Saturday, June 14, 2014

Ideal recall visits

Ideal Recall visits

I am going to begin this blog talking about the most repeated service provided in a dental office, a recall prophy and exam visit.  

We believe in providing templates in our office to insure the quality of our services.  We use the template idea in a number of settings including our hygiene visits.  The idea of a template is that we outline how a certain procedure should take place if everything went perfectly and then we strive constantly to make events follow that template.

Here is how the template for a recall visit works.

1.     The hygienists meet their patient at the front desk promptly at the appointed time.  Exceeding patient expectations is a key to success in a dental practice.  How often have you gone to a doctor’s visit and had zero wait time before being seated?  Right, it doesn’t happen very often.  Being exactly on time is a great way to exceed expectations.
2.     We have the multiple doctors in our office.  As the patient is being escorted back to the treatment room the hygienist asks the patient, “Do you have a preference which doctor does your exam today?”  We don’t ask, “Which doctor to you want to see today?”  Think about it, that is a very different question.
3.     The patient is seated and their medical history is reviewed and updated on the computer.  Any significant changes are noted for the doctor to see when he comes in.  We have toyed with doing this on a iPad and having the patient make the updates themselves.  This is cool and kind of high tech but we met a fair amount of patient resistance, especially among our older patients.  It is also less personal and that isn’t what we are about.
4.     The patient’s blood pressure is taken and recorded for the doctor to view when they comes in.  If the numbers are not ideal, the hygienist talks to the patient briefly about what that might mean.
5.     The hygienists determine the appropriate radiographs to be taken.   The standard in our office is four posterior bitewing radiographs and four anterior peri-apical images, three on the upper and one on the lower.  We are currently using digital radiographs.  We also take vertical bitewings in the posterior because they show the bone so much better.  Panoramic radiographs are taken once every four years starting at age eight.  Having said that, there are reasons to alter this protocol.  Radiographs should be determined individually.  If we recommend radiographs and the patient refuses, we ask the patient to sign a radiograph waiver.
6.     Hygienist sits the patient up and reviews the radiographs with the patient.  Point out to them any areas of concern.  Teach the patient what you are looking for and you will find them looking for problems with you rather than being at your mercy.  In our office we call this co-diagnosis.
7.     Six photographs are taken and added to the patient’s permanent record.  I find that these pictures are invaluable in keeping track of patient conditions and initiating discussion about cosmetic concerns.  These six photos include:

a.     Smile, lips at rest
b.     Full smile
c.     Retracted, teeth slightly apart
d.     Retracted, teeth together
e.     Maxillary mirror view
f.      Mandibular mirror view

8.     Full mouth perio probing is done on every adult patient.  If this is a non-perio patient then we simply record any number that exceeds the norm, (deeper than 3mm in any pocket, bleeding, mobility, furcations etc.).  We note in the chart that a full perio exam was completed with abnormalities noted.  At this time we also record all recession levels so that we can track total clinical attachment loss.  If a patient’s probing show evidence of periodontal problems then the doctor is informed promptly to come in and confirm the periodontal diagnosis.  While waiting for the doctor to come in the hygienist can discuss with the patient what the numbers mean and what you discovered.  We need to explain in clear, easy to understand terms what is going on and then to focus on solutions.  Help them understand the problem but focus on the solutions.  This should be a hopeful discussion.  It is often helpful to use an intraoral camera during this discussion.  The goal should be to help the patient understand and own their condition.  Without ownership we will never win this battle.

9.     A brief discussion about Perio.
a.     This is how we approach perio in our office.  There are a number of triggers that can move a person into a periodontal program. 
                                               i.     Unresolved gingivitis.  If the patient has gingivitis and the record shows that this is ongoing, in other words it has been talked about before, but the problem continues, then we move them into a perio program.  If this is the first time the gingivitis is noted then we would inform them and tell them that if the problem continues to be present at the next visit we will need to move them into a perio program.  We have a lot of patients in ortho who enter the perio program while in braces.  We don’t call it a perio program.  We call it “Treatment for gum disease”
                                             ii.     If a patient has isolated 4 mm pockets without bleeding, we would inform them about the situation and warn them about the problem that were observed.  It is helpful to be aware of smokers.  These people often have disease without bleeding.  Don’t be tricked by smokers.
                                            iii.     If a patient has isolated 4 mm pockets with bleeding we move them into a perio program.
                                            iv.     If a patient has any pockets 5 mm or greater, with or without bleeding, they enter a perio program.  Patients need to understand that 4 mm pockets or bleeding are a real wake up call.  5 mm is a dangerous situation.  6 mm or more represent major, maybe irreversible, disease.  Every mm makes a big difference in the prognosis.  Make sure that you talk to patients in words that they understand.  If you are probing, tell the before you start, what the numbers mean, and then tell them to listen for any numbers greater than 3 mm.  Don’t use words like perio, probing, pockets etc.  Use words like gum disease, infection, etc.  Use words that they understand.
                                             v.     If a patient has a spouse or partner with active gum disease we want to determine this as well.  The infected partner will need to be treated at the same time so that they don’t re-infect one another.
                                            vi.     When the doctor comes in the doctor will expect to have the hygienist explain the situation and give their recommendations for treatment.  Treatment recommendations might include:
1.     Shortened recall, usually three months, maybe more often
2.     Improved home care
3.     Oral hygiene aids, including Sonicare, Waterpick, floss holders, Perioguard, gum tonic, oral probiotics etc.
4.     Scaling and root planning.  The number of quadrants will be dependent on the needs of the patient.
5.     Chemical agents, such as Arrestin or other agents.
6.     With non responsive patients we may recommend testing to determine the dominant type of bacteria and the best antibiotic’s to approach the problem.
10.  If the patient is not a perio patient then the hygienist simply passes a note to the doctor or doctors letting them know that they are ready for an exam at any time.  It is much more efficient to have the doctor come in and interrupt the hygienist to perform the exam than to have the doctor come at the end.  If you don’t inform the doctor until you are done then you will waste time waiting for them at the end.
11.  Proceed with the prophy.
12.  Passing the baton”.  When the doctor arrives in the room, immediately sit the patient upright so that the doctor can talk to them at eye level.  Introduce the patient to the doctor.  If the doctor already knows the patient then start the conversation with a personal note.  “Doctor, John just got married…” or something to that effect.  “They are first a person and then a patient”.  Next tell the doctor anything that you have noticed that the doctor should be aware of.  These might be medical changes, blood pressure problems, things that you noticed on the radiographs etc....  It’s good to mention positive things that you may have noticed as well.  Don’t get into the habit of only reporting on negative items.
13.  In our office the doctor provides both the dental exam and the soft tissue exam/cancer screening.  In some offices the soft tissue exam is delegated to the hygienist.  I prefer to do it myself.  If the hygienist has images or radiographs of a problem area it is helpful to have these up on the screen when the doctor enters to begin the discussion.

14.  At the conclusion of the appointment, make sure that the patient understands any work that needs to be done.  If the patient has significant treatment needs, 3 or more crowns or treatment costing more than $3000, then schedule them to come back with the doctor for a consultation before beginning treatment.  We introduce this by simply saying “You have some significant challenges with your teeth.  The doctor would like to take some time to carefully consider how to best take care of you and then have you back to talk about your options”.  We almost never have anyone unwilling to come back when it is presented in this way.  If they have a spouse or significant other we invite them to bring them to the consult as well.  This will allow them to get their questions answered as well and help to avoid conflict at home regarding the cost of treatment.  If the patient has less complicated treatment then you can proceed to treatment plan the case in the computer.  Feel free to ask the doctor what they would like to do first and how much time they will need.  These patients should leave with a print out of their proposed treatment and the associated costs.  The hygienist can also set up their appointments or this can be deferred to the front desk if time is short.
15.  Set up the next recall visit with the patient.  We never let a patient leave without their next visit scheduled.  If a patient says “well, I don’t know my schedule that far out” we simply say “Well, I know one appointment that you have now” or if we want to be more serious then we say “This will reserve a time for you.  If there is a conflict when it gets closer we will give you plenty of notice to change your appointment for a more convenient time.”
16.  “Passing the baton” Escort the patient to front desk, let the front know what is needed next.  If they have more than $300 of work to be done, the front desk person will set up financial arrangements with the patient and make sure they know what to expect at the next appointment.

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