Written by Michael D. Goldstein, DDS, FAGD Tuesday, 22 March 2011 20:07
Michael D. Goldstein, DDS, FAGD
It’s impossible to pick up a journal or attend a dental seminar without being exposed to a host of ideas about how to “predictably” improve your efficiency and increase your income. Upgrading to the latest laser technology, learning efficient endo or implant techniques, and becoming a recognized cosmetic dentistry expert are just a few of the techniques often discussed. One seldom-mentioned subject is the periodic oral evaluation (0120), often called the recall or recare exam.
Think about it. If a dentist works 200 days per year with one dental hygienist who averages caring for eight recall patients per day, that dentist will perform 1,600 recall examinations per year. With two dental hygienists, that works out to 3,200… you get the idea. If it were possible to trim just four-minutes from each examination, a dentist working with one dental hygienist could potentially save 106.66 hours per year, or the equivalent of 13.33 eight-hour workdays. Since an average dentist’s time at chairside is worth $300 + per hour, I calculate a potential savings of at least $32,000 per year. Of course, if a dentist has more than one dental hygienist working with him or her, the savings would be greater. All that extra income for just making a few strategic changes to the way the recall examination is conducted. And as an extra bonus, the recall examination will be stress-free.
With appropriate training of your dental team members, it’s possible to make all recall examinations go smoothly, efficiently and stress-free. The key to successfully achieving these goals is to educate the dental hygienist on providing clear communication about the patient once the dentist enters the operatory. The dentist should not have to flip through a chart or “click” through a computer file to obtain information about the patient or the services provided during the appointment. Additionally, the dental hygienist should enable the dentist to view the most current radiographs immediately upon entering the operatory, either on a view box or a computer monitor. Below is a guide for the sequence of the examination process:
- Address family and personal issues first. The hygienist can begin the communication by addressing personal matters concerning the patient to the dentist. For example, “Dr. Jones, Mary’s daughter, Lucy, just had her first child…”
- Address the patient’s health status and blood pressure. Since the patient’s medical health is an important priority, we verbally acknowledge any changes that have occurred with the patient’s medical status since the previous visit. We also acknowledge when there have been no changes to the health history. Additionally, the patient’s blood pressure reading is communicated at this time.
- Inform the dentist about the patient’s radiographs. If radiographs were taken during the appointment, the hygienist should point out, “As you requested, we’ve updated Mary’s full-mouth x-ray today.”
- All x-rays are taken under the direction of the dentist, so if the policy of the office is to update the panorex every three years, then the dentist did request it. The dentist should always review new radiographs while the patient is observing.
- Special Tip: Inform the doctor, out loud, when x-rays are not necessary. I also recommend that when the patient is not due for new x-rays, the hygienist loudly proclaims, “Mary was caught up on her x-rays, so none were taken today…” Too many times, from the patient’s perspective, it appears that dentists are constantly taking x-rays. By hearing this announcement at least once per year, patients should no longer have this perception.
- Announce all clinical procedures performed on the patient during the appointment. The dental hygienist should announce every service that he or she performed or discussed with the patient during the appointment. The dentist should not have to consult the computer or the chart to discover this information.
- Point out all dental problems noted during the cleaning. A dental hygienist who spends 40 to 60 minutes, or more, with a patient, cleaning and polishing every surface of every tooth, will sometimes take notice of conditions that a dentist may “gloss over” during the examination. As the dentist prepares to examine the patient, the hygienist should verbally acknowledge all conditions he or she noted during the clinical time with the patient.
- Special Tip: Rate the patient’s oral hygiene competency level. The dentist and the dental hygienist should designate a numerical system to categorize the patient’s oral hygiene level. For instance, a score of “10” could designate a patient that presents at the beginning of the appointment with an immaculately clean mouth. Conversely, a score of “2” may designate a patient with heavy calculus, and remnants from yesterday’s Philly cheese steak sandwich present on the lower molars.
- Years ago, before instituting this system in my own office, I remember an instance when I examined a teenager whose mouth looked quite healthy. Not realizing that my hygienist had just politely reprimanded this patient about her poor oral hygiene, I proceeded to praise her for doing a great job taking care of her teeth. After all, by the time I arrived into the operatory, this patient’s teeth were beautifully clean, and there was no evidence of chronic perio problems. Now, if I hear that the patient’s “O.H. Index” is “4,” before I begin my exam, I know that regardless of what her mouth looks like now, my job is to reinforce my dental hygienist by trying to motivate this patient to do a better job with her homecare.
- Announce your clinical findings during the examination. I’ve found that there’s no better way to get a patient’s undivided attention than by talking about him or her to someone else. As you examine the patient’s mouth, call out your findings to the dental hygienist, aware that your patient will be intently listening to your every word. “The back portion of the lower right first molar has a large crack that I’m afraid will work its way into the nerve in a very short time. Make a note for us to put top priority on fixing this tooth right away, in order to prevent a serious nerve problem.”
- Along with communicating problem areas discovered during the examination, I recommend that the dentist call out all normal findings as well. For instance, “The lips, cheeks, and frenum are normal. The palate and oral pharynx are fine. Occlusion, TMJ, gingival, tongue…” You get the idea. Your patient must know that you’re performing an oral cancer screening, TMJ screening, periodontal examination, and all the other valuable services you provide during this “periodic evaluation.”
- Document the results of your examination. A wonderful tool to educate a patient about the value and thoroughness of their recall examination is to use a document to record the findings of your examination. I designed an “Oral Diagnosis Form” to be completed at each recall visit. The form is a tool to record all the systems that are being examined and all conditions that warrant close follow-up or further treatment (please call or e-mail Dr. Goldstein to receive a copy of this form). Most of the time, there will be check marks on the majority of the items on the form, as most areas will appear normal. Detailed comments may be provided for the items that require additional explanation—for example, a note about the patient’s need to floss more frequently, or the importance of having tooth number 12 crowned before if fractures. The Oral Diagnosis Form can now become a part of the patient’s record until the next recall visit. As a bonus, the form can be photocopied and given to the patient to serve as a motivation tool. Finally, the form can also serve as a reference for any staff member to consult when communicating with a patient about a future recall appointment.
- Special Tip: Decide on the time required and services to be provided at the patient’s next recall visit. I have a pet peeve about the way some offices schedule their recall appointments. Many offices schedule a full 50 or 60 minutes for every recall patient visit. Think about how inefficient that is. Too many times I’ve seen a patient with a full-dentition and significant calculus given the same amount of time for his appointment as a patient with an upper denture and six lower anterior teeth retaining a lower partial denture.
- The key to efficiently scheduling the next recall visit is having the dentist and dental hygienist decide together, during the current recall visit, what will be performed at the next appointment and how long the next visit should take. A patient requiring a full-mouth series and a fluoride treatment during today’s visit will certainly not require the same time allotment the next time, when only a prophy and examination will be performed.
You might want to consider holding a staff meeting to discuss each of the items mentioned in this article. Once the dental hygienist assumes the role of “emcee” and facilitator during the recall examination, you will see your practice efficiency dramatically increase. Use these tips to save valuable time and enjoy stress-free hygiene recall exams.