You Made Your Bed, Now Lie in It
Dental teams often forget that
when it comes to patient retention they make the bed they lie in.
In other words, you may not get what you want, but you will most
assuredly get what you ask for. Let me explain.
A dentist will lament the fact that patient retention is not where
they want or believe it should be. The doctor will pressure the
staff to fill open appointments, but he/she has little or no interest
in listening to what the current and former patients are saying
about the practice. Take the case of “Mary” a business
staff employee who recently contacted McKenzie Management
for the silver bullet phrase that would convince
wayward patients to beat a fast path back to the practice.
Mary deserves a fair amount of credit because she has been following
up with inactive patients for some time. Over the years she has
heard a number of “excuses” as to why patients
don’t return to the practice. The fees are too high,
the hours are inconvenient, insurance doesn’t cover enough,
the office is too far away, and so on. Mary may not realize it but
she has some crucial patient information that the doctor and his/her
staff could use to conduct sweeping patient retention reform in
the practice. That is if they actually choose to do so.
Mary, like many staff members, may be gathering the information
and doing absolutely nothing with it. Shoving it
in a drawer or simply filing it away in her mind. She assumes that
the current office practices – such as hours for appointments,
fees, and insurance payment concerns cannot be addressed. In some
cases, Mary is absolutely right. The doctor is aware of the patient
complaints but doesn’t consider them to be problems for the
practice; rather he/she considers those to be the patients’
problems. “Oh that’s just so-and-so complaining.
You know there isn’t a thing we could do that would make her
happy.” The doctor has no interest in acknowledging the issue
let alone being responsive.
Or the dentist wants to make changes but the staff cringes at the
mere suggestion of doing things differently. Instead, the team engages
in a convenient hand wringing session. They shake
their heads, fault the economy, blame the busyness of people’s
lives, dismiss the complaints as insignificant
and carry on as usual. In other cases dental teams simply dig in
and hide behind their rigid “that’s the way it is”
policies. “We are here from 8 a.m. until 5 p.m. 4 days a week,
and if patients don’t care enough about their teeth to make
an appointment well that is just too bad.” Or, “We have
our standard financial arrangements – cash or credit card
now – and we don’t plan to change those.” Fine.
Then don’t complain when patients fire the practice
on the grounds that it is too inflexible.
When it comes to patient retention, many of you have made your bed.
Next week, maybe it’s time you consider changing the
you have any questions or comments, please email Sally McKenzie
in having Sally speak to your dental society or study club?
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to improve management techniques through your technology platform
VP Professional Relations
Last issue, [see
article], I discussed your automated recall system and how to
establish and document your recall game plan. You might want to
look back at the article and print it for reference by clicking
on the link above. Hopefully, you already have a list of weekly
(even daily) recall tasks identified, understood, and implemented
by someone in your office.
This week I want to keep moving forward with your recall system
and discuss the
and reporting responsibilities of the person assigned to
the recall system. In your office it may be just the one person
at your front desk. Below you will learn “some” of the
reporting mechanisms used to show the overall health of your recall
system. I am purposely just writing “some” of the reporting
mechanisms to make it easy to implement and keep track of on a monthly
Recall System Reporting
Patient flow ratio
The first (in my opinion most important) measurement is your patient
flow ratio. Your patient flow ratio shows the total number
of new patients for the past year (00150) vs. the total number of
patients overdue for recall over the past year. You simply run a
production report for all providers for the past year and total
the number of 00150’s (or whatever code you post to show a
truly new comprehensive exam). Then you run an overdue recall
report for the past year and tally the number of patients
represented on the report. You don’t even have to print the
overdue recall report. Most practice management systems can print
it to the screen. Just count the patients per page and multiply
that number by the number of pages on the report.
Compare your new patients vs. the total number of overdue
patients. Write the numbers down. Finding your patient
flow ratio should take no more than 5 minutes. Therefore, there
is no excuse not to do it!
Total number of hygiene cancellations in the tickler (unscheduled
Print your unscheduled treatment list (or tickler file). Tally the
total number of previously cancelled, missed, or broken hygiene
appointments. This represents the number of patients who responded
to your recall system but didn’t quite make it into the office.
Make a note of the total number. Again, this report should not take
any more than 5 minutes to generate and tally. This too
is very simple.
Most practice management systems have poor tracking of the inactivated
patient. That’s ok, there’s a way around that. I want
you to create a treatment code for “patient inactivated”.
When a patient goes all the way through your recall system and hasn’t
responded within an agreed amount of time, you would go into their
ledger and post your patient inactivated code. Some practice management
systems have an area of the patient record where you can mark a
patient inactive. Do that as well. Posting the “patient inactivated”
code in the ledger will allow you to report on patient inactivation
by date range. This is an important measurement within your recall
Every month, run a production report for your patient inactivation
code. Run a production report for the last whole month and another
report for the last whole year. Make a note of both numbers.
The end result of collecting this data (which should have only taken
10 minutes or so) would be the following. I will use fairly common
data results as an example.
New patients in the past year = 450
Overdue recall patients in the past year = 450
Patient growth = 0 (new patients minus overdue patients)
Cancelled or broken hygiene appointments three months ago = 110
Cancelled or broken hygiene appointments two months ago = 130
Cancelled or broken hygiene appointments last month = 150
Inactivated patients in the past year = 300
Inactivated patients last month = 20
Is this practice really growing?
Is the recall system working?
What area of patient retention needs obvious training and focus?
I welcome any and all readers to email
me with specific questions, problems, requests and challenges.
Who knows? Maybe your inquiry will lead to a new Tips For Today
article! Don’t worry, your inquiry will remain anonymous unless
you want credit for the question.
in having Mark speak to your dental society or study club?
DOES YOUR OVERHEAD
TO INCREASE THE SUCCESS OF SRP
Dr. Allan Monack
Hygiene Clinical Director
year I attended a symposium on “Implementing New Strategies
For Treating Periodontal Disease: A Systematic Approach”.
The focus was on why periodontal disease happens and how it progresses.
The presenters discussed implementation of new protocols to interrupt
the disease process. I have known for the past seven years that
antibiotics and other chemotherapy enhanced the results of scaling
and root planing procedures. The research on the initiation of
periodontal disease has greatly
increased our ability to identify specific microorganisms that are
involved in the active disease process.
the symbiotic relationship of the microorganisms in different environments
gives us the ability to implement new methods to combat their effects.
We now know it is an organized community of bacteria that results
in the destruction of the periodontal attachment. Dr. Sigmund Socransky,
Head of the Department of Periodontics of The Forsyth Institute,
is working to identify the relationship between the microorganism
complex and the host cell response. This subgingival microbial complex
is called a “biofilm”.
Socransky has identified different biofilm communities present in
a periodontal pocket depending on the depth and proximity to the
root surface. For simplicity let us identify the main types as the
tooth proximity biofilm (green/yellow complex), interspacial biofilm
(orange complex), and the epithelial invasive biofilm ( red complex).
His research has shown the more advanced the periodontal disease
is, the greater percentage of red complex is present. It has also
been shown that at greater depths the more anaerobic is the environment.
Research has not identified the mechanism that actually causes the
attachment breakdown or why certain hosts are more resistant to
loss of attachment. It has shown that there is a direct relationship
between the red complex and the disease. The bacteria most associated
with the red complex are Streptococcus intermedius, Streptococcus
micros, Porphyromonas gingivalis, Prevotella intermedia, Bacteroides
forsythus, and Fusobacterium nucleatum. These are both gram-positive
and gram-negative microbes. Dr. Socransky presented two theories
on how the red complex invades shallow pockets and causes deepening
pockets. The first is called the spread theory. The red complex
present in some areas spread to noninfected areas and begin to create
a destructive process with deepening pockets. The second theory
is that red complex is present in the epithelial layers in small
amounts and the inflammatory host response triggers the increase
of the red complex in that site to cause attachment loss. Dr. Socransky
thinks the spread theory seems to be the main occurrence in periodontal
after scaling and root planing there is a dramatic reduction in
red complex. According to Dr. Charles Cobb, who also presented at
the symposium, it doesn’t matter if all the calculus is removed,
if the root surfaces are rough, or if the scaling is done by manual,
sonic, or ultrasonic techniques. The problem is how do we keep the
red complex from returning to destructive levels? If we can remove
all the calculus and have perfectly smooth roots we can prolong
the suppression of the red complex in the pocket. It has been demonstrated
that even the best practitioners can’t achieve those results
in pockets greater than 4 mm. The problem is exacerbated by restricted
access, root proximity, furcations, and restorations. There is a
constant race between healing and the reintroduction of the destructive
biofilm. Papers presented in the “Journal of Periodontology”
have suggested, quoting Dr. Cobb, “The concept of removing
all subgingival calculus and contaminated cementum has been shown
to be unrealistic and quite likely unnecessary”. There have
been many papers on the need to control the supragingival plaque.
It appears that the supragingival plaque is the source for both
the initial infection and reinfection after scaling and root planing.
the Journal of Clinical Periodontics in 2001, Serino, Rosling, Ramberg,
Socransky, and Lindhe reported that treating patients with adjunctive
systemic antibiotics produced significant improvement in attachment
gain and pocket reduction over root planing alone. The researchers
used a combination of amoxicillin and metronidazole. More than half
the patients were stable after three years with quarterly maintenance
and 29% of the patients were stable after five years. Since that
paper there have been research papers that site specific agents
that reduce and suppress the red complex. The objective is to give
the host the time to repair the damage caused by the destructive
biofilm. In shallower pockets of 4mm or less mouth rinses, such
as chlorhexidine, triclosane, essential oils, cetylpryidinium chloride,
and other bacteriostatic agents appear to be effective if used regularly
after scaling and root planing procedures (JADA, JUNE 2003). Enough,
so diligent home care and quarterly office maintenance can be predictable
in maintaining health.
about deeper pockets of 5mm or greater? At those depths, rinses
are not effective and scaling procedures have been shown to be inadequate.
Obviously, surgical reduction of the pocket will establish a maintainable
sulcus with minimal pocket depth and enable the rinses and home
care to be effective. Is there a nonsurgical protocol that will
work in deeper pockets? There are a few agents available that appear
to suppress the red complex and reduce periodontal pockets predictably.
They are the new generation of site specific antibiotics. They are
not detectable systemically when properly used as recommended by
the manufacturers. They are most effective at the initial scaling
and root planing procedure. They seem to reduce the red complex
for up to 21 days after placement. There is minimal host sensitivity
or side effects to the use of these agents. The objective is to
place theses agents where the red complex is in greatest concentrations
which is the base of a 5mm or greater periodontal pocket.
the effective therapeutic effect should be at least 4 weeks. This
gives enough time with proper scheduling to treat all affected quadrants.
This would suppress the red complex and reduce the chance of spread
or reinfection before the therapeutic effect wore off. There is
a systemic product that also suppresses the breakdown of the attachment
apparatus. It needs to be administered over 6-9 months on a daily
dose to maintain its effect.
Once you learn about these products and develop the protocol for
your office that will effectively deliver consistent positive results
for your patients, you will be able to greatly enhance the success
of scaling and root planing procedures. You will be able to maintain
your patients in periodontal health with less relapse. There is
no magic bullet, but we are getting close to allowing our patients
to keep all their teeth for a lifetime.
YOU LIKE TO IMPROVE YOUR HYGIENE DEPARTMENT?
Management’s Hygiene Clinical
Practice Enrichment Program is designed to improve Hygiene
Clinical Skills and develop and implement a step-by-step Interceptive
Periodontal Therapy Program that will immediately bring greater
productivity, with enhanced patient care. For more information...GO
PAST ISSUES OF OUR E-MOTIVATOR NEWSLETTER?
than it is?. . .
. . . but not sure
where to start?
Well, I have a long term and I mean long term hygienist that is
moving across country with her husband. Imagine that? And leaving
me? Anyway, I have an ad in the paper and have gotten some resumes
so feel blessed but…my problem is that I don’t know
what questions to ask them to help me determine if they would be
a good candidate. Can you help me out?
Dear Dr. Kidder,
Here are questions from my How
To Hire The Best Dental Employee book that I think you will
often do you think x-rays should be taken?
do you feel about performing sealants?
do you feel about bleachings?
was your daily average production in your previous/present position?
do you consider to be an average patient load per day?
much experience do you have with scaling and root planing?
do you think should be responsible for the recall system and why?
How do you feel about the use of ultra sonic scalers?
you had a broken appointment, what would you do?
do you feel about the use of antimicrobial therapy?
Do you prefer to be paid an hourly rate, daily rate, salary, or
commission and why?
this helps. Good luck,
US TRAIN YOUR
Center for Dental Career Development
Business Education for Dental Professionals
737 Pearl Street,
La Jolla, CA 92037
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