Never Let ’em See You Sweat

Do you remember those deodorant commercials in the 70s and 80s? I think it was Right Guard that coined the term “Never Let ’em See You Sweat”. Well, I’ve been faced with a couple situations recently that had me depending on my Right Guard to get me through.

The concept of those old commercials was to keep your cool when under pressure. Never let your colleagues or clients see you sweat under stressful situations.  It happens to us ALL and it’s a lesson in mastering our emotions, to say the least.

I mentioned last week that I recently spoke to about 300 hygienists at the Utah Dental Hygiene Association meeting.  I have to tell you, we had some technology gremlins trying to take us down.

Before my talk even started, I realized that my brand new laptop was not going to work with the projector.  I had to use a loaner and my jump drive.  That meant all the cool web links and video I’d implanted in my power point program wouldn’t work.  Then, right in the middle of my presentation, the entire ballroom went black.  The power went out completely for what seemed like an eternity (it was probably 2 minutes max).  While I was sweating on the inside, the reality was that the audience never missed those web links or knew that we had to change computers because the content remained the same and we just kept on trucking.

Whether you’re speaking to 1 or 100, these hiccups happen to us all from time to time and they happen in your clinical practice too. Just the other day, I experienced a situation where an innocent error was made in scheduling a patient’s hygiene appointment.  The patient arrived at a time different than what was on the schedule.  Needless to say, it turned into a ‘learning experience’ for everyone, me included.  See, this was the perfect opportunity to shine in the face of a challenge so the patient never knew of the error OR fall into all the reasons why it had happened and allow the patient to get caught up in the stress of the situation.

Managing these situations may make us sweat but the beauty is that our patients never need to know it!  Here are few situations and how to handle them with grace.

Patient shows up late– Greet them with concern and relief that they are ok. You control the course of the appointment (and your day) by saying “I’m so glad you made it. Of course we’ll see you and we’ll do as much as we can in the time left in your appointment”. Whether it’s 45 minutes or 15, we can accomplish something.

Patient shows up at the wrong time– Cheerfully great them and, before telling them THEY messed up, explore all opportunities to care for them now. Then you can say “We’ll be happy to take care of you in just a few minutes”.  This is an opportunity for the entire team to step up and be massively flexible! Then take a moment to determine what happened and how you can prevent the problem in the future.

The computers go down in the middle of charting -rather than saying “Darn, my computer just died. We’ve been begging doctor to get new computers but the economy is just killing us”(ugh!), just pull out a piece of paper and keep on going. You can always add the data to the computer chart later and the patient will never know the difference.

Take a “Never Let ’em See You Sweat” approach and you’ll nurture patients that have ultimate confidence in you. And we all know how great that feels…

Disclaimer- I know a few of you will email me so just know that I’m not talking about habitually inconsiderate patients. That’s another article for another day.  🙂

Step-by-Step System for the Ultimate Hygiene Exam

Greet patient by name with a handshake

  • “Hi, Ms. Jones. My name is Rachel and I will be taking care of you.”

Escort patient to treatment room

Ask patient for any questions/concerns they may have

  • “Have you noticed any changes with anything in your mouth? Do you have any questions or concerns before we start today?”
  • Address any specific concerns

Take Blood Pressure and record in chart

Review Medical History

  • “Are you taking any medication, supplements or over-the-counter drugs? Are you taking aspirin daily? Have you had any surgery or new diagnoses since your last visit?”

Take radiographs if necessary

Review radiographs

  • Observe bone level and compare to periodontal probe readings
  • Observe decay visible on x-rays
  • Observe margins of restorations
  • Observe any lesions in the bone

Do extra-oral head/neck oral cancer screening

  • “Ms. Jones, I am going to be my exam by feeling for any unusual lumps or bumps on your face and neck. Is that ok? Have you noticed any lumps or bumps?”

Do intra-oral cancer screening

  • Complete a visual exam
  • Utilize technology for oral cancer screening-Velscope or Vizilite

Complete general intra-oral exam

  • Observe restorations, teeth and gums
  • Calculus detection
  • Decay examination
  • Evaluation of existing restorations
  • Cosmetic evaluation-shade guide analysis
  • Breath Analysis
  • Oral Hygiene Evaluation
  • Occlusal Analysis

Complete 6-point periodontal examination

  • “Ms. Jones, I am now going to do a very thorough exam of your gums. This exam looks for signs of gum disease. I will be taking several measurements on each tooth and you will hear me call out lots of numbers. If you hear numbers that are 1-3 with no bleeding, that indicates that your gums are healthy and normal. Any numbers you hear that are 4 or higher or if you hear me say there are many areas of bleeding, that is a sign of gum infection. I will review all the numbers when the exam is finished”
  • Using a periodontal probe, measure the depth of each pocket.
  • Start on the upper right facial moving around the arch taking 3 measurements on per tooth. Then move to the lingual and take 3 measurements per tooth. Repeat on the lower arch.
  • Say all perio numbers aloud from the upper right to the upper left facial. Then look back at upper facial areas and say aloud any points of bleeding, pus. Repeat on lingual and on lower arch.
  • Measure recession from the CEJ to the gingival margin. Say all numbers aloud with surfaces to be recorded on perio chart.
  • Record mobility and furcation aloud and record on perio chart
  • Read aloud the total number of bleeding sites and pockets over 4mm
  • Print perio chart in color.
  • Highlight infected areas on periodontal chart (4mm or greater).

Determine patient’s periodontal status: healthy, gingivitis, periodontal disease

Share your observations with the patient

  • Share with patient their periodontal status-healthy or infected
  • Share with patients any teeth you are concerned about
  • This is a good time to discuss whitening, fresh breath solutions

Take intra-oral photographs

  • If patient has periodontal disease, take photos of inflamed, bleeding tissues and/or visible calculus.
  • If patient has healthy gums, it is now time to discuss their restorative needs. Take photos of next restorative priority (area of concern).

Create periodontal treatment plan or preliminary restorative plan for doctor approval

Call Doctor for exam (doctor may do exam any time after hygiene exam is complete)

  • Doctor confirms all findings and makes final diagnosis
  • Doctor reinforces need for perio therapy as first priority when there are no emergency restorative needs
  • Doctor reinforces need for restorative treatment when patient’s periodontal status is healthy
  • This may occur immediately following hygiene exam or closer to the end of the appointment depending on doctor’s schedule

Begin hygiene service

  • Prophy for healthy patients
  • Gingivitis therapy for gingivitis patients
  • Initial scaling of healthy areas or begin perio therapy for perio patients

You may now begin scaling

Do you value Perio maintenance?

Perio maintenance is one of those procedures that always brings up questions and differing opinions. Much of that is due to the conflict between the CDT definition of perio maintenance, that patients with periodontal disease should stay on periodontal maintenance for life, and the insurance industry’s lack of support for this service. There are a few challenges to overcome to get better results when enrolling patients into a perio maintenance program.

First, ask yourself a few questions.

  • Are you alternating perio maintenance and prophies for patients that have periodontal disease?
  • Do you have a hard time getting patients to “buy in” to perio maintenance every 3 months?
  • Does your hygiene team see very few periodontal maintenance patients each week or each month?
  • Do you ever feel that there is little or no difference between the services you provide during a prophy and those you provide at perio maintenance?

I bet you answered “yes” to at least one of these questions and you are not alone. There are thousands of hygienists and dentists that share your frustration. Here are a few strategies to help you increase the value of perio maintenance and keep your patients healthy. Isn’t that our #1 job after all?

Strategies

#1-You must believe in what you do. I could write a book on this alone. It especially applies to periodontal therapy and maintenance. If you don’t believe in your heart that the treatment you are recommending is the best treatment for that patient, they won’t believe it either. Alternating perio maintenance with prophy creates confusion and degrades the value of your skills to help prevent perio disease flair ups. Although every patient may not need to remain on perio maintenance forever, it’s for sure that patients with moderate to severe disease will benefit from 90 day maintenance for LIFE.

#2-Know the science. If you’re not sure what you believe about perio, that’s ok. It just means you need more information. Learn more about the mouth-body connection. Three months is not an arbitrary number made up by some periodontist. It is based on classic studies and the AAP’s statement on the benefits of frequent maintenance intervals. Learn some of the new information about bacteria and biofilm. A great resource for new perio information is a FREE online CE course delivered by Dr. Richard Nagelberg through Hygiene Town’s website. Here is the link.

#3-Educate early. When you first recommend perio therapy to a patient, include the fact that the long-term success of your treatment depends on maintenance and what they can do at home. Don’t let perio maintenance or the additional cost be a surprise to your patients. Remind them as you proceed through therapy and even schedule their 1st perio maintenance before therapy is complete.

#4-Make it different. Always, always, always do a complete periodontal assessment and charting including bleeding, mobility, furcation and recession at every perio maintenance visit. You must believe that your perio maintenance therapy is different from a prophy and that your frequent clinical services are critical to preventing future perio breakdown and worth MORE than the fee you charge. If it’s not different, make it different.

#5-Add extra services. Maybe you simply add irrigation with an anti-microbial rinse at the end of the perio maintenance appointment. Maybe you add fluoride to coat those root surfaces or create a special fee for Arestin placement at perio maintenance. The definition of perio maintenance includes the isolated treatment of recurrent perio infection. Set guidelines so you know when it’s time to recommend active therapy again.

#6-Make sure your patients get what they pay for. When you know they’re getting more than they paid for, you will feel great about the service you provide and you will have no trouble enrolling patients into a lifelong maintenance plan. This includes giving patients support with the right tools for homecare too.

Technology-Out of the Closet and Into Hygiene

So, you’ve invested thousands of dollars on various technology breakthroughs in dentistry. Whether you are a technology geek or just beginning to dabble, the key to getting a healthy return on your investment is to get your team on board. Achieving this starts with you, Doctor. Being excited and confident about your new piece of technology is the first step. The next step is to inform your team BEFORE the equipment arrives. Nothing sends a piece of equipment to the back closet faster than the old, “unpack it and figure it out” mentality.

Let’s look at a few other tips for successfully implementing new tools into your routine.

1-Training- Before purchasing a new tool, be sure the company selling it provides adequate training for you and your team. Skipping this step results in slow adoption and failure to learn the full capability of the product. I’ve been in several offices where team members don’t even know what technology tools are in the practice, much less how to use them.  You and your team can quickly learn the ins and outs with the help of a good trainer.

2-Agreements-It’s so simple but sometimes team members need to create written agreements for the use of technology equipment. If your hygienists share a digital x-ray sensor, you might put in place an agreement that as soon as x-rays are complete, the sensor is ejected from the computer and put into a basket with all the needed holders and accessories. The basket is then placed on the edge of the counter or another spot where it can be easily picked up by the other hygienist. This small step can save loads of frustration and resentment between team members.

3-Accessibility- This is huge! I often coach hygiene teams that have various technology tools in their office and they are all located in one central location…that back closet again. The theory is that if they are kept there, everyone will know where to find them. The reality is, it just doesn’t work. Hygienists live and die by the clock. If they have to walk down the hall to get the intra-oral camera, that just ate a valuable 5 minutes of appointment time. A better solution is to store the tool in the hygiene operatories. Let’s say there are two hygiene ops side by side. If your hygienists are using a digital camera for intra-oral photos, it too can be placed at the edge of the operatory. Another great idea that I learned from my Doctor is to buy a digital photo card for each team member. This way, one hygienist can take photos, eject her card and then pass the camera on to the other hygienist without having to worry about lost or deleted photos.

4-Scheduling-Allowing enough time for your team to use technology is a piece of the puzzle often overlooked. You’ve heard me say this before…I have never coached a team that didn’t increase production when they increased their adult hygiene appointment time to 60 minutes. It takes time to take quality intra-oral photos, put them up on the monitor and then share the information with the patient. This is a huge practice builder in the hands of a well-trained, motivated hygienist. It can add tens of thousands of dollars to the doctor’s production each month. Adding 5-10 minutes to the hygiene appointment time is a small investment that pays you back, big time. So, pull out that intra-oral camera, dust it off and get it into the operatory where it will work to increase patient care and productivity.

Who Scheduled This?

A few weeks ago I had an interesting conversation with a member of our Mastermind program during one of our focused coaching sessions. Bev is the office manager of a large practice with multiple hygienists.  Her frustration is one that you may have faced too. How do you schedule a productive day that won’t send your hygienists over the edge? Bev was struggling because her hygienists have a very specific way they like their day to be scheduled. No back-to-back x-rays or perio maintenance patients. That’s pretty hard to pull off.  Your schedule isn’t static, changes happen. The admin team is responsible for creating a productive day and the hygienists must deliver the care.

I have to admit, it is a fine balance and there are many moving parts. In fact, one of the first things I do with my private clients before I ever step foot in their office is look at their schedule. I set up a web meeting and work with the hygiene coordinator to put systems in place to ensure that when I go in-office to do training, there’s somewhere to put the increased perio therapy and maintenance and the hygienists have time to spend on co-diagnosis.

So I had a few bits of advice for Bev and I’ll share them with you.

1-Reality Check– The fact is there will be days when you have back-to-back patients that need x-rays, you will have days where you have several perio maintenance patients. Hygiene isn’t a leisurely occupation. If we want to be productive, we usually have to hustle.  And when a patient drops out of the schedule, be thankful when your admin team fills it quickly.  Let me be clear here… it is counterproductive to cut appointment time. Be sure to schedule the appropriate amount of time to do a thorough exam, co-diagnosis and the needed treatment and know that there are going to be days that are more challenging than others.

2-How Can I Help-When you see that you’ve got a busy day on the schedule, identify the points in the day that will be a stretch and then come up with a proactive plan!  For instance, if a perio maintenance is followed by a patient that needs 4 bitewings and a panorex, call the patient and see if they can come in 5-10 minutes early and then have someone immediately seat the patient, take the x-rays and then move the patient to hygiene. In your morning huddle (you’re having one, right?) look at the schedule and have the hygiene team tell you where they will need support. Often hygienists don’t like to ask for help when they’re knee deep in patients.  At that point, they’re just focusing on completing one patient and seating the next.

The key is to have a plan and support each other in meeting your responsibilities. Create a win for everyone-the practice, the team and the patient.

5 Mistakes That Are Costing You Thousands – Part 1

#1 Assuming Perio is Taken Care Of

Having a sharp hygiene team is a beautiful thing. But assuming everything is being taken care of is a big mistake. Be sure you know that a complete perio exam is taking place at every hygiene visit AND the data is being recorded. This is a huge area of liability for you and it’s your hygienists responsibility to collect and analyze this information. One way to find out where you stand is to do an audit of your charts. Randomly pull 20 charts of adults seen in the last 6-12 months. How many have a complete perio exam recorded in the last year? Chances are very good that if the percentage is low, so is the amount of perio treatment.

#2 Starting Perio Treatment Too Late

My interpretation of the AAP’s Perio Classification system is that Beginning (slight) periodontal disease is 4mm pockets with bleeding and slight bone loss and 1-2mm CAL. This is a huge distinction for many dental teams. Often, these are the “difficult prophies” or the patients that have 3 month prophy intervals. I see it time and time again- teams waiting until pockets are 5-6mm deep before beginning treatment while valuable the patient loses valuable bone that could have been saved.

#3 Too Little Time for Hygiene Visits

I’ve mentioned this before and I’ll say it again. Every time I have ever coached a team to increase their hygiene time, their production has increased as a result. Now that wasn’t they only thing they did. They put in place systems to deliver a higher level of service and enroll more treatment. Critical steps that drive production are left out of the hygiene exam when time is short. When you choose to allow 60 minutes for adult recare and perio maintenance, it’s important to outline exactly what will take place during that time. If you are going from 40min hygiene visits to 60min, what are you going to add?

To Be Continued…

Wait- Here are a few action steps to help you get started NOW:

  • Do a chart audit-look for current perio charts
  • Communicate to your hygiene team that you’d like them to do a complete perio exam on every adult patient
  • Give your hygiene team the time they need to complete a comprehensive hygiene exam
  • Be proactive and get the information you need to really believe that starting perio therapy early is the right thing to do.

New Pre-Med Guidelines

In April, the American Heart Association, along with the ADA released new guidelines for antibiotic premedication of patients with certain heart conditions. The new guidelines do not include any changes in premedication for those patients with artificial joint replacement.

According to the ADA’s statement, these patients no longer need pre-med:

  • mitral valve prolapse
  • rheumatic heart disease
  • bicuspid valve disease
  • calcified aortic stenosis
  • congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy

The ADA says patients with the following conditions DO need to pre-medicate:

  • artificial heart valves
  • a history of infective endocarditis
  • certain specific, serious congenital (present from birth) heart conditions
  • a cardiac transplant that develops a problem in a heart valve

It is imperative that you, as a dental health professional carefully read the ADA‘s statement. In addition, please read Dr. Michael Rethman’s article in the May issue of Dimensions of Dental Hygiene. Dr. Rethman makes a great point when he says “it’s possible that the dentist or hygienist may have an incomplete medical history” and that “a patient’s physician may still recommend antibiotic premedication based on older recommendations”. In a nutshell, there may be situations that warrant continued antibiotic coverage. When in doubt, check with the patient’s physician.

Here are links for both articles:

ADA Statement

“New Guidelines for Antibiotic Premedication” by Dr. Rethman

Back it up!

We’ve heard a lot about Evidence Based Dentistry in the last few years. With all the claims about the Oral- Systemic link and all the products and techniques that are emerging, it’s important that we’re aware of the research and science that supports them. In short, if we’re going to offer services and education to patients, we better have the evidence to Back it Up!

But who has time to pour over volumes of research in order to come to our own conclusions? The good news is there are a few key organizations that can provide reliable resources to help you create an evidence based practice.

Now don’t get me wrong, I don’t think there’s anything wrong with anecdotal evidence as long as we present as just that…our own clinical experience. And we all know that there is a piece of research that will support and refute just about any claim. It’s our job to use the resources available to determine what we believe, based on the research.

There was a great article on Evidence Based hygiene recently published by Modern Hygienist online. It was written by Shirley M. Beaver, RDH, PhD. Click here to view the article. I encourage you to read it. In the article she mentions PubMed and Medline. These are government supported search engines for research abstracts.

PubMed is a resource I use a lot. I learned about it when doing research for my senior paper while studying at UNC and I’ve used it ever since. Any time I’m creating new clinical training material, I want to be sure what I’m teaching has a sound scientific basis. So if I read a news alert about a possible link between perio and cancer, I’ll go to PubMed and see what I can find.

Other helpful resources are The Cochrane Collaboration and Gordon Christensen’s Clinician’s Report.Click on each of these titles to go to their website. They are both non-profit organizations. The short reports and abstracts you’ll find will give you the highlights of the studies and their conclusions.

I often use what I learn from these resources when talking to patients. Our patients want to know that we keep up with current research. And it’s pretty powerful when we recommend a service and we can quote research to Back it Up!

3 Steps to Increase Production through Hygiene in 2010

Has your hygiene department production flat-lined? Are you under-utilizing your hygienists’ skills for observation and assessment and their ability to connect with your patients. Now is the time to change all that. You’ll be blown away to see how some simple changes can create more than $100K in additional production next year.

Here’s the bottom line: If you could increase hygiene production by $150/day or just $19/hour, 2 hygienists can increase their annual production total by almost $60,000!

If those same 2 hygienists each enrolled at least $1000/week in restorative treatment, that boosts your production by $96,000. Together, that’s over $150,000 in increased production for your practice. I’m not going to leave you hanging. I’ll tell you how to get there and it’s really not that hard.

Step 1- Pump Up Perio! I preach this every other month and I won’t be quitting anytime soon. The fact is that if two hygienists enroll just 10% of their current patients into active perio therapy and then perio maintenance, hygiene production will increase by $60-70K in the first year. You better believe their are more than 10% of your “prophy” patients that have perio disease right now.

Step 2- Empower your hygienists to help you enroll restorative. Remember: The first step is to spend time educating your team on your treatment philosophy and get all Docs in your office on the same page, too. Enrolling $1000/wk out of each hygiene operatory is very conservative. The trick is, those patients have to actually schedule that treatment for those dollars to show up.

Step 3-Financial Arrangements and Follow-up! Every patient that is presented with either perio treatment or restorative treatment should never leave your office without a written and signed financial arrangement. If you don’t have a financial arrangement form, create one. Make this Priority #1 for the new year. Patients that are confident say YES. Patients that are confused say NO. Make it clear how you make it easy for them to pay. Make it clear what portion of the fee they are responsible for and when it’s due. Then follow-up! If the patient isn’t ready to schedule that day, then put them on your follow-up list and ask for their permission to call in 2- 3 wks, and then DO IT!

Bonus Step 4- Share this with your team! Talk with your hygienists about what you’d like to see happen in 2010 and then support them in accomplishing it. Give them the support they need to develop and implement a perio protocol and make technology accessible so they can use it for perio charting, taking intra-oral photos, etc. AND, share the increase. How can you share the growth with your team next year? Implement a plan for a Team Bonus, Profit Sharing or Team Trips. These are just a few of the ways you can acknowledge your team for their dedication to you and your patients.