The Heat is On ... Protocols help the sizzle fizzle!

Internal dental office heat is on. Office temperatures between staff members rise when oral assessment and treatment sequencing protocols are not followed.

Dec 1st, 2009
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by Antoinette Covino, RDH

Internal dental office heat is on. Office temperatures between staff members rise when oral assessment and treatment sequencing protocols are not followed. Read what happened in an office to make the heat stifling for all involved.

A 29–year–old Caucasian female presented as a new patient. Her last dental visit had been approximately 10 years ago. The patient's chief complaint was sensitivity and bleeding gums. She was a non–smoker with no known medical allergies, and no prescription or over–the–counter medications other than multivitamins. Upon completion of a comprehensive periodontal examination (0180), which included full periodontal charting and recording, Panorex, and BW radiographs, the dentist diagnosed the need for localized periodontal therapy, and recommended that treatment be initiated immediately.

The treating dental hygienist educated the patient regarding periodontal treatment services, possible treatment risks, future periodontal maintenance visit intervals, the potential consequences of not having treatment, patient home care responsibilities, and treatment fees.

The patient felt adequately educated and signed an informed consent for periodontal treatment. Treatment provided at the visit consisted of chlorhexidine gluconate pre–rinse, needle–free local anesthetic (one carpule of Oraqix 2.5% lidocaine/2.5% prilocaine), localized scaling and root planing (D4242) on Nos. 2, 3, 30, and 31with subgingival irrigation, and Arestin was placed in periodontal pockets (D4381) of 5 mm with BOP. The patient scheduled her next visit to treat the remaining two quadrants and left, apparently satisfied with her services.

The patient called the dental office the next day and said she detected roughness on her tongue. She demanded immediate relief. Since the dentist and periodontal therapist from the day before were absent, the receptionist appointed the patient for an emergency visit with the hygienist in the office that day. This is where the sizzle began.

How the visit unfolded

The patient was seated. When the second hygienist looked in her mouth, she saw supragingival calculus on the patient's teeth. She asked, "When was the last time your teeth were cleaned?" When the patient said "yesterday," the hygienist responded, "Well, it certainly doesn't look like it!"

The hygienist repeated the periodontal probing and recording that had been done the day before. Upon completing the charting, the patient was told the services provided by the office on the preceding day had not been necessary. She was told she only needed a simple cleaning. The patient was dismissed and rescheduled to return in four days for a prophy by the hygienist.

As the patient left she called her spouse to relate her experience at the dental office. Minutes later, the patient's upset spouse contacted the dental practice and demanded his money back for the services his wife had received the previous day. The dentist honored the wishes of the patient's spouse and refunded the fee for the procedures rendered during the initial visit.

The patient received a prophylaxis four days later. Treatment notes were made in her chart regarding heavy bleeding, as well as heavy supragingival and subgingival calculus. Imagine the patient's confusion and dissatisfaction. Is it any wonder this patient consequently questioned the validity and integrity of the dental office? How many of her family/friends did she tell about her experience?

How to avoid office "heat"

How might this critical issue have been eliminated? How could the patient have been spared this experience? How could the practice have escaped the shame and emerged unscathed?

The answer to these questions is office protocols. When protocols are followed, the office and patients benefit. Let's take a look at how this scenario could have been different with a periodontal diagnosis and treatment protocol in place.

The initial appointment would have proceeded much the same. The major difference would have been that ALL team members, whether working or not on that day, would have known what screening, diagnosis, and treatment had been delivered during the initial appointment. Protocols provide a standard operating procedure so all providers are on the same page and everyone knows what the treatment sequencing will be.

For example, if the office protocol included Florida Probe's computerized probe and software, the patient would have received a periodontal risk assessment, a standardized probing examination, and a completely documented treatment plan, as this would be the standard operating procedure for a new patient. Probing would have been preceded by an educational video, which is an integral part of the Florida Probe software. These videos help patients understand information regarding periodontal probing and periodontal disease, as well as information regarding their own periodontal status.

Accurate printouts of the patient's periodontal condition would have been presented to the patient, along with her risk assessment. She would have been given an informed consent for periodontal treatment and been asked to accept or decline treatment. This system hastens treatment plan understanding and acceptance, which saves precious time in the hygiene operatory. Based on this data, the dentist would have still authorized site specific scaling and root planing, as was done at the initial visit.

The real issues were derived from the second visit. With protocols in place, the hygienist would have known what services had been provided for the new patient the previous day. This would have precluded the need for a second periodontal charting. If, however, the hygienist had probed again, she would likely have recorded the same pocket depths as the first hygienist the day before because Florida Probe excels in producing accurate results.

Dental patients and practices benefit from the Florida Probe's decades of research. The computerized probe delivers the recommended 15 grams constant force pressure while probing, regardless of the provider. The probe digitally gathers data that is accurate, consistent, and reproducible. This would have resulted in the second hygienist obtaining nearly identical results, within .2 mm, as the first hygienist. Minus the Florida Probe, a practitioner's probing pressure and skill may vary, thereby skewing the outcome.

The consistency of the probing depths helps confirm the patient's diagnosis.

In this scenario, the question of whether or not the patient needed periodontal procedures would not have been brought up if a periodontal protocol had been in place. The data collected would have dictated the treatment.

If a protocol had been in place, the second hygienist would not have questioned the patient about her previous cleaning because all information would have been readily available. After reviewing the data she would likely have supported initial treatment services because office protocol had been followed. This would have allowed the second hygienist to address the patient's chief complaint that day, which was roughness to her tongue. The roughness would have been removed, and the patient would have been dismissed after confirming her next dental appointment for continued periodontal therapy.

The sizzle would have fizzled after the second hygienist reviewed the data collected at the initial visit. The patient, patient's husband, both hygienists, and the dentist would have been spared this experience if the office had taken time to determine office protocols. So, take time to cool the heat of provider discrepancy and promote patient harmony by establishing periodontal protocols today.

About the Author

Antoinette Covino, RDH, has been practicing dental hygiene since 1969. She is president of Registered Dental Hygienists of Collier County, a delegate to the Florida Dental Hygiene Association, and a 2009 CareerFusion graduate. She can be contacted at acrdh@comcast.net.

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