Running from a challenge?

'Customized hygiene' relieves monotony and stress, and individualized care focuses on a triumvirate of roles for dental hygienists.

by Misty Franklin Perkins, RDH, BS

Do you ever wonder how you can be a more effective hygienist? Do you sometimes feel frustrated with the level of patient care you provide? Do you want to be challenged and stimulated by your work on a daily basis?

The key to effective practice as dental hygienists is in individualizing the care we provide for each and every patient, offering them "customized" hygiene service in education and treatment.

Patients who experience customized care will feel very special and receive more from an appointment than they otherwise might. The employer who supports customized care will reap the benefits of happy, motivated patients and a hygienist that produces well over her keep. Most importantly, the hygienist who is excited and challenged by her work is less likely to experience "burnout."

Studies have concluded that many hygienists burn out within two to five years of practice due to monotony, stress, and the feeling that they fail to make a difference. In The Truth About Burnout: How Organizations Cause Personal Stress and What To Do About It, Christina Maslach and Michael P. Leiter propose that energy, involvement, and efficacy are direct opposites of burnout. They state that burnout occurs when "energy turns into exhaustion, involvement turns into cynicism, and efficacy turns into ineffectiveness."

I believe that if we remain passionate and stimulated in the daily practice of dental hygiene, then we will be at low risk for becoming emotionally exhausted, frustrated, and eventually burned out. We must keep our practice challenging and varied. What better way to do this than to individualize, or customize, our approach to each patient?

Maslach and Leiter say, "People who are good at what they do enjoy the process of the work itself...They respond to a complex situation such as a client's problem, a diagnostic question, or a technical puzzle by bringing their skills and experience to bear with creative initiative." Since each patient is different, we must strive to play a more sophisticated role than just "tooth scraper."

I picture hygiene as being triumvirate, requiring us to play three very important roles: oral health educator, periodontal therapist, and preventive service provider.

The recipe for customizing our hygiene practice is efficient scheduling, efficient utilization of resources, and the accurate assessment of patients' individual needs, concerns, and desires.

Scheduling

Individualized scheduling is essential to running an efficient hygiene practice. No matter how fast or slow a hygienist we think we are, proper time management tailored to how we practice will keep us steady, happy, and relatively stress-free.

We may have the luxury of working out of two operatories with an assistant, but even if we work solo in one room, we can still increase our productivity.

Computerized network scheduling is the easiest and most effective way to allow advance scheduling of recare appointments. This encourages the patient to stay on a regular maintenance program, while allowing us to individualize the time needed for each patient. If a patient is difficult and needs 90 minutes, schedule 90 minutes. Conversely, if a patient is easy and healthy, schedule thirty minutes.

Scheduling the exposure of radiographs is also a great way to individualize patients' needs while increasing production at the same time. If we know a patient will be due for bitewings at the next visit, and it has been years since any elective perapical views were made, discuss the indications with the patient and schedule enough time at the next appointment to include a full-mouth survey.

Having a set "standard" time for an adult prophy with or without x-rays is inefficient and stressful. We are less likely to take a FMX when we are running 10-20 minutes behind schedule than if we are on schedule.

It is much more efficient if the hygienist is able to schedule her own advance appointments, but she can still develop a system of communication for the front office to schedule "custom" appointments. Time can be blocked out for periodontal or new patients. This is also a terrific way to keep our books full, but not hectic. An efficient schedule contributes to higher production, which will allow the hygienist to be better compensated by her employer. If we produce more, dentists can afford to pay us more.

Equipment and technology

Having the tools that we need not only to do our job, but to really excel at our job can make all the difference where individualization is concerned. Intra-oral cameras, digital radiography, educational CD-ROM, ultrasonic scalers, and air polishers can make hygiene more fun and exciting, but many hygienists feel pressured to "use it all" on every patient.

This not only overwhelms the hygienist, but makes her constantly run behind, so eventually she may give up on all of it or develop a "cookbook" approach to hygiene, completing the same protocol on each patient whether needed or not.

I find this "overkill" tactic exhausting and monotonous, no matter how impressive the technology!

Maximize both technology and time by assessing patients' needs and desires, and instrument accordingly. Does the patient truly need to be cavitroned, hand-scaled, and prophy-jetted? Or is hand-scaling and selective polishing adequate? Perhaps the time spent on cosmetic imaging for a patient who doesn't value esthetics could be better spent on tobacco cessation counseling that he or she desperately needs.

Moreover, patients who are hesitant to do needed crowns may be persuaded if time is taken to show their structurally-compromised teeth on the monitor with an intra-oral camera. It is conceivable that patients who wear removable partial dentures might have questions about how implants are placed, and they can watch a patient education CD-ROM on implants while they are waiting for the doctor's exam.

Digital radiography is an excellent way to save time and educate patients simultaneously. We can "digitize" a full mouth series in half the time it would take to expose, develop, and mount regular film, plus the patient can actually see the subgingival calculus and caries you are pointing out to them. Customizing different types of radiographs ensures better diagnostic ability as well. For example, taking vertical bitewings on perio patients; FMX's on patients with many treatment concerns or an extensive dental history; and panorals on healthy, young patients, or patients with little oral disease will better utilize time and provide the necessary data for a comprehensive, individualized examination.

Organization

Being organized goes a long way towards efficiency, since time wasted searching for materials or repairing equipment only increases stress and frustration. If we discipline ourselves to do regular equipment maintenance on the radiograph processor, for example, we will be less likely to waste time exposing retakes. Keeping treatment rooms adequately stocked and supplies ordered in a timely fashion will do much to keep patient flow running smoothly. A few minutes spent sharpening instruments will not only save time, but will reduce operator fatigue as well. Learning proper ergonomics and posture will keep us fresh and more comfortable during the workday, and possibly prevent long-term physical damage that may result in permanent disability.

Sometimes it may seem that we have not a minute to spare in the busy workday, but a few minutes spent in preventing anticipated problems will pay great dividends in our ability to practice efficiently, and therefore effectively and productively.

Soft tissue management

Providing nonsurgical periodontal treatment for patients who need and accept it, not only allows us a more flexible and productive schedule, but also keeps our "standard operating procedure" from getting monotonous. Consequently, we will have adequate time to do a thorough job on someone who really needs more than just a "routine cleaning."

Implementing an STM program requires a team approach, since all staff members need to play a role in making the program work. Issues such as dialogue, consent forms, insurance codes, periodontal charting, and administering local anesthesia will have to be discussed in order for a system to be implemented and effectively utilized. Many offices obtain outside expertise by hiring a consultant and/or attending a seminar designed to establish a new program or reform an existing one.

An STM program allows the hygienist to customize care for her patients' periodontal needs, while at the same time allows for a more efficient and productive schedule since adequate time is allotted for debridements, root planing, periodontal charting, and oral hygiene instruction that may not have been performed if a system were not in place.

Patient education

I believe the most important hat we wear as dental hygienists is that of "Oral Health Educator." It is most stimulating to be in an environment where we can teach our patients about their individual oral disease's etiology, treatment, and prevention. When our patients understand the "what, how, and why," they are more likely to take responsibility for their disease. This is essential if a patient is to be motivated to modify his or her behavior.

Much research has been done on the different ways people learn. According to Dr. James W. Keefe, an expert in education and author of Profiling and Utilizing Learning Style, "Learning style indicates how a student learns and likes to learn; Style characteristics reflect genetic coding, personality development, motivation, and environmental adaptation."

Sub-styles may exist within learning styles, such as cognitive styles. These are the information processing habits an individual possesses "which represents a person's typical modes of perceiving, thinking, remembering, and problem solving" (Keefe 1988).

As hygienists, if we realize that our patients have individual learning style variables that we may specifically address, we may be able to make more of an impact in behavior modification regarding their oral health.

Assessing how an individual patient learns is key to determining how to teach a patient about his particular oral condition. People learn through different senses, and it is estimated that approximately 25 percent of the population remember what is heard; 40 percent recall things visually, while others internalize information or skills by applying them to real-life activities (Teaching Students to Read Through Their Individual Learning Style, Carbo, Dunn, and Dunn, 1991).

If the patient is a visual learner, showing the patient visual aids such as intra-oral camera images or videos is effective. Sometimes patients need to see three-dimensional visual aids if they are spatial learners. If the patient learns by audio technique, communicating to him or her with a hand mirror and allowing a question-and-answer dialogue is usually effective.

Because we all learn differently and at different rates, many patients may require a combination of verbal, visual, and tactile information. Sending home a brochure is a good way to reinforce what was taught in the treatment room, and allows the patient a recall reference when discussing it with a family member.

Many hygienists express frustration over not having enough time to do proper oral hygiene instruction. Having patients learn good plaque-control technique by watching, feeling, and hearing while you scale, polish, and floss their teeth is a great time saver.

Taking advantage of every minute for effective communication will make the appointment more of a learning experience. Demonstrating proper toothbrushing technique in the adult patient's mouth while he or she looks on with a mirror is an excellent teaching method, and should not be reserved only for small children.

Because many patients have automated toothbrushes that resemble our prophy angle, they can learn the ergonomics for using it by watching and feeling how we use our handpiece. Intra-oral pictures of "before" and "after" not only motivate and educate the patient, but also allow the dentist to see how much deposit we removed so that he or she can reiterate the etiology of the patient's disease.

Another way to help economize time is to have the patient hold a mirror while we detect caries with an explorer, or better yet, have them watch intraoral camera images while we survey their mouths. That way, they can see specific areas of decay we point out, while they hear us discuss how this disease can be prevented in the future.

I like to explain to someone with smooth-surface caries about the 20 Minute Rule: "Every time you eat or drink something with sugar in it, acid can be produced in your mouth for up to 20 minutes. Therefore, it is best to eat sweet foods and drinks quickly or with meals to prevent a continual acid attack on your teeth." Discussing the benefits of fluoride while we do the chairside fluoride rinse can be very informative as well.

Explaining to patients why bleeding gums are not healthy is often tedious, but very essential. Patients need to know the basic disease processes involved in periodontitis, and there may be many obstacles in doing this. Of course, we will be more effective if we tailor our dialogue to the patient's age, interest, and educational background. For example, we may be able to use more advanced terminology with a patient having a science background than with one who does not.

Customizing how we educate patients based on what motivates them can be very instrumental in initiating behavior modification. Patients may be motivated due to financial, social, or professional reasons. Perhaps the patient values prevention of pain and good health above all else, so we can discuss the correlation of periodontitis with certain systemic diseases. Often the psychology of figuring out how to get through to a patient is in itself an intriguing challenge that will keep us on our toes.

Good communication is really the main way to assess a patient's needs, desires, and concerns. We must have two-way dialogue, which involves truly listening to what a patient is saying in order to find out what motivates or hinders that particular patient (see table above). It takes time, but in the long run we will be more effective and efficient in delivering care for our patients. Otherwise, we may be spinning our wheels since the patients don't know what is expected of them or how to go about preventing more oral disease. They must accept ownership of the disease, and if they do not, we will become frustrated when more energy is exerted than necessary.

Sometimes simply asking a patient, "What are you here for today?" is a good start. Don't be afraid to ask patients if preserving their dentition for a lifetime is a priority. Some people still think that it is inevitable that they will lose teeth due to genetics, and therefore feel powerless about their condition. As an oral health educator, the ultimate reward is for a patient to comment, "I learned something about my mouth today."

Teamwork

The feeling of belonging to a team helps facilitate a sense of well-being and a feeling of striving together for a common goal. In a dental team, our common goal is simple: caring for the patient's oral health needs. Not only will a lack of teamwork undermine the ability to achieve that goal, but it will also contribute to burnout indirectly.

In The Truth About Burnout, the concept of breakdown of community is cited as being one of the major contributing sources of burnout. "Organizations that lack community are vulnerable to conflict among their members [because they are] more likely to get in one another's way than to enhance their performance as a group." Consequently, a lack of teamwork contributes to a loss in productivity.

By setting a good example as a team player ourselves, we will motivate our co-workers to do the same. If we ask assistants to help us with periodontal charting or developing radiographs, reciprocate by offering to sterilize instruments or stock a treatment room. By serving our co-workers, we will maintain a sense of togetherness that will translate into synergy for attaining a common goal.

We all want to enjoy practicing dental hygiene, to make a difference in our patients' oral health, and to be adequately compensated for our efforts. By using a customized approach to our patients' needs and delivering individualized care in an efficient manner, we can achieve these objectives.

An added perk would be avoiding burnout by keeping ourselves challenged and stimulated. It is important to remember that we will only get out of hygiene what we put in to it. Honestly evaluating how we practice, and then implementing systems that will enhance our abilities to practice effectively, will be difficult initially. In the long run, however, they will contribute to a rewarding and fruitful practice as a dental hygienist.


How to practice effective listening

• Limit our talking
• Ask open-ended questions
• Listen for concerns and overtones
• Restate the person's concerns for clarification
• Don't interrupt

Misty Franklin Perkins, RDH, BS, earned her dental hygiene degree at the University of Oklahoma College of Dentistry. She has worked in several states, moving to Natchitoches, La., in May 2001, where she currently works part-time for two dental offices.

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