HOW TO PROFIT FROM... hygiene

First impressions are so important. They color the way we think about so many things. How many times have you said to yourself, "I just don`t like the looks of `it,` and then gone on to refuse to have anything to do with `it.` " We make snap judgments about clothes, food, music and other people based on the brief first impression that they make on us. It`s simply a fact of life.

Jan 1st, 1998

Those vital first impressions!

Carol D. TEKAVEC, CDA, RDH

First impressions are so important. They color the way we think about so many things. How many times have you said to yourself, "I just don`t like the looks of `it,` and then gone on to refuse to have anything to do with `it.` " We make snap judgments about clothes, food, music and other people based on the brief first impression that they make on us. It`s simply a fact of life.

The first impression that we make on our patients can determine whether we have a great relationship or a poor one. It can influence our patients` decisions about treatment and payment. It can determine whether or not a patient refers friends and relatives, and it is a factor in the decision-making process emergency patients undergo before converting to regular patients.

First impressions count!

When I was six years old and just starting school, my grandmother gave me some advice that has stayed with me. She told me that on the first day of school, I should go up to my first-grade teacher and say hello, tell her my name and sit in the front row. She said that all that first day, I should sit up straight, pay attention and raise my hand with answers to any questions I knew.

She explained that this would make my teacher take notice of me as an interested, eager student. Later, if I didn`t do too well on a test or didn`t have the answer to a question, she still would think favorably of me. Instead of thinking, "this student really isn`t on the ball," she would think, "Well, she must be having an off day. I`m sure tomorrow she will be back to normal."

What grandma didn`t realize was that her advice about making a good first impression has been studied by experts. The tendency to think well of someone we already like, even when they do something "wrong," is called the "halo" effect. It is what we call the situation when a person who actually might not be that smart, that beautiful, that organized, etc., is perceived to be that way due to past, positive associations. It means that if we have made a good first impression, even if we fall somewhat short on occasion, others will look upon us as being "good people having a bad day," rather than "bad people doing what comes naturally."

Why should we pay attention to making a good first impression? Because it is so important in helping our patients feel comfortable and in making our practices a success. It is something that we can accomplish fairly easily and it can have long-standing benefits. A good first impression can bring patients to us and help patients stay with us.

Frequently, we make things harder on ourselves than we need to. We make our lives too complicated. In trying to attract and keep patients, we attend courses, read books, listen to tapes, watch videos and peruse patient surveys. All of these activities can be profitable because we may learn more about ourselves and our patients. However, nothing can replace the simple efforts we make to help our patients feel cared for and at home - at their very first visit and from then on. A simple way of looking at how to orchestrate a patient`s first visit is to think of how you treat a guest visiting your home for the first time. It isn`t complicated, but it does take effort and planning.

Let`s take a typical new-patient "first appointment" and look at how it is handled in hundreds of offices. It starts with the patient`s phone contact with the office, and it usually goes something like this:

Front-Desk Person (abruptly): "Dental Office."

Mr. New Patient: "Is this Dr. Smith`s office?"

Front-Desk Person (impatiently): "Yes."

Mr. New Patient: "I`d like to set up an appointment for a check-up and cleaning."

Front-Desk Person: "Have you been to our office before?"

Mr. New Patient: "No, I`m a new patient."

Front-Desk Person: "I can set you up for an appointment next Tuesday at 9 a.m."

Mr. New Patient: "Well, afternoons really are better for me."

Front-Desk Person (firmly): "I`m sorry, Dr. Smith only sees new patients in the morning."

Mr. New Patient (reluctantly): "Well, alright. I guess that will be OK."

Front-Desk Person: "We expect our new patients to pay for their examinations at the time of the appointment. The charge is $85 for the exam and $45 for the cleaning for a total of $130."

Mr. New Patient: "I have dental insurance that covers 100 percent of whatever I need."

Front-Desk Person (trying to hide disbelief in voice): "We will give you a superbill at the end of your appointment. You may use it to file for reimbursement from your insurance company. Dr. Smith does not accept insurance."

Mr. New Patient (more reluctantly and thinking, "What`s a superbill - a really big bill?"): "Well, alright. I`ll see you Tuesday."

The following Tuesday, Mr. Wilson, the new patient, comes to the office. He sits in the reception room noting his surroundings and the other patients. He notices the carpet, the wall coverings, the chairs, the lamps, the magazines, the fish tank, the "advantages of tooth-colored fillings" video playing on the TV monitor in the corner console and the front-desk person talking on the telephone behind the desk. The carpet is nice and clean, but the walls show a slightly discolored circle above each chair, corresponding to the approximate height of a person`s head. ("A grease spot from people`s hair?" he thinks. "I hope the treatment rooms are cleaner.") The video looks interesting, but the volume is turned so low, he can`t really hear what is being said. He also observes that the fish tank could use a good cleaning.

The front-desk person notices him sitting there and says, "Did you write your name on the list on the clipboard?"

Mr. Wilson (standing and walking to the desk): "I didn`t see a clip-board."

Front-Desk Person (handing him the clipboard over the top of the desk): "Here it is."

Mr. Wilson signs in and sits down again.

Front-Desk Person: "They will be with you in a minute."

After 15 minutes, another woman comes from the back of the office to the reception room. Mr. Wilson does not know who she is, but assumes she is the hygienist.

Ms. Hygienist: "Mr. Wilson, I`m ready for you now."

Mr. Wilson follows the hygienist down the hall. They go into an X-ray room and the hygienist indicates that Mr. Wilson should sit down.

Ms. Hygienist: "I will be taking some X-rays of your teeth."

Mr. Wilson: "Do I need X-rays? I really don`t want to have X-rays."

Ms. Hygienist (wearily, having heard this 100 times before): "We always take X-rays on our new patients. Otherwise, how can we tell if you have any cavities?"

Mr. Wilson (reluctantly): "Well, O.K. I only want the X-rays I absolutely must have."

Ms. Hygienist: "That`s fine."

Ms. Hygienist takes a full-mouth series of radiographs, but not without being interrupted by Mr. Wilson several times to ask if they are almost finished. While the X-rays are being developed, Ms. Hygienist takes Mr. Wilson to her operatory to begin his "cleaning." After just a few minutes, she realizes that Mr. Wilson has heavy calculus and stain, with 5 mm-plus pockets in all molar areas. She lays down her scaler and rings for Dr. Smith.

Ms. Hygienist: "I`m sorry, but you have deep pockets and heavy calculus throughout your mouth. You are going to need to have RPCs. I won`t be able to finish you today. I will have to set up several more appointments for you."

Mr. Wilson: "RPCs, what`s that?"

Ms. Hygienist: "It stands for root- planing and incidental curettage. It is a deep scaling clear down to the base of your pockets to remove the diseased cementum and toxins."

Mr. Wilson (suspiciously): "I think that I would like to see the doctor."

Ms. Hygienist: "He will be in in a few minutes. I will start on your top right side. That is probably all that I will be able to finish today."

Ms. Hygienist begins the deep scaling. Mr. Wilson is very sensitive and very uncomfortable. He keeps asking to rinse and coughs repeatedly. "Am I bleeding?" he asks after noticing blood on the neck napkin.

"A little," Ms. Hygienist answers. "It`s common during root-planing."

At this point, Dr. Smith comes in.

Dr. Smith: "Good morning!" he says briskly, looking down at Mr. Wilson in the chair. Mr. Wilson has his mouth full of water, so he gurgles a reply. "It looks like we have you down for an exam this morning," the dentist says.

Ms. Hygienist moves out of the operator chair and Dr. Smith sits down. "Let`s see what we have here."

Dr. Smith begins to examine Mr. Wilson`s teeth, calling off decayed areas and problems to a chairside assistant, who has materialized suddenly. In addition to his periodontal condition, Mr. Wilson needs several crowns, has a missing tooth that needs to be replaced with a bridge and has numerous leaking amalgams.

"After we finish with your perio treatment, we will get started on your crowns," Dr. Smith tells Mr. Wilson. He pats him on the shoulder warmly and leaves the room. "Thank you for coming in," he calls politely as he pushes through the swinging doors.

Ms. Hygienist continues to struggle through the appointment, finally completing slightly less than one sextant of Mr. Wilson`s right side in the time she had. She then uprights the chair and begins to explain home- care responsibilities to Mr. Wilson. "I want you to use dental floss at least once a day, brush at least twice a day and get this prescription for chlorhexidine. It will come with instructions."

The hygienist hands Mr. Wilson his chart and a routing slip that she has hastily filled in with what was done today. "Take these to the front desk and they will set up your next visit."

Front-Desk Person: "Do you need another appointment?"

Mr. Wilson: "I think I do."

Front-Desk Person (looking at the routing slip and glancing at the chart. Nothing in the chart or on the routing slip indicates what the next appointment should be for.) "Do you know what they want to do?"

Mr. Wilson (thinking, "Don`t you know?! You work here, not me."): "I haven`t the slightest idea."

Front-Desk Person (looking at the progress notes and charting and seeing that part of a root-planing was completed today): "It looks like you need to have the rest of your root- planing completed and two crowns begun on your right side."

Mr. Wilson: "Two crowns?"

Front-Desk Person: "Well, it says right here in your chart that you need to have a total of five crowns. We would start with the two on your right side since they are together."

Mr. Wilson: "How much is all of this going to cost?"

Front-Desk Person (looking at chart): "You have XYZ insurance. It will cover a portion of our $650 per crown fee."

Mr. Wilson: "A portion! The employee benefits coordinator at my job told us that our insurance covers 100 percent of our dental treatment!"

Front-Desk Person: "That is very unlikely. Insurance rarely covers more than 50 percent for crowns."

Mr. Wilson (with exasperation and astonishment. He had no idea that crowns were so expensive.): "Will you at least bill my insurance for what I had done today?"

Front-Desk Person: "I`m sorry, but Dr. Smith does not accept insurance. We expect all of our patients to pay for services when they are rendered. I will give you a statement that you can send to your insurance for reimbursement."

Mr. Wilson (with resignation): "OK., whatever you say. What do I owe for today?"

Front-Desk Person (adding up the figures on the routing slip): "That will be $85 for the exam and $135 for the partial quadrant of root-planing, for a total of $220."

Mr. Wilson: "I was told on the phone that my appointment charge for today would be $85 for the exam and $45 for the cleaning."

Front-Desk Person: "But that was before we discovered that you need to have extensive root-planing."

Mr. Wilson (whipping out his wallet): "Fine. I think I will have to let you know about that next appointment."

While he is filling in his check, several of the chairside assistants congregate at the front desk talking about the course on "Attracting New Patients" they attended the previous weekend. They are excited about beginning an advertising campaign that will bring many new people into the practice.

Mr. Wilson slams his check on the front desk and leaves. On his way back to work, he uses his car phone to tell his wife and then later his brother about the terrible experience he had at Dr. Smith`s office.

Mr. Wilson will not be back!

What happened here? What kind of first impression did Dr. Smith`s office make on Mr.Wilson? What problems arose because of combining a new-patient visit with a hygiene appointment? What good is attending a course on attracting new patients if the office is not focused on treating the patients who already are there?

Let`s go back to Mr. Wilson`s first phone contact with the office and see how the entire visit could have been orchestrated to make a better impression.

Front-Desk Person: "Good morning, Dr. Smith`s office. This is Cathy."

Mr. New Patient: "Hello Cathy, this is Jim Wilson. I`d like to set up an appointment for a check-up and cleaning."

Cathy: "Have you been to our office before, Mr. Wilson?"

Mr. Wilson: "No, I`m a new patient."

Cathy: "I can set you up for an appointment with Dr. Smith next Tuesday at 9 a.m or in the afternoon at 2 p.m."

Mr. Wilson: "Well, afternoons are better for me. I will take the 2 o`clock."

Cathy: "This appointment will be to see Dr. Smith, but not the hygienist, Mr. Wilson. Dr. Smith likes to see patients first before scheduling any cleanings or other treatment."

Mr. Wilson: "I really would prefer having both my exam and cleaning done at the same visit."

Cathy (knowing that almost everyone needs to have some type of cleaning, but understanding the importance of not scheduling a new patient exam and a hygiene visit together): "Well, Dr. Smith likes to see if his patients need a cleaning before scheduling it." She puts the emphasis on the word "need."

Mr. Wilson: "I guess that makes sense."

Cathy: "Who may we thank for referring you to our office."

Mr. Wilson: "My co-worker, Dave Peterson. He is a patient of Dr. Smith`s."

Cathy: "Great!" (She makes a note to send Dave Peterson a "thank- you-for-referring letter" and the small gift that the office is providing this month. She will send them both out as soon as she hangs up the telephone.) "Do you know how to find our office?"

Mr. Wilson: "I`m not sure."

Cathy: "I will be mailing you an appointment card with your time filled in. It has a map to our office on the back. I also will be sending you a medical history and information form. If you would complete them at home and bring them with you to your appointment, we can save you time while you are here."

Mr. Wilson: "That`s fine."

Cathy: "Do you have dental insurance?"

Mr. Wilson: "Yes, but I haven`t used it before. My company`s employee benefits coordinator says it covers 100 percent of whatever we need."

Cathy (knowing that this is impossible, but responding pleasantly): "Well, we work with all kinds of insurance. They all seem to cover things differently. If you would bring in any information that you have about your insurance, we will work with you on it. Your first visit will be $85. We would appreciate your covering that amount when you come in."

Mr. Wilson: "Thank you. I will see you next week."

Next Tuesday, Mr. Wilson comes to the office. He sits in the reception room and takes note of his surroundings. He observes that the carpet is new and clean, there is a sparkling fish tank with several shiny fish, the wall coverings are fresh and the chairs, lamps and tables are spotless. There is a video playing on the TV monitor in the corner console. There is no sound, but a close-captioned narrative explains what is happening on the screen. On the video, a patient is receiving some type of tooth-colored filling. "I wonder if I could have some tooth-colored fillings to replace some of my old silver ones," Mr. Wilson thinks.

Cathy (standing up behind her desk and smiling): "Hi, you must be Mr. Wilson."

Mr. Wilson: "Yes. Good afternoon."

Cathy: "Did you bring those forms I mailed to you last week and your insurance information?"

Mr. Wilson: "Yes, they`re right here."

Cathy: "Reneé, Dr. Smith`s assistant, will be out to get you in just a minute."

Cathy begins assembling Mr. Wilson`s record and alerts Reneé, one of the chairside assistants, and Dr. Smith.

Reneé (walking over to where Mr. Wilson is sitting): "Mr. Wilson?"

Mr. Wilson (standing): "Yes."

Reneé (offering her hand): "Hi, I`m Reneé, one of Dr. Smith`s dental assistants. I wanted you to see a little of our office before we get started." Reneé takes Mr. Wilson on a brief tour. She shows him the treatment rooms, X-ray area, sterilization area and then, finally, Dr. Smith`s private office.

Reneé: "Please have a seat and make yourself comfortable. (She indicates a comfortable chair next to a small table.) Would you like a fruit juice or some coffee?"

Mr. Wilson: "Some black coffee would be nice."

Reneé gets the coffee and returns with Mr. Wilson`s record.

Reneé: "I want to go over the forms you brought with you today."

Reneé reviews both the medical/-dental history and patient-informa-tion form with Mr. Wilson. Just as they are finishing, there is a knock at the door and Dr. Smith enters.

Reneé: "Mr. Wilson, this is Dr. Smith."

Dr. Smith (extending his hand): "I`m very glad to meet you. Reneé has been going over your forms with you and I wanted to see you before we go back into the treatment room."

Dr. Smith looks over the forms, asks a few questions and makes notes as needed. He also asks Mr. Wilson if he has any special problems that he would like taken care of. Dr. Smith writes down his perception of Mr. Wilson`s main concerns. These concerns will be focused on during the treatment conference, so that Mr. Wilson knows that he is in the hands of a dental team that puts his needs first. Mr. Wilson will be more trusting and better inclined to accept treatment from professionals he trusts to have his best interests at heart than from people he feels have their own agenda. When Dr. Smith is finished, he says:

"Reneé, please take Mr. Wilson back. I`ll be in there in just a minute."

Reneé and Mr. Wilson move to a treatment room. Reneé leaves the patient chair upright and visits with Mr. Wilson until Dr. Smith comes in. After Dr. Smith arrives, Reneé places a neck napkin on the patient and reclines the chair. She moves the intraoral camera closer and positions herself to help point out problems seen on the screen.

Dr. Smith says, "First, I want to take a look at your mouth and see what is going on." He uses the camera to inspect Mr. Wilson`s mouth. He and Reneé point out areas of concern on the screen. He also performs a periodontal screening, explaining what the numbers mean as he goes. Mr. Wilson has several deep-pocket areas and very heavy calculus. Both of these problems are quite evident on the screen and Dr. Smith takes several photographs. When he is finished, he orders radiographs.

"Reneé, I would like for you to take X-rays of both the teeth and gums." (Reneé understands this as a full-mouth survey.) "When they are developed, we will complete the exam and finish checking Mr. Wilson`s gums, bone and teeth." Dr. Smith and all members of the dental team are careful to use layman`s terms when talking around and with patients. It is inconsiderate to use overly technical terms that require patients to keep asking for clarification or terms they just simply do not understand.

While she is taking the radiographs, Mr. Wilson has no questions for Reneé about the need for X-rays because it is obvious that Dr. Smith has assessed the situation and feels they are necessary.

Conversation is kept to a minimum and time is saved during the X-ray process because of this. (If Mr. Wilson had questions about needing radiographs, he would have had a chance to voice them with Dr. Smith and then again with Reneé. If he was worried about them, Reneé would have taken the time to answer his concerns in detail and/or have had Dr. Smith return to address them in person.)

Reneé (leading Mr. Wilson back to the treatment room and handing him several magazines): "While the X-rays are developing, you can relax here. I will be right back."

When the X-rays are mounted, Dr. Smith and Reneé return to the treatment room.

Dr. Smith: "Mr. Wilson, I will be making a record of all of the existing conditions with your teeth and the rest of your mouth. Any decay or other problems also will be noted. I will do a cancer exam and evaluate your bite, too.

Dr. Smith and Reneé work together to collect the data needed for Mr. Wilson`s complete evaluation. Reneé reads from a detailed chart form for initial clinical particulars and hard-tissue issues. Dr. Smith responds with information Reneé writes down. Mr. Wilson listens during the exam. He is astonished at how much information is being assembled and he is interested in what is being said about his mouth and health. Dr. Smith is concerned with Mr. Wilson`s perio condition and talks to him about what he is seeing throughout the exam. When the exam is finished, Dr. Smith uprights the chair.

Dr. Smith: "It is my job to let you know exactly what the conditions are in your mouth, what I recommend and what options you might have. It is your job to decide what you want to do. I am going to have Reneé show you a short video on periodontal health. It will better illustrate what we have been talking about in your own mouth. After the video is over, my clinical coordinator, Sue, will be talking to you about our findings. I will be recommending that we begin by taking care of your gums and bone and then, when they are stable, we will start with any fillings and crowns you need. It has been a pleasure meeting you and I look forward to seeing you again."

Dr. Smith shakes hands with Mr. Wilson and leaves the treatment room. Reneé takes Mr. Wilson to a small office where a video machine/television is set up. She puts in a short video that details the stages of periodontal disease and talks about perio scaling and root-planing. While the video is running, Reneé and Sue go over Mr. Wilson`s chart and Sue writes up an estimate for him on recommended Phase I or initial therapy. When the video is over, Sue goes into the office and talks to Mr. Wilson about having complete perio charting and scaling and root-planing with the hygienist.

She begins the conversation by asking Mr. Wilson if he has any questions about what he saw on the video. (The video provides initial information, so Sue does not have to begin at "square one.") She gives Mr. Wilson the opportunity to ask questions. She gives him a brochure explaining perio problems and goes over an informed-consent form describing all Phase I procedures. She tells Mr. Wilson that after his perio scaling has been completed, his condition will be re-evaluated and, if stable, another estimate will be given to him for treatment for his restorative needs. She is careful to focus on his areas of concern, such as Mr. Wilson`s worry about time away from work that Dr. Smith noted during their initial interview. Any of Mr. Wilson`s perceived problems are given a top priority, even if they are not really that important to his overall dental health. The patient`s concerns come first.

She gives Mr. Wilson a copy of his signed informed-consent form and signed estimate form, and she fills in a complete treatment-plan charting form (from Dr. Wilson`s data) for Phase I. This form will be kept in Mr. Wilson`s record so that all members of the dental team know what needs to be done at each appointment. No routing slips or other outside notes are needed because the patient chart is designed to contain all information about the patient. She reiterates that the staff will help Mr. Wilson obtain his insurance benefits, but the tone of the conference emphasizes the fact that treatment comes first; insurance is helpful, but is not what dictates what treatment patients need.

Mr. Wilson is not thrilled that he needs to have perio scaling and possibly quite a bit of restorative work, but he is satisfied with the information he has received and feels a definite rapport with Dr. Smith and the staff. He feels that he is in control of what will happen to him, and he feels that the staff has his best interests at heart. Dr. Smith and the staff were nonmanipulative; friendly, but not overly so; and extremely professional.

Mr. Wilson sets up an appointment for the hygienist to start his root-planings the following week. He has had such a positive experience that when he gets back to work, he tells several co-workers and then, later, a neighbor about the great dentist he has found. (An interesting side effect of making a good first impression is the tendency of patients to want to boast about how smart they are to have found such a great dental office. It has been said that after a positive experience, a patient will tell five people. After a negative experience, 10 people will be told.)

When Kate, the hygienist, sees Mr. Wilson for his first appointment, she spends very little time with explanations about what to expect or what will be happening at this visit. She simply says, OLast week, Sue went over what we have planned for today. Do you have any questions?O Mr. Wilson asks for clarification of a term and then the appointment begins. Kate performs a complete periodontal probing and recording and two quadrants of root-planing in record time because Mr. Wilson knows what to expect and is ready for treatment. The good feeling (halo effect) that he developed during his initial visit with Dr. Smith, Rene?, Cathy and Sue has carried over into this visit with Kate. He feels in control of the situation and views the dental-team members as people who can help him obtain what he needs, not people trying to convince him to have treatment he doesn?t need or want.

New patients, first impressions and hygiene care have to be carefully choreographed to help patients ease into the treatment experience. It is seldom a good idea to combine a new-patient visit with a cleaning. Too many details may be left out, too much may be left unsaid and too many misunderstandings can occur. Time spent at the beginning of the relationship increases the chance for a successful, long-term association. Good first impressions bring more patients to us and help our patients stay with us.

Follow the leaders as Dental Advantage launches the 1998 seminar series at La Costa Resort & Spa

La Costa Resort & Spa in Carlsbad, California is the setting for the first in a series of nine Dental Advantage Seminars - all set at Leading Hotels of The World™. The leaders of the industry - both clinical and practice management, along with dentistry`s top dental manufacturing companies - are joining together to provide practice and lifestyle advice, as well as techniques for practitioners who desire Solutions for Growing Practices™.

Each seminar will be limited to a maximum of 250 doctors to provide an intimate environment and personal, interactive educational opportunities with the leaders and expert clinicians lecturing in dentistry today.

From February 25-28, beautiful La Costa Resort & Spa, renowned as the only "Total Resort" experience for its world-class spa treatments, golf course and tennis facilities, will host the premier Dental Advantage Seminar. La Costa has been the celebrity retreat for over 30 years and will now host a virtual Who`s Who of Dentistry including Drs. Larry Rosenthal, David Hornbrook, Bill Dorfman, Michael DiTolla, Stewart Rosenberg, John Jameson; practice-management specialists Cathy Jameson and Jim and Suzanne DuMolin; as well as Dr. Joe Blaes, editor of Dental Economcs, Teri Reis-Schmidt, editor of Dental Products Report and Erla Kay, senior publisher of Oral Health.

Each participant in the Dental Advantage Seminars will receive a free trial membership and six-month subscription to Dental Advantage`s practice and lifestyle magazine VANTAGE™.

For more information on Dental Advantage Seminars and to register for the February 1998 seminar at La Costa Resort & Spa, please call (800) 584-5000.

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