#8 – Performs scaling and pumice prophys on recall clients | Dental Practice Coaching

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#8 – Performs scaling and pumice prophys on recall clients

Preventive Care

Goal: Our goal is for the patient to have the best preventive care appointment of their whole life ‑ and know it!  We have the opportunity to make the patient’s tooth cleaning appointment as meaningfully different as eating at McDonalds vs. eating at a fineDaytonrestaurant.  Both places serve the same basic purpose, to satisfy your hunger.  The quality of the experience though is entirely different.

Our goal is for you to be more than a tooth cleaner.  Why should a patient drive past 100 dentists to get to us?  Are we that good?  Would perfectly clean teeth justify this?  Remember we sell caring, concern, gentleness, kindness, comfort, acceptance, compassion, warmth, appreciation, love, competence, empathy, credibility, confidence, conviction, sensitivity ‑ not fillings and crowns.  “The hygienist is the most important person in dentistry” ‑ quoted Dr. Chuck Smith.

Philosophy

Your job as a hygienist is not to “save” poor, unfortunate dental patients.  Many hygienists believe they are “doing their job” or “doing what’s best” by providing the care they would want for themselves. After all, this is a variation of the Golden Rule, isn’t it?  You’re right, I think the answer is no!  Here are several reasons while your “help” may work against your client.

1.  “Help” assumes that the person assisted got better from the clients’ perspective!  Often a health care worker will storm into   “save the day” only to find out that the client has different   values and attitudes about dentistry.  The hygienist’s well   intentioned “help” turns out to be unappreciated “interference” in   someone’s life.

2.  “Help” also assumes that the client had a choice ‑ whether to willingly accept the assistance or not.  Hygienists (and   assistants, secretaries, and dentists) often get in a hurry, survey   a technical problem, and supply a technical answer ‑ without having   a heart to heart discussion with the client.

3.  Hygienists often think their job is cleaning teeth.  Clients have a large number of reasons (benefits) for using a hygienist’s   services:

a.  Fear of dental disease

b.  Romance

c.  Improve business

d.  Avoid major dental expenses

e.  1000 more ‑ almost as many reasons (or combinations) as there are clients

4.  Hygienists often think there is little for clients to learn.  Clients want to find out about all the newest ideas ‑ and get their questions   answered knowledgeably.

5.  Hygienists think people come to get their teeth cleaned.  Clients believe they are coming to satisfy their own individual, personal   needs.

6.  Hygienists often organize their appointment time for their convenience and efficiency.  Clients want their own convenience to come first. If the client’s values are different than yours and you demand a behavior change (brush, floss, fluoride, diet, etc.) you may get it, but at a price.  The price is the loss of the chance to develop an adult relationship with your client.  When you accept a parent/child relationship, you have two ways to get changed behavior:     1.  Threats ‑ “If you don’t do this, you’ll lose your teeth!” (or variations of it)     2.  Manipulations ‑ Look for “hot buttons”  Wouldn’t you like to (save money, be sexy, avoid pain, etc.)?  Both of these techniques can work, but at a price!  Since the client has accepted a childlike position to your parent, s/he can respond like a child.   1.  Punish you by not doing what you expect.    2.  Failing and blaming you for the failure.  After all, it was your idea!

The check-off sheet is designed to help you avoid manipulating people and enjoy them by developing an understanding of who they are, what their values are, and why they believe what they do.

At first, this will seem very time consuming and inefficient.  Why not just tell them what to do?  After all, it’s their mouth.  I show them how, then they either do it or not.  Some people just aren’t very responsible.  Does that sound familiar?  Don’t get stuck with this. Compare the above paragraph with this next paragraph.

When your clients accept ownership of their problems, their success is your success.  Ownership implies that they;

a.  Participate in discovering with you what the problem is ‑ is there more than one (of course), how extensive, etc.

b.  Spend time to discover what their attitudes and values are that led to the behavior that allowed these problems to develop.

c.  Decide on a new behavior supported by a modification of their value system that will help them solve the problem that they have defined.

d.  Try out various alternatives until your clients find the “right way” for them.  Your job is to provide these alternatives in a supportive, loving, non‑judgmental environment.

e.  Cementing the relationship occurs when your clients can put the problem and chosen solution into their own words.  Now you are only a resource that the clients will use to achieve their goals!

At the beginning of each day or before each 1/2 day review each patient’s chart on your schedule to help you know your patients as people.  The average RDH’s career last 2 1/2 years.  If you focus on people rather than on teeth to the best of your ability you will have a long and honored career!

Tray set ups should be completed one half day in advance.  Don’t get caught in the “trap” of trying to set up your trays during the day. You are robbing yourself of the time you need to spend with your clients developing relationships.

Here is the standard tray set up:

1.  Saliva ejector

2.  Mirror

3.  Explorer

4.  Disposable prophy angle

5.  Straight sleeve/hygiene prophy handpiece

6.  Bristle brush if needed

7.  Prophy paste disposable container

8.  2 gauze squares

9.  204, 204S H6/H7, 7/8 younger Good

10. Gracey 1/2

11. Gracey 7/8, 11/12 or 15/16, 13/14

The Prophy Recall

Either at the end of the previous day or as much before your first client as necessary, set up all your trays (at least the first half of the day).  Make sure everything you need is within arms’ reach in your operatory. Before you begin treating your first client for the day, review all your folders. Learn about every client you are treating.  Never treat a stranger.

How to understand our client folders

1.  The following information is contained on the outside of the patient file folder: Patient’s name, last name first

2.  The following information is stored inside

a.  Panoramic x‑rays

b.  Full mouth x‑rays and other x‑rays mounted chronologically on acetate sheets

c.  Lab prescriptions

d.  Written treatment estimates

1.  Recommended treatment

2.  Alternate treatment

3.  Payment information

4.  Numerical priority of treatment

5.  Other recommended treatment

e.  Treatment schedule (salmon sheet) contains:

1.  Treatment scheduled

2.  Treatment to be scheduled with provider, time required

f.  Dental and medical histories and area to update medical histories (yellow sheet)

g.  Initial database and observations (yellow) sheet to be completed at time of complete exam contains:

1.  Present restorations

2.  Pathology by tooth

3.  Existing removable appliances

4.  Notes on each treatment appointment

h.  Periodic examination (pink sheet) contains recall data

1.  Perio probing chart

2.  Doctors, hygienists, and assistants initials

3.  Yellow tx sheet

4.  Tooth number(s) treated

5.  Narrative of treated

6.  Fees charged

Now review each client’s folder and answer these questions

At the start of your day, you will be part of one dentist’s “huddle.”  This huddle includes the dentist, a secretary, his chairside(s) and perhaps an expanded function dental assistant(s).  This 15-minute meeting is your chance to let your team know what you think is important in your schedule and how they can help you (client problems, money problems, production goals, holes in the schedule, commitment goals, etc.)

Introduction ‑ “Grace Under Pressure” (6 minutes)

1.  Always be on time. Watch your computer monitor.  When your schedule shows your next client is here, you are on the clock.  You have 2 chairs available to you.  When you are within 5 minutes of finishing your client, excuse yourself and let your dentist and his assistant know you are ready.  Make sure the assistant knows so she can remind her dentist.  Now, return to your client.  If your dentist is not in your operatory 2-3 minutes before your next client is due, excuse yourself and seat your next client (or better, if available, have the cleaning/sterilization person do this for you). If you see you will be more than 5 minutes, late excuse yourself from your client and apologize to your next client.   Look for their picture in the folder or computer file so you can go right to them personally.

2.  Greet Patients cheerfully, introduce yourself. Rather than say “How are you?” say “It’s good to see you today!”. This is a much more positive start.  Speak a little slowly, very clearly.  Use your first name and their last name. (Mr., Mrs., unless you see on their health history they have a preferred name).  Then ask them what they prefer to be called and note it on the pink sheet.  Shake hands.  A warm, friendly handshake is a great way to greet a patient.  It welcomes, communicates confidence and ease and initiates physical contact with the patient, which helps make contact during the appointment less awkward.  It’ll be more comfortable if you are both at the same level.  This handshake helps to relax nervous clients.  Try to exert the same pressure as your client.

3.  Escort your client to a private office.  Plan to spend about 6 minutes here reviewing their past medical and dental history and their goals and expectations of you.  Use the following questions to guide this time.

4.    Don’t start talking about teeth.  “What do you do?”

A.  Establish Relationship – strong eye contact, break eye contact occasionally, learn about your patient.     ‑ Get the Patient to like you.  Most significant diagnoses start at this time.  Most clients will tell you what they need if you give them a chance.

B.  Show the patient you like them ‑ you care ‑ your interest in them as a person ‑ Use their name often.       ex. ‑ “Sue, I’d like to spend a few minutes getting to know you better ‑ What do you like to do when you’re not working?” or “How long have you lived in this area?”  Form your conversations for the rest of the appointment.  Don’t rush through this time.  You’ve been trained and rewarded for clean teeth.  This is important, but your clients are more important than their teeth.  Slowly nod when your client  is speaking.

C.  Health History ‑ Review your client’s past medical conditions, current medications, drug allergies, and significant past radiation experiences.  The past medical history should give insight into the physical and psychological factors about the patient which may influence the patient’s reaction to dental procedures.  It should include:

a.  Current medical treatment and hospitalizations within the last 5 years.

b.  Significant past illnesses or diseases that may contraindicate certain dental treatment.  These conditions may require medical consultation before treatment.  If such illnesses are present, make a medical alert on the inside and outside of the patient record.

c.  Current medications

d.  All drug allergies.  Drug allergies are noted on the front and inside of the patient record

e.  Past radiation experiences are noted that influence or contraindicate radiographs taken for dental purposes

f.  If a medical alert is necessary it should appear on a sticker at the very bottom right hand corner of the front side of the jacket.  Also, note this medical alert in the computer.

g.  If pre-medication necessary, write “pre-medication taken” on the yellow exam sheet. Note pre-med on front of chart & top of all pages.  If not taken, reassure your client that it is ok if the antibiotic is taken within 2 hours of finish of appointment.  Give dose to client when return to operatory.

A completed personal health history, containing the above information, and signed by the patient, must be in the dental chart before dental treatment can begin.  The hygienist seeing the patient on the first visit must also sign it as evidence that the information has been reviewed.

D.  Establish your Contract – review the pink sheet

1.  “Sue, I’ve been reviewing your chart.  It looks like everything has been really healthy ‑ Do you feel as healthy as you were last visit?”

2.  “Sue, how would you rate your dental health?  Why?” Provides insight to both values and self image.

3.  “Sue, I’ve never cleaned your teeth before.  Is there anything special you would like me to do? ‑ Is there anything special you don’t want me to do?”  Try to identify what motivates your client and reinforce the positive aspects of this drive.

A.  Money ‑ future dental bills

B.  Self Preservation ‑ example for family

C.  Recognition ‑ looks, business, success

D.  Romance ‑ social, dating

Don’t make value judgments!

4.  During dialogue find out who referred them.  Write this down.  This is very important.  Take notes while you are talking.

5.  Ask if there has been any change in their health.  If so make changes listing why and who much medications they are taking.  If health history is more than 3 years old have them complete a new gray one at the end of appointment or if you don’t have time give them a stamp addressed envelope to mail it back to us.

Initial Patient Interview 

Before client arrives write out this information:

  1. How many years has the client been in the practice?
  2. Any health problems on the medical history?
  3. How many clients have they referred to us (listed on the inside cover of the clients folder)? Also in computers.
  4. What do you know about this client’s hobbies, etc. from their remarks?
  5. Pink sheet ‑ look for the progression of health.  If starts with gum disease controlled up through esthetics accomplished.  What level has your client accomplished?
  6. Is there a treatment plan outstanding that hasn’t been completed?  Why?
  7. Look at the diagram on the treatment sheet.  Are teeth missing? How does the client feel about this?

Client Interview

  1.  ________________, I see you’ve been a patient here at HealthPark since _____.  What do you like best about your visits here?
  2. How has your health changed since the last time we saw you?
  3. I see you had ____________________________ done last time.  Is it comfortable?  (Ask if any treatment accomplished)
  4. Did the hygienist do anything in your previous visit that you particularly liked?
  5. Did she do anything that you didn’t like?
  6. Are there any areas of your mouth that I should avoid?
  7. In reviewing your chart I see that you come in every ____ months.  Does that work for you?
  8. “What I’m hearing you say . . .” is a great line to gain more information

Escort the client to the operatory

  1.  Take blood pressure and record it on the pink sheet.  Tell the patient what it means high or low.  If above the normal range, alert Dr. during check and fill out blue sheet (physician alert) for Dr. to sign.
  2. Ask if there is anything they need to improve their comfort.  Offer headphone, N2O, Topical, message pad. If the light seems too bright for them, dark glasses are available.  There is also a small pillow for anyone who may need it for arthritis in neck, etc.
  3. Let your client talk!  One study showed doctors interrupted every 18 seconds.  Once interrupted, clients don’t return to their topic.  Don’t judge or hop in with discussions of diagnoses or treatment.  Listen.
  4. Keep a watch or clock wherever you sit.  Stay on time!

Safety

  1. You wear gloves, mask, eye protection with side shields and lab jacket.  This will be difficult at first, but you deserve a long healthy life.  This is a requirement of your employment.  Gloves and masks are to be changed after every patient.
  2. Your client:  If an antibiotic before prophylaxis is required and your client forgot, s/he can take the dose up to 2 hours after the appointment.  Usually, you will just provide it before you begin.
  3. Offer your client a chapstick if lips are dry.

Exam (2 minutes)

1.  Tilt chair (legs first then back) ‑ this will keep them from slipping down the chair.  Inform the patient that you are going to lower the chair so it is not a “surprise”.  Place hand lightly on shoulder as they recline.  Ask the patient if the position of the chair is comfortable.  Some older patients do not like to lay their head very far down.  Flip the client mirror down so they can watch.  Begin by touching the client on the shoulder as you are talking.  This is a reassuring, non-clinical way to “break the ice.”

2.  Do a thorough cancer exam.  Tell the patient, “I’m going to check for lumps and bumps that aren’t normal”.

3.  Offer chapstick.

4.  Do a thorough exam.  Take note of soft tissues, deposits, teeth, (etc.).  If patient has only slight to moderate calculus and no acute gum infection (can be completed in one appointment) proceed with prophy.

5.  Wait for evaluation of teeth until after cleaning

If you see more than one area of inflammation DON’T try to “educate” your patient while they are lying down and you are cleaning.  Our patients deserve a great deal better than this poor level of communication!  Restrain yourself and prove yourself to be an ace communicator!  Recommend a soft tissue management appointment.

If acute gum infection or much subgingival calculus, recession, or patient uncomfortable while checking (very sensitive) ‑ sit them up again.  NEVER HAVE AN IMPORTANT CONVERSATION WITH THE PATIENT WHILE THEY ARE ON THEIR BACK.  Always say what is important eye to eye   (adult to adult).

Tell the patient what you are seeing and ask if they were aware they had this problem.  Has it been this way a long time?  If an established patient ‑ are they concerned about not dealing with the problem?

Discuss recommended treatment with them on what you found: soft tissue management, could hurt to clean today.  Again offer N2O, topical, anesthesia, headphones, etc.  At this point you may start the cleaning appointment or refer your client to another hygienist who can do the soft tissue management program.

If the client has quite a bit of calculus and stain, bring the client to the upright position and let him/her know that it may take 2 appointments to complete the cleaning and that there will be a fee for each appointment.  If it has been several years since their last cleaning you can state that actually this is an economic bargain ($/cleaning x 2 per year x # years since last cleaning = what cost would have been).  Remember, when you tell the client of this possibility before you begin you look sharp.  If you tell them it will take 2 appointments when you run out of time, you look incompetent.

If the client says they don’t want to pay for 2 appointments, then your contract is to do the best you can and then try to complete when s/he is back in 6 months.  This 2-appointment sequence assumes that there is no significant gum disease and the client’s care appears adequate.  If not, then you should recommend STM and refer to one of the higher-level hygienists.

Probing (2 minutes)

1.  Use perio probe for about 2 minutes to get an estimate of pocket depths and detect calculus.  Tell your client what you are doing.  “Mr. Crago, I am going to measure the gums around you teeth.  I’ll call off a bunch of numbers that measure any gum swelling or bone loss.  1‑3 is normal 4‑5 is some trouble, but can heal.  6 is a danger sign and 7 or more will need gum surgery to correct.”  Before starting scale. IF YOU WILL NEED MORE THANONEAPPOINTMENT, STOP, UPRIGHT THE PATIENT,ANDLET THEM KNOW THAT YOU WILL NEED MORE THAN 1 APPOINTMENT.  This makes you look like a knowing professional.  If you wait until you’re finished, you look like an incompetent making excuses.

Probe all 6 areas on each tooth as you were taught.  Try to find someone to record for you.  Not only is it faster, but it allows you to call out the numbers so your client knows how they are doing.  Explain 2-3mm are normal, 4-5 are beginning problems, 6mm will probably require some treatment, and 7mm+ will need Dr. Hamal’s evaluation.  Bleeding is a real warning.

Instrumentation (18 minutes)

1.  Ask patient if they are familiar with the scaling procedure ‑ (especially if using the cavitron).  Explain in understandable terms what the cavitron is, how it works and why you’re using it, so they will know what to expect.  Contra indication is pacemaker.

2.  Explain the value of scaling teeth and why we want smooth roots: The smoother the teeth, the harder for food and bacteria to attach it and the harder to get decay and pyorrhea.‑ if this is the 1st of several scaling appointments ‑ pick a segment that you can complete at this appt. and scale.  Have the Dr. numb area if necessary ‑ Irrigate with perio RX at end of appt.

It is important to establish a sequence for instrumentation that is right for you as a hygienist.  An established sequence of instruments can save you time while working through the appt. and it can also prevent you from missing any areas of the mouth while scaling.

Be sure to have your client rinse with Listerine ‑ mint before instrumenting.  This will reduce the bacterial count by 40%!

Remember to protect porcelain crowns from scratches!

1.  Use curettes rather than scalers, ultrasonics, or prophy jets ‑ easier to control

2.  Use air to dry teeth and make calculus look chalky

3.  Use unwaxed floss to check for proximal caluclas

4.  Stain removal from around porcelain restorations

a.  Use the least abrasive sandpaper/aluminum oxide strips possible.

b.  Be careful!  The most abrasive strips may open tooth contacts.

c.  Use the newer plastic strips that have a plain center

d.  Aluminum oxide discs can remove stain on the broad surfaces.

1.  Protect the gums with a plastic instrument.

2.  Start with a medium grit to remove the stain.   Progress to extra fine and then Dia Glaze.

e.  Never use an air abrasive.

f.  If you find a rough edge, tell your dentist.

5.  Use Diaglaze ‑ (not fluoride pumice) it’s too abrasive

6.  Use lots of praise: hold open well, dentistry nice, gums good, etc.

7.  If it’s been more than 5 years since your client has had a thorough    exam, point out various “things” in their mouth that could be reviewed and discussed with the doctor: missing teeth, old appliance, discolored teeth, worn our silver fillings, etc.

8.  Bleeding gums, probing depths ‑ use “I” messages to show your    concern ‑ “Jill, I’m concerned that your gums are bleeding.  How often are you able to floss between these lower right molars?”

9.  Use air gently to push gingival away from teeth to examine margins of restorations

Use your Cavitron where possible.  It has several advantages.

1.  Minimal root damage

2.  Flushes the gingival pockets

3.  Much less stress on your hands/arms

4.  Less trauma to tissue and faster healing

5.  No sharpening needed

Tips

1.  A low power setting reduces sensitivity

2.  Place the hose on top of your forearm or in your lap to reduce pressure on your wrist

X‑Rays (5 minutes) – if needed

‑ take before begin polishing so you can check for any calculus you may have missed

1.  Take four decay (bite wings) x‑rays ‑ we do take yearly decay x‑rays on some people who have a high decay rate or if the patient is having a problem with a tooth.    We call them “decay x‑rays” rather than “bitewings” so the patient understands

2.  New patients ‑ request x‑rays from previous dentist if taken within the last two years.  If no recent x‑rays take necessary decay x‑rays.  If patient is not sure when last x‑rays were taken, but they look healthy, wait until we have received previous dentists’ x‑rays.  We can always take them at the next appt.‑ Follow up periapicals should be taken on root canal teeth one year after the root canal was completed.

3.  Use decay x‑rays to check for calculus and all other pathology.

4.  Show patient what you see on the x‑ray

a. Decay between teeth

b. Bone loss

c. Bone support for any drifting teeth

d. Standard reference for the future

e. Abscesses that haven’t started to hurt yet

f. Extra teeth ‑ 3rd molars

5.After placing x-rays in scanner, alert your dentist you are starting to polish and he can exam at his convenience.  This gives him more time to break without getting you behind.

6  Clients that need a dentist check:

g. On an annual basis

h. You see a problem

i. Client requests a check

Prophy Paste Polish (10 minutes)

1.  Selectively polish only stained teeth using the correct grit of prophy paste.

a. cleaning agents

1. no abrasives to scratch porcelain

b. abrasives

1. coarse-remove stains, scratch restorations/teeth which will then pick up stains quicker

2. medium-still good for stain removal, but less scratching

3. aluminum oxide-best for composites

4. diamond paste-for porcelain

2.  Using floss or dental tape carry abrasive polish into proximals and check all contacts before the patient rinses.

–          If contact too tight use lightening strip to loosen or EVA.  If open contact check if it packs food or if there is a problem mark contact on chart to watch.

–          Floss will also show calculus between front teeth

3.  Rinse thoroughly.

4.  Irrigate any pockets – flush to ½ of probing depth.  Fill irrigator with 1 ¼ glass of water & 4 cupfuls of chlorhexidrine.

5.  Check for any missed stain that client can see.  Either re‑polish or use prophy jet.

6.  Place a small amount of Crest toothpaste on your index finger and massage it into the gums.

Should you polish teeth?

Every day many of your clients will either say how clean their teeth feel or rub their tongues over their teeth and smile after your polish.  However, no research has ever found stain to create a pathological problem.  Esthetics-yes, pathology-no.  Most of your client think its’ necessary.

In school you were taught selective polishing – the heavier the stain the coarser the grit.  In practice, to save time, 85% of hygienists use a medium/coarse grit through out which can open dentinal tubules, remove the fluoride rich outer layer and increase sensitivity.  The coarse grit also pulls the silica filler particles out of composites causing more rapid wear and staining.

Contraindications to polishing

1. Lack of stain

2. Demineralized areas (outer surface of enamel has the most fluoride

3. To smooth after ultrasonics

4. Exposed cementum

5. Sensitive teeth (opens the tubules and makes more temperature sensitive)

Prophy Jet (plus polish ‑ 12 minutes)

1.  Explain why you are using the prophy jet and how it operates.  This will clean the stain off that we could never remove before!  More importantly it removes all biofilm.

2.  Have patient wear safety glasses

3.  Always use high volume suction when using prophy jet or cavitron to cut down on the spray that reaches the patient and yourself.

4.  Rinse thoroughly

5.  Let patient wipe off face – get a warm wet towel.

6.  Never run prophy jet on the roots of teeth, composites or porcelain crowns!  Enamel is 20 times stronger than dentin.

Pink Sheet (4 minutes)

There is a logical sequence on the pink sheet from #1 gum infection to #6 missing teeth replaced.  How far has the patient come?  Your goal is to move them ahead one square each recall visit.  When you review the chart it is easy for you to see how effective you are.  Make pencil notes on the right side of the green sheet so it is easy to see how the patient is progressing.  Tell the patient what you are doing with this sheet: “Mrs. Jones, we use this sheet to record your level of health. It’s updated every time you’re in.  This is one way we have to ensure that we help you maintain the highest level of dental health.

Today we know periodontal disease symptoms fluctuate.  Pocket depths move up and down.  Bleeding starts and stops.  Your records, recall by recall is our best source of information over an extended period of time to determine when surgery or other periodontal intervention is needed.

  1. Use explorer to check for decay, overhangs, broken fillings.

a. Discolored enamel doesn’t mean active decay that needs to be removed.

b. Occlusal catches on an other‑wise healthy tooth with no x‑rays confirmation of decay can be sealed.

Use diagnodent on these areas. Chart numbers.

c.Facial and lingual areas that are only beginning to discolor and soften should be charted, shown to the client, and the client encouraged to control these areas with fluoride.

  1. Record pocket depths  (attachment loss)

Don’t record the “pocket” from the gingival crest to the attachment.  Record from the CE junction to the depth of the attachment.  For example, a tooth with 5 mm of gingival recession and a 3mm pocket is in worse shape than a tooth with no recession and a 4mm pocket.

Walk the probe around the circumference of the tooth in 1mm increments, keeping the probe in the sulcus.  Record 3 depths ‑mesial, central, distal on both the facial and lingual.  This means that even though you’ll only be recording 6 measurements, you’ll be checking many more areas.  Record the deepest markings. Round off to whole numbers.  Probe the proximal areas very carefully.  This is where most bone loss begins.

Here are the factors to consider that determine the accuracy of your probing.

1.  Size of the probe

2.  Force used (particularly with inflammation present, you may    push through the attachment for an extra ‑ 1 1/2 mm)

3.  Dimensions of the pocket

4.  Access to the pocket

5.  Angle at which you probe – probe as close to the proximal contact as possible

6.  Calculus in the pocket

7.  Health of the gums (The healthier the tighter, the harder to    get to the base.)

8.  Your accuracy ‑ clear away saliva, blood by drying

9.  The response (pain) of the client, (the greater the amount of    inflammation, the greater the pain) topical anesthetic can help

There are so many factors involved in probing accuracy that you really need to see a 2 mm change to know the pocket has actually altered.  You can get a 1‑1 1/2 mm change due to “operator error.”

Periodontal charting should include:

a.  Mobility

b.  Furcation involvement

1.  Class I ‑ Detectable, but can’t enter

2.  Class II ‑ Can enter

3.  ClassIII‑ An instrument will pass through

4.  Class IV –  You can see through

c.  Gingival recession

d.  Bleeding upon probing (lack of bleeding is a good sign of health)

e.  The case type of the patient can be recorded on the back of the    pink sheet.  BOP (bleeding on probing) is recorded by placing a dot above the pocket depth.

  1. Have patient open and close with your fingers on their TMJ.  Do you  notice any clicks or pops, deviation on opening or closing, crepitis?
  2. Manipulate the clients jaw into centric relation and have them close.  Are there any occlusal interferences?  If so, are any teeth loose?
  • Now is the time to sit the patient us and reestablish and adult eye-to-eye relationship.  Take their picture.  Now see how well you can motivate your patient to accept a better level of health!
  • How do they feel about the appearance of their teeth?  What would you change?
  • Does she have missing teeth?  Is she ready to replace them?
  • Finish pink sheet ‑ many of the questions (how often do you brush, floss, etc.) can be worked into the conversation during the course of the prophy appointment.  Try to avoid making this a “20 question grilling.”  Answer as many questions out loud so the patient can agree with you as often as possible.  This lets them know you’re a good listener and breaks up the questioning.
  • Fill out yellow treatment sheet.  The secretary will bill your client based on what you write down.  Note any x‑rays, prescription fluoride, etc. that would be an extra fee. Underline chargeable service and products.  Write your initials and your doctors.  Don’t skip any lines and write in ink (malpractice requirements).  For example, don’t ask, “How often do you floss?”  Try, “What do you notice when you floss?”
  • Use your own judgment in deciding on a personal continuing care (recall) appt. for the patient and discuss it with them.  (See task #8) Try to avoid the standard 6-month interval.  This will personalize their future appointments.
  • Decide why the patient should return.  Pick from the computer list and make sure this is entered in the computer and that the patient knows.  (This list is shown later)
  1. Tell Dr. that you are ready while waiting for Dr.:

a. Explain 5 year Review ‑ if needed

b. Discuss upgrading their level of health.

1)      Remember people change constantly

2)      The client must accept us before they will accept our ideas and this sometimes takes years

3)      Try to understand why they feel and act as they do

4)      If you want people to trust you, act in their interest

5)      Help the client be successful, praise all positives and only pick 1‑2 negatives to point out.  If you dwell on negatives the client will become defensive and he won’t grow.  Success produces a positive mental attitude that produces more success.

6)      It’s more important to know what kind of client has a disease than what kind of disease a client has.

7)      Now is the time to decide when the next recall appointment should be and why!  If everything looks good, say “Jeanne, everything seems fine, we could extend your cleaning interval one month if you would like.”  Set a specific time for a specific reason.

c. Words for wise

1)      “For that tooth to be healthy, it needs a crown”

2)      “That is a smooth, clean root!”

d. Take the basic series of intraoral pictures

1)      Full face

2)      Smile

3)      Upper sextants

4)      Lower sextants

13. If you are waiting for your doc check and it’s within 5 minutes of your next appointment, excuse yourself and seat your next client in the second room you were allocated during your huddle.

Doctors Exam (4 minutes)

Before your dentist enters the room, leave everything prepared.

Getting ready for Exam

  1. X-rays on TV monitor
  2. Chart opened and placed behind client – placed so name and personal history can be read easily

Health History on the left with Medical History face up

Current Progress notes on the right – not in the pockets

Salmon sheet between them so it can be moved easily.

If assisted, notes to assistant must be legible and understood.

Mirror and explorer separated and placed on side closest to dentist

Patient laid back and chair raised if doctor stands during exam

When doctor comes in the room – Hand the doctor his gloves

Be sure to introduce the Dr. by name to all new clients s/he hasn’t seen before.  Use the client’s preferred way to be addressed (formal or informal).  If the client has been in before “Dr. ________, John is with us today!” look through the client’s chart.  If this is the first time your client has seen this doctor, TELL THE DOCTOR!  If the client is a child, introduce both the child and the parent.

Your dentist will signal when he/she is ready to begin the exam by saying something to you like “Well, how did everything look today?”

Don’t make the dentist ask 20 questions.  Give him a complete report on your patient.  Begin by telling something that has happened recently non‑dental about your patient.  You’ve just spent 30‑ 60 minutes with your client.  What topics (personal) have been most interesting?  Bring your dentist into this conversation.  Give your dentist about 1 minute to follow up on this and then interrupt if necessary to begin your pink sheet report.  This is your chance to show Doctor and the patient you are more than a tooth cleaner.

1. Begin by reviewing any treatment completed in the last 12 months

2.  Explain all findings on pink sheet.  Follow the sequence as written on the pink sheet, focused on notes you made in the right hand column.  This sequence is in the normal order on which we build.

1)      Gums,OHI,CAexam – discuss bleeding points, pocket depths (changes)

2)      Decay – discuss teeth in 1-32 order, slowly allowing dentist to evaluate each area before moving on to the next, include watches and your post-treatment discussion, X-rays questions, concerns that client has

3)      TMJ, missing teeth

4)      Bite

5)      Esthetics

6)      Recommended recall/x-ray/doc exam interval

For example, if the gums aren’t healthy or there is a decay problem, we wouldn’t discuss replacing missing teeth.  Try to advance each client one level each recall.  This will insure you meet all the commitments you need each quarter, also.

2.  Make notes on any treatment that is needed on the treatment-scheduling sheet.  Include who is to do the treatment and how much time is needed on the orange treatment routing sheet.

The doctor doesn’t need to examine after every cleaning appointment. Ohiolaw requires a doctor’s exam annually.  Every time a doctor examines, two negatives occur:  The doctor must break away from the client he is treating.  The hygienist must wait for the doctor.

The dentist should plan to examine a client at certain specific times:

1.  Once annually

2.  When x‑rays are exposed

3.  When you see any disease

4.  If the client requests it

One way to reduce the inconvenience of the dentist’s exam is for the dentist to examine at any time during your appointment rather than waiting for you to finish.  Be sure to check for decay, gum disease, missing teeth, esthetics, etc. after you have seated your client.  From this point on, you can break to allow your dentist to examine and point out any client needs.   Don’t take your decay x‑rays until you have finished scaling unless you are assisted.

Indications for x-rays:

  1. 2 years since last decay x-rays
  2. Decay visible
  3. Problem tooth (PA)
  4. Implant – PA annually
  1. Write up notes on what you did today including recall and time needed on the yellow treatment sheet.  Also note any significant conversation that the dentist had with your patient.  What treatment did the dentist suggest that the client denied?
  2. Make “personal notes” on yellow sheet, on the right side remarks section.
  3. Thank patient for coming today: “I really enjoyed meeting you today.  I recommend that I see you again in ___ months.  That way we can (see choices). A. Keep track of (problem).  or B. Keep everything as healthy as possible
  4. Give toothbrush and floss.  Sometimes you may give fluoride, floss threaders, perioaides, etc.  Use your own judgment.
  5. Escort patient to front desk.  Explain to receptionist what the patient needs and thank the patient for coming in.  Ask for referrals.
  6. The last 4 minutes, like the first 4, are the most important in building a solid relationship with your client.  This last impression is the one your client leaves with ‑ and remembers the longest.

Does your client understand what you did?  Does s/he appreciate the extra time and trouble you spent?  What made him/her special to you? If your client has an appliance, it should be cleaned as soon as possible.  Place the appliance(s) in a baggy with cleaning solution and run for 10 minutes in the ultrasonic. Brush with toothpaste and rinse,  return at the end of the appointment.

If the client asks you to adjust a sore spot, remember the sterilization procedure!

1.  Scrub the denture with Chlorhexidine soup and water

2.  Rinse, adjust the denture

3.  Polish

4.  Soak for 1 minute in Sodium Hypochlorite

5.  Rinse, return to client

If the client is older, remember these ideas:

1.  If inter-dental gingiva has receded leaving spaces, a Viadent irrigator may be helpful.

2.  Smoking becomes more of a problem for the gums.  Try again to help them stop smoking.

3.  Look closely for lesions, bumps, color changes in the mouth.

4.  If arthritis or reduced dexterity makes control of a hand toothbrush, allow them to try a Power brush.

5.  If they have reduced saliva, they can use saliva substitute or chew sugarless gum or mints and use Home Fluoride.

Dismiss Client, Clean Up, Set Up (8 minutes)

1.  When the dentist exits, upright the client, offer a rinse, remove the bib.

2.  Reinforce any treatment recommendations as you guide your client to the front desk.

3.  Pass your client to a specific secretary.  “Mrs. Walker, Judy will arrange your next appointment.”

4.  Return to your operatory, put on a pair of nitrile gloves and clean up the operatory.

a.  All instruments are placed in a presoak container of soapy water.

b.  All blood soaked disposables are placed in the biohazard receptacle.

c.  All disposables are placed on the tray

d.  Run water through the suctions and ultrasonic (if used) for 20 seconds.

e.  Wipe down all tubing and work surfaces (spray‑wipe‑spray)

f.  Remove the tray from the operatory and place disposables in the trash

g.  Place instruments in ultrasonic

5.  Set up

a.  Place sterile disposables: saliva ejector, prophy angle

b.  Place barriers

1.  Air/water syringe handle

2.  Slow speed handpiece cover

3.  Ultrasonic handpiece cover

4.  Light and unit handles

5.  X‑ray head and switches

6.  Dental chair

c.  Place air/water syringe tip

d.  Listerine mint pre‑rinse in cap

e.  Bib clip and bib

f.  Prophy paste

g.  Gauze 2×2’s

h.  Toothbrush and floss to dispense

i.  Instrument bag

Finally, what benefits will your client receive by going through this appointment with you?  Smile!  Be enthusiastic!  Enjoy yourself!

Special Notes

Scaling

1.  Ask patient if they are familiar with the scaling procedure.

2.  Explain the value of scaling teeth & why we want smooth roots:

“The smoother the teeth, the harder for food and bacteria to attach to it and the harder to get decay and gum disease.”

If this is the 1st of several scaling appointments pick a segment that you can complete at this appointment and scale.  The client must be comfortable for this appointment.  You will be expected to use some methods to achieve this.  These methods will include (often used in combination: topical anesthetic, Oraqix, local anesthetic, nitrous oxide, headphones, or electroanesthesia.  If the client refuses these and then shows signs of discomfort, urge their use!  This is an uncomfortable appointment so it is expected by the doctors that you will develop sufficient rapport so the client will tell you what they need. Irrigate at the end of appointment.

Use the cavitron whenever possible it is quicker and often more comfortable than hand scaling.  The cavitron: the ultrasonic unit consists of a handpiece assembly (prophy jet and cavitron), interchangeable prophylaxis inserts, and a foot control.  The cavitron is an adjunct to manual scaling, and it is primarily used for patient with gross calculus.  It may also be used to remove overhanging restorations.  The ultrasonic instrument is based on the use of very high frequency sound waves and the vibratory action fractures the deposit and causes it to be removed from the tooth.

Run water through the tubing to the ultrasonic unit for about 10 seconds.  When there is a steady drip out of the tubing then insert the prophylaxis cavitron tip.  Push the foot control again until there is a maximum mist about the working tip to prevent overheating.  There are two adjustment knobs ‑ one for water and one for power.  The power setting is usually set on Medium but can be adjusted to low or high ‑ depending on patient’s general sensitivity.  In adjusting water flow, the greater the water flow, the lower the water temperature; the lesser the water flow, the higher the water temperature.  If during treatment, you feel the handpiece getting very warm, you need to correct the temperature by increasing the volume of water flow.

Use the high-powered suction to reduce water spray, remove excess water and debris from the patient’s mouth.  Place the suction opposite the cavitron. The ultrasonic method is principally for treatment when deposits are gross, but is not applicable for preventive scaling measures when small deposits are removed at frequent recall appointments.

Ultrasonic treatment is contra‑indicated for a patient with a cardiac pacemaker.  It disrupts the electrical impulses the pace‑maker sends to the heart. Always follow the cavitron with hand instruments to do the final smoothing.  Increasing the water spray to the cavitron will often decrease sensitivity.

Implants

Implants are the newest area of dentistry.  There are no connective tissue fibers attaching the implant to the bone.  However, there is a perimucosal seal that stops toxic substances from working down around the implant and destroying the implants bone support.

The ideal periodontal relationship is attached gingiva around the implant.  If the gingiva is not attached, watch closely for inflammation.  Look closely for any:

1.  Color changes

2.  Moveability of tissue around implant

3.  Bleeding

4.  Stability of implants

 

Cleaning is “a new ball game.”  Remember:

1.  No metal instruments

2.  No ultrasonic

3.  Use fine prophy paste and rubber cup

4.  Use plastic hand instruments to remove visible calculus

These can be ordered from

Brevet Inc

P.O. Box17713

Anaheim,CA92817

5.  The exposed implant neck must be perfectly clean and smooth.Butlerinterproximal brushes are good for cleaning screw holes.

6.  Instruments are with each full time hygienist.

Home care recommendations

1.  Power Toothbrush

2.  Listerine (or Peridex if flavor is a problem) one time per day for 30 seconds

3.  Super Floss soaked in listerine

4.  Mouth mirror to see lingual side of implant prosthesis

 

Special consideration for esthetic restorations.

1.  Read your client’s chart.  The remarks section should warn you which teeth needs special care.

2.  Use a curette instead of a scaler.

a.  You’ll have more control and increased tactical sensation.

b.  Less chance of scratching porcelain.

3.  If scratching occurs, use Diaglaze to repolish.  If this is not done, the scratches can stain and pick up plaque.

4.  Don’t use pumice or even our standard prophy pastes on a prophy cup    ‑ too abrasive.  Plain toothpaste or our Gel Kam is okay.

5.  Don’t use the cavitron or Prophy jet ‑ too abrasive

6.  Remove proximal stain by using a small fine grit sandpaper strip. If this doesn’t work, go to a medium.  Keep moving up until the stain is gone.  Repolish with a fine grade.  Be careful not to polish off the contact.

7.  If you find an overhang or rough area at a margin, don’t remove it, tell your dentist.

8.  Use a composite polisher (Prisma Gloss, Euamelize, or Composi ‑ Glaze) on all anterior restorations or aluminum oxide

9.  Check gingival margins of restorations used to close diastemas.

10. Keep 4 grades of flexidiscs and 3 grades of sandpaper strips and    several bullet shaped and cup shaped rubber polisher in your room at all times.

11. Use a double-ended plastic instrument to retract the gums or    papilla when you are polishing margins.

12. Write on the outside of the folder and in the remarks section    “bonded veneer.”

13. Toothpastes too abrasive for composites

a.  Advanced Formula Crest

b.  Colgate

c.  Aqua Fresh

d.  Pearl Drops

e.  Topol

f.  Baking Soda

14. Best paste (smoothest) Rembrandt

15. Polishing teeth ‑ use 2 grades of Nupro

a.  Nupro Plus (extremely coarse) for strain removal (grade 30+)

b.  Nupro Medium (19.7) for general use

c.  Nupro Fine (7.3) for porcelain/composite restorations

16. Clients should avoid high alcohol mouthwashes.  They can weaken a    composite bond.

17. Mark in the client’s chart where esthetic restorations are located.

18. To remove stains, go from least to most abrasive: Aluminum oxide (Enamelize) Enhance rubber discs ‑ Sof‑lex discs, then reverse back to Aluminum oxide to remove scratches.

 

Making correction in a client’s chart

1.  Draw a single line through the incorrect entry.

2.  Initial and date this change.

3.  On the next line, write the correct entry.

4.  Never use white‑out or pencil in entries

 

Do’s and Don’ts when writing in a chart

1.  Don’t make uncomplimentary comments (“nasty person”).

2.  Don’t criticize the care form previous offices.

3.  Don’t guess about possible reasons for problems.

4.  Don’t second guess a treatment performed that didn’t work.

5.  Document all details of a client’s non‑compliance with recommended    treatment.

6.  Document all informed consent forms.

7.  Make sure the client’s name is on every page of the record.

8.  Document all client contacts ‑ including telephone calls and    letters.

9.  Chart the complete date on all entries ‑ initials at the end.

10. Green ink for hygienists.

11. Write legibly.

12. Never leave a blank line.

13. Use only standard abbreviations.

14. Update the health history every visit.

15. Document all client instructions and handouts given.

To do: Arrange a polishing kit for silver, plastic, and porcelain restorations in your operatory.

Time schedule view of average appointment

A.  Introduction-private office     6-8 minutes

Greet client, take to private office

Health and dental history update

Pink Sheet – BP, problems/concerns

B.  Exam                                     3 minutes

Oral cancer screen

Spot Periodontal probing, BOP, recession, furcation, mobility – update chart

Assessment of time needed for this appt.

C.  Instrumentation                       20 minutes

Use Cavitron/prophy jet where appropriate

D.  X‑rays                                   5 minutes

(lay out before appointment)

E.  Polish/floss                           5 minutes

F.  Doctor’s exam                         4 minutes

G.  Add information into computer   2 minutes

H.  Complete Pink sheet                    2 minutes

While waiting for the dentist

I.  Dismissal of Client                      8 minutes

Clean up/set up

Total = 59 minutes

If you are running behind, ask the cleaning/sterilization person to seat your next client and clean up this room.

1.  Low speed nose cones wipe down between clients, sterilize at end of day

2.  Spray/wipe/spray – let stand as long as product requires (2-10 minutes)

3.  Wrap light handles, air/water syringes

Options to customize a cleaning appointment to your client

Computer Description Code Time Cost (as of 02/10) Best for
Child Prophy D1120 2u $55 Under age 18
Adult prophy D1110 3u $71 Over age 18, healthy
Difficult/*Overdue Prophy D1110.2 4u $91 Heavy stain or not seen for over 2 years
Mini Cleaning D1110.1 2u $55 Fewer than 10 teeth
Perio maintenance D4910 4u $115 Completed STM2+
Oral hygiene instructions D1330.1 2u $55 Training to brush, floss, fluoride, periogard, etc.
STM1 Series 8u $493
STM2 Series 18u $732
STM3 Series 22u $940
STM4 Series 26u $1092

* Ex: if due for 6 month prophy and it’s been over a year – give extra unit; if due for 3 month prophy and it’s been over 6 months – give extra unit.

 

Signed off by: _________________________     Date: _____________