Dental Practice Solutions

Optimize your dental hygiene department by taking an integrated, team approach

  • Do you feel like you are working hard and your production is not increasing?
  • Do you feel like your hygiene department is under performing?
  • Is your hygiene department producing 25-30% of your total production?
  • Are hygienists in your office treating bloody prophys?
  • Does your hygiene department help enroll implant cases and high-end treatment?
  • Do you have one or more holes in your schedule daily?

I am so happy that you are here because we have answers and solutions to your challenges.

Dental Practice Solutions - Debbie Bittke

What is a Dental Hygienist to Do with The New AAP Classifications?!

By: Debbie Seidel-Bittke, RDH, BS

January 30, 2020

The American Academy of Periodontology has not updated their guidelines for categorizing periodontitis since 1999.

This should be a big deal; right?!

Most clinicians: dentists, dental hygienists and even periodontists tell me they are confused with the new staging and grading for categorizing periodontitis.

What is a dental hygienist to do with the new AAP classifications?

Are you using the new AAP classifications?

Most clinicians I speak to are not using the new classifications.

We are currently working with our client hygienists to embrace this. We show them how to laminate the forms and refer to these when making patient clinical notes.

Let me shed some light on the topic here.

If the AAP has not re-classified periodontitis since 1999, there is a good chance it will be at least ten or twenty years before we have new guidelines.

Let’s embrace the “change!”

The American Academy of Periodontology Classifications are created to help dental hygienists diagnose and treat periodontitis.  Follow these guidelines so consistent diagnosis can occur.

The first step is to assess your hygiene patients and of course, every new dental patient must have a comprehensive periodontal exam.

Steps to Use the American Academy of Periodontology Staging and Grading

Step 1: Assessment

  • Up-to-date full mouth radiographs
  • Up-to-date comprehensive periodontal exam (CPE)
  • Chart missing teeth

Step 2: Establish the Stage

As you know cancer is categorized by stages. Think stages of cancer only this is oral inflammation causing destruction of the supporting bone that results in tooth loss.

When you are assessing the stage of periodontitis, explain to your patient and show them what you “see.” Refer to the mouth/body connection as you explain inflammation in your patients mouth.

Now is your opportunity to speak with your patient about the connection between inflammation in your patients mouth and inflammation in the body.

Inflammation in the body year after year contributes to other inflammatory disease such as (and not limited to) heart attack, stroke, rheumatoid arthritis, Crones, Alzheimer’s, diabetes, etc.

  • Confirm clinical attachment loss (CAL)
  • Rule-out non-periodontitis causes of CAL (cervical restorations, caries of root fractures)
  • Determine CAL or radiographic bone loss (RBL)
  • Confirm RBL patterns (Ex: Vertical or horizontal RBL)

For moderate to severe periodontitis (think Stage III or Stage IV):

  • Determine CAL or RBL
  • Confirm RBL patterns
  • Assess tooth loss due to periodontitis
  • Evaluate complexity factors (Ex: severe CAL frequency, surgical challenges)

Based on your findings from step 2, determination of mild-moderate periodontitis can be made, and this is considered Stage I or Stage II. Severe or very severe periodontitis is considered Stage III or Stage IV.

Step 3: Establish the Grade

What I like best about this new system to categorize periodontitis is we now bring into the picture: inflammatory diseases, systemic considerations and outcomes of non-surgical periodontal therapy.

What’s a Dental Hygienist to Do with the New Classifications?

So glad you asked!

  1. Your first step is to print out this article including the staging and grading charts.
  2. Take the staging and grading charts, add them to a plastic sleeve or laminate them. Keep these in your operatory.
  3. When you evaluate your patients, refer to your staging chart.
    1. In your clinical notes write, “Stage I, II, III or IV”.
    2. Write as indicated
  4. When a patient has 15%-30% RBL definitely consider writing clinical notes a category for the stage and refer to your Grading chart printed and on the flip side of your staging chart.
  5. If a patient has <15% CAL but smokes 10 or more cigarettes, you will write in your clinical notes: Stage I, < 15% localized horizontal BL (Ex: @ #19 & 30), Grade C (Pt smokes 10+ cigarettes daily).
    1. That is all. If you have a positive outlook on this, it won’t be difficult to write these chart notes
    2. If you have templates add staging, horizontal, vertical < or >, etc.
    3. Now using your template mark or indicate the correct description
    4. Use the staging and grading charts to add these notes in your practice management templates
  6. For patients who have diabetes and/or a tobacco user with RBL you will grade them B or C and this is your time to talk about their “potential” for tooth loss if things do not improve.


Many clinicians I meet are fearful about scaring patients ‘if” and “when” they do tell patients “the facts.”

Imagine this, if you have a colonoscopy or mammogram and the doctor finds a suspicious lesion, will the doctor not tell their patient about this for fear of the patient never returning?

Does a physician feel concerned that their patient’s insurance may not pay for removal of an abnormality?

I have never heard of a physician not telling a patient they have an abnormality because of the above mentioned.

Why do us dental professionals fear telling patients what is truly happening in their mouth?

We have a legal and ethical responsibility to tell our patients what we “see” happening in their mouth and body.

In 2020, dental hygienists are doing more than cleaning teeth.

Dental professionals are in the business of helping people live a longer and healthier life.

Will you join me and help conquer the disease process?

This…….is our JOB!


Debbie Seidel-Bittke, RDH, BS

 is founder and CEO of Dental Practice Solutions. Debbie is also a former dental hygiene program director. Her expertise is optimizing the hygiene department by taking a total team approach; including the doctor as the leader.

Check out this FREE RESOURCE to treat the gingivitis patient which also includes a new patient appointment sequence of treatment here.

Dental Hygienist’s Patient Scheduled for a Prophy but NOT a Prophy!

By: Debbie Seidel-Bittke, RDH, BS

December 30, 2019

I want to talk about the elephant in the room. Let’s take for example Ronda who is a twenty-year patient of Dr. Curry. Susan is her hygienist of ten years, but Ronda is out sick today. On this particular day the dental hygienists’ patient is schedule for a Prophy but Ronda, the patient, is NOT a Prophy!

To set the stage for the first challenge, Sally is the temp hygienist.

Sally is an amazing clinician. She is good with patient’s; knows how to build rapport and she definitely has excellent clinical skills.

Sally completes all the necessary clinical exams and discovers that Ronda is more than a prophy patient.

The next thing Sally does is talk to Ronda about the change in her oral condition and explains she needs more than a “cleaning” at today’s dental hygiene appointment.

Sally begins treating Ronda for gingivitis and Dr. Curry enters to complete the hygiene patient exam and everything seems fine with Rona.

Everything seemed fine until Ronda got to the front desk and was asked to make a 2nd hygiene appointment in two weeks PLUS, Ronda was told that only one of these two hygiene appointment would be covered by her insurance.

WOW! Now we have a problem!

Ronda complained about all this to the lady at the front desk!

Ronda was NOT happy! She says, “No one ever told me I have gum problems until today!”

I do NOT like this hygienist I just saw!”

Ronda continues, “That hygienist does not know what she is doing!”

Oh my!

The lady at the front desk is rather new and she did not know what to say.

Ronda left without a next appointment.


How can this situation which turned sour become like lemonade at your next party?

Well, a dental hygiene appointment (to most) doesn’t feel like a party but how can we overcome this overwhelm and confusion.

Let me outline a few steps that can make a positive change:

  1. When possible, for the long-term patients of your hygienist, let the know you have a temp hygienist
    1. This may take out some of the shock of a different hygienist
  2. Always explain what your patient is there for
    1. Ex: Routine preventive care, x-rays, “abnormality exams (oral cancer and “gum exam”., Comprehensive perio exam), doctor exam, etc.
  3. Before you complete the Comprehensive Periodontal Exam (CPE. To the patient it is called “Gum exam), let your patient know you will check the health of their gums with a ruler. Explain what the numbers mean. Ex: 1 through 3 is healthy. If you hear a 4, that means there is inflammation and if you hear a 5 or higher, that most likely means you have infection and active gum disease.
  4. Ask your patient to listen for the numbers because at the end of your exam you will ask them, “What was the highest and what was the lowest number you heard me call out?”
    1. The purpose of having your patient listen is because when they do hear a number that is more than 3, they will TELL YOU. Rarely, does the hygienist need to ask the patient, “What was the highest number your heard and what was the lowest number you heard?”
    2. I can almost guarantee you that when your patient hears a 4 or 5, they WILL be letting their hygienist know, “that did not sound good!”
    3. If your patient hears you call out “Bleeding on Tooth #3, etc.,” your patient will also be very likely to let you know,
      that did not sound good!”
  5. Whenever you see something that is abnormal, always take this opportunity to “show” your patient.
    1. Use the intra-oral camera
    2. Take pictures of heavy supra build-up on lower lingual of lower anterior, take pictures of BOP and holes, discolored teeth in your patients mouth. When you see areas of papillary and marginal inflammation, take a picture of the area with your intra-oral camera. Use the intra-oral camera for stains on their teeth and old composite stains and discoloration.
  6. When showing your patient, the intra-oral pictures, ask your patients to tell you what “they see.”
    1. Interestingly, many patients will not be able to tell you they see anything out of the ordinary so at this point in the conversation, you will want to compare health to the disease in their mouth.
    1. Be sure to show them the heavy supra calculus especially if they don’t recognize anything abnormal on the picture you will show them.
  7. Be sure you sit your patient up-right in the chair as you discuss what you “see.”
  8. Explain what you see, using words your patient will understand and yet, use words that add value to the hygiene service.
    1. For ex: Deep cleaning is not going to be value enough to return and pay more money.
    2. Use words like Gingivitis, gum disease, inflammation, infection, bleeding, disease.
  9. Explain the change in today’s appointment after your initial exam of abnormalities.
  10. Explain what future appointments are necessary to treat the abnormality today and what is necessary to prevent disease in the future.
  11. Always follow the system and process of each dental practice.
    1. Many offices find it valuable to quote a fee to the patient when there is a change in the service.
      1. Be aware that it is not “best-practice” to have a patient lying or sitting in a dental chair and then give financial estimates.
      2. Patients should always be in a place that feels “Safe” and “confidential” when discussing private matters such as “finances, etc.”
  12. What do you do when a patient is angry like Ronda became?
    1. This is where a written office- hygiene department system is super important!
    2. When you have a new hygienist and especially when you have a temp hygienist, you should have a guide, a blueprint written for when you treat a prophy and when it is not a prophy.
      1. When does a prophy patient receive treatment for gingivitis?
      2. When does a gingivitis patient return for their next hygiene appointment?
      3. When does a prophy patient become a perio patient?
      4. What happens after scaling and root planing is completed? When does that patient return for a hygiene appointment?
      5. The list of processes for the hygiene appointment is long. It must be written out so everyone on your team knows what is expected……and especially when you have a new or temp hygienist.


Not every dental office has a system where the doctor will complete a hygiene-patient exam in the hygiene room.

It is very helpful to have doctor and hygienist together for the hygiene patient exam. This provides effective communication, and nothing should be missed.

When doctor and hygienist complete the patient exam together, the hygienist can bring doctor into the loop on what has transpired during the hygiene appointment, up-to-this point.

In the situation with Ronda being new to Sally the hygienist, Dr. Curry can also build up Ronda’s confidence about the temp hygienist and let her know how great Ronda is even though she is the temp hygienist today.

At the end of the doctor exam, instead of asking the patient, “Do you have any questions,” change this question and ask, “What questions do you have for me today?”

This is an open-ended question and gets the patient thinking.

When asked a yes or no type of question, patient will usually tell the doctor,
“No, I don’t have any questions.”

But as you can see in this situation, Ronda had a lot of questions. She never felt comfortable asking.

I could provide a one-two hour course on this topic.

It’s a hot topic in today’s world of dental hygiene. It’s a big-reason, dentists have been calling our office for support.

Dentists and dental hygienists want to know, what to say to a patient who has always been a prophy but is now “more than a prophy patient.”

I recently wrote a course called, “What’s Blood Got to Do With it?” and I highly recommend you enroll because I will review in two video training modules how to handle patients who are more than a prophy patient.

In this training you will have numerous resources to support reimbursement and so much more. This is not only for the knowledge of the dental hygienist but will support the front office with patients who will pay for more than a prophy appointment.

Also remember, we are here to provide optimal oral health for our patients. It is not the standard-of-care to treat a patient with a specific service because you know a specific service is what their insurance will or will not pay for.

When you are able to help patients “own” their disease, they will be most likely to schedule and pay for treatment.

These patients will continue to return for their appointments at your office.

These are your patients who will tell their friends and family about your dental office!


Debbie Seidel-Bittke, RDH, BS is founder and CEO of Dental Practice Solutions. Debbie is also a former dental hygiene program director. Her expertise is optimizing the hygiene department by taking a total team approach; including the doctor as the leader.

Checkout our latest training about treating the gingivitis patient. Each paid registration will receive 2 CE Credits once the complete the course.