Episode #574: Encouraging Dental Hygienists to Diagnose Periodontal Disease, with Miranda Beeson

Hygienists are more than mouth janitors. They have the power to improve and potentially save your patients’ lives. So, why is your perio percentage still at zero? To help you improve that number, Kirk Behrendt brings back Miranda Beeson, one of ACT’s amazing coaches, to share five strategies that will empower and elevate your hygienists to diagnose more perio in your practice. Half the population has this disease! Let's give patients the optimal care they deserve. To learn how, listen to Episode 574 of The Best Practices Show! 

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Links Mentioned in This Episode:

Best Practices Show Episode 573 with Jaime Taets: https://www.youtube.com/watch?v=3W-sAG9LtXg

Other Best Practices Show episodes with Miranda: https://www.youtube.com/@actdental/search?query=miranda%20beeson%20

Best Practices Show episodes with Robyn Theisen: https://www.youtube.com/@actdental/search?query=robyn%20theisen

Pearl: https://www.hellopearl.com

5 Strategies to Encourage Dental Hygienists to Diagnose Periodontal Disease: https://www.dropbox.com/s/0jm5gywzaquobuu/5%20Strategies%20to%20Encourage%20Dental%20Hygienists%20to%20Diagnose%20Periodontal%20Disease.pdf?dl=0

Beat the Heart Attack Gene by Dr. Bradley Bale and Amy Doneen: https://bookshop.org/p/books/beat-the-heart-attack-gene-the-revolutionary-plan-to-prevent-heart-disease-stroke-and-diabetes-bradley-bale/16685772

Books by Patrick Lencioni: https://www.tablegroup.com/books

Main Takeaways:

Establish what periodontal health looks like in your practice.

Provide hygienists opportunities for education and training.

Foster a culture of collaboration and communication.

Implement a periodontal disease screening program.

Use all the technology you can to your advantage. 

Quotes:

“We all know how prevalent periodontal disease is and how impactful periodontal disease is on overall health and systemic health. And if we’re not navigating our patients through that process and helping them to understand what the risks are, if they have the disease how can we manage it, are we truly helping them to the fullest potential?” (2:42—3:01)

“When we look at the prevalence of periodontal disease in our culture, we know that over half of the population, depending on the data around people’s age, has some form of periodontal disease. And as patients get older, 65 and up, we know that goes up into the 60s, and based on some research, even to the 70th percentile of people who have periodontal disease. And with the correlation we know now to so many systemic health risks — heart disease, diabetes, Alzheimer’s, and I think prostate cancer is in the mix now. There are so many things — patients are starting to become aware of that too. And so, it’s our responsibility to make sure that we’re doing everything that we can to support our hygienists to make sure that they're comfortable and confident in helping patients navigate that disease process.” (3:02—3:46)

“If you're not diagnosing and treating periodontal disease in your practice consistently, hundreds of thousands of dollars a year are walking out the door. And periodontal treatment itself, as well as building value, when people start to get more inquisitive about their health and their oral health and they start to look for more answers and, ‘How can I be healthier and better?’ that feeds into restorative as well. So, we’re leaving money on the table, for sure. So, from a business and profitability standpoint, if we’re not doing this, the profitability isn't where it could be, significantly. But then, on the other side of that is, we’re decreasing more and more risk for patients. And so, that's where we have to balance. Because as business owners, if you tell me I'm going to be hundreds of thousands of dollars more profitable — hygienists, you'd better get out there and start diagnosing perio. But the hygienists, they're not receiving that same impact that you are as a practice owner. Where it’s really going to impact the hygienist is knowing the impact that you're having on your patients, who a lot of these hygienists consider friends after years and years of taking care of them.” (5:05—6:10)

“When I first graduated, I graduated top of my hygiene class. I was so excited to go out into the world, and be this hygienist, and share all the knowledge that I had. And on day one, I remember having a patient, and I remember thinking, ‘Wow, this is more than I can do in one visit.’ Like, ‘This is perio. I'm pretty sure this is perio, but I don't know what to do here.’ And I remember the dentist who was so sweet. He took me in the hallway, and he was like, ‘So, are you finished with this patient?’ after the exam. And I'm like, ‘I don't think I am.’ He’s like, ‘I don't think you are either. There's a lot more going on here.’ And so, some of [the hesitancy] is a lack of knowledge, a lack of awareness of, how do we navigate treatment planning, diagnosing, talking about this with our patients? And then, there's also a lack of confidence. So, it stems from confidence and knowledge.” (6:33—7:21) 

“For those hygienists that are a bit more seasoned, it can sometimes be a level of complacency. Like, we as a practice have never really made this a priority. We have never really talked about our philosophy around perio in this practice. I'm doing a good job. And a lot of times, they're doing perio and not actually treatment planning perio. They're just working really, really hard . . . They're breaking their bodies, honestly, over delivering care that is more than what they're coding or presenting to their patients. A lot of hygienists are doing perio in a prophy visit when the impact should be focused and deliberate so that also the patient is aware of the disease state and the risks that it has to them in their overall health.” (7:21—8:17) 

“When [my client and I] talked today about creating a hygiene priority and working through some of these ways to encourage them to align, I said, ‘Do you feel like this is going to be valuable to you?’ And [one of the hygienists] said, ‘Yes. Even just having time for all of us to sit and talk about hygiene. Like, we do hygiene all day, but we don't ever talk to each other about what you do, or what I do, or what works well for you.’ So, the time dedicated to having that alignment time, she was like, ‘That in itself is so valuable.’” (9:24—9:57) 

“You said something last week when we were at our To The Top study club about alignment, ‘Alignment and agreement are not always the same thing,’ which I thought was so cool to say out loud. You can align with someone even if you don't fully agree. It’s a compromise that you're making so that you're all on the same page. You don't have to be in full agreement to be aligned. I thought that was really cool.” (10:31—10:54) 

“The first [strategy] is providing opportunity for education and training. So, like we just talked about, a lot of times, the hesitancy isn't because they don't want to do a good job, or they don't believe in perio, or maybe they [don't] recognize they're seeing perio. They just aren't exactly confident or have the knowledge to really move forward with diagnosing and treatment planning. So, creating that awareness and knowledge through providing opportunities. So, bringing in continuing education into the office, doing things as a team, internally, or seeking out and encouraging your team members to look externally for opportunities to learn about periodontal disease and where it’s going currently in our research.” (12:04—12:47) 

“Having the opportunities there for the team to grow and learn together, it’s team building, and it’s alignment driven, and it’s going to help for them to have the knowledge and the confidence that they need to feel comfortable bringing that up with patients, and being able to answer the patients’ questions when they ask them.” (12:57—13:15)

“There are experts that are out there like Katrina Sanders who are going internationally to learn this information. You can't do that as a practicing hygienist working four or five days a week, chairside. You can't go to all of the best symposiums throughout the country, internationally, to learn all of these new processes. But you can find an expert or a couple of experts or mentors who are doing that and learn from them. They are teaching you through their learning. The whole community needs to come together to start to see that we can impact, starting very small, and go as big as we want to go. But it’s how much time do you have. And sometimes, the teams don't have that time. That's why it can be helpful to carve time out, where you're bringing someone into the office, or playing some webinars in the office together as a team.” (14:14—15:04) 

“There are so many books in the world that we can learn from. There are so many people with a plethora of information. They're out there. We have to seek them out and then carve that time intentionally to make sure that every year, we’re not just going online and getting our 15 free CEs, clicking through the videos as fast as possible and just answering the quiz because we already know this information. Seek out new information that might take you into a more mindful growth place in your career.” (15:06—15:36) 

“The other thing is, if this is something that's important to you and to your practice, then have clear expectations from the beginning, when you're bringing people on board, that we have an expectation of you to want to be a lifelong learner. We have an expectation that you as a hygienist in this practice are going to stay up to date on the changes in the profession, and that you're going to build those into your practice with our patients.” (16:34—16:57) 

“If it’s just one hygienist, doctor, go with your hygienist. Get aligned with your hygienist. You're both diagnosing periodontal disease in your practice. And if your hygienist goes and learns how to do staging and grading and starts building it into the practice, and you're not talking about that when you're diagnosing perio, now you're not aligned. So, if you're in a solo hygiene practice, you don't have to do this alone. You can partner with the doctor when you're learning this new information about periodontal disease.” (17:51—18:16)

“[Strategy] number two is, implement a periodontal disease screening program. Have it be consistent across everyone in the hygiene department. So, you can use your practice management software. Most practice management software, if not all, have a component that's a periodontal screening form or periodontal evaluation component. And so, using that to its fullest potential and making sure that all of the hygienists know how to use it, how to share that information with their patients, and that you have a standard of care frequency documented for how often we’re doing this and sharing it with our patients so that you're all in alignment.”  (18:37—19:18) 

“We know, as a profession, that there are standards around — we do need radiographs so that we can see things. But it doesn't really say how often you need radiographs. Most offices are leaning towards their insurance frequency limitations to dictate frequencies and things like that. But what we can do as a team is we can decide for ourselves what's best for our patients. And so, when we talk about our standards of care, what's the optimal care package that we’re going to offer for our patients? How often are we going to update radiographs? How often are we going to update periodontal charting and share that? Oral cancer exams, intraoral photos, do we do them? If so, who does them? How often do they do them? And so, that's built in so that anyone that joins the team knows, ‘This is how we optimally take care of our patients here in this practice.’” (20:00—20:49) 

“Soapbox for me as a hygienist. To say that you're doing full periodontal charting every year, some offices, every two years, but all I see is pocket depths. It’s so much more than pocket depths. We know that periodontal disease is involved much more than just that pocket. So, we need to be recording pocket depths. We need to be recording recession so that we can know what our true clinical attachment loss is. Furcation involvement is huge. And how is that developing or changing over time? Bleeding, separation, any risk factors, previously missing teeth. A lot of our practice management software, as the awareness around the robust nature of disease has become more [known], they have updated our systems to allow for us to input a lot of that information. And what I see most practitioners doing is pocket depths, maybe bleeding. But it’s rare that you see all of those things. And if you're charging a D0180, a comprehensive periodontal evaluation, once a year with your patients, to do a comprehensive periodontal evaluation, we need to be looking at all of those factors and documenting all of those factors, not just the pockets. Because the pocket doesn't tell the whole story.” (21:16—22:35) 

“Robyn just did a podcast recently, another one of our amazing coaches, and she was saying a lot of times, patients see their dental hygienist more than they see any other healthcare provider, with consistency. So, what we have as hygienists, as an opportunity to impact our patients’ health, is huge. That's why I sway away from “it’s just a cleaning.” We’re oral health therapists. We’re comprehensive care providers. And so, if we start setting our mindset that we can be so much more to our patients than a mouth janitor, just picking at calculus, we have an opportunity to help them navigate risks that otherwise may have gone unnoticed for years.”  (23:15—23:55)

“Staging and grading is challenging. And whenever I talk about staging and grading in the hygiene world, some people get excited. Most people roll their eyes like, ‘Ugh. Why do they even have to change it?’ And I was like that at first too. So, I get it. Because, ‘It was working fine. That's the way we've always done it, and there haven’t been any issues.’ But what I do love about staging and grading is they build in those risk factors. And I think that's something that was missing from the way that we were evaluating periodontal disease and classifying it before. We’re looking at missing teeth. We’re looking at the rate of progression. We’re looking at smoking, A1C levels, all of those risk factors that really have a strong impact on how quickly this disease could progress for a patient. And that wasn't something that we were building in consistently with the classification system we had before.” (23:56—24:46) 

“In the same way that we talk about core values being the filter for all of the decisions that we make in the practice, I think that your hygiene philosophy needs to be that same beacon that helps us when we’re starting to struggle through, ‘Do I really want to put in the initiative I need to do here? Is this the right decision? If we look back to what we agreed upon as a hygiene department and as a team, is our hygiene philosophy how we want to treat hygiene patients in this practice?’ It’s a good beacon in the same way core values are to make sure that we’re on the right path.” (25:13—25:44) 

“[Strategy] number three is using technology to your advantage, using the technology to enhance your diagnosis. So, radiographs are so important. Those have been around for a really long time, and not much has changed. But I will challenge the hygienists listening to incorporate vertical bitewings into their strategy and into their modality. So, the number of times that I look at horizontal bitewings on a periodontal patient or a recare visit, and how do we know where their bone level is? We can't even see it. So, again, thinking mindfully and not just checking the box of like, ‘If I take a horizontal bitewing on a new patient and I can't see their bone, I might need to flip that vertically and get a different angle to really see what's going on to make a proper diagnosis.’ So, X-rays and photography, intraoral and extraoral photography, is huge. And the more you can show the patient what is happening in their mouth, the less I have to talk to the patient about what's going on in their mouth. Let them see it for themselves.” (26:20—27:25) 

“Co-discovery. If the patient can see it and learn it for themselves alongside you, they're going to ask for the solution. They're going to want to know, ‘What do I need to do about that?’ So, using those visuals can be incredibly helpful.” (27:32—27:47)

“My mind was blown the first time I saw AI in dentistry . . . What AI does in dentistry, a company like Pearl, is you take dental radiographs, and it overlays artificial intelligence over top of that to help us to be able to see, less subjectively, and for our patients to be able to see decay and open margins around crowns. And it actually can measure and show the bone loss around teeth. And so, where before we would pull up X-rays and show our patient, and they'd say, ‘I don't know. It looks like toes to me,’ which happens so much more often than you would think it should, they can now look at it and they can see through color and imagery. And there are line measurements that indicate how much bone loss by the millimeter. And so, it does take some of the pressure off of that hygienist, the clinician, and allows for that software to be a bit more of the hitman in that conversation. It's less me trying to sell you something, sell you this disease and prove to you that you have it, and the patient is able to look at that. And all you have to do is explain, what does this imaging look like, and let them soak it all in, and ask you, ‘Well, how do I fix that?’” (28:52—30:15) 

“I may look and see some shades of bone loss. There’s horizontal bone loss that I may see that you're like, ‘Well, I don't really know if I would consider that bone loss,’ because we look at things subjectively. So, five different hygienists in one office may look at one vertical bitewing and have varying degrees of what they suspect that true bone loss to be. We also know that bone loss can be 30% greater than what we see when we’re looking at the radiograph. And so, if we all have the same tool in our practice and it’s helping to measure that for us through AI, there's a lot less subjectivity amongst providers as well. Heaven forbid, I diagnose perio and a patient doesn't come back to do it, and they end up in someone else’s operatory next time, and that hygienist is like, ‘Well, I don't know. I think we could just see you back in three months and see what happens.’ No, no, no, no, no. If we have those tools and alignment in place, they're going to have the same exact recommendation that I have for that patient.” (31:44—32:47) 

“[Strategy] number four is fostering a culture of collaboration and communication, making sure that we are creating a safe space within our practice for our team members to admit what they don't know and don't have confidence in, and that it is okay, and that we’re going to support each other in making progress and growth together. So, it all starts with trust and making sure that we encourage our hygienists to come together, and make sure that that confidence in diagnosing — it’s okay to admit that we’re not there yet when we’re not there yet. It’s a safe space.” (33:26—34:01) 

“We need to celebrate [vulnerability]. When I have a team that I'm coaching and I have team members that are a little reserved about sharing their voice, I always say, ‘Put your voice into the room.’ And if they're feeling uncomfortable doing that because that's a vulnerable thing to do in a group of people where you feel like, ‘I might be judged,’ I celebrate those people when they do speak up and share like, ‘You know, I don't think I'm there yet. I don't really know what you're talking about. Can you help me with that?’ ‘Yes! Thank you so much for asking for help! I can't help you if I don't know.’ So, if your team feels comfortable and you create a culture where being vulnerable is okay, and they share with you, ‘I want to be better, but I don't know how to get there,’ great. Now, let's create a space where we can collaborate together and get aligned.” (34:15—35:00)

“That's so common, like, ‘How do you expect me to take an hour or two hours a week for me to close down my patient care and lose that production to focus on something like this?’ I think you can't afford not to. The way that you're going to progress and become more profitable over time, to build greater brand recognition for yourself about the way you care for patients, is going to be committing to your team and committing to that time it takes to truly align around things like this. The alternative is you go on forever like you are: really busy, really frustrated, and not making any progress.” (35:36—36:16) 

“When you have these meetings and these things come up over, and over, and over, don't get frustrated by this issue. It just means this is something we need to focus on. Now, we are clear that, yes, this is an issue in our practice. I thought we were on track. I thought our hygienists were good to go with this. But now, I'm seeing that that's not the case. There's now a trend, meeting after meeting, that we don't know where we’re going with this or how to get there. And so, you could hire a coach, and we can help you. But when you have those issues that come up repetitively, that's when an awareness should come about within yourself and your team that this is a topic that we really need to drive some intention around.” (36:33—37:18) 

“[Strategy number five] might be my favorite because it’s so actionable that people can really bite right into it. Establish an agreement in your practice of what periodontal health looks like. If you can start with collaborating together and defining, ‘What does a healthy periodontal patient look like in this practice?’ then that becomes your bar from everything moving forward. So, maybe we've decided that periodontal health means there's no bleeding at all. Or another practice may say less than 30% bleeding that's localized. There's no swelling, there's no inflammation. The patient doesn't have risk factors. Whatever you decide the bar is for health, it should obviously follow suit with what we know through evidence. But there's going to be some level of variation based on your hygiene philosophy of care, because we go back to that as our beacon. But if we can define, ‘In this practice, health looks like this,’ now we know, every patient that passes through my chair that doesn't look like that is something else. It’s some form of periodontal disease. But what is it? And we can go from there.” (38:34—39:47) 

“The easiest place to start is defining health, number five that we just talked about. I think that's something that if you really take the time to calibrate with your team and talk about, it would be interesting for you to learn and see the differences in what people consider health. But it will also be a great eye-opener for your team to start being able to talk about, ‘Oh, I see it all day long now. A lot of my patients aren't truly healthy, and there might be something more going on.’ They're going to be more motivated to want to learn more about, ‘Okay, how do I treat those people that aren't showing up as health in my chair?’ But if you don't have it identified, there's no bar for them to measure that against.” (46:07—46:44)

“To anyone listening, no judgment. If you are at zero percent perio, you're not alone. If you're at three percent perio, you are not alone. A lot of practices, especially practices that seek coaching that we see, start somewhere under ten percent. It’s very common. A lot of them, under five percent. That's why we’re there, to help navigate that. And I'm not going to set a goal for that hygiene team that's 30% at the end of quarter one. It’s going to be disappointing, week after week after week, when they're not able to reach that goal. We need to make small increments. We need to see small change. So, if you start at five and we end at seven, I'm going to feel really good and celebrate with you that you had a two percent increase. That’s that many more patients in your practice that had access to better healthcare than they had a quarter ago, a month ago, however long it takes us to get there.” (47:28—48:24) 

“We say, at ACT, words matter. Language matters. How we communicate is really important. How you're talking about periodontal disease needs to be another thing that you calibrate on. And you need to practice as well.” (49:34—49:47) 

“It’s really important for every member of the team — now, they don't all need to know staging and grading. The business team, the dental assistants, they're not diagnosing. But a patient might come and sit down for a limited exam three weeks after having been recommended periodontal therapy and say to their assistant, ‘They recommended this deep cleaning for me. I don't know if I really need that.’ And that dental assistant needs to have that consistent message about why, and what, and how that's going to be beneficial to the patient. So, setting up some communication anchors within the practice that the business team, the assistant team, the doctors, and the hygienists can all align around will be really helpful in the success of integrating these diagnosis strategies.” (50:06—50:51) 

Snippets:

0:00 Introduction.

1:50 Why this is an important topic.

3:48 Balance profitability and value for patients.

6:10 Why there's hesitancy with diagnosis and treatment.

8:30 Create alignment within your hygiene team.

11:47 Strategy 1) Provide opportunities for education and training.

16:31 Set the expectation to be a lifelong learner.

17:49 Go with your hygienist to their courses.

18:35 Strategy 2) Implement a periodontal disease screening program.

19:19 Standard of care, explained.

22:37 Hygienists can improve and save lives.

26:17 Strategy 3) Use technology to your advantage.

28:29 How to use AI in hygiene.

33:21 Strategy 4) Foster a culture of collaboration and communication.

35:02 Why you need to have team meetings.

36:16 Why you need to hire a coach.

38:28 Strategy 5) Establish what periodontal health looks like.

39:48 Other things to get aligned around.

45:57 Last thoughts.

Miranda Beeson, MS, BSDH Bio:

Miranda Beeson, MS, BSDH, has over 25 years of clinical dental hygiene, front office, practice administration, and speaking experience. She is enthusiastic about communication and loves helping others find the power that words can bring to their patient interactions and practice dynamics. As a Lead Practice Coach, she is driven to create opportunities to find value in experiences and cultivate new approaches.

Miranda graduated from Old Dominion University, and enjoys spending time with her husband, Chuck, and her children, Trent, Mallory, and Cassidy. Family time is the best time, and is often spent on a golf course, a volleyball court, or spending the day boating at the beach.