by Carol Tekavec, CDA, RDH
Do your patients really understand why they have been scheduled for a root planing procedure? Do they complain about coming in for "cleanings" several times a year? Do they know what a "cleaning" really is and how it differs from periodontal maintenance? Confused and unhappy patients are increasing their complaints to state dental boards about these procedures. They are reporting that they are being pressured into having their teeth "cleaned" over many appointments, that they are being over-charged for these "cleanings," and that their insurance is not paying.
What can you do to prevent any misunderstanding when discussing procedures?
The answer is to explain, illustrate, and cover the topics again and again with patients who need root planing and subsequent periodontal maintenance, as well as with patients who only receive regular prophys. Written materials, brochures, fee estimates, and insurance estimates are important. Patients should be able to explain their treatment in detail before the procedures begin. Patients should also know the cost of their treatment, with or without insurance. The explanations given before a procedure are the reasons treatment is needed. Explanations after the fact are often viewed as excuses.
If you want to keep patients happy, it is essential to answer their questions before treatment. Unhappy patients not only do not come back to a practice, they do not refer others. Without referrals the office loses revenue, and with a loss of revenue comes a loss of hygiene job security.
When answering common questions, try using patient-friendly terms. For example:
• What is a cleaning? For the profession, the ADA defines a cleaning or prophylaxis (D1110) as being performed on transitional or permanent dentition that includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. It is important to note that the ADA CDT-4 definition previously stated "scaling and/or polishing." On Feb. 14, 2003, the Code Revision Committee "clarified the original intent" of the definition and removed the word "or." The ADHA was instrumental in securing the clarification.
Even so, this definition still does not truly describe the adult prophylaxis procedure as it is actually rendered by hygienists in offices throughout the nation. In fact, during the past few years, despite objections by the Kansas Dental Hygienists' Association and many others, Kansas passed legislation that provides for "above-the-gum scaling and polishing" by a dental assistant, thereby fitting the ADA D1110 definition perfectly.
A change in the definition to include the words "coronal and subgingival scaling" would more accurately describe the prophylaxis procedure performed by most hygienists on the majority of their patients.
As for an explanation to patients, keeping the ADA definition in mind, we can tell them that a cleaning means removing plaque and tartar from the crowns of the teeth using scaling and polishing. Only that part of the tooth that is exposed above the gum line is scaled and polished or "cleaned." We can tell them that tartar is also known as calculus and is a hard, mineralized deposit, somewhat like cement, that is formed from the plaque in the mouth and the minerals in a person's saliva. Plaque is a soft, sticky substance that forms on teeth, regardless of what types of food are eaten, which is composed of bacteria and bacterial byproducts. Scaling means to use a dental instrument or ultrasonic machine to scrape plaque and tartar away from the teeth.
We can say that a "regular cleaning" is recommended for persons who do not have any bone loss, periodontal disease, or infection around their teeth. There should be no bleeding, mobility of teeth, receded areas where the gums have pulled away from the teeth, or areas where the roots of the teeth are exposed.
• Isn't a "cleaning" when my teeth are polished? I've never had "scaling" before. Polishing the teeth can remove stains and some plaque, but the teeth cannot truly be cleaned without scaling. It would be like rinsing dirty dishes instead of washing them with soap and a dishcloth. The stuff on top might come off, but the dish would still be dirty.
• How often do I need to have my teeth cleaned? Many people believe they should have their teeth cleaned twice a year. This idea actually originated from a 1940 toothpaste advertisement! Today, many dentists and hygienists set up a cleaning schedule based on the patient's personal needs, not by a pre-set timetable. This may be as often as four times a year.
• My insurance only pays for teeth cleaning twice a year. Why should I have it done more often? Most benefit plans are designed to cover only a portion of the total cost of a person's necessary dental treatment. While a twice-yearly insurance payment toward the cost of teeth cleaning is common, that type of payment arrangement actually has no relationship to what a patient might really need. Many patients need more frequent cleanings. People who have heavy plaque and calculus are prime candidates, as are people who are generally healthy but have certain types of systemic conditions, such as diabetes, or those taking specific medications.
• What is periodontal disease? Periodontal disease can be described as an inflammation and/or infection of the gums and bone that support the teeth. Bacterial plaque and its toxic byproducts, plus calculus and roughened root surfaces, can overwhelm the mouth's defenses. Typically, unhealthy gum tissue covers eroded bone, resulting in abnormal pockets around the roots. Left untreated, periodontal disease can result in loss of teeth. It is a common, and sometimes silent, condition in many adults.
• I have been told that I have periodontal disease and that I need root planing. What is root planing? Root planing and scaling are therapeutic (healing), meticulous, and time-consuming treatments designed to remove toxins and bacteria from the root surfaces of the teeth, thereby allowing the body's immune system to begin the healing process. Calculus, diseased cementum and/or dentin are scaled away. (Cementum is the hard tissue that covers the tooth root. Dentin is that part of the tooth that is underneath the cementum.) These procedures are used as a complete treatment in some stages of periodontal disease, and as part of preparing the mouth for surgery in others.
Scaling the root surface is considered by the American Academy of Periodontology to be a critical element in establishing periodontal health. Recent studies are also beginning to show a relationship between gum and bone health and certain heart conditions and other systemic diseases.
• What is a periodontal maintenance procedure? After a patient has been treated for periodontal disease, either with root planing and surgery, or root planing and scaling, a standard cleaning and check-up recall is no longer appropriate. While a standard cleaning addresses scaling and polishing of the teeth above the gum line, a person who has experienced periodontal disease requires meticulous below the gum line maintenance. A periodontal maintenance procedure is not the same treatment as a regular cleaning even though a hygienist may perform both services. This procedure may include, but is not limited to:
• An update of the medical and dental history
• X-ray (radiographic) review (radiographs are billed separately)
• Mouth/face exam inside and outside including cheeks, lips, tongue, gums and throat
• Tooth examination by the dentist (the dentist's exam is billed separately)
• Gum and bone examination (periodontal probing and recording around each tooth to check for bone loss)
• Review of home care
• Scaling and root planing as needed
• Polishing of the teeth as needed
• Irrigation with medicine of the gums surrounding the teeth as needed
Typically an interval of three months between appointments is effective, but more frequent appointments may be needed. As in many other chronic conditions, successful long-term control of the disease and prevention of tooth loss depends on continual, and possible lifetime maintenance.
• How often does my insurance pay for periodontal maintenance? Many insurance plans pay for periodontal maintenance twice a year, even though most patients require appointments four times a year. Remember that insurance plans limit the number of exams, cleanings, and periodontal maintenance appointments that are covered because these are the types of treatments that many people need frequently. The good news is that any amount paid reduces what a patient must pay out of his or her own pocket.
• If my insurance plan will only pay for periodontal maintenance twice a year, why should I have it done more often? It is a mistake to let benefits be the sole consideration when a person makes decisions about their dental health. People who have lost their teeth often say that they would pay any amount of money to get them back. A person's teeth, smile, attractiveness, ability to chew and enjoy food, and a general sense of good health are dependent on dental health. It is worth the time and expense to keep your teeth for a lifetime.
The hygienist and the rest of the dental staff will need to reinforce the reasons behind periodontal care throughout their relationships with the patient. Concepts that seem so apparent to us are often quite foreign to our patients. A frank ongoing discussion is essential.
Author's note: This article excerpts a patient brochure on the topic of prophys, perio maintenance, and root planing. To view the brochure go to www.steppingstonestosuccess.com and click on "What is the Difference Between a Regular Cleaning, a Root Planing, and Periodontal Maintenance?")
Carol Tekavec CDA, RDH, is the author of the Dental Insurance Coding Handbook (fourth edition), which contains updated information about current and new ADA codes, insurance industry guidelines, and description explanations. She also wrote the patient brochure, "My Insurance Covers This ... Right?" which explains the limited nature of dental insurance in laymen's terms. Her newest brochure details the differences between prophys, root planing and periodontal maintenance. She is the designer of a dental chart, an informed consent booklet, and a scheduling system, as well as a speaker with the ADA Seminar Series on the topic of record keeping and insurance. Still practicing as a clinical hygienist in a general practice, Carol can be contacted at (800) 548-2164 or by visiting her company web site at www.steppingstonestosuccess.com.
