AADOM Clinical Corner

For patients to be treated accurately, hygienists need to have the appropriate instruments to do the job. Dull instruments can take the hygienist longer to scale, can cause more discomfort for the patient and burnish or not effectively remove deposits. It was estimated several years ago by Hu-Friedy that curettes last 6 -12 months, periodontal probes 2 – 4 years, and ultrasonic tips 100 – 120 hours. All of these are dependent on how often the instrument is used and the type of patients seen. Hygienists should be sharpening instruments on a regular basis, again dependent on number and type of patients. Sharpening however, decreases the size and shape of the instrument thus making it thinner and less productive. Additionally, many hygienists struggle with sharpening, either in doing the correct method or not having the time to do it on a regular basis. Even ultrasonic scalers wear during use. There are measuring tools that show how much of the ultrasonic tip has worn from use. Since the original instrument length study, there have been several improvements by a variety of dental instrument companies in the materials used for hygiene instruments. This makes the sharpening experience less difficult because it requires less sharpening. Yet, instruments still must be replaced as any other piece of equipment is replaced. Practices feel that rather than purchasing new instruments, re-tipping existing instruments is a better, less expensive alternative. Unfortunately, re-tipping can weaken the instrument making it more prone to breakage. If it breaks during a procedure, complications can arise. Therefore, it is often better to purchase new instruments. Enlist the hygiene department in what type of instruments they are interested in purchasing. Research with your supply vendor possible options. Many instrument companies offer generous rebate or purchase options (buy two, get one for example). Practices should also work with an instrument supply budget so that instruments can be purchased as needed. With a budget the team can understand how and when new instruments can be purchased.

Hygienists are taught in dental hygiene school that a full periodontal charting includes recording probing depth, bleeding and/or suppuration (pus), recession, clinical attachment loss, tooth mobility, furcation involvement and mucogingival junction. In school, hygiene students have hours to gather data and perform hygiene procedures. Once in the real world of dental hygiene where remaining on time and production are important, many of the elements taught in school fall by the wayside. From not completing a full periodontal exam to working in un-ergonomic positions, hygienists compromise patients, the practice and themselves. Even the most seasoned hygienist who has been in practice for years may not perform a complete periodontal charting. Without complete information, the dentist however cannot effectively diagnose and prescribe appropriate treatment. It would be as if a medical professional asked only your age and height but didn’t ask you about your weight when determining your BMI (body mass index) to assess your health and if you should diet. Therefore, hygienists should be documenting all of the periodontal status of patients. Yet, it is often difficult to “do it all” in a 45 minute to hour hygiene appointment without some type of assistance. Whether that be someone to record as the hygienist performs the exam (assistant. business or other available team member) or the hygienist using a voice activated or remote-controlled device, a hygienist cannot go it alone and be expected to complete the full periodontal charting. As dental billing and coding becomes more metrics driven, insurance companies are going to asking for more detailed information regarding treatments provided, not only periodontally but in other areas of dental treatment. Additionally, with the new 2018 American Academy of Periodontology Staging and Grading criteria (review previous Clinical Corner regarding AAP guidelines), full periodontal charting will enable the hygienist and dentist to provide appropriate care given the patient’s periodontal stage and grade. Most dental practice management software allows for full periodontal charting to be recorded. Hygienists and team members need to understand how what is done clinically can influence the entire team and the patient’s overall health. Documenting appropriate full periodontal charting is an important component of comprehensive care of the patient and the techniques and manner to record are practice specific. Awareness of both the charting technique and how to document in the practice management software, team members can ensure that the appropriate information is provided to any third-party that may request the information.

Whether full mouth, bitewing or periapical intra-oral radiographs, in order for x-rays to be considered diagnostic they must contain all aspects of the area being viewed. For example, when teeth are radiographically examined the crown, the root and several millimeters beyond the root apex must be clearly visible depending on the x-ray taken. Bitewing radiographs for example show both maxillary and mandibular posterior teeth and bone but not the root or apex, while a full mouth intra-oral series will show each tooth on at least one radiograph with crown, root and apex. An occlusal film will show maxillary and mandibular arches or sections of arches that are primarily used with pediatric patients. A panoramic radiograph views the entire mouth from outside the mouth using extra-oral imaging.

Many assistants and hygienists were taught to take intra-oral radiographs initially with x-ray film. In today’s digital dental practice, imaging sensors or phosphorus plates are used. Imaging techniques are a bit different when using sensors than with film or plates. Film or plates are pliable while sensors are rigid and can be bulky. Therefore, imaging techniques with patients must be adjusted to accommodate the sensor rigidity and bulkiness along with individual patient anatomical considerations. When using sensors, clinical team members try to use the same techniques that are employed when film or plates are used, which can cause undiagnostic image quality. Common issues such as when the bicuspid bitewings are taken, the distal of the canines are not obtained or contact points between teeth are not visible. An unopened contact may be considered an undiagnostic radiograph depending on the area being viewed. A simple repositioning of the sensor and x-ray tube head can often alleviate the problem, but many hygienists or assistants are unaware of the adjustment. There are a number of other problems that can cause an undiagnostic image and depending on the doctors’ criteria can cause unwanted patient x-ray exposure. Bringing a software or sensor educator/trainer into the practice to assist the team in correct positioning and use of the sensors may be beneficial. Team members may also want to update themselves on current proper radiographic techniques by taking continuing education courses on digital imaging. A clinical team discussion between the doctors, assistants and hygienists as to the diagnostic criteria the practice is utilizing may also be beneficial. Remember “beauty is in the eye of the beholder” and what one practice may feel is a good diagnostic image, another may see the image as undiagnostic.

D1110 is described in the ADA CDT 2020 code book, “prophylaxis – adult” removal of plaque, calculus, and stains from the tooth structures in the permanent or transitional dentition to control local irritational factors. D4910 “periodontal maintenance” is the procedure instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist for the life of the dentition or implant replacements. It includes the removal of bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment considerations must be considered. In other words, adult prophylaxis is considered in healthy mouths to maintain health, while in a patient who has undergone periodontal therapy, periodontal maintenance is a procedure to maintain the new level of bone health. Periodontal therapy can be surgical or non-surgical with non-surgical being scaling, root planing, (D4341 or D4342) and antimicrobial therapy with evidence of radiographic bone loss. A patient that initially had a D4346 (scaling in the presence of moderate to severe gingival inflammation – full mouth after oral evaluation) where there is no bone or attachment loss, can become a surgical or non-surgical periodontal patient if there becomes evidence of bone loss and would then become a periodontal maintenance patient. The new 2018 AAP periodontal classification system can help guide clinical team members to understand how proper coding is important (see previous Clinical Corner for explanation of the AAP classification system).

With a patient that has undergone periodontal therapy, research has shown that bacterial regrowth can occur within months of treatment. Therefore, it is recommended that patients that have had surgical or non-surgical therapy return for maintenance every 3-4 months depending on a number of factors in order to keep the bacterial levels in check. A periodontal maintenance appointment may “feel” the same to the patient, but the dentist and hygienist are doing much more than a regular “cleaning” or prophylaxis. In addition to evaluating the pocket depths and inflammation (which all patients need to have done on an annual basis), the hygienist may be irrigating specific areas with an antimicrobial solution, placing anti-microbial materials or performing site specific scaling on deeper pocket areas. All this is done to maintain the health that was achieved by the periodontal therapy. As dentistry learns more and more about the link between inflammation and systemic health, maintaining the oral environment as free from inflammation and bacteria as possible is essential. Educating patients in understanding their periodontal disease process in the same manner as one would learn about a medical condition is essential for patients to understand the differences between 1110 and 4910. Education begins in the clinical area and is reinforced by the business team in many aspects from the choice of words to describe hygiene procedures to explaining dental benefits. Once patients understand that the services the team is providing are in their interest both financially and health-wise, they are better equipped to understand the differences in treatment. Use of the AAP guidelines will reinforce this education.

If the dentist evaluates the patient and feels that periodontal health has been maintained for a period of time, the patient MAY qualify for D1110 for future visits. With that said, however, alternating D1110 and D4910 for the sole purpose of obtaining dental benefits is considered fraud. A patient cannot be healthy at one visit, have disease the next visit, be healthy on the third and so forth unless true health and disease exist. Again, patient education is essential in assisting patients to understand their disease or health. Dentists and hygienists are bound to treat the patient by the situation seen and diagnosed, not what the dental benefit (insurance) will cover. Therefore, patients may be required to pay more for periodontal maintenance than a prophy but it is in their best interest to have the appropriate care.

Fluoride has been used for years as a treatment both in and out of the dental practice to help reduce tooth decay. Fluoride is a naturally occurring element in water, but may not be in high enough concentration to impact oral health. In areas that are not naturally fluoridated, public health officials have fluoridated the public water supply with a controlled amount of fluoride. Fluoride is also added to many types of toothpaste. Yet, many patients either don’t drink fluoridated water or have a high risk for tooth decay, so that additional in-office fluoride treatments are recommended. Fluoride trays were once thought to be the best in-office option but there are also other options available for today’s dental practice. With the fluoride trays, a double foam tray is placed into the patient’s mouth with fluoride gel or foam and is held in place for about 1- 4 minutes. The patient is then instructed to not eat or drink for 30 minutes. The tray can be disposable for use in the office or customized for the patient to use at home. A number of years ago fluoride varnishes entered the dental practice. A fluoride varnish is “painted” on the teeth and forms a protective barrier. First generation varnishes were colored and often had a bad taste, but newer products are clear with pleasant flavors. Fluoride varnishes have become the treatment of choice for most hygienists since they are easy to apply and can provide additional relief from tooth sensitivity. Hygienists consider ease of application, fluoride exposure and wear time, and varnishes that contain additional ingredients such as calcium or phosphate as benefits of using varnishes. Additionally, many patients, not only children could benefit from fluoride treatments. Patients often present with a range of issues or medications that can cause them to have dry mouth. Dry mouth patients have an increased risk of caries/decay therefore many patients who were previously thought not to be candidates for fluoride, should have regular in-office treatments. Whether insurance covers the treatment or not, it is in the patient’s best interest to treat appropriately and that includes recommending fluoride treatments as necessary.

The latest weapon in the war on decay and dentinal hypersensitivity is silver diamine fluoride. In 2016, the American Dental Association approved D1354, Caries Arresting or Inhibiting Medication. Although ADA was not specifically approving SDF, many practitioners use this code during placement of SDF.  SDF is used to arrest advanced cavitated carious lesions (decay) on surfaces of primary or permanent teeth. It is used extensively in pediatric dental practices for patients at high risk of caries and for the elderly who are either institutionally bound or limited dexterity and who have moderate to high caries risk. Its main concern is that it turns decay “black” which can be unsightly for a period of time, but the benefits of SDF outweigh the negatives for certain patients. Similar to fluoride varnishes, SDF is “painted” on the affected teeth.

With the variety of types of fluorides available, the dentist and the hygienist determine the best method of treating the patient using available fluoride products to achieve optimum health.

In late 2017 the American Academy of Periodontology and the European Federation of Periodontology met at a joint meeting and released a new classification system for diagnosing and classifying periodontal disease. The previous version had not been updated since 1999! Previously the classifications were categorized into localized or generalized, chronic or aggressive periodontal disease, necrotizing disease or disease as a manifestation of systemic disease. There was no mention of implant related periodontal diseases. With the increasing number of patients who have implants and the new technologies and diagnosis methods available, the two organizations agreed that a more consistent and reliable diagnosis system needed to be in place. Thus the new system was born.

The new system is very similar to the staging and grading system medical providers use in diagnosing disease and it includes information on implant disease. Stage relates to the severity of the disease while the grade is the progression of the disease. For example stage 1, grade 1 represents minimal disease with a slow rate of progress, while a stage 4 grade 4 is severe disease with a rapid rate of progression. Treatments by dentists and hygienists would then be based on the stage and grade of the disease with specific guidelines as to what each stage and grade represents. Click HERE for an exact review of the stages and grades.

In order to determine the appropriate stage and grade of periodontal/peri-implant disease the dental professional will need to collect and review information obtained on radiographs, complete periodontal charting and assessing the patient’s risk factors for periodontal disease including lifestyle and systemic considerations. With the information collected the dentist can diagnosis the appropriate stage and grade and treat accordingly.

Although the information was actually published in 2018, many dentists and hygienists are aware of its existence. Many still cling to the 1999 version since they are not comfortable with the new terminology. There are a number of publications and continuing education courses related to the guidelines. If team members are not aware of the guidelines, as the office manager, you can research programs in your area or provide literature for team members to review. The AAP has a number of resources. There are a variety of companies and organizations that provide quality CE on the process. Not only do you have an obligation to the practice to protect the health of your patients, but also in order to effectively document treatments, the most accurate codes and diagnosis need to be submitted. Previous Clinical Corner’s have discussed using the most appropriate code for treatment, while the most accurate diagnosis for periodontal disease is the new periodontal classification system. Once the clinical team becomes comfortable with the new terminology they can begin to use it in their clinical notes, thus the business team can bill appropriately. At your next team meeting begin the discussion of the new AAP Periodontal Classification system. It will take time to implement but better outcomes for both patients and the practice will be achieved.

The hand-off from the clinical team member to the business team member is an important communication skill that provides the patient with the assurance that the team members know what their needs are and are confident in the treatment provided or needed. When clinical team members merely bring the patient to the business team and “drop off”, the business team and the patient are often wondering what was done that day and/or what needs to be scheduled next visit. Whether the practice uses the practice management software for communication or provides paper or other communication tool, the hand-off from clinical to business needs to be seamless. Often there is the communication between doctor and hygienist or assistant in the operatory, but sometimes that doesn’t get transmitted to the business team. If the communication between doctor, hygienist/assistant and patient has not been initiated in the operatory, the hygienist/assistant can begin the process by recapping for the patient the day’s treatment and the next visit needs before bringing the patient to the business office.

Initiate the hand-off process by bringing the patient to a seated position in the operatory chair and maintaining eye contact, the hygienist/assistant can recap the day’s treatment and discuss future appointments. The importance of the day’s visit and future treatment can be stressed to the patient at this point, which helps build value for the patient for future dental care. Once that is completed and any questions asked and answered, the hygienist/assistant can bring the patient to the business office and reiterate the completed treatment and future treatment for the business team.

The business team member should already be aware of the information since the clinical team should have communicated the information prior to bringing the patient to the business office. The repetition is done for the patient’s benefit – the more times an adult hears a message, the more they understand and will take action. Additionally, the clinical team should position her/himself between the patient and the door to signal to the patient that it is not time to leave yet, while also shielding from other patients in the reception area.

Following HIPAA guidelines, especially if other patients or team members are within hearing, the exact treatment completed or planned should not be stated, but generalizations used. If appropriate, the clinical team member can give the patient her/his business card for any further questions or information (as well as to build potential referrals) and then the business team member can finalize the day’s appointment or handle scheduling future appointments.

If the patient does not wish to schedule future appointments at that time, the business team member should ask the patient for permission to make a follow-up contact if they have not heard back from them in a specific time frame. Often “life gets in the way” and well-meaning patients often forget to contact the office to schedule treatment. All of this does take a few extra minutes during the appointment, but since repetition is the key to learning, the patient’s current care and future needs will be reinforced, thus building value and respect for the practice and their individual treatment needs.

This triangle of patient, clinical team and business team communication may need to be practiced – spending time at team meetings to review the process may be effective. While business team members are not only responsible for checking out patients, there are a multitude of other responsibilities that exist. By planning and practicing an effective hand-off, all team members begin to understand how their actions, or lack thereof, can affect others abilities to do their job well and improve patient case acceptance.

When team members don’t “pull their weight”, resentment builds within the practice. The old adage, “there is no I in team” is so true when dealing with team members who refuse to complete assigned duties. Often when these same team members are asked about their job roles and responsibilities they don’t know how to respond. Many times clearly defined job descriptions are lacking. Does your practice maintain a job description for every employee? Are these discussed annually and changed appropriately?

Once clearly defined roles and responsibilities are outlined and discussed, the team members need to be held accountable for actions or non-actions based on their role. If a hygienist, assistant or business team member is assigned a task and the task has been clearly defined yet the hygienist, assistant or business team member does not follow through with task, she/he needs to be held accountable for their lack of action. Whether the owner/doctor or office manager is the person holding the accountability, team members need to understand the consequences of not performing according to their position.

All team members need to be held to the same standards; when some are “getting away” with not performing appropriately, other team members feel that they can get away with similar actions and tensions can build within the practice. Tension can then be felt by not only the team, but by patients. When patient care is placed in jeopardy by tension or inaction, the entire team and practice suffers. Holding team members accountable for actions based on clearly defined roles and responsibilities can be difficult, yet holding these discussions and holding the team accountable is a sign of a good leader.

Each team member is an expert in her/his area of the practice; whether a business or clinical team member each person specializes in their knowledge and skills that benefit the practice. When a team member discusses an area that another in the practice is an expert on, it can create confusion in the patient’s mind. Confusion creates paralysis – the patient may or may not proceed with recommendations.

Clinical team members whether hygienists, assistants or doctors are the experts in the practice regarding patient treatments and conditions, not the insurance and financial aspects of the care the practice provides. Business team members understand the complexities of the financial world of dentistry whether involving patient investments or insurance benefits. When the clinical team ventures into an area that they are unfamiliar, inaccurate or inappropriate information can be presented to the patient. The clinical team may have knowledge of the patient’s insurance and while practice management software programs allow the clinical team to review insurance basics with the patient, the intricacies of patient finances need to be devoted to the team member who understands those intricacies.

Whether a small or large practice, a business team of 1 person or 20 people, the details of finances need to be handled by the expert of the practice in finances. Additionally, clinical team members are required to provide the patient with the appropriate treatment at the time. Insurance benefit plans require the treatment to be documented by the appropriate treatment code. Clinical team members are not experts in the codes, that is an area for the business team, yet the business team doesn’t know the treatment provided. Practice revenue is based on the treatment provided and the code that is used – teams need to understand these requirements to use the appropriate code for the treatment provided. Anything less can cause issues. When clinical team members venture into discussing that a code or service can be billed if it wasn’t appropriately used, ethical, legal and moral issues can arise. It is the practice manager’s responsibility to ensure the appropriate discussion is provided.  These discussions can be either one on one conversations with the clinical team member or a team meeting to discuss the practice philosophy regarding handling the treatment investments for the patient and use of the appropriate code. These can be difficult discussions but in order to be a high performing efficient practice, each team member needs to understand the role their words and communication can have on the practice.

Being “insurance aware, not insurance driven” focuses on the importance of understanding the patients’ insurance but not being driven to provide treatment that only is “what the insurance will cover” rather than the treatment the patient needs. Team members need to understand that concept and the practice manager is the person to best convey that message.

First, does the practice hold regular team meetings, including morning huddles and scheduled monthly, quarterly and annual meetings? Who runs these meetings? If the practice manager always organizes and runs the meetings, the team can be missing an opportunity to learn about various services, procedures or products. When team members are offered the opportunity to educate other team members, all members grow in their knowledge and understanding of each other’s roles and processes. Other than AADOM, dental managers and other business team members often don’t have opportunities to learn about clinical information while assistants, hygienists, and doctors are required to maintain continuing education depending on state requirements. During continuing education programs clinical team members often learn about new products. Having the ability to present the information learned at these programs back to the rest of the team during team meetings enhances the entire team’s knowledge and understanding.

With treatment planning, have you asked a clinical team member to explain a procedure to you or why it was recommended? A few years ago, an advertisement lauded potential buyers to “just ask about xxx.” Clinical team members enjoy when others ask for their opinion or to explain procedures or products. Everyone likes to feel valued and appreciated and asking a team member about a certain treatment or product in a non-judgmental manner can enhance the relationship. The key is to be non-judgmental since the clinical team member may consider it to be questioning her/his clinical expertise. Also, during team meetings time can be devoted to learning about a procedure to enhance everyone’s knowledge of the “why” behind a treatment.

The hygiene team is correct given what the patient presents with on the day of service.

If the patient has symptoms of periodontal disease, with or without bone loss, the clinical team needs to document what the patient has and the appropriate treatment. When there is bone loss, D4341, D4342 or D4910 are the appropriate codes. If the team uses these codes the clinical notations need to document the reason for the treatment. If there is no bone loss but inflammation, D4346 may be used. With that said however, the ADA code D4346 reads: scaling in the presence of moderate or severe gingival inflammation – full mouth, after oral evaluation.  This means that the treating dentist should do an evaluation prior to the use of the code and that there must be 30% or greater of sites of inflammation in the patient’s mouth. Inflammation means bleeding points. When periodontal probing is done the clinical team should be marking not only probing depth but bleeding, suppuration (pus), gingival margin (recession), clinical attachment loss, mobility and furcation. All of this information constitutes a full mouth periodontal charting, not just marking probing depths. Practice management software should be able to assist the clinical team in determining the percentage of inflammation. If the clinical team is using a paper periodontal chart, the percent of inflammation can be determined manually. If there is greater than 30% of inflammation, complete periodontal charting, intra-oral photographic images and radiographs showing no bone loss can be sent to the insurance benefit company. There is no guarantee however that it will be a covered benefit. Some benefit plans cover completely or cover at the periodontal (50 – 80%) rate, some downgrade to prophylaxis subject to prophy limitations, others provide no coverage at all. Dental practices are not responsible for determining whether a patient has coverage or not for a particular procedure. It is the practice’s responsibility to document what was done and the medical necessity of the treatment. As dentistry moves towards the medical model of care, medical necessity will become more important in documentation. Documenting that there is inflammation present with appropriate treatment notes and images can assist in maintaining that responsibility. Additionally with the advent of the new AAP (American Academy of Periodontology) staging and grading of periodontal diseases there is more information that can be documented. Clinical team members need to document what was done and the reason for the treatment. Many practices are reluctant to use the D4346 code since “insurance won’t cover it” and therefore they are not following the appropriate ADA guidelines. A number of years ago a new ADA code was introduced. The first year some practices didn’t use the code for fear of upsetting patients because insurance didn’t cover it, yet many other practices did submit the code. Due to the fact that many practices did submit the code since they coded what was done appropriately, the following year insurance companies began to pay for the service. If it isn’t submitted, it won’t ever become a benefit. Yet this involves educating the patient about their disease process and practices providing the clinical team with the time and tools to educate. Inflammation/bleeding is considered periodontal disease that is reversible – bone loss may not be reversible. Treating the disease the patient presents with is the ethical and legal responsibility of the clinical team and submitting the appropriate information to the benefit provider or billing the patient is the responsibility of the business team. Both must work together to provide the most accurate documentation.

As business team members, you may or may not have the skills and knowledge to read x-rays (radiographs). Yet, the nature of the business team’s work is such that the business team member needs to know which x-ray to send to a referring practice or to an insurance benefit provider. Because the clinical team member can see or feel the decay, doesn’t necessarily mean that the business team member can process the claim or forward an image to a referring office. Appropriate documentation and information must be included in both the clinical chart notes and the imaging software. Imaging software should allow for noting the clinical information, therefore the clinical team can denote the appropriate tooth number and possible diagnosis for ease of documentation. Yes, it may take an extra click or two to denote the correct information, but one of the clinical team’s responsibilities is to record the appropriate treatment. The clinical chart notes, images, billing and scheduling all need to be consistent and all team members play a role in the documentation process. If there ever was a review or audit regarding treatment rendered, the images and clinical notes would be held in question. It is not the business team who sees the patient, renders treatment or diagnosis, but the clinical team. The clinical team members are held to a level of professional standard of care. The standard of care is defined as the level and type of care that a reasonably competent and skilled health care professional with a similar educational background would provide under the circumstances. The standard of care for documentation usually mentions the appropriate notation of treatment rendered and diagnosis in a SOAP formula – Subjective, Objective, Assessment and Plan. All team members should be documenting any diagnosis, treatments, correspondence, patient compliance or non-compliance and conversations in a clear and accurate manner shortly after any interactions with the patient, family member/caregiver or other health care provider in order to protect the team member, practice and the patient.