Smiles ahoy!

May 1, 1999
The search for beautiful smiles should start in the hygiene operatory. Instead of hygienists being considered as a wasteful `loss leader,` many dentists are embarking on a journey away from traditional dental practice management.

The search for beautiful smiles should start in the hygiene operatory. Instead of hygienists being considered as a wasteful `loss leader,` many dentists are embarking on a journey away from traditional dental practice management.

Joseph Blaes, DDS

Editor`s note: If RDH readers pay any attention to journals or seminars tailored for dentists, they likely will have noticed that a cadre of dentists and hygienists advocate a radical change in how dental practices operate. By broadening the focus and services that a practice offers, dentists have experimented with untraditional philosophies. They appear to be, so far, very successful. Besides increasing patient satisfaction, a motivation for this change is to shift back to fee-for-service dentistry. Invariably, these writers and speakers refer to "transforming" the hygiene operatory. RDH wanted to know what they were suggesting. So we asked Dr. Joseph Blaes, the editor of Dental Economics, to explain. Dental Economics is closely allied with these new practice philosophies. While PennWell Publishing owns both magazines, RDH is not under any pressure to convey or endorse the interests of Dental Economics readers. We do feel, however, that it is important for RDH readers to be aware of how these visionaries perceive the role of dental hygiene in the contemporary practice.

A profitable hygiene department within a general dental practice is an opportunity that has consistently eluded many dentists for many years. Even though the awareness level about periodontal disease is much higher among patients, most dental practices have hygiene programs that are managed as "loss leaders." When the grocery store runs a "loss leader," they do so to get customers into the store, knowing that other items will be bought. But in a dental practice, the loss of income does not necessarily lead to other income or sales. These practices generally see a high number of hygiene appointments per day. They tend to have a high number of broken appointments, and some will even double-book to keep schedules full.

This type of practice usually allows 30 to 45 minutes per hygiene patient. This fast-paced routine contributes to the high rate of burnout among hygienists. Many hygienists move on to other professions and jobs, because they get tired of hassling with that kind of schedule. There is hardly time to say "hello" and certainly not enough time to do any kind of periodontal treatment. Just scrape and polish and say everything looks fine and get the dentist to do a quick exam. When perio problems come up, patients are referred to the periodontist and are probably never seen again. Many times the hygienist is doomed in this type of practice. Either they move on or do something else.

What a waste!

How many times have you or one of your team members told a periodontally involved patient that the answer is home care? They must brush and floss daily to remove the plaque and bacterial colonies. You tell them that, if they are faithful and compliant, they will be able to control their disease. If they are adequately motivated, it works for a while. But, eventually, they quit flossing, don`t brush as often as they should, and then they fail miserably.

You then refer the patient to the periodontist so he can tell the patient the bad news that you either did not have the time to tell them or because you were afraid to confront them. Generally, surgery is done, but the patient usually does not have the tools to control the disease, so he/she fails again. By this time, the patient is totally confused and goes to another dentist seeking other solutions.

Another waste! Does anyone really care? Do you ever do exit interviews to determine why a patient is leaving your practice? Or do office members mutter, "It happens," and collectively shrug their shoulders?

According to Mary Osborne, RDH, a consultant in Seattle, the recall appointment of the 1990s:

* Does not promote relationships

* Has little clinical justification (since we have no long-term plans for patients)

* Has, for the most part, no relevance to our patients

This is why there are so many changed appointments, cancellations, and failed appointments in hygiene today. In a busy practice, people in the business office can easily spend close to 50 percent of their time keeping the hygiene book full. We all need to become more skilled in helping people understand periodontal disease and the behavioral changes they need to make to become healthier.

Fourteen years ago, my practice was much as I have described in the paragraphs above. I had one hygienist who saw patients on a 30-minute schedule. I charged a low fee for hygiene, thinking I would make it up on volume or on any needed restorative treatment found during the hygiene exam. The hygienist always ran behind because I was always late for checks and rarely did she get a full lunch hour. She usually used that time to catch up.

After about 10 months of this, Pam came to me at the end of the day and said she was giving her notice. She had had enough! She asked, "How can you treat people like this? A 30-minute schedule leaves no time for patient education, no time for probing, no time for small talk, and no time for relationships. In fact, you hardly have time to say `hello` and `goodbye.` "

Pam had a lot of talent, enthusiasm, and passion for her chosen career, but she told me that her job as a racquetball club manager was more fun. She was going to leave hygiene and go back to that. I did not want to lose her. You probably won`t like the reason, but I just did not want the hassle of finding another hygienist. I asked what I could do to change her mind. Pam was reluctant to say anything except that she had made her decision.

For some reason, she took one last chance with me and quickly said that if I would make a commitment to a tissue management course that she would stay on. I quickly agreed, thinking that I had bought at least six months of time while she found the course. In a month, we were at a tissue management course with all of the office staff and, in less than three months, had fully implemented it. This decision made a major impact on my practice and my life.

I had always controlled the practice. With this decision, the practice was forever changed. I opted for a participative type of management. Most of the staff responded enthusiastically, but some left, and the rest of us began working as a team. We changed hygiene schedules to 10-minute slots. Each patient was scheduled for an hour, and everyone was probed. Some patients didn`t like that and left the practice. More perio therapy was done in the office, more restorative was referred from hygiene, and our staff became a strong team working toward a common goal. Pam stayed for 10 years, doing six to eight quadrants of root planing a week and consistently producing over $20,000 per month.

I relate this abbreviated story as an example of how quickly a leader`s philosophy can change - if you finally get the leader`s attention. Sometimes, it takes a two-by-four on the head. But the change must come from the leader (that`s the dentist).

So what does all this have to do with an esthetic restorative practice? I found that the change to esthetic restorative dentistry in my practice began with the change in hygiene. Once the hygiene department was on a solid footing and patients were responding well to treatment, we began to explore the new world of esthetic dentistry. The staff (including the hygienists) attended technique and material lectures and seminars to learn all that we could about this relatively new area. The first thing we did back at the office was to esthetically restore the team`s mouths (including the dentist). After that firsthand experience, it was easy to talk to patients about the benefits of this type of dentistry.

This is a critical point. I believe that everyone on the dental team should have their mouths optimally restored. I know that some practices do this and charge their staff a fee for it. I do not believe in charging the team members. I include this as a benefit in their complete salary package. I know from experience that these people will be able to sell more dentistry simply because they have learned the value of excellent dentistry.

Pam`s front teeth were crooked, and her smile did not look very good. She didn`t wear her retainer as she should have. As a result, she attempted to hide her front teeth when she smiled. Using porcelain veneers, I did some instant orthodontics on her six anteriors. The result was life-changing! Pam was now proud of her smile and showed it all the time. Pam sold more esthetic dentistry simply by asking her patients if they ever considered improving their smiles. She would hand them her "before" model and then simply smile for them. "Look what Dr. Blaes did for me," she would say.

Her patients were amazed, because they never realized that we had the skills to do that for them. Most would schedule an exam appointment with me. With imaging and waxups, I would show them what could be done.

This all begins with the hygienist`s commitment to providing excellent dental care for the patients in the practice. If hygienists are only concerned with treating the perio problems, then I believe that they are doing their patients a major disservice.

A short story will illustrate my point. My office has no "front desk." The first person you meet upon entering the office is our concierge, Kathleen. She is a retired schoolteacher and a wonderful person; all of our patients love her. Kathleen had been with us for about six weeks when she asked for a day off because she had an appointment for periodontal surgery. I had not had a chance to examine her mouth but told her that I would like to do an examination before the day was out.

When I examined Kathleen, she was like many patients her age - a mouthful of very large amalgam fillings with deep pockets and bleeding gums surrounding them. All of the problems were in the upper arch. There were wide-open contacts between the molars, and one of the second molars was mobile. Pocket depth ranged from 5mm to 9mm with many bleeding points. Obvious debris was below the tissue where the open contacts were.

I questioned Kathleen about the restorative plan that had been presented to her. She said that her dentist and hygienist had only mentioned that she had gum problems, and the periodontist had concurred and recommended surgery. For anyone to cut on her gums without correcting the contributing cause of the problems is malpractice. I told her to cancel the appointment, and I would restore her mouth first and then we would see if she needed surgery.

Kathleen`s first appointment was with Pam for some initial perio therapy and instruction in the use of the RotaDent Power Brush from ProDentec. Over the next few weeks, I restored Kathleen`s posterior teeth. I had to take out the second molar because too much tooth had been destroyed with the filling and because of the mobility. I removed all of the amalgam fillings and the new decay under them. While I had the interproximal areas open, I scaled and planed the root surface. I restored the teeth with porcelain inlays and reinforced her use of the RotaDent. Pam continued to see her on a regular basis for the next six months.

At that point, Pam and I re-evaluated her case. There were no bleeding points upon probing. All pocket depths were 3mm and below. The tissue appeared very healthy and the patient was obviously very compliant. Kathleen was also very happy with the results.

Kathleen had seen many of the esthetic cases that we had completed over the time that she had been with us. Now that her perio was under control, she asked me if I could help her smile. I placed six anterior veneers on her upper teeth, and her smile was gorgeous. Now she was totally restored and would show off her new teeth to all the patients as they entered the office. I could not have bought advertising like that.

In order for the hygienists to be effective in an esthetic restorative practice, they must become completely aware of the restorative philosophy of the practice. The hygienist must become a student of the clinical techniques and materials of the office. This means spending time watching clinical procedures and learning the process of restorative dentistry as it exists in that practice. It probably means attending some clinical continuing education courses with the rest of the team.

Once hygienists understand restorative dentistry, they are better able to contribute to the success of the practice by educating patients to the restorative possibilities of the practice. The hygienists can show off their own beautifully restored mouth as a model of the commitment to excellence that exists in the practice. Patients will better understand the need for esthetic restorative dentistry and what the benefits are for them. Case acceptance levels will rise dramatically. Stress levels drop, and dentistry becomes more fun for everyone on the team.

Joseph Blaes, DDS, is the editor of Dental Economics magazine. He can be contacted at [email protected].