by George Salem, DMD, FAGD
Let's face it — we all dread it. That sweet, innocent, little voice that, every 60 minutes or so, floats softly into our operatory and over our right shoulder. You know those words ... "Doctor, can you please check my hygiene patient?" Those words can wreak more havoc in our schedules and more stress on our heart muscles than a pterodactyl swooping down and dragging us by the ear into the hygiene room at the worst possible moment. Yet, the periodic oral examination, properly executed, can provide countless dental procedures to add to our schedules and dramatically enhance the efficiency and profitability of our practices. No practice is devoid of patients in need of dental treatment who present faithfully for hygiene visits, yet do not proceed with appropriate dental treatment. As the old saying goes, "There are millions of dollars of uncompleted dental treatment sitting in every dentist's file cabinet."
The goal of an effective periodic oral examination is to educate and motivate the hygiene patient to proceed with appropriate dental treatment without disrupting the dentist's and the hygienist's schedule. This is no small task when you consider that the dentist must see a hygiene patient every 60 minutes or so to carry out a thorough examination, determine the next course of treatment, and present it to the patient in a charming, confident manner. Also keep in mind that this must be completed in a minimum of time because the dentist is likely to be treating another patient at the same time. Conversely, ineffective and overly time-consuming periodic oral examinations result in the dentist destroying the ability of the hygienist to stay on time, an emotionally and/or physically stressed unattended patient in the doctor's operatory, and a dentist who operates below his or her potential due to the inability to motivate patients to proceed with treatment that will enhance their oral health.
Establish a protocol and stick to it!
The periodic oral examination deserves a careful analysis, an effective and time-efficient protocol, and a predictably positive outcome. Done correctly, it is easy to imagine all of the positive effects this would have on our practices: more patients on the path to enhanced oral health, a full schedule for the doctor, and hygienists unimpeded (or, at least, less impeded) by the doctor to stay on time. In addition, the doctor's primary patient will be left unattended in the operatory for far less time.
The first step in this protocol may surprise you. It is actually the initial oral examination that took place six months before the hygiene appointment. In a previous article, I explained the importance of carrying out the initial oral examination at a separate visit prior to any hygiene appointment. I discussed the rationale and the critical importance of an initial-examination experience that effectively and efficiently educates and motivates new patients to enhance their oral health. When the dentist adheres to this initial oral-examination protocol, the result is well-educated and highly motivated recall patients. The initial oral examination also will provide a written diagnosis of all oral pathologies and a comprehensive, written treatment plan. This makes the task of the periodic examination a veritable walk in the park for the dentist. In other words, the proper initial oral examination sets up an effective and time efficient periodic oral examination just as one falling domino inexorably knocks down the next.
The doctor's choice
We conduct periodic oral examinations on our adult patients every six months. This includes patients on a three-month recall schedule. We utilize a nonrestricted, doctor-discretion format. This means that the doctors, not the hygienists, determine the time during the hygiene appointment when the periodic oral examination will be carried out. The doctors choose a time that is convenient for them relative to the other procedures they are carrying out on their primary patients.
For example, the doctors might attend to the hygiene patient immediately after administering local anesthetic to their primary patient, or while waiting for impression material to set. This time is not chosen by the hygienists and it may occur any time after the hygiene patient is seated . If the hygienist has completed the hygiene protocol and the dentist has not yet performed the exam, she will then let the the doctor know she is finished with her part of the appointment and only the periodic oral examination remains to be done. In this case, the doctor has had the entire hygiene-appointment time available to perform the exam, yet he or she has not utilized that time. That time was squandered, and it is now up to the hygienist to dictate the appropriate time to carry out the periodic oral examination. As you have probably deduced, that time is now ... and I mean right now! At this point, the doctor must adhere to one rule: When the hygienist comes calling, the dentist must follow her back to the hygiene room and perform the periodic oral examination. No exceptions, no excuses, no kidding, doctors!
This may seem rigid, but this strategy creates a smooth, on-time hygiene department while, at the same time, nearly eliminating interruptions in the doctor's schedule.
Once the doctor enters the hygiene room, he or she should complete the following protocol for every adult patient in precisely the same fashion. First, pleasantries are exchanged while the doctor washes and dries the hands. The hygienist then brings to the attention of the dentist any changes in the patient's medical history. Next, a thorough oral-cancer screening is completed. The patient is then asked if there has been any sensitivity or discomfort since the last visit. This helps the doctor focus on specific areas that require special attention during the examination. It also helps the doctor to deliver a patient-specific presentation at the end of the examination. At this time, any sensitivities or discomforts are discussed in general terms. The specific causes and solutions to these problems will be discussed when the examination has been completed. If there are no problem areas, the doctor then asks the hygienist about the condition of the periodontium.
Trained hygienists are a must
The hygienists in our practice are trained to present an accurate, yet concise, description of the patient's periodontal health, as well as their recommendations for improved or continued periodontal health. Our hygienists are exceedingly knowledgeable and, as such, allow me to engage them in intelligent discussions of possible strategies to improve or maintain that patient's periodontal health.
Once these periodontal concerns have been addressed, it is time to examine the patient's restorative needs. At this point in the visit, I will examine the dentition for any new restorative needs, if any. If there are none, I will simply review and recommend the next treatment on the previously developed treatment plan.
If the initial oral examination was carried out properly, the chart will already contain a detailed description of completed, as well as uncompleted, restorative needs. Having this information in the chart provides several important advantages in terms of efficiency, consistency in communications, precision in our treatment recommendations, and satisfaction of medical-legal documentation requirements.
The periodic oral examination is one of the most frequent procedures performed in any dental practice. In our practice, we conduct nearly 3,000 of these procedures in one year. Three-thousand effective periodic oral examinations will result in a tremendous number of dental procedures. By the same token, three thousand ineffective and inefficient periodic oral examinations will result in vast amounts of wasted time and an unmotivated patient pool. As such, the effectiveness of this exam is second only to the initial oral examination in determining the success of any dental practice. Invest the time to develop and fine-tune this critical area of your practice, and both you and your patients will reap profound rewards.
The following example illustrates the value of the periodic oral exam. Mrs. Smith has reserved a hygiene appointment at 8 a.m. on Tuesday morning. At 7:45 a.m., our daily morning meeting begins with the entire staff present. I quickly review Mrs. Smith's record, along with all of the other patients we will be seeing that day. Remember, I had previously reviewed my findings, diagnoses, and comprehensive treatment recommendations with Mrs. Smith at her initial oral examination six months earlier and documented them in a highly organized fashion in her record.
After reviewing her record, I announce to the staff that Mrs. Smith's next preplanned procedure is four crowns in the lower right quadrant. That is all that I have to say about Mrs. Smith in the morning meeting. The hygienist treating Mrs. Smith now knows that during the hygiene appointment, she will be discussing with the patient the importance of properly restoring the lower right quadrant with crowns, as I had previously recommended. Furthermore, our front-desk staff will calculate Mrs. Smith's insurance coverage and co-payments and present these figures to her at check-out. Most importantly, I will be mentally prepared for Mrs. Smith's periodic oral examination before I even walk into the hygiene room. I will know exactly what I am going to recommend, the rationale for recommending it, and how I am going to present it. This allows me to deliver a thorough, patient-specific and well-choreographed examination in a time-efficient manner. With this complete, I bid Mrs. Smith farewell and return to my primary patient.
If all has gone as planned, Mrs. Smith will make her appointment for her crowns on her way out, and she will be informed of her financial obligations by our well-prepared front-desk staff. You can imagine the professional and competent image our front-desk staff members project when they are capable of presenting the patient's next treatment, the time needed, and the estimated copayment at check-out. This preplanned approach reduces check-out time considerably and helps prevent bottlenecks in patient flow.