Trisha E. O`Hehir, RDH
How do you determine just what to charge for periodontal therapy in a general practice? Is your only choice the same quadrant fee for all perio patients? Some of you may have a sophisticated program already in place. Others may question current fee schedules, especially if production from a periodontal appointment is lower than seeing a couple of children during the same amount of time for "prophy, bitewings, fluoride, and exam." Not only that, but subgingival debridement with anesthesia requires more skill and intensity, leaving you more exhausted despite lower production.
Maybe you`re OK with the fees, but you feel an hour is never quite enough time to complete a quadrant of debridement therapy? Let`s take a look at what should be considered when setting fees for conservative periodontal therapy in a general dental practice.
First, there is the conflict between the "prophy" fee and what to charge for periodontal therapy, especially when the same person is providing both services, in the same room, and often with the same instruments. Secondly, just what constitutes periodontal therapy and what level of therapy do you provide? Is it the instrumentation, or does it also include administration of local anesthesia, disease control instructions, overhang removal, amalgam polishing, tissue checks, retreatment of an area or two, and re-evaluation appointments? What are we trying to squeeze into that hour per quadrant?
Low value associated with `prophy fee`
Dental hygiene care (specifically the "prophy" appointment) has long been considered a loss leader. In other words, prophy fees have been kept artificially low in order to get patients into the office with the understanding that restorative procedures would recoup any revenue lost due to low "prophy" fees, substantially lower than the actual cost of providing the service. This has been the case for decades, leading to a mistaken idea of the value of dental hygiene services - both by us as well as the patients. The low fee and the associated low value for dental hygiene services is also affected by the fact that, for so many years, hygienists have given periodontal therapy away free. It is not surprising to encounter patients who think periodontal treatment should be part of the "prophy" fee.
As hygienists, we struggle to establish an appropriate fee for periodontal therapy. Our value system revolves around the artificially low "prophy" fee. It`s hard to step back from that and realistically determine the value of conservative periodontal care. If you are an Olympic-level hygienist who provides an alternative to surgery that controls periodontal disease in order to save teeth, what is your therapy worth?
Our first step should be to separate the two. A "prophy" is done for periodontally healthy patients who do not have attachment loss, subgingival calculus, or any sign of an active periodontal infection. Periodontal therapy, specifically, debridement therapy, is provided for those patients who have an active bacterial infection leading to attachment loss. This distinction should be very clear in our own minds before we attempt to make changes at the office.
Finding a comfort level over what we charge
The hygienist must be comfortable with whatever fee is assigned to debridement therapy. The service provided must fit the fee. Are you confident your treatment - which is followed by final surgical evaluation - can be viewed as an alternative to full-mouth surgery? Many of you do provide this level of care. Others may be developing those skills and confidence, feeling more comfortable providing pre-surgical debridement.
You must be critically honest with yourself before setting these fees. This is also the time to determine the case difficulty you feel confident treating. I must be confident that my technical and communication skills will result in halting the progress of periodontal disease. Three levels of expertise are involved: subgingival debridement, instruction in daily disease control, and securing from the patient a commitment for three-month dental hygiene visits. Providing high-quality service with predictable results should be assigned an appropriate fee.
Since insurance plans use quadrant fees for periodontal therapy, we often restrict our thinking to instrumentation without taking other aspects into consideration. Administration of local anesthesia, whether by the dentist or the dental hygienist, takes time and expertise which must be considered. In some cases, overhangs must be removed during the debridement therapy and amalgams may need polishing. Following instrumentation, tissue response should be evaluated within two weeks and again at six weeks. At that time, areas may be identified which need to be reinstrumented. These aspects need to be considered when arriving at a fee.
What about time? One hour per-quadrant for all levels of periodontal disease is not realistic. Just as a dentist doesn`t schedule identical appointments for procedures of varying difficulty, such as a small occlusal amalgam and a full crown, neither should we.
Case difficulty should also be a factor
A distinction should be made between varying degrees of periodontal involvement. A Case Type III with generalized 5 to 7mm pockets will require more treatment than a Case Type II with only 4mm pockets. A Case Type IV would require even more time and attention. Rather than determining a quadrant fee, a case fee would better reflect the time, skill, and attention needed to provide sufficient treatment. Case Type I or gingivitis might need only two appointments, while Case Type II may require the standard quadrant approach. More advanced periodontal disease usually requires longer appointments to completely instrument each quadrant, or these difficult cases may be best treated by sextants.
Whatever treatment decisions are made, a fee based on the case type would reflect all aspects of treatment.
Since treatment fees vary across the country, as discovered in a recent RDH magazine survey, a formula using restorative fees in your office can provide case fees.
This formula uses your office fee for a full gold crown. Case Type I equals one-third of a full gold crown, Type II equals one gold crown, Type III equals two gold crowns, and Case Type IV equals three gold crowns.
Figures from the RDH survey indicate an average full gold crown fee of $554, with a range from $178 to $1,300. Using the average of $554, the formula would work out to $185 for treatment of gingivitis, $554 for treatment of early periodontitis, $1,108 for treatment of moderate periodontitis, and $1,762 for treatment of advanced periodontitis. Just for comparison, the high, low, and average survey figures for a prophy were: $125, $10, and $48. The figures for debridement were $650, $15, and $95.
The time should also be adjusted for each case type, being certain to have enough time to adequately treat a case. You may simply increase the number of one-hour appointments, or you may find that longer appointments of an hour and a half or two hours are more appropriate.
These fees provide a hypothetical example, based on national averages. But the formula will provide a direct correlation to the restorative fees charged in your particular practice. When establishing your periodontal debridement fees, remember that your skills must match your fees. Providing optimum therapy to control the bacterial infection of periodontal disease and thereby preserve the bone supporting those teeth is certainly worth the price of a couple of crowns, isn`t it?
Trisha E. O`Hehir, RDH, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.