Difficult conversations: When medical conditions threaten dental hygiene production, patients will be thankful

Jan. 9, 2018
Susan Quan, RDH, understand the pressure of dental hygiene production. But she also knows poor health can intervene with appointments, and patients appreciate the fact that more than teeth are saved.

By Susan L. Quan, RDH, MBA

“I’m just here for a cleaning today, right?”

Hearing these words makes most hygienists cringe on any given day. This implied triviality can be made more uncomfortable when there is a circumstance that would necessitate the clinician to postpone the appointment, such as a medical contraindication.

Dental hygienists have been conditioned to think that breaking appointments has disastrous impacts for the dental practice: lost production, broken schedule, downtime, guilt of sending a patient away, etc. Such fears can often lead to compromising our standard of practice in the interest of production and keeping the peace in the office. Pressure to see the patient can lead to compromised care and even greater health risks.

In some cases, patients can become upset. To some, breaking their appointment is too disruptive to their daily schedule. To others, they were really counting on having “better looking teeth” that day. Others may feel that their medical conditions are related to their overall health—therefore, of no concern to the dental hygiene appointment.

How do we handle such an uncomfortable situation that produces the best outcome for everyone in the practice?

With the growing knowledge bank about the relationship between oral and systemic health, dental hygienists must consider their role as one of a patient’s overall health-care team. As such, they are in the position to save lives with basic auxiliary services such as blood pressure screenings. Additionally, the dental hygienist must consider their training and practice with enough authority to make best clinical decisions, even when unpopular.

This article discusses the strategies to be establishing your dental hygiene practice without fear that your job is in jeopardy, as well as, more importantly, be of greater value to your patients and the practice in which you work.

Stroke prevention more important than clean teeth

Two recent situations that necessitated the postponement of patients’ periodontal maintenance appointments illustrate the importance of this point. In the first, a 60-year-old female presented for overdue dental hygiene therapy with extremely high blood pressure. Review of her medical history revealed recent bouts of fatigue, shortness of breath, dizziness in recent months, and pale appearance.

In addition, her husband also reported recent, incoherent conversations at home. This information prompted a phone call to the patient’s physician, resulting in an immediate transport to the nearest hospital. Needless to say, this patient’s overdue dental hygiene recall appointment was postponed, even though she said she “really needed her teeth cleaned” and had come such a long distance for it.


Suggested reading:Dental professional update: Blood pressure guidelines changed


I told the patient that her risk for a stroke far outweighed her dental hygiene needs at this time, and that having clean teeth would be of no benefit if she had a stroke. She eventually agreed and was taken to the nearest hospital.

A follow-up phone call to this patient three weeks later revealed that she indeed experienced multiple mini-strokes that necessitated immediate medical attention. The patient’s husband expressed extreme gratitude for my insistence on addressing her medical symptoms, since she resisted his pleas to see a doctor. Although our practice did not “get production” from breaking her appointment, her life was saved instead.

A command decision needed to be made

In another case, a 47-year-old patient presented for his recall appointment and revealed in his medical history review that he was scheduled for upcoming, work-related spinal surgery in two weeks. His surgeon required that he have his oral health checked beforehand. Upon taking his blood pressure, it was found to be 180/130.

Since it was early in the morning, and the patient just had his morning coffee, the higher reading was attributed to the caffeine and a stressful morning commute to his appointment. Two subsequent readings showed even higher readings. This patient also shared that his general physician also found higher blood pressure readings in the last few months and had some degree of concern, but only suggested lifestyle changes to address his condition.

After a thorough discussion regarding the increased risks of having a sustained high blood pressure, stroke risk, and possible complications for his upcoming back surgery, the patient agreed that it was best to inform his physician of these findings and of his upcoming surgery. After a chairside call to his general physician, the patient was advised to go immediately to the emergency room. His physician had no idea of the upcoming surgery, and the patient did not realize that his blood pressure and upcoming surgery could be related.

Once the patient was educated about the significance of these findings, he agreed to seek immediate medical care. His periodontal maintenance appointment was postponed, as was his back surgery. Doing so greatly reduced his risk of an adverse outcome. The patient was extremely appreciative that his risks were recognized and addressed when he was only expecting to have his teeth cleaned. A few days after being put on high blood pressure medication, the patient called our office to thanks us for looking out for more than just his teeth.

The DH’s command decisions regarding the direction of care for both patients likely averted negative outcomes. Unfortunately, and all too often, we are pressured to proceed with appointments despite of the contraindications for fear of the earlier stated concerns.

However, having these difficult conversations that result in short-term production loss will have greater value in the long run. Patients appreciate the education and care that extends beyond the mouth. When patients recognize this, they are more likely to remain loyal to your practice and even refer loved ones knowing that they will be in excellent oral and systemic care.

Production vs. health care

But how do we overcome these conflicting interests? How do we get past the job-related fears? How do we help the rest of the practice understand the significance of these situations when they arise?

The first priority is to have the backing of the dentist, and that can be established during the interview process. A two-way interview allows each of you to learn about the other. Clinical staff who hold aligned values minimizes potential tension and means that there will be continuity of care for patients. While it is important to discuss the usual labor contract issues, I highly recommend discussing vision, values, and protocols.

Be clear about your standard of practice and your decision-making process. This is also the time to ask how your potential employer handles difficult situations. Doing so minimizes misunderstandings and fosters a collaborative relationship between providers. Furthermore, this establishes you as a skilled associate responsible for the complete preventive care of their patient base. An established dental hygienist can play a big role in creating such an environment that fosters understanding how important it is to be a complete clinician.

Once established as an equally contributing colleague, it is our responsibility to seek opportunities to educate your office staff on various aspects of the practice. One strategy can include leading staff meetings on a variety of dental hygiene topics that would be pertinent to the rest of the practice such as health history review, oral-systemic links, oral care products, etc. This can be arranged beforehand with the office manager and incorporated into the regular business activities of the practice. Opportunities to lead workshops also establishes the dental hygienist as a provider, educator, and well-rounded clinician.

Breaking a patient’s dental hygiene appointment is an uncomfortable situation for everyone in the practice. There is tremendous pressure to keep the production on the books. However, a dental practice that invests the time to align values will have a much easier time dealing with this when an occasion arises. As a clinician, it is our responsibility to act with due diligence in delivering best-practice care to the patient.

As a contributing provider to the practice, it is also our responsibility to create value for the practice. Creating an environment in which all staff members understand where you are coming from can go far in doing so. In the cases of medical contraindication discussed above, both patients were at risk for very bad outcomes if their high blood pressure conditions were not promptly addressed.

Best clinical practice required these two patients seek immediate medical care. However, the value creation came fourfold:

  • The newly educated patients led to confidence in our care, which lends itself to loyalty to our practice
  • This can lead to internal referrals of friends and loved ones
  • Satisfied patients are likely to give favorable social media reviews, which builds a great Internet reputation, and can lead to external referrals
  • Taking the time to invest in aligning office staff helps to establish your role as a contributing and established clinician.

All of these results will result in increasing production down the road, which creates great value for the practice.

Susan L. Quan, RDH, MBA has been a private-practice dental hygienist for 27 years and is currently the Director of Oral Wellness Department at Ueno Center, a large-scale periodontal practice in Campbell, CA, that is bridging the gap between dentistry and medicine. Susan is also a member of the American Academy for Oral Systemic Health.