It is about management and procedures around the dentist's field of work in a general practice.
In this post you will find inspiration for:
Better procedures for dental assistants
Procedures that give patients a better experience
In an attempt to keep the reference to a manageable length, I have chosen to describe only parts of a procedure.
Some time ago I had a conversation with a general dentist who had a liking for the surgical treatments. He was happy to have the opportunity to work exclusively with surgical procedures a few days a week.
While we were talking about his enjoyment of surgery, a dental assistant came and asked the dentist to answer the phone. She told us that a patient who had had an operation a few days earlier was in a lot of pain. Clearly annoyed by this interruption, the dentist went to the phone to talk to the patient and possibly find a medical solution to the problem.
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While the dentist was talking on the phone, I asked the dental assistant how often the practice had this kind of phone calls. The dental assistant told me, with a defiant attitude, that it was on a weekly basis. This puzzled me and prompted me to ask about the practice's protocol for pain control. The assistant looked at me puzzled and said she didn't know anything about that. It was the dentist who was in charge of that.
When I later asked the dentist about the procedures for pain control after surgery, he replied that it was the duty of the dental assistant to inform the patient that he could take some paracetamol if pain occurred after surgery.
This was a somewhat different procedure from the one I had worked with when I was a practise owner. So I asked if there were other measures that were used to give patients a good experience. The dentist said he had the dental assistants call the patients the day after the surgery to see if everything was OK. In addition, he did not have any procedures related to the patient experience or pain control.
Where were the challenges?
3 things caught my attention.
Lack of clarity, as a result of blind spots in the practice leadership and management.
A dentist who got overwhelmed by even small challenges.
A pain protocol that did not provide patients with a good experience.
To keep the blog post within a manageable size, I'll just stick to the patient experience, which is strongly linked to point #3: Pain protocol.
I asked why NSAID agents were not used for pain control.
Referring to the much publicity that had been given to young athletes on long term treatment with high doses of NSAID and the related heart attacks, the dentist did not think it was justifiable to use NSAIDs. He had therefore changed his approach to using only paracetamol and prescribing opioids for severe pain.
As it is more than 3 years since I stopped practicing, I don't know if there are new guidelines for the use of NSAIDs in dental practice. However, it seems to me rather extreme to do away with such a good and proven short-term medication in conjunction with surgical procedures in the oral cavity.
I would be particularly concerned about the inappropriate side effects of opioids if I were to discontinue NSAIDs. Especially in view of the risk of more opioid-dependent citizens as opioid use increases.
If I am completely wrong with my recommendations, please feel free to comment on them. Either here or on my LinkedIn page, so I can correct the post.
We all want the best for our patients
You may be thinking that what you've just read belongs in the slightly more extreme category. You may also be thinking that it's perfectly normal. Whatever you think, are thinking or are doing right now, I am sure that you, like every other dentist I know, only want the best for your patients.
In what follows, I will try to give my take on how it is possible to improve the post surgical protocol and then let you decide if anything I write could improve the patient experience in your practice.
Passive or active procedures?
In this context, it is important to consider that just because the clinic has a procedure description does not mean that the procedure will be followed by the team.
Nor is it certain that the procedure will be followed in the way the practice owner intended it to be followed, just because the procedure is documented on paper or in electronic form.
Any procedure requires thorough instruction AND subsequent training, as well as persistent focus and follow-up - until it becomes routine.
Prerequisites for recommendations
To give you the right background to read a small part of my former practice's procedure description, you should know that all members of the team worked according to the motto: "Denmark's best experience".
It was not a motto we had written, hung up in a frame and forgotten all about. Rather, it was something against which all our decisions were held. Not just in management but in the whole team. Everyone had the freedom to interpret what they thought would give the stakeholders of the practice "Denmark's best experience" in each situation.
In all our meetings, we talked about how we could be better at giving our patients "Denmark's best experience". Everyone was constantly working to improve the "Best Experience in Denmark", and we evaluated the situations in which each team member seemed to have been in a difficult situation. These situations were used to discuss what was good and what we could do better, allowing us all to learn from the difficult situations and thereby build an even stronger common direction. A stronger practice brand.
I think it's important that patients know a little bit about what they're going in for before they come into the practice. Therefore, I think that a dental assistant should have the time to sit undisturbed with the patient and go through what is going to happen the next time the patient comes to the dental office. (Patients should always know what is going to happen next and have a sense of why it is important to them)
This is done after the dentist has obtained the medical history, so that the dentist is sure what kinds of medications can be safely used before, during and after the surgery. If a prescription needs to be written for the patient, the dentist will do this.
Depending on the internal protocols of the practice, the dentist may inform the patient about the medication himself or have a dental assistant do this. Provided that the dental assistant is trained to do so. (I was fortunate that my dental assistant was a trained pharmacist with several years experience in a pharmacy. It made this part much easier for me)
The review by the dental assistant should, as a minimum, include a description of the following:
The patient should eat well before arrival, as only cold and liquid food should be consumed after the operation.
After the procedure, there may be stitches that may bother the tongue and which must be left alone. Similarly, it will be necessary to remove any sutures at a later stage.
As instructed by the dentist, the patient should be given information on what kind of medication to use after the operation. This way, patients can make sure they have the medication they need before the day of surgery. (Unless the practice arranges for the patient to leave the practice with all the necessary medication - see later)
If antibiotics need to be taken - the amount, timing and length of treatment.
In addition, I would also at this time give initial instruction in optimal hygiene after surgery.
Klinikassistenten sidder med klinikken skriftlige præ-operative instruktioner, som gennemgås mundtligt med patienten. Efter instruktionen gives udskriften af informationerne til patienten.
You may find it too much to inform patients about all this before surgery. But once the surgery is done, not many patients listen to our post-op information. Most just think about going home. (Keep in mind that patients often just want to go straight home - especially if you have planned what your patients will take with them from the practice once they have undergone surgery. More on that in a moment)
On the day of surgery:
Before the patient's arrival at the practice:
The dental assistant takes out painkillers and prepares to send any relevant prescription electronically.
The dentist performs a health and safety check. Together with the dental assistant, the dentist ensures that the correct medication is prepared.
The patient in the practice
The dental assistant brings the patient to the surgery and makes sure that it is the correct patient and the correct procedure that is prepared for. Pre-operative medication is then dispensed.
The standard (which I taught in the surgical department at Aarhus dental school 15 years ago - please comment if this has changed):
600 mg. Ibuprofen and 1g. paracetamol and possibly antibiotics. The patient rinses the mouth in chlorhexidine 0.12% or 0.2% for 1 minute (use a stopwatch!), after which, no rinsing with water is allowed.
The dentist comes in and anaesthetises the patient and prepares for the operation.
There is nothing worse, as a patient, than experiencing the challenges of managing oral chlorhexidine with a blockage of the inferior aleveolar nerve.
It may take an extra 4 minutes to do it this way. I have tried both. Both can be done in a time-optimized manner for the dentist. But from the patient's perspective (customer service), there is no doubt that the way I have described is the most pleasant.
The patient is given the usual postoperative information by a trained dental assistant. This is based on the practice's written instructions, which are also given to the patient after the operation.
Pain control (IMPORTANT!)
It was in fact this that prompted me to write this blog post.
This protocol should include taking painkillers every 4 hours (600mg ibuprofen) for the first 16 hours. After that, painkillers are taken as needed.
In this way, pain is prevented for the first 16-20 hours. If pain is not prevented during this period, the patient risks the pain becoming much more severe and much more prolonged. If severe pain develops within the first 20 hours, it will be much more difficult to control than if it is prevented. This is one of the reasons why we give painkillers before any operation.
The dental assistant tells the patient when the first pain medication was given and indicates when the next tablets should be taken over the next hours. The times are noted on the paper with the written instructions to the patient.
In addition, instruction is given in the use of chlorhexidine with reference to the patient's experience before the operation. This includes the time at which mouth irrigation should be commenced, if indicated.
The patient is instructed not to pick at the wound with the tongue, fingers, cotton buds or similar. Use compress in case of bleeding + how.
Instruction is also given on the intake of cold and liquid diet for the first 24 hours, as well as indications for diet for the following 24 hours.
The written instructions are placed in the bag that is also given to the patient.
The contents of the bag are then reviewed.
Among other things, the bag contains:
Appointment card with time for suture removal
The necessary medication so that the patient does not have to go to the pharmacy for this. It's just not a very cool experience to have to go to the pharmacy to pick up medication with a numb lower lip potentially leaking blood out of the corner of your mouth in front of all the other pharmacy customers.
Surgical toothbrush and possible swaps
Extra sterile gauze (plenty)
Extra cooling compress
A cold protein drink with the patient's favourite flavour (vanilla, strawberry, chocolate)
The paper with all the instructions given.
Then the protocol for the follow-up of the patient is followed. (Phone calls, flowers, gift cards, or whatever you can think of)
I'm sure you have some good tips
Above, I have reviewed the most basic elements of a good patient experience, related to the activities that take place during a surgical procedure.
I'm sure there are some dental practices that specialize in surgery that have additional tips and tricks they can share. If you fall into this category, I encourage you to leave a comment at the bottom of the comments section, or on our LinkedIn page. This way, more colleagues - and therefore more patients - will benefit from the knowledge you have.
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Many kind regards
Jesper Hatt DDS
Phone: +41 78 268 00 78