Best Practices: Standards of Care

First and foremost, I am a HUGE supporter of dental hygienists working to the top of their license in all aspects.  Second, I am a HUGE supporter of dentists that support dental hygienists working to the top of their license in their practices and I need to give a shout out to my docs for that privilege.  Working to the top of your license comes with a great deal of responsibility to the dental team and the dental patient – especially when treatment planning a patient.  I am also a HUGE supporter of COMPREHENSIVE treatment planning at initial patient appointments.  This blog post explores options for practices that do not immediately place new patients in the hygiene chair, rather a separate chair all their own, and practices that do not perform limited exams on new patients.

Imagine the following patient presents to your office for a new patient exam::

CC: #14, 15, 30 pain in all three; patient does not want to save the teeth that require major restorative work

PANO and FMS revealed several other teeth require RCT/CR or are broken to the gum line, interproximal decay, radiographic bone loss is present with heavy calculus, CPC revealed active periodontitis and poor home care  – COMPREHENSIVE EXAM looks like this per the DDS diagnosis and patient preference:

Ext 2,3,4,14,15,18,19,20,30 with iPUD/iPLD

OCS, NSPT w Arestin, Oral B Professional series, Fluoridex and Stannous, Zoom

Fillings 8,9,29

6 mo cast PUD/PLD

When the patient goes to consult, they have the autonomy to accept and decline whatever they want – down to the bare minimum – this is patient autonomy.  However, what happens as providers is that we forget we also have clinician autonomy – the ability to hold patients to a clinical standard to get them as healthy as possible.  As providers, we also have an obligation to our license and to protect what we have worked hard for.  I fully respect patient autonomy but I am unwilling to bend my clinician autonomy to give them what they want in place of what they need.  This includes even a bare minimum standard of care.

That leads us to the discussion on standards … It is without question that patients get their care in the following order (and I can thank my DDS for helping to reinforce this daily):

  1. Pain Management
  2. Hygiene
  3. Restorative

Let’s take a look at the case to see what this could look like in a few different treatment planning options:

OPTION 1: Patient wants only minimum treatment and was only approved for $1200 financing option

Visit 1: impressions

Visit 2: Ext 2,3,4,14,15,18,19,20,30 with iPUD/iPLD + NSPT all 4Q, irrigation all 4Q, OB

Visit 3: fillings 8,9,29

This was all done w financing option and patient financial agreement reads: treatment includes Visit 1-3 and patient will pay with financing option – treatment NOT included in financial agreement that patient will pay out of pocket for day of service or when financing option revolves –> 3 month periodontal maintenance (PMP) and perm cast PUD/PLD – patient is aware that 3MRC PMP must be completed prior to impressions for perm cast PUD/PLD

OPTION 2: This same treatment plan could also look like this:

Patient wants only minimum treatment and was only approved for $1200 financing option

Visit 1: Ext 2,3,4,14,15,18,19,20,30 + NSPT

This was all done w financing option and financial agreement reads: treatment includes extractions of teeth 2,3,4,14,15,18,19,20,30 and patient will pay with financing option – treatment NOT included in financial agreement that patient will pay out of pocket for day of service or when financing option revolves –> iPUD/iPLD, periodontal therapy with one follow up appointment and zoom, fillings 8,9,29, and 6 mo cast PUD/PLD – patient is aware that PMP must be completed prior to fillings which must be completed prior to impressions for perm cast PUD/PLD

OPTION 3: Patient does not want to use a financing option:

Visit 1: Ext 14,15,30

Financial agreement reads: treatment includes extractions for pain management with 60% down ($X.XX) to schedule and the remaining 40% ($X.XX) due day of service; patient was made aware of remaining dental needs and will call the office to schedule and review when they are ready.

These options protect the DDS and the DH from any legal issues AND they set clear expectations not only with the patient but with the rest of the team – we do not have to sway from our standards because the patient was made fully aware that we are happy to help them but we have to be respectful to our office standards of care.

The first option is ideal because it addresses all three standards while still being mindful of the patients need to remain in control and being sensitive to their financial situation.  The office will continue to produce, make the patient healthy, and create a return for services.

The second option is ideal because it allows the patient to have all necessary teeth removed at once and gives them function.  By addressing each item individually, you also gain the patient’s confidence (you listened to them!) and break down the cost of each appointment to a manageable situation.

The final option is ideal because it alleviates the patients pain.

The DDS or hygienist, in my opinion, is the most appropriate person to enter their treatment into the computer to ensure that each portion of treatment planning is done correctly per the office standard – both hygiene and restorative.  A treatment coordinator*, in my opinion, is not the appropriate person to be entering patient treatment into the computer.  However, during consultation, treatment can be moved into future work or a later phase by the treatment coordinator.  The only time treatment should be deleted is when it is no longer necessary.

Whatever your standards are in the office, it is beneficial to review them and adjust according to new standards set but ADA and ADHA.  Here is a link to ADHA Standards for Clinical DH Practice – one of my favorite resources!! http://www.adha.org/practice

I also recommend the AAP Parameters of Care; it is an excellent review for even those sage dental hygienists out there! https://www.perio.org/resources-products/clinical-scientific-papers.html

What standards does your office follow? How would you have approached the patient’s treatment plan?  Let me know in the comments!!

*See my post on T.E.A.M.

 

 

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