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Prediagnostic Skills for Hygienists

Traditionally, hygienists identify and treat periodontal disease, provide preventive care instructions, and administer chemotherapeutic agents such as fluoride, locally administered antibiotics, and other antimicrobial agents. However, the role of hygienists is now expanding to include identification and enrollment of restorative needs. With the aid of technology such as intraoral cameras and digital radiographs, patients and hygienists can work together to identify needed treatment and pre-frame the doctor’s diagnostic exam. The keys to success are identifying patient actual and perceived needs, communicating and clarifying the need back to the patient, and understanding how to present necessary treatment and the various payment options available.

What does this patient need? Before you read further, take a moment to look at Figure 1 and make a few notes regarding your perception of patient needs.
Did you reply “Replace filling on No. 13”? Or perhaps expand that to replace all leaking amalgams?
Progressive clinicians look at images like these and ask, “What does the mandibular dentition look like? I wonder what the bone support looks like on radiographs. What is causing the anterior wear?” Adopting a thought process that stems from curiosity opens up many possibilities for care. Let’s take a closer look at Figures 2 to 5.
With 4 simple photographs, it becomes apparent that this patient needs more than “filling replacement.” One underlying factor in this patient’s disease is occlusion. Here’s what I see when I look at these images:

  • loss of vertical dimension
  • uneven anterior wear
  • crowded anteriors
  • inadequate canine rise
  • abfractions
  • traumatic occlusion
  • bulbous tissue
  • high dental IQ—considerable investment in previous dentistry

Figure 1. Pretreatment view of maxillary arch.

Figure 2. Pretreatment smile.
Figure 3. Pretreatment, retracted view. Figure 4. Pretreatment, side view.
Figure 5. Pretreatment, mandibular arch. Figures 6. Treatment completed.

In order to provide comprehensive treatment plans, there must be a commitment to identifying underlying factors and a willingness to share these findings with the patient. We often evaluate patient needs based on available insurance coverage. This is a great formula for doing one crown per year. The downside to this type of treatment is that it may not rectify the underlying cause of the broken fillings and bulbous tissue.
What does this mean to the hygienist? In the prediagnostic stage of evaluation, hygienists are required to gather information that will facilitate a complete examination by the doctor. Expanding our education to include restorative needs supports the examination process and provides insight into periodontal health.
Systematically evaluating patients’ needs must include identification of infections (both periodontal disease and decay), function, and aesthetics. Technology affords a variety of tools for this type of comprehensive evaluation. Use your current protocols, such as visual examination, radiographs, and photography, in unique ways. For example, when evaluating the temporomandibular joint, listen for clicking and popping; also look for wear facets, group function, and signs of traumatic occlusion. Radiographs, particularly digital, are the cornerstone of diagnostics. Read each film 4 times, representing specific clinical areas within dentistry.
First, read them from the standpoint of periodontics, then endodontics, oral and maxillofacial surgery, and restorative dentistry. When utilizing an intraoral camera, provide the patient with a laser pointer and ask them to point to anything on the screen they find unusual. Freshening your examination protocol to provide a more interactive experience for the patient will instantly boost enrollment.

A picture is worth a thousand words. This rings true when discussing treatment needs with patients. A primary barrier to care is patient perception of need. Most dental diseases do not hurt, are not urgent, and can be postponed if needed. Creating a compelling reason for action can be a difficult task. Gaining patient buy-in of his or her disease must be the goal.
Utilize digital photographs or intraoral cameras to convey the message. With either method of photography, it is helpful to have full-arch images and photographs of the patient’s natural and retracted smiles. These 4 photos will tell the story.
Walter Haley once said, “If you want to sell, ask don’t tell.” Once the images are on the monitor, start asking questions. This is the time to create curiosity for the patient. Appearing to be the “expert” too soon in the communication process will defeat the enrollment process. Here are some great questions you can use:

  • These are your upper teeth. Tell me what you see.
  • What do you notice about your smile in this picture?
  • I see the gums are red and puffy. Have you noticed this?
  • You have several crowns. Why did you need these?
  • If we could do one thing for you, what would it be?

Asking open-ended questions encourages people to see their oral health in an entirely new light. You will often get comments such as these:

  • I think the black fillings are ugly.
  • My front teeth are crooked and have always bothered me.
  • That puffy area must be where my gums are bleeding.
  • I wish I could have a prettier smile.

Make note of what the patient sees and the comments made. This will help you feed back his or her concerns during the presentation. Simply state to the patient, “Bob, if I’ve heard you correctly, you’d like to replace the black fillings with a strong material that looks nicer, and you are concerned with the way you are wearing the teeth. Do I have this right?” (Pause.) “Is there anything I’ve missed?” Asking open-ended questions keeps the conversation moving and allows the patient to participate actively.

Now that you and the patient have identified his or her highest priorities and possible treatment needs, you must follow through with support to remove all obstacles to care. The primary factors that delay treatment are time, money, and fear, not necessarily in that order. Many clinicians mistakenly think that “finances” is a conversation to be had after the patient leaves the operatory. It has been my experience that with every treatment plan presented, two questions will arise in the patient’s mind: “Can I afford this?” and “Do I trust this office (doctor) to deliver care?”
Progressive offices realize that the cost of dentistry often exceeds the ability to pay in full at the time of service. It is helpful to become familiar with financial options so that you can open a dialog regarding the investment. Partnering with a lending institution to create a dental credit line will massively improve enrollment.
The hygienist plays a critical role in easing patients’ tension regarding finances and quality of care. These topics typically arise naturally with patients. Having a ready response to common questions positions you as the patient’s advocate and helps him or her to focus on clinical needs. When patients ask the clinical team, “Will my insurance cover this?” or “This sounds expensive,” be prepared to respond: “Nine out of 10 times our business office can help you find a way to work this into your budget. Assuming we can work this out, what other questions about your needs can I answer?” This type of response refocuses the conversation to the treatment plan and keeps the dialog open and nondefensive.
The second question in patients’ minds is, “Is this the right office (doctor) to deliver care?” This offers you the opportunity to praise your doctor. Use key words such as trust, gentle, conservative, and progressive. Share any continuing education, advanced degrees, and honors your team has achieved. This is the time to shine and provide social proof for the quality care provided.

Maintaining career vitality means constantly stretching boundaries and exploring new territory. Incorporating prediagnostic skills to aid in the doctor’s proper diagnosis of decay, traumatic occlusion, periodontal disease, and aesthetic options greatly enhances career satisfaction.
So how did the case we’ve been studying turn out? See for yourself. Comprehensive care has delivered beautiful, long-lasting results (Figure 6).

The author thanks Dr. Jim Ed Watson for the photographic contributions and the beautiful dentistry he provides patients in Jackson, Miss.

Ms. McManus is a business development leader, international lecturer, and author of FUNdamentals of Outstanding Teams. She can be reached at (888) 347-4785 or This email address is being protected from spambots. You need JavaScript enabled to view it..

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