EP31: 5 Steps to Periodontal Case Acceptance; Perio (2 of 2)

Wendy Briggs, RDH, gives practical and essential steps that will aid hygienists, assistants and doctors in communicating the urgency of periodontal treatment. She discusses the science behind doing MORE than removing the calculus and plaque for your patients. While giving an easy to follow system for providers to assess, explain, and provide this treatment, she also gives the solution for those patients who have continually denied this treatment in the past. 

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“EP31: 5 Steps to Periodontal Case Acceptance; Perio (2 of 2) ” Transcript:

[music] welcome to the Double Your Production podcast with The Team Training Institute, the one place designed for dentists and their staff who want to go their practices by following in the footsteps of those that have done it or in the tranches who know exactly what you’re going through. And now, your leaders, the stars of the podcast, Dr. John Meis and Wendy Briggs.
Hello, everyone. Wendy Briggs. Welcome to the Double Your Production podcast where today, we do our part two of a previously released podcast where I am going through five steps to increase periodontal case acceptance. Now, this is a sneak peek into a conference Dr. John and I did all across the country this year. And we share some amazing highlights on how hygienist could maximize their partnership, the treatment planning partnership between the doctor and the hygienist. And there’s a treatment planning partnership that exists when we’re discussing periodontal disease. So here, I walk through five steps to increase periodontal case acceptance, and hopefully, you’ll get a few tips and tricks that can help have higher level conversations with your patients that have periodontal disease and help them see the value, right? Patients don’t buy what we do. They buy why we do it. So hopefully, by listening in on this lecture, you’ll be able to gain a deeper understanding of how to have higher level conversations and share the why with the patients that we serve.
Right now, we’re going to be talking about the five steps to increase in case acceptance, okay? So we should again have a good [inaudible]. We know where we’re going to go. Let’s dive into our five steps, okay? Let’s talk about step one. Step one is to use specific language when probing. Remember, patients who were informed accepted the care of higher level. So we feel it’s very important to inform the patients prior to starting what the numbers actually mean and to verbally call out those number. Hygienists, even if you don’t have assistant and you’re recording your own numbers, you got to call them out loud, okay? That’s a big part of it. And this specific language that you use for probing, language that we found to be very effective is to say something to this effect. Three and others considered healthy. Any number higher than a four means there is infection. Remember, using the word infection is important. Any number higher than a five means the infection has already spread into the bone. So that additional phrase creates a much higher level of urgency with patients. I don’t have to have any knowledge– maybe I don’t have any training or background about dentistry at all. But infection to the bone, does that sound serious? Yes. And it is. Isn’t a five-millimeter pocket– that’s serious with patients. It’s time to move once we have infection that’s spread into the bone, okay? So that’s step one. Using the correct language when probing. Step two, we want to show the patient– utilizing the intraoral camera any areas of concern. They need to see what we see. And technologies made this possible now more than ever before, okay? So we look at images that show gingivitis, inflammation, redness, swelling of the tissue. Patients can see for themselves why we’re concerned. And one of the things that I love to do is I love to take where they are and put it next to an image of much more advanced case. We’re highlighting their problems, but then we’re also using the camera to show what? Consequences of doing nothing, okay? So that’s what the camera can help us do. The cameras can really help drive patient awareness and help them see what we’re specifically concerned about. Now, I mentioned earlier that one of our biggest challenges is getting insurance companies to reimburse. And here is one of the strategies that we have found to be very effective here is don’t just send probing depths, also insert that probe into the bloody pocket and capture a picture of it at that point. There’s more urgency here when they see the redness, the blood, the infection. It’s hard for them to say, “We’re not paying for it. We don’t believe there is periodontal disease,” when you’ve provided proof that it is a problem, okay? So that’s another way you can use your cameras. I don’t think we use cameras enough on the hygiene side. We use them a lot on the restorative side, but I think there’s opportunities for us to use cameras more consistently on the hygiene side as well, all right?
So step three. We’re going to [review the findings?] to the patient and fill out the assessment form, okay? So the assessment of periodontal condition– this is where we often find teams slow down. This is where the struggle typically begins because maybe we’re not all using the same formula. Maybe we haven’t calibrated. And so what I think is perio may not be what my doctor thinks is perio, and it can create some conflict. So here’s the caution flag. Especially if you have multiple providers all serving patients under the same roof, especially if you have multiple locations, finding consistency can be a challenge, okay? Finding consistency can be a challenge. So here is our solution. We created a periodontal health assessment worksheet. And if your perio percentage– utilization percentage, not acceptance percentage. Those are two different numbers. Your perio utilization percentage is in your [inaudible] report. If that number is below 15%, I almost think you’ve got to use this tool every time you assess and evaluate periodontal disease because this tool will help you determine when it’s time to move beyond the regular [inaudible], okay? And sometimes, again, we need a framework. We need to have data that can help us decide where we stand with this patient. So that’s why the periodontal health assessment form that we created has you give the patient a score in a variety of areas. You’re assessing tissue appearance, bleeding, calculus deposits, pocketing, bone levels, mobility, patient management issues, like, are they a diabetic, do they have a smoking habit. Those also come into consideration. And then, of course, you have a total of all the points.
And you can see that you may have two different providers that got different scores. One may have gotten a six, and one may have gotten an eight. But what’s amazing about this worksheet is that, usually, almost always, it means the same result. So you don’t have to agree on every single risk factor or– your provider judgment is going to vary somewhat, but, usually, it doesn’t change the recommendation when you all are using the worksheet appropriately, okay? And, of course, this is in no way intended to be a final diagnosis. This is just a guide to help us have a conversation about what’s ideal for this patient in the chair, okay? So when we look at what’s happening with patients that aren’t quite perio, aren’t quite gum healthy, that’s where we tend to see the most practices stumble. And we have a relatively new code, 4346. It’s still a new code for many of us. We’re still learning how it works. And I don’t want to spend our valuable time here today, when we’re working on the provider partnerships, diving into this topic. I know it’s important and I know you probably would like some guidance on it. So we recorded a video training on how to use this code that’s readily available to you online. So you can go to the team theteamtraininginstitute.com, and you can search that resource for this. You can also google Wendy Briggs 4346 and it’ll probably pull up that video training. So I would encourage you, hygienists, if you’re not quite confident with how you use this code, how you reimburse it, how you get paid for it, you can watch that on your own time on a lunch hour next week. Or if you happen to have open time on your schedule this is a great way for you to brush up on how to use that code. Dr. John and I have a Double Your Production podcast that’s free. And we did a podcast on how to use this code as well, okay? So take some time to dive into that if you feel like this is causing a little bit of a challenge for you. If you don’t quite know how to handle the patients that aren’t healthy but they’re not full-blown perio yet either this can help provide a bridge for you. So dive into that and get some more help with that.
Step three, we’re going to use the assessment form. And now we’re going to begin the conversation. Let’s talk about where you are. Hygienists here’s where we focus on the problem. I’m worried about the infection I’m seeing in your mouth. If we listed a sheet of paper that had all the consequences from not treating periodontal disease, we could probably come up with quite a long list. So just pick one or two that you feel may resonate with the person in your chair, okay? If left untreated the bacteria can enter your blood and it’s been linked to serious health risks like heart disease and cancer. Pick some consequences. And again, creating the urgency is all about helping them realize that this is serious, okay? So then we get into the solution. To clear up this infection and treat this infection we need to do three things. So we try to simplify this. The first thing we need to do is we need to do gum infection therapy and more advanced treatment than you’ve had in the past. That’s thing one, okay? So let’s talk about that for a minute. We’re going to use lasers, locally administered antibiotics, and antimicrobials as a part of your therapy. So we’re going to let them know we’re using a multifaceted approach. Because if we don’t give them clarity on why these things are important sometimes it gets to the point where we’re going over the estimate and they use a line item veto. I want this but not this. Has that ever happened to you or is it just me? That happens, right? Can you imagine how the medical profession would react if the patient had cancer, they’re going in for treatment and they’re like, “Hey, you know what? I’m good with the chemo and the radiation. I just don’t want the IV after surgery. That doesn’t happen. They go with the protocol. They go with the treatment that’s recommended to get the best possible outcome for their disease. Why do patients treat this differently? Why do we treat this differently? And when we go over our best scenario, they need to understand why we’re making these recommendations. So we need to understand why we’re making these recommendations.
So let’s talk about it for a minute. Why are we using lasers in conjunction with scaling and root planing?  So we’re going to talk about that for a moment because it’s amazing what happens. I mentioned before this. Scaling and root planing removes the deposits, right? And it removes any rough areas that may be on the tooth. The laser treatment helped dramatically reduce the bacterial load and in some states, we can actually remove the diseased epithelial lining, any of that epithelial that has lesions on it, we can actually remove that and the body’s going to replace that regenerate and heal. Okay. So that’s one of the reasons why we use lasers. I mean, the results we get with lasers are mind-blowing. This is three weeks after just one treatment with the laser. The laser helps dramatically reduce the bacterial load. And then we follow that up with our Arestin, our locally delivered antibiotics. So as I mentioned before we’re grateful that we have OraPharma here. They’ve been a great partner for this program across the country. And when we look at the statistics that they have, the research that they have, we also recognize we’re in alignment because we both know that mechanical therapies do have limitations, okay? If we’re scaling and root planing we may not be adequately treating the infection after we’ve removed all of the deposit without antibiotics. And we know that bacteria remain multiplying and can return within days. We’ve already talked about that. So even the most intensive mechanical treatment can’t fully address the bacterial nature of periodontal disease and help us restore an environment that supports healing, okay? So when inadequately treated, we often see that there’s ulcerations in the epithelial lining. As I mentioned before, that diseased epithelial lining, research has shown us that this is how the bacteria is entering the blood. They enter through those open wounds, if you will, enter the blood and travel to attack other vital systems in the body. They may settle on the heart valve. They may settle on the lungs. They may settle on breast tissue and create problems there. So all of these bacteria can enter through those diseased lesions to enter the bloodstream and attack other vital systems. Which is why one of the images you have in the very back of your handbooks is the image of the bleeding gums, the infection in their mouth, and a tunnel. You might have looked at that earlier and thought, “What the heck is this?” Right? Well, this is a way that we show the patients when there’s infection in their mouth it’s essentially a wide-open tunnel for the bacteria to enter the blood. That’s why it’s important. We know that the diseased epithelial lining is creating a portal for the bacteria to enter the body and attack other vital systems, okay?
So that’s why it’s important that we do more than removing the calculus and the plaque. We’ve got to address the bacteria which we do with lasers, but also we’ve got to recognize the bacteria is tissue invasive and may embed deep into that gum tissue which is why the Arestin is the next step, okay? Especially because we’ve seen dramatically improved pocket depths when Arestin was used in conjunction with scaling and root planing, okay? So there you go. Reduced harmful by as much as two times more, okay? So this is not a strategy that doesn’t have the support of our organizations. The AKP actually says chemotherapeutic agents may be used as appropriate to improve results. So that’s one of the reasons why we have a multifaceted approach and Arestin is so much easier to use. Think about it. Hygienists have been around for a long time. Isn’t Arestin so much easier than the first iterations of these products we’ve had over the years? Remember that first one, it was like a 10-inch long [inaudible] fiber that we had to pack and [inaudible] the pocket with the cord packing instrument? Come on. Right? So it’s so much easier to use in place that I think sometimes we take how important it is and how effective it is for granted. It really is a compelling part of our treatment protocol, okay? So we use Arestin. It’s released over time and treats the infection that exists in the pocket, okay? So that’s why we have scaling and root planing. We want you to look at how are we doing with both? Scaling and root planing and Arestin. You may have opportunity to use Arestin more consistently with your patients. And again, the results speak for themselves. Significant packet death reduction versus scaling and root planing alone, okay? So that’s why we started by the solutions. We need to do gum infection therapy more advanced treatment than you’ve had in the past. We’re going to use a multifaceted approach. Lasers and locally administered antibiotics. Because it’s not enough just to remove the deposit, right? We don’t just remove the splinter. We also treat the infection that remains after the splinter’s removed that’s, I think, what patients need to know. So that’s why we talk about this solution, okay? That’s the first step, okay? We’re going to do gum infection therapy and more advanced treatment than you’ve had in the past. You noticed that the word cleaning is nonexistent. That’s on purpose. This is not a cleaning. This is gum infection therapy, a more advanced treatment than they may have had in the past, okay?
The second step. We need to change a few things that you’re doing at home. And here is the thing. This always is a challenge for us because we have been trained to provide OHI, right? We need to help them learn how to floss better and how to brush better. But this is also an area that we’ve got to tread carefully on because nobody likes to be guilted or shamed or lectured. And if our goal is to grow the practice and get patients to refer and return and leave positive reviews, we’ve got to be super careful, or we’re not going to [inaudible] in that. So we have to approach OHI in a careful manner that– the best way that I have found to approach this is to just let them know straight up, “We need to get you some better tools. We need to get you better tools,” okay? We need to help them. We need to introduce power brushes and prescription-strength mouth rinses. And here is the commercial that I show every single time we have this conversation. I love it. It’s brilliant. It’s actually produced by Philips Sonicare, who is another partner today. This is interesting. So we invited these companies to participate. I’m not showing this because they’re here. They’re here because we really appreciate their products, okay? So you’re going to love this commercial, okay? You’re going to love this one. So do patients. Patients love it.
Don’t you love that? My goodness. Patients love that too. So when you have the opportunity, talk to them about getting their tools. Delivers more brush scrubs in two minutes than your manual toothbrush can do in a month. Technology matters. [Get?] back to the [inaudible] video. What did we say was one of the most impressive parts of that video? Technology. We have this technology. We need to help patients understand why they should make the investment, okay? So one of the things we often say is we have these power brushes here as a service to our patients. And I also like to add, when it’s appropriate, we can provide them two for less than you’ll pay at Target or Walmart or whatever it may be, okay? So go on Target.com or Walmart.com and beat their prices by $1 or 2. Chances are, you still have plenty of room in there to be profitable within the practice because of your buying power of your organization, okay? So get them better tools. Here’s the other thing. I hear from dentists all the time that say, “I don’t want to mess with all that. The return on investment, it’s not that big. I’m not going to– I’m not going to go down that path. I just don’t want to retail things. They can go get it at Walmart.” And here is the reality we have to consider. Patients that need these products often don’t follow through. That’s why they need them. So in my mind, if we’re really committed to patient care, they need it in their hands when they leave. That’s what they need, okay?
So also, mouth rinses. Again, I could go on for an hour and a half about mouth rinses and what to choose and all of the studies. It’s kind of a pet project of mine, okay? But I don’t have time to go into that now. But get them something that’s proven to be effective. Their balance of risk and benefit is firmly in the favor of continued use of toothpaste and mouthwashes containing active antimicrobial agent. So that’s what the study’s showing us. They need more than just the brushing and flossing. They need antimicrobial agents to use every day at home, okay? So with that, we’re going to do a gum infection therapy, a more advanced treatment than they’ve had in the past. We’re going to change a few things they’re doing at home. And the third thing is we need to see them back more often So set the expectation very early on that from now on, things will be different. Many markations that we need four [inaudible] of scaling and root planing. How long will they have periodontal maintenance? How long going forward?
Forever, and it actually says that in the definition of the code. Did you know it actually says, “Periodontal maintenance begins after completion of that therapy and continues for the life of the dentition?” It says that right in the code. So they need to know that going in because many times, I think they have an expectation that it’s like a broken bone, like, we fix it once and they’re good and everything goes back to normal. But it’s not like that. Periodontal disease is more like arthritis or diabetes where it’s a chronic disease and it needs constant diligence, constant maintenance to make sure that we don’t have lasting consequences. So they need to understand that going in as well. So helping them see that from the very beginning is important. Use an oil change analogy. Many of you are already using this. I love it, I think it’s a great analogy. You know, a brand new car, but if you don’t change your oil, how long does that last? Not very long. Okay? So help them see that this is part of what we have to do from the very beginning.
Step four, we’re going to spend some time to review the findings of the perio brochure. This customizes our recommendations for them, specifically. It helps them. Again, you have some examples there on the table in front of you. Okay? This is where we review the benefits of treatment. We go over what’s in it for them and why it’s important that we treat them in this way. Okay? So you could use that tool to have that conversation. Again, the whole point behind getting things healthy is that that wide open tunnel that exists when we have diseased epithelial lining, essentially, once we get the patient healthy, the goal is to brick over that tunnel, eliminate the pathways. At least make it a lot more challenging for the bacteria to enter the blood and attack other vital systems of the body. Okay? So that’s what we focus on. Once your gums are healthy, we’re able to reduce the bacterial load in your mouth, and at the same time, we work to seal off the pathway into the bloodstream for the bacteria. We’re going to work together to keep them healthy in the long term. You actually have little cards, card stock on your tables that go over some language to make sure we’re all speaking the same language with your teams. Dental assistant, BA Language, doctor, hygienist. And those are really helpful when you’re trying to figure how to get everybody speaking the same language. Okay?
Step five, it’s about finding the money. And what I love about your organization is your 10- step financial process is solid. Okay? So you’ve got help here, you’ve got back up here which is incredibly helpful. So what we’re going to do at this point, you also have in your books an image of an iceberg. And when I found this, when practices follow the five steps, we are able to see acceptance at a much higher level because patients are very clear on what needs to happen. You’re going to have fewer circumstances in your practice where patients won’t do the care. You may still have sometimes when they can’t, and we have to get creative in helping them find a way to fit it n their budget or find a way to move forward. But you’re going to have fewer circumstances where they just won’t do it. Okay? If they won’t do it, or if you still have patients asking for the regular cleaning and the free cleaning, can you see how this image becomes powerful? You know,  if you’re here for a $59 cleaning, a $59 new patient offer and they have infection, we walk them through those five steps and what we’ve found is that almost always, they get it and they accept it and they understand that things are different for them. Occasionally, you’re going to have some pushback and when you do, I think this image is powerful because you could say, “We can certainly clean your teeth today. We can do the cleaning that’s included. But essentially, what you’re asking us to do is remove what we can see above the gum line and what I’m really worried about is all the bacteria that remain below the gum line where you can’t see. And that’s what’s causing the infection. Right? That’s what we’re worried about. So we certainly can get started today, but we do need to get serious about coming up with a solution to handle everything else.” Okay? So you’ve already walked them through those five steps so they should be clear on the ideal outcome.
Okay so here’s what we’re going to do now. We have such a big group today that sometimes once you download, it’s hard to get you all back. So listen carefully. I’m going to give you some instructions and we’re going to see how efficient and effective you are. You all wanted out early today right?
So efficiency and high-level conversations is how we make that happen. So listen in for a second. Okay? Here’s your first case study. You’re going to discuss this patient who’s got seven to eight-millimeter pockets, so those are the deepest pockets throughout calculus. You can see slight, super, and moderate some even evident on the x-ray. This is a diabetic, no smoking habit. And what we’re going to talk about is how you build urgency. Walk through the conversation you have with this patient and figure out if there’s a piece of that five-step process that you’re not currently doing that you feel would add value to the conversation. Okay? So that’s your first item. I’m going to give you another. Can you handle two at one time?
Okay. So now you’re going to talk through this one. You have this on your worksheet in front of you. Then we’re going to take a look at this left side. Now, this patient’s numb. They accepted the care, we got started today. Now, they’re numb. How are we going to convert them to same-day restorative treatment? Okay? Again, it can go both ways, right? We can convert on the traditionally healthy patient, do some restorative today. But also when they’re here for scaling and root planing, we may already have planned that, but we may not have. So how can we convert them? How can we build urgency for that restorative treatment? That’s your first task. I’m going to give you literally seven minutes to talk through that because we have one more case study. Okay? So talk through that and when I call your attention back up, I’ll introduce the next topic and we’ll keep moving forward. Okay? Ready, set, go.


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