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  11.12.04 Issue #140

Patient Dismissal – Whose Job is It Anyway?

Sally Mckenzie, CEO
McKenzie Management

       “Mrs. Jones, did doctor happen to mention what he was charging you for today’s procedure?” Yes, you read that line correctly. The employee is asking the patient how much she should be charged. Believe me; I’ve seen this scenario play out more often than you care to know. The front desk employee is trying to dismiss a patient, but the employee does not know what the charge is for the visit, nor does she know exactly what procedures have been performed, and it’s likely she doesn’t know if the patient is to be scheduled to return.

But before you start rattling off a string of negative comments about the incompetence of the front desk employee think about the check out procedures in your office. Do you make certain that you and your assistant complete all of the necessary paperwork on a patient before you send them to the front desk? Do you have a clear standard operating procedure for patient dismissal in your practice?

Too often Ms. Front Desk is twisting in the wind. She waits, watches, and hopes that the chart is going to come sprinting to the front. It isn’t. Once the chit-chat time is exhausted, Ms. Front desk makes a final attempt to actually take care of the patient. She politely excuses herself and goes ripping through the office in search of necessary documentation to actually do the job you’ve hired her for.

How should patients be dismissed in your office? Read on.
Near the end of the procedure when the doctor is finishing the restoration, checking the contacts with dental floss, and checking the occlusion with articulation paper, the dental assistant should rise from her chair and remove her gloves and log today’s procedures in the patient record. (Logging into a computer terminal instead of a paper record would be ideal.)The assistant confers with the doctor to ensure that she is documenting the correct information. For example, “Doctor, was that an MO on #30 that we did for Mrs. Jones today?” The assistant also asks if Mrs. Jones needs to come back, reiterating the next step on the patient’s treatment plan.

The doctor confirms or corrects the statement and dictates to the assistant any other information that he/she would like documented in the progress notes. In some states, the dentist is legally required to sign off on the entry. Other states only require that the assistant initial the entry. The doctor also indicates the next step in the treatment plan. “We’ll need to see Mrs. Jones again for 3 units on #14.” The doctor will then explain to Mrs. Jones that at her next appointment they will be treating the tooth on the upper left side.

The patient record and charge slip are complete. At that point the assistant leaves the operatory and seats the next patient in the next chair. The dentist finishes up with the patient, says goodbye, then moves on to the next treatment room to administer the anesthesia. Oftentimes when patients beat their charts to the front desk it is because the dentist has given the patient the signal to flee. He/she removes the bib and adjusts the chair – the universal signals that this appointment is over and the patient can leave. When the dentist finishes he/should thank the patient, leave the bib on and explain that the assistant will be right back to dismiss them.

The assistant returns, provides necessary post-op instructions, explains what the doctor did, raves about the quality of the doctor’s care. She then removes the bib from the patient and uprights the dental chair. With patient chart and necessary paperwork in hand, the assistant escorts the patient to the front desk. Her attention remains focused on the patient. The assistant hands the records to the front desk and thanks the patient.

This simple procedure ensures that the focus is always on the patient, and no longer will the front desk staff have to walk away from their jobs to finish yours.

If you have any questions or comments, please email Sally McKenzie at

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Can Gingivitis Contribute To Systemic Disease?

A Review of the Literature

Dr. Allan Monack
Hygiene Clinical Director
McKenzie Management

Physicians and dentists have become increasingly aware of the link between gingival inflammation and increase risk to cardiovascular disease, stroke, and low birth weight. There is growing evidence that other health problems are influenced by periodontal disease. What are the pathways that influence the systemic disease process? The July supplement issue Vol. 25 of the “Compendium of Continuing Education in Dentistry” lists four potential pathways:

bacteremia, systemic dissemination of locally produced inflammatory mediators, provocation of an autoimmune response, and aspiration or ingestion of oral contents into the gut or airway.

Pulmomary Disease
It is possible that oral biofilms serve as a reservoir for respiratory pathogenic bacteria. (1) It has been shown that lung function is reduced by periodontal disease. Patients with more attachment loss tended to demonstrate less lung function than patients with less attachment loss.(2)

Adverse Pregnancy Outcomes
There is evidence that gingival inflammation influences the birth process. It is believed that chronic infections stimulate the inflammatory process. This causes inappropriate levels of prostoglandins and TNF-a, which can cause uterine contractions and promote preterm birth. Recently, periodontal pathogens, such as Fusobacterium nucleatum, originating in the gingival sulcus have been found in the placenta. (3) It is possible that these bacteria enter the bloodstream thru the periodontium to directly effect premature birth.

Cardiovascular Disease
Periodontal diseases are associated with an increase in C-reactive protein (CRP) levels. CRP has been shown to be a more predictive marker for acute coronary events than are low-density lipoprotein (LDL) levels. (4) Periodontal pathogens such as P gingivalis have fimbriae that allow it to attach to host epithelial and endothelial cells. (5) and produces proteases that degrade collagen. (6) These and other pathogens may contribute to the development of artherosclerotic lesions when they enter the bloodstream thru the diseased periodontal pocket. Mattila et al (7) examined patients with acute myocardial infarction. Their study showed that poor oral health correlated directly with coronary heart disease (CHD). A National Health and Nutrition Examination of nearly 10,000 individuals indicated a 25% increased risk of CHD. (8)

The periodontal inflammatory process has been shown to release cytokines. These in turn are linked to the formation of polymorphonuclear (PMN) leukocytes. PMN can cause oxidation of LDL, which stimulates production of fibroblast growth factor, which is linked to the formation of a bulge of the luminal wall of the cardiovascular arteries. (9)

The increase in CRP also contributes to vascular damage in the brain, leading to strokes. This direct result to the inflammatory process causes blood vessels to dilate and become more permeable. The result is increased blood flow and plasma leakage into the surrounding tissues. (10)

It is imperative that dentists communicate the seriousness of periodontal disease. It has been demonstrated that inflammation caused by periodontal disease affects the systemic health of your patients. Monitor and treat early signs of periodontal disease and you can help REDUCE THE RISK of life threatening disease for your patients.

1.Scannapieco FA, Periodontal Inflammation: From Gingivitis to Systemic Disease? Compendium Vol. 25 No.7.16-25
2.Scannapieco FA, Ho AW. Potential associations between chronic respiratory disease and periodontal disease. J perio 2001:72:50-56
3.Han YW, Redline RW, Li m, et al. Fusobacterium nucleatum induces premature and term stillbirth in pregnant mice: Infect. Human. 2004:72:2272-2279
4. Glurich I, Grossi S, Albini B, et al. Systemic inflammation in cardiovascular and periodontal disease. Cin. Diagn.Lab Immunol. 2002:9:425-432
5.Dan BR, Burks JN, Seifert KN, et al. Invasion of endothelial and epithelial cells by strains of Porphyromonas gingivalis. FEMS Microbiol Lett. 2000;187:139-144
6.Holt SC, Kesavalu L, Wailer S, et al. Virulence factors of Polhyromonas gingivalis. Periodontol. 2000. 1999:20:168-238
7.Mattila KJ, Nieman MS, Valtonen VV, et al. Association between dental health and acute myocardial infarction. BMJ. 1989:298:779-781
8. DeStefano F, Anda RF, Kahn HS, et al. dental disease and the risk of coronary heart disease and mortality. BMJ. 1993:306:688-691
9.Anayeva NM, Tjurmin AV, Berliner JA, et al. Oxidized LDL mediates the release of fibroblast growth factor-1. Arterioscler Thumb Vasc Biol. 1997:17:445-451
10.Sbordone L, Bortolaia C. Oral microbial biofilms and plaque-related diseases: microbial communities and their role in the shift from oral health to disease. Clin. Oral Investig. 2003:7:181-188

If you have any questions concerning your hygiene program submit them to me at and I will answer them in future articles.

Interested in having Dr. Allan Monack speak to your dental society or study club? Click here


Are You Scheduling…By ACCIDENT?

““It is not enough to be busy, so are the ants. The question is, what are we busy about?”
Henry David Thoreau

Belle M. DuCharme
RDA, CDPMA, Director
The Center for
Dental Career Development

          At The Center for Dental Career Development, I teach a course that enhances the skills of Scheduling Coordinators. I feel, after my 35 years in dental offices and my experience with doctors and staff at The Center, that formal business training for a Scheduling Coordinator is a must. The job description of a scheduling coordinator includes duties of a receptionist, but by no means is the person responsible for “making your day” just a “receptionist”.

In smaller practices that see less than twenty patients a day, the Scheduling Coordinator is

also… the Financial Coordinator. Not only does she have to create the day she must see that you get paid for that day. In either situation, your Scheduling Coordinator needs to understand the “background and figures” that determine how the schedule should be created.

Let’s compare two women from two different practices a thousand miles apart. Jane was hired a month ago as a Scheduling Coordinator. Her office had McKenzie Management’s consultant in last year to analyze the office systems and give recommendations for improvement. All systems were in place and the office was running smoothly and profitably. Jane had a written job description and a clear idea as to what she expected from our training session. The office was seeing an average of thirty three new patients a month and the office was meeting or exceeding production and collection goals each day. How do I know? She brought the reports with her. I was able to train her more effectively knowing the production per hour goal. Why is that important for a Scheduling Coordinator to know? The business side of dentistry has overhead to meet monthly and without an actual number to work with, scheduling is by chance. The stress of a $500 day and the stress of a $5,000 day can cause a practice to be “manic depressive” as you ride the roller coaster of chance.

Martha came in for the Scheduling Coordinator course with an unclear job description. Her office did not have McKenzie Management in for consulting services. She had a title of Business Administrator on her business card, yet a written job description listed her as Manager of Production. She was instructed by her employer to speak to other employees about behavior issues only to be told, “You are not my boss.” This issue was distracting her from her main position of Scheduling Coordinator.

Looking over the reports, I noted that the new patient average for the year was only six patients a month. The schedule for the doctor was routinely booked out eight weeks or more with no open time reserved for new patients. They had recently decided to stop pre-booking hygiene appointments due to the frequency of cancellations and failed appointments yet they were unable to appoint new patients because the doctor was booked solidly for eight weeks or more. New patients were seen on a cancellation base only. This is very poor customer service and is the reason they could see only six new patients a month. I asked Martha what the production per hour goal was for her office. She replied, “ I don’t know, Dr. L asked me to pick a figure that sounded good.” After showing her the overhead figures and how to calculate production per hour based on fees and the amount of time doctor needs per procedure, she became enlightened and had a new found sense of ownership of what she was doing for the practice. She left here far more confident than when she arrived.

If you would like more information on how your systems, and the performance of your employees can reach peak levels. Call us at 1-877-777-6151.

Belle M. DuCharme, RDA, CDPMA

Exceptional Front Office Employees?
The Center for Dental Career Development can provide your team with “customized” expert training to improve the performance of your practice ...Go Here Now...

I look forward to each new day with my team, and what we will accomplish today that will create the tomorrow that I want. I am happy because I feel in control again. I am happy because I understand my and my team’s role. I am happiest to have my feelings of fear, for the future of my practice, diminishing daily and being replaced by confidence.

I am looking forward to having my finger on the pulse of my practice again. Thank you McKenzie Management.


Dental Insurance Coding Handbook
4th Edition

By Carol Tekavec

This manual is an office essential!

Much more than just codes and definitions, this manual helps you speed up insurance reimbursement, reduce requests for "more information" and decrease payment delays! Additionally, under the provisions set by the HIPAA Act, all dental offices and insurance carriers that transmit health information electronically must use the current version of dental procedure codes found in this Handbook. Also, you will receive information on treatment estimates and how to talk to patients about insurance.

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Sally's Mail Bag

Dear Sally,
What is the best approach to take with patients who need to come in for recall but they owe us money?
Dr. Florida

Dear Dr.,
First of all, don’t avoid contacting the patient. Confront the patient but have as much information about the patient’s payment as possible. For example, let’s take a patient who has dental insurance and their coverage will pay 100%. State the facts to the patient, i.e., you have a balance, you’ve been paying your commitment, we appreciate it, you’re due for this service, your insurance should pay 100% so you shouldn’t be incurring any additional charges to your account, let’s schedule an appointment.

Now let’s approach the situation where the patient will be responsible for paying and there is an existing balance.
“Mrs. Richmond? Hi, this is Carol from Dr. Thompson’s office. I wanted to let you know you’re due for your periodic oral health exam and professional teeth cleaning. Because you have an existing balance of $320, we will expect you to pay for the service when you come in, which would be $125 or would you rather we keep checking your account status and notify you once your account has been paid in full?”
This shows consideration on the part of the office rather than being inconsiderate by not addressing the patient’s financial concern.

Hope this answers your question.


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La Jolla, CA 92037

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This issue is sponsored
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Date Location Sponsor Speaker
Nov. 19-20 Griffin, GA Endo Magic Root Camp Sally McKenzie
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