Breaking it down

Over the past few months, RDH readers have been given information regarding dental hygiene appointment content, timing, and procedures.

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Oral cancer screenings, periodontal assessments enhance the Ritz-Carlton experience

by Lisa Dowst-Mayo, RDH, BSDH

Over the past few months, RDH readers have been given information regarding dental hygiene appointment content, timing, and procedures. In one of the articles we discussed practice management advice for patient care and referred to this experience as the "Ritz-Carlton" standard of care.

For those who have not read the previous articles in RDH, the Ritz-Carlton is a famous hotel chain that is renowned for its ability to make all patrons feel like VIPs every time they visit. It is possible for dental offices to offer this same level of service to our patients by using a few simple tricks that add value to dental appointments and can make our patients feel very welcome, calm, and important to our establishments.

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The other two articles in this series

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This article will expand on this Ritz-Carlton patient experience as it pertains to procedures dental professionals perform inside the oral cavity. Topics to be discussed include:

1. Oral cancer screenings and enhanced devices
2. Periodontal assessments and screenings
3. Polishing, floss, and fluoride
4. Appointment conclusion and wrap-up

ORAL CANCER SCREENINGS

This is one of the most important parts of any dental hygiene appointment. I have known two women who battled oropharyngeal cancer and both were diagnosed under the age of 25. They are not patients of mine; I did not discover the lesions, but they are close college friends. One is an RN and the other has a master's degree in marketing. Both had lesions discovered in the oropharynx -- one on the posterior tonsillar pillars and the other on the soft palate just opposite the uvula. My reason for sharing this is to remind everyone how truly important you are to your patients. Dental professionals are well positioned in the medical community to help save lives through oral cancer screenings with our increased knowledge and skill level of head-and-neck anatomy.

If any dentist or hygienist had made either one of my friends say "AHHH" when they did an oral cancer screening, their cancers might have been caught in an earlier state. Both of these women saw their dentists every six months for cleanings, they are both well educated, and both had good jobs with good insurance benefits. As a dental hygiene educator, I share their stories with my students as a reminder of how important their roles are in the lives and safety of their patients.

It takes only five seconds to have a patient say "AHHH" as you depress their tongue in order to get a good visual field of the soft palate, uvula, and tonsillar pillars. Five seconds could save a life. Five seconds could have saved one of my friends from chemotherapy. Five seconds of my life could potentially change the life of one of my patients through a thorough intraoral cancer screening.

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You can find more information on these devices at these websites:

VELscope: www.velscope.com/
Identafi: http://www.identafi.net/
Microlux: http://www.addent.com
ViziLite: http://www.zila.com/vizilite/

I do not blame my friends' dentists or dental hygienists for not catching their cancer lesions. I am thankful they both sought medical attention from an ENT and MD when they realized something was not right. With the advent of HPV-associated oral cancer, it is imperative all dental professionals check the oropharynx area of patients' mouths, no matter their age, sex, or race.4

I worked as a full-time private practice clinician for 12 years before I transitioned into a full-time dental hygiene professor. I know what a busy day in hygiene feels like. I know all too well what it's like to have the first patient of the day show up late to the appointment, which then makes the hygienist late for the rest of the morning. As I relentlessly try to catch up, I may forget things such as oral cancer screenings or oral hygiene instructions, or more commonly I purposely cut them out altogether so as not to upset the rest of my patients, the front office, and the doctor because I'm running behind.

I try not to pass judgment on others as I would not want people to pass judgment on me. But, my "tip of the trade" when it comes to situations like this -- the last thing we should ever cut out of an appointment is the oral cancer screening. A one- to two-minute assessment is not going to make or break my day, nor will it make a huge impact on helping me get caught up. It could, however, make a huge impact on the life of a patient if I were to identify a suspicious lesion.

Anytime I feel like getting lazy during appointments because I'm tired or my kids kept me up all night, I think of my two college friends and their personal journeys with oropharyngeal cancer. When I see their faces in my mind, I will always, without fail, take the time for thorough intraoral cancer screenings on my patients.

To date, dentistry does not have a universally accepted early-detection device/screening/lab test for oral cancer, according to the National Cancer Research Institute. We vastly rely on clinician visual exams, which are limiting even if clinicians are doing them at every recare appointment. As we all know, oral cancer lesions may not be easily visible until the cancer has spread and become more invasive, which greatly reduces the survival rate of the patient.

I remember walking into a dental office as a temp hygienist six years ago, and my first patient of the day was scheduled for a ViziLite screening. I had no idea what ViziLite was, how to use it, or the cost to the patient. I remember the office manager telling me to "just do it because it's your job and we need the production" when I told her of my unfamiliarity with this type of armamentarium. That experience made me mad, and was a glaring signal that I needed some education in this technology. I did that screening and had no idea what I was looking for and felt even worse that the patient had to pay $65 for a screening I was not trained to do!

Over the past decade, there have been developments in the science of screening devices for oral cancer. I've used all the listed devices in different practices and have found they do help enhance my visual oral cancer screenings. Many clinicians are now aware of their existence but may be confused on whether it is something they should incorporate into their practices. Here is my two cents' worth as it relates to these devices -- even if this technology is not proven to detect every cancerous lesion that could afflict a human mouth, I have still found myself willing to use it. After all, these devices will never harm my patients, and if they can help even one patient detect oral cancer at an early stage, then I feel its use and cost are justified.

Many devices have a high initial purchase expense, but the long-term expenses are low. For example, the long-term costs for VELscope and Identafi include the barriers that average out to around $2 to $3 per patient. In my experience with offices that use this technology, the patient charge is usually $25 to $45 a screening, which makes me feel financially ethical in promoting and educating my patients about its benefits to their health. I also feel confident in my abilities to use the equipment correctly after attending continuing education courses, which makes me feel ethical in providing the screenings to my patients.

This technology can be a fantastic benefit and service to your patients, but only in the hands of someone trained to use it. I believe this is where dentistry can fall short in its training of professionals. Hygienists go into offices, are asked to use equipment they have no training or familiarity with, and are expected to perform miracles by identifying possible oral cancer lesions. Not many dental or hygiene schools can afford to have these devices on their premises, and if they do, they cannot afford to have all of them. Students come out of school with only a mention of these devices in their programs and are sometimes asked to use them at their first working interview with an office. This is not fair to them or the patients.

Learning to use these devices correctly has had a positive impact on me as a clinician; it forced me to have a higher standard of care, a Ritz-Carlton standard, if you will, to my cancer screenings. The first thing it did was make me slow down and start noticing the smaller, less obvious, innocuous-appearing inconsistencies, both extra- and intraorally. They made me look twice at lesions I would have otherwise overlooked. Then I updated my documentation of lesions and follow-up care of my patients. If I found something that registered as abnormal on my device, my doctor would usually reappoint the patient for a two-week follow-up, at which time a referral would be made to a specialist if the findings were still present. Most devices come with cameras that can take photos of the findings so doctors can have an accurate comparison from the last visit.

Of course, the only true way to know what is happening on a cellular level is with a biopsy. Until we can notice what to biopsy, that life-saving procedure will not be performed. Enhanced oral screening devices can help clinicians, who are not trained surgeons, better identify areas that may require attention and possible referrals. It is also a nice piece of equipment for those whose intraoral screening techniques are still developing, and it adds a bit of Ritz-Carlton magic to the patient experience.

PERIODONTAL ASSESSMENT

One personal story that comes to mind is an interview I had at an office about two years ago. The doctor's wife was the hygienist and her husband was looking to hire a part-time hygienist so his wife could stay home more with their kids. I asked her about the office's periodontal protocol, and she replied, "I do not six-point perio chart on every patient. I only record readings above 4 mm and I don't waste my time or the patient's time charting recession, furcations, or anything else. I can see more patients if I spot probe, and then they don't feel I am trying to sell them on treatment they don't need."

For me, this interview was over with her strange comments, and that job opportunity was not something I was interested in. I left that office confused and shocked by this hygienist's poor standard of care for her husband's patients. I also have no idea where her standards or protocols came from, because that is not what we teach in dental or hygiene schools, nor is that anything close to current AAP recommendations.

AAP recommendations are clear on proper periodontal assessments. The AAP outlined their "Parameters for Periodontal Screenings" in an issue of the Journal of Periodontology1,2 that stated, "Clinicians should be charting the distribution of plaque and calculus, periodontal soft tissues, presence and types of exudate, probing depths, location of the gingival margin (CAL), presence of bleeding on probing, mucogingival relationships to identify deficiencies of keratinized tissue, abnormal frenulum insertions, gingival recession, presence/location/extent of furcation invasions, visual and radiographic inspections" in the "Comprehensive Periodontal Examination Section."2 AAP's website states this type of screening "should be performed at least annually for all adult patients. Clinicians should bear in mind periodontal disease is a very episodic disorder and conditions will change frequently in patients, which is why many comprehensive practices do a full periodontal charting at every hygiene appointment."

In the "Parameters on Periodontal Maintenance" guidelines, the AAP stated the following items should be included in every periodontal maintenance appointment:

1. Review medical/dental history
2. Extra- and intraoral examination
3. Dental examination: tooth mobility/fremitus, caries, restorative, prosthetic assessment, other tooth-related problems
4. Periodontal examination: probe depths, bleeding, general plaque/calculus levels, furcation involvement, exudation, gingival recession, occlusal examination and tooth mobility, other signs and symptoms of disease activity
5. Examination of dental implants with the same periodontal assessment as for natural teeth
6. Radiographic examination
7. Treatments: removal of supragingival and subgingival plaque and calculus, behavior modification, OHI, counseling on risk factors, antimicrobial agents as necessary or surgical treatment of recurrent disease
8. Communication with patient or other health-care professionals
9. Plan and establish an appropriate recare interval

There is no set age at which a periodontal charting has to begin, according to the AAP website. This is where clinical judgment comes into play. Many offices will begin probing one to three years after patients present with a full dentition. I personally probe children (under the age of 18) one to two years after exfoliation of the last primary tooth, or if the patient presents with any gingival inflammation, bleeding, or signs of disease.

A well-paced, experienced hygienist should be able to do a comprehensive periodontal charting of this nature in five to 10 minutes, especially in offices with computerized periodontal charting. For deeply involved periodontal patients, charting could take up to 15 minutes. If your speed is not to this level, be honest with your doctor and office staff. Let them know you want to improve your speed but will need help with this section of the hygiene appointment if anyone is available. They will probably appreciate your honesty and be more inclined to help you if they know what you need help with. Refer to the first part of this series in RDH for more details on when a periodontal assessment usually occurs during a dental hygiene recare and/or new-patient appointment.

Using charts and templates like the ones provided in the first article will help the whole staff know what is going on in your hygiene room at any given time. It will also clue everyone in to just how much hygienists have to accomplish in such a short amount of time. You may experience certain staff members finally understanding why "the hygienist needs help all the time," as I overheard one front-office person say to another about me in the past.

A dentist or specialist cannot diagnose periodontal disease without radiographs, visual inspection of the gingiva, and periodontal charting. All three factors have to be completed to make an accurate diagnosis and design the appropriate course of treatment. If one piece of the puzzle is missing, treatment may go undiagnosed or unrecognized, which is considered "dental negligence" on the part of those providers.

There are devices on the market designed to aid clinicians in efficient, repeatable, time-efficient periodontal charting. Electronic probes such as the Florida Probe (Florida Probe Corp., www.floridaprobe.com), InterProbe (The Dental Probe, Inc., www.interprobe.com), or Probe One (The Dental Probe, Inc., www.probeone.com) may be useful tools for your office.3 The Dental R.A.T. (Beckmer Products, Inc., www.dentalrat.com) allows the clinician to perform periodontal charting using a foot pedal and a computer. There are voice-controlled devices for charting such as the PerioPal (PerioPal LLC, www.periopal.com). Henry Schein's Dentrix and Patterson's Eaglesoft software have the capability of voice-controlled periodontal charting.

APPOINTMENT CONLUSION AND WRAP-UP

Set complete and make next recare visit
There's nothing that will make your front office love you more than helping to make their job a little easier! By setting complete and making your next hygiene recare appointments, you will accomplish two things. One, by having your patients commit to their next visit with you, they may be more inclined not to cancel or move an appointment because they committed to you personally and not some random person on the phone. Two, it helps remove a task from the front office. We are all aware of the internal conflicts that exist between the front and back offices in a dental setting, so any friendly gesture goes a long way with the people working up front.

Dismissal
Another way to get in good with the front office is to perform a proper hand-off of your patients. If you follow these easy steps, you will give your patients and your front office personnel a Ritz-Carlton experience.

Step 1: The last office I worked in had hot disposable towels in a warmer they would give to their patients before they were dismissed to the front. This allowed them to freshen up, especially if aerosol-producing equipment was used on them.

Step 2: Walk with your patients up front and find something nice and positive to say. "I hope your visit today was good. I know I enjoyed seeing you again!"

Step 3: Wait with your patients at the front counter until someone is ready to help them. This may mean I have to wait a minute or two until the front-office personnel gets off the phone or wraps up checking out the patient ahead of us, but it's worth the wait to ensure a good hand-off. An assistant can always help by turning over my room if they see I am waiting at the front for a check-out. It takes a team to make sure each patient feels like a VIP in your dental office!

Step 4: Hand-off. This step is extremely important. You could have performed every Ritz-Carlton step to perfection in this appointment, and if a hand-off doesn't happen or doesn't go well, it could undo all your hard work. If the front-desk person is trying to hunt you down to get a patient's question answered or a patient doesn't completely understand what he or she needs to come back for, all could be ruined. There are a few basic things that need to be covered in a good hand-off from the back to the front.

1) Initiate the conversation between the front-desk person and the patient. "Maggie, Mr. Jones has finished his appointment with me today."

2) Tell them what you did today. "We completed his six-month check-up and cleaning today."

3) Inform them if you made the patient's next hygiene appointment. "I made Mr. Jones' six-month appointment."

4) Give a brief summary of treatment recommendations/plan and provide a sense of urgency so the patient returns in a timely manner for treatment. "Dr. Stratton found two new cavities today that are fairly large. Would you please schedule him back at the doctor's first available appointment. We don't want to wait too long on taking care of these cavities as to avoid more expensive or complicated treatment."

5) Ask the front-desk person if he or she has any questions before you leave. They may need more clarification on a treatment plan, or have a question on how long the doctor needs for that procedure.

6) Shake your patient's hand, thank him or her for coming in today, and tell the patient you look forward to seeing him or her next time.

CONCLUSION

This article and the ones preceding it should provide guidance to hygienists in appointment structure and timing, but it is in no way intended to present information as absolutes for every clinician. What works best for one may not work best for another. We all have our own way of doing things and as long as our sequences and treatment recommendations are in line with current recommendations from our guiding bodies (ADA/AAP), then we are providing our patients with correct and effective care. These templates are designed with office management, hygiene timing, and production values in mind, and hopefully will be a good starting point for your office! RDH

Lisa Dowst-Mayo, RDH, BSDH, graduated magna cum laude from the Caruth School of Dental Hygiene at Baylor College of Dentistry in 2002 with a bachelor's degree in dental hygiene. She has held numerous leadership roles in the tripartite of the American/Texas/Dallas Dental Hygiene Associations. She is an author, clinician, educator, and enthusiastic public speaker. Lisa is a dental hygiene instructor at Concorde Career College in San Antonio. She has published numerous articles on a broad range of topics for both RDH and Access Magazine and has written CE courses for PennWell, Inc. She is a cofounder of the company Diamond Dental Education that provides CE courses for dental professionals in Texas. Contact her through her website at www.lisamayordh.com.

There are four main devices on the market today for enhanced oral cancer screenings summarized in the table below. Each device uses a different type of technology and physics, so abnormal findings will appear different in all four devices.6,7

POLISH, FLOSS, FLUORIDE

It is easy to give this portion of an appointment a Ritz-Carlton flare with a few simple tricks:

  1. Never use a flavor of polish or fluoride a patient does not like! Ask them what they prefer and have a few choices. I temped at one office that had a wiper board in the operatory, and the "flavors of the day" were written for the patients to see. I thought that was a unique and fun addition to the hygiene experience.
  2. Have prophy jets as an option for patients who do not like polishing. There are patients who hate polish paste; my husband is one of them. For some weird reason unknown to me, he hates "the gritty paste stuff" and loves the "baking soda-tasting thing." To each his own, right
  3. Don't hurt your patients while flossing. Slow down flossing, don't pop the floss into the gums, and use waxed floss such as Glide or Satin Floss from Oral-B.
  4. Experiment with fluoride brands and flavors. There are newer fluoride varnish products on the market that are not as sticky and are invisible. The ADA does recommend in-office fluoride treatments for all patients, especially those at moderate to high risk for caries. For more information on the ADA's recommendations for in-office fluoride, refer to http://ebd.ada.org/ClinicalRecommendations.aspx.

REFERENCES

1. AAP. Parameter on Periodontal Maintenance. J Periodontol. 2000;71:849-850.
2. AAP. Parameter on Comprehensive Periodontal Examination. J Periodontol. 2000;71:847-848.
3. Calley K, Hodges K. Automate Your Probing Process. Dimensions of Dental Hygiene. Feb 2011;73:2686-2688.
4. Cleveland J, Junger M, Saraiya M, Markowitz L, Dunne E, Epstein J. The connection between human papillomavirus and oropharyngeal squamous cell carcinomas in the United States. Implications for Dentistry. JADA. August 2011;142(8):915-924.
5. Darby M, Walsh M. Dental Hygiene: Theory and Practice. 3rd ed. St. Louis, MO: Saunders Elsevier, 2010.
6. Huff K, Stark P, Solomon S. Sensitivity of Direct Tissue Fluorescence Visualization in Screening for Oral Premalignant Lesions in the General Practice. Gen Dent. Mar-Apr 2010;58(2):126-9.
7. Messadi D. Diagnostic Aids for Detection of Oral Precancerous Lesions. Int. J. Oral Sci. June 2013;5(2):59-65.
8. Wilkins E. Clinical Practice of the Dental Hygienist. 11th ed. Philadelphia, PA: Lippincott, Williams and Wilkins, 2013.

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