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.
