Season 1 Episode 25: Going Back to Hygiene


In our previous discussions, we’ve seen the role of the front desk or customer service and how they impact our overall dental practice. Today, we’re going to take the limelight and put our hygiene department into the spotlight.

Our guest for this episode is Rachel Wahl. Rachel has over 25 years of solid experience as a hygienist and she’s with us today to share her secrets and tips on how to get your team back to work with you and your practice’s goal

What you will learn in this episode:

  • the measure of longevity for any business is profitability
  • strive for at least three times hygiene compensation for net production
  • your hygienist should A) deliver high-level care and B) help promote your dentistry and help the patients want the dentistry that you’re offering
  • Remember Parkinson’s Law
  • Expand hygiene services so that we’re offering higher level services
  • get creative with the scheduling
  • the relationship is way more important than a little bit of hygiene production
  • We got to spend some time really focusing with our team on why
  • we got to make sure that we’re communicating to our patients really clearly on what is really happening with their health
  • if we want to get a different result we’ve got to take some different action

Listen to the Full Interview:

 In Deciding Your Priorities

The first thing to do is to really be clear with your entire team on your philosophy about what comes first. Give them some really clear guidelines. You’ve got to decide what are the priorities and what takes precedent and that’s going to be specific to your philosophy. That’s the first step.

The second step is really having kind of a decision tree and making sure that your hygienist are spending their time before they start scaling on this exam process right so they’re not starting the scaling five minutes after the patient sits down.

The worst thing is for a hygienist to get half way thru prophy and realize, “oh shoot like this patient really needs therapy” and now I’ve got to back pedal.

Full Episode Transcript:


Full Episode Transcript

With Your Host

Dr. Tarun Agarwal

Welcome to T-Bone Speaks with Dr. Tarun Agarwal where our goal is to change the way you practice dentistry by helping you achieve clinical, financial, and personal balance. Now, here’s your host, T-Bone.

T-Bone:    Ok everyone, welcome back for another episode of T-Bone speaks. I’m your most ungracious host today and today. I have with us a wonderful person and a subject that is not near and dear to my heart  but is actually a source of great frustration in my practice, and quite honestly it’s not frustration because I don’t have the right people but I would honestly say that this is what I do have some really good people in my practice and it’s an area where I think I have missed the both in terms of leadership and showing the need and how important it is for me and my practice. I’m talking about the hygiene department and today we have Rachel Wahl with us.                  

Rachel how are you doing?

Rachel:     I’m doing fantastic T-Bone, thanks for having me.

T-Bone:    You sound southern today, a little bit.

Rachel:     I do, okay. Well, I’ve been in California for the last week, so I’m home and I’m just sinking in to the southern drawl.

T-Bone:    You’re re-acclimating to North Carolina?

Rachel:     Yes, exactly. I’m over compensating.

T-Bone:    Well, you know, Rachel, we actually first met in 1999-2000.

Rachel:     We did, we did.

T-Bone:    That’s a long time ago.

Rachel:     It is long time ago. We were first very enthusiastic newbies at SCN. And yes, it was great and it’s been really fun watching your career soar and just loved all the stuff that you’re doing and I always enjoyed being around you because you know you always know where you stand with T-Bone.

T-Bone:    Why does everybody tell me that?

Rachel:     And you know but it’s you’re real, you’re very real and you just put it out there and I really like that, I appreciate that.

T-Bone:    My favorite thing I just did recently is we did a hot tub video.

Rachel:     Yes.

T-Bone:    My wife says I should watch it and I actually watched it to see if I’ll ever do it again, but there’s nothing like four shirtless guys in a hot tub at 1am shooting a dental video.

Rachel:     It’s real, you can’t get more real than that, right?

T-Bone:    It was real. That is very true, so alright Rachel, so tell me who is Rachel Wahl and how and why should our listeners know you?

Rachel:     Yes, so I’m a hygienist, first and foremost.  I’ve been a hygienist for 25 years now, hard to believe.

                   I started probably about thirteen years ago, I started in Sparring hygiene and I had been working in the consulting field for few years before that and worked on my own as a solo consultant for many years.

And then, probably about six years ago I started to build my team and so now we are a team of all of our coaches are hygienist and we have a fantastic supportive team as well here at the home office and so we just have the privilege of going out and speaking at you know all most of all our major meetings between all this and a lot of local study clubs and things like that and just sharing ways that dentists and hygienists and really the entire team can help grow the practice thru hygiene

And then, we also do private coaching where we go out into practices and help practices customize a program for them that really helps them grow in the way that works best for their practice and really tap into the potential of what’s lying there as far as growth, potential and hygiene. And so, I’ve coined a term. Listen, I’m going to put this public now first on T-Bone speaks since I’ve coined this term “return on hygiene” and I just read a book and will share a little bit more about that as we chat, but this kind of we’re going to peek into a little bit into this book and it looks you know at where these potentials lie.

                   So you shared some frustrations and things that are happening in your practice with me several years ago and then again we talk about them recently so if you can just kind of lead us into that.

T-Bone:    Sure, yes it’s cool. You know I think like you said I’m honest and open and sometimes too open. My wife calls it verbal diarrhea, but you know, I think one of the things that drive me crazy is when I hear dentist say well hygiene is a lost leader, like it’s bread or milk or something at the grocery store and I don’t look at hygiene like that at all. In fact, I would say that hygiene is quite honestly one the most important if not the most important part of your practice because seventy percent of (at least in our practice seventy to eighty percent of the work that we do comes through our hygiene department) at least in the restorative side.

                   And so when you have great well trained hygienists, I think that’s unbelievably important to have and so one of my major focused over the years, in fifteen years of practicing has been always been I have my hygienist focused on me and my needs and my patient’s needs with me and what that’s done is it’s taking the emphasis on their needs in terms of the perio numbers and the perio treatment and some of those things and that doesn’t mean that we’re not diagnosing because I don’t want to believe that we’re doing substandard care. What I call it is where miscoding so, I know that we’re treating perio. I know it because I go in there and I see the tooth by tooth the bloody tooth by tooth so I know we’re treating perio I just know that we’re not coding it correctly.

And so as we’ve develop that practice and as our practice is moving into different phases, I’d like to see our hygiene team perform at the same level that our practice is performing at where they’re in the top ten percent of practices nationwide.

A lot of us gives excuses and my excuse been; one is I’ve always have no focus on my staff only so that’s been my excuse, I always said things like I don’t care about the perio numbers as long as they keep me busy and as long as we treat patients properly by that mean who cares if I call the propendo perio?

That’s just the money issue, correct? So as long as the overall practice numbers are fine, I’ll take a little bit of a hit there and then the other thing I say is, “Well, you know I hear Rachel, I hear so many other people talk about great hygiene numbers and I go wow and fee for service environment that’s fine but in a PPO environment like mine where we take multiple PPO network insurances and they certainly limit or suppress your fees. I think that’s an easy excuse to make and quite frankly I don’t want to have that excuse anymore. I want us to focus on being a top ten percent hygiene department because I have top one percent people. We have a top one percent practice and we have a top one percent practice and we have a top one percent technology so let’s start making the hygiene department itself that way as well.

Rachel:     And that’s something that we see a lot in practices that we work with because you know all of us that are out there presenting and speaking and working with practices and the doctors that come to your seminars, T-Bone, we come to think of them as the average dental practice but they’re really not. I mean, they’re really not it’s just because we are fortunate enough to work with these professionals that want to continue getting better and better becomes our normal, but it’s not the average, right? These are like you said the top ten or less percent of the dental practices out there and so what we see a lot is we see the dentists have gone to your course. They’ve gone to Sphere, they’ve gone to LVI, they’ve done all of these additional education and at some point in their career like sounds like maybe you’ve reach that point as they will look back and they say, “Okay, so I’m practicing here right in maybe in 2017 I’m practicing a year or two ahead of where most of the other practices are and or maybe a decade ahead of where a lot of other practices are but my hygiene team is still back in 1999. And so, how do I bring them up to speed with technology? How do I bring them up to speed with their service mix? How do I bring them up to speed with their prophytability fees?

                   That’s really where we come in and help and see where you want to be? What is your practice model? How can we help you tap into that level of growth?

So that’s common and you know we’ve have some heart to heart leadership conversations with dentists. I remember one client here in the Charlotte area that I had to say hey you know, “Can I give you some coaching and you know this particular doctor was using the next version, the version of CEREC that haven’t even released yet and I said, so you’re using this type of technology and your hygienist were using ultrasonic units that are from 1990’s?”

T-Bone:    Or they can be like me three years ago, we we’re using Chinese ultrasonic units.

Rachel:     Yes, I remember you and I had a conversation about that.

T-Bone:    Rachel I don’t mind you calling me out on that thing on this okay, because that’s okay, because I want people to know that you know we all make this solely mistakes sometimes. Yes, you know, but it hurt my feelings but you know we got to get challenged sometimes, we got to get disrupted.

Rachel:     Absolutely!

T-Bone:    And there honestly is a difference and you know I would never use inferior product or things in my end of things so why should I expect my hygienist to do it just like the thing with instruments. My hygienist came to me the other day and said, “Hey it’s been x number of years since you got new instruments well can you just re sharpen them again she goes when was the last time you re-sharpen one of your instruments?

Rachel:     Right. It’s like using a [unclear] so this dentist took that advice and that coaching very well and immediately you know updated the equipment that they had because truly they were operating with subpar equipment. And that’s one of the things that the hygienist appreciates about you know when we come to this we’re looking at how can we maximize the department but also how can we create a return for them, for the provider, right? So we create some more optimal working environment because then your hygienist is going to be happier and they’re going to be more loyal and they’re going to want to help build the practice. So it has to be a win for the patient for the practice and for the provider.

                   So you sent me some question so we’re going through some of these questions but to start out let’s just look at kind of the two classic hygiene benchmarks and where the rubber meets the road and when you speak about being disruptive you know this influx of PPO participation is, to be quite honest is a little bit disruptive for us because you know we’ve work a lot with in the past with a lot of fee for service practices. It’s very easy. We teach them to do XYZ. They do it.  They see a huge great return and as we’re working with more and more practices that are participating have only PPO’s and more and more small group practices we recognized, “Hey, we got to look at this and we got to figure out what is the most creative, most effective way to help these practices and we’re constantly learning that right, with every client. We’re learning something new with every seminar we take and insurance person that we listen to. We refer to the gurus and for all of the ins and out of all the coding that there’s some basic things that we have to know and teach and ways to maximize what you’re doing to make it prophytable because the bottom line is from visit, between business owner and business owner the prophytability of your business measures that’s the measure of longevity for any business, really. And so, yes, go ahead.

T-Bone:    I’m sorry, you know I was going to say, I had a nice conversation with Meghan, my hygienist and she asked me about some things and I said, “listen I’m happy to do anything you want at the end of the day and here’s what we got to do to get there and what’s amazing is so for the hygienist that maybe listening to our podcast and I encourage dentists to have their team mates and their team members to listen to it as I said if you don’t have the right equipment it may be a financial situation where the practice can’t really afford it. Well the practice doesn’t see the value in it and see what I always people what I believe in is that you should never allow someone else to dictate your future. So that means if you’re working with practice and I’m not saying leave your practice, although sometimes that situates ok but just because you’re working in the practice like in my practice my focus is on so many different things, so many much honestly and I don’t mean this demeaningly but so many much higher level things that I tell Meghan I said Meghan don’t let me in my focus not being on you, hold you back.

                   So if you come up with something if you say hey I want to implement this, don’t wait on me you know take the initiative, make it happen and see you know and then show me.

I always I use the word sell me on it, I mean, because I’m a business person at the end of the day. If you want a new XYZ you know tell me what’s in it for me, what’s in it for you, what is it going to take how much does it cost, how long before you know get the recoup on that? What’s in it for the patient, certainly and what’s in it for the practice? But hey I want to do one thing before we move forward ok so and I want to try to establish some realistic goals here ok so what would you say I call it knowing the score, what would you say our current hygienist and a typical PPO practice does per day in an eight hour day right now?

Rachel:     Yes, okay, so that’s where exactly where I was going is looking at this prophytability so I would say, we still set the – when people say where should our hygienist be producing? We still have the at least a thousand dollars to twelve hundred dollars a day.

T-Bone:    That’s establishing our goal.

Rachel:     Yes, that’s establishing our goal and obviously there going to be practices that are on both ends of the spectrums and we’re going actually go through some math in just a minute.

T-Bone:    And that is on my practice, right?

Rachel:     Yes, it is, it is your practice yes.

T-Bone:    that’s an open book so what do you think most practices are at when they – in general?

Rachel:     Yes, I would say they’re probably at a more or like eight to nine hundred a day in PPO practices. That’s where I would say they probably are and your fees and your reimbursement are very typical goal so this is going to apply to a lot of practices they’re in same situation as you.

T-Bone:    If you don’t mind, I want to focus our talk today on the PPO practice and I want to focus on, I call it the do-it-yourself-model let’s give them some tips and tricks and then the other thing I want to do is I want to set a couple of groundwork here for people ok because this is another thing that irks me about dentistry, I call it the male member contest okay?

                   When we use production numbers we’re talking about adjusted production ok we’re not talking about this fake numbers because at the end of the day my practice produces ten million dollars a year we collect like five cents, okay, because I charge five thousand dollars per crown but my insurance company allows six hundred dollars so when we say $800-900 these are collectible dollars, these are adjusted numbers for your insurance allowable and when were saying a thousand to twelve hundred dollars that again also is your adjusted production so what you can expect to collect and so by doing some quick Indian math – so that works out to me about a hundred twenty five to about hundred and forty dollars an hour, okay.

Rachel:     Yes, so if you’re at $800 day that’s about a hundred dollars an hour and your question for me was frustrating situation where practices contracted lots of PPS, this is the primary for their patients and they get stuck at eighty five to ninety five an hour.

T-Bone:     Right.

Rachel:     How do we get out of that? so the questions are that we’re going through is what causes these, what can we do about it, you know how can we expand our services without negatively affecting your side of the practice? So taking the hygienist focus away from helping fill your  book because this seventy to eighty percent that’s coming from hygienist is fantastic.

                   Our average work is at least sixty percent of restorative should be coming out of hygiene and that supports the concept that if hygiene is the backbone of the practice like we’ve heard  for so many years, then they got to be the backbone. They’ve got to pull the weight and helping fill the doctors’ restorative book. And then next is you know how does the dentist go about implementing effective plan to overcome the problem? And how do you know you’re making progress?

So that’s what we’ll go through today. So yes we’ll be talking in real numbers. This is net production. This is collectible production and so if we go back and just start with the prophytability fees you know our classic benchmark is that  hygienist should be producing at least three times their compensation so I don’t know that we have answered this question in the industry as to whether this benchmark still apply and have PPO practice, but in my opinion you still have to be prophytable, right?

I mean that’s the measure of longevity for any business is the prophytability point and so that’s the goal that we still need to strive for.

Now we’re going to look at some, some variances around that in just a few minutes, but I don’t think there’s anything wrong with continuing to strive for at least three times hygiene compensation being that net production.

Okay, so if your hygienist is making $35 an hour then that net production should be a hundred and five dollars per hour or more ok.

T-Bone:    Got you.

Rachel:     So what causes this, what causes that getting stuck at $85-$95/hour? In my opinion it’s really a conflict between philosophies, standard of care and basic Math, right?

                   You want your hygienist to have the time to deliver the high level care so how much time does Meghan have with a recare patient typically?

T-Bone:    Sixty minutes.

Rachel:     Okay, so you want her to have the time to A) deliver high level care and B) to help promote your dentistry right and help the patients want the dentistry that you’re offering?

T-Bone:    But you know Rachel, it’s never enough time.

Rachel:     Right, and so here we’re going to get to that ok so don’t let me put it back.

                   I know, you want to preserve the amount of time they have right to identify co-diagnose disease present treatment and your participating provider in several plans which limits right the amount that you’re being reimbursed. So let’s just look at the math here.  Let’s look at this example. So your fee and we’re just kind of start with some just basic hygiene code here so the prophy code the 1110, right your practice fee is $95 and your lowest reimbursing is we’re not going to name the insurance companies that insurance company that sure made that name.

T-Bone:    Medlife.

Rachel:     Their fee is I think this is a six.

T-Bone:    Yes, probably.

Rachel:     Sixty seven dollars, yes, ok it looks like it’s $67 right so and then the exam is – your fee is $70, their fee is $53 and then let’s say four bite wings their fee is $41.

T-Bone:    No, no that’s the Comp exam.

Rachel:     No, according to what they sent me it says $53 for the exam.

T-Bone:    For the periodic?

Rachel:     Yes, for the periodic.

T-Bone:    That’s incorrect. I know that’s incorrect. So they gave you the wrong number that’s the comp exam, but that’s ok

Rachel:     And that’s ok because it doesn’t really matter when we we’re talking about hygiene production and here’s something that [crosstalk]

T-Bone:    Yes, that’s good I want to clarify that as well so go ahead.

Rachel:     Yes, here’s the thing, we’ve changed our opinion about is that we used to have the exam included in hygiene production because really and truly if your hygienist are doing or promoting and rolling seventy to eighty percent of your restorative then they’re probably doing seventy to eighty percent of the exam, right?

T-Bone:    I want them to do ninety nine percent of the exams, Rachel.

Rachel:     Yes, yes right so and the best hygienist do that and it’s frustrating for hygienist for them to do all that work and not be credited towards their production, but what we have to realize is that those exams that is a doctor procedure.

T-Bone:    Legally.

Rachel:     legally it has to be billed to the doctor and for you to do all the corky math to work that back into their numbers I mean some practices used to do that, but I would say, just set the goals so that its realistic and takes that into account so really and truly whether that your comp exam or your periodic exam reimbursement, it doesn’t make any difference.

T-Bone:    It doesn’t matter.

Rachel:     When we’re talking about you know hygiene production, so if we’re looking at the lowest reimbursement is this – if your hygienist is doing a prophy and four bite wing she’s going to be billing out a hundred eight dollars in that hour, right? So that’s better than the eighty five to ninety five but not much.

T-Bone:    No.

Rachel:     Right and so then if she continues to do that appointment after appointment after appointment then you know it’s going to be pretty hard for you to hit that hundred and twenty five dollars an hour, right?

T-Bone:    We’re not doing bitewings in every appointment let’s call that every other appointment, essentially.

Rachel:     And then you throw in a miss appointment here and then all of a sudden now you’re down to that eighty five to ninety five dollars an hour.

                   So it’s really just basic math and so we have to look at how do we get that up. And so you have a few choices here you know and we’re going to kind of jump around a little bit because we’ll go back and forth. These things kind of naturally come together but what do we do about it?

We can expand our services where we can offer things like we can tighten up our perio program so that she’s not doing the bloody prophy’s because by the way the bloody prophys are one of the reasons why it feels like there is never enough time.

T-Bone:    Yes!

Rachel:     So, right? So if that prophy expands one of the things I talk about is I do a course on hygiene time management that actually really fun because we get to talk about the things that we couldn’t do in hygiene school like you know I showed a picture of before and after a stay-in patient, well you know you’re not in hygiene school and if there’s a spec of stain there but yet you’re able to present treatment that’s in the patients’ best interest then maybe you need to leave the spec of stain and let them do more important things, right?

                   So what we find is that you know there is this thing called Parkinson’s Law and it says that a task would expand based on the time that is allowed.

If we allow forty five out of our sixty minutes for scaling then a lot of times a hygienist is going to do forty five minutes of scaling and that is where this time crunch comes in very often, not always, but very often is looking at how much time I’m spending on scaling and if we’re doing a lot of bloody prophy’s then a lot of times it takes longer than it should. And so one of our benchmarks and things that you can take I can just kind of  measure is if you’re spending more than  twenty to twenty five minutes on the scale and polish, that patient probably needs something other than a prophy. They may need a  two prophys or maybe they need perio therapy, but that’s a good benchmark if you’re spending if you as a hygienist or if your hygienist if your dentist or you know office manager spending more than twenty to twenty five minutes on that  piece and that patient probably need something other than a prophy. And so what that means is then we must allow about twenty minutes or so in the beginning of exam at the hygiene appointment before we start scaling to really do our exam. That’s where all of that happens is in that first twenty minutes is what is the perio status? What is their restorative status? What opportunity they show there for the patient to get healthier? What have we presented in the past that the patient hasn’t move forward with yet?

So when we look at what can we do about it? One of the things we can do about it is expanding hygiene services so that we’re offering higher level services in that same amount of time and it can be the typical things, right? Increasing perio, fluoride therapy where it’s appropriate, sealants if that fits to your philosophy, products although you have cost the products so there is not huge margin on products but certainly that can help.

The other option is decreasing hygiene appointment time. I mean you know the downsides of that are; the conversation we just had right there’s never enough time that we want to make sure that our hygienist are doing the things they need to do to help build your side of the practice. One thing you can do about it is drop your lowest reimbursing plan.  We had a client years ago that was in West Virginia and they were on a very similar plan to this and forty percent of their patients were in that one plan and they were bumping up against the capacity issue their hygienist was very busy and they were considering adding another hygienist and at this time that plan was reimbursing $37 for a 4342 which is a localized quadrant of scaling they’re putting on, I’m not exaggerating and I said you can add another hygienist but you’re just kind of going to go deeper into the hole.

T-Bone:    Yes, that doesn’t make any sense.

Rachel:     That doesn’t make any sense because you know he was paying his hygienist at least thirty dollars an hour so you’re not, you’re in the negative, right?

                   That $7/hour, if she would have spent an hour on that particular procedure is not even covering the overhead, aside from her compensation. So you know look at those things like that you know how, what are we looking at as far as capacity goes. Are we max out and does it going to be prophytable to add a hygienist or does it make more sense to make a decision to drop a plan? And again we refer to the pros on that when we see the best an option we refer to a couple different groups to analyze that because that’s a big business decision and you need to have all of the facts before you do that.

One of the other thing that you can do is adjust your compensation model, right? Maybe pay your hygienist the base plus a percentage of whatever they hit over that 3 to 1 and that is based on that production again.

The other choice that you have is just like and probably like you’ve done in the past is accept the lower prophytability on the direct billable services and really empower your team to help build the other  side of your practice and that’s been your model in the past and then you asked about Comp exams and these like we just said before that might increase your [unclear] exam production but it won’t increase the hygiene production.

So let’s go back to the math here and if we look at a morning you know where Meghan maybe seeing a prophy and bite wings at eight o’clock, a prophy and bite wings at nine then she’s doing a perio maintenance and then maybe she has two parts of therapy, well even with two quads of therapy in there, if she’s doing and again we pick the lowest reimbursing we’re going to pick the 4342 which this plan is reimbursing at a hundred and two dollars. So if she you got to drove those two quads, an hour per quad, then you’re never going to get your goals.

So the other piece of this is how do we get creative in our scheduling while still preserving the time to do things the right way and so you know what I would do with you Tarun is I would say, “okay, let’s look at this could she do you know if we say we got two quads of 4342,  could we do two quads of that in one hour?

Right now all of a sudden she’s doing two hundred and four dollars in that one hour and that can help carry the production that’s not there for the other hours.

So you just got to really template your schedule and you got really agree with your team on what can we do to still deliver high level but get creative with the scheduling and that’s one thing that you can do and say hey if we’re doing two quads of 4342 then we’re going to do that in one hour.

T-Bone:    So I want to go back on a couple of things that you talked about here. There’s a couple of things that we have found in the last few months to be helpful in our practice is we focus on fluoride therapy on adult ok so that help us quite a bit because – I don’t know what the fee is ten fifteen twenty bucks, whatever the dollar amount is, but if you can get 70-80% conversion you know suddenly you go from that seventy five, eighty five, ninety five dollars per hour, per visit and now suddenly you’re bumping and ended up to the hundred plus dollar per visit and I think fluoride is a significantly underutilize service in the practice and its honestly a very, very good service to provide patients.

                   So I want us to come back to some verbal skills on how we get hygienist to do fluoride to get them to understand because we went through that struggle a little bit in the beginning because they’re like, now I feel like I’m selling fluoride and I don’t want them to feel like I’m selling anything.

I’m anti products just personally because there’s Amazon for God’s sake. So I’m anti decreasing our hygiene time because I think the relationship is way more important than a little bit of hygiene production because the way I look at it is if my hygienist can produce one crown for me because I gave her an extra ten minutes or fifteen minutes per patient that’s like her whole entire day so and the dropping insurance plan that’s a yeah-but for anybody listening. They can be like yes I can do that, that will work for my area and then this Comp exam thing, yes, you’re right it doesn’t help hygiene production but it helps office production and this was an area that I forgot about. And it’s amazing how we forget about things so we – I was trained to believe that Comp exams were only for new patients.

Rachel:     Yes, right.

T-Bone:    And the truth is, is that Comp exam can be done every three to five years based on your insurance carrier and should be done every three to five years. So one of the things that we worked on our practice is setting up a recall schedule within you know within our new practice management software to remind you when your patient is due for Comp exam, just like yes, you can set up every six month to do for perio by prophy whatever you can set up that the due for I don’t know 04150 one of the number maybe for the Comp exam every three to five years so that way – because that’s a twenty bucks right and then last time we check if we do an extra fifteen of those or two hundred of those a year, that adds up you know and it makes a difference.

                   But I want to come back to I think [unclear] because it sounds so easy to stop doing bloody prophy’s ok but why is it so hard, Rachel? Why is it so hard to just stop doing them why is it so hard to have the verbal skills to tell patients that you’ve been seeing for so long, well maybe you’re a new hygienist that’s walking into a practice and then you’re inheriting patients and you don’t want to be the bad guy or girl that has to tell somebody this stuff, so tell me what are, how do we overcome some of that stuff?

Rachel:     So here’s what we found and I want to go back to this math in just a minute because it’s going to tie it all together.  So your first brought up fluoride therapy and now we’re talking about the bloody prophy’s and the things that those two items have in common is that they can increase production and we can say because what I calculated here while we were talking was, adding two more two fluoride therapies to this morning that we just did will actually get us to go and will go through that in detail in just a second however, what we consultants have been guilty of is just that is saying, “Okay, all you need is two more fluoride therapies in the morning you know and you can get to go”. And that works for a little while but what we find is it doesn’t result in long lasting change and here’s the reason it’s because we’re starting with production in mind instead of starting with the why.

                   It sounds kind of you know floppy and all that but it’s really true is that the majority of the folks in our practice thankfully are very ethical and we want to do things that are in our patients best interest and if we ever do things that feel kind of icky, which is doing treatment that are focus on production then we might do it for a little while but we’re not going to, we’re not going to be able to sustain that because it doesn’t feel right.

So with anything that we’re introducing, all the technology that you’ve been introducing in your practice and that you teach you always go back to, “Okay, how does this help the patient and how does the result in a better restorative outcome, right?”

How does this either help me do this faster so the patient does not have to be in the chair longer, there’s got to be a return for the patient here and we got to focus on that first.

So we first have to look at why, why should we even do anything differently aside from the production fees and part of it is because if we can do bloody prophy and we may feel like we’re treating the perio but our patient doesn’t know it and I can tell you I’ve met practices where they’ve been called before the board and they did therapy on the patient and the patient didn’t even know it. So we got to make sure that we’re communicating to our patients really clearly on what is really happening with their health and we have to spend some time whether it’s with the fluoride therapy or whether it’s bumping up our perio.

We got to spend some time really focusing with our team on why.  What is the return for the patient if we do this? And why is this in our patient’s best interest and how is this going to help the patient have better oral health? How is it going to have them better overall health? How is it going to save them money in the long run as far as reduce risked for decay and things like that.

We have to focus on that and then go to the production fees. So if we have that that belief in place and we work on that and that’s where the things we do very specifically and right away with our clients is we got to establish a belief then the verbal skills are easier.

T-Bone:    This is coming from the heart.

Rachel:     Right, because if it’s coming from our production stand point then all of a sudden we got to create all this these things right things to say and all that it feels kind of phony, but if it’s coming from the heart then we can use some key words and it just go so much smoother and the patient can tell that we have their best interest at heart. So a couple things that really quick kind of verbal things that we have found work really well with practices whether it’s a new patient or I’m sorry new hygienist  or whether it’s an existing hygienist with a long term patient is you know just like with anything if we want to get a different result we’ve got to take some different action and so a lot of times the hygienist feel like, “Gosh I’ve been doing this prophys’ forever and now all of a sudden I’m recommending therapy,” but that’s not true ninety five percent at the time.

                   Ninety five percent of the time what’s true is they’ve been talking to the patient about the bleeding, right? They’ve been you know recommending in different oral care device. They have been shortening their interval. They’ve done something. They have some discussion with the patient about this inflammation and so go back to that, right? You already planted the seed, go back to the seed you planted and say look we’ve talked about XYZ and we’re not getting –your body is not responding the way we had hope and it’s time to do something different.

So basically go back to all those seeds you’ve planted. It’s not a new conversation, you’re just now going to be presenting a new solution to the problem, but let’s look back at these problem that we discussed over several recare visits and it’s not getting any better, your body is not responding the way we had hope it’s time to do something different and now and you present them with the evidence, right? You bring the patient alongside you just like with you know the interim care where the patient is seeing the problem, we can do the same thing with perio, right? We can take photos. We can call out those number. We can bring the patient alongside us rather waiting till the end of the appointment then dropping the bomb so that they they’re getting a picture of the problem and then we can offer that solution and the same thing is true with fluoride is, talk to them about what is the problem, the problem is they’ve invested all of these time and energy and money into this beautiful restorative work and the problem is this bacteria are still there, right? They still have risk for decay so what can we do to reduce the risk or the problem is they have exposed root surface and that root surface is seven times softer than an enamel but the bacteria is still there what can we do to reduce the risk of that decaying? And so can it be being the solution rather than being you trying to sell them something.

T-Bone:    So you, would you say that – so one of the things that we do with the hygienist is I said let’s identify candidates for fluoride therapy and I said basically to me this is very simple.  Any patient that has recession is a candidate for fluoride therapy and any patient that has restorations is a candidate for fluoride therapy.

Rachel:     Ninety-five percent of your patients, yes.

T-Bone:    Right, so if you look at that way and to me the “sell” and we all hate that word but anyway that’s what we’re all doing ok. The sell is, “Mrs. Jones we’d like to add a protection layer to your teeth to help protect you from needing more expensive dental care down the road, okay? And look I’m a joker to my practice I tell my patient look it’s like a cheap insurance policy, you can pay me hundreds later or you can spend a few dollars now, whichever one they prefer and I think ultimately you got to find your own way that’s why I don’t believe in scripts which is probably part of my problem.

Rachel:     Yes, no I don’t think it’s part of the problem and you know we feel the same way. It has to come from the heart and then you have some key words which is what you just said so you have a script but it’s one that feels natural it’s not one that’s been pushed on you. You have to say it this way.

T-Bone:    Right and so I find that the fluoride it just drives me nuts but we’re not providing fluoride because it is easy and honestly to me you know we can – I can go back and forth with my hygienist and so with some of the team members like and you’re doing it or let’s say my raspy then like you’re doing it too cheap I’m like what’s too cheap it cost like two dollars or whatever the…

Rachel:     Two dollars, yes.

T-Bone:    Whatever it cost you right? And so charge your patient ten dollars, fifteen dollars make it. You know if the thing with your hygienist is going to be that they’re so worried about how much you’re charging for it then make it affordable so that they are comfortable with it because it should be about the patient, so don’t make it thirty dollars I mean to me that’s high in my opinion that’s highway robbery to paint some two dollar fluoride on their teeth, ok? Make it affordable for them because that’s really good treatment for them.

Rachel:     Yes, I agree and that was one thing that came to mind for me is make sure your pricing is set where it’s easy for your team to recommend it and so yes fifteen dollars I mean it’s still… I completely agree with you on that and what I would say is just to add to it is just make sure you’re making it personal. So often we kind of get into this robotic mode of you know when you do for your X-Rays when you do for your fluoride is patients don’t care about they’re due for they don’t want to be put into our like standard, right? They want it to be because it makes sense to them.

T-Bone:    Rachel I listen to the ladies, I shouldn’t say lady I listen to somebody speaking one day and…

Rachel:     You did, you did see a lady [laughs]

T-Bone:    I didn’t mean it that way ok and it happened to be a lady ok and she said I just happened to ask her about this fluoride thing she said you should have a thing at the front desk and your patient should check off if they want fluoride or not and then the hygienist will know if they want fluoride. I’m like no person in their right mind is going to check off if they want fluoride. I mean that’s the most impersonal thing I‘ve ever I’m not going to check off just like me when I go to the car wash place thing I want check off that I want detailing of my car because I’m never going to do it.

Rachel:     Well, right, so that goes to my next one which is going to be don’t ask the patient if they want it right assume – because I hear this too. Do you want this? No, I don’t want this. I want to get out of here as fast as possible and do the minimum. Instead it’s assuming based on what their risk is, right?

                   So if you have a patient that has zero decay and has zero recession and zero restorations then they really have very, very low risk for decay and so it is not in their best interest but not the rest of the ninety five percent of your patient is make it personal right make it make sense to them just like, just like you said you know I was just going to bring up, I was listening to the podcast that you did with your friend that’s the insurance adviser and you know you don’t go in saying Mark I want to give you, five hundred dollars a month to insure me. But Mark created value because it’s protecting all these investments and your family and all of these things like that so I love that analogy I think that’s perfect.

T-Bone:    And it comes on trust right?

Rachel:     It does and you’re being authentic which is you and we really should all be comfortable being ourselves and being what our patient are saying, here’s the thing like you’ve invested a lot, you spend a lot of time here we want to know how do you protect that so it’s fifteen dollars now or if you have to replace this crown it’s another five hundred dollars.

T-Bone:    Thousand dollars, yes, exactly.

Rachel:     It’s just doesn’t right. It doesn’t make sense. So here’s where the Math comes in. If you look at your hygienist schedule and we look at prophy and bite wings, prophy and bite wings a perio maintenance two quads of a localized perio therapy in an hour and then another prophy with no bite wings just sixty seven dollars prophy, if you threw in three fluoride therapies in those one, two, three, four, five patients all of a sudden you’re up to $125 an hour. Now, is that an ideal day? Yes, it is an ideal day, but we’re also using your lowest reimbursing fee so you got you know one…

T-Bone:    And right now I take it, I take it

Rachel:     Right you’ve got well I would say yes you’ve got six to eight other plans that reimburse higher than this so chances are you’re going to hit that. So let’s look at yes so if we can let’s look at you know just kind of next question about expanding services. How do we focus on increasing perio without negatively affecting the restorative?

T-Bone:    Yes, so my concern on that is suddenly we’re so focus so much on perio, like I had one hygienist ok and she was, her perio numbers were off the chart but I never got any work on her out of her opertory like all of her patients like all they do is perio and I actually learned those patients didn’t like our practice very much afterwards. I think she was selling them to be quite honest with you or they perceive she was selling them.

Rachel:     Okay, so first and foremost is you got a really establish your philosophy strongly with your team and you know with Meghan’s been with you for a long time and she has shown how great she is at helping you in all restorative and so she understand your philosophy and so chances are she’s going to be able to balance this really well. Your newer hygienist is going to be really important for you to just really express, what your philosophy is around this and look at when is it appropriate for perio to take the front seat and when is it appropriate for it to take the back seat, right? because the bottom line is the non-negotiables are that we have to identify and co-diagnose disease and present treatment to address the disease. We have to do that and so that’s probably an area where you could really grow things as far as like you said you don’t feel like there’s untreated perio but it’s being treated as a bloody prophy which means they may or may not have the time to appropriately address the problem and also to educate the patient into what’s happening and so that they’re very aware so…

T-Bone:    I call it approval [crosstalk]

Rachel:     So you said it was ok, tell me about that.

T-Bone:    So I think what happens is it’s easier for people to do bloody prophy’s this patients will just say yes to you versus having to get up and sit down and tell them that they have gum disease and that they need something different. That’s what I really think it boils down to because I think A) we perio probe our patients ok so another practice that perio probe ok so I think it really boils down to having that uncomfortable conversations and I think, I think that’s really, really where the problem lies in most practices out there. Not that the patient don’t exist because that’s total garbage ok and it’s not that the patient don’t want to be healthy because I believe that’s total garbage, I think it’s more that our team members or us ourselves you know because I’m just as guilty if not more guilty than my hygienist of this is we just want to do what makes it easy for the patients and what’s easy for the patients is just to keep to what we’ve always done.

Rachel:     Yes, but it’s not always what’s in the patients’ best interest now sometimes it may you know sometimes it maybe but sometimes it may not be and I think that’s an interesting theory and I would say it goes back to the conversation that’s really focusing on the why because what has to happen is our conviction to help the patient get healthier and our conviction that this is in our patient’s best interest has to be stronger than the uncomfortable feeling that we have when we are about to have this conversation.  We got to shift the balance on that.

T-Bone:    I think sometimes as a practice leader whether and I say leader not as the owner and I’m the owner but whether you’re the owner or not as a practice leader even if you are the hygiene leader I think sometimes you have to draw a line in the sand and like on some patients where you know what we can’t do prophys’ anymore we can’t say you know what next time if it’s this way, then you have to do this right and I’ve heard this before, right? So next time hey Mrs. Jones next time is this way but the next time is the next time right and at some point you have to draw the line saying Mrs. Jones we no longer can accept to neglect what’s going on here, if you can – and it’s so hard and I get it is if we can’t do this then maybe this is not the right dental home for you.

Rachel:     And we and there are times that that’s conversation comes, but again it’s the you know that’s a small percentage of your patients that, that happens with so we’re…

T-Bone:    But I think that sends the message sometimes. It lets your team know that you’re serious that like – listen that you’re willing to say you know what in other words the production isn’t that important in other words that I’m willing to do, I’m willing to do whatever the patient wants versus what’s right so…

Rachel:     Okay, so, first is getting really clear with your entire team on our philosophy about what comes first and it’s not always black and white, but give them some really clear guidelines here’s some questions that you can ask when you’re going through this with your team is you know – what are the patients’ medical risk factors right because that can play a huge role in what comes first.

                   If you’re dealing with the diabetic patient you know and obviously we’re going to use a very obvious example but this can also become very subtle and you know you start with the obvious cases and then you refine your skills to where you’re looking at least more closely with other folks, but if you got a diabetic patient that has even some localized bleeding four to five millimeter pocket  depths with bone loss and you’re looking at doing restorative, it probably be in the best interest of that patient to get that information cleared before you start restorative because you’re depending on that strong foundation to hold and for them to have a good healing overall. So what are the patient’s medical risk factors, does the presence of the disease affect the risk factors and vice versa? Are there imminent emergencies right, the imminent emergencies take precedence and does the patient have a specific concerns that might direct our first course of action?

So you know is the patient having a toothache will I mean again this sounds super obvious but what we’re saying is because with hygienist sometimes like you said they can get blinders on and get so focused on the perio, it’s like yes, but the patient’s having a problem here that we need to address and if we don’t address that they will not going to gain the patient’s trust. So sometimes planting the seed helps with the trust and you know we’ve been working with this one client and they kind of have the philosophy of we’re going to present the perio even with new patient, we’re going to just not  going to schedule them for anything.

Well, that patient is not going to call you up and say you know I know you don’t do any treatment on me last time I really want to do  that perio therapy so that I can come and be a patient. They’re not going to do that and they’re not going to call another dental office they’re going now into the dental twilight zone again for another five years and that’s not in anybody’s best interest either. So we have to work together because they really have a hard time understanding how I can say ok so you know you’re not ready to move forward with this treatment, what’s the next step so we can at least keep that patient engaged in our practice and build trust with them right? Get them to know us what can we do that’s not going to compromise their treatment but is going to be at least one little baby sit to get them moving forward. You know that might be bringing them back for and above the gum line prophy and I know that sounds kind of crazy to some people, but again if we send the patient off into you know back into their world they’re not going to get engage with another dentist right away, they’re going to be you know stay then to collect again for several years.

So if you’re going to this philosophy look at some cases. Post some cases. I remember we had a patient that had I would say beginning to moderate periodontic disease, pretty generalized but she had – she was very young she had six teeth that were decayed at the gum line. So you know that’s an imminent emergency so what we did first is she had to have those all those teeth removed and have that risk of infection reduced then we could go back and we could look at you know the perio. so you’ve got to decide what are the priorities and what takes precedent and that’s going to be specific to your philosophy that’s the first step.

The second step is really having kind of a decision tree and making sure that your hygienist are spending their time before they start scaling on this exam process right so they’re not starting the scaling five minutes after the patient sits down. So that’s something to look at is what are we doing before scaling start because we really got to know what we are dealing with before we can decide what procedures being delivered that day.

The worst thing is for a hygienist to get half way thru prophy and realize, “oh shoot like this patient really needs therapy” and now I’ve got to back pedal.

So let’s find out before we start scaling what the needs are and kind of coming up with the decision tree. Ok so if we see the disease then you know now we’re moving and let’s look at the perio, let’s look at the restorative needs what are we seeing with restorative. And if we’re seeing this level of disease and this level of restorative then we’re going to move to restorative first, but we always got to make the patient aware that there are other need so whether you are doing perio first or restorative first you got to let them know that there are other underlying issues that we’re going to get to but we’re addressing the most urgent thing and patients like that, right? I mean how many times have you had a patient say ok is this the most important thing first? Are we just doing this because you know this is where doctors want to start?

They want to know that the most important problems are being addressed first. So have kind of you know go through some cases, go through some scenarios but make sure the time is there so that the hygienist has an opportunity to go through that mental process and decide here’s what’s happening, what I’m expecting is doctor Agarwal is going to recommend this or they say there’s several issues and I’m really depending on him to help us determine the first priority so you know with new hygienist that maybe your first step is you say I want you to highlight all the problems and then I will come in and we’re going to determine our priorities together and that’s part of your training for them whereas with the more seasoned hygienist they’re going to know your philosophy and they’re going to know what comes first.  Does that makes sense or did I answer your question?

T-Bone:    Absolutely, absolutely.

Rachel:     Yes, because there are going to be some conditions that you say we need to address this before we get to the perio and there are going to be some perio conditions that you say we need to address this before we get to the restorative.

                   And then the next step is, as soon as we can if they’re going into perio then we bring that restorative conversation back up and it could be that we bring it up in a kind of different level so maybe they come back, you know for that first session of perio therapy and we just share with them, “hey next time you come we’re going also you know, we’re going also make sure you know that we’ll let you know about those cavities that we mention and what’s the first step is with that.”

And then maybe that’s all we say at that first you know perio session. And then the second perio session may come in and then maybe we bring it up right and then and so you got to decide like how fast are we going to move them into perio or I’m sorry into restorative once they’ve gone through perio.

So I think part of it is just a general awareness of your philosophy and awareness of from you is I want to make sure that we’re not slowing down this restorative process.

T-Bone:    It’s interesting you say something about that Rachel, because one of the things that I think we’re very good at is when we see patients with perio and other significant needs or I should let me not say significant, other needs what I always tell my patient is listen first thing first we got to get that foundation straight which is your gum get the help of your gum in your bones around your teeth ok and then we’re going to schedule you for a re-examination of co-diagnosis and at that point we’re going go through tooth by tooth after we got everything cleaned up so we can see better and then we’ll do a complete thorough examination.

                   Now, if they have teeth with holes, big holes in it get the thing stabilization we’ll combine that with perio treatment and get that taken cared of as far as stabilization but yes, you’re right I think too often what happened is we overwhelm the patient and we start talking about the perio situation and the restorative situation and the situation and they have let’s say hey I want to get my teeth straightened up and we get excited about the teeth straightening and just suddenly before you know it we haven’t really given the patient a concrete plan of action.

Rachel:     Right, and then we present them with this giant financial obligation and they’re completely overwhelmed so yes so I love that I love that approach and then what you can do is you can combine that tooth by tooth with one of their perio session so again you know we want to make it easy for the patient so we’re not having to bring them back time after time, after time so let’s make it make sense and make it efficient for them. I think that’s great.

T-Bone:    Alright so we’ve got a few minutes left here so I think we’re going to make fun of my practice numbers for a second.

Rachel:     Okay, yes.

T-Bone:    What kind of bad news you want to tell them-the listeners.

Rachel:     Well, here’s what I want everybody to ask themselves is, first I want you to ask yourself, I want to ask you this and you may not know the answer to this and that’s ok you can go back and ask your hygienist is first question is; with your existing recare patients, so these are the adult prophys, perio maintenance that come in to your practice every day.  What percentage of those patients would you say have four millimeter pocket depths bleeding and some even crystal bone loss? What percentage of your patient would you say present with that existing patient if you have to guess?

T-Bone:    Fifteen-twenty percent.

Rachel:     Ok so let me make sure I said this correct four percent, four millimeter or greater bleeding and bone loss ok fifteen to twenty percent alright great, and then what about new patients, new adult patients that come in four millimeters are greater bone loss and bleeding.

T-Bone:    Twenty five percent

Rachel:     Ok, so your numbers are actually a little bit lower than what we typically hear in our practice and that surprise me.

T-Bone:    That was a guess though.

Rachel:     Yes, and so go back and ask your hygienist

T-Bone:    I promise I may be wrong

Rachel:     Maybe not because I know not everybody kind of use this excuses.  I live in this patient where everybody is educated and nobody has disease.

T-Bone:    Yes, but listen those are the people like I probably have perio disease and I’m educated and I have money, come on.

Rachel:     Right, right so we’ve all seen that so that’s ok because this is probably what most dentist would say I would say most hygienist would probably say higher. So what I want everybody to do is go and ask yourselves, ask your hygienists this questions and then what we’re going to do is we’re going to measure that then against your perio percentage.

                   So your perio percentage and your practice based on how we had inspired hygiene calculate this is eight percent right so your perio percentage is a lot lower than what you’re saying the you know reality of perio is in your practice. Now every patient that you present therapy to is not going to say yes, right, but if we just look at your new patients right and again we’re super conservative so you said thirty to forty new patients a month. So let’s say you got forty new patients a month and twenty five percent of them have some level of perio’s that’s 10 patients, right? So if you have ten patients and then again let’s be conservative. Let’s say are those ten patients, two patients let’s say those ten patient’s that have perio that they need two quads of therapy, okay, times two so now we are up to twenty quads so that would be your, I would say that would be a fair estimate to the potential of perio like low in potential of perio therapy in your practice based on new patients and you guys are actually doing about seventeen quads a month so you’re pretty close to that. That means that you’re probably pretty good at, you’re probably pretty good at in rolling your new patients into therapy right because your number match it.

T-Bone:    That goes back to approval addiction.

Rachel:     Yes, right, so you’re probably pretty good at that but what’s happening is there’s probably very little or no perio being presented to existing patients. So you have another nine hundred and fifty to a thousand recare patients and there’s probably a good percentage, I would say twenty percent what we use is ten percent we look at ten percent so if you have nine hundred patients in recare which I think you actually based on your numbers I think you have more, times that’s another twenty quads a month at least.

T-Bone:    And when you say quad you’re talking 4342 and 4241? It doesn’t matter, right?

Rachel:     Right, it doesn’t matter. You could conservatively double the amount of perio.

T-Bone:    Right, which is what I want I want us to be a fifteen to twenty percent.

Rachel:     Yes, so you could easily do that.

T-Bone:    Do you think this business of being a thirty percent of hygiene production being perio number is that realistic?

Rachel:     Yes, I think it is realistic but it depends on a lot of things I mean remember we’re including perio maintenance on that too so we haven’t even talk about that, that’s a whole other thing but…

T-Bone:    We can’t talk about perio maintenance until we get people enrolled in perio.

Rachel:     Exactly, and you only have probably about five patients in perio maintenance right now in your whole…

T-Bone:    Yes, it’s unbelievable, Rachel.

Rachel:     So that that’s part of that calculation and math but it takes time so you’re not going to go from eight percent to thirty percent in six months. You might go from eight percent to thirty percent in it in eighteen months because that includes the perio maintenance. So yes it is real and we have a clients that are at that level but you could easily double and that would help you.

                   So let’s look as we wrap up here because I know we’ve gone a little bit long but this is big fun.

How do you know you’re making progress? Right. You have to measure so again going back to that three to one profitability, so measure that, right? What is your hygiene net production compared to hygiene compensation right and that includes you know your vacation and uniform allowance [crosstalk]

T-Bone:    Taxes, all that nonsense.

Rachel:     Yes, so some people put taxes in overhead, some people put it in compensation, then it doesn’t matter whichever way you choose to do it.

                   Figure out where you are with that. Open timev you know that excessive open time obviously can be a huge culprit for profitability so you know is it that you got a lot open time or is it that your hygiene schedule is packed and you  need more available appointments and that how do you make that profitable?  Look at your perio percentage, we say we’d like to see our progress as if twenty five percent are higher but there needs to be a balance between the SRP and the perio maintenance.

You can go to and you can run your numbers just like I did with TBone’s practice and figure out what your perio percentage is. So that’s and look at your net production how close are you to that twelve hundred dollar mark, a thousand dollar day mark with your net production and then the other thing that we look at is recare effectiveness. These are all things that we look at when we do our hygiene analysis. We’ve done this for you and your practice in the past but you know even if you just pick one of this or two of these to measure and just track it you know for several months you just create that awareness with your team and establish the why if I can give any advice that’s it, really discuss why is this in our patients’ best interest before we discuss how does this increase our production.

T-Bone:    So Rachel, we didn’t talk about there’s so much we could have talk about, Jesus I wrote down so many things like…

Rachel:     We could do a part two.

T-Bone:    We should because I talk about, you just talk about being book and then I just said ok so if I had a new patient that comes to my office right now, you know what drives me crazy is when people don’t follow the blocks and then [crosstalk] we fill our schedule with eight recalls a day and then we get a new patient that comes in that needs perio treatment and now we’re working through lunch, we’re working late, we’re adding days, and then we’re creating this whole problem in the practice because and then or then we’re afraid to diagnose perio because then we’re like we’re the hell we’re going to put them.

                   There’s so many moving parts to this and I think you know that’s part of the problem there and I think to me the biggest thing so if I were to give people a couple of messages okay, I would say this, I would say 1) you got to know the score of where you’re at now in your practice ok it doesn’t matter where you at in terms of whether it’s a thousand dollars a day, eight hundred dollars a day, five hundred dollars a day or two thousand dollars a day, we all want improvement and then we can’t look and listen to people that say you should be at this number  because getting there takes as Rachel said eighteen months, twenty four months every practice can be a little bit different. And what you have to do is you have to define how you’re going to get there in the stair-steps method ok and what I would say to you from my perspective and I have seen how numbers increase for me I look at what are the easiest ways for us to get there and for me the easiest non-intrusive ways for us to get there was the first thing we did was we added fluoride therapy to our hygiene department.

We started looking at for adults; 2) While this didn’t help our hygiene numbers it helped our practice numbers, we started doing Comp exams every three to five years in our patients and also that allow us to actually do a Comp exam on patients every three to five years and re-establish that level of trust and we looked at everything asked those tough questions you know asked those overall looking questions with them which was great. And then I think the other couple things and I wish we have more time to talk about it was the concept of a 4342 because when I was in school I don’t think that existed. We only had this whole the entire quad and now we can have localized perio treatment ok and then [crosstalk]

Rachel:     And that’s a very under-utilized code so yes.

T-Bone:    And there’s a quick question on that if you do a 4342 can you do a prophy at the same time?

Rachel:     You can do whatever you want if you’re expecting reimbursement the answer is no.

T-Bone:    Ok so that’s ok because the insurance can come and dictate everything ok and then the other thing that I think that’s underutilized this is the source of frustration for me as well is Arestin because now Arestin I used to hate Arestin because I have to buy it and it expired now they have Arestin RX program so like you know you have to buy the stuff you just have to write a prescription for it and the company you know your patients go get it prescribe to them and you can just charge a placement fee of fifty seventy bucks whatever you want to do makes it super easy for you and your patient so we should be utilizing that more.

                   I would say that if you’re doing a forty five minutes schedule I would say seriously consider going to a sixty minute schedule on that and you know and then I really like – we utilize this, we don’t do hygiene checks at the end of appointments anymore, we tried to do a hygiene check at a fifteen to twenty minute mark because we tried to break down the visit down into three sections twenty, twenty, twenty, twenty minutes is to do a fact gathering, twenty minutes for the actual prophy and then twenty minutes for God knows what at the end I don’t even ask anymore and then the other thing I would say is if your hygienist don’t have their own cameras get them some cameras.

Rachel:     Camera in every opertory.

T-Bone:    Yes, that’s what we’ve done, we put digital SLR in every opertory in the practice and enough mirrors and we track those to go through the day so…

Rachel:     And take photos on perio patients just like you would for prophy patient because that’s going to help your reimbursement and going to help with educating the patient so that’s something that a lot of us have never thought of in the past but, yes, take pictures of those bleeding gums.

T-Bone:    So Rachel, in conclusion if people want to get in touch with you what’s the best way to learn more about Rachel or get in touch with you or hear you speak and you know all of that stuff.

Rachel:     Yes, so our speaking calendar for all of us Inspired Hygiene is in our website which is Anybody can email me at and I want to offer too your listeners our book so this is a – we’re just releasing, I’m just releasing my first book it’s called ROH Return on Hygiene and it really goes into even more detail, TBone. I’ll send you a copy of this and some of the things that we discussed. I’ve got some cool worksheets and some things that you can do with your team and it will be on our website very soon, but for your listeners if you all e-mail us at and just put in the subject line “book request” then we will send you a book and we will take care of the shipping, we’ll send it to you and the shipping will be on us and I love to share that with your listeners and thank you so much for having me on.

T-Bone:    Oh, Rachel, thank you and I appreciate that and you know as an Indian my listeners will love anything free.

Rachel:     [laughs] I love it you’re awesome thanks everybody for listening and have a super day.

Thanks so much for listening to T-Bone Speaks with Dr. Tarun Agarwal. Remember to keep striving for excellence and we’ll catch you on the next episode.




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