Have You Lost "Your Grip?"
Do you find yourself complaining of hand, wrist, or lower arm pain? It could be because you've “lost your grip.” You may have let your hand slip into the usual way you hold a pen and let some fingers take a vacation in their grasp duties. The way that we usually hold a pen is unsuitable for use by dental professionals to hold their instruments. This is because the way we hold a pen to write requires increased force of the muscles of the hand and upper arm. Stability and flexibility of this type of grip are low as a consequence of using the middle finger for both holding the instrument and supporting the hand.
As we hold a pen when we write, the third finger is fixed. Therefore, many movements have to be made in the wrist. This causes unfavorable positions such as an extensive palmar flexion. It is understandable that the use of a normal pen grip can give rise to "CANS" (complaints of arms, neck and shoulders), formerly called RSI (repetitive strain injury). Did you know that you get FOUR times the strength when you use a modified pen grasp when instrumenting?!? You DO, as well as less discomfort in you hand, wrist and arm.
When my students complain about hand or arm pain, I look first to their grasp. When my students complain about ineffective calculus removal, I look first to their grasp. I often see fingers taking a vacation, being lazy or taking on the duties that another finger is supposed to perform. Let’s review the duties of each of the fingers:
The thumb and the index finger are used to sandwich the instrument. They are responsible for holding the instrument steady and providing the rolling function of the instrument in adaptation.
The middle finger is the feeler finger to help assess calculus deposits.
The ring finger is your fulcrum, powerhouse and stabilizer.
The pinky is a freeloader, no other finger can have the job of the freeloader because the pinky has the job covered.
The most common mistake I see is that the feeler finger takes the job of the pointer finger, which I have seen decreases effectiveness in assessment and in calculus removal. Remember to get a grip and to use the modified pen grasp to help your body and your practice.
Watch our demonstration of correct grasp below.
What Code To Use When Patients Have Heavy Calculus But No Periodontitis
We have all been in a situation when a patient has bucket loads of calculus but doesn’t present with periodontitis. It has been 3+ years since they have had any dental care and you know you will need more than the average 20 minutes to complete the treatment. There is really no dental code for this situation, so below are some options for care. Decide what is best for your office and make a plan to get everyone on board so that when the situation comes up, it will be a smooth transition.
OPTION 1:
When to use: Use option 1 if you need more than one visit to complete treatment.
Bill the prophy code D1110 and complete the right side of the mouth. Then at the second appointment charge another D1110 for the left side.
Pro:
1. If the insurance covers D1110 twice per year any time. The patient gets full coverage of cleaning the entire mouth.
Con’s:
1. At their 6 month check up, the next prophy would have to be paid out of pocket depending on the time of year they came into see you.
2. Some insurances will only cover the D1110 exactly 6 months and 1 day apart. If this is the case, the patient must be informed that the second prophy will be paid out of pocket.
Special note: If you start with the right side, the patient will notice an annoying difference with their tongue on each side and will want to return for care of the left side.
How to present the treatment plan: "After assessing the health of your mouth, I have noticed that you have generalized gingivitis with a heavy amount of build up on your teeth. If we leave the build up there, it may quickly turn into a more serious disease called periodontitis. Since it has been such a long time that you have had treatment, I am going to need more time to complete your treatment. I recommend that we clean the left side of your mouth today and then schedule you back for one more 30 min visit to do the right side. Here is what the cost will be…...
Treatment plan:
APT 1: D1110 - $64-$100 covered at 100% by your insurance
APT 2: D1110 - $64- $100 out of pocket expense
Option 2:
When to use: Use option 2 if you have extra time in the schedule to complete all of the treatment in the same day but you will be taking more time than just the average 20 minute prophy time.
Charge D1110 and then bill D1999 (and unspecified preventive procedure) for the extra time you took to complete the treatment.
For example every 5 minutes extra you use you could charge $10. So if you take an extra 15 minutes to complete the treatment you would charge the patient $30.
How to present the treatment plan: "After assessing the health of your mouth, I have noticed that you have generalized gingivitis with a heavy amount of build up on your teeth. If we leave the build up there, it may quickly turn into a more serious disease called periodontitis. Since it has been such a long time that you have had treatment, I am going to need more time to complete your treatment. Luckily, we are running ahead of schedule and I can complete it all today. Here is what the cost will be…...
Treatment plan:
APT 1: D1110 - $64 covered at 100% by your insurance and D1999-$30 for the heavy buildup removal.
OPTION 3:
When to use: Use option 3 if you can’t see to do a proper exam because there is too much calculus or biofilm. The patient should be rescheduled for an assessment to determine if periodontal therapy or a prophy is needed.
Charge D4355 (Full mouth debridement) IF you can justify that a proper exam cannot be completed unless the biofilm and heavy buildup is removed first.
Then in 1-2 weeks, perform a follow up assessment and D1110 (prophylaxis).
Pro:
The patient gets full coverage from insurance of care for the dental treatment.
Con’s:
The D4355 code states, “the gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.”
Therefore you must be able to justify, and state in your notes, that a comprehensive exam cannot be performed based on the amount of calculus and biofilm present.
2. Removing just the gross debris leaves a risk for periodontal abscess and a potential of the patient thinking that they are “clean” and not return for the rest of the care. That is why this code should be used only in rare cases.
How to present the treatment plan: "After assessing the health of your mouth, I have noticed that you a heavy amount of build up on your teeth. Due to the amount of build up, I will need to remove some of it for the dentist to do a proper exam. Then I will need to see you in 1 week to re-evaluate the health of your gingiva and teeth. Here is what the cost will be…"
Treatment plan:
VISIT 1: D4355 - $64 covered at 80% by your insurance.
VISIT 2: Re-evaluation of periodontal health with new treatment plan presented.
Want more help with codes and billing. Check out our 1 page guide to billing and coding for hygienists in our store. On sale now.
Are you expected to be an expert on codes? Then check out this ONE page guide to billing and coding. This simple digital download contains information about frequently used codes in the hygiene department. It reviews when to bill for a procedure, and what the general coverage for such procedures are.
Building an Office Anti-Caries Protocol With Xylitol
I graduated hygiene school with all of the enthusiasm in the world! I really felt like I was going to save Americans from this horrible oral health crisis. Then I started working in the real world. I began to see patients that asked me questions that I had NO idea how to answer. I felt panicky, confused and frustrated. I had little knowledge beyond brush, floss, and fluoride.
I graduated hygiene school with all of the enthusiasm in the world! I really felt like I was going to save Americans from this horrible oral health crisis. Then I started working in the real world. I began to see patients that asked me questions that I had NO idea how to answer. I felt panicky, confused and frustrated. I had little knowledge beyond brush, floss, and fluoride.
I remember one time in particular I had a patient with excellent oral hygiene. She had great probe readings, little plaque and LOTS of cavities. She did not have any of the typical causes of decay (heavy soda drinking, etc.) She was so frustrated, and I was too. I went to another hygienist and presented her with my findings, she replied, “she must just have weak teeth.” The patient had no trace of congenital problems with teeth formation and I couldn’t accept the idea of “it must just be the way it is for her.”
I went home and began to research everything I could from dental journals, books and hygiene message boards. That is when I really started learning about the benefits of xylitol. There are actually over 2000 studies that have been conducted. It has the ability to drastically reduce decay (around 70 percent) and cut down plaque (50 percent,) which is more than patients usually remove by brushing.
I learned about how other countries use it in their schools but we are a little bit behind in the U.S. I also learned that when mothers had enough exposures to xylitol their babies had a huge reduction in decay because cavity-causing bacteria were not being passed.
I was so excited about xylitol and found my patients really shared my enthusiasm. I had great compliance and saw great results. I find that hygienist are not offering xylitol to their patients because of various barriers. Below are a few solutions to those barriers.
Lack of Knowledge: A lot of hygienist don’t feel confident talking about a product that they don’t know a lot about. I would recommend brushing up on the topic. I love Trisha O’heirs writing on the subject. Check out her article in dental town HERE.
Also, a xylitol company called Xlear does lunch-in-learns over Skype. You can also check out another amazing xylitol company called Xyloburst that has an awesome website full of information.
Here at Hygiene Edge we have also created a FREE informational handout for to give to your patients as well HERE.
Accessibility: I’ve heard from hygienists that they don’t like having to send their patients to the health food store or on online to get xylitol. A resolution to this is do what my office does and carry the product in-office. It was hard to keep on the shelves! We mostly sold the Spry 30 day system from Xlear. I’ve also personally been really impressed with Xyloburst’s selection of products; especially the suckers for kids!
Exposures: One barrier for hygienists is that the patients have to get five exposures throughout the day. This sounds like a lot but think of the concept of simply replacing out their existing gum/candy habit. A lot of already snack and chew gum so simply swap it out with the products they are using. I tell my patients to “Strive For Five”!
Expense: The beauty of having xylitol in your office is that you can lower the price a little bit. Xylitol is definitely more expensive than gum with sorbitol and other sugars but it’s a LOT cheaper than a cavity and precious tooth structure. I always let my patients decide and most are willing and grateful to try something “new.”
It will take some work but you too can create an anti-cavity protocol for your office that will benefit your patients long term.
Mixing and Pouring Dental Stone
Our latest video shows how to mix and pour stone for the perfect dental model.
Do you take impressions or pour up models at your office?
Medical History Update Tip
The first thing we always ask our patients when they sit in our chair is "Have you had any changes in your medical history?" Of course, they quickly answer no. Nothing is more stressful than half way through treatment, the patient casually mentions they had a heart attack a month ago or started taking a blood thinning medication a week ago.
Instead of asking if they've had changes, start off by asking your patient if they have been to the hospital since the last time they were at your office. Patients forget a doctor's visit or a change in medication, but they don't forget being in the hospital. If they haven't been to the hospital, they are now thinking on medical terms and will remember their slight changes in health with your follow up questions. Asking if they've been to the hospital will also give you an idea of how controlled their health is. If you know they have diabetes and they report they were admitted to the hospital for a day, you know the are not in control. If they have high blood pressure but their numbers were within the normal ranges for that day but they were hospitalized in the last few months, they probably are not well regulated. Knowing if they have been to the hospital will give you a better understanding of their overall health.
How do YOU update medical histories in your office?
