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Operatory in a box: servicing high-anxiety patients

April 20, 2010
Tina Calloway, CDA, tells readers how her practice employs hospital-case dentistry to perform complete restorations in one visit, helping patients achieve optimal care and easing their dental anxiety.
By Tina M. Calloway, CDAThere are several ways to treat dental patients with comfort, such as spa dentistry, intravenous sedation, Valium, and more. However, in our practice we are frequently asked about hospital-case dentistry. This is complete sedation under the watch of an anesthesiologist in an operating room, which allows a dental team to perform complete restorations in one visit. This helps our patients achieve optimal care, and it eases their dental anxiety.The apprehensive dental patientSome local dentists who know the level of care we provide have referred patients to us because we offer hospital-case dentistry. Some patients suffer from severe gagging, bulimia, gastroesophageal reflux disease (GERD), and gross decay. We recently had a new case because the person saw our dentist on the local news talking about the optimal levels of care that patients can now receive. During our morning meeting, our front desk member provided us with information on the new patient and her concerns, such as the fact that she did not want to see any pictures of her smile. The patient also informed us that during her last dental visit she felt like she was being talked down to, and she did not like the sound of the handpiece. The blossoming of a new relationshipWhen the frightened patient walked through the door, she was greeted warmly with a smile from one of our front desk members, who assured her that she was in good hands. Next, the clinical assistant greeted the patient with a smile, a handshake, and a gentle touch on the shoulder for assurance, thanking her for being with us today. The patient then walked alongside (not in front of or behind) the assistant to the consultation room, where the dentist was waiting to meet her and introduce himself. The dentist then began his research and listening skills. First, we always ask our patients questions, such as where are they from, their education, work, and family. We ask questions, making conversation the same way as if we are getting to know a new friend. This sets the tone of the practice and visit, and helps break patients’ tension. An assistant is also in the room, taking notes and listening. We find this step extremely valuable so that patients do not have to repeat the same answers to the same questions when the dentist is not in the operatory. This also allows the assistant to get to know patients and understand any of their anxiety.One question the doctor may ask is what type of sedation dentistry the patient wants. Some people are not aware of what is available to them, such as being completely asleep in a hospital room setting. This question leads to why the patient feels he/she is a candidate. There are a number of answers, but mostly we hear about severe anxiety and fear. Some people even say they have neglected their care and just don’t have the time to invest. They would like to have optimal care provided in a short period of time while being completely under sedation.Our new patient said she stayed away from dentistry because of fear and a bad experience as a child. She also shared that she is embarrassed by her smile and frightened of needles. Knowing this valuable information helped us to know how to care for the patient and educate her on her oral health. When the dentist completed the full patient exam, we scheduled a consultation to discuss treatment plans and finances and what it would take to make a hospital case possible in our local same-day surgery center. For the dentist to have operating room privileges in our area, he completed a two-year hospital residency in oral medicine and staff orientation. It is very important to tell patients, “If there is anyone else who will be making the financial decision with you, please bring that person to the next consultation appointment.” Make the possibilities a realityA case at this level was going to be fairly costly, considering how long the patient stayed away from dentistry. We like to use the analogy that “You are a Volvo that has not had a tune-up or an oil change in a while.” The dentist begins with his case presentation and ends with a smile simulation. In dentistry, we must be careful not to overpromise; however, we let patients have a visual of the possibilities to help them make an educated decision based on their oral health. These cases are usually full-mouth rehabilitation.No one likes to discuss money, but you would be amazed when patients are presented with a $25,000 case that it is not surprising to them. They usually expect it to be more. Most hospital-case patients realize this is the same type of investment as a surgical procedure recommended by their physician. With the help of our financial coordinator, we discuss how we can help make this affordable. Remember, with a case of this magnitude, the fee has to reflect the commitment the office has made for closing the office for a day. With this patient and her husband’s support, we discussed a full-mouth restoration of 24 teeth, crowns, build-ups, two root canals, and four quads for periodontal treatment (Figs. 1 and 2). After the finances were discussed, the dentist left the room and the financial coordinator offered to help the patient make this affordable. If patients feel overwhelmed by the information, our financial coordinator lets them know that they are still in control and have our permission to accept single-tooth treatment, part of the treatment recommended by the doctor, or none at all. She also reminds them that though this may be costly, it is worth it in the long run. Patients usually accept all treatment for a hospital case and have found many creative ways to afford their care. Some have used home improvement loans or borrowed from their 401(k), but most have worked with a dental financing program, such as CareCredit.
Fig. 1 — Preoperative
Fig. 2 — PreoperativeWhen a patient accepts a case and finances are in place, we coordinate with the local same-day surgery center to schedule a hospital-case dental procedure. The dentist discusses the need for nasoendotracheal intubation (NETA) with the physician and anesthesiologist. One week before the hospital case, patients must receive signed approval of a physical from their physician. Operatory in a boxHospital-case dentistry is not your typical setup for assistants. Assistants are responsible for helping these cases go as smoothly and efficiently as possible. First, we make sure we have our checklist. There is nothing more time consuming than when an assistant has left the curing light back at the office, and a teammate has to go get it. Time is money, and the more time taken in the operating room, the more the patient is required to pay for the service of using this room in the hospital. This list is put together by all departments — clinical, hygiene, and front desk; however, it is ultimately the assistant’s responsibility to see that all arrangements are in place at least two days before the case (Fig. 3). The patient chart and treatment plan, recent X-rays and diagnostic casts, wax-ups, and Glidewell Biotemps® (pre-made temporaries) from Glidewell Laboratories are among the first items to be placed in the box.
Fig. 3 —All instruments must be in place prior to the procedure so there is no need to go back to the office for anything that the staff missed.Second into the box are materials used for all procedures, even if the procedures are not planned, as sometimes changes are made during treatment. Third are handpieces and burs — three each of the handpieces the doctor uses and a complete inventory of burs. KOMET USA’s portable bur organizer makes packing very efficient so as not to misplace loose burs, keeping them organized in a tight case while working in any setting. Fourth, arrangements must be made to have all heavy equipment transported, labeled, owner addressed, and approved by the hospital electronics department. Another must is to find out who will be attending and to make sure each person has an operating room protocol orientation update.Not our usual day at the officeThe operating room opened at 7 a.m., and the dental assistants, hygienist, and dentist were all on deck. The patient arrived with her family in the preop room where she met with the dentist and anesthesiologist, who reassured her about what would be done and asked her to sign consent forms. Meanwhile in the operating room, both assistants and hygienist, along with the operating room nurses, busily organized the dental equipment and tray tables and counted instruments (Fig. 4).
Fig. 4 —Dental equipment and tray tables organized in the operating room.As the patient was rolled in on a gurney and ready to be put under complete anesthesia, the nurse anesthetist asked the dentist if he required a nasoendotracheal intubation. This is usually best; otherwise, tubing will obstruct the oral access. Before the procedure began, the dentist placed a throat pack (gauze saturated in saline) to prevent any inhalation of tooth particles. The attending operating room nurse recorded the time and placement of the throat pack to ensure that it would be removed at the end of the procedure. When the dentist was ready to prepare the teeth, the assistant placed a bite-block and retracted the tongue by using a surgical retractor. Most of the time this requires eight-handed dentistry — the dentist to prep, the first assistant to water and suction, a second assistant/hygienist to retract, and a third assistant to pass, place, and retrieve instruments.We began preparing 24 teeth, removing all decay. In our procedure the dentist chose to prepare the teeth with the Crown Prepping Carbides from KOMET USA. Using this bur cut our time in half compared to using a diamond, which was very helpful for saving time in the operating room. After removing decay, we used cavity-detecting dye to make sure all decay was removed. We placed our build-ups, and began our CEREC scan (Sirona Dental Systems) (Fig. 5) and milling process for the teeth requiring inlays/onlays. After CEREC cementation, we checked our clearance of the preparations and opposing teeth for the full-coverage crowns and the dueling cords began. During this time, the dentist felt some hand fatigue. By dueling cords, two assistants shared the task of double-cord placement; one assistant placed on the left and the other on the right side (Fig. 6). Occasionally we had our dentist apply lidocaine with epinephrine to help reduce the hemostatic agent in the cord-placing process.
Fig. 5 —CEREC scan begins as well as the milling process for the teeth requiring inlays/onlays.
Fig. 6 —Two assistants share the task of double-cord placement; one assistant is placing on the left and the other on the right.
During this time, we also kept the preparations hydrated with wet gauze placed across the preparations. With the cord placed, we were ready for a final impression using stock trays with adhesive. The dentist/assistant removed the top cords. The dentist applied the light body as one assistant retracted and the other filled the tray with heavy-body material. The tray was then held in place for four minutes. This is the part of the procedure that most patients do not like, and in this case our patient was experiencing a peaceful sleep. Usually we take two final impressions, upper and lower, along with two bite registrations of the preparations. Next, we try in our Biotemps® to make sure all fit well. We had to make some adjustments to the temporaries because of the preparation changes; however, using Biotemps® saved the assistant a lot of time compared to making 24 temporaries from a preoperative matrix. Before cementing the temporaries, the hygienist began her procedure with assisted hygiene. When our hygienist was done, the assistants checked the placement of Biotemps® and temporarily cemented them in place. The dentist then did a gross check on the occlusion of the temporaries. It is easiest to have the patient return to the office the next day to finalize the bite. The dentist removed the throat pack, and it was time for our patient to wake up. While the anesthesiologist performed his duties to wake the patient, the dental auxiliary performed the cleanup and packing duties. During this time, the dentist recorded the procedure electronically for the hospital staff. He also informed the patient’s family that the procedure went well and gave them a thank you gift. The gift basket contained dental essentials such as mouthwash, toothpaste, floss, a complimentary Sonicare® or Oral-B®, and a handwritten thank you note signed by each team member (Fig. 7). It is so important to say thank you for choosing our practice because there are so many others out there to choose from. We make it a point to make our patients and their families feel appreciated.
Fig. 7 — The patient’s gift basket containing the essentials and a handwritten thank you note signed by each team member.Celebrating teamwork and successWe have found success in hospital-case dentistry in that it fulfills our patients’ expectations (Figs. 8 and 9). In most cases, patients overcome their anxiety because we listen and provide excellent care. We’re glad to be able to provide a service that is sought after by high-anxiety patients, but is rarely an option in most practices. Each year, we create practice goals as a team. This year we decided to revamp our marketing to promote hospital dentistry. Because of this service, we are able to survive through a tough economy and provide for our families.
Fig. 8 — Postoperative
Fig. 9 — Postoperative
Author bioMs. Calloway is a Texas native, who served in the U.S. Navy in 1992 and received her dental assisting training in Marietta, Ga. Now living in North Carolina, she has worked in dentistry for 14 years as a full-time dental assistant, is the past president of the Piedmont Dental Assistant Society and currently is a clinical assisting consultant. Ms. Calloway is a member of the North Carolina Dental Assistants Association and the American Dental Assistants Association (ADAA). She is also an award-winning graduate of the Dale Carnegie Organization, an advisory board member of Dental Assisting Digest and Inside Dental Assisting magazines with several published articles. Ms. Calloway is a regular KOMET Korner participant in Dental Assisting Digest, and in conjunction with KOMET USA, helped develop the Tina Calloway PRO-Visional Kit TD2103A, the first bur kit from KOMET USA designed for dental assistants by a dental assistant to work on provisional temporaries. She is a member of the Speaking Consulting Network, and the American Academy of Cosmetic Dentistry’s Team Advisory Council. Ms. Calloway has also been a guest lecturer at the Thomas P. Hinman Meeting, the Holiday Dental Conference, the University of North Carolina, School of Dentistry, and PennWell’s Professional Dental Assisting Conference.