The red flag strategy

July 1, 2010
In my office, all new patients are scheduled in hygiene first. I don’t know why they aren’t scheduled with the doctor first, but what the heck, I just work there.

by Dianne Glasscoe Watterson, RDH, BS, MBA
[email protected]

Dear Dianne,
In my office, all new patients are scheduled in hygiene first. I don’t know why they aren’t scheduled with the doctor first, but what the heck, I just work there. We have two recurring problems related to new patients. First, since we’ve never seen these patients before, we have no idea what to expect regarding their oral condition. The range of severity could be from an easy prophy to an advanced periodontal patient. New patients who have periodontal disease seem disappointed when they don’t actually get any scaling on the first visit. The second problem is the high no-show rate for new patients. We schedule a full hour for new patients. If they fail to show up, it’s a whole hour lost.

These two problems have gotten so bad that I dread seeing a new patient on my schedule. Can you give us any strategies to solve our issues with new patients?

Hannah, RDH

Dear Hannah,
I have always recommended that new adult patients be seen by the doctor first. Doing so allows the doctor to complete a comprehensive new-patient exam that includes complete restorative and periodontal charting. The doctor can then decide the level of services the patient needs in hygiene. When the patient arrives in hygiene, there are no surprises.

I recommend that new-patient time be blocked in the schedule with the first 30 minutes on the doctor schedule and then 60 minutes on the hygiene schedule. This allows the hygienist enough time to complete periodontal charting, particularly if the doctor only did a screening (PSR), and commence definitive care dictated by the patient’s needs.

However, there are wide variations among doctors regarding examinations. I’ve worked with some who schedule a full hour or more for a new adult patient. Often these exams include cosmetic imaging, photos, study models, and medical screenings for diabetes or other nontraditional tests, as well as the standard restorative and periodontal examination.

Other doctors can easily conduct a comprehensive new-patient examination in 30 minutes, while some never schedule examinations on the doctor schedule. In most situations, doctors who do not see adults on their schedules first are heavily scheduled with restorative work and do not believe that reserving slots in their schedules for exams is a wise use of their time.

While I prefer that new adult patients be seen by the doctor first, I also recognize that hygienists have excellent skills in gathering data and performing assessments. Hygienists are qualified to perform all the necessary preliminary functions — introductions, medical history review, blood pressure screening, intraoral and extraoral assessments, periodontal charting/recording, charting of existing restorations, and radiographs.

As an example, let’s assume in your assessment that the new patient in your chair has Class III periodontitis. You can see some significant subgingival deposits on the radiographs, and you see bleeding upon probing. Now is the time to raise the red flag.

You say, “Mrs. Jones, have you noticed this particular area bleeding when you brush?” After a little more probing, you say, “Have you noticed this area being inflamed?”

Now is the perfect time to engage your intraoral camera to let the patient see exactly what you are seeing in her mouth. In the absence of an intraoral camera, pointing out calculus and/or bone loss on an X-ray is also recommended. All you are doing is calling attention to what you see in the patient’s mouth.

Then you lay down your probe and say, “Mrs. Jones, according to what I see in your mouth and on these X-rays, there appears to be some problems with your gums and even the bone around some of your teeth. Before I proceed any further, I need the doctor to come in and have a look.”

You have raised the red flag!

Leave the operatory to go and inform the doctor about your findings (out of the patient’s hearing) and request a brief doctor examination. Most likely, you have interrupted the doctor with his/her patient, so an extensive exam should not be expected at this point.

When the doctor enters the room, introduce the patient to the doctor. Then the doctor will sit down, look at the X-rays, and perform a cursory exam. The doctor should say, “Mrs. Jones, from what I see in your mouth and on these X-rays, you have periodontal disease. It is a chronic infection in your gums, and over time it destroys what supports your teeth, namely the gums and bone. Your teeth are like fence posts in the ground. As long as the earth around those posts is strong and firm, the posts will stand nice and straight. But if the earth around the posts deteriorates or falls away, the posts get loose. That’s what happens in the mouth too. The disease in your mouth is destroying what supports your teeth. The good news is we know how to treat this disease and get it under control, usually in a nonsurgical manner.”

Depending on how much time you have left and the patient’s periodontal severity, you might be able to do limited scaling, possibly 1-3 teeth (code D4342). By performing limited scaling, your patient will not feel the disappointment of receiving no definitive scaling services at that visit.

The no-show problem you describe requires new strategies from business assistants. While I know of no bulletproof way to completely eliminate no-shows, it is possible to increase the “show up” rate.

First, it is never appropriate to leave an appointment reminder message for a new patient on voicemail. New patients need to be spoken with directly, which may necessitate a reminder call after hours. At the initial contact, the business assistant must get all pertinent phone numbers, e-mail addresses, etc., and ask which number and time of day the patient can be reached directly. I recommend a new-patient packet (which includes the patient registration, medical history, and welcome letter) be sent after the appointment is scheduled.

Any new patient who disappoints on the first visit is not permitted to schedule again without first prepaying the visit.

Please refrain from saying, “I’m calling to confirm …” This sends the message that the appointment is uncertain and needs to be “confirmed.” Our mindset should be that when the patient gives approval for an appointment to be placed in the schedule, it IS confirmed. Rather, we extend courtesy reminders. Here is a script for a reminder call:

“Hi, Mrs. Smith, this is Julie from Dr. Harvey’s practice. I’m calling to give you a courtesy reminder of your appointment on Tuesday, May 5, at 10 a.m. We’re looking forward to seeing you then.”

New patients are the lifeblood of the practice and play an important role in overall practice profitability. Doctors who have made the mistake of not taking new patients for a season eventually see practice stagnation set in. A steady flow of new patients is seen as a sign of practice health. The key to controlling new-patient no-shows is to expand communication at the initial contact and ensure direct patient contact 24 to 48 hours before the appointment.

Best wishes,

Dianne Glasscoe Watterson, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe Watterson for speaking or consulting, call (301) 874-5240 or e-mail [email protected]. Visit her Web site at

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