Ah, the hygiene department, often called the “lifeblood” of a dental practice. Or, depending on how you’re coding, it might be the “bleeding heart” (literally and figuratively) of your financials.

In today’s world, hygienist wages have skyrocketed faster than a patient’s blood pressure when you mention scaling and root planing. And while many practice owners grumble about shrinking margins, the truth is… we can still run a highly profitable hygiene department if we actually code and bill correctly.

Unfortunately, many offices are unintentionally sabotaging themselves with a dangerous combo of habit, fear, and “this is how we’ve always done it” syndrome. Let’s fix that.

Step 1: Know Your Exam Codes Like the Back of Your Hand

The ADA has given us a beautifully organized set of diagnostic codes, and yet, I still see offices default to one code over and over. If your chart notes read like a broken record, you’re leaving money on the table.

D0120 – Periodic Oral Evaluation: For established patients. Use at recall visits only when it fits the definition.

D0145 – Oral Evaluation for Patients Under 3 Years of Age: Yes, toddlers count as patients.

D0150 – Comprehensive Oral Evaluation: For new patients or established patients who haven’t been seen in years and need a full-mouth review.

D0180 – Comprehensive Periodontal Evaluation: The Travis Campbell special. Dr. Campbell loves to remind us that if you skip this when perio is suspected or diagnosed, you’re under-treating and under-billing. The ADA’s definition is clear: this is for patients showing signs of periodontal disease, whether new or established.

Pro tip from Charles Blair: Your documentation must match the code’s definition. If you call it a comprehensive perio eval but your chart notes look like a prophy recall, you’ve just invited an audit to the party.

Step 2: Stop Calling Everything a Prophy
The number one financial leak in hygiene? Bloody prophies masquerading as D1110s.

Let’s review:

D1110 – Adult Prophylaxis: For healthy patients or those with mild gingivitis only. If the gums are bleeding like a crime scene, it’s not a prophy, it’s something else.

D1120 – Child Prophylaxis: Similar definition, but for the under-14 crowd.

Why it matters: A prophy pays less than other hygiene codes. Every time you incorrectly code a bloody mess as a D1110, you’ve just thrown away legitimate production, under-treated the patient, and reinforced the “patients will get mad” myth.

Step 3: Embrace the Perio Codes, They’re Your Friends
There’s a fear in many offices that patients will revolt if they hear the words scaling and root planing (SRP) or periodontal maintenance. But here’s the thing, patients can’t accept treatment you never present.

D4341 – SRP, four or more teeth per quadrant
D4342 – SRP, one to three teeth per quadrant
D4910 – Periodontal Maintenance (after active therapy)
D4346 – Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation – This gem is criminally underused. The ADA says this is for patients with generalized gingival inflammation, no attachment loss, and who need more than a prophy.

As Travis Campbell points out: D4346 was created to address a treatment gap—patients too inflamed for a prophy but not yet perio. If you’re skipping it, you’re leaving clinical and financial value behind.

Step 4: Don’t Forget D4355 – Full Mouth Debridement
D4355 – Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis is often misunderstood, underused, or misused.

This code is for patients who haven’t had a cleaning in years—typically five years or more—and present with so much plaque, calculus, and debris that you can’t even see what you’re diagnosing. The goal is to remove enough buildup so you can then perform an accurate comprehensive evaluation.

Two common mistakes with D4355:

Skipping it entirely because it adds cost and going straight into SRP. This skips an important step in properly diagnosing what’s going on under all that debris.

Billing it with D0120 in the same visit. Most insurance companies won’t pay for both, and it can cause D4355 to be denied.

Best practice: Bill D0140 (limited evaluation) at the D4355 visit, then bring the patient back for a D0150 (comprehensive evaluation) or D0180 (comprehensive perio evaluation) once you can actually assess the mouth fully. This sequencing keeps you compliant, gets you paid, and follows ADA definitions.

Step 5: Documentation is Your Armor
Proper coding without proper notes is like a toothbrush without bristles—useless.

Record pocket depths, bleeding points, inflammation notes, and plaque scores.
Take intraoral photos of inflammation and calculus.
Write why you chose that code over a prophy.

Charles Blair often warns that in an audit, your notes are your only defense. If the chart says “prophy” but the bill says “SRP,” you’re in trouble.

Step 6: Stop Apologizing for Dentistry
One of the biggest cultural shifts we need in dentistry is confidence in presenting hygiene treatment.

Patients don’t get mad because you diagnosed perio—they get mad when you surprise them with unexpected costs or fail to explain the “why.”

Solution: Train the team to:

Use layman’s terms (gum infection vs. periodontal disease).
Show them their own mouth (photos don’t lie).
Connect treatment to overall health (“This infection can affect your heart, blood sugar, and more.”).

The Bottom Line: Hygiene Can Still Be Highly Profitable
With today’s wage demands, you can’t afford to undercode. If every exam and treatment is coded exactly to ADA definitions, you’ll:

Increase production without increasing chair time.
Improve patient care by matching treatment to diagnosis.
Protect your practice from insurance audits.

Hygiene is not just “cleanings”—it’s preventive medicine, and it should be coded (and valued) accordingly.

So, next time you see bleeding gums during a “prophy,” ask yourself: Is this really a prophy, or am I donating perio care to insurance companies?

Do the right thing for your patients. Do the right thing for your practice. And for heaven’s sake, let’s stop doing bloody prophies.