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Profile in Oral Health Trisha O’Hehir, RDH, BS, MS

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Procedures Done Without Informing or Charging the Patient

by Trisha E. O’Hehir, RDH, BS, MS


The idea of doing procedures on patients without telling them and without charging them seems more fanciful than factual. You might be laughing, but this happens every day in dental practices across the country. It's very likely happening in your practice. From a business standpoint, profits are lower than they could be. From a professional standpoint, why provide free treatment without even telling the patient. They can't even be appreciative if they don't know they've just received several hundred dollars worth of treatment for which they will never be billed. At least give them a chance to say "thank you." If you're providing subgingival instrumentation at a prophy visit without telling them and without charging them, instead of being appreciative, they'll just think you're rough!
To find out how much undercover dental hygiene is provided in your practice, try this simple experiment for just one day: Assign a fee for each procedure done by the dental hygienist, a list is provided (see Dental Hygiene Procedures below). Feel free to add other procedures I might have missed. Just imagine you were asked by a patient to have one of these procedures done and they needed to pay for it. How much would you charge? What are these procedures worth? Still having a hard time? Check your last medical or hospital bill for itemization and you'll see how easy it is to assign a dollar amount to each procedure. Your current prophy fee should equal the fees you assign for supragingival instrumentation and polishing added together. After all, that's what a prophy is.

Now, complete a procedure sheet for each dental hygiene patient you see in one day. Add up all the individual procedure fees and see how that compares to the actual "prophy" fee you're charging. This will give you an indication of how much undercover dental hygiene is going on in your practice.

Well, you say, "These are all part of a prophy appointment." If they are, do your patients even know you're doing this? Or do they think the visit is just for "polishing" and the rest is just poking around, looking for a good place to start. That's what one of my patients said to me when I began working with an assistant who recorded the periodontal records for me. Calling the probing, recession and bleeding scores out loud gave the patient a new perspective. He asked why I had just started doing that, after three years of seeing him. When I told him I'd been recording these numbers every three months for the past three years, he was amazed! I showed him the charting forms and he said, "I had no idea you were measuring something, I thought you were just poking around looking for a good place to start scraping." Ask your patients what they think you're doing and you might be quite surprised at their answers.

If you found the procedure sheet experiment interesting, take it to the next level. At the end of each dental hygiene visit, give the patient the sheet, with all the fees for all the procedures and then mark "No Charge" next to all the ones you now give away for free, leaving only the supragingival instrumentation and polishing fees. Let them see the true value of their visit and how inexpensive it really is by comparison.

When you add up day by day, week by week and month by month how much money you are giving away, you might want to rethink your "prophy" appointments.

This didn't just happen, it's evolved over many decades. When I started clinical practice more than 40 years ago, prophy appointments were much simpler. We reviewed the medical history with very few medications being taken back then. We didn't take blood pressure or vital signs, we didn't chart probing depths or existing restorations and we didn't have cameras in the operatories. We scaled and polished and the dentist did the exam, preceded by a question to the hygienist "What did you find?" That was it.

We weren't doing scaling and root planing (SRP) on hygiene patients back then; they were all referred to the periodontist. We did do "deep cleanings" on those who didn't accept the referrals or those who hadn't yet lost half the bone around their teeth. Criteria back then for referral was significant bone loss evident on the radiographs. Periodontal charting was reserved for the periodontist.

Over the years, more and more procedures were added to the prophy appointment, all the while hearing complaints from the dentist that an hour was too much time and from the hygienists that an hour just wasn't enough time.

First it was periodontal records, then head-and-neck cancer screening exams. Anesthesia was added and with that came the need to record blood pressure and vital signs. Cameras came next, both for taking intraoral photographs and intraoral cameras to show patients cracked teeth and red, inflamed tissue. As new products came out we were expected to provide desensitizing procedures, and discuss products for xerostomia, fresh breath and remineralization. New tests are now available to measure pH of the saliva and check for specific bacteria by their DNA. All this and more, while practice management experts and financial advisors suggest cutting the prophy appointment time.

It seems that a "prophy" is no longer a "prophy" in terms of included procedures. It's become an appointment filled with undercover dental hygiene services. An oral prophylaxis or recall visit is designed for periodontally healthy (no pockets and no bleeding) patients to keep them healthy. This appointment includes supragingival instrumentation and polishing. That's all. It does not include subgingival instrumentation, as that is considered SRP. It does not include caries counseling, fresh breath counseling, oral myology or periodontal therapy, which are so often given away as part of a prophy appointment. Even oral hygiene instruction has a separate code and should be listed and billed separately.

The solution: simply give up doing undercover dental hygiene services. Offer and charge for all those products and procedures that were previously given away. Now, in separate appointments, you'll have the time to professionally discuss the caries process, the importance of pH changes in the mouth, which foods and drinks are highly acidic and contribute to caries, and the value of striving for five exposures to xylitol each day. And this is just dealing with those patients at risk for caries. Add to that a fresh breath program, oral myology, periodontal therapy and you have a very busy, successful dental hygiene department.

The biggest obstacle to making this change is the altruistic view of dental hygienists. As a profession, we would love nothing more than to give away our services. We want everyone to have optimum oral health, but by providing undercover dental hygiene services, we have actually undermined our ultimate goal. Those who do not clean between their teeth daily with floss, sticks, picks or oral irrigation are very likely to have gingivitis or periodontitis, with bacterial biofilm and calculus in each interproximal space. By providing undercover dental hygiene treatment in the form of subgingival instrumentation to treat this disease, the message to the patient is "you're healthy." The "bloody prophy" is accepted as normal and within the definition of health.

Following the exact definition of the oral prophylaxis code 1110 and treating those with gingivitis using another more appropriate code at a higher fee actually sends the patient a message they can easily understand. Clean between your teeth, prevent gingivitis and the fee is lower. Fail to clean between your teeth, allow gingivitis to occur and the fee to treat this condition is higher than the fee to treat a healthy mouth.

For too long, the oral prophylaxis code 1110 has been used inappropriately to treat gingivitis and early periodontitis. Using the code 1110 implies a diagnosis of health. Gingivitis is not health. Medicine uses diagnostic codes linked with treatment codes. Doing that in dentistry would be an important step in preventing undercover dental hygiene. The problem is we don't really have a code for treating gingivitis. We do have treatment codes for treating periodontitis, both localized and generalized. But no treatment code specifically for gingivitis. Therefore, the periodontitis codes are the most appropriate at this time.

Another approach is to create new treatment options that patients want and will pay for, rather than focusing entirely on insurance codes. Paying for what you want is more desirable than paying for what someone else tells you, you need. Focusing on insurance codes hasn't worked as well as it should, so it's time for a change, time for a new marketing strategy.

The primary cause of bad breath is failure to clean between the teeth and the dorsum of the tongue. Creating a fresh breath program in your dental hygiene department will offer patients a solution to a problem they might have. Treating gingivitis isn't all that exciting or motivating to most people, but getting rid of bad breath is. The treatment for bad breath is often the same as treatment for gingivitis or periodontitis, plus tongue cleaning and product advice to neutralize volatile sulfur compounds (VSCs) or eliminate the bacteria that cause VSCs. By taking the gingivitis treatment out of the prophy appointment, you increase compliance, create a new revenue stream and offer patients something they want.

The same is true of caries counseling, remineralization therapy, xerostomia advice and coaching to stop thumb sucking. To be effective, this takes time, lifestyle questions need to be answered and the process explained carefully to both young and old. These undercover dental hygiene services can be taken out of a prophy appointment and offered as Oral Health Coaching, with an appropriate fee. This will take the stress off the prophy appointment and give adequate time and attention to the many new therapies now available to help patients achieve optimum oral health. Don't keep these a secret, announce to the practice the scientific advances you now have available for them, in the form of Oral Health Coaching.
Dentaltown Magazine
September 2025
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