Tuesday, October 17, 2017

Believe it or not, it's great to be on your own! No longer do you have to wait on faculty, fill out unnecessary paperwork, or feel someone breathing down your neck you while you work. Competencies and proficiencies are gone! The real world really is different than your clinic at school. You are not forced into a mold of practicing hygiene in a sequence that someone is basing a grade on. You are finally able to use your educated clinical judgment and can practice the way you want, provided it's in your bosses agreement to do so of course! You won't have 1.5-2.5 hours with a patient anymore, either! Yikes! How will you ever speed up your work without sacrificing quality of care? There are a few tips and techniques that I personally developed for myself that was useful in becoming more efficient. Please remember that there is a way to develop your speed without compromising efficiency, ethics and quality of care. To truly become efficient means you must be fast enough to make the most out of every minute possible during a patients time with you. You must do this and at the same time do it within a certain time frame so that you are efficient.

Here is what I do step by step on "most" appointments. There are many variations how an appointment could be completed. 
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Greet patient in waiting room, introduce yourself and shake hands while making eye contact. You are new to them and some patients can be weary outside of their comfort zone and what they are used to.

Seat patient and place bib.

Review medical history and current medication. Make sure you do not ask "Are you on any new medications?", but instead ask "What medication are you currently taking?" This brings the patient into conversation because you didn't ask a yes/no question and you are creating dialogue. At the same time you are getting a list of their medications. Sure, it might be listed in the chart and on the medical history right in front of you but there could be many other possibilities as well. They may have filled out the medical history three years ago and forgot, or there could be a notation of a medication change 8 appointments ago and you would have to scan and read everything just to find it out. In regard to the medical history form, each office has different policies, or in some cases no policy at all! The general rule is to have the patient fill out an updated medical history every two to three years.

Tell the patient who you are and that you are the new hygienist to the office. Sometimes they will ask how long you have been a hygienist (especially if you are young or look young!) and if you feel comfortable tell them you are a recent graduate, but I preferred to tell them "I've been doing this for about two years." (Technically you have been doing it for two years in college, right?)
Time: 2-4 Minutes.

Take blood pressure. I use an automatic wrist blood pressure cuff. It's easy, and it's fast. During the one minute it takes to read the blood pressure, you can be making notes in the chart about the patients medical history, you can open up the chart for easy viewing, you can place radiographs on the view box, you can put on your mask and glasses and lay your gloves out and you can write the patients blood pressure in the chart because by the time you've done all that there bp reading is finished. This also helps create discussion later during the appointment because a lot of patients never had their blood pressure taken at their dental visit previously. This is one of the first things seasoned hygienists stop doing because of laziness or because they think it saves time. Don't compromise this important part of a dental appointment! 
Time: 1 Minute

Lay patient down and do your dental hygiene exam. Check restorations for bad margins, explore for caries, check amount of calculus buildup (this is what I call a big "phew!" moment! If they don't have a lot of buildup you know that the appointment will run relatively smoothly time wise). This is also the time to do an oral cancer screening. 
Time: 3-5 Minutes

If they don't have a lot of calculus, I recommend polishing first. Yes, that's right - I said polish first! How many of us have been taught that in school? Polishing first is a great way to improve your speed, believe it or not. How many times does it take you an extra few minutes to scale the patient’s plaque because they have poor home care? Well, you no longer have to be the hygienist that spends too much time scaling what in essence could be polished off. Once you are done with polishing, not only do you have a great view of the mouth and what's left to scale, but also any stain that didn't come off may need to be scaled and the next step is perfect timing. 
Time - 5 Minutes

Next ultrasonic the whole mouth. Regardless of calculus accumulation research has shown that ultrasonic debridement is the best tool we have to fight the biofilm and at the same time it will flush out any plaque that may be located subgingivally. 
Time - 5-15 Minutes
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TIP: Did you know that you can see a lot clearer in the mirror while using the ultrasonic by wetting the mirror? It will add a little layer of water that you can see right through. You can use either your air/water syringe or use the ultrasonic near the mirror for a second to wet it. 
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Hand scale and explore. Sure polishing and the ultrasonic probably removed 100% of calculus and plaque, but I always like to explore and hand scale certain areas just to ensure they are smooth. 
Time - 5-15 Minutes

Floss and OHI. OHI should be given throughout the appointment. You will eventually find places during your routine that are great times to ask questions. For instance, I always time myself to ask a question just as I am finishing a certain area - right before I am switching positions, moving the light, getting gauze, or changing instruments. During that time the patient has time to respond and I am doing something at the same time. Try your best to not lose eye contact with the patient for a long period as this can seem insensitive. As soon as the patient is done speaking, you can begin working and then discuss the oral hygiene instructions that were just discussed. This kills two birds with one stone, so to speak. 
Time - 3-5 Minutes

Doctor exam. Sometimes this is what kills you! If your doctor tends to be slow, I would let them know you are ready for a hygiene check at some point during you treatment. For instance, one job I had the doctor was known to take up to 30 minutes and I would notify him halfway through my appointment that I was ready. There really is nothing wrong with the doctor coming in to do his exam before you floss, etc. The majority of dentists only check for caries and don't spend time dealing with calculus unless it’s visible on radiographs and supra on mandibular anteriors and maxillary buccals. Even if there is calculus, I still doubt most dentists would have a problem checking your patient before you are completely finished. In offices that have more than one hygienist, a great tip is for when the first RDH is ready for a check, the dentist goes in to see that patient - when they are finished, have them come to your room and interrupt you to check yours. This helps the dentist in that they are not forced to get up twice, it helps you not have to wait, it helps the patient to leave without unnecessary wait times and believe it or not, it even helps the front desk because they can walk out two patients in a row and they wont be interrupted as much meaning they can spend more efficient time doing phone calls, recall, insurance, etc. This option really increases efficiency for the entire office up to 50%! Talk it over with your doctor and earn some brownie points for this idea. Truth is, most dentists despise checking hygiene patients. In a recent survey, hygiene exams was voted as the #1 thing that bugs them the most during their work day! Any dentist would love getting interrupted 10 times a day as opposed to 20! Oh, and by the way - since some dentists can become irritated when you call them for a hygiene check it's good to earn some brownie points and treat them good when they come into you room, which you can read more by clicking here. It's crazy that they would even be perturbed by you coming for a check in the first place. (Like it's really your fault you are finished on time span besides he needs hygiene exams to keep himself busy later so don't feel sorry for them! I don't!) 
Time - 3-10 Minutes

There are times you probably should scale first. Using your clinical judgment, if there is obvious heavy supragingival calculus buildup on maxillary molars and lower anteriors you probably want to scale first. Quite frankly, the majority of your patients in private practice are on a 3-6 month recall and generally don't have huge amounts of deposits like you've seen in school, so if you scale first (and there several times I do scale first), I recommend the following order. Working following this way is based on the positioning I was taught in school and still follow. Some of you may learn different positioning but this works for me. The more you change positions for both you and the patient, the more you have to change the overhead light and the more time you waste.

* It may help to use a dentaform, or look at a picture while visualizing this scenario.

At 12:00 Scale Lower Anteriors surfaces away from you (ex. ML 26, ML 25, DL 24, MF 26, DF 25, DF 24)
Change position to 7:00
Scale Lower Anteriors surfaces toward you (ex. DF 26, DF 25, MF 24, DL 25, ML 25)
(Same position) Scale Lingual LL, Buccal LR, (change instruments*) Lingual UL, Buccal UR
Change position to 12:00
Scale Buccal UL, Lingual UR, (change instruments*) Buccal LL, Lingual LR
While still sitting in 12:00 pick up the polisher in your working hand and saliva ejector in other hand bended like a candy cane. Place one gauze in your hand with the saliva ejector. You will use the saliva ejector to suction and retract the entire time and shouldn't need to use the mirror until the end.

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TIP: Did you know that by retracting with your suction, instead of you mirror, will allow you to reduce aerosols and work faster? It will also prevent the patient from pooling up saliva in the back of their throat and makes the procedure much more comfortable for them. Studies have also shown this is better for infection control due to the aerosol reduction. 
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Start by going almost in reverse order that you scaled in with only a minor change. Polish Lingual LL, Lingual Lower Anteriors, Buccal LL, Facial Lower Anteriors, rinse and suction. Turn patient head toward you and polish Lingual LR, have patient tilt head up and polish Lingual UR, Lingual Upper Anteriors, Tilt patient head back down and polish Buccal UL, Facial Upper Anteriors, rinse and spit. 
Change positions to 7:00 and polish Lingual UL, Buccal UR, Buccal LR, rinse and spit. 
Floss
Take Mirror and air/water syringe to check distals of molars, dry air on linguals, etc.

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TIP: Are you having trouble with your mirror constantly fogging? Are you working on a mouth breather who makes it impossible to see your mirror? Wipe 2x2 gauze with some mouth wash on it and wipe your mirror. It will make your mirror anti-fog for a long time allowing you to see clearly! 
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You can work on the entire mouth both scaling and polishing by only changing positions three times! This means it's less time the patient has to move, less time you are fighting with the light and more time you save to be more efficient! If you polish first then the next order will be to substitute polishing for the scaling and vice versus.

Remember we are not in a cookie cutter profession. Every patient does not fit into a specific mold and now that you have those official R.D.H. initials after your name, you can now use your clinical judgment and critical thinking skills to make your own decisions when and how to do something. You will be able to determine who, what, when, why and how - most of the time. Remember in most states we are practicing under "supervision of a dentist” and legally they dictate what we do, but in most circumstances they realize you have the education to not have to "baby sit" you.

There are other ways to be more efficient even when you don't have a patient in your room. Always go to work early and review your charts and take notes on who needs radiographs, who will need topical anesthetic, prophy jet, superfloss and bridge threaders, etc. Having your room ENTIRELY set up saves tremendous time of having to take your gloves and mask off just to pull out some bridge threaders, for example. If they need radiographs, have them set up and ready, the tube head out near the chair, the lead apron over your chair and if you take them digitally, have it already loaded so that all you need to do is stick the sensor in their mouth and push the button.

Take note as to who has restorative treatment that has not been completed. Perhaps the doctor has a cancellation and if you have a patient who needs something they might want to come in a few minutes earlier or stay a few minutes late to get it restored. This helps the doctor’s schedule by helping them to produce more, and it helps the patient not have to miss more days of work, school, etc. Also an added benefit of this is if the patient has outstanding treatment to be done, and the doctor has time to see him after you are finished - move the patient into the doctors operatory and have them do the hygiene exam in there! This allows you to avoid the excessive wait times that sometimes occur!

 

This also applies to your downtime. Check the patients who are there to see the doctor and perhaps they need their teeth cleaned. Maybe there is a family member who needs treatment, a full set of radiographs or hygiene recall and they forgot to schedule it. Always, always be looking for opportunities to increase the office production and efficacy. The more you prove your worth - the more you are worth!

 

Anytime you have time with your patient while waiting for the doctors exam should be spent building rapport and educating! The more the patient is sitting there quiet, the more time they have to realize they are finished and ready to leave. If you keep them occupied you are making them feel important and at the same time you are educating them and/or learning about them as a person. We are dental hygienists but at the same time we can be friends and a shoulder to lean on in certain times. The patient could be having a bad day and by you making one comment such as "I really like your shoes" or something similar can be the turning point from a pessimistic day to an optimistic one. Teach kids how to shake hands, how smiling is not a smile unless you are showing teeth, how to spell dental words (see kid appointment help here), etc. We need to give our full attention to our patients! I have worked with several hygienists that the moment they are done with the patient and they are waiting on the doctor - they are up front chatting with the receptionist (killing the efficacy of two staff members now), they are on the phone with family, or in the break area snacking. You can do this anytime, just not on your doctor’s time and especially not when you have patients! Be courteous and respectful of your coworkers and have good schedule recognition. Schedule recognition is a key trait that most dental employees just "don't get". That means not just knowing if you are on time, but how the rest of the office is performing. If you finished a prophy first, are ready for a doctor exam and you are running 10 minutes early, and your co-hygienist is 20 minutes late and waiting for a check but finished after you - its common sense that they should be checked first. Some doctors don't even notice this and will just go to who called them first because "they've been waiting longer" - which is fine if you are both on schedule, however it's not always the case. Remember again that if you are running behind and the rest of the office is on schedule then you will be the reason they are late for lunch or why they might have to pick the kids up late from school. Sure, this is okay sometimes as we will always have days where we are stressed and behind schedule, but making a daily habit of running late will only create animosity with the staff, especially if the reason is you wasting productive time!

 

I strongly suggest purchasing loupes. Sheervision (www.Sheervision.com) has the best high quality loupes of anyone on the market today and with one of the best prices. I've worn loupes from three different companies and Sheervision has the best depth of field, field of view, clarity and price on the market. To read more about my loupe experiences click here (insert link). Once you get adjusted to using loupes make a next investment in your career by purchasing a portable LED light. I have recently started using one and it's amazing how I ever practiced without one. Combining loupes with a portable light has many benefits both tangible and intangible. You can see clearly and magnified, your posture is better and having the portable light means you never have to use the overhead light! Anywhere you turn and look to is now lighted and magnified! This is just another way to work more efficiently. I can honestly say having loupes with a portable light makes you a better hygienist. Read the section on what you should purchase for other items you NEED!

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