	Millennials in almost any arena except dental hygiene know entry level is a bachelor's degree. Many dental hygienists have an associate’s degree but have paid for a baccalaureate in time, energy and cold, hard cash.

	The only people who don’t know it are recent grads, non-dental people and registered dental hygienists that just ignore this cold, hard fact.

	Once hygienists learn they’re gypped out of an undergrad degree, it’s usually too late. Physical limitations start to become evident, and working chairside becomes increasingly difficult.The only way to change it is to talk about it.

, who started her own university for dental hygienists with associate's degrees. Trish was motivated because of the disdain she saw between orofacial myofunctional therapists (OMTs) trained via the speech pathologist route to those on the dental hygiene route.

More from DiGangi and Gutkowski: The truth about alternating codes D4910 and D1110

	They said hygienists weren’t educated enough.Trisha sat down and counted all the credits associate's degree hygienists earn before finishing the 90 they earn for their degree. It turned out hygienists have more credits than speech pathologists.

	One of the dark days Shirley had as state DHA president was hearing a dentist in a legislative hearing tell the legislators that dental hygienists had only a technical school degree and could not be loosed onto the unsuspecting public. Patti sat in a legislative committee hearing in 2015 in her state when it was said a dental hygienist with only cursory education does not have the skills to review health history.

 has emphasized the need for advanced practitioners yet the majority of the currently practicing professionals don’t have the degree needed to even consider this.The ADHA says in its 

 (page 23), “the American Dental Hygienists’ Association declares its intent to establish the baccalaureate degree as the minimum entry level for dental hygiene practice.”

Free on-demand webinar: Understanding medical billing and its relationship with 3D

	Unfortunately, the ADHA has no direct standing, authority or say-so in the credentialing of a school or setting the standards of education. The ADA requires students to take courses and hire people who are schooled to only work in a

dental office. Today, there are 50 or more applicants to every chairside opening. The more experienced clinical hygienists cannot move out of their clinical position; they don’t have the education they need to work in any other health care field. The new, need-to-practice hygienists can’t find an empty chair to sit in. In addition, the hourly wage of an employee is about 2/3 of what it was 15 years ago.

	Even worse is the decreasing number of four-year schools offering a dental hygiene baccalaureate program and the price of the two-year non-transferable degree that costs the same and has the same credit outcome of a four-year degree.

	This education system is so broken it’s hard to imagine a repair. The fox guarding the hen house is costing the country billions of dollars. People need access to dental hygienists at every life stage. In long-term care alone, billions of Medicare and Medicaid dollars are wasted because oral care is delegated to a nursing assistant with a higher comfort level with the end of the alimentary canal without teeth.

More from DiGangi: 5 things your dental practice needs to know right now about Medicare

	Here hygienists are like battered spouses still willing to work with the very people who have had a foot on hygienist’s neck for the last 75 years. 

 was right when he said hygienists are necessary to help patients learn how to care for their teeth.

	The current educational system is a double-cross, and we need to sound an alert-Patients and legislators need to know. Dental hygienists are uniquely qualified to care for the mouth-the center of the person, the most innervated area of the body, the center of health and disease, love and communication. Our Boomer, Xer, and Yer, compatriots may be able to look to our Millennial co-workers to set this system right. Let’s get out of the way and let them try.

	We want to hear from you on this issue. This is huge for the future as well as anyone looking for employment right now. Please post your thoughts below.

	Check Out Training Podcasts at Blog Talk Radio with 

More from DiGangi and Gutkowski: Bleeding on punching in the nose: Thoughts on bleeding on probing

	Millennials in almost any arena except dental hygiene know entry level is a bachelor's degree. Many dental hygienists have an associate’s degree but have paid for a baccalaureate in time, energy and cold, hard cash. The only people who don’t know it are recent grads, non-dental people and registered dental hygienists that just ignore this cold, hard fact.

Once hygienists learn they’re gypped out of an undergrad degree, it’s usually too late. Physical limitations start to become evident, and working chairside becomes increasingly difficult.The only way to change it is to talk about it.

They said hygienists weren’t educated enough.Trisha sat down and counted all the credits associate's degree hygienists earn before finishing the 90 they earn for their degree. It turned out hygienists have more credits than speech pathologists.

One of the dark days Shirley had as state DHA president was hearing a dentist in a legislative hearing tell the legislators that dental hygienists had only a technical school degree and could not be loosed onto the unsuspecting public. Patti sat in a legislative committee hearing in 2015 in her state when it was said a dental hygienist with only cursory education does not have the skills to review health history.

Unfortunately, the ADHA has no direct standing, authority or say-so in the credentialing of a school or setting the standards of education. The ADA requires students to take courses and hire people who are schooled to only work in a

Even worse is the decreasing number of four-year schools offering a dental hygiene baccalaureate program and the price of the two-year non-transferable degree that costs the same and has the same credit outcome of a four-year degree.

This education system is so broken it’s hard to imagine a repair. The fox guarding the hen house is costing the country billions of dollars. People need access to dental hygienists at every life stage. In long-term care alone, billions of Medicare and Medicaid dollars are wasted because oral care is delegated to a nursing assistant with a higher comfort level with the end of the alimentary canal without teeth.

Here hygienists are like battered spouses still willing to work with the very people who have had a foot on hygienist’s neck for the last 75 years. 

The current educational system is a double-cross, and we need to sound an alert-Patients and legislators need to know. Dental hygienists are uniquely qualified to care for the mouth-the center of the person, the most innervated area of the body, the center of health and disease, love and communication. Our Boomer, Xer, and Yer, compatriots may be able to look to our Millennial co-workers to set this system right. Let’s get out of the way and let them try.

We want to hear from you on this issue. This is huge for the future as well as anyone looking for employment right now. Please post your thoughts below.

Articles

 Millennials in almost any arena except dental hygiene know entry level is a bachelor's degree. Many dental hygienists have an associate’s degree but have paid for a baccalaureate in time, energy and cold, hard cash. The only people who don’t know it are recent grads, non-dental people and registered dental hygienists that just ignore this cold, hard fact.

Do you have an associate's degree but paid for a bachelor's?

	Since 1991, people have had questions about alternating codes 

Even those who think they know the answers don't quite understand the why. It all comes down to dental-medical necessity. Not sure what that is? 

 series of books to help professionals understand the process and use critical thinking, which is more important than knowing a bunch of code numbers.


	Coding should not depend on what a benefit package will cover. It should be based on the individual dental-medical necessity determined at each visit. Dental-medical necessity is a thought process and terminology not well known in dentistry. Yet, as a dental hygienist, you know and probably document it daily. Dental-medical necessity documentation simply requires recording the reason a procedure is needed. In other words, treatment is based on the documented risk assessment and the diagnosis.

, there are parameters used for periodontal treatment coverage. Though the parameters vary policy to policy, let’s consider a current example from 

, which states, “To be considered for a benefit, diagnostic materials must demonstrate the following, consistent with professional standards:

		Clinical loss of periodontal attachment and/or

		Radiographic evidence of crestal bone loss or changes in the lamina dura and/or

		Radiographic evidence of root surface calculus …” –Revised 1/16/15.

The third parameter of root surface calculus is based on the philosophy that calculus is the cause of periodontal breakdown, a theory that has not been supported in periodontal research since the 1960s. Waiting for bone loss is somewhat akin to waiting for a heart attack before treating someone with high blood pressure.

The second parameter, bone height, must be evaluated to determine if there is loss. What is a normal bone height measurement if measured from the alveolar crest to the CEJ? One would think that every professional instantly knows the answer. Yet, as we asked the question around the country, the opposite is more often true. Very few dental hygiene professionals seem to know the answer is 1.5-2mm. This measurement can only be taken on radiographic images.

The first parameter, clinical loss of periodontal attachment, involves a measure of periodontal attachment. This is a derived measurement combining probing depth and distance of the gingival margin relative to the CEJ. Suppose we are evaluating tooth No. 2, and the sulcus depth measures 3-2-3. That sounds okay, yet what if there is recession? Would it make a difference the recession is 3-3-3 or 3-2-3 or 1-1-3 or 3-3-1 or 3-2? Each of those a distinctly different levels of attachment and same tooth. If inflammation is noted in an area with 3mm AND 3mm of recession, how clinically significant is it? The parameters of this carrier seem to count it toward something-Do you?


	Many times, hygienists have been told the insurance company said it was okay to alternate D4910 and D1110. What must be understood is the carrier can only say what would be covered under the policy. This does not mean this is accurate coding.

What if patient comes back for her three-month appointment and her periodontal condition is stabilized? Can she go back to D1110? 

 has said it is a matter of clinical judgment of the dentist. It is appropriately reported as D4910, but if the treating dentist determines the patient can be treated with routine prophylaxis, D1110 may be appropriate. D1110 can be used, but later you cannot go back to D4910 without a new diagnosis and treatment of an active periodontal infection with bone loss. The words of the D4910 state, “…if new or recurring disease occurs…” The problem, as we have discussed before, is 

Follow-up care for a patient who has received active periodontal therapy can receive the D4910 code. Again, a carrier can only say what is covered under a policy. This does not mean this is the correct coding. Back in 2006, a dentist from the ADA Dental Benefits Office said, “D1110 and D4910 are not interchangeable and should not be alternated. The dentist must make the diagnosis, but then the proper code for the procedure provided needs to be used. It does appear that you could choose one code or the other, based on the diagnosis, but it would never be appropriate to alternate them.”

A narrative can be added to a claim form stating, “If periodontal maintenance (D4910) is not available for reimbursement, please provide the alternative benefit of (D1110) prophylaxis.” This is different than changing the code. Purposely changing a code for the purpose of increasing reimbursement can be considered fraud.

More from DiGangi and Gutkowski: Be part of the oral cancer change


	The challenge in understanding alternate coding is based on past thinking confusing current choices. Dentistry has so long been accustomed to thinking directly about the treatment and often skipping over documenting risk assessment and diagnosis. When those steps are routinely documented, coding is much simpler. No games need to be played. The coding is clear-cut. Fraud is no joke to anyone holding a license. Taking the time to understand coding leads to success.

What do you think? Have any ‘war-stories’ to share? Let's help each through this mine field.

More from DiGangi and Gutkowski: Evidence, hype or manipulation?

Listen to DiGangi and Gutkowski's podcast on this topic below:

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More from DiGangi and Gutkowski: Breaking the law, dental hygiene style

 Since 1991, people have had questions about alternating codes D4910 with D1110 for follow-up of periodontal care.

The truth about alternating codes D4910 and D1110

	If we described a team member who produced 30 percent of the practice revenue, was the reason more than 80 percent of new patients came into the office and from whose operatory 60 percent of restorative treatment was discovered, you may likely be thinking this is one heck of an associate and partner.

Actually, we have just described your hygienist!

As a provider of care, generator of revenue and a chief draw of new patient and recall traffic, the hygienist should be viewed as a 

 in the practice, and yet we often relegate them to subordinate, auxiliary employee status.

There are various reasons why we overlook the value hygienists bring to a practice, chief among them the fact that hygienists do not view 

 as partners and often do not realize their own value and contributions.

We are not advocating that professionals who do not diagnose treatment be given equanimity with the doctor. We all know that treatment decisions ultimately fall on the doctor’s shoulders. For that reason, giving a hygienist that 

A partnership does not mean identical equality in decision making or having complete financial ownership and responsibility. “Partnering” can mean many things and take many forms. 

 defines a partner as “a person who takes part in an undertaking with another or others, especially in a business or company with 

Giving hygienists a collaborative role in the practice has more benefit than risk. Give them a stake in the success of the practice, and you increase their accountability to the group. Partnership fosters responsibility and discipline. It sparks an awareness of accountability that we don’t see with more subordinate team members.

It is a known fact that those who have a sense of ownership in an endeavor take more thoughtful actions, view their work as more meaningful, show up early, leave late and generally work harder. They are more apt to educate themselves and others.

In short, they are less likely to be self-focused and tend to be more team-centered.

Hygienists weigh in: The most helpful hygiene products

These are the things we want from our hygienists and are often frustrated when they do not seem to take ownership. We don’t understand why they do not demonstrate the leadership qualities we know they surely possess.

However, when we relegate them to the hygiene operatory, exclude them from having input in decisions that affect the team and have closed-door “leadership” meetings without them, we will continue to see more of the same “subordinate” behavior we want to discourage. In other words, if we view them as auxiliary, they will never rise to be 

In order to spark a sense of leadership and accountability in your hygiene team, you will need to take leadership yourself. It may not happen overnight, but with each step you take, you will likely begin to see those latent leadership qualities emerging.

Read on for some simple actions that will elevate your hygienist to partner status:

		Hire hygienists whom you want as a partner, and understand the importance of strong patient care and the business objectives. Just as you would not hire a doctor who would not be on board with practice goals, hire hygienists whom you can see yourselves collaborating with and whose judgment you respect.

		Clearly define goals and expectations for your hygiene team. Using key performance indicators is the best way to communicate this and track success.

		Give them a financial stake in the practice-whether through production based compensation or bonuses.

		Provide training and coaching to them so they can reach their full potential.

		Have an open- door policy, and let them know honesty is safe.
		 

Related reading: Wendy Briggs on the future role of the dental hygienist 

		Give them autonomy where it is warranted. Do not micromanage.

		Highlight their contributions. Have a great production month? Let them know their contribution in more detail than, “Great job!” Tell them instead how much revenue they produced-and what that means for the practice.

		Share practice financial reports and goals with them.  Knowledge is power!

		Hold them accountable to being solution-focused.

It’s lonely at the top. Having a partner ensures burdens are shared, and we have another advocate we can depend on. It means knowing that this person has the good of the whole in mind. It means folks will mostly manage themselves rather than having to be managed.

Hygienists are fundamental to the success of a practice. Making sure your hygienists know and feel that is fundamental as well.

Andrea Kowalczyk, RDH, BS, works as a senior hygiene performance coach with 

. She is a national speaker and author. She can be reached at 

Related reading: 4 characteristics dental hygienists need to become successful entrepreneurs

 If we described a team member who produced 30 percent of the practice revenue, was the reason more than 80 percent of new patients came into the office and from whose operatory 60 percent of restorative treatment was discovered, you may likely be thinking this is one heck of an associate and partner.

modernhygienist.com-2015-05-01

Do you have an associate's degree but paid for a bachelor's?

The truth about alternating codes D4910 and D1110

The importance of partnering with your hygienists