--Offer to present a program on the topic in local schools, brown bag lunch seminars in your office and / or in various locations throughout your community.

--An in -service program for the staff at your local hospital /s is a great way to attract new patients.

--Prepare an informational brochure and deliver to local physician specialist in your area. Include: cardiologists, endocrinologists, ob-gyn, oncologists, orthopedists, surgeons, etc. --Create an office newsletter highlighting this latest information and invite patients to call for preventive dental hygiene appointment “which includes an assessment for periodontal health.”

Two new codes pertaining to perio in the new 2003 ADA-CDT:
0180 Comprehensive periodontal examination. Start to use the code but do not charge additional for the perio exam (yet). If you have been charging for perio exam, then continue to do so.

4342 is the new code for SRP less than 4 teeth (i.e. site specific treatment - less than a quadrant).

GOOD News that our work is FINALLY being recognized by the ADA-CDT coding mechanism.

Professional brochures are available to the dental office and should be distributed to patients. Consider including one of these brochures as a “Statement Stuffer”. Include it in your monthly statement with a note “because we care about you, here is the latest research information…” Additional ways to increase patient awareness include creating an Oral Hygiene Fitness Report for each hygiene patient as part of their take home materials. Include ALL of the examinations, procedures, freebie home care products, etc. (visit www.AnnetteLinder.com for a sample) A patient walk-out statement that details all of the services rendered at the typical dental hygiene (recall appointment) is a real winner.

The National Institutes of Health recommends a thorough oral evaluation by the dental team . Develop office protocols for routine oral cancer screening for every patient and assure that everyone on the team understands the benefit of the service. Educating patients, coupled with early detection through regular examinations will create a more aware public and – hopefully reduce the morbidity rate.

© 2003 ANNETTE ASHLEY LINDER, B.S. R.D.H.

Exclusive Marketing Tip:
"Dear Annette, It was a pleasure listening to you at the Chicago Mid-Winter meeting yesterday. I am overwhelmed with the information I need to implement into the practice. Here is a copy of the "Insurance Sign" that we've had so much positive feedback with from our patients. I hope to hear you at many more conventions. We will be in San Francisco for ADA. Hope to see you there." Sharan Tash Mishoulam, Irwin C. Mishoulam, DDS

BEAUTY INSURANCE and OIL CHANGE INSURANCE
Have you heard about the new insurance that covers 2 hair cuts, 2 hair colorings, and 2 perms per year? What about the oil change insurance that covers 1 oil change per year?

Well, we haven’t heard about it either, but we get our hair cut approximately every 6 weeks, and get our oil changed every 3 months. Our looks are affected by messy hair, and our cars can break down if not maintained.

Why not the same consideration for our teeth: which we only get one permanent set of – and which don’t grow back if we lose them?

We are suggesting that YOU have control over YOUR oral health – DON’T LET INSURANCE DICTATE WHAT IS BEST FOR YOU. - Irwin C. Mishoulam, DDS

The Trouble with 4910 SPT… Annette A. Linder
Edited and reprinted from RDH Magazine 12/02

We have a problem with 4910 in our office - My patients won’t return for care every 3 months because “the insurance will only pay for cleanings twice a year.” The patient went through active periodontal treatment two years ago and now they are presenting with full blown perio again – what do I say and do now? My insurance / financial coordinator is upset with me because the insurance isn’t paying and patients are complaining to her. How do we get insurance to pay? How do I help my patients see that this appointment is different from a 3 month prophy – and what makes it different? Should we charge for an exam? Can we alternate with the prophy (1110) code? If these are questions that you are asking, please know you are not alone! They are among the most frequently asked at my lectures and when consulting with a dental practice. Managing 3 month periodontal therapy maintenance is a real and valid frustration for hygienists. And it is no fun for the financial/ insurance coordinator. Ongoing supportive periodontal maintenance is well established in the research as critical and key to long term periodontal stability. Patients treated for periodontitis who comply with suggested SPT intervals experience less tooth loss and attachment loss than patients who do not comply. Because the progression of the disease is unpredictable, SPT protocols allow for close monitoring as well as professional procedures. In other words, ongoing and supportive periodontal maintenance is an integral part of the treatment plan. (Visit AAP.org for tons of research) The challenge is how to get this message to the patient? How do we attack this problem? Here’s what I see working out there - some concepts and ideas for change that are used by dental hygienists throughout the country.

PATIENTS DON’T GET IT !
My research and over the shoulder consulting observation demonstrate that one of the contributing factors for low SPT compliance is the “uni-lateral” enrollment of the patient in periodontal treatment. What does this mean? In many dental practices the patient is simply told by the dentist or the hygienist that they have a “gum problem” and they need to have “quadrants of scaling and root planning to remove the calculus from below the gum line.” The patient is typically told that it will “require 3 – 6 appointments and cost around $900. The insurance may pay for a good portion of the treatment – perhaps ½ to ¾ of the treatment.” The patient often responds with “go ahead” and is thinking: Go ahead and fix it, hygienist, clean me up really well and I am on my way -- and no lectures, please. It is a set up for a no-win hygiene scenario. Just what you need -- another compliance battle. Suffice it to say that there will be no calculus on the root surface when you are done. However, you and I know a successful periodontal therapeutic outcome is very much dependent on what the patient does when they leave your chair. You can scale and root plane till your blue in the face - if the patient isn’t participating; i.e. performing exquisite daily bacterial plaque removal, chances are slim for ongoing perio stability. Patients that accept perio treatment “because the hygienist or the dentist said to do it” are the patients that cancel appointments, don’t perform homecare, complain about money and fail at 3 month supportive care because “insurance only pays for 2 cleanings a year!” Our goal is to allow patients to take ownership of their health – periodontal or otherwise and to coach them to be informed and pro-active health care clients.
Here are some ways to do that.

START AT THE BEGINNING – BEYOND THE ROOTS
The solution starts at the very beginning, during the assessment and treatment proposal phase. Ideally, we would like everyone to say “yes” to treatment. But in the real word and for a whole variety of reason, that is not likely. Trying to talk the “no” patient into treatment leads to another no-win scenario because these are the patients that do not comply with total treatment. When and if they return for care, they typically present with active disease again and require re-treatment. Back to ground zero for the hygienist who assumes all the blame and struggles with some explanation to the patient. Talk about stress levels and burn out – this is not fair to the hygienist. There are better and easier ways to do this. As hygienists, we are continually educating and discussing oral health with our patients. The interrelationship between existing health conditions, medications, and personal history impact on the patients’ periodontal status and should be discussed with the patient. Have research articles readily available in the reception area, treatment rooms, office newsletters, office comm- unications. Periodontal disease is a multifactorial condition with complex and interconnected causes. It is episodic in nature and genetic factors, local and environmental factors, and the host immuno- inflmmatory response are contributing factors. In other words, it is more than just the bacteria. Therefore, updated histories are an important part of data collection. Audit the patient record for a current and updated complete health history. Discuss the significance of the patients’ current health status, meds, life changes and stressors, and periodontal health. Examples of a patient conversation might be: John, you have indicated that you have been diagnosed with diabetes. We have a lot of new research information demonstrating a link between diabetes and periodontal infections in the mouth and the body. I would like to share that information with you….. OR Mary, you have indicated that you smoke. The latest research reports that smokers have the greatest risk for periodontal infections and tooth loss and I would like to provide you with some information ….

Periodontal evaluation is part of every dental hygiene appt and part of the patients’ record. Create an open environment of co-examination and co-discovery to bridge the gap between “the lecture” and the patient willingly saying “yes – because –they-value” the treatment good health. Prior to beginning the periodontal exam, remind the patient of clinical signs that they can understand. This might include bleeding and numbers, pocket depth, bacteria getting deeper into the bone and connec -tive tissue causing infection, inflammation and bone loss. Offer the patient a mirror so they may watch Proceed through the periodontal exam calling out the numbers, bleeding points and other clinical signs so that the patient can see, hear and participate in the examination. With a team member recording the data, it becomes time efficient to complete the full mouth examination. Some patients will watch, others will not. The important part is to allow the patient to hear any clinical signs of perio infection. Use the examination to educate and motivate. In this model, at the completion of the exam, most patients want to know what “does this mean and what do we do to fix it.” The hygienist is then able to present the appropriate periodontal treatment plan. Sample 1 illustrates a written Periodontal Treatment Recommendation and Information Form including informed consent components. Notice that the form includes information for 3 month ongoing care as part of the treatment plan. At each therapy appointment the patient leaves with written information to take home. This may be a professional pamphlet, a piece of research, your own office information forms. Each appointment is perio-focused in conversation and form, involving the patient every step of the way. Utilizing the intra oral camera or a hand held mirror gives the patient the opportunity to “see” the difference between healthy tissue versus infected tissue. At the final active therapy appointment, the patient receives “Why Maintenance is Important’ information letter. This says it all. Positive written and verbal communications invite the patient to “own” their oral health, have greater responsibility and unburden the hygienist as the sole person responsible for the patients’ “clean teeth.” The patient has to want to do this. If they don’t want the treatment then you cannot do it. Bottom line, we are no longer scraping roots and cleaning teeth! Patients clean their own teeth. Todays’ hygienist is a periodontal therapist and partner in health care with the patient.

WHAT IS THE DIFFERENCE
The SPT appointment is a perio appointment. It is part of periodontal treatment. It is not 3 month prophy. It is more than a routine supragingival scaling and polish prophy. The definition “This procedure is for patients who have completed periodontal treatment (surgical and or non-surgical therapies exclusive of 4355) and includes medical history review, evaluation of periodontal status (charting), removal of bacterial flora from crevicular and pocket areas (i.e. scaling,root planing, debridement) scaling and polishing of teeth, periodontal evaluation, and a review of the patient’s plaque control efficiency. Typically, an interval of three months between appointments results in an effective treatment schedule, but this can vary depending on the clinical judgment of the dentist. When new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered. Periodic maintenance treatment following periodontal therapy is not synonymous with a prophylaxis.”

Components 4910 include:
-MEDICAL HISTORY REVIEW
-EVALUATION OF PERIODONTAL STATUS (PERIOCHART)
-REMOVAL OF BACTERIAL FLORA FROM CREVICULAR &
POCKET AREAS
-SCALING & ROOT PLANING WHERE INDICATED
-POLISHING OF THE TEETH
-REVIEW - RE INSTRUCT - PATIENT'S PLAQUE CONTROL
- RECORDS AND DOCUMENTATION

NUTS and BOLTS Insurance information:
Once the patient has received periodontal treatment (4341) they are a 4910 patient. Only submit for 4910 after utilization of code 4341.

1. The procedure is billed 4 times per year as 4910.
2. Examination and radiographic analysis are charged separately
3. Use of a narrative is reported to help patient gain insurance payment. SUPPORTIVE statements include:

“Following a course of active periodontal treatment, periodic ongoing care at regularly prescribed intervals is essential. Although the standard of care recognizes that these intervals may vary due to the nature of microbial plaque, calculus formation and host factors, a three month time interval for periodontal maintenance therapy remains the most generally accepted. The majority of clinical studies have shown that three months is most effective in controlling the disease. " SOURCE: AAP

“The successful long term control of periodontal disease depends upon active and continuous maintenance therapy. It is not considered acceptable practice to establish patient care on the basis of an arbitrary fixed interval. Ex: 6 month recall” ADA CDT -1

Many carriers typically pay for 2 “cleanings” a year and include 4910 in this category. They are going to pay twice a year and that is it. Some will pay for 4910 four times a year and some contracts cover 4910 twice a year and modify the other visit codes a 1110. As with many ADA codes, the insurance will only reimburse for “what is covered by the contract.” You could send them a perio book of research, form a picket line in front of their office and send some of your own blood, but it won’t help-- if it is not a covered benefit, that it is it ( and it is not your fault) The contract is between the employer, the patient and the insurance company. When patients enter into the commitment of ongoing periodontal treatment because they do not want to have an infection in their mouth or their body and because they value and appreciate the benefits of maintaining optimum oral health, then insurance doesn’t matter. The “two cleanings a year” mentality falls by the wayside and along with it your feelings of frustration. Realistically speaking, we are not talking about thousands of dollars here. Typical SPT appointment fees are about the same as dinner for two at a nice restaurant.

DOCUMENTATION AND SUBMITTING THE CLAIM
Always include a narrative with the 4910 claim and the date of the last 4341. A sample narrative looks like:
Patient completed active periodontal therapy on date of 4341 and is now receiving periodic and ongoing care as prescribed by the AAP

Many offices are also including intra- oral photos of bleeding, swollen, inflamed tissue with their perio claim submission and it appears to be having some positive effect.

March 2002, Dental Economics Insurance Column, C. Tekavec, 4910 claim should also include: a) Periodontal Case Type b) Dates of root planing and or surgery c) Copy of the perio chart depicting and describing progression of the periodontal status and d) Assessment of home care ( poor, adequate, good).
Tekavec reports that “alternating between the codes 4910 and 1110 is not reasonable because the patient’s insurance carrier may require evidence of further surgery prior to paying for a 4910 following a 1110.”

The code 4910 does not include a periodic examination. Therefore, the periodic exam (0120) is performed and charged out separately, usually at 6 month intervals. The same is true for necessary radiographic evaluation. Will the insurance pay for the exam? The short answer is “they should” if preventive exams are covered twice a year. Again, it always depends on the insurance company and some do not pay for 0120 on the same day as 4910, even though the CDT description is clear.

DON’T HESITATE TO
1. re-submit claims with letters of explanation, charts, pictures, blood (just kidding), documenting research
2. tell the patient to call their insurance company (they are the customer, after all) and find out why they are not paying
3. always charge out for your services rendered
4. re-treat active periodontal infection, as needed and site specifically. An example of this is be the patient who completed active therapy (4341) several years ago and has or has not maintained 3 month 4910. Patient presents needing a quadrant or quadrants of therapy. Changes in their medical history, stress factors in their life, poor compliance are all contributing risk factors. Remembering that periodontal diseases is a chronic infection, incurable but controllable (most of the time) it is not extraordinary to have to re-treat with quadrant/s of mechanical and chemical therapy, 4341 . (Please see ADA 4910 description regarding re-treatment.) Most carriers do not define 4341 as a once – in - lifetime procedure and many will reimburse the patient for 4341 procedures following an appropriate time interval (typically 24 - after 36 months. )

This is the most exciting time to be in our profession. Thanks to technology and research, our role as oral health care educator and provider is expanding every day. Patients are finally beginning to realize that the teeth and gums do not exist on a separate planet -- what is going on in the mouth is a reflection of what is going on in the body. Before I hit the road as a full time consultant and speaker, I practiced clinical hygiene for some 30 years. During those years I learned the hard way that it was unrewarding to force a patient into perio treatment with the uni-lateral approach. These patients did not comply and I was always “the nagger.” That did not feel very good for me nor did my patients like it very much. Once I allowed the patient to be a full participant in the exam and gave them everything that I knew about perio, the “no’s” became a yes to treatment… because they wanted to. And those that asked for treatment also complied with an appropriate interval of care, be it 2 months or 3 months. Even my gingivitis patients returned for 3 month intervals until we (the patient and I) felt comfortable with lengthening that interval. Did the insurance pay in that scenario – not for four perio visits. But my patients did not mind “picking up” the cost because “they felt so good about their oral health. Determining an appropriate interval of care for your patients is a clinical decision based on current research and protocols, the patients’ clinical presentation and risk factors, and what you think is best. I work with hygienists throughout the country that see many patients every 60 days, if that is what is best for the patient. And the decision has been positively made in partnership by the patient and the clinical hygienist . That’s a happy ending that we can all feel good about.
A. Linder, RDH, BS 11/02

A personal note from Annette ... "And you thought all you did was clean teeth!"
Jan 2003 From the desk of: Annette Ashley Linder, RDH, BS
Study: Inflammation Worst Heart Attack Risk
THE Associated Press November 2002

BOSTON A landmark study offers the strongest evidence yet that simmering, painless inflammation deep within the body is the single most powerful trigger of heart attacks, worse even than high cholesterol. The latest research is likely to encourage many doctors to make blood tests for inflammation part of standard physical exams for middle-age people, especially those with other conditions that increase their risk of heart trouble.

The study, based on nearly 28,000 women, is by far the largest to look at inflammation's
role and it shows that those with high levels are twice as likely as those with high
cholesterol to die from heart attacks and strokes. Over the past five years, re- search by Dr. Paul Ridker of Boston's Brigham and Women's Hospital has built the case for the "inflammation hypothesis." With his latest study, many believe the evidence is overwhelming that inflammation is a central factor in cardiovascular disease, by far the world's biggest killer. "I don't think it's a hypothesis anymore. It's proven," said Dr. Eric Topol, chief of cardiology at the Cleveland Clinic. Inflammation can be measured with a test that checks for C-re- active protein, or CRP, a chemical necessary for fighting injury and infection. The test typically costs between $25 and $50.

Diet and exercise can lower CRP dramatically. Cholesterol- lowering drugs called statins also reduce CRP, as do aspirin and some other medicines. Doctors believe inflammation has many possible sources. Often, the fatty build-ups that line the blood vessels become inflamed as white blood cells invade in a misguided defense attempt. Fat cells are also known to turn out these inflammatory proteins.

Other possible triggers include high blood pressure, smoking and lingering low-level infections, such as chronic gum disease.

Inflammation is thought to weaken the fatty build-ups, or plaques, making them more likely to burst. A piece of plaque can then lead to a clot that can choke off the blood flow and cause a heart attack. For the first time, Ridker's study establishes what level of CRP should be considered worrisome, so doctors can make sense of patients' readings. However, experts are still divided over which patients to test and how to treat them if their CRP readings are high. In March, the heart association and the Centers for Disease Control and Prevention held a meeting of 50 experts to review the evidence and make recommendations on CRP testing.

Although it hoped to be finished this month, the committee went back to the drawing board after learning last week of Ridker's latest results, which are being published in today's New England Journal of Medicine.

U.S. Study Links Smoking, Gum Disease
By Lindsey Tanner AP June 1999

Chicago---Cigarette smoking might play a major role in more than half the cases of severe gum disease in adults nationwide, suggesting that one of the main causes of tooth loss could be prevented, a government study shows. While it long has been known that smoking can help cause gum disease, the national study is the first to show how widespread the problem is, said Dr. Scott Tomar, a researcher with the Federal Centers for Disease Control and Prevention. Jack Caton, president of the American Academy of Periodontology, called the numbers “staggering” and said the study should “compel more dental-care providers to get involved in tobacco-cessation efforts.” Smokers were about four times more likely than people who never smoked to have periodontitis, but ex-smokers who had abstained for 11 years faced no increased risk, said Tomar, whose findings were published in the may issue of the Journal of Periodontology. Overall, 52.8 percent of periodontitis in the study was attributed to current and past smoking. Periodontitis, advanced gum disease that destroys the tissue and bone surrounding the teeth, is caused by bacteria contained in plaque build-up.

Researchers said smoking causes damage that makes the gums more vulnerable to bacterial infection. Tobacco can suppress the body’s immune system impeding its ability to fight infection. It also reduces blood flow to the gums, depriving them of oxygen and nutrients that allow gums to stay healthy.