By Brenda Kibbler, RDHAP, BHSc
It was a cloudy Friday afternoon in February, and the weather forecast called for heavy rain later in the day. I was on the way to provide an in-home dental hygiene treatment to my 92-year-old patient. As I drove, I noticed sprinkles on the front window of my car. No problem, I thought; the heavy rain is due later in the afternoon. But by the time I parked in front of my patient's home, the rain was already pouring down.
I sat in my car and contemplated how I would manage to carry all of my heavy equipment in one trip to the house and stay dry. Something was going to get soaked, and I did not want it to be me. It turned out that both the equipment and I were soggy when I reached the door.
Once inside the warm, dry house, I was escorted to my patient's room. I unpacked my new dental patient chair and set it up in front of the closet. I proceeded to construct the operator stool and then neatly set up my instruments on a tray just like in the dental hygiene office. I also prepared my portable dental unit, which contained a suction, high- and low-speed handpiece connections, and a Cavitron connection. I had converted the room into a dental hygiene operatory and was ready to offer my patient the best dental hygiene service I could.
My frail patient entered the room in a beautiful wheelchair with the option to recline it into a position that allowed me to view her mouth better than my dental chair. After months of planning and purchasing what I thought would be the best equipment for my patients, I realized I did not have the best equipment for this patient and had to come up with plan B. For this particular situation, I had an abundance of equipment that I really did not need, including the dental unit. I believe there is a time and place for which the dental unit is a significantly important piece of equipment. For example, it would be very effective at a community event where there is a one-time setup and then, at the end of the day, the equipment is dismantled. I would caution against using it at every in-home visit, however, because the unit weighs about 80 pounds and is very heavy to lift out of a car.
I evaluated my patient's overall health and felt it would be best to treat her in her wheelchair. The risk of moving her to the dental chair was not one I was willing to take when I could keep her comfortable in her own surroundings. Over the next few weeks, I rethought my equipment setup and decided to incorporate the use of an antigravity-type lounge chair. The chair is perfect for ambulatory patients who can easily lift themselves in and out of the chair. It is also ideal for the operator since the chair reclines back and resembles the traditional position of a dental chair. Some chair styles come with an adjustable or removable neck pillow and a hideaway tray that is perfect for the instrument tray. It slides under the seat of the chair when not in use. I purchased my chair from Costco, but they are also available at many sporting goods stores and home repair stores. The lounge chair is very inexpensive at approximately $50 compared to a traditional portable dental chair, which costs $500 and up depending on the brand and style. The weight of the chair was also a concern. My beautiful patient chair not only came at an expensive price, but its weight made it challenging to lift out of the trunk of my car even when it was not raining.
1. Chair in folded position for transportation, as well as when assembled for patient care.
2. The side rails on a hospital bed are used to provide support to operator when having to lean forward.
3. Scott uses his suction unit during a periodontal maintenance appointment.
4. Plastic box for patient setup
5. Portable suction unit.
6. A side view of a scrap-book carrying case.
I learned so many things from the series of events that took place during my patient's appointment that I decided I needed to create an operatory setup that had the flexibility to adjust to many different scenarios. My medical intake includes questions pertaining to the patient's daily living situation, which gives me the information I need to successfully arrange for dental hygiene care. With these new questions added to the medical history questionnaire, I save a lot of time and energy, as well as protect my patient's health from a potential fall during the transfer to a traditional portable dental chair.
Many medically or physically compromised patients have a hospital bed at home. These types of beds are ideal for providing dental hygiene care, because they are able to incline and decline. The head support is typically comfortable for the patient during treatment and the bed height is adjustable, which helps support my back. Some of the beds have metal bed rails on the sides, which offer assistance when leaning over to reach the patient.
Generally, the more comfortable the patient, the easier the appointment will be. When many of my patients in hospital beds are cuddled up with warm, cozy blankets, they tend to be more relaxed and enjoy the appointment better. Additionally, many patients who have hospital beds also have a long, horizontal, adjustable-height table that can be rolled next to the patient or over the patient's bed. Use of the table helps reduce taking extra equipment and makes it easier to prepare instruments and other items for dental hygiene treatment. I always ask patients who say they use a wheelchair what capabilities their chair has. Some chairs are equipped to recline by the back of the chair or the entire chair reclines, offering complete access to the patient's mouth.
In several situations, a suction unit is required. If a patient has muscular dystrophy or a respiratory condition that requires daily use of a suction unit, ask if it can be used during the appointment. One of my most enjoyable patients to treat is Scott. I met him in 2003 when I was enrolled in the Alternative Practice Program at West Los Angeles College. Scott was diagnosed with muscular dystrophy when he was three years old. The day of Scott's appointment was full of emotion. My introduction to Scott was when he was in the intensive care unit a couple of rooms down from my dad, so knowing that he was home was comforting. I knew he had recovered. I was excited that he was home and feeling better, but also a little nervous since I had not treated a patient who had had a tracheostomy and was ventilator dependent.
I did my research and had my equipment ready to go. I had learned from my research that individuals with respiratory failure would have a suction unit present since they require regular removal of oral and respiratory secretions, but I had my unit packed since I was more familiar with how to use it. After setting up my equipment and examining the workings of Scott's suction unit, I decided to use his since it was much easier to use, compact, and quiet.
I realized at that time that I needed to think outside the "dental equipment box" to make treating my patients easier and the appointment time more efficient while still maintaining a high level of care. Scott's suction unit was purchased through a respiratory care supply company that stocked many different styles and sizes of suction units and additional supplies. It was the perfect resource for me as it had many small, portable, lightweight devices to choose from. Price ranges depended on the model. Medical and respiratory equipment companies are the best suppliers of suction units, and most companies will sell directly to individuals versus only large hospitals. I have purchased suction units from DeVilbiss Healthcare and Roscoe Medical Supply.
Scott's appointment went smoothly. He was a great patient and assistant, because he likes to use the suction himself when needed. Unfortunately, I do not have Scott with me at all times to be my assistant, so I need to rely on the Blue Boa suction appliance to help me. This device attaches nicely to the tubing on the suction unit and stays securely in place, as well as being comfortable for the patient. An additional benefit to using the patient's suction unit is that minimal cleanup is necessary when treatment is completed compared to my suction device, which needs to be thoroughly cleaned after each use.
Many of my patients cannot tolerate the vibration of a polishing device, but for those who look forward to having their teeth shiny and smooth, I use a prophylaxis angle and paste and hand polish. This eliminates the concern of how to sterilize a portable polishing unit, and there is no worry of splatter. I find this practice is best for me and my patients in maintaining the best infection-control practices. Patients love the feel of their smooth, clean teeth.
1. Always keep the patient's health and your health in mind.
2. Use what equipment that is available at the facility or home (paper towels, soap, water, chairs, etc.).
3. Think outside the "dental equipment box" when purchasing equipment.
4. Consider the weight of equipment.
5. Contemplate transportation of equipment.
Preparing in Advance
Once I have reviewed my schedule for the day, it is time to prepare the instrument setups I will need. I have two instrument setup plans for the different treatment plans I have established. I use the one that will initially pertain to my clients' needs and alter it as needed. One tray setup includes a sterilized instrument packet, prophylaxis angle, prophylaxis paste, 2x2 gauze, mask, gloves, bib, disposable bib clip, plastic barrier covers, pen, cotton tip applicator, topical anesthesia, and fluoride varnish, which is placed in a plastic pencil box. The pencil box is a perfect way to carry all of the supplies I need, because it snaps closed and is secure for traveling.
After the appointment is completed, all disposable items are properly disposed of, and the instruments are rolled in the plastic tray cover, which is then placed back into the empty plastic pencil box and stored safely and securely for traveling.
My second tray setup includes a small tray inserted into a plastic tray cover. The sterilized instrument package is placed on the tray along with the other essential items: prophylaxis angle, prophylaxis paste, fluoride varnish, cotton tip applicator, topical anesthesia, disposable bib clip, bib, plastic barriers for pens and polishing systems, mask, gloves, and 2x2 gauze. The completed tray is then wrapped with the extra plastic tray cover for protection and is ready for transportation.
The different setups are used for different situations. For example, if I am treating many clients at one home, I will use my small tray setup and have as many trays out and ready to go as I need. In this situation, I have a separate plastic pencil box labeled biohazard material that I use and designate an area for the used instruments to be placed in until I am finished for the day.
When I am finished with my clients for the day, I clean and disinfect the trays and instrument box and prepare them for travel. Over the years, I have had many different methods of transporting my equipment from home to home. Initially, I started out with a black backpack that my son had used for his school books and was now stored in my closet. I thought it would be the perfect fit for my needs since I wanted something on wheels that was lightweight. It served me well until I outgrew it. I did not have enough space to carry the trays and boxes that I needed daily.
My next traveling case was a scrapbooking case that I purchased from a local craft store. I thought the little black backpack was great until I moved all of my equipment into the new bag. I loved my new bag, and it made traveling with all my equipment so much easier.
Another system that my husband stumbled across while I was shopping for makeup was a makeup train tote. This tote is amazing. The makeup train tote is divided into three separate sections and can be used with either two or three of the compartments. It has wheels for easy transportation and is fairly light to carry depending upon how much equipment is in it. I recommend investing in one. I am now on my third scrapping tote bag and not sure what I will do next if the manufacturer stops making the bag size I need. If that happens, I will just have to think outside the box, and I am sure I will find something.
Once I am home, I place the instruments in my ultrasonic cleaner and then sterilize them. The plastic boxes are disinfected, sanitized, and stored until dry and ready to be repacked.
I will continue to try new equipment and ways to transport my equipment so I can make someone smile. RDH
Brenda Kibbler, RDH, RDHAP, BHSc, is a consultant and business owner. Her independent dental hygiene practice, Dental Hygiene For The Homebound, provides specialized and individualized dental hygiene treatment to medically and physically compromised patients. She is a recipient of the 2013 Sunstar/RDH Award of Distinction. Brenda can be reached at [email protected]. Visit her website at hygienehousecalls.com.