a successful hygiene practice must reflect the office’s overall mission statement. In our office, patients understand that we are driven by the latest diagnostics and preventative services available in dentistry in order to keep their teeth until their 85th birthday (which relates to 92 years old in true lifespan of the teeth). Can we accomplish this in every patient? The answer is absolutely not, but as you read through this you will quickly understand the reasoning for our approach.
In our practice, adult appointments (we are an adult-focused general practice and, yes, we see kids) are designated at one-hour intervals for either prophy and or periodontal maintenance appointments. In this one hour, our hygienists follow specific guidelines in which they perform medical and dental history reviews, undertake appropriate and patient-specific diagnostic testing, follow oral hygiene customized protocols, have adequate time for relationship building, and have discussions based on clinical findings. Included in this hour is also instrumentation, along with examinations that include oral cancer screening, occlusion review, periodontal assessment, and caries risk. The hour simply flies buy. During those appointments, instrumentation takes 20 to 25 minutes, and if a patient requires more time for this, they are reappointed for “active therapy.” All of our hygienists are laser certified and must utilize both loupes and lights for their patient care.
Diagnostic testing can include the following:
• Fluorescence (CamX Spectra Caries Detection Aid, Air Techniques) for smooth and fissure demineralization evaluation and continued monitoring
• Transillumination (CariVu, DEXIS) for evaluating nonrestored Class II surfaces in the contact zone. This can allow greater surveillance of demineralization changes (versus 2-D) in these areas, along with evaluating recurrent decay around existing Class I restorations. This system can provide enhanced imaging of cracks and craze lines.
• 2-D x-rays continue to be an invaluable technology for a plethora of indications.
• Oral cancer screening with palpation, visualization, and Velscope (LED Apteryx)
• Cone beam computed tomography (CBCT) has become our mainstay in replacing panorex images along with replacing the full mouth series of x-rays (FMXs).
These services are all covered in our in-office plan. CBCTs, like previous full mouth series, receive a 13% discount via credit cards or 15% check or cash.
Diagnostically, we have changed protocol, with far fewer 2-D x-rays and far more transillumination and fluorescence in our patients under 18 and our lower caries risk patients. The literature continues to move our practice into these directions based on the accuracy of these tests versus traditional explorers and 2-D x-rays for nonrestored teeth. For our practice, we no longer take FMXs as our CBCT technology by Prexion offers far more information and less radiation—yes, less radiation! In our practice, we take rapid CBCT scans instead of panorex images for our younger patients when evaluating third molars or tooth eruption sequences because, again, these offer far more information than a traditional 2-D panorex.
These technologies all fit into our format of diagnostically driven dentistry. For example, prior to any sealant being delivered (in our practice, Ultradent’s UltraSeal XT Plus and UltraSeal XT Hydro, or Premier Dental’s BioCoat), we mandate fluorescent testing to verify noncarious fissures. With transillumination we can evaluate Class II nonrestored surfaces far better than traditional 2-D imaging, and with such we can offer our patients far more clarity in their continued care. For example, in a patient with early enamel breakdown, we can utilize Icon from DMG to infiltrate and seal these early lesions and follow them year by year accurately with CariVu. For older patients, we can monitor demineralization change, and often if we see little changes year by year, we simply continue to monitor. If we see changes, then we take a restorative approach. Equally, we can monitor craze lines and understand far more when we use systems, because viewing cracks is far more optimized with transillumination.
Diagnostics can also occur in other formats. Two examples come from GC America. The first is their latest plaque test, called GC Tri Plaque ID Gel. The hygienist simply applies the product directly onto the plaque areas. After rinsing, one can evaluate if the patient has new plaque (which becomes pink in color), old plaque (which becomes dark blue and shows where patients need to focus home care), and acidogenic plaque (which appears light blue and equates to high caries risk). Yes—all in a gel! The second test we have used for years is GC America’s Saliva-Check Buffer kit. Again, it is a must-have in evaluating our patients in regards to saliva health and caries risk.
At this point, we are often 25 minutes into the appointment, and now comes the instrumentation aspect. For our 4910s, we routinely complement our instrumentation with lasers. One of our favorite lasers in our practice is Ultradent’s Gemini, which offers complimentary dual wavelengths of 810 and 980, allowing us the benefits of both. During the above appointments, the single-use laser tips are nonactivated (simple decontamination), and for our four certified hygienists, this procedure has become extremely valuable in our long-term maintenance appointments of our 4910 patients. Our fee of $49 is added onto our normal 4910 fee, and the results continually are better than similar treatment without laser therapy. As an aside, for active therapy appointments, our hygienists utilize the single-use activated tips, which allows them to remove inflamed tissue during their s/p appointments.
As our appointment now approaches its final 10 to 15 minutes, the hygienist often has to customize the patient’s care to include varnishes (e.g., Voco’s Profluorid Varnish or Ultradent’s Enamelast) and this is a mandatory protocol in our high-risk patients. Generally, these include the majority of our geriatric patients, who are caries prone and/or xerostomic, and our orthodontic patients, because of significant white spot reduction when applied during orthodontic treatment.
Customized home care recommendations often revolve around brushing, flossing, and Waterpiks. In our office, we utilize Proctor & Gamble’s Test Drive routinely to teach patients the best techniques in brushing to minimize plaque and subsequent issues. This has become essential, again, in our geriatric patients, and we often now are teaching caregivers how to brush their client’s teeth! With such, we sell gloves to these care providers every visit.
The hygienist often advises our patients on specific toothpastes that may be better suited for their own clinical situations. In our high-risk caries patients, these can include Enamelon gel and paste from Premier Dental and GC America’s new MI Paste. These additionally work very well with sensitivity for patients who have not had success with other potassium nitrate formulations. These complement remineralization products that are digitally applied, such as Remin Pro from Voco, and, again, all customized for our patients. Today’s fluoride trays we have renamed “remineralization trays,” and they are still very much in vogue in our practice. Today we can digitally scan these patients and have our labs create these trays or, in the very near future, 3-D print models in our offices and simply utilize our Drufomat from Dentsply to custom fabricate such trays.
Another very beneficial procedure in our office that is hygiene driven is Perio Protect. Over the past four years, we have implemented Perio Protect to redefine our long-term approach for treating our periodontal refractory patients, along with many other indications. These customized, gasket-sealed trays allow us to deliver 1.7% hydrogen peroxide up to depths of 9 mm for 10 to 15 minutes. We all know gram-negative anaerobic bacteria are amongst our enemies within the pocket, and as you treat these complex biofilms in your office with hygiene/laser therapy, the best way to maintain them is to have your patients actively manage their pockets/biofilms with this oxygen-releasing daily therapy. The hygienist often initiates the discussion reqarding Perio Protect. This is then followed with an appointment with the dental assistant, who scans or impresses the patient, and subsequently delivers these trays two to three weeks later. This oversimplifies this product, but it’s an absolute must-have and an incredible compliment in our high risk periodontal maintenance patients, who are in all of our practices.
A few final inclusions about customization would have to include our pre- and postrinses for our high risk medically compromised patients. We begin each appointment with a prerinse of OraCare from Dentist Select. This activated chlorine dioxide is truly different than any other chlorine dioxides on the market and works against bacteria, viruses, and fungi. As a further preventative measure, we have the patient do a postrinse prior to leaving the office.
In this one-hour appointment, the dental hygienist must guide and instruct the patient via intraoral cameras and software. Currently we use quality intraoral cameras and Guru animations. Later this year, Smart Mirror, a new company to the dental industry, will be launching the next game-changer technology. Imagine an illuminated, fogless mirror with an embedded video microchip camera in a 1 mm slot in in the middle of the mirror that allows live imaging of what you’re looking at through onto an iPad or monitor in your operatory! Clinically, you will be able to view your procedures at an entirely different level, but as an educational tool, the boundaries are unlimited. Add a voice-activated technology in the handle of the mirror for voice dictation (yes, periodontal charting), and you have the beginnings of the next game changer in dentistry.
Lastly—and there is so much more I could discuss—analytics have become a mainstream word in our profession. Today we understand KPIs (key performance indicators) and numbers that truly help guide our success. One such KPI is the hygiene reappointment percentage, and in our office it is our goal to have 90% of our patients reschedule their hygiene appointments before they leave. Other KPIs can track hygiene treatment-plan acceptance, hygiene productivity, varnish applications, and far more. We also use these analytics daily in our morning huddles to track patients who have unfulfilled restorative treatment and patients due in for hygiene who are scheduled that day for restorative work. These analytics are offered by many quality companies, but as an office that uses Weave daily for enhanced patient communication, we feel their launch of analytics will greatly complement their current platform. The beauty is we can see which patients every morning we need to contact and then the simplicity is to just click their names and immediately see the options to text, email, or call these patients, and with such, Weave continues to be a seamless must-have technology in our office.
Yes, the one-hour hygiene appointment has come a long way. Gone are the days of simply scraping, an explorer, a mirror, a probe, and a 2-D x-ray. Thanks goodness! As you implement new technologies into your office along with new protocols and pathways, your hygiene department will continue to expand your practice. Hygienists today have become one the most essential components to sharing the “why” of the practice and guiding your office forward.
LOU GRAHAM, DDS, is an internationally recognized lecturer extensively involved in continuing education for dental professionals. He is the founder of the Catapult Group, a continuing education company whose philosophy and programs use interactive formats to integrate time-proven conservative dentistry with 21st century materials and techniques. Dr. Graham enjoys providing dental care at his multispecialty private practice group, University Dental Professionals, in Chicago, Illinois.
