Tearing down the brick wall of dentistrys Dogma

March 1, 2000
Dogmatic rigidity in the way we do things can prevent dentists from serving the people who need their services.

Dogmatic rigidity in the way we do things can prevent dentists from serving the people who need their services.

Ted Morgan, DDS

For a long time, dentists with aspirations to be "quality dentists" have clung to a curious belief about new patient exams. This belief has just about reached the status of unassailable dogma. In spite of the fact that new patients nearly always ask for a cleaning the first time they call, the belief is that we must convince them to have a comprehensive exam first.

This is what I call the "Dogma," and it originated with the teachings of some of our most revered dental gurus. It says: "To be a quality dentist, thou shalt always see every new patient thyself in thine own schedule for a comprehensive examination the first time the patient comes to thine office." To be considered comprehensive, this exam must include complete medical history, full-mouth radiographs, examination of occlusion, TM joints, and soft tissues - intraoral and extraoral, a periodontal exam, diet-screening, an extensive interview, facebow-mounted diagnostic casts, centric bite registration, cosmetic smile analysis, etc.

The truth behind the Dogma is that good dentistry requires a full diagnosis and careful planning before treatment is initiated. This, of course, is an important foundational principle for anyone serious about doing his or her best for the patient. However, rigid adherence to the idea that the patient`s entry into the practice must always start with the comprehensive exam - regardless of what the patient wants first - can be destructive in terms of both managing patient relationships and managing profitability in the practice. The Dogma says that even something as innocuous as a simple cosmetic cleaning will not be allowed until after the exam, treatment-planning, and case presentation - and then only if the dentist determines that it is the "correct" treatment.

According to the Dogma, complete ideal dentistry must be presented to the patient at a separate visit, featuring diagnostic casts that are so beautifully mounted, articulated, and polished that they practically come to life and talk to the patient themselves! If you don`t do this with every patient who comes into your practice, regardless of what dentistry this person needs, people in your community will come to think of your practice as just another drill-and-fill shop ... a place where they can just call up and order a cleaning, an extraction, or a filling whenever they see fit. Therefore, you the (formerly) caring, quality dentist will lose control of the relationship and of the treatment. You will become the dental equivalent of a fast-food franchise proprietor.

One of the underlying ideals of the Dogma is that you must spend as much time as possible with the new patient diagnosing, co-diagnosing, interviewing, treatment-planning, and case-presenting before any actual dentistry is performed. In fact, bragging rights are earned by the total length of time the exam appointment takes: The longer the appointment, the greater the skill and care of the dentist!

Believers and nonbelievers

The Dogma divides dentists into two categories: believers and non-believers. Believers look down their noses at nonbelievers. Nonbelievers see believers as idealistic, ivory-tower, elitist dentists. Believers see themselves as having superior values, integrity, and skills. Nonbelievers see themselves as pragmatic realists who are more in touch with their patients` real-world needs and wants. Believers talk a lot about quality and excellence; nonbelievers talk about doing their best under the circumstances. Believers say cost is of no concern when it comes to optimal dental health; nonbelievers say their patients cannot afford ideal dentistry.

A corollary to the Dogma is that quality dentists should only accept into their practices a patient who knows - or can be readily convinced - that they really don`t want their teeth cleaned first. If this "conversion" to an exam is not done on the first phone call, the encounter is considered a failure. In that case, the patient frequently will not be allowed to enter the practice at all. If the patient is accepted into the practice, he or she will be labeled as having a "low dental IQ," and will be treated as a second-class patient from then on. To successfully enter the practice with a full "desirable patient" status, the patient must first be completely diagnosed and treatment-planned before the proper kind of prophylaxis (the word "cleaning" is forbidden) or periodontal therapy can be prescribed.

In a believer`s practice, much time and energy is devoted to verbal strategies designed to get the patient who asks for a cleaning to accept a comprehensive exam. One of the common strategies is to reply to the I`d-like-to-make-an-appointment-for-a-cleaning request with, "Oh, and which kind of cleaning did you need?" (condescension in the voice is recommended). This is followed by a brief description of every permutation of prophylaxis and/or periodontal therapy known to man, in order to confuse and to expose the ignorance of this patient. This, of course, makes patients who ask for "just a cleaning" realize that they really doesn`t know what it is they want after all. The believer dentist, after all, always must stay in full control of the relationship.

Challenging the `brotherhood`

Clearly, not all dentists subscribe to the Dogma, but it is revered at such a level that few would dare admit to not practicing in accordance with it. Immediate ostracism from the "Brotherhood of Quality Dentists" would result. Never could any self-respecting dentist say in front of any gathered group of his peers that he does not follow the Dogma. Yet, we know the reality is that many dentists do have new patients who enter their practice through hygiene, usually with a cursory exam included at the initial visit.

Of course, this merely adds confirmation to adherents to the Dogma that they truly are among the elite remnant of quality dentists. But is the Dogma true? While the necessity of complete diagnosis and careful treatment-planning is undeniable, is doing the comprehensive exam on every new patient`s very first visit the hallmark of excellence? Conversely, is seeing new patients first in hygiene really the telltale sign of mediocrity?

I was a true believer in the Dogma for over 20 years. My conscience was clear; I knew I was doing the right thing, even though I was aware that many prospective new patients did not schedule their exams because they didn`t want to go through the long entry process. During those years, we noticed that no matter how skilled we become in converting patients at their first phone call from the cleaning they said they wanted to the comprehensive exam, their first contact with our office was still a confrontation. Many times, the patient simply would not schedule because of this issue. At other times, the patient would schedule, but then not show up for the appointment. We rationalized that these people did not belong in our practice, anyway, because they obviously didn`t value their dental health.

I also found out that sometimes when I had devoted an hour or more of my schedule to a new patient, it turned out that this person had minimal or no dental needs or that he or she was not financially qualified to pay for even the most basic treatment. Other times, I would have a new patient scheduled and there would not be enough time to do all of the diagnostic procedures the condition warranted. This meant I either had to rush through the exam or add yet another appointment before initiation of the treatment. We could never find just the right length of time for an exam that fit everybody. We either ended up with wasted time on some patients or we were rushed through the exam on others.

When many patients had to schedule another visit for the consultation, they complained that it was taking too long to get to the treatment they knew they needed. Some left the practice before the new-patient process was ever finished. Others would seem very interested in solutions to the problems we uncovered in their exam, only to come to the case presentation and say they wanted to "think about it." Looking back, this was due to our removing the urgency of treatment in the patient`s mind by taking so long to even get to recommending what should be done.

It began to look like we had to choose between integrity and profit, but that we couldn`t have both. Either we had to do a full comprehensive exam on every new patient, as prescribed by the Dogma, or we had to shortcut the exam process to avoid lost time. Either we had to lose many new patients before they ever entered the practice, plus lose time and profits when the exams we did failed to produce any scheduled treatment, or we had to allow new patients to come in on their own terms, but give up our integrity by doing less than a complete exam. The Dogma didn`t allow any alternatives to get us out of this dilemma.

Some advice from a friend

A close friend through those years practiced as an admitted non-believer. Many times he tried to convince me that I should do what he did: Commit the ultimate sin of allowing my new patients to have their cleaning first because that is what they asked for. It horrified me to hear this kind of talk from my good friend. If I hadn`t already known him to be an excellent dentist, I could easily have dismissed his advice as unenlightened or as coming from a nonvalid, unbeliever source. Besides, he practiced in the "ultra-boonies" of Maine, so a few compromises were to be expected. But I knew his dentistry to be at least as good as mine, so I had to allow him his heresy. In our discussions, I always took the high ground and tried to convince him to join us ethical, morally superior believers. But he seemed satisfied with his "corrupt" method, and he showed no interest in converting. We both learned to live with a standoff on this issue, both convinced we were right.

Then, about five years ago, I met another excellent dentist who, in describing his practice, made me realize he was doing exactly what I wanted to be doing. His practice consisted primarily of large, high-end restorative cases (yes, "quality dentistry"). He practiced a shortened schedule and earned a high gross, doing the dentistry he liked doing the most. Naturally, I assumed he must be a believer to have reached such a high level. But then, a Dogma-shattering thing took place: He told me that all of his new patients see his hygienist first! How could this be?

He began asking me questions:

"What does nearly every new patient ask for when they call your office?"

"Well, a cleaning," I replied, "but only because we haven`t educated them yet."

"Would you be hurting them if you gave it to them?"

"Well, no, I guess not. But what if they need periodontal therapy?"

"When you try to convert them on the phone to a complete exam at the first visit, what is your batting average?"

"Maybe .500, but we get all the ones who appreciate quality."

"How do you know that the ones who didn`t schedule didn`t appreciate quality?"

"Because they didn`t schedule. Obviously."

"If there were a way to get more of what you want and less of what you don`t want - and still practice `quality dentistry`- would you be interested?"

"Well, of course. What`s the catch; losing my integrity?"

I was interested, but I was sure that allowing the patient to have hygiene first meant quality last. After all, the gurus said so, didn`t they? This enigmatic dentist who was asking me these questions clearly didn`t have his "guru" credentials. In fact, he was so soft-spoken, good-humored, and at peace with himself and his profession, he really didn`t even seem like a real dentist. He had to be a counter-cultural subversive, perhaps planted by the insurance industry to sabotage "quality dentistry." Who but a subversive could even suggest anything so radical as a patient being eligible for quality dentistry after having the hygiene visit before the exam?

But I was in a particularly open state, since I was just then at the conclusion of a life-changing growth experience; my first Dental Boot Kamp. As a result of this learning experience, which included this unusual dentist to whom I was speaking, I was now in the process of overthrowing one paradigm after another. Why not one more? I was ready to consider taking a new look at the validity of the Dogma.

Making the paradigm shift

I won`t further belabor the process that led me to the heretical view that it really is OK for new patients to see my hygienist for their first visit. I will jump ahead to the conclusion I reached after getting up enough courage to actually try it. Not only does this paradigm shift not cause moral death and practice mayhem, as I had been led to believe, but hygiene first is, in my experience, actually the superior way to introduce new patients.

By now, if you subscribe to the Dogma, you no doubt believe me to be a dental low-life, turned to the "darkside of dentistry." My only hope is that you can keep your mind open just long enough to finish reading this.

First, answer this question: What really is the harm, biologically or clinically, in doing a prophy on the patient`s first visit? Yes, even prior to diagnosis of the patient`s periodontal condition; even if the patient`s periodontal condition is Type IV or Type XXX, for that matter. What is the harm? Keep in mind that prophy is narrowly defined (thanks to the insurance industry`s need to assign a code to everything we do) as supragingival plaque removal and polishing. Sounds a little like what we expect our patients to do two or three times a day by themselves with a toothbrush, doesn`t it? Prior to any diagnosis, is it unethical or dangerous to remove supragingival plaque and polish supragingival enamel? (Clue: Is it unethical or dangerous to have patients brush their teeth?)

Other questions to ask

OK, now ask yourself this: Are patients more likely to schedule an appointment and show up for it if you give them what they asked for rather than immediately try to persuade them to do something else? Will your front-desk team have an easier job or a more difficult job connecting emotionally with new patients on their first call if they schedule what patients wants? Or do new patients really want a comprehensive exam first after all, and they`re really just testing us to see which of us are the quality dentists and which are the low-lifes? What other business or profession routinely tries to talk their clients out of what they ask for and into something entirely different on the first contact? If you have thought of such a business, it is probably not one that you would like to emulate.

By now, perhaps you`re thinking, "Wouldn`t it be great if I could actually just let these people come in for the cleaning they want? But how could I live with myself? And what about all the money I`ve spent getting verbal skills to talk them into an exam like every quality dentist does?"

Well, for now, just imagine that you have allowed a new patient to see the hygienist first and this patient is now in the hygienist`s chair. The patient has had a prophy and maybe it just fit this person`s condition; he or she is healthy. Whew! But wait! What if this new patient did have periodontal disease? Haven`t we just dug ourselves into a hole? Won`t this person think he or she doesn`t need the periodontal treatment we will be recommending because "I`ve already had my cleaning; why do I need that?" Or they`ll say, "Why did I pay for a cleaning if I actually needed periodontal treatment?"

What if I told you that after five years and hundreds of new patients, I have yet to hear either of these questions from patients! What if I told you that now, as compared to when we followed the Dogma, patients understand the difference between their cleaning and their periodontal therapy better than ever? Rarely, do they even think of any connection between the two. The cleaning they wanted already is a nonissue when we bring up the need for periodontal therapy. They more easily understand that the therapy we are recommending treats an area totally different from what was just cleaned.

Dealing with mental obstacles

If you`re like I was, one of your mental obstacles to abandoning the Dogma is the idea that a prophy is not the appropriate treatment if the patient has periodontal disease. Remember this: You never met this patient. This person asked for a cleaning and you have no way of knowing if it is exactly what is needed or not, but you do know it will not harm the patient and the patient wants it. In fact, your patient will feel better physically and emotionally and possibly look better as a result. You have to start somewhere, so why not start by saying "yes" to what this person asks for?

Without a diagnosis of periodontal disease, a prophy actually is the correct form of hygiene treatment, is it not? If, at this first visit, you discover that the new patient does have a need for periodontal treatment, you will be able to more easily guide this individual into the exam appointment for full diagnosis of this problem. Keep in mind that patients don?t resent you doing what they want at the first visit; they appreciate it! Furthermore, they are more likely to listen to you when you recommend treatment if you have first listened to their requests.

Training for your team

To make this change may require some careful training of your hygiene team. They will have to resist the temptation to scale subgingivally on the first prophy visit. Remember, the patient asked for a cleaning (translate: prophylaxis). To scale subgingivally would be to render periodontal treatment without consent.

The hygienist needs to learn verbal skills to handle the patient with periodontal disease: OHave you noticed this infection in your gums?O

Am I arguing that doing the comprehensive exam first is bad practice? Not at all! If that works best for you, keep doing it! What I am saying is that having a new patient see the hygienist first does not mean the level of care is sacrificed or that an office is practicing mediocrity. In fact, seeing the patient in hygiene first can be a way to enhance both the quality and comprehensiveness of care and increase practice profits. I am also saying that dogmas do not work in our favor.

Too often, dogmatic rigidity in the way we do things prevents us from serving the people who need our services. Let?s realize that excellence in patient care grows out of the integrity of the dentist, not from his or her blind adherence to a particular dogma. Real quality dentists have the grasp of treatment principles that allow them to alter their format to fit the individual patient.They also have the integrity to ensure that every patient receives their best care.

For more information about this article, contact the author at (207) 839-2655.

The initial hygiene visit

In my practice, the initial visit with the hygienist includes a full six-point periodontal exam. With sufficient explanation before and during the probing, the patient invariably becomes aware of his or her condition. If the patient has disease, the discussion that follows informs him or her of the potential seriousness of leaving it untreated. That`s when we assure this patient that we will be able to recommend appropriate treatment.

I want the new patient`s first appointment experience to be like a massage or manicure. It should be a luxurious break from the day`s chores to be with happy, friendly people who pamper this person while he or she receive a needed service that feels good and makes him or her look better. Who can create this experience better than a skilled hygienist?

Into this setting walks the dentist. His first encounter is not as the sterile clinician, but as the friendly, caring proprietor of a state-of-the-art health-care establishment. No longer does the first visit follow a telephone confrontation where the patient was talked out of what he or she asked for.

After being introduced and meeting the patient, the dentist will explain that the next visit - unless there is an urgent need for treatment - will be to look over the entire mouth in detail, to report on what he sees, good or bad, and then to discuss a plan for anything he and the patient decide together will need to be done. Then the dentist asks, "How does that sound?" New patients says yes to the exam almost 100 percent of the time.

The dentist determines what X-rays will be necessary for the exam, which can be taken at this visit, with the patient`s permission. Again, patients almost always say yes to the X-rays. They say yes because they already have consented to the exam and the X-rays are a necessary part of that exam. The dentist also determines the diagnostic procedures and time needed for the exam visit. Now every patient can have the exact amount of time his or her exam deserves, with little risk of a waste of precious time. If there are obstacles to treatment, the hygienist has had a chance to uncover them and to get a feel for what that patient really wants from the dental team.

Now the dentist can go into the exam having already met the patient and reviewed the X-rays, knowing the level of complexity of the dentistry needed and, most importantly, knowing something about the patient`s emotional needs, communication style, and potential obstacles to treatment. New patients go into the exam feeling more at ease with the people they will be with, feeling heard and understood and, therefore, more trusting than if they weren`t able to get what they asked for. As a result of this, case acceptance goes up and wasted time goes down.

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