Annelise Rich
Guide for the new Hygienist
View the complete Guide in Microsoft Word here.
What I didn’t learn in school Questions & Answers to common problems entry-level hygienists face
Most new dental hygienists entering into the working field have one thing in common-we all feel a little inadequate! To better prepare for the “real world” and be more open to new options as a newbie travels through the transition from student to professional, I decided that it would be helpful to know what “seasoned” dental hygienists think about what advice and experience they wished they would have had entering the workforce after graduation.
While researching the best way to accomplish what might be most useful, there was a world of in-depth question and answers found online in professional dental hygiene forums. There are many of them available on different websites. Some of the most helpful forums were:
· www.hygienetown.com
· www.dimentionsofdentalhygiene.com
· www.andyfuturerdh.com
· www.amyrdh.com
It is always good to remember as Joan Gonzales put it, “Your education doesn’t stop with your degree, but merely provides an excellent foundation in becoming an excellent hygienist!” Experienced hygienists such as Joan were asked the question, “What are three things you wished you would have learned in school?” The top responses that were continually repeated are going to be the focus of this guide. They are:
· Efficiency
· Communication
· Being an employee
Hopefully the little tidbits included will help to ease some of the inadequacy felt. If you are still left wanting though join a dental hygiene forum. Ask questions for yourself and read what others have posted. It will be immensely helpful to research these forums and see what others have gone through on their way to becoming a true professional.
-Annelise Rich
Efficiency
Time efficiency is always one of the biggest worry facing a new hygienist. Coming from three hour appointments to one hour or sometimes less obviously presents a problem. Know that all hygienists have faced this problem, and below are words of advice and tips on how to help become more time efficient without compromising your patient care.
· Try giving yourself the opportunity to work as a temp for a good while. It is nerve-wracking at first, but it can help gain confidence and help you learn how to work more efficiently. It will also allow you to figure out what type of office you would like to work in. Just try to stay organized best you can.
· Arrive at the office 30 minutes prior to your first patient. Review your charts, perform as much prep work as possible, and be ready for your day before your first patient arrives.
· Speed comes with experience and a routine. Once you have a routine established you will get up to speed. The idea is that you have to talk and work. If you do things the same way all of the time (example take bwx first, go over medical history, etc.) then you will naturally become faster. You won't have to think about things so much they will just come naturally. Also use disclosing solution, slap that sucker on, hand the patient a mirror. While you are cleaning all of the plaque and tarter off let the patient be looking in a hand mirror to see where they have missed and what they need to work on more. Also if you explore first and find the areas that need the most attention to begin with, then this can really make things move along faster as well. There are ways to cut corners without compromising a person’s dental care. You will find your own niche it just takes a little time to get there.
· If there is a lot of soft debris polish first, so you can see what you are doing. You can also disclose, do patient education and then polish. Start polishing on the mandible before the mouth fills up with saliva and some times you can get away without having to do a mid rinse and suction. Note anything special for you to remember for the next hygiene visit. Speed comes with practice, but try not to loose the personal touch. Let each patient know they are special.
· One time saver that helped our assistants was in the set-ups. Even though the instruments are in a cassette and bagged, we all use many extra things on the bracket table or tray with each patient. We found that we could create a packet by opening the bib in a specific way and inside stuff the pieces of gauze, floss, saliva ejector, HVE, surgical suction, air/water syringes, plastic syringe sleeve covers and whatever else you may put on your tray. Then the bib was folded over in such a way that it was all enclosed inside and not exposed to the air. This way when they needed to set up the room for the next patient, they grabbed one of these preset "packets" and one cassette from the sterilizing room and everything was there that we needed for the treatment room. This saved the time of having to open and close several drawers to grab all those extra things we need during the appointment.
· The way that you chart can also help save you time. This is an example of hygiene notes on a recall established patient:
Exam , 4 BW, Dr......, medical Hx update.............., BP , Pulse, OCE=all areas normal Viziltie= clear. Cavitron, scale, probe=WNL, no BOP, tissue pink, healthy, polish, Fluoride tx. Rev OHI, Demo bass, flossing, demo and dispensed sulcabrush, rec Listerine 2x day/ Act nightly.
Plaque light @ gingiva 1/3rd. Advised pt they need to IP clean. Dr. discussed replacing #2 with implant. Ref to OS to have all 3rd molars ext.–The use of abbreviations will help save time too.
Communication
Communication is the key to patient compliance. The advice given in this section is extensive and includes scripts and many examples for different topics. The different topics have been divided into general, overcoming objections, periodontitis and oral health education.
General
· The key elements are when effectively communicating with your patient are:
Diagnosis. Know your patient.
Listen to the patients concerns, needs and wants.
A shared treatment plan after all the reasonable choices have been understood.
A concerned follow-up and continual reappraisal of the treatment choice.
Always offer a choice for a second opinion to the patient if either of you are not happy with the results.
· Speaking to a patient about what they want, and listening to what they want- that is the first step to working with the patient. This may help to change the dynamics around from telling a person, to working with a person. You ask a patient what they want for their mouth--clean, white smile, fresh breath, they have then given you the opportunity to explain that the cleaning that they want may not accomplish all that they want, but different treatment might.
Overcoming objections
This section features information from www.andyfuturerdh.com and his advice on word phrases. He offers tips on what to use and what not to use when being faced with patients who are objecting to your recommendations.
Wrong response: "Okay, but can I just tell you something first? I think its best because..."
Why it's wrong: First, never start with the word "okay". Saying "okay" is what is called a positive negative. It reinforces their objection and makes it seem that you are agreeing with them and are on their side of the field. It's basically saying, yes you're right. Next, you shouldn't ask questions that leave time for a response. By asking "can I just tell you something first?" This is an open ended question and puts control of the situation back into their hands, especially if you leave a pause after asking your question for them to respond.
You want to be assertive enough in the situation to be the one in control. That doesn't mean you shouldn't breathe in between sentences, but that does mean you should not breathe long enough to let them object again. Also, there are several words you should never use under any circumstance. The word "think" sounds unsure. You are an educated professional. At this point you shouldn't be "thinking", you should be "knowing". Substitute it by saying "I know its best." You should also avoid saying "because". Because was never a good answer for your momma when you were a child, and it's still not a good answer now. Because also implies that you are an authority. It reminds me of my mom telling me "Because I'm your mother and that's why". You should also never use the words; but, because, okay, since, can't, won't in your transitions.
What helps the most is what is called an "I transition". It is a statement starting with "I" followed by a sympathetic word that acknowledged you heard them, understood them and didn't ignore what they said. Including the patients name also is a great attention grabber and draws attention to what you are saying from that point forward. It's similar to falling asleep in your community dental health class. If the teacher yells out "Jill!” you are more prone to waking up, paying more attention, etc.
Here are some examples,
"I understand where you are coming from Mrs. Smith and let me..."
"I appreciate that Mrs. Jones, and ...."
"I can understand that Mrs. Smith, and my last patient said the same thing, however they didn't realize that..."
Correct Response: I understand, Mrs. Smith, and let me remind you that treating your periodontal disease really is the correct thing to do. We need to...."
Let's analyze what we just said. First we related our self to our patient and acknowledged that we did hear them by saying "I understand". Next we used the patient’s name. That signals them to listen right before we started explaining what "needs" to be done and why we are correct without making them feel wrong. Remember, in my opinion one of the main things to accomplish when overcoming and objection is to not make the patient feel as if they are not being listened to, yet at the same time assertively showing why you are correct in your response. Don't make the patient feel wrong, but rather misinformed. It's our goal to present the facts to the patient and hope they chose the right decision.”
Also, avoid what I call are "filler" words. Filler words are "uh, um, you know, like, eh, hmm, etc." These are all words that people generally use when they don't have anything better to say, or are fishing for words to use. They all show insecurity and unprofessionalism, not to mention people who use them a lot sound very uneducated.”
(www.andyfuturerdh.com/newgrad/overcomingobjections.htm)
· Here are some questions that Andy from www.andyfuturerdh.com suggests that you be prepared for.
1. I just want what insurance will pay for; can't you just do a regular free cleaning?
2. Maybe I can get that type of cleaning one day, but all I can afford right now is what insurance pays for. Can't we just do that in the future if I still need it then?
3. How can I have periodontal disease? I don't even feel any pain.
4. I can't need that type of treatment. I floss all the time and brush all two times a day.
5. I went to the dentist every six months my entire life and my last dentist never said anything about it. Why are you telling me I have periodontal disease now and they never mentioned it?
6. My gums always bleed. No matter what I do, they still bleed. I don't think they are in bad shape since they've always been that way. I also take aspirin, so that's probably why they are bleeding. Just do a regular free cleaning.
7. I don't floss, but I use Listerine. They said it helps that gingivitis stuff right? Why do I still have gum disease when I use Listerine?
8. I don't have money right now. Can't you just clean some of the teeth a little bit? Maybe flick that stuff off down under my tongue? I'll say its okay if anyone asks.
9. My dentist/hygienist has never said that to me before and it's only been 6 months since my last visit. Why didn't they say anything to me about this?
Periodontitis
S. Cottingham, a consultant for dental hygienists, offers her scripts that she uses in helping her patients understand periodontal disease and treatment.
· She starts by explaining that she is going to be measuring a naturally existing area the tooth called a sulcus, in health it measures between 1 and 3 mm with no bleeding on probing. She tells the patient, “it is like your cuticle, when you press that area you expect a slight opening when you push on your cuticle and you do not expect to be able to go any further under the skin or get any bleeding when it is healthy.”
She then does the charting, if there are signs of periodontal disease she sits them up and says, "so what do you think about you heard?" They usually say, “I heard some big numbers and it sounds like many were bleeding-or close to that." Then some will go into saying, "of course I am going to bleed when you poke me with that thing". She responds to that comment with, "if I was to use this instrument to touch the healthy tissue on your hand do you think it would bleed?” Some say yes some say no. If they say yes she tests that theory with a clean probe. Or they may say that they have always bled their whole life, she responds, “If your hands always bleed just a little bit when you wash them would you be concerned?” They say yes, and she goes on, "you should have that same concern about your gums, because bleeding is not healthy in the mouth, it is a sign of inflammation and infection that the body is not fighting off.”
She then continues by saying, “The doctor will evaluate all of the information that I have reviewed with you and I believe that she may recommended a conservative treatment for periodontal disease called scaling and root planning. It allows us to effectively get to the base of the pockets that we looked at on the x-rays and disrupt and remove the calculus and bacteria that is causing this situation. Our goal is to get the pocket to heal from the inside/out, making this area much shallower and easier for you to maintain. We will also be coaching you with the tools that you need to be using at home to support the healing. This entire situation is a bacteria game, they are currently winning and their payoff is the destruction of your bone that holds your teeth in. We want to create an environment that bacteria do not want to be in and give you the tools to keep the bacteria numbers down so that your body can heal.”
· If she is in a new office or temping she explains that she will be checking the health of the gums. Then indicates that her charting may seem a bit different as she is going to be doing a complete charting including and loose teeth and open spaces so she can get really familiar with their situation. This way they are somewhat prepared for listening to me call off all of the deep readings and hemo (usually).
Then comes tricky part when you sit them up and ask if there has been anything extremely different going on the past year or so? She will say, “My findings are showing that there are several sites of active infection, did you hear that 6mm reading on the LR-are you having difficulty in that area??" The patient’s response here is where you have to really watch the body language and see how they are taking the news. It will either land well or they will put up all of the defensive shields. This is where you have to stay in the conversation and individually mold your education.
She educates on the bone level and then we look at the x-ray together. Then shows them the loss that they have TODAY, and how things are active TODAY, and that they need to take a step back and consider the options to treating this disease that they are presenting with TODAY. This is when she usually gets the statement, "how did this happen in 6 months." She then responds, “It didn't. This has been working up to this stage and now we are at a stage of disease that we need to get in there and treat it so we can avoid any future loss. She will then fall back on the notes from the previous hygienist saying, “Now do you remember when such and such was speaking to you about that bleeding area on the LR and that you needed to really floss and take on the oral hygiene in that area? Well what she was speaking of is periodontal disease, the attempts made to this point have been unsuccessful in controlling the disease, so let's get the doctor in here to take a look and see what they think. I believe that the doctor will most likely recommend a treatment for periodontal disease called scaling and root planning. Then she’ll dismiss herself to get the doctor and update them on the situation.
She will take time to completely review OH as well. It is a huge piece! Demonstrate hand in hand, give out the tools recommended. Communicate about the choice they are making and the results that should expect with that choice.
EXAMPLE- “I realize that flossing is a challenge and that you have not done it before and that you say you won't really do it now. I have had several patients that have felt that same way and choose not to floss and what we have found is that we usually end up having to perform SRP several times over the course of time because without that piece the disease will usually never stabilize.” Then stop. Do not say a word. Let them process the choice. They usually will sit still and then they wiggle in the chair and start asking questions like, "ok where can I get that woven floss?" "Would an electric toothbrush help?" , "But my fingers are so big I can not reach back there." Then you have an open door to really uncover what stops them and help them to conquer that.
Here is advice from other dental hygienists on the same topics.
· There will be patients who decline to seek further periodontal care and they are very clear that they only want to "maintain" until the tooth needs to be pulled.” They may say something to the effect that they just want you to keep working on them instead of someone else. Thank the patient for their trust and explain that the extent of their disease is beyond your expertise. In order for you to take the best care of them recommend that they see Dr. Perio to stabilize their active infection. If a patient does choose to "maintain", cycle them between a "hygiene team" for re-care so the patient has overlapping clinical skills from the clinicians. This approach helps because another hygienist may phrase something a little differently so the patient "gets it". It works well.”
· If they seem intimidated by the idea of having surgery. Suggest scheduling an appointment for a consultation to discuss what options they have to save their teeth. It's not to schedule surgery, merely an opportunity to have excellent second consul so THEY can make the best decision for themselves.
This next example comes from a former hygienist who is now a periodontist and his take on how to explain the disease to patients.
· “When I was a hygienist I thought that it was my job to do everything possible to keep the patient from having to go to the periodontist, because I thought it meant I had failed. How would I explain it to the patient? I'm sure many of you have had that same sinking feeling when, in reply to your recommendation to see the periodontist, the patient replies, ‘So the root planing didn't work?’ As a periodontist, I still want to help the patient avoid surgery if rationally possible. So when patients are referred to us for periodontitis we do all we can to make the patient successful with root planing and home care. And although some dentists still think of the surgery as the cure (and so they expect surgery should always be done when a patient goes to the periodontist) most hygienists know better.”
“What we do is begin explaining prior to the root planing. The first periodontal question is, ‘Ms. Jones, are you a flosser yet?’ Because if someone can't get the patient to floss (I'll accept some other interdental aids as half-measures) then we can slow the disease down with periodic recall and re-root planing every 1-5 years but we can't stop it. The patient has to understand that the plaque is the disease. And that every time they remove it, they just cured themselves. If the patient understands that they must actually ‘cure’ themselves and will accept responsibility for flossing then we can work with them to make them a winner.”
“I explain to the patient that there are two obstacles to their being able to cure themselves: 1) tartaron the root surfaces holds bacteria within it and so the patient can't remove the disease bacteria thoroughly (so root planing is essential regardless of home care) and 2) pockets are so deep that the patient can't thoroughly get the bacteria removed. So I explain to the patient, ‘if you didn't have tartar or pockets, I could just tell you to go home and cure yourself with flossing, and brushing of course, but flossing is more important (always take the opportunity to stress flossing). But since you have tartar and pockets (keep repeating those terms so they sink in) we have to get rid of those obstacles before you will be able to fully cure yourself.’”
“We start out with root planing to get rid of the tartarbecause that is a non surgical technique. We start with that, because sometimes the gums will shrink enough after root planing that some of the pockets will also be gone and then you might need less gum surgery. I wouldn’t say that this will get rid of all their pockets. I would always leave that open. Don't over-promise and you won't feel guilty later about failing to resolve all the pockets. We should concentrate on telling the patient that it usually reduces the need for surgery but doesn't always eliminate the need. But then use this as incentive for better home care. ‘Ms. Jones, the amount of reduction in the need for surgery will also depend to a large degree on how well you are cleaning after the root planing and thereafter. So you want to really start practicing your home care, particularly with the flossing.’”
“We have the patient back for re-evaluation at 4 weeks after root planing. If we wait until the first recall at 3 months their home care deteriorates. If they stay on track for the time of the root planing and a month afterwards, they have much more tendency to continue, especially if you can tell them, ‘you are really doing great on your home care Ms. Jones-- a star performer! Just keep that up and we're going to be able help you get this gum disease under control.’”
“Then you focus them where they are having difficulty. ‘Ms. Jones, you are doing great but you still have some pockets in the lower left. Let me show you how to use a rubber tip stimulator to try to get rid of those pockets too. Just keep up the good work and if you can get rid of the pockets with the flossing and rubber tip that will be great. However, if you cant' get rid of the rest of the pockets by the time of the first (next) cleaning, then it indicates a bone problem that will have to be corrected first before the pocket will go away. So, if the pockets are still there at the next recall, we will want you to see a periodontist who will likely recommend surgery to get rid of the rest of the pockets. Unfortunately, if we don't get rid of the pockets, then we will have to accept that you will likely lose those teeth. You will be able to keep the ones that don't have pockets because you can clean and cure them twice a day but wherever pockets remain the disease will continue because you won't be able to clean the gum disease bacteria our. So work hard until the next cleaning and we'll see how the pockets are at the next recall.’”
“If patient doesn’t comply then, ‘Ms. Jones, I'm going to justannotate in your chart that you don't want to see the periodontist at this time, but please keep in mind that the longer you wait the more difficult the disease is to treat. Sometimes it can advance more rapidly and eventually it can become too advanced to save the affected teeth. In fact, studies overwhelmingly show that moderate disease is treated much more predictably and effectively than advanced disease. When studies look longer term at successful outcomes of surgery it is significantly better for cases that were surgically treated in the moderate stage of disease. But always remember that flossing/interdental care is the foundation of periodontal success.’ – Help your patient remember these facts, so that they know that you really just want the best for them.”
Oral Health Education
· Use rhymes or sayings that stick in their heads. “If the proxibrush doesn’t fit…you must quit!” (Meaning don’t force it into any areas.) How about this one for those pre-teen and teenagers who "can't remember" to brush. Tell them to brush every time they change their clothes! So, they usually change into school clothes in the morning. They probably also change out of them at night. That's twice a day!!
· Also you can tell your patients the BIG secret of just trying to floss at least every-other-day. That's 3-4 times a week. I would much rather have them TRY to floss than to NEVER TRY. You will get more positive responses from patients when they realize that you know they are only human and as humans we are not all perfect.
· You will notice when disclosing everyone that A LOT of people miss #2 and #15 constantly, but their plaque levels might be light everywhere else! Tell/show them these areas and tell them it's such a simple fix to get to those two teeth. You can put your finger alongside the right posterior teeth and tell them to open wide. This shows them how the area gets really tight. It's like when you flex your bicep muscles, they get hard when flexed and opening flexes this muscle. Then have them bite down and move your finger around the buccal mucosa showing them how much more room they have to get all the way to the back. It's THE OPPOSITE OF WHAT YOU WOULD THINK to close -not open- to get to the very back teeth. It's kind of the same with the lower anterior linguals. It SHOULD be the easiest place to brush in your mouth because it's in the front, but it is actually the hardest. For this you can use a dentoform and show how a sideways toothbrush never fits no matter how hard you push. Then stand the toothbrush on its head. This lets the patient know that with simple changes like closing down or changing a toothbrush angle it can make a HUGE difference in how much plaque they can remove from their teeth!”
· Try recommending Stimudents/floss picks, etc. to patients who swear they cannot floss. Men, especially, because many of them are used to using a toothpick anyway. Explain to them how to use it properly, then tell them it is easy, because you don't have to watch yourself in the mirror you can do it watching the news, reading the paper, or on your commute to work. You will get a lot of patient compliance if they think they can get by without floss, just using a "pick."
Being an Employee
There have already been a lot of great tips for being a good employee as far as communication skills and being a team player, but there are other aspects that an employer will look for. Included in this section are parts of a power point presentation that Andy from www.andyfuturerdh.com created to help entry level hygienists be able to become indispensable to their employer.
· Things to focus on when communicating with employers are: it is important to work with a dentist who can discuss procedures with you instead of dictating them; an employer who will listen to your ideas for improving the practice and productivity of you time and their time; and someone who will trust you and respect your knowledge, yet not burden you with unrealistic expectations; and someone with the patient’s best interest in mind.
As a professional an important lesson is to approach your boss with respect and privacy, ask for a meeting, prepare yourself with topics of concern (backed with research), and discuss in a calm and civil manner the things you want to help him improve in his practice. When you open yourself up to him you may see a side of him that no one else has allowed themselves to see due to their clouded opinions based on gossip, etc. The doctor may begin to see you as an ally and not someone who is going to leave like everyone else.
· A valuable employee will be a strong team player. Say you have a cancellation or no show; your first task should be to see if DMDs or DAs need an extra set of helping hands (anesthesia, radiographs, sterilization, etc.) This is a great way to meet new patients (remember, you’re a new face) and introduce yourself, not to mention a big stress reducer for DMDs/DAs in their busy schedule. If the doc does not need help, check with the front desk about making calls or filing/pulling charts. If they are fine, THEN do your charts/stock etc. I find this also erases that prima-donna stereotype we got stuck with and creates a pleasant working environment. If I were an employer, I would want to be surrounded by enthusiastic and dynamic individuals who seek SOLUTIONS and are self-motivated.
· Remember that no two people are the same- this goes for patients, co-workers, and employers. What works for one person may not work for another. No one is really a “cookie cutter” model, so don’t expect them to be. Some employers are going to spoil you and give you everything you need. Others may not have the means to be able to do that so you may have to invest in yourself and get some of your own equipment. Find the practice that allows you to be the best hygienist you can be and keep growing. Don’t give up on communication, you will have moments or days when things are awkward, but just keep talking it out.
· This last section is a summary from a PowerPoint presentation given by Andy Cotting.
Dentists want employees with:
Sales
Marketing skills
Interested in their contribution
Able to take constructive criticism
Selling
“Selling dentistry implies that you can properly diagnose (DH diagnosis) the patient, treatment plan, present the case to the patient and gain acceptance for the plan from the patient. Selling is educating the patient to OWN their condition and accept the recommended treatment.”
Andy offered 6 steps to selling dentistry
Introduction (first impressions)
Gain attention
Create the need
Relate features to the need
(Use “before” and “after” case photos. Explain the benefits of the treatment plan and why you have chosen one procedure over another. Help the patient understand why each procedure is necessary. Then listen to the patient)
Close
(Listen to the patient- be interested instead of trying to be interesting! Be assertive and assume the patient will schedule the treatment)
Follow up
(Don’t leave your patient out on a limb let them know that you really have their best interest in mind by following up on the treatment.)
A lot of the times when the patient says no to the treatment plan it really means that it is “no” to the timing or their understanding of the problem. Relate to the patient and show empathy, help re-educate and leave it at that. They have the final decision after we do all we can do.
Marketing
Internal marketing is for existing patients. This just takes some extra work to help reactivate patients by making phone calls, recall cards or offering incentives. Always mention what needs to be done at the next appointment, so that they realize there is a need to come back.
Internal marketing can also be done by seeing if your next patient has some restorations or other unfinished treatment plan and encouraging them to schedule it or better yet if the dentist has a cancellation see if they can stay a few minutes longer and see him at the same time.
There are plenty of different ideas out there for external marketing. The biggest thing that we as hygienists can do is ask our patients for referrals “Mrs. Smith, we would really like to have more patients like you. If you know of someone in need of a dentist please give them our number.” Carry your office’s business cards and hand them out when the occasions arise.
-Andy Cotting (PowerPoint presentation form seminar for graduating dental hygienists March 2008)
Acknowledgements
Special thanks to all the wonderful hygienists that offer advice and ask questions on the many professional forums. Their comments have been immensely helpful in putting these words of advice together.
Also thanks to Andy Cotting for his wonderful website and PowerPoint presentation.
I can’t forget to thank my mentors and teachers for their guidance on this project, especially Trisha Nunn.
