Confessions of the Dental Team- Patient Personalities

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If you’ve been in dentistry for more than 10 minutes, you know the different types of patients and how they get you off schedule and exhaust every ounce of your patience. Most patients are awesome, and you enjoy their visits, but lighten up for a minute and identify these “special” patients:

  1. Talkative Tammy- Talkative Tammy is usually very nice and compliant with homecare. However, she never stops talking the entire time she’s in the office. She even talks with instruments in her mouth, and if anyone else enters the operatory while she’s there, she’ll talk with them for thirty minutes. You barely get her teeth cleaned and she leaves you so out of sorts and off-schedule that you don’t know which way is up!
  2. High Maintenance Mary- High maintenance Mary is the patient who, when you look at her chart, has an entire page listing her dislikes and preferences. Some of her necessities include rinsing with mouthwash before and after the procedure, no lying back, earphones, covering her eyes, no power scaling or x-rays, applying lip balm throughout the procedure, etc. The list is truly endless, and so are her demands. High maintenance Mary is an extremely particular patient who makes you see double while trying to keep a smile on your face!
  3. Grumpy George- Grumpy George is a tough nut to crack. He’s always mad about everything. If kept waiting even 1 minute past his appointment, he loses his mind. He never answers questions because he merely grunts, and he won’t be pleased with any treatment you provide. When George leaves, you need some soothing tea and encouragement.
  4. Always Late Larry- Always late Larry is usually quite pleasant, but always significantly late. He phones 10 minutes after his appointed time and says he’s “5 minutes away”. There is no such thing as 5 minutes away in dentistry. Five minutes is always at least twenty. He’s good at the game too. Even when you put on his appointment card that his appointment is at 3:30 when it’s really at 4 pm, he arrives at 4:30. Always late Larry leaves you exasperated and off schedule.
  5. Disorganized Debbie- Disorganized Debbie forgets everything. Often, she’s forgotten that she has an appointment. If she remembers her appointment, she’ll run into the office in the nick of time looking like she just leaped out of bed. She’s probably forgotten to premed and hasn’t brushed her teeth. She digs through her purse the entire appointment looking for something or stays on her phone talking and texting. She must also visit the restroom before and after the appointment. Disorganized Debbie is a human tornado leaving you in her wake and shaking your head.

While not an exhaustive list, all offices have their classifications. Seminars dealing with difficult patients can’t even touch these cases. Fortunately, there usually aren’t too many in each practice, and these patients make us appreciate the great ones even more.

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Tetracycline staining and bleaching - is it effective?

bleaching

Tetracycline staining is the most difficult intrinsic stain to treat with bleaching because it’s very tenacious and results vary. Following are some guidelines to achieve optimal results while providing realistic expectations:

  1. Tetracycline-stained teeth take longer to bleach than unaffected teeth, and the process can take 2 to 12 months to reach optimal results.
  2. Like “normal” teeth, tetracycline-stained teeth will lighten until they reach a plateau regardless of technique or product used. They will never become “white,” but they can lighten dramatically and look very nice when compared to the initial shade.
  3. The first few days of bleaching will usually produce noticeable whitening followed by no observable change for about one month. Therefore, patience is required.
  4. 10% carbamide peroxide worn in custom trays nightly is the method of choice for bleaching tetracycline-stained teeth. Carbamide peroxide remains active for 6 to 10 hours and delivers the bleach over a longer period than hydrogen peroxide. Using a strength over 10% doesn’t change the speed of whitening measurably, but it does increase sensitivity.
  5. As with unaffected teeth, existing restorations will not change color with bleaching. Therefore, the patient must be advised that new restorations may be necessary after the bleaching process to match the new shade of their teeth.
  6. Tetracycline staining takes an extended amount of bleaching over time to achieve the desired results, so sensitivity must be considered. A low concentration of carbamide peroxide (10%) and a proper fitting tray is imperative. Potassium nitrate 5% which is found in over-the-counter desensitizing toothpaste is very helpful in managing sensitivity. The patient can brush with the desensitizing paste and/or wear it in the bleaching trays for 15 minutes daily to treat and prevent sensitivity.
  7. The patient must be made aware of the reality of bleaching tetracycline-stained Treatment takes longer, there is an ongoing cost, and the results vary.
  8. Many practitioners and patients choose the “single arch treatment” approach treating one arch at a time. Most patients prefer to begin with the upper arch. This plan can be more cost effective for the patient, and it also serves as a great motivator when comparing the bleaching arch to the untreated arch. Furthermore,  sensitivity is reduced, wearing one tray versus two is easier on the TMJ, and it’s more comfortable for the patient.
  9. Bleaching is recommended before any other treatment such as veneer placement because the shadow of tetracycline-staining can show through veneers. Sometimes, after the bleaching is complete, the patient is satisfied with the results and decides against veneers.
  10. The bleaching process may have to be repeated over the years. It’s difficult to predict, but many patients do have to repeat the bleaching process after five It may or may not take as long with subsequent sessions.
  11. As with all bleaching, the cervical third of the tooth is the most difficult to whiten, and the blue-gray staining is more difficult to whiten than the yellow-brown

Bleaching tetracycline-stained teeth aren’t impossible, but it takes time, dedication, and patience to achieve the best results. The cost is far more than bleaching “normal” teeth, but it’s not ridiculously expensive. As long as the patient is realistic and compliant, it can be very beneficial and life-changing.

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Foods to Avoid While Wearing Oral Appliances

braces

Oral appliances include braces, space maintainers, retainers, overbite correction appliances, expanders, and devices to help cease oral habits. They are used to correct, treat, or prevent conditions related to the upper and lower jaw, teeth, and tissues. Some of these devices are cemented on the teeth, and some are removable. If an appliance is removable, it’s best to remove it while eating. The appliances are durable, but they do have to be treated with care to be successful in treatment. Therefore, many foods should be avoided during treatment to keep them in working order and efficient.

Ice- Chewing ice is very detrimental and can destroy appliances, and even ice with a softer consistency isn’t safe to chew. Ice can bend wires, break or loosen brackets, and damage palatal expanders, overbite correction appliances, and retainers.

Hard food - Hard pretzels, tortilla chips, jerky, pizza crust, uncooked carrots, and nuts can bend wires, break rubber bands, break brackets and tubes, and loosen cement holding the appliance(s) in place.

Hard Candy- Hard candy can stick to the appliance(s) and coat the teeth in sugar for prolonged periods. If chewed, it can break or loosen brackets, loosen cement, bend or break wires, damage tubes, and retainers.

Sticky candy- Gummies, caramels, taffy and any other candy of this sort can bend wires, loosen cement, break or loosen brackets, and destroy retainers. These candies also surround the teeth with sugar for an extended amount of time.

Foods with a high sugar content- Although these foods don’t need to be avoided altogether, cookies, cakes, puddings, and other desserts can linger around the appliance(s) constantly coating the teeth with sugar. It’s best to rinse with water after consuming sweet treats and limit consumption.

Foods high in starch- Starchy foods such as pasta, potatoes, bread, popcorn, and cereals are hard to remove from oral appliances because they are sticky when consumed. They get embedded in the appliance(s) and constantly saturate the teeth with sugar. Popcorn kernels also break, bend, and damage mechanisms.

Suckers and sour candies- Suckers are terrible for teeth with or without appliances. They last for far too long and attack the teeth with sugar byproducts. They are detrimental to oral appliances because they stick to devices and can cause damage. Sour candies are also horrible for teeth, tissue, and oral devices because they are acidic and can cause deterioration of the teeth.

Gum- Gum seems harmless, but it can cause a dental apparatus to malfunction. It sticks to everything and gets intertwined with the appliance(s) and can become a place for plaque to hide. Also, gum can bend wires.

Wearing an oral device is usually for a limited time and although inconvenient, avoiding these foods is a must. It only takes one piece of candy or food to break or damage the appliance and many orthodontics charge fees for fixing or replacing the device. Eating these foods and candies can become expensive and delay treatment. Once the appliance(s) is removed, you can celebrate in moderation with “forbidden foods.”

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Assisted Dental Hygiene

whitening

Assisted hygiene refers to a schedule in which a hygienist operates out of two operatories and sees patients every 30 minutes with the help of a designated assistant. The assistant stays with the hygienist the entire day, and the two switch off between operatories treating patients. The hygienist performs therapeutic scaling, irrigates periodontal pockets, measures gingival and periodontal health and disease (pocketing, recession, bleeding points, and exudate), removes plaque, calculus, and stains, applies antimicrobial agents, provides patient education, and administers other treatment deemed necessary. The assistant seats patients, updates medical histories, takes x-rays, polishes teeth, makes recare appointments, applies fluoride, dismisses patients, and performs other duties within the scope of state law.  Many practices operate successfully on an assisted hygiene schedule, but before transitioning, explore why the change may benefit your practice.

First, assisted hygiene shouldn’t be used to offset missed or last-minute cancellations. Holes in the hygiene schedule are usually due to problems with patient management. When patients begin de-valuing your services by missing appointments, it’s time to reevaluate how easy it is for them to reschedule. Never be dishonest with patients, but allowing multiple choices after they repeatedly cancel or no-show sets the stage for more of this behavior. There are valid reasons patients miss appointments, but with a chronic offender, it’s best to limit choices for rescheduling. Also, make staying on schedule a priority and don’t make a habit of keeping patients waiting. If patients are kept waiting on a continuous basis, they will no longer respect your time because you’re failing to respect their time.

Second, evaluate your patient base. Many generational practices have patients who have been with them for fifty years or more. It may be very difficult to transition from the hygienist spending the entire appointment with the patient to the appointment being split between the hygienist and an assistant. It’s not impossible, but tradition plays a role in this scenario, and certain patients will expect an explanation as to why there’s a new appointment protocol. Patients are accustomed to spending time with an assistant while seeing the dentist, but many don’t expect to see an assistant during their prophylaxis.

Third, are you incorporating assisted hygiene to increase hygiene production? Using assisted hygiene to help increase production while practicing as a DMO can be tricky. It’s very difficult to make a decent profit while participating in reduced fees programs. However, increasing production by incorporating a soft tissue management program and stressing more frequent recalls for patients with certain conditions can benefit from assisted hygiene. Also keep in mind that converting to assisted hygiene means that a dedicated assistant for the hygienist is imperative, and more instruments and supplies will be necessary.

The most important part of whether assisted hygiene will work in your practice depends on the hygienist and the assistant. Is the hygienist willing and capable of handling such a schedule? Will there be an assistant who is dedicated to the hygienist? A hygiene assistant is different than a dental assistant. The hygiene assistant can’t be “borrowed” to assist the doctor because this type of schedule is extremely tight, and getting off schedule is disastrous. As long as you’re honest with yourself and adopt assisted hygiene for the right reasons, it can be beneficial for your practice.

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Filing Medical Insurance in a Dental Office

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Has your dental practice ever filed a medical claim? While not a common occurrence in dentistry, there are instances where filing a dental claim on a patient's medical insurance is permissible. Furthermore, filing medical insurance can be very helpful to the patient and profitable for your office.

Procedures that may be covered include:

  • exams/consultations
  • Sleep Apnea appliances
  • TMD devices
  • Appliances used in breaking habits- e., thumb sucking
  • Orthodontic appliances
  • Some surgical procedures
  • Periodontal surgery
  • Bone and tissue grafts
  • Some implant surgeries
  • Traumatic injury cases
  • Biopsies
  • Interim prosthesis during trauma cases or after radiation or chemotherapy
  • Final prosthesis after trauma
  • Crowns, bridges, and other removable and fixed prosthesis following cancer treatment

Filing a medical claim is nothing like filing a dental claim, and even the most skilled insurance coordinator will have much to learn. There are many seminars on processing medical claims live and online. Your dental rep should be able to locate these resources for you. Basically, four steps are crucial to getting the claim paid quickly.

Step one is ensuring that the dentist is properly credentialed. This credential is granted through the Council for Affordable Quality Healthcare (CAQH) and isn’t the same as being a participating provider in a medical insurance company’s network.

Step two is filing the claims electronically. Paper claims aren’t permitted which usually isn’t a problem since most offices file electronically anyway.

Step three is obtaining preauthorization before proceeding with treatment. In dentistry, preauthorizations can be time-consuming and inaccurate. However, with medical insurance, preauthorizations are often required. There are clearinghouses portals online that make preauthorizations quicker and less of a headache.

Step four is using the proper format. Delivery of treatment won’t change, but chart notes and reporting information in the patient’s electronic records will have to be in the correct format. In addition, clinical notes are legal documents and must be written by the doctor and no other team members.

The entire dental team should be on board with this process. Although it will be a bit of a learning curve, mastering the art of filing medical claims successfully in the dental office will be beneficial to your patients and your practice.

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