Success is in the Details
Please feel free to go back and reread about case presentation. We will refer to it often. Remember that getting a “yes” from your patients is a team effort. Your success is dependent on mastering the fundamentals, so, I want to cover a little more on the details of hygiene. One difficulty that sometimes arises at this point is what to do with the patient who comes in wanting a cleaning, but is in need of soft tissue? You are now faced with a “confrontational tipping point”. This is the exact moment where case acceptance could go towards success or rejection by your patient. NOTE: Confrontational tipping points tend to occur often. With this fact, remember that you need to be proactive prior to this point of confrontation so that you are the one that brings it up, not the patient. In this way, you can disarm this point from confrontation to a mere discussion. Knowing when these points are likely to occur is the difference between great doctors and average ones. How do you help them get better, while having them want the treatment they really need? It is usually compounded by the patient that walks in talking about their previous dentist who for 40 years has taken care of them and the last three generations of their family. He goes on to explain that “good ‘ole Doc Neverlook” was a great dentist. He didn’t use those little hygienist girls. He was a real dentist and did everything himself.” You seat him and take one look and realize that the only thing holding his teeth in is a calculus bridge. In fact, every time he breathes the entire anterior dentition waves in the breeze. So, what do you do? How can you build a bond with the patient and still move them in the direction of understanding that a “cleaning” is not what they need? What follows is from a seminar by Walter Hailey with additions by yours truly.
This set of scripts and the system itself, is called “Blood and Pus”. It goes something like this:
- You have used the permission statement and discussed their insurance just like we discussed in “100% Case Acceptance”.
- You have taken the x-rays and charted the mouth for existing conditions and restorations.
- You explain about probing and show the patient the periodontal probe. You explain that the color-coded markings on the instrument are in two-millimeter increments, and that pocket depths of 2-3mm are normal but anything deeper (larger number) means the patient has a periodontal condition. You further tell them that any bleeding points or pus around any tooth indicates an infection.
- You swing the monitor around and involve the patient in “co-diagnosing” their mouth. We always handed the patient the “mouse” and had them click it to save the probing depth while watching the monitor indicate green lines for a normal probing and red for anything over 3mm. The moment you find a bleeding point, you stop and inform the patient that they have “blood and pus” around that particular tooth.
- You take the mirror or, even better, the intraoral camera, and show them the bleeding site.
- You then ask: “How long have you had that infection”? To which they will always reply: “I didn’t know I had an infection”.
- You then say: “We need to get the doctor in to see about this infection because you may need something other than a cleaning”.
- I will be the doctor here so I walk in and before I say anything the hygienist will brief me on what has occurred. “Dr. Abernathy, I called you in because Mrs. Jones has blood and pus around tooth number 30 and 31 on the lower right. I have not finished the entire probing because I knew you would want to be informed immediately.”
- I then would turn to the patient and ask: “How long have you had that infection?”
- Just as before she will respond with: “I didn’t even know that I had an infection until a few minutes ago”. (Keep in mind that before we ever began the probing and oral exam the hygienist had taken the time to explain about normal and diseased probing along with the fact that if “blood or pus” is present they have gum disease. We will always try to precede confrontational blockage points with explanations that preempt any push back from the patient. This ensures that we don’t surprise them with anything. Surprises will usually trigger a negative emotional response and cause the patient to be less likely to accept treatment.)
- Then I ask: “Does it hurt?” At this point the patient leaps at the opportunity to make it very clear that it doesn’t hurt at all. They do this because, like most of us, we think that if it doesn’t hurt then there’s not a problem.
- I pause just a moment with a reflective, thoughtful expression and say: “That’s the problem with gum disease. It’s kind of like cancer in that it never hurts till it is too late.” The use of the words “blood and pus” and “like cancer” creates a word picture (mental image) that the patient cannot ignore. They are now listening and own the problem.
- At this point I suggest that we take a little more time today to diagnose the disease and that we will probably need to see them a few times to clear this up. I allude to the fact that the hygienist will get her more information about her condition and as soon as we completely finish our comprehensive exam, determine what needs to be done, how much time it will take, and what the cost will be. I always close by saying: “We will maximize your insurance and make sure to help you fit anything that the insurance does not cover into your budget”
So, what about clients other than new patients? What about those recall patients that continually come in smelling like a toilet bowl and needing 50% more time to clean their teeth because they never brush or floss? You know the patients I’m talking about. You should have confronted them years ago about their periodontal condition, but somehow there was never a “right time”. Let me say that when we begin to make changes, we always begin with the new patients. With the patients of record the easiest thing to do is tell them you have gone to some continuing education classes and these are the new standards of care. You can mention about the “oral systemic connection” and that how the health of their mouths indicates the health of their heart, circulation, hormones, and overall health. My suggestion is that with these patients you just advise them that you are going to shorten the length of time between this cleaning and the next one to 4 months instead of 6. At that time, you will reevaluate their gum disease and if there are still bleeding points and pus that we will need to treat their periodontal condition. I would give them written literature including the periodontal handout from the ADA and your Oral Hygiene Fitness Report, and then make the appointment. Bottom line: You have to confront disease conditions and guide your patients into the proper treatment without pushing too hard.
To make this sort of a check the box routine with hygiene, here is an outline of a hygiene/patient appointment:
NEW PATIENT WITH HYGIENIST
- Pick up patient chart or open the digital chart and greet patient from reception area – introductions, etc.
- Review paperwork and forms while escorting patient to operatory from reception area.
- Be sure all required info is complete. It is not OK to leave blanks or have a partially filled out form.
- Review medical history form – Ask patient specifically what Rx meds they take. (They usually have a tendency to not write these down)
- Briefly discuss patient’s prior dental treatment, etc.
- Always ask if there is anything specifically, they would like to ask the Doctor about.
- Find out why they left their last doctor so that your office does not make the same mistakes the previous doctor or office made.
- Seat the patient. Give a brief explanation of what you’ll be doing today. Try to discover what they want, any phobias, negative prior experiences in dental offices, general dental IQ and/or concerns. NOTE: Make sure that with every patient’s chart notes, that you template everything so that whether there is one or twelve hygienists, there is consistency in the treatment notes that meet the standard of care from a legal and dental perspective. For example, every chart should already have a statement that “there was no change in medical history” on your template for every patient. If there are changes, which are rare, you make a notation of them. If there are no changes, you don’t have to type anything in the record, because it is already there. Every patient should have the legal definition of informed consent (including hygiene visits) already templated: “The patient was given the advantages, disadvantages, risks, and alternatives to treatment and has given us permission to proceed”. Remember that is always in the record regardless of the procedure and is in addition to any signed informed consent for specific procedures.
- Ask if they are currently having any dental discomfort. (NOTE: This is an entirely different question than #6 above – be sure to ask both.)
- Take patient blood pressure every single time you work on a patient, and yes, even with hygiene visits.
- Ask the patient if this is a normal BP for them and is their physician aware of this. Be sure to document if you suggest they consult a physician. All State Boards require base line blood pressure and a follow up any time dental work is done along with recording the reading.
- Take FMX and Pano. (The Pano will not take the place of an FMX.)
- Begin x-ray processing if film or arrange digital x-rays.
- This is a good time for the patient to work on any incomplete forms.
- Full perio probing. Record on paper chart or computer. (All states require a full perio charting for new patients and patients of record every 5 years.)
- Before you probe, tell your patient any number greater than 3 or any points that bleed are areas of concern. Call your numbers out loud so the patient can hear.
- Perform oral cancer screen.
- Let the patient know you are looking for any “abnormal” tissue growth.
- Consider using Visio system or other technology to be more thorough in your cancer screening.
- Perform video exam with the I/O camera. Involve the patient in the process. Capture images. Print as necessary. No patient should be seen without recording at least one.
- Save digital x-rays in patient’s digital chart.
- Chart existing restorations and any obvious needs.
- Every patient (unless they already have full anterior crowns or veneers) should be asked if they’re interested in whitening their teeth. Assume that all patients are interested in cosmetic dentistry until they tell you otherwise – DON’T PREJUDGE. Many people who might not look like whitening or cosmetic candidates will say yes. You’ll be amazed. The easiest way to do this is to ask: If there was anything you would change about your teeth, what would that be? You should always take a shade on every patient to elicit a question about what you are doing. This leads directly into discussions around cosmetic procedures.
- Fill out the treatment plan section of your practice management software by recording any necessary treatment in the digital chart and discuss with the patient as you go about what was found and how it may need to be taken care of.
- NOTE: Throughout all the above, be talking to the patient. Explain what you’re doing and why. This is education time. Don’t criticize their personal dental hygiene or their previous dentist and/or hygienist. This is relationship building time. You need to discover the patient’s chief desire and or highest perceived need.
- DECISION TIME: Decide whether to:
- Perform prophy (A), or
- Recommend SRP (B).
- If A: Begin the prophy. NOTE: Always, always make sure you clean their teeth on the first appointment if they are not a periodontal candidate.
- Call for the doctor.
- Doctor arrives – introductions, etc. NOTE: We covered this before, but the number one reason for a patient to not say yes to case presentations is having the doctor do the diagnosis before the cleaning. Partner with your team and create trust before the doctor confirms needed treatment.
- Give a brief overview of what you found, what the patient wants, and other things that were discussed.
- Exam is completed.
- Treatment Plan is presented. Starting point is determined. Hygienist consults with financial coordinator to have FA prepared.
- Doctor leaves.
- Prophy is completed.
- Recall appointment is made in the room with the hygienist. (Not at front desk.)
- Give the patient the “Oral Hygiene Fitness Report”.
- Give the patient 2 business cards. Tell them one is for them to keep, and one is to give to a friend if they were pleased with your service. (NOTE: This should be the hygienist’s own business card, not the doctor’s and not one generic to the practice. Some hygienists will even include their cell phone number and/or email address on their business card.)
30.If B: Begin discussion and explanation of perio problem with the patient. Use the “Blood and Pus” script and stage your next actions to help the patient want what they need. Treat people and suggest treatment that you would do on your own family. No short cuts, no cleaning when it is really a Perio case.
- Call for the doctor.
- Doctor arrives – introductions, etc.
- Exam is completed.
- Hygienist requests financial coordinator to prepare cost info.
- Patient meets with financial coordinator to make FA.
- Patient is scheduled at front desk for SRP.
Hygiene is all about relationships. It is the cornerstone of every great practice. Hopefully this will give you the insight to transform your hygiene department into the profit center it should be for your dental practice.
Michael Abernathy, DDS