesthetic and analgesics, and supportive periodontal therapy intervals.
Type III: moderate periodontitis is often treated by quadrants and requires several visits. Treatment includes complex plaque control instructions and scaling and debridement by quadrants using anesthetic and analgesics. Type III may require locally administered antibiotic therapy and more frequent supportive periodontal therapy intervals.
Type IV: advanced periodontitis often requires treatment by quadrants or sextants over several treatment visits. The assessment considers referral to a periodontist. Treatment includes patient education and plaque control instructions with reinforcement at subsequent visits. Scaling and periodontal debridement is performed by quadrants or sextants and requires anesthetic. It may require locally administered antibiotics and establishment of appropriate supportive periodontal therapy intervals.
Type V: refractory periodontitis may be treated in a single visit or multiple treatment visits. Pocket depths are present, but often with little calculus or plaque. Assessments usually require referral to a periodontist. Also needed are patient education and plaque control instructions, scaling and periodontal debridement, and more frequent supportive periodontal therapy intervals. Courses of antibiotic therapy—systemic and/or locally—are often needed.
THE MAXIMUM HYGIENE DEPARTMENT
A Maximum Hygiene department consists of a hygiene assistant, 2 recall hygienists, and a soft-tissue management3* hygienist. This type of hygiene department typically produces revenues of $45,000 to $60,000 per month. The department has a career ladder, with entry level typically being the recall position, unless an experienced hygienist chooses a recall position due to a personal situation or scheduling need.
In our program, the hygiene production increased from $750,000 in 2000 to more than $2 million in 2003 (Figure 1). This is a large-group practice with 10 dental centers.
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| Figure 1. Maximum Hygiene revenue growth (large-group practice with 10 dental centers). |
The Hygiene Assistant
The hygiene assistant records the periodontal probing depths and takes the required full-mouth series of x-rays or panoral and vertical bitewing x-rays. This assistant seats and dismisses the patients, confirms appointments, and keeps the operatories ready for the next patient. The hygiene assistant is vital to our department and a major reason for our success.
The Soft-Tissue Management3* (STM) Hygienist
Since 75% to 85% of the US population has periodontal disease,2 a vast amount of periodontal therapy is diagnosed nationwide. As a result, the STM hygienist is kept busy rendering periodontal therapy. This individual must have a strong background in periodontal therapy as well as impeccable clinical and personal skills. The STM hygienist is paid on commission. A commission-based salary motivates the hygienist to have a high level of commitment to the position and the office. The STM schedule is purposely kept open (with few advance appointments) in order to accommodate new patients who want to start their periodontal therapy immediately after probing and diagnosis.
The Recall Hygienist
With all of the new periodontal therapy generated by the Maximum Hygiene approach, demand is increased for supportive periodontal therapy. Therefore, the recall hygienist’s role is elevated to taking the patient’s periodontal care to another level. Recall hygienists must also have excellent clinical skills and be able to communicate the need for restorative dentistry to the patient. We also depend on this individual to refer dentistry to the doctors. Under this system, doctors will see their production increase 30% to 40%.
The point/referral system evaluates the recall hygienist for the referrals made to the dentists. Points are assigned to each referred procedure: ie, PVC—10 points; implant—20 points; and bleach tray—10 points. The points are used to score the performance of the recall hygienist, who is paid an excellent daily rate as well as bonuses related to communication skills. With multiple recall hygienists, accommodations can be made for new patients who need prophies and full-mouth debridements.
Equipment
The hygiene department in our large-group practice has state-of-the-art equipment: 4 operatories with hygiene handpieces, ultrasonic scalers, a PDT scaler, a sealant light, and hand instruments. The hygiene department can be set with a minimum amount of equipment.
CONCLUSION
Implementing the Maximum Hygiene system increased our hygiene production by 280%. We became the model hygiene department and were asked to develop a training program to teach other offices how to duplicate what we did. We developed a program following the parameters recommended by the AAP and received program approval from the Texas Dental Hygienist Association for 2 CE credits. We researched several soft-tissue management3* programs and utilized the best information from each. The Maximum Hygiene Concept can be implemented in any private dental practice.
After 4 years of use by the authors, the Maximum Hygiene program clearly sustains many long-term benefits. Significant health benefits to the patients satisfy our medical and legal liability. The system continues to increase doctor and hygienist production. We have established a vehicle for ongoing care of patients’ oral health. And the office consistently exceeds revenue goals.
The key to getting started has 3 steps: probe every patient aloud, which creates urgency and desire; inform the patient of early periodontal disease, which eliminates selling and closing; and help patients find financing for the necessary treatment to get them back to health. The Maximum Hygiene concept can be implemented in any private practice or small-group practice.
References
1. World Health Organization Global Oral Data Bank. Periodontal Conditions at Age 15-19 Years; 35-44 Years. WHO Oral Health Country Profile Programme, Division of Noncommunicable Diseases/Oral Health, School of Dentistry, Niigata University, Japan. January 1, 1994. Available at: who.int/oral_health/media/en/orh_report03_en.pdf (Pages 5, 13). Accessed on April 21, 2003.
2. Lambert R. The Non-Surgical Treatment of Periodontal Disease [lecture]. Arestin + SRP in Austin, Tex, on August 17, 2004.
3. Pro-Dentec. Soft Tissue Management, A Practice Management Guide for the General Practice. Batesville, Ark: Pro-Dentec (800-228-5595); 1997:1-2,3-9. *Soft-Tissue Management is a trademark of Pro-Dentec.
4. American Academy of Periodontology. Parameter on comprehensive periodontal examination. J Periodontol. 2000;71(suppl 5):847-848. Also available at: perio.org/resources-products/posppr3-2.html.
5. Perry DA, Beemsterboer P, Taggart EJ. Periodontology for the Dental Hygienist. WB Saunders; 1996: 141, 157, 158, 172-174, 176, 177.
Ms. Weaver attended dental hygiene school at Medical College of Georgia, Augusta. She worked as a clinical instructor at Broome Community College in Binghamton, NY, practiced clinical hygiene for 14 years at Austin State School in Texas, and was an oral health educator for all the state school staff. She presently concentrates her time and energy as the hygiene director and STM hygienist for Bright Now Dental centers (formerly known as Castle Dental) in Austin and San Antonio, Tex. She can be reached at annedan1@aol.com or aweaver@castledental.com.
Ms. Uhl graduated from Bee County College, Beeville, Tex, and practiced clinical dental hygiene for 12 years in a periodontal prosthodontic practice. She has focused on implementing STM and internal marketing recall systems in the past 5 years. She is the hygiene director for Bright Now Dental centers in Austin and San Antonio, Tex. She can be reached at luhl@castledental.com or lcurdh@aol.com.
