Th 151721

The race against the clock

June 1, 2004
Two perspectives on structuring the workday more effectively.

by Diane Chandler & Connie Sidder

Finding the Line
by Diane Chandler

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We all remember the hygiene school days where we had all the time in the world for patient education, treatment planning, and instrumentation. We took the time to get to know our patients. With our instructors, we decided on the best possible treatment for our patients. Those were the days.

When we graduated and began to work as dental hygienists the initial shock was great. No longer did we have all the time in the world. Demanding schedules and patient quotas made us wonder what happened. Can the real world really be that different from the school setting? Sometimes the workload is so great that we question our decision to go into dental hygiene.

The answer to these questions must come from within. We can always fantasize that there is an ideal practice out there that will give us all the time we need to properly do our job — to do the job we were trained for — but this is just what it is, a fantasy. More frequently, we are forced to make our current employment work to everyone's advantage.

What does that mean? We are still committed to the importance of patient education and proper patient care, but we refocus to the real world. Practice management specialists now closely monitor many dental offices. These are usually people who are well trained in the business side of dentistry. Their goal is to make the office more profitable. Their goal is not a bad thing since it is from those efforts that raises and bonuses will be generated. Most of us realize that dentistry is a business. For that business to be successful we must do our part. Does that mean forsaking all of our hygiene focus?

I don't think so. I think it means finding the line where we are comfortable.

All of the self-help specialists stress, "Prioritize, prioritize, prioritize." This is exactly what we need to do during our workday. Each one of us must set our own personal professional standards. I have set some personal priorities for myself, and it really has taken a lot of the guilt off of my shoulders. In hectic situations, I just remind myself of my professional priorities, and it really does have a soothing effect.

My first priority is that — I don't care how busy I am — I will take the five minutes to update the health history of my patient. Anyone who doesn't do this is taking an unbelievable risk. Patients just don't see the connection between the hip replacement they had last fall and today's dental cleaning appointment. The medical community may or may not have instructed them in the need for pre-meds, or the patient may have just simply forgotten.

Some people are just not that concerned about their health issues. Some patients get annoyed because we have had to call their physician first before rendering any treatment. In some cases, the physician has not approved dental treatment because they have not been able to adequately stabilize health problems. It always surprises me when these patients then get annoyed because they need to be re-appointed. I feel that when patients are in my chair their health issues are my problem and doing the proper thing is my concern, regardless of how long it takes. Just asking about changes in their medical health or medications is sometimes really all it takes.

The next priority I have is to give my patient at least four to five minutes of hygiene instruction. This may be just pointing out the inflamed areas and offering some quick solutions, such as:

* Quickly demonstrating on the typodont exactly where the tooth brush should be.
* Or asking them to faithfully rinse with an antibacterial rinse between this visit and next.
* Or giving them a pat on the back for the progress they have made since the last visit.

This is not only a good hygiene practice but also a good practice builder. Patients have said, "I did what you told me and now I'm anxious to see if you see any changes." I think the instructions are indicative of a very caring dental practice.

Finally, my last priority is to be a part of the solution. I will promote my practice. I will take a moment to promote the necessary dentistry, which is treatment planned but not completed. This may be only a brief statement such as "Mrs. Jones, that tooth that Dr. Smith wants to crown is really getting broken down. Let's set up that appointment now before that tooth breaks," or another observation could be "Let's fix some of those sensitive areas for you so that your next cleaning appointment will be more comfortable."

You will be hard-pressed to believe the number of patients who will schedule these appointments — just because you have encouraged them to do so.

If there is no work listed on their treatment plan, compliment the completed dentistry and "mention" the bleaching system you have in your office. I have found that this is an area where I can really make a difference. In my practice, we have as many men as women who are bleaching their teeth. The conversations usually begin with the discovery that patients have tried many over-the-counter bleaching products for unsatisfactory results. This opens the door to a discussion about in-office bleaching. In my experience, more than half of the patients who I urge to bleach their teeth do so — maybe not during that appointment or the next, but eventually. They will return before a wedding or other special event. They really want to look their absolute best. One practice management specialist asserts that it takes about eight times for a person to hear about a bleaching procedure before they actually do it. I provide information during each appointment about what we offer in our office.

These are my personal priorities that I am sharing with you. They may not be your priorities. But sitting down and deciding what is important to you is the first step in taking ownership of your profession. Will it have the same empowering effect on you? It is worth a try. In the real world, there are days when the wheels come off and, on those days, I may have to slip by the second and third priority. But the point is that I am constantly trying to deliver my standard of hygiene care to all of my patients. Some days I am 99 percent successful — some days only 50 percent. But striving for my personal professional goals is where the line is for me.

Diane Chandler, RDH, has practiced dental hygiene in the same office for 19 years. Once a year, during dental awareness month, she provides a dental information program to her community through a public access cable network. She can be contacted at [email protected].

Going With the Flow
by Connie L. Sidder, RDH, BS

Most hygienists in private practice have 45 to 60 minutes for each recall patient. During this time, we see patients we've known for years as well as a steady flow of new patients. We are expected to do periodontal evaluations, medical history updates, oral cancer screenings, blood pressure checks, plaque control analysis, update and evaluate home care needs, and let's not forget the oral exam for comparison with the dentist's exam. We answer questions our patients have regarding bleaching or crowns, maybe prepare the patient for the need for crowns or third molar extraction, evaluate tongue thrust, and, oh yes, we have to update bitewings while we make light conversation. And, of course, stay on time for our next patient. Whew!

Our goals may be that every patient would be able to show us they are capable of maintaining excellent home care, or going decay-free for more than one year. Whatever their levels of plaque control, we want them to fit nicely in our schedules. It can be difficult trying to wear so many hats, stay on schedule, and still enjoy our days.

Sometimes we have to go with the flow. Time will dictate how we approach each patient's needs. What's expected and what's important will vary from office to office as well as each individual hygienist. Where I work, it is expected that an oral exam (including oral cancer screening) be done before the dentist comes in to check. It is also expected that X-rays have been updated, as well as any discussion about home care needs or nutritional information. The dentist may reinforce something that has been discussed, but, again, the time factor usually doesn't allow for the dentist to get into a lengthy conversation.

New patients, of course, have just completed medical histories. But recall patients of six months to a year need to be asked for changes.

I will often slip in the question, "Do you know what your blood pressure is?" If they don't know, I will whip out my digital blood pressure cuff at some point during the appointment. Remember that high blood pressure is considered to be the "silent killer." Many patients are not aware that they have a problem. I once had a patient come in with a broken blood vessel in her eye. Upon taking her blood pressure, it was recommended she see her physician immediately! Her blood pressure is now controlled with medication, and she is very thankful that it was caught. We are in the position to provide many services.

Some of the most frustrating patients are those who exhibit good home care skills, but still have persistent pockets. They may even come in every three to four months religiously. With these patients, decay is usually not a problem, so time is saved there. But, trying to inspire them to take more responsibility will take more of the appointment time. Brushing twice a day and flossing once is not enough, yet they feel they're doing a good job. Some hygienists may use disclosing tablets to make their point. At a recent continuing education course, the speaker advocated disclosing to show plaque scores. If, for example, plaque was detected on all M, D surfaces only, a plaque score of 50 percent would be given. Ideally, a score under 10 percent would be adequate.

In a general practice, our ability to motivate is predicated on our patient relationship. Is there trust? Have they learned something from us in the past? As teachers we have to remember to praise as well as be able to encourage change. We're asking patients to do things that most of us don't need to do ourselves.

Plaque control may not be pertinent to all of our patients. Often, they do well enough without our input. If a few areas of gingivitis are as bad as it gets, I say, "Save your breath!" Not everyone strives to be perfect, and harping on them at every appointment is a sure turn-off. How many have had new patients come in and defensively state, "I know, I know ... I don't floss enough. I've already heard the lecture."

Get to know that person — build a base of trust and friendship. You'll have another chance in six months to get your point of view across. In all probability, their teeth won't fall out! Also teaching them something they haven't heard before will get their attention. Pick just one point to drive home per visit. Overloading will only cause the patient to "tune you out."

Plaque control has varying degrees of importance for each individual. Correcting toothbrush habits often does the trick. Do they always start in the same place, causing recession? Do they spend less time in an area such as the maxillary lingual? Using the "heel" (the lowest row of bristles on a brush) can be advantageous for mandibular anterior lingual. (The bristles will bend into the gum line, as opposed to bending away when the tip is used.) Or maybe they should be using a powered brush. This is where your role as a teacher and the trust you've established pays off. Maybe the patient should go to a drugstore and choose a home care tool. Often, tools given at previous appointments have found their way to the back of the drawer. Explain that the healing process is not happening due to the plaque levels.

If the patient understands the need for a change, they may ask, "Where is the problem area?" With a hand mirror, or an intraoral camera and an explorer, we can quickly show areas of plaque and explain the plaque-perio-healing process. If they care enough to come in three to four times a year, they'll want to be more diligent at home. (Yes, there are those who expect US to do it for them; they can't be bothered. For them, don't keep banging your head against the wall. Find something else to talk about.)

Being able to take this information home is critical. Knowing precisely which areas — whether it's L or B, M or D — allows the patient more control over their needs. Take-home charts are a good adjunct. These charts can be used following antimicrobial therapy, too. Also, for the college student needing dental work away from home, they can have a slip notating where the areas of decay may be for the other dentist.

The more information we can disseminate to our patients, the better off they are. We can't always be everything to everyone, but sometimes just taking one step in the right direction is a giant breakthrough. Our patients do appreciate our thoroughness; fitting it in to a standard prophy appointment time can be challenging.

We don't pick our patients; so relax, get to know them, and know that trust is built one visit at a time. Then "pick" your battles accordingly.

Connie L. Sidder, RDH, BS, is based in Fort Collins, Colo. She can be reached by e-mail at [email protected].