What better time to reflect on your hygiene department than during National Dental Hygiene month! It is no secret that a strong hygiene department takes commitment, calibration, and continued learning to stay up to date with current practices within the industry. Ultimately, we want to create a team and a department that doesn’t just clean teeth but also treats infection and disease. A strong hygiene team also prioritizes patient education about the mouth/body connection, the inflammatory process and how to reduce their risk for infection.
Many patients are uneducated about the research that supports early, non-surgical treatment for Periodontal disease. It is essential that Hygiene teams are promoting the overall health of the client and providing recommendations for periodontal care. Current periodontal care requires more than recording pocket depths and bleeding scores. The 2017 World Workshop Classification introduced the hygiene field to periodontal staging and grading, providing a structured way to describe disease severity, treatment complexity, rate of progression and risk factors.
Diagnosis with Staging and Grading:
The structure can seem daunting at first, especially if you have not coded for periodontal therapy in the past, but if you dig in as a team it can be simplified.
Step One: Diagnosing the stage of the infection. Keep in mind that healthy gums and gingivitis are their own category and staging happens after bone is lost. The stages range from I(1) to IV(4) and each one describes the current severity and complexity of periodontitis, or bone loss. It also looks at the clinical attachment loss (CAL) and tooth loss due to periodontitis.
The stages are as follows:
- Stage 1: Initial Periodontitis
- Stage 2: Moderate Periodontitis
- Stage 3: Severe Periodontitis
- Stage 4: Very Sev ere Periodontitis
Step Two: Determine how to grade the patient’s disease. Grading estimates the biological behavior of the disease, or the prognosis. In this step, we assess the speed of disease progression and future risk levels. Clinicians should start at Grade B and adjust accordingly to the patient.
Grades are as follows:
- Grade A: Slow Progression
- Grade B: Moderate Progression (Default Grade)
- Grade C: Rapid Progression
Step Three: Assign the extent of the disease. How many teeth in the mouth are affected.
- Localized: Less than or equal to 30% of the teeth
- Generalized: More than 30% of the teeth
- Molar-Incisor Pattern: Characteristic distribution seen in some cases
Ultimately, after looking at each of these three areas, we should be able to put it together to create a diagnosis that includes Stage + Grade + Extent that would look something like: “generalized stage 3, grade C periodontitis”.
While this is change for many dentists and hygienists, this new staging and grading assesses the whole patient, not just probe depths and bleeding points. This means that when you have a patient with pockets, recession, and risk factors, you can begin providing patient education focused on overall health and treatment consistent with the identified grade and stage. The goal is for your team to feel armed with information for these conversations with their patients.
Calibrate the Team:
Once there is an established understanding of the staging and grading protocols, the next step is to ensure the team is on the same page and diagnosing patients consistently. We would recommend that you schedule check-in times with your hygiene department on a regular cadence for some time. Use this time to discuss patients and evaluate staging and grading for each. The best way to do this is to have each team member bring 1-2 patient examples to the meeting to discuss how they classified the patient and why. Promote a collaborative conversation around why you agree or disagree. The goal is to find common ground, centered around best practices so that the team can agree to a standard of care for the practice. Remind your team that staging and grading is a framework to use and that clinical judgment remains the most important piece of the puzzle.
Treatment:
One of the clearest benefits to accurate, consistent staging and grading is that it enables dental teams to provide a solution or treatment option to patients, moving them toward dental health. In order to determine which services would be most appropriate for a particular patient, we take the following into consideration:
- Is the patient stable or unstable (bleeding)?
- Do they have medical comorbidities?
- Have we already “treated” the patient during a regular prophy and given them thorough OHI (Oral Health Instructions) to try and get the localized area back to health?
- Have they had any other treatment at our office or elsewhere?
The answers to these questions help to guide a clinical decision on what the best recommendations are for this patient.
Billing Considerations
There are several ADA codes that have been established to help treat early periodontal disease. Bringing these in as early interventions within your standard of care is a great help for both your team and your patients to understand all the risks involved with periodontal disease. A couple of codes to be aware of:
- D4346: Scaling in the Presence of Gingival Inflammation
- D4342: Localized Scaling and Root Planing
- D0180: Periodontal Evaluation (in place of a Periodic Evaluation)
These are designed to treat disease when it is more predictable. Run a report in your software to verify if these codes are being used. Using the CDC statistic that says that approximately 42% of Americans over the age of 30 have early to moderate periodontal disease, we should statistically be treating a similar percentage within our practices. The D0180 code should be utilized when discussing periodontal issues and periodontal charting. It is recommended that you run a report to ensure that this code is being utilized appropriately.
Implementation and Team Support:
If you haven’t been coding and billing these services in the past, it will take time to build confidence in case presentation. Come up with a written protocol for your team. This protocol should help identify expectations on how to perform accurate assessments, obtain a periodontal diagnosis, and appropriate coding procedures. The team should align on common terms and practice their verbiage to use with the patient. Enough patient education is essential to connect the dots on their change of condition and why they should invest in their health. Develop a strong hand-off between your hygienist and you so that you aren’t looking for areas of concern in the exam, but instead you’re able to confirm what has been presented by the hygienist. This helps the team to feel supported, and the patient gets to hear the diagnosis multiple times as well.
While your administrative team and assistants aren’t diagnosing the patient, they do need to understand the implications that periodontal disease has on systemic health and what the risk of no treatment is for your patients. Patients often trust assistants and administrative teams as much as they do the clinical team and sometimes the admin team is the last person they will speak to in the office. Your admin team and assistants can help create value and urgency to the patient. The expectation is that admin and assistants are continuing the messaging to the patient about investing in their overall health.
Repetition:
As with working on anything new, it will take time and effort to get full implementation with your team. The key is to have scheduled check-ins with them and to hold everyone accountable, maintain consistency, and hold open dialogue for clinical differences as your team learns. Doctors often find that shifting the hygiene department’s mindset can impact the whole practice. When the focus moves from maintaining routine care to guiding patients towards overall oral health, the admin and assistant teams often embrace the approach as well. The result of this is more effective patient education, improved case acceptance and ultimately, healthier patients.
If you would like help on any of the following topics, please reach out to a member of our team HERE:
- How to establish a periodontal program in your office
- How to evaluate what codes you are billing and ensure you are utilizing your periodontal codes
- How to establish a standard of periodontal care in your office
If you missed our clinical blog post about essential extraction instruments for the general dentist, you can read it HERE. To request a FREE Practice Optimization Analysis for your practice and to learn more about how to create more profitability in your practice, click HERE.
