Improving Periodontal Treatment Acceptance

Today, most dental treatment providers clearly understand the importance of periodontal disease and its ramifications on patients’ health. So why are fewer than 5% of patients receiving the treatment this disease requires? There are several factors required to create a successful Periodontal Program. First, there must be an office protocol for perio diagnosis that reflects the vision of the practice. Second is the commitment to change from the dental team. The entire team must agree on the protocol and work together to execute it, including providing patient education and motivation. Third, scheduling must allow enough time for the hygienist to provide treatment and operatory capacity to support that treatment. Finally, perio coding must be done properly to ensure appropriate insurance reimbursement and patient compliance. Proper coding provides a means for helping patients achieve ideal oral health and proper insurance coverage.

Sadly, even though science and technology related to diagnosis and treatment of periodontal disease have significantly changed over the past 30 years, many dental practices are stuck in a “business as usual” mindset. Despite the prevalence and persistent nature of periodontal infections, more than 70% of dental offices do not perform full-mouth probing and charting on a regular basis. The popular “adult prophylaxis” procedure is being offered to patients who have all the clinical evidence of an active periodontal infection. We must start by informing patients of their current disease status and making recommendations for their treatment. The next step is to use the proper CDT 2011-2012 codes for billing and help the patient understand what these codes mean and why they are being used. Periodontal Program Goals should be customized for each individual, practice but the following are recommended:

Periodontal imagePeriodontal Program Goals

  1. Use education to motivate the patient to accept the necessary recommended care.
  2. Increase the patient’s level of periodontal health.
  3. Help the patient receive maximum insurance benefits.
  4. Make sure the hygienist is paid for the procedures she/he
    is actually providing*
  5. Increase the practice profitability by using the correct periodontal codes.

*It’s important to understand that many hygienists are already doing the work, and should be paid accordingly. The use and documentation of proper billing codes will ensure the offices are paid for the proper periodontal treatments.

1. Diagnosing Periodontal Disease

The Periodontal Examination–Everything begins with the gathering of the clinical data necessary for the diagnosis of periodontal disease. Full Periodontal Probing Charting and X-rays generally need to be sent to the insurance company to demonstrate presence of periodontal disease. They will not allow the patient coverage without these. Full Perio Charting involves 4 or 6 measurement points of pocket depth on each tooth. Notation of tooth mobilities, furcation involvements, occlusal trauma, and tissue attachment abnormalities, bleeding points on probing, etc. must also be included. All of this supporting documentation demonstrates active disease and some evidence of bone loss and allows you to use proper, periodontal insurance coding. Be prepared with scheduling; it will take extra time to probe and chart and can be done manually with the help of an assistant, voice recorder, automated probes or computer recorders, etc. Computer voice recorders can be extremely effective and can be done without the help of an assistant.

2. Explaining the Diagnosis to the Patient

During the exam, give the patient a mirror and show them at least one bleeding area. Use an intraoral camera. If patient is complaining about bad breath let them know it will clear up after treatment. Touch the patient’s hand with the probe and discuss pain and bleeding associated with touch. Explain that any probing reading over “3” is not good. It is important that the patient hear the numbers and recognize the importance of the probing depths. Call out the Pocket Depths during the exam—this gives a patient a warning so they are prepared to accept the news.

3. Confirm the Diagnosis With X-rays

Periodontal X-rays–Full Series X-rays are appropriate for both perio and non-perio patients. Full series X-rays show bone levels of perio patients better than routine bitewing X-rays. A full series should generally be taken on new patients rather than vertical bitewings.

Codes for Periodontal X-rays

  • Full Series X-rays (D0210) are appropriate for both perio and non-perio patients. Full series X-rays show bone levels of perio patients better than routine bitewing X-rays. A full series should generally be taken on new patients (D0210) rather than vertical bitewings. Full series X-rays are payable every 3–5 years depending on the plan.
  • 7-8 Vertical Bitewings (D0277) show bone levels/loss better than regular (horizontal) bitewings (D0274). Some use (D0277) for annual checkups instead of four bitewings (D0274). D0277 is in reimbursement “no man’s land.” Some insurance companies “downgrade” and pay as four bitewings (D0274). Some insurance companies “up code” D0277 to a full series (D0210), if available at the D0277 fee, and then refuse to pay for the full series (D0210) when taken. Some insurance companies will accept a panorex (D0330) and vertical bitewings together but all companies will accept a full-mouth series.

4. Achieve Treatment Plan Acceptance From Patient

After the doctor reviews the pocket depth readings, bleeding-on-probing (BOP) readings, the Clinical Attachment Levels (CAL), and the full-series X-rays for bone levels and for extent of bone loss, he/she confirms the diagnosis of periodontitis and prescribes a Treatment Plan. Each level of periodontal disease requires a different treatment plan and uses different coding, sequences, treatments, and appointment lengths. The hygienist then discusses the prescribed treatment plan with the patient. This should be presented so that it’s clear the patient is involved in lowering/improving their pockets depths; it will be a joint effort between the patient and the dental team. Print out the perio chart and send it home with patient. Explain that pocket depths will be compared to track the progress during the next appointment. Help patients understand that treatment now may help them avoid Periodontal Surgery down the road. After the patient understands and accepts the treatment plan, transfer to the Financial Coordinator for financial arrangements and appointment scheduling.

Originally published in Sidekick Magazine.

Kristen Esler is a Registered Dental Hygienist and Regional Manager for Henry Schein Dental. She teaches Henry Schein Sales Consultants how to help dental offices implement and properly code for Periodontal Management programs. For help with your perio program, please visit or contact your local Henry Schein Sales Consultant.