Point / Counterpoint: How to stop your hygiene department’s inefficiency – today! Scott Perkins, DDS
Director Research & Development
Simple Dental

There is a lot controversy surrounding the merit and profitability of hygiene departments. Many of our colleagues will flat out tell you that hygiene is not profitable and they wish they could do away with prophys and focus on predictable and profitable procedures such as fillings, crowns and root canals.

Years ago, I was convinced my hygienists could see a new patient in one hour. I gave them a list of what I wanted accomplished, then I closely monitored them. Sadly, even my best hygienist did not complete everything. “Why can’t you simply perform a good prophy in an hour?” I asked them. “We don’t have time,” they replied. “Why that’s preposterous!” I exclaimed. “One hour is more than enough time!”

Convinced my hygienists were wasting time, I marched to the front desk and told my appointment book secretary to put the next new patient on my book. “I’m going to show these hygienists how it's done! They’re sandbagging on me!” was my thought.

When the new patient arrived, I began the exam. I was determined to show my hygienists how to accomplish everything and still have time to spare in a one-hour appointment. My expectations for a ‘quality’ exam included numerous questions concerning the patients health, an oral cancer exam and taking the patient's blood pressure-a value added service I believe sets my practice apart from others. I wanted my new patient to be so impressed with the thoroughness of the exam, I would maintain him/her as a patient and get plenty of referrals.

I had my assistant read off my checklist and I systematically completed all the phases of the exam. I continued down the list and by the time the hour was up, not only was I far from finished, I was exhausted from the pace!

With a sense of defeat and humility I called for my hygienists. “You were right,” I confessed, “An hour is not enough time.” “We told you so,” one of them replied. I told them to go back to scheduling an hour and half for new patient exams.

For days afterward, I analyzed every aspect of the components of my patient exam checklist as well as the delivery of the prophy itself.

Back in the saddle
I started doing as many prophys as possible. I got to know patients, many of whom had been in my practice for years that I barely knew. The first thing I do at the beginning of every prophy is pull out a piece of floss, hand it to the patient and ask them if they would mind showing me how they hold their floss. I swear not one in ten knows how to do it.

I also perform an oral cancer check on all my patients during their hygiene exam. If we don’t perform this exam, who will? I consider it a duty and I don’t resent the task.

How long should a prophy take?
How long a prophy takes, really depends on what modules you are going to perform.

Let’s say you have a recall patient and they’re due for a complete perio exam, Pano and BW. In addition, you are going to review their medical history, take their blood pressure, perform an oral cancer exam and check for decay with a KaVo Diagnodent. Next, you’ll palpate their TMJ and muscles of mastication, review their oral hygiene, check over their existing restorations, see how their NG is fitting, clean their teeth with moderate amounts of stain and calculus and listen to their concerns about a particular tooth that’s been hurting them.

During the exam, you discover some decay and notice the patient hasn’t moved forward on some treatment that you will need to discuss in detail. Perhaps the patient has become a candidate for perio SRP. In addition, you may want to shoot some digital photographs and show the patient their plaque on a slide with phase contrast microscopy. After doing all this, you’ll want to discuss prognosis with and without treatment. Perhaps you also will have to explain the differences in gold crowns, porcelain-fused-to-metal crowns and all-porcelain crowns. Don’t forget the fluoride treatment and writing the chart and finally giving the patient a bag with a toothbrush and floss in it.

So, how long do you suppose it would take to perform all of these things? Obviously, an exam of this caliber could not be consistently completed in an hour. The length of a prophy appointment is dependent on the number of “modules” you wish to perform. Each operation may be thought of as a module. Each module has an average amount of time.

Efficiency by Classification
It’s important to assess the difficulty of the prophy (this is notwithstanding perio disease). Here is my classification system:

Type I: None to slight accretions.
Type II: Moderate accretions.
Type III: Advanced tenacious accretions.

The next step is to communicate to the patient they will need more time if they are classified as a Type II or III. After getting tired of repeating this information over and over, I had a custom video animation created to do this task extremely well in a short amount of time. All I do is double click on the accretions icon and a succinct but effective animation plays on my computer. It even shows the scaler scraping the accretions off. It’s a hi-tech, cutting-edge hi-res, 3-D animation. After the animation, I say, “The advanced amount of build-up on your teeth will require some additional care.” I then inform them that most insurance companies refuse coverage for proper and adequate treatment. They have a financial incentive to keep as much of your premium as they can. I then ask, “How would you like to be treated?” and let the patient decide.

After the appointment is over, I prefer to place Type II and III patients on a more frequent recall. I tell them, “Since recall appointments are predictable, and your company has a flex plan, the government will help pay for your extra cleanings next year. All you have to do is take the estimate of your co-payment to your human resources person or benefits coordinator and they will budget the cost for you.” This is a great strategy. Once the patient has put aside the money, they must use it or lose it. From a patient care standpoint, this helps insure compliance and the patient is better served. Patients benefit because they are getting the amount of time they really need for proper care, the scaling is less traumatic and besides that, the government will pay for a significant percentage of it.

Besides, it’s also in my best interest to encourage frequent recalls. The accretions have less time to build up and become tenaciously attached making the prophy much easier on the hygienist and the office is remunerated fairly.

Performing the most efficient prophy
Now, onto the prophy itself. I must tell you that I learned a lot by doing prophys. The patients were a bit surprised, but I had a bit of fun with their reaction telling them, “Don’t worry, I watched a video on performing cleanings this morning, I feel quite confident that I can do this.”

I began by modularizing the prophy procedure into flossing, polishing, scaling and fluoride treatment. Suctioning is also considered a “parallel” module and as such consumes time and is subject to gains in efficiency.

I then considered my tools; suction tip, air/water syringe, scalers, sonics, prophy angle, floss, prophy paste and fluoride. “Where is the wasted motion in a prophy?” I asked myself.

I immediately noticed using hand scalers is a pain in the neck. If there's very much plaque, you have to go in and out of the mouth while you dig into a pile of muddy plaque. In and out…in and out…repeatedly! Multiple repetitive motions are a red flag of inefficiency to me. Not only is hand scaling inefficient, plaque, blood and chips of calculus on a piece of gauze, is downright gross.

The manipulation of the edge of an instrument against the curve of a tooth requires a great deal of effort and dexterity. If there was very much calculus that was difficult to remove, I found myself occasionally catching a little gingiva with my scaler. Patients think this is a lot bigger deal than you do. You feel like it is a natural consequence of having your teeth scaled and as such a very forgiveable slip. Your patients, on the other hand, may not take it so lightly. They may feel assaulted.

I needed a way to perform scaling more efficiently and effortlessly with more comfort for the patient.

Sonics
I found the answer lies in sonics. Sonics are, in a word, wonderful! They require less fine motor control. In and out motions are eliminated and there is no bloody, plaque covered, calculus chip infested gauze to deal with. Sonics are much more efficient and less traumatic than scalers and they produce a water spray that floods the mouth and washes away debris and accretions where they are suctioned away. Sonics cut the scaling time in half! That’s a significant time savings.

After studying sonics and their efficiency, I ordered enough tips to insure that we could go all day long without running out of sonics. Life is way too short to clean teeth with hand scalers. That would be like using hand files to perform endo.

You will come across some patients who can't tolerate the use of sonics. These patients have severe dentinal sensitivity. I have found these patients are actually suffering from acid exposure. They need to be assessed with a questionnaire which may or may not reveal the most likely etiology because 20% of refluxers are silent. These patients should be referred to a gastroenterologist and prescribed fluoride to be delivered in fluoride carriers.

I like to give sensitive patients an ibuprophen/Tylenol combo to decrease their sensitivity. I find this mix to be as potent as hydrocodone. This will keep you from torturing your patients when using sonics.

For a free copy of my questionnaire that helps determine the etiology of acid erosion, visit SimpleDental.com.

I still go over the teeth with handscalers, but I have little work left to do after I first use the sonic.

Dealing with the Sound of Sonics
Keep some high-end headphones around with good ear muffs. Bose makes a nice noise reduction set. Plug these into an MP3 player that uses flash memory. Keep 4 or 5 flash cards labeled by genre and let the patient listen to music while you use your sonic. You want your patient to have as pleasant and caring experience as possible and be focused on the music they enjoy so you can do a thorough cleaning.

By the way, make sure you always use full coverage ear protection when using sonics. You will lose your high frequency hearing if you don't!

The wasted time in suctioning
Suctioning is one of the greatest time wasters in the prophy process! Having to handle a suction tip and an instrument like a sonic at the same time requires a lot of effort and it takes time for the patient to close their lips around the suction tip. Some patients get addicted to it. Have you ever had a patient who latched onto your suction tip and didn’t let go? It may be great fun for them but it’s running up valuable time. How about when your suction tip accidentally breaks loose and drops to the ground? I find myself looking around for a jar of alcohol sponges–that always seems to have disappeared–and finally just get up to go find another suction tip. I started asking myself “Where would I put the suction tips if I were a hygienist?” While I’m searching for an answer, my patient has a mouthful of saliva, calculus chips, plaque and water. Their cheeks are bulging while they look around for help and point to their mouth and say, “MMFFF.” “Just one second, Mr. Smith, I need to find another saliva ejector.” By the way, who ever came up with the name saliva ejector anyway?

Realizing just how inefficient saliva ejectors are, I discovered the Hygoformic. Acutally, these ingenious devices have been around for years, but have been widely disregarded as a gimic. Let me tell you, they are simply fantastic! They fit against the chin, are comfortable and leave your hands free. And best of all, they eliminate those in and out motions with a saliva ejector. They even retract the tongue. Now that we use these in our office, we’re wondering how we ever overlooked such a great time-saving product.

Prophy SpeedPaks™
Maintaining inventory for prophys is difficult, in fact, I believe that inventory control is one of the most mismanaged aspects of the dental practice. Inventory is usually so screwed up in a dental practice that most offices pay approximately $20,000 per year in higher costs to local distributors. Not to mention that the stock rooms and operatories are set up so inefficiently that significant amounts of time are wasted by trying to keep stock current. I never realized this fact until I did a “rotation” of being in charge of inventory control in my own practice. I was no better than any of my employees and it was a very time-consuming and frustrating process.

To solve this problem, I developed Prophy SpeedPaks. This systemized method of inventory control is so easy and slashes the cost of supplies by 20-30%! Here are some of the ways Prophy SpeedPaks are efficient and economical:

• Less cost in inventory
• Elimination of overnight charges
• Elimination of missing items that cause a slow down in your office
• Utilize the McDonald’s Method–Use less experienced and costly labor to administer
• Fewer overstocks

Prophy SpeedPaks are like a hygiene assistant in a box. Set-up is virtually instantaneous. There are never any missing items. The Prophy SpeedPaks are stocked directly in the operatory from the box they came in and are contained in their own disposable pick bin box. Simply remove shrinkwrap and place on shelf.

Polishing Teeth
Polishing teeth is a pain in the neck. Usually saliva is stimulated and then wraps around the prophy angle and gets slung all over the place making a mess. Ever get saliva slung in your eye? How about in the patient's hair or a nicely laundered and pressed white pinpoint oxford shirt with a little bit of colored paste to go with it? It's not fun to sling saliva everywhere.

How about when you heat a patient’s teeth up with the prophy cup? Rotary cups are messy, potentially harmful to fragile free gingiva, and they can produce heat. I would often have a rotary prophy cup grab a hold of my gauze while I was attempting to wipe it and then wind around the prophy cup. I would have to stop and unwind the gauze from the prophy angle. What a fumbling hassle! It’s inefficient!

Then I discovered ‘The Twist’ by Twist2it, Inc.. Now, this is an awesome solution. It is a reciprocating prophy angle that does not produce heat, doesn’t sling saliva all over the place and is very kind to the gingiva. It’s efficient, requires less effort to use and makes doing a prophy much easier. I can honestly give ‘The Twist’ my strongest endorsement as an optimal combo of efficiency and quality in a dental product, and no I don’t get any financial reimbursement from them, I just believe in the product.

Conclusion–Long Live the Prophy
So, what have I learned from my hands-on experience? I know that prophys are not only good for my patients, they are far from a loss leader in my practice and can be in yours too.

Scott Perkins, DDS, is a solo, private care clinician who practices in downtown Houston, TX. He has authored several articles on achieving extreme efficiencies in clinical dentistry. You may reach Scott Perkins at www.scottperkinsdds.com or at 713-658-8636.

To order Prophy SpeedPaks™, videotapes or other efficiency items developed by Scott Perkins, call 800-454-5161 or order online at www.simpledental.com/.