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Improve Restorative Treatment Acceptance

July 1, 2004
Before the stage door opens and the theater curtain rises, proper preparations will help make the production a success.

Before the stage door opens and the theater curtain rises, proper preparations will help make the production a success. The actress has memorized her lines and should be at ease with the flow of the play. The director has rehearsed with the performers and prompted them during the rehearsal. The stage crew has methodically placed props in their places and cued the sound for the production. Just as a play is rehearsed before a performance, the hygienist sets the stage for your restorative treatment acceptance time and time again.

Restorative case acceptance is cued by the hygiene department. As hygienists, we spend prime time with patients as a captive audience during their recare visits. We discuss product recommendations, bring cosmetic options to the forefront, and address urgent needs to place the patient's dental health center stage. When your intention is to increase restorative case acceptance from the hygiene platform, it makes sense for the players to recite from the same script.

Take your places

Case acceptance is a rehearsed process with the hygienist being the first to enter the staging area. During the initial look-see, the hygienist spots areas of concern that necessitate further evaluation, treatment planning, and repair. For example, a tooth with an aged amalgam has a leaking margin with vertical craze lines. This upper molar has presented itself time after time in recare visits, but today the restoration is nearing the final act. The hygienist has a prime opportunity to discuss the patient's weakening restoration and cast the tooth's treatment needs. First, address the issue honestly with the patient and voice your concern about the tooth's current presentation. Open margins spell trouble. Discuss with the patient how bacteria and decay are burrowing around this alloy and deteriorating the strength of the tooth. The integrity of the older restoration is at risk with the fracturing craze lines. Clarify for the patient that the amalgam filling does not flex and just sits unbonded in the tooth acting as a wedge. Explain that every time the patient chews, this wedge is activated and causes the remaining tooth structure to weaken. The potential for irreparable tooth fracture is great. Once the hygienist and doctor have assessed the situation and voiced their concerns (in layman's terms) to the patient, the performers are ready to move into the second act.

To have awesome case acceptance, the hygienist must believe that the doctor does some of the best cosmetic work she has ever seen, or case acceptance will be a moral compromise playing on her hygiene integrity. Substandard treatment can lead to poor margins and unhealthy tissue with maintenance issues, leading to periodontal breakdown. Displeased patients with shoddy restorations are not about to recommend a repeat performance for their friends. Being confident with the doctor's work is a must for conscientious hygienists. Doctors, you may not be getting standing ovations from your hygienists if they are anxious about your restorations or unfamiliar with the procedures you perform. Address these issues upfront. Invite your hygienists to watch you perform.

Hygienists are being underutilized if they are expected to come to work and then promptly jailed within the limited confines of their hygiene "cell." Please allow your hygienists to grace the presence of the other actors in the restorative performance and move freely throughout the building. I personally enjoy "visiting" the restorative side and seeing the patients I performed periodontal therapies on complete their care with firm tissues in a blood-free zone. Touching base with patients during their restorative visit shows seamless care between the hygienist and the doctor. I often ask patients how the recommended fluoride we dispensed is working and if they need refills while they are in the office. Playing off each other, my doctor states that the tissues are healthy and in prime condition for the cosmetic work she is providing. This reinforces the hygiene care we provide. I then go on to tell the patient that the new restoration will improve periodontal success and allow the tissues to snuggle up to a margin without an overhang. When the doctor and hygienist follow the same script, the patient becomes the star.

When the hygienist is confident and comfortable with cosmetic recommendations, the practice will prosper from elective care. Invite your hygienist to observe (even assist) a large restorative case as well as simple fillings. Cosmetic materials are constantly improving, so your hygienist needs to be on the same page with you. If your hygienist has not visited your restorative backstage area lately, you may be embarrassed by the critical esthetic knowledge she lacks. As a former dental assistant, I appreciate the advances in materials and techniques and am continually amazed by the products that have evolved — hybrid nanocomposites with complex shades, indirect resin techniques using in-office CEREC units and self-etch primers and bond, impression materials with syringe automix delivery systems ... WOW! I share these material upgrades with hygiene patients to set the stage for the cosmetic construction they will have at the next dental visit.

In the hygiene operatory, the CAESY educational DVD system can assist with treatment recommendations. The convenience of the CAESY system, viewed on patient overhead video monitors, allows for regular use. Not only does CAESY cover hygiene topics thoroughly, the restorative topics are formatted for easy understanding as well. By programming your custom links (My Links), you can specify that a unique sequence be played. For instance, I have perio, pedo, and recare links set up for the hygiene topics I select to be viewed. This way, the treatment I deliver on a daily basis can run on the screen in my chosen order.

Do not underestimate the starring role of the hygienist's smile in case acceptance. Has your hygienist ever asked you about doing restorative work in her own mouth? Doing those porcelain veneers, whitening teeth, using Invisalign straightening trays, or addressing even simple cosmetic concerns could be the push your hygienist needs toward recommending additional care. Showcasing your hygienist's smile is an investment you will reap the rewards from by having your hygienist shouting accolades about your treatment. Patients constantly ask me, "Are those your real teeth?" I say, "Yes, they are, and let me tell you about the possibilities for whitening your teeth or bonding veneers to improve upon your smile!" This cosmetic conversation is a daily occurrence. Recommending treatment can begin with Crest Whitestrips® and lead into a smile zone complete with laminate veneers — or both!

When the stage is set and the goal is to increase case acceptance, the hygienist should be front and center. As a primary educator for your returning patients, it makes sense that treatment options would be initially scripted and cued from the hygiene area. Confidently show your esthetic cases to your hygienist by inviting her to see what you do and then extend smile-enhancing procedures free to her. Use current educational systems to augment treatment discussions. When the roles are cast and acted upon, your office will elevate treatment acceptance, merit a standing ovation, and enjoy many curtain calls.

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Karen Kaiser, RDH
Ms. Kaiser has been in the dental field since 1986. She graduated from St. Louis, Mo., Forest Park hygiene program in 1994 and practices in Illinois at the Center for Contemporary Dentistry. Ms. Kaiser authors articles, presents, and can be reached at At Your Fingertips: [email protected].