I recently received a phone call from one of my former dental hygiene students. She graduated almost a year ago and has yet to find a permanent position. To keep her skills up while she’s actively job seeking, she stays busy temping – a daunting work environment for a newbie right out of school. During our phone conversation, she shared with me her confusion of what’s expected during a prophy appointment. She proceeded to tell me story after story of various practices where she was “expected” to do prophies on patients, irrespective of periodontal status. Does that sound familiar to some of you reading this?
As a hygiene coach with Inspired Hygiene, the scenario detailed above is extremely common. Prophy-heavy practices are almost always the result of two things:
- Lack of clarity on what is clinically defined as “healthy prophy” and what is considered disease
- No clear standard of care (protocol) on how to treatment plan something other than a prophy for patients who present with disease
One of the best ways to ensure your practice is delivering the best standard of care in the hygiene department is to develop standard of care documents. Practices with standard of care documents typically yield better case acceptance as well as higher levels of team calibration.
CDT code description
One of the most common procedures performed in the hygiene department is the prophylaxis (D1110). To many coding experts, the D1110 is also one of the most misinterpreted codes in all of dentistry. As defined in the CDT procedures book, a prophylaxis is described as a preventive procedure – not a therapeutic one. Therefore, patients presenting with bleeding 4’s and 5’s with radiographic bone loss are defined as having periodontal disease – and as a result, periodontal disease would not be appropriately treated as a prophy.
How to clear up the confusion
Here are 2 great resources for dental professionals looking for clarity on the hygiene codes.
- Dr. Charles Blair’s book Coding with Confidence and his online service PracticeBooster.com are great resources for practice managers, doctors and hygienists. Dr. Blair is an expert in interpreting all of the CDT codes used in dentistry so that all offices are clear on how to appropriately (and legally) use the CDT codes for various procedures. It is an eye-opening exercise to STUDY what the codes say and to realize HOW OFTEN offices misuse them.
- Patti DiGangi’s new book Dental Codeology is another great resource. Specific to hygiene codes, this resource provides easy to understand definitions of codes including tips on how to properly use them.
The Prophylaxis appointment
Before we discuss what happens during a prophy, it’s important to review what the APP defines
as health versus disease. Click here
to review the AAP parameters of care. Getting clear on what the AAP considers early perio (bleeding 4mm pockets with radiographic loss of crestal bone) and how to treatment plan early, moderate and advance periodontal disease is critical for appropriate diagnosis and treatment planning of prophies versus periodontal therapy.
Here is a step-by-step outline of the appointment flow for healthy prophylaxis patients:
- Medical History Review
- Blood Pressure Screening
- Open Ended Questions Regarding Patient Questions/Concerns
- Necessary Radiographs
- Radiographs are prescribed based on ADA guidelines of risk-based prescribing. To view the ADA’s prescribing protocol, click here.
- Extra Oral Exam
- Hygienists must explain what this procedure is. “Mrs. Jones, I’m now going to be doing your external head and neck exam. In just a moment, I’ll be doing the intraoral exam.” Telling the patient WHAT you’re doing helps to build value for the dental hygiene appointment. Too often, clinicians don’t involve and inform the patient in the procedures being performed (like oral cancer screenings, periodontal screenings, etc.) which diminishes the value of the appointment. Patients need to know how well you take care of them!
- Intra Oral Exam
- Hygienists will explain what they’re doing in order for patients to be fully informed. A patient can certainly feel the hygienist doing the tongue pull but many times they have no idea what the basis for that procedure is. Informing patients of not only what you’re doing but also why reinforces your practice’s commitment to an exceptional standard of care. Here’s what the narrative might sound like prior to performing the intraoral exam: “Mrs. Jones, I’m going to be doing your intraoral cancer exam. When Dr. Smith comes in to do your exam, she’ll also be repeating this procedure.”
- 6 point Probing
- All numbers charted and all bleeding sites charted at least once annually. It is a good idea to place this perio charting protocol in your practice’s Standard of Care document.
- Hygienists must inform the patient of what the periodontal screening is. Often patients feel us “poking” their gums but have no idea it’s an evaluation for periodontal disease. Tell the patient you’ll be calling out each number. Normal readings are typically between 1-3mm and healthy gums don’t bleed. Tell the patient this procedure is a screening for periodontal disease.
- Be sure to review the results of the periodontal screening with the patient once full perio charting is completed.
- Consult with the dentist to determine periodontal disease status or to confirm periodontal health. A great new piece of technology that can help elevate the patient’s understanding and “ownership” of their disease is using a product such as Florida Probe’s noise-canceling voice charting system, “Voiceworks”. Consider how impactful it is for a patient to hear the computer call out “4 warning” or “7 danger” during perio charting.
- Restorative Assessment
- All Necessary Intra Oral Photos
- Capture image of inflamed tissue (this is particularly helpful when your insurance coordinator is submitting for reimbursement for gingivitis therapy, periodontal therapy, or for periodontal maintenance).
- Capture image of heavy bleeding upon probing (this is particularly helpful when your insurance coordinator is submitting for reimbursement for gingivitis therapy, periodontal therapy, or for periodontal maintenance).
- Capture image of faulty restorations
- Customized Patient Education
- Based on CDT Codes, D1110 – not to be performed on patients unless they are healthy
- Prophy on healthy patients (1-3mm probing depths with less than 15 sites of bleeding)
- Using magnetostrictive or piezo electric ultrasonic scaling devices for calculus removal and subgingival biofilm disruption
- Site specific hand scaling for supragingival stain and hard deposit refinement
- Coronal polishing (fine grit preferred) or use of air polisher
- Topical Fluoride Varnish for moderate – high caries risk individuals
- Review the evidence-based review of topical fluorides and prescribing protocols:
- August 2006 JADA, Vol. 137
- Hygienists will give the patient specific recommendations determining patients recare interval based on individual risk.
- Final note: the above comprehensive appointment sequence is nearly impossible to accomplish if hygienists are given less than 60″ for the prophy.
Putting these steps into practice
Granted, the routine prophylaxis has become just that – routine; but considering the AAP’s estimates of the incidence of periodontal disease, it begs the question, “Do you currently have patients in recare that are already beyond the healthy-prevention state?” Regardless if you’re a relative newbie to the profession of dental hygiene, or you’re a seasoned pro, enrolling existing recare patients into active periodontal therapy is a necessary step in order to adequately treat their chronic periodontal infection.
Are you curious about your own numbers?
As a courtesy to DentalPost.net clients, Inspired Hygiene is pleased offer a free download of the Inspired Hygiene Perio Calculator Tool. This free download allows you to determine your baseline perio percentage. Are you performing mostly prophies in your practice? The perio tool will help you answer that question. If the answer is “yes”, you may want to consider some of the resources detailed in this article. For offices wanting more information on how to implement a perio program, please visit inspiredhygiene.com to sign up for our free weekly e-zine where we email you practice tips, like the ones detailed in this article, every week in our electronic newsletter. Good luck!