THE INCI-DENTAL BLOG

I’ve had a few conversations with new VT’s about how to manage the first appointment you have with a patient. There seems to be some confusion on how best to take radiographs in examinations and complete all the treatment planning in the time available. So basically I just thought I’d share some ramblings on the subject.

The main issues people seem to be encountering are:

1) How do you make sure that after a first exam appointment you have all the radiographs you need

2)How do you get all your treatment planning done in time and write comprehensive notes

3) How do you stage treatment what can/can’t you do

I think in order to answer these questions we have to remember two key points

• That unlike in the dental hospital on consultant clinics you will be able to see the patient again.

• Treatment plans do change, they have to be flexible and you should warn patients to expect this

I think there a few keys to making sure your exams are as thorough as possible and I’m going to discuss them in turn these are:

1) Exam appointment times

2) Managing the pain patient

3) Managing radiographs

4) Staging treatment

Exam appointment times

Lets start by looking at the amount of time you allow yourself for appointment times. Practices vary how long they allow from 5 minutes to around 40 minutes. Most of those who manage a 5 minute appointment are able to do so because they have a long established list of dentally healthy patient who they can manage in this time. Those with 40 minutes either want longer to provide a concierge service to a patient and possibly have time to discuss treatment the patient wants not needs (i.e. offering private treatments) they are also used for new dentally unfit patients who require much from any given exam.

What we need to do as young associates or VT’s is look at that range and decide where we are. Unfortunately the length of your exam is governed nearly as much by your patient base and their previous treatment as it is by your own efficiency (which I believe is the whole reason for UDA values…lets not go there). Therefore I would say that for exam times even more than other treatments you should never be influenced by the times people manage over the fence!

So having been at work for a few weeks you should be able to start working out how long you will need for a first exam. Questions you should be asking are:

1) Have the patients got a generally high decay, periodontal problem rate

2) How up to date are the notes, are all medical histories fully completed are charts always up to date, have BPE’s been recorded, are there baseline radiographs and recent ones available

3) Are the new patients ones who have not seen a dentist for years or are they usually ones who have transferred from another local dentist (how good was that local dentist)

If the answer to these questions is generally good that the patients are well maintained and the notes are up to date then you would require a shorter first exam time. If however the answer is no that the notes are not up to date and the patients have very high caries rates then the exams should be longer. If your patients have generally stable dentitions and you are looking to offer more aesthetic treatments I would also extend appointments so you have time to discuss what you could offer the patient above the “what is clinically necessary” tag-line.

I take 20 minutes for the first exam I have with a patient regardless of whether they have been seen in the practice before or not. I made this decision because we have a large number of new patients from a local dentist who got struck off and they seem to need more attention than most, also the radiographic records we have, having converted to digital just before I started need a little sorting out.

It’s up to you to set your own first appointment time but I would suggest between 20 and 30 minutes when you first start. If you feel your patients have very stable dentitions I would suggest that you shorten the exam appointment for patients who have bee seen in the practice before and have a different average time for new patients to the practice. Once you’ve decided on these times let your reception know or give them a little list of your average times (this is what I did after a few weeks).

At the end of your course of treatment I would then suggest you grade your patient in terms of caries risk and how up to dates the records are then leave a post it on the notes or computer with how long you will need for the next exam. This could range from:

• A= 10 mins (everything in order and low caries risk)
• B= 20 mins (medium/ low caries risk but needs more radiographs/investigations/discussion about crowning a tooth we mentioned this time etc)
• c=30 mins High caries risk, unsure how stabalised and likely new radiographs needed

You need to do this grading seperatly to the recall time as you have to let the reception know what time you want not just when you want them. You may also get the situation where you don’t need a long exam appointment but you want to see the patient soon to monitor oral hygiene or assess a root filling etc.

The advantages of this system are that you are generally more efficient with your time. You can give more time to those who need it and less for those who just need a quick check and scale. I don’ think the patient loose out really becasue they all should have up to date notes and be approaching a good standard of oral health.

I know that a few people will point out that I have discussed giving longer to patients who need some records updating and you will correctly point out that surely this should have been done before you TC a treatment. I guess your right but I don’t think it’s fair for a person who has not been seen for 10 years with gross decay to expect every single bit of treatment completed in that first session. I would instead aim to get them functionally fit, the gross caries managed and then look at further investigations to find and manage early lesions. I’m happy  for you to disagree with this and I’ve had the conversation with other people but in my mind if you want to make banded treatment work on the NHS we have to split up treatments at some point and if I taike an OPG for a grossly carious mouth and manage all that work before getting them back for bitewings I don’t think I’m doing them a disservice. It comes down to the first key point that you should expect to see these patients again.

Obviously there will still be times when a lovely mouth comes in for a long check up with radiographs all on the computer and no calculus to scale. These are my favorite visits because this is the time when you get to sit back in your chair face your patient and just have a chat to them. Take a few minutes and just say that there mouth is dentally healthy but is there anything they would change about their smile? You would be amazed how much patients appreciate this question and how often you can really improve their confidence by placing a composite filling on a lower molar or simply closing a space in front teeth with a small addition of composite. It doesn’t always have to be whitening and full veneers but if patients are interested in cosmetic treatment I think it’s our duty to let them know the options and advantages/ disadvantages. If your not keen to provide this kind of work, why not find a local dentist who is really good at it and offer them a referral. These are exactly the kind of patients who would benefit most from cosmetic treatment and if they are interested you are doing them a real service by helping them improve their smiles. Lets face it the best bits of dentistry have always been giving people what they want, not what they need. If you disagree talk to people who have had braces, or veneers or full mouth reconstructions and see how happy they are after the work is finished, Ive never seen anyone skipping for joy because they got a beautifully carved amalgam in an upper 6. You can disagree with cosmetic work if you want but I think you should always offer patients all of the options for treatment and help them get what they want.

The last point I would make on this is that you should try to judge how likely your patient is to return for treatment and book them their first session accordingly. If the patient has a history of not turning up for appointments and gross decay why not start with a short scale appointment for say 20 mins. This gives you a chance to make sure the patient will turn up without loosing loads of clinical time and maybe you could finish taking some radiographs for the notes etc. I just think booking the first appointment as a 2 hr root filling appointment is unwise sometimes.

Next section to follow soon Comments welcome and may be incorporated into final guide!