The procedures pile up; time allotted for them doesn't
BY Kathy S. Forbes, RDH, BS
Why is the dental hygienist typically given 60 minutes to complete a continuing-care (recall) appointment?
I hear this question all the time from hygienists who are struggling to provide quality patient care within the allotted time. They describe scenarios of skipping the head-and-neck exam or intraoral exam; their employer will not purchase blood pressure cuffs so they don't collect vital signs; they only record pocket readings when a full-mouth charting is indicated; and other compromises to patient care. How did we get here?
Since history always plays an important role in relation to the present as well as the future, let's go back in time.
The simple life of 1972
The year was 1972, and as I eagerly crossed the stage to receive my dental hygiene pin and the coveted second purple stripe on my cap, I felt freedom! All the late nights of studying, early mornings at clinic to set up for my patient, completing handwritten outlines (no computers back then), tests, clinical requirements, and much more were all behind me.
No more having to find and schedule my own patients and pray they showed up. No more faculty peering over my shoulder during clinic, looking for that one speck of calculus or plaque I missed. I was prepared for boards (it helped that my dad was a perfect patient), and I had an interview lined up the following week. I was ready to take on the world and motivate every patient to better oral health!
My interview went smoothly and I was offered a full-time position at an hourly rate of $4 per hour-not bad since the minimum wage in Oregon in 1972 was $1.25 per hour. I was ecstatic!
After successfully passing my boards, I received my license, and I was off and running! Even though the equipment in the practice was a bit dated from what I was used to in school, it was my operatory. During my first day I saw eight patients, one every hour, which was more than enough time to get to know each patient, determine and complete necessary treatment, and complete all my handwritten chart notes.
From a historical perspective, it's important to understand what procedures I was expected to complete during those 60 minutes (with no dental assistant help, ever):
• Greet and seat patient/wash hands (no plastics, gloves, or masks)
• Take BW X-rays/process films in developer, water, fixer dip tanks
• Perform intraoral/soft-tissue exam
• Spot probe entire mouth unless "significant perio," then full-mouth probing
• Full-mouth calculus removal and coronal polish (almost always billed as prophy)
• Review brushing technique, correct if necessary/recommend and demonstrate flossing
• Get X-rays from darkroom (usually wet) and place on view box
• Get dentist to do restorative exam/document findings
• Dismiss patient and escort patient to front desk/tell receptionist the treatment recommended for next appointment
• Return to room and complete chart notes/take chart back to receptionist
• Return and wipe down operatory with alcohol wipes/take instruments to sterilization area/scrub and put instruments in cold sterile solutions or autoclave
• Pick up next tray
That was it. I even had time for bathroom breaks between patients. I loved my job and I loved the patients. There was no pressure about "production," and dental insurance was just coming into its own with a more direct reimbursement type of approach (paying percentage of dentists' fees with no middleman making reimbursement decisions or benefit limitations).
As time marched on, science and technology made leaps and bounds in the diagnosis and treatment of periodontal diseases. Patients were living longer and keeping their teeth, and they were accepting our treatment recommendations.
What led to the transition?
In 2001, the American Academy of Periodontology released the position paper on "Guidelines for Periodontal Therapy." This paper set forth the clinical objectives and scope of periodontal therapy. Hygienists were encouraged to work with their employers/dentists to incorporate these into their general practices.
In 2008, the American Dental Hygienists' Association adopted "Standards for Clinical Dental Hygiene Practice," which "provides a framework for clinical practice that focuses on the provision of patient-centered comprehensive care." These standards describe "a competent level of dental hygiene care as demonstrated by the critical thinking model known as the process of care." Hygienists now had a document that outlined their responsibilities to their patients, but how were we to accomplish everything during the 60-minute appointment time?
In 2011, "Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology" was published to "assist all members of the dental team who provide periodontal care, and it should be considered in its entirety." That means us! Dental hygienists are considered specialists when it comes to providing periodontal assessment, therapy, and so much more. These protocols would truly benefit the patients we serve, but how to convince our employers (and schedulers) that additional time may be needed, that the old model of 60 minutes will not work?
Using all of the resources and guidelines mentioned here, here is a listing of the minimum procedures that need to be completed on the continuing-care patient in 2015:
• Greet and seat patient
• Review health history/document medications/research medications for contraindications/discuss with patient
• Take and record vital signs (BP, pulse, respiration)
• Review and discuss risk factors to any medical/systemic conditions and correlate to potential periodontal conditions
• Wash hands and put on mask, loupes, gloves
• Discuss any chief complaints or concerns the patient may have
• Perform head-and-neck exam
• Perform intraoral/soft-tissue/oral-cancer exams
• Review need/no need for radiographs/if appropriate take necessary films (Remember, new "Guidelines for Prescribing Dental Radiographs" states, "Radiographic screening for the purpose of detecting disease before clinical examination should not be performed.")
• Perform general screening for tooth-related problems (broken teeth, etc.), tissue pain, issues patient may have mentioned earlier, take IO photos at this time
• Periodontal charting - probe entire dentition, recording measurements at least once a year to include pocket depths, bleeding, recession, furcations, mobilities, etc.; determine AAP disease classification as well as insurance case types
• Develop dental hygiene treatment plan and present to patient, including specific procedures recommended - adult prophy, SRP, etc.; provide and document informed consent
• Review oral hygiene methods, aids used, frequency; assess motivation, attitude, etc., and develop personalized plan
• Perform calculus removal and coronal polish (if prophy)
• If SRP recommended, depending on state practice acts, have dentist collaborate on treatment plan and determine what quadrants need to be completed today (dentist could do restorative exam at this time or at another appointment)
• If SRP to begin this day, administer local anesthetic as needed
• Determine if any of the following would be beneficial to patient's oral condition - fluoride application for caries control and/or sensitivity, irrigation of periodontal pockets, etc.
• Provide patient with appropriate post- op information
• Remove gloves and complete chart notes; if computer is in operatory, make next continuing-care appointment or SRP appointments/complete walkout statement
• Complete chart/treatment notes before escorting patient to front desk to make any restorative appointments and give walkout statement
• Return to operatory, put on gloves, tear down plastics, take instruments to sterilization area where assistant prepares them for sterilization or hygienist does his or her own; remove gloves
• Return to operatory from sterilization area and put on gloves and disinfect with appropriate solutions; then cover with clean plastics, etc.
• Retrieve new tray of sterile instruments and set up delivery area
Now, over 40 years later, dental hygienists are still expected to complete a continuing-care appointment in 60 minutes! Why? The historical reason would seem to point to tradition-"Because we've always done it that way" or, my favorite, "It's easier to schedule in one-hour blocks." We are short-changing our patients' well-being and oral health, which can unfortunately lead to mistrust and malpractice claims. We don't hear about them often, but claims against hygienists are increasing.
RDH magazine published an article in November 2013 titled, "Top reasons hygienists are sued" by Dianne Glasscoe Watterson, RDH, BS, MBA. As the article points out, "Life in the dental office can be hectic at times. One reality is that hygienists fight a never-ending battle with the clock." The top four reasons hygienists are sued are:
• Failure to update medical history
• Failure to detect oral pathology
• Failure to detect periodontal disease
• Injury to patient
I personally believe the reason for the "failure" is not having enough time to complete those procedures. Hygienists must become proactive in scheduling their patients appropriately in order to provide quality care. Their patients' lives could depend on it.
To answer the original question, why is the dental hygienist typically given 60 minutes to complete a continuing-care (recall) appointment?, my answer is that I don't know. I've been in this profession long enough to consider the following:
1. Dentists do not understand, or they choose to ignore, what procedures must be completed by the hygienist, and they fear production will decrease if more time is given.
2. Hygienists, as employees, are afraid to ask for more time for fear they may lose their jobs.
3. Business staff does not seem to understand the complexities of what procedures must be completed during the appointment time.
As specialists in providing preventive and periodontal care to patients, dental hygienists must take charge of their schedules, which means educating employers and staff regarding what must be done during the appointment time. It will probably not be an easy discussion, but it's one that must be done. Our patients depend on us to be their advocates for the comprehensive care they deserve. We are more than just the "cleaning" ladies/men! RDH
Kathy S. Forbes, RDH, BS, has been a dental hygienist, educator, speaker, and author for over 30 years. She speaks frequently about the correct classification, documentation, treatment planning, procedure code selection, and long-term case management for patients with periodontal disease. She is a contributing author for the Insurance Solutions Newsletter, a national publication for Dr. Charles Blair and Associates, where she addresses issues related to dental hygiene procedures and proper billing practices. Kathy is also owner of Professional Dental Seminars, Inc., a continuing education provider recently relocated to Colorado. She can be reached at (253) 670-3704 or [email protected].