by Elizabeth Nies, RDH, AS
Recently I attended a membership meeting that the American Dental Hygienists’ Association presented to our constituent society. I was pleasantly surprised to hear of the new direction ADHA is taking. I am very fortunate to be employed as a hygienist in an office where I have an assistant and head up the hygiene department. Let me explain ...
I have a separate hygiene budget that allows me to order the supplies I want without having to ask for them. I interviewed and chose the assistant I wanted. My first hygiene assistant, Amber, started in our office during her externship. She enjoyed working in our office, so when she graduated from her assisting program she joined our team as the hygiene assistant. We decide on the length of time for each appointment, depending on the patient and my needs. All this creates a wonderful working relationship with my employer. We both practice assisted oral health care. He has two assistants, and I have one. All three of our assistants are always willing to do whatever it takes to keep both the preventive and restorative sides of the practice running on time. We are a true dental health team!
ADHA now focuses on bringing dentists and hygienists together for the greater good of our patients. The Advanced Dental Hygiene Practitioner (ADHP) position is being presented as an adjunct to private practice rather than a threat. ADHA is working toward autonomy in oral health care, and I love it! The team approach is a win for everyone.
I was born and raised in New Jersey. I practiced on the East Coast for 20 years under direct supervision, was not allowed to administer anesthesia, and was not even able to use the DIAGNOdent. Three years ago, I moved to Idaho and have broken the chains that bound me for so long. I now practice under general supervision, administer local anesthesia (in fact, I give most of the injections in the office), and use the DIAGNOdent. I often see patients when the doctor is on vacation or out of the office. I even work in a paperless office. In other words, I love my job!
Assisted hygiene is the ultimate in preventive care - everyone wins. The dentist wins by enjoying increased revenue. The hygienist wins because he/she no longer rushes around, working alone. The patients win because they actually receive improved oral health care. Now, don’t raise your eyebrows, keep an open mind, and I will explain how you, too, can reach Utopia.
First, the dentist and the hygienist must agree on the way the department will be run. I was lucky that it was Dr. Cox (my employer) who wanted to change things for the better, and he was willing to let me run with the ball. The first six months in my practice, I worked alone out of two rooms. When I say alone, I mean I did not have a dedicated assistant. The doctor’s assistants, receptionists, and I worked as a team. The receptionists would help me chart and clean the operatories, and the assistants would take X-rays, clean my room and set it up, do exams, and whatever else I needed them to do. I worked hard and was tired at the end of the day. It was bearable because I knew it was only for a short time. At that time, I was seeing patients every 50 to 60 minutes, with 30 minutes for children. I was also entering all of my own notes into the computer. I was also in the operatory while the doctor completed his exam.
Every patient left my operatory with the next recare visit scheduled. In this way I had control of my patient flow. I knew that with an assistant I could see a new patient or complete two quadrants of periodontal therapy in 80 minutes (chairtime), a recare with X-rays in 50 minutes, a recare without X-rays with a teen or periodontal maintenance appointment in 40 minutes, and children 12 and under in 30 minutes. I would arrange appointments that worked for me. Figure 1 shows how my day might look.
The dentist requested that I see 12 patients a day, but in reality I could schedule 14 to 16 patients since 98 percent of the time four or five people need to change their appointment time after receiving their recare card in the mail. I usually see between 10 and 12 patients a day. That’s probably information for another article, but I think you understand my point.
After four months of working on my own, it was time to hire my assistant. My first assistant was Amber. She and I were an awesome team; we worked together for two years. When an assistant left on the operative side, Amber replaced her and now works with Dr. Cox. Dr. Cox and I agreed that this would be the only time an assistant would be allowed to move from one department to the other. This is vital, because the hygiene assistant is a totally different team member and has different duties, one of the lessons I learned while treading on new territory.
I needed to find someone to replace Amber, and I asked to do the initial interviewing. I would have the candidates I liked come in and complete a working interview. This was great, because Dr. Cox would have the opportunity to work with the assistant to see if he liked him or her. We placed an ad in our local newspaper and received many calls. Many people asked us how long until they would assist the doctor. We made it quite clear the answer was almost never. This is important because the hygiene assistant is a new member of the dental team. Ideally this position is vital to the health of the hygiene department. Chairside, the assistant’s duties include seating the patient, reviewing the medical history, taking X-rays, computer charting (periodontal and existing restorative if needed), intraoral photographs, polishing, fluoride treatments, playing any appropriate CAESY educational video and/or flossing and brushing instruction, setting up recare appointments, and doing the exam with the doctor. The assistant also cleans the operatory and sets it up, performs sterilization duties, and does the ordering. She also enters my notes into the computer. Hold on - wait a minute, you say! You’re wondering if all I do is scale? The answer it is a big fat no! I, too, do all of the same duties. I will explain that in more detail shortly.
We interviewed many candidates for the position, and I selected two to complete working interviews. The final decision was to hire Kat (Kathleen) as the new hygiene assistant. Kat joined our team for a six-week trial period. Fortunately, everything worked out and Kat is still my assistant. The other day, as Kat and I were placing some sealants, I reminded her that she had to remain my assistant for four years, as I had mentioned during the interview. Kat corrected me (it was five) and told me I didn’t have to worry because she wasn’t going anywhere. She loves being my assistant. I just smiled under my mask.
Let me walk you through a typical hygiene day in my office. The first patient of the day is brought into the operatory either by Kat or me, usually Kat. She reviews the medical history and takes X-rays if needed. Before I enter the operatory, I view the patient’s medical history. I check for accuracy and address any concerns I have with the patient. I trust Kat, because I trained her how to do it my way. (After all, dentists have trusted us to do this for a long time.)
I then go into the operatory and greet the patient. If the patient is new, Kat introduces me. She also gives me some fun facts about the patient such as what the patient likes to do, where he or she works, hobbies, and any concerns. These exchanges are called pass-offs, an essential ingredient in keeping our office running smoothly. I will talk more on pass-offs a little later.
Next, I complete an oral cancer exam, chart restorations, do periodontal charting, chart recession, check bleeding on probing, take intraoral pictures, and give the information needed to enter a note in the patient’s record. Kat then leaves the room as I ultrasonically scale and hand-scale the patient. I also recommend additional home-care techniques or devices. While I am working, our next patient arrives and Kat continues her routine: seat the patient, review the medical history, find out the chief concern, and take X-rays if needed. If I am not finished yet, she asks Dr. Cox to complete his exam.
The patient is now ready for me. I either complete the rest of the treatment and set up the recare appointment for the patient I am with in the first operatory, or Kat comes in and finishes. For example, I may have just completed polishing and Kat is ready for me to move to the next room. Kat enters and I say, “Mr. Smith, I would like Kat to show you the technique I was talking about to make sure you clean that area better. Then she will polish your teeth (assistants may do so in Idaho), do your fluoride treatment, and make your next recare appointment.” I pass-off to Kat any significant findings for her to pass-off to the dentist when he completes his exam before saying my goodbyes and moving to the next operatory.
Sometimes it works out that I seat the next patient while Kat is completing an exam with the doctor or scheduling treatment for the patient. I then review the medical history, take any necessary X-rays, and chart either with Kat or ask Amber to help me until Kat has passed-off the previous patient to the front office staff. I always go back and review the notes entered before I leave and make sure all information is there. Kat also reviews all notes as she is in the room with the dentist for the exams.
I have used the word pass-off many times. A pass-off is the exchange of information from one person to another. There are many pass-offs during a recare appointment:
- Pass-off from patient to receptionist.
- Pass-off from receptionist to Kat or me.
- Pass-off from patient to Kat or me.
- Pass-off from Kat to me.
- Pass-off from me to Kat.
- Pass-off from me or Kat to Dr. Cox.
- Pass-off from Dr. Cox to Kat or me.
- Pass-off from Kat or me to the receptionist.
Patient care is a big circle. You will find that when pass-offs are done correctly and routinely, appointments will run smoothly. The pass-off process actually begins during the morning huddle. We all gather in front of the computer and review the day. We discuss a game plan for each patient. Whether it is financial, medical, operative, preventive, or personal, every member of the team has all the facts. The entire dental team is aware of these issues and can address them throughout the day. Pass-offs also cut down on unscheduled treatment and incorrect billing for treatment items.
When I first began doing assisted hygiene, the hardest thing was letting go of all the duties I have done for so long. I would catch myself wanting to jump in and do it myself. I can remember one day standing in the lab and having to remind myself to breathe as the assistant reviewed the medical history. I now smile as she comes to me with her concerns and findings to review with the patients. After all, isn’t that what we have done for the dentist for years?
Preceptorship, threat of scaling assistants, and the restrictions in the scope of practice are happening in many states because the threat of independent practice has left dentists no choice but to grab hard and hold on tight. Our passion for self-regulation has been misconstrued; it is hard to see through the fog. Dentists trust us to let them know about any suspicious areas we find in patients’ mouths, explain these findings to our patients prior to their exam, as well as explain treatment options. Dentists like to be able to come into the operatory, diagnose the condition, and have patient acceptance with no explanation needed. They trust us to educate and provide preventive oral health care. They enjoy having a well-trained hygienist on their team.
I am viewed in my office as a health-care provider who works side by side with the dentist treating patients. I anesthetize his next patient while he finishes up on the previous one. While I am numbing the patient, my assistant is cleaning the operatory, exposing radiographs, taking intraoral pictures, reviewing a medical history, etc., so I can begin once Dr. Cox’s patient is anesthetized.
This is a total team approach that I thrive on. I am excited about the Advanced Dental Hygiene Practitioner position and look forward to it becoming a reality. I see it as an addition to private practice as well as a solution to access-to-care issues. It would be wonderful to work beside the dentist in an ADHP capacity. Think of how much more dentistry could be accomplished on “Give Kids a Smile” Day! Is ADHP for everyone? Probably not. I love private practice, and I love working as a team with the dentist. I’m just sharing one hygienist’s opinion and gratitude for the new attitude of ADHA.
About the Author
Elizabeth Nies, RDH, AS, is a graduate of Fones at the University of Bridgeport, class of 1984. She has been practicing dental hygiene for 23 years. Active in the ADHA, she is currently president of her local component in Idaho and past president of the New Jersey association. She also is the Practice and Regs Chair for the Idaho DHA and the chair for their annual session in Boise (Sept. 13-15). Liz can be contacted at (208) 866-4271 or Lizabiz_2000@ yahoo.com.