Th 198917

The Mental Checklist

Jan. 1, 2006
When treating patients, it is necessary to “downshift” with each patient so that one does not get caught in the routine of performing the same services with each patient, or using the schedule as your guide to patient care.
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When treating patients, it is necessary to “downshift” with each patient so that one does not get caught in the routine of performing the same services with each patient, or using the schedule as your guide to patient care. The insurance dilemma can also create barriers for some. As a result of all of these things, I have decided that, in a perfect hygiene world, the best way to avoid all of these pitfalls would be to have a schedule with only names - no services listed, no prescheduled times, and, most importantly, no knowledge of whether or not a patient has an employer dental benefit plan. Well, that will likely not happen, so it is necessary to have a plan B, from which my mental checklist concept has developed.

As clinical dental hygienists, it really is necessary to have a systematic way to treat our patients. There are many services that must be delivered to patients in order for them to receive a complete dental hygiene experience. The procedures that are outlined are based on things that we have been taught through our educational process. Patients are better educated about the services that we provide and the importance of good oral health to total body health. There should be no fear in discussing our findings and the disease process with patients. I am amazed that when I have this discussion with patients; they so often say that they just heard or read about it somewhere. Surely, when Time magazine discusses the impact of inflammation and mentions gum disease as an example, we can expect that our patients might be among the millions of subscribers who might have read this.

So, what does this mental checklist include? Let’s start at the beginning.

The importance of a current, complete medical history is essential. There are many medical conditions that have oral manifestations, and the significance of prescription medications cannot be overlooked. There are many that can cause xerostomia and overgrowth of gum tissues or increased risk of bleeding to name a few. Poor oral hygiene is no longer the only thing contributing to poor gingival health. Blood pressure screening is also part of my health history review, and once the baseline is established, I continue to perform a blood pressure screening at each recare visit as part of my protocol.

The head-and-neck examandoral cancer screening is next. Dental hygienists were taught to do these as part of our training, yet it seems that they are among the first things to be forgotten in clinical practice. Why? This can be a lifesaving service for our patients. Most oral cancers are detected in the latter stages, and dental hygienists are in a prime position to detect suspicious lesions early. Referral by the dentist, when necessary, should be a regular part of the care plan. Let’s not forget the extraoral examination. Patients cannot see behind their ears and on the top of their head. We should be palpating as well as performing a visual screening of any suspicious areas.

I speak from experience in this area. The reward is great in knowing that a precancerous mole was removed from one of my patients as the result of my persistence in reminding him at each visit that it did not look normal and was changing in size. This is one way that we can build relationships with the medical community; they will recognize that we are educated to do more than “clean teeth.”

Evaluate the shade of the patient’s teeth. Simply asking the patient, “Have you ever wanted whiter teeth?” is not enough. They need to have a reference; most patients think their teeth are whiter than they actually are. The dental hygienist is also in an excellent position to educate patients about the actual shade of their teeth, and what could be expected with the different whitening options that are available in the office. Take a shade, then ask the patient to pick from the shade guide where they think they are. This will open the door for discussion about whitening. There is some thought that patients who have their teeth whitened become better dental patients. They care more about their teeth and become more aware of the other things going on in their mouth. Of course, the patient must be a good candidate for this procedure in order for the outcome to be successful. This procedure is one of the “wants” for our patients. They need to know that this service is offered in your office or they may look elsewhere to find it.

Dental screening/restorative evaluation is an area that I have found needs to be addressed between the doctor and the dental hygienist to find the parameters of what things should be discussed. Once the hygienist knows the doctor’s criteria for performing procedures, he/she can become a valuable resource for the patient. The dental hygienist spends more time with the patient and can use some of this time to discuss possible options for treatment.

No, I am not implying that the hygienist make a dental diagnosis. The hygienist can open the conversation by discussing the problem: “Mary, it appears that you have broken off a large portion of this back molar on the lower right side. I want to talk with you about some of the things that Dr. Smith might discuss with you as options to repair that. This way, when he comes in to perform the exam today, you will already have an understanding of what the procedure might involve.”

Some hygienists might consider this as “selling” dentistry. I would encourage you to remove the word “selling” from your dental vocabulary. Yes, there is a cost for this treatment, but there is with any other consumer service as well. This step should also include a caries-risk assessment. Typically, dentistry has provided care under the surgical model. When there is a hole, we fix it. A shift in thinking is necessary to operate under more of a medical model, where the disease and the whole person are addressed. In this model, the disease - caries, which is caused by bacteria - is addressed, and there are recommendations made to help the patient reduce/eliminate the bacteria, address dietary concerns, evaluate saliva quality and quantity, and provide remineralization strategies when necessary.

Periodontal evaluation is the foundation for the dental hygiene treatment plan. The importance of proper diagnosis cannot be overestimated. Those who get frustrated with a day full of “bloody prophies” and patients who never respond to treatment even though they come in every six months need to evaluate the diagnostic aspect of their patient care. A complete periodontal charting, risk assessment, and current radiographs are some of the main things that are essential to formulate the diagnosis. There is no cookie-cutter system for this, and the need for treatment other than a prophy should not be based on a single measurement such as probe depths or bleeding, but should be based on a comprehensive evaluation of all of the information gathered through the exam, the patient’s history, and the patient’s ability to comply with recommendations.

Execute the dental hygiene treatment plan and establish a maintenance interval. This should be based on the diagnosis. Treatment will provide the best opportunity for the patient to achieve a state of improved oral health.

Recommend additional treatment/products. This might include in-office and home-care fluorides, breath control products, oral hygiene aids, power toothbrushes, and whitening maintenance products to name a few. Fluoride is another one of those areas that has become more of an insurance-driven service rather than a need-driven service. Patients should not be denied the recommendation for treatment because it is not a covered benefit. Step out of the box and look at the needs of the patient and let them decide. This is another area where some clinicians struggle with the feeling of “selling.” When training in our group, I often use the analogy of visiting the hairdresser. It is rare that I leave without a product that she has recommended because she has created value for the product based on my needs. We should do the same for our patients.

So, as you can see, there are many things to consider in providing a complete hygiene experience. It really is a lot to think about each time we seat a patient. For that reason, it is necessary to have a checklist in your head. It will assure that each patient receives the same level of care. Taking time to explain what we do will also help to build value for the services that we provide.