The Ickiest Things You Can Do at the Dentist

Putting Your Finger Inside Your Mouth

It always hits me with surprise how clueless people are about transmission of infections. In the middle of the treatment they might show with their finger which tooth feels sensitive. That’s when I say Eew in my mind. Why would you put your finger inside your mouth? And it’s always the index finger which we use to operate our smart (and dirty) phones and push the elevator button (I don’t actually, I use the proximal interphalangeal joint (PIP) of index finger because of my fear of bacteria – read more about it here) that gazillion people have pushed before you with their dirty index finger. Some even do grosser things with their index finger.

So please, do not put your finger inside your mouth. Your tongue is able to do the job instead.

Carrying Your Toothbrush Without Cover

Some people are obsessed about brushing their teeth prior the dental visit. They might do it at the practice’s toilet just before they come in to the surgery. No problem with that, but when you walk in to the surgery with the toothbrush, your car keys and wallet in your hands and place them on our office desk, that’s when we go Eew again. Especially if the toothbrush doesn’t have any travel case. We don’t wipe all the practice’s surfaces after each patient, so there will be germs on the table surface where you leave your stuff. And where are you going to put it when you get back to your car?

Equally gross thing is to put your toothbrush inside your handbag without travel case. But at least then we are not able to see it.

“Sucking the Sucker”

By far the ickiest thing to my mind are the patients who close their lips around the saliva ejector or the high volume suction. I was horrified for the first time it happened with my patient. To be fair, it’s not their fault. They do this probably because some of the dental professional advise patients to do so. Honestly, fellow dental professionals, do your research and stop advising to close the mouth when the suction is inside the mouth.

Why?

It’s because of the backflow of bacteria and viruses. When patients close their mouth and form a seal around the tip of the saliva ejector, a partial vacuum occurs. That’s when the nasty stuff in the tube of the suction start travelling backwards – blood, viruses, saliva, bacteria, debris. They might travel as far as into the patient’s mouth. If you don’t believe me, read this.

If you are a patient and your dentist or hygienist advises you to close your lips around the suction, don’t do it. You don’t need to. This might of course mean that you need to swallow tiny amount of water, but the water is cleaner (or is it?) than the stuff that comes out from to suction with the backflow.

It is also absolutely your right to ask if they take care of the suction tube cleaning. They should answer you that

Yes, we flush the lines after each patient with clean water (this will take the nasty staff further away) and at the end of the day we flush the tubes with disinfectant. Also once or twice a week we use special cleaner for the suction lines.

Ok, there it was. Three of the ickiest things patients can do at the dentist. Do you know even grosser thing? Feel free to share it on the comment box below. Let’s see if it gets an Eew -reaction.


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Years of Malpractice – How Is It Possible?

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Where there is smoke, there is fire. Dentists negligent behaviour should be act upon.

Ever wondered how it is possible that the dentists who are not practicing dentistry up to the standards get caught only after years of practicing the profession? Well you have come to the right place to find out.

Is It the Patients’ Fault?

Nope. Absolutely not.

The patients cannot tell the difference between a good and bad dentist when it comes to the skills of a dentist. Or if the procedures have been done as they should and if they are necessary in the first place. Or if the instruments entering their mouth have been properly cleaned (take a look at my previous post about this).

An average patient can only judge the dentist by the looks of him and the practice, and by the dentist’s chairside manners. The rest is build on a trust of receiving good and adequate care. But every once in a while this trust is broken and the dentist ends up in the headlines.

But please remember that not all the dentists ending up to the headlines are rogue dentists as I have written previously.

Collegiality Gone Bad

Collegiality between the dentists means respect to one another’s abilities to work towards the same purpose. Helping patients. But collegiality has an ugly side as well. It is an unwritten code between the dentists which means one should not interfere or especially under any circumstances critizise a fellow dentist’s work. It is a code one should not break. The hygienists are expected to play by the same rules.

Now, this creates a problem. When a dentist is underperforming, the colleagues hear this from the hygienists and nurses. They see see it from the teeth of the patients who come too see them instead of their regular dentist (e.g. for emergency visit or whilst the regular dentist is on a holiday). They know there is a problem but very rarely they raise questions.

Instead the patient is kept under an illusion that the regular dentist has made the right decisions by distorting the truth.

Distorted truth:

“This decay is in such a difficult area to notice.”

The truth:

“This massive decay is so big that even my half-blind grandmother would find it.”

Distorted truth:

“Your dentist has marked it as an early decay, something to be kept an eye on… it has now grown bigger and needs a filling.”

The truth:

“Your dentist needs to have his eyes checked. This decay should have been filled ages ago. If you are lucky enough, you avoid the root canal treatment.”

Conclusion

It should be every dentist’s duty to report problems in colleague’s way of practicing dentistry. The Code of Ethics by ADA state the following:

Dentists should be aware that jurisdictional laws vary in their definitions of abuse and neglect, in their reporting requirements and the extent to which immunity is granted to good faith reporters. The variances may raise potential legal and other risks that should be considered, while keeping in mind the duty to put the welfare of the patient first. Therefore a dentist’s ethical obligation to identify and report suspected cases of abuse and neglect can vary from one jurisdiction to another

In my opinion, you don’t pull out the biggest guns if you suspect negligent behaviour from your colleague. The dentist in question should be given adequate time to correct the problem e.g. by revising.

The privilege of dentists to be accorded professional status rests primarily in the knowledge, skill and experience with which they serve their patients and society. All dentists, therefore, have the obligation of keeping their knowledge and skill current.

If nothing changes, more severe means should take place. This includes giving warnings and as a last resort filing a complaint to the relevant authorities.

Naturally, if the negligence is severe, one should not hesitate to contact authorities urgently.

The bible of dentistry aka ADA’s Code of Ethics 2016 in full.

If you fancy further reading on the subject, here’s a true story by yours truly.

Compensation Culture Sucks

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A 30-year-old lady had been to see a hygienist for a scale and polish, went home and took a small mirror that she put inside her mouth to have a look behind her front teeth.

“Stains!!”

She went back to the surgery and complained to the receptionist about inadequate scaling. She was booked in to see another hygienist who confirmed there were some stains left behind (palatally) the upper front teeth. Otherwise the scaling was done well enough.

Patient left the practice seemingly happy but the next day she called the practice that she still wasn’t happy. She also complained about the dentist she had seen.

The hygienists and the dentist discussed about the patient and came into conclusion that this patient could not be pleased and the complaints would be never-ending. They all had had the same feeling about the patient when she was in the chair. It was a feeling of unease and of a need to explain excessively everything they were doing or saying to avoid a complaint. They decided together that the patient would not be welcomed anymore and the practice manager was the one to break the news to the patient.

Thankfully the practice owner was supportive over the decision.  He said

“We don’t need that kind of patient in our practice. She will only bring bad blood and it’s just not worth it. We can’t help her.”

The Compensation Culture

The compensation culture in the UK (and perhaps even more so in the US) is making a life of a dental professional very hard. It is ludicrous that the main focus of seeing the patients is in the avoidance of possible complaint.

The rotten apples amongst us dental professionals are perhaps to blame. And the media has done their share as well (has there actually been a program about rogue dentists?). The way the media is sharing news is focused on gruesome headlines and there seem to be less and less investigative journalists in the payroll of the media. Instead there are these copy-paste-wannabe-journalists whose main focus and reason for existence is to get as many clicks as possible on their news. Here’s one example:

Dental anguish: Indiana man who expected to have four teeth pulled woke up in hospital TOOTHLESS” (Find the news here)

This and similar headlines were quickly released around the world without giving the dentist a chance to respond. He would have wanted to respond, I’m sure but there are laws that prevent us dental professionals responding publicly to the accusations made against us when it is about doctor-patient relationship.

Later on the dentist was allowed to discuss the patient case but far fewer media released his response (you can find the response here). So the dentist suffered financial loss over these headlines only because the media is fishing the clicks. Of course there wouldn’t be these headlines if there weren’t people clicking them…

Learn the Phrases

You know what? It is time to fight back the compensation culture. You can do this by learning to use certain phrases. I will list the phrases I use myself when I see a patient. And without sounding like a super human, I rarely get complaints. It is just the opposite. People are happy after they have seen me.

And before you tell me that there is no time to explain everything to the patient I will say that it takes no extra time. You can use the time when you have your fingers inside the patient’s mouth. Don’t wait until you are finished with the treatment. You chit-chatting might even relax the patient!

Ok here we go and remember these are just examples and you can easily create your own phrases for every situation.

The phrases need to cover:

Post-operative pain/sensitivity/bleeding and instructions

“The gums might feel tender afterwards and it is ok to take a painkiller for them. But do not take aspirin because it might make the gums bleed.”

“Sometimes the teeth get sensitive after scaling which normally will pass very soon. If prolonged it is advised to use a sensitive toothpaste.” 

“Some stains cannot be removed by scale and polish. They are in the deep grooves or inside the enamel or between the filling and a tooth and only replacing the filling will help.”

“The teeth will feel very different afterwards as the tongue has got used to the tartar. You will feel the gaps between the teeth.”

Looks and the feel of the new filling

“You might have sensitivity after new white filling and in the worst case the sensitivity can last for months but it should gradually get less and less. If not, you need to come back to have it checked. And if the pain gets worse you need to come back straight away.”

“The filling is never the same as your natural tooth (so you should think twice next time before you snack between the meals and neglect the teeth… )”

The list of these phrases is endless.

And the most important thing is to remember to write down every advice and information you have given so that it can be easily checked what the patient was told if they complain. In this digital age it is a matter of copy-paste if you have created templates on you computer.

Tell What You Do

It takes no extra effort to babble while you are treating the patient. Of course some people won’t like us talking while we treat them but telling the basic stuff is normally ok. This means very simply informing the patient what you are going to do next.

“I’m going to tilt the seat back…”

“I will rinse now..”

“I will use a drill next. There will be water and you will feel vibration…”

I hear it numerous times per week that the patient felt it was good that I told everything I did. I think it is only respectful thing to do. After all patients come to see us, trust their health in our hands and pay our wages.

There. Now go on and try these advises out! I’m sure you won’t regret it.

Yet Another Anti-Patient

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How on earth did I not remember this type of Anti-Patient? I guess it is all coming slowly (but surely) back to me after returning to work.

Before you read any further, it might be good idea to read my post Anti-Patient so you know what I am on about.

Anti-Local Anesthesia

Now, this type of patient is not so uncommon in the dental chair. Let me tell you about the two of the most typical situations I face.

Patient Case I

I am about to start the scaling and root planing and I can tell from the looks of the gum that it is going to be painful. I offer local anesthesia (LA) but the patient declines by saying:

“I once had such a bad experience with LA that I have not taken any since..”

Or

“Oh, I never take any LA, not even when I have a filling done.”

I explain that it will most likely hurt but the patient does not change his mind. Not even when I explain we could use topical LA (I use Oraqix) which would not require needles.

So I begin the treatment. The sonic scaler goes relatively well but when I begin to scale those deep pockets the patient is jumpy (as if somebody was poking his limbs with a needle), turns his head suddenly (exaggeratingly) and is kinda slowly sliding towards my lap as he’s pushing from the handles of the chair.

After I have nearly injured my own finger and patient’s lips for the third time because of the unpredictable motions and after I have three times asked patient not to move his head, I stop the scaling and tell the patient that I won’t be able to carry on unless he keeps the head absolutely still. Because it’s not safe. I offer the LA again and usually at this point they agree.

Patient Case II

The patient (who also just declined LA) keeps still throughout the treatment (scaling) and says she’s fine when I ask her if she’s ok  (multiple times). So naturally I carry on to finish the treatment.

Once the patient gets up from the chair she does not look happy and says

“It hurt a lot.”

Or

“Oh I hate having this done.”

Or

“It’s never hurt before.”

Soooo annoying! Did I or did I not offer you LA? Of course it hurts if you decline LA when it is recommended. And why would you say you are fine when you are not?

What is the most annoying in all this is that she will go and tell ten of her mates how horrible experience it is to have the teeth cleaned. Simple marketing rule – bad experiences you tell to ten people, good experiences to one. So unfair!

Repost with Forewords: Cold Sore Is Herpes – Cancel Your Dental Appointment Because Your Dentist Won’t!

Dental Revelations Blog

I am reposting one of my blog posts in the light of the news of the 10-year-old Briony who died from herpex simplex virus which the doctors failed to diagnose.

In this blog post I wrote about a dental nurse who contracted the herpes simplex virus whilst the dentist was treating a patient with a cold sore. I wrote that the GP diagnosed a primary herpes (meaning she had never had herpes infection which most people do have as a child). What I did not share with you was the fact that the dental nurse attended the GP’s practice on Friday and the GP sent her home thinking she had gingivitis. The nurse tried to tell the GP that she had seen a periodontist in her practice due to the ulceration in her mouth and it definitely wasn’t gingivitis. Nevertheless the GP advised the use of chlorhexidine mouthwash and sent her home.

Over the weekend she developed high fever (40 degrees) and could not eat anything due to sore mouth. At this point the ulceration was covering every corner of her mouth including the lips. She returned the GP’s practice on Monday morning and was barely able to stand up. Still the GP insisted it was gingivitis. But at that point the nurse realised the GP needed to see more than what he could with her just opening the mouth and him poking with this wooden spatula. So she grinned as wide as she could. The GP jumped back and said “Well that is definitely a herpes infection!” and prescribed the antiviral medication.

So it is not so uncommon that the herpes infection goes undetected by the professionals. This is one more reason to take the virus seriously – even though the deadly side of the virus should be enough of a reason, eh? Please read my post Cold Sore Is Herpes – Cancel Your Dental Appointment Because Your Dentist Won’t!

In case you haven’t read the news about Briony, click here.

My heart goes out to Briony’s family who must be devastated. RIP little Briony.


A patient came in for a long appointment to have a bridge done. This appointment was to include filing down the teeth to abutments which meant that the high-speed drill was to be used. A lot. High …

Source: Cold Sore Is Herpes – Cancel Your Dental Appointment Because Your Dentist Won’t!

Told You So

 

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You think the floss is effective? In most cases it is not.

I couldn’t hide my satisfaction when I read the news in the US about effectiveness of the floss. Finally something I have been preaching about is out and in the open for everyone to read.

You see I have met many dental professionals who have doubted my way of giving oral hygiene instructions especially regarding the floss. I have met so many of them that I have stopped explaining the reasons behind my recommendations.

My hope has been that some day they would get enough experience to notice that the floss isn’t doing a proper job. Or that they would start using the disclosing solution (I use Rondell Disclosing Pellets) which would definitely prove it.

We’ll see what happens. My fear is that many will stubbornly stick to their old ways. Change will always bring along resistance.

If you haven’t read my blog before, please take a look at this page about my recommendations.

And click this link if you haven’t read the news about the effectiveness of floss yet.


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Told You So, Part II

Told You So, Part III

Eeny Meeny Miny Moe – Which Type of Tooth Wear?

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There are four types of tooth wear that we diagnose from patients’ mouths. Erosion, abrasion (I’m sorry for a missing link – I did not agree with any of the images of abrasion), abfraction and attrition. The easiest ones from these to diagnose are the erosion and attrition. You can’t go wrong with them. But it is completely different case with abfraction and abrasion. I run into this very often with my patients.

When a dentist or a hygienist sees tooth wear on the neck of the tooth they diagnose it by default as abrasion caused by too vigorous brushing. They recommend softer toothbrush and this silly brushing technique called Bass (it is so silly that I think I am going to dedicate one post entirely to this technique).

This normally leads into a situation where patient begins to be too careful with the brushing because she doesn’t want to cause further damage to the teeth. That’s when the plaque starts to build up to the gum line, gum gets inflamed because of the plaque and the patient begins to notice bleeding when brushing. Now she’s even more careful with the brushing as in her mind bleeding means she’s doing something wrong – brushing too hard like the dentist said she is.

But what if the dentist/hygienist misdiagnosed the tooth wear? What if the correct diagnosis was the abfraction?

Tooth wear – What to Check?

When you see a tooth wear that you are tempted to diagnose as abrasion, stop for a moment before you proceed giving advice on brushing. Instead do the following:

1. Check if there is mobility on the teeth affected by tooth wear

2. Check if there are interferences on side movements and protrusion

3. Check if there are shiny facets on occluding surfaces

If you get positive answer to even one question the chances for the tooth wear to be abfraction are great. And in this case telling patient that the tooth wear is caused by her brushing can be damaging in many ways:

  1. It is hard to convince a patient that they are not actually brushing too hard and that they have not damaged their teeth by it. I have my ways of convincing the patient but life would be soooo much easier if I didn’t have to.
  2. The dentin will decay very easily (as I’m sure you know) and plaque accumulating and staying there undisturbed for longer period of time because of too careful brushing will very quickly cause decay. And we all know how these fillings in the cervical area are pain in the butt. Somehow they always seem to have overhangs or they come off when scaling. Sound familiar?
  3. The teeth where the surface of the root (dentin) has been exposed by receding gums will get sensitive if the plaque builds up.
  4. If the tooth is mobile and has already bone loss the plaque building up to the gum line and inflaming the gum can be disastrous. Please memorize that

MOBILITY + PLAQUE = RAPID BONE LOSS

The Cause for Abfraction Needs to Be Dealt With

When a tooth interferes with full closure, it will trigger deflective interferences6-8 and cause any of the 7 signs and symptoms of occlusal disease such as hypersensitivity, abfractions, mobility, excessive wear or fractures, and muscle or temporomandibular (TM) pain.

There is no consensus amongst the dental professionals over the right approach to occlusion. Is this the reason why signs of interferences on occlusion are ignored or unchecked and the tooth wear is so easily made as patient’s fault?

The quote above is from an article The Three Golden Rules of Occlusion in dentistrytoday.com and you can read a full article here.

But by Whom?

To be honest – and like I have expressed in my previous post – I would not let just anyone touch my occlusion. I would love if the dentists would refer patients to the specialist in prosthodontics and stomatognathic physiology because they have the best knowledge and skills to treat the occlusion. And that’s something every patient is entitled to.

Guilt Is a Heavy Load to Carry

I have often noticed that patient feel unnecessarily guilty over damaging their teeth. They feel guilty and desperate over the fact that the damage done by brushing is irreversible. And that they are not sure if their brushing technique is still damaging their teeth hence too careful brushing to make sure they are not.

I believe that guilt does not lead us forward in life, it does not bring anything positive into our lives. Therefore I always try to relieve my patient’s guilt whenever it is possible.

In the case of tooth wear and some dental professionals way of putting the blame on patients’ brushing technique I always have the same conversation with a patient. It goes like this.

Me: Have you been told that you brush too hard?
Patient: Yes I have.
Me: I thought you might have. You see when a patient is told this, she starts to be too careful and then the plaque starts to build up and there is actually plaque in the gum line of your teeth. (I take a mirror and show the plaque to the patient)
Patient: Eww..
Me: I personally try not to tell patients that they are brushing too hard because this leads to too careful brushing which will cause more problems like decaying and gingivitis. Instead I interview the patients about how they brush their teeth and correct it if necessary. You see the tooth wear can be caused by other things than just vigorous brushing… 

Prior to this conversation – in the beginning of the treatment – I have interviewed the patient and asked about her oral hygiene habits. Which brush she uses? How often? How often does she replace the brush head/brush? How does the brush head look like before replacing it? Spread or still like new apart from colour fading? This is why I can continue the above conversation like this.

Me: In your case I doubt it that the tooth wear is caused by your brushing but I will just in case show you the right technique. I will first just check couple of things…

And then I check the mobility, the interferences and the occluding surfaces. I feel great satisfaction when the teeth affected by tooth wear have mobility on the side movements. I am on the right path!

The patient is visibly relieved when they can stop worrying about their brushing. Well who wouldn’t be! There is enough to worry about in life even without worry over brushing.


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Don’t Let Just Anyone Touch Your Occlusion

 

Ever Seen a Patient with an Implant? Read This!

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Today I saw a patient who had had an implant done to replace upper right first molar. The implant treatment was finished a year ago in another practice.

Since then the patient had seen hygienist twice in my practice. The implant crown itself looked immaculate but the gum was very red and puffy and it bled heavily after probing.

I knew what to ask next and I even knew the patient’s reply to this.

“Were you told how to clean the implant at home?”

“No I wasn’t” replied the patient with is-it-supposed-to-be-cleaned-expression on his face.

This happens too often. Almost every time I see a patient who has recently had an implant done.

Note for all the dental professionals who make the implant treatment’s final stages and do not give oral hygiene instructions (OHI) for the patient:

You should always tell and show how the patient can clean these costly pieces of metal and porcelain. It is your responsibility as a dental professional and the paying patient’s right!

Can you give me any other excuse for not giving OHI than the fact that you are too busy making money and forgetting the basics? I believe you cannot.

And you hygienists who see patients with implants:

  1. Always check how the patient is cleaning them. More so if the gum around the implant is either bleeding or there is plaque around it
  2. Advice if necessary and show in their mouth how it is done
  3. Check if the patient understood your instructions by asking them to show they can do it. Teach them if they struggle
  4. Check on a follow-up visit that the gum has healed. If not, refer to a dentist

Why Is It So Important?

With the implants it is vital that there is no bleeding in the surrounding gum. They will get an implant’s equivalent to gingivitis – peri-implant mucositis which can lead to the peri-implantitis (same as periodontitis with teeth) very rapidly. The worst case scenario is that the implant will lose it’s integration to the bone which could have been easily prevented.

The patient I saw today left home with instructions on how to look after his implant. And I will see him for a follow-up visit to make sure the gum has healed (can you see the shining halo around my head?).

Honestly, it’s not that hard to do your job properly so shape up please!


Here‘s further reading on the subject.

Part II: Just Another Day at the Office

Dental Revelations Blog-

“The most dangerous irony is, people are angry with others because of their own incomptence” – Jar of Quotes

Goodness gracious me! It has been too long since my last post. Hope you are still there and reading my posts!

It is time for the dentist’s point of view as a team member of dental practice.

At 8.45am

Oh no, not the Ms. Flumsy again” thought the dentist in the morning when she entered her surgery. Apparently her regular nurse was off sick or something as the practice manager (PM) had called in the temp. The one that had visited the surgery before.

The dentist was disappointed at the PM who clearly had not listened to her when she said she would not want to see this temp again.

You see, everything was wrong with this one. She had long and colourful nails. She had heavy makeup and strong perfume. She didn’t have any idea of assisting a dentist. She thought that using the suction was the most important thing as a nurse. And every task she did took ages to do. And she did them in wrong order. And knew nothing about cross infection control. And went for a cigarette when she should have called a new patient in.

Even though the dark cloud hanging above the dentist head was obvious she forced a smile and said with overly sweet voice “Good morning. How are you?”

“I’m good. And you? Okay?” replied the nurse with a wide cockney accent sending shivers down the dentist’s spine.

The dentist took a look at the day’s schedule. She could feel panic increasing the further she read the day’s treatment plans. Check-up, root canal treatment, crown work, extraction of wisdom tooth, check-up… And of course the time-table had been planned so that the dentist would have her regular nurse assisting her. It was a tight schedule but manageable when the nurse knew her business.

Nevertheless the dentist made a decision not to cancel any patients.

At 9.05am

The first patient was sitting in the patient chair with the bib and safety glasses on. She was about to have a check-up done.

“Oh, I didn’ remember yew ‘ave dis computer software! Don’ know ‘ow ter use it” the nurse says suddenly. The dentist sighs and gives a piece of a paper to the nurse to record her findings.

Then she begins her check-up routine and after checking the teeth with a mirror and a probe she reaches for the fiberoptic. Only it’s not there. She turns her gaze at the nurse who is at the front of the computer screen cleaning her fingernails and looking disinterested.

“Could I please have the fiberoptic?” she says with overly calm manner.

The nurse begins to go through the drawers but cannot find the device. The dentist waits. The nurse checks the autoclave.

“Gawdon Bennet! There are instrumun’s ‘ere from yesterday but its not ‘ere, innit.”

The dentist remembers that her colleague sometimes borrows the fiberoptic as the practice has only one of them. She asks the nurse to go and check from there. She examines the patient’s soft tissues meanwhile.

“Here i’ is” the nurse says triumphantly when she returns and waves the fiberoptic in the air and attaches it to the unit. The dentist notes that the nurse did not wipe it with disinfectant but she thinks it’s not that big deal especially now when she’s running 5 minutes behind the schedule.

She completes the check-up and sends the patient to the reception. Then she records her notes to the computer as quickly as she can.

“Exam” she writes. No time for all the gibberish.

Then she updates the chart from the piece of paper and checks the next patient’s records. A root canal treatment. She notices that the nurse has placed only the basic instruments on the tray and disappeared somewhere – probably for a ciggie. The dentist starts to collect instruments she needs and calls the patient in. She feels her blood pressure raising.

I really cannot be doing nurses duty, simply just cannot…” 

She is numbing up the patient when the nurse walks in.

“Oh, yew ‘ave already taken da patien’ in! Wasn’t da appointmen’ at 9.45?” 

The dentist does not reply and carries on with the treatment.

At 10.10am

The dentist is done with the filing of the root canals and is about to rinse the canals with the sodium hypochlorite for the last time. The nurse grabs the suction.

Silence.

The nurse places the suction back to its holder and takes it off again.

Silence. Not a sound.

The dentist realises that something is wrong and it cannot be fixed quickly. She asks the nurse to inform the practice manager about the malfunction.

Meanwhile she tries to figure out how she can finish the treatment without the suction. Luckily she wasn’t born yesterday and she takes a sterile gauze and places it close to the root canal treated tooth before she rinses the canal with the sodium hypochlorite. The gauze absorbs the liquid. She puts the calcium hydroxide to the root canals and seals the canals with temporary filling.

She escorts the patient to the reception in an intention to ask the PM what she has done about the suction but then she sees two practice’s regular nurses entering her surgery. She goes after them to see if they can fix the problem.

The nurses try to figure out why the suction is not working even though all the other suctions in other surgeries are fine.

The dentist checks the time. She’s now over 10 minutes late from the schedule. And the next treatment is crown work and that cannot be done without the suction.

The nurses need to return to assist their dentists and the PM needs to call in repairman. This means the dentist needs to cancel the next patient’s appointment. Zero income for the next two hours or so or until the suction is fixed. She walks to the reception to meet the patient and break the news.

The patient is not happy. He has taken two hours off work to come to the appointment. In a fear of losing the patient to another practice the dentist promises a discount from the treatment.

At 12.30pm

The dentist has tried to make a use of the spare time and goes through laboratory bills in her surgery. The repairman has not been in yet and it is soon lunchtime at the practice. Things are not looking good. She won’t be working until the late afternoon.

The surgery door opens and the hygienist pops her head in.

“Great, you don’t have a patient. Would you mind coming in to my surgery to check something? I have your patient in the chair and I think I found a decay on the lower right 6 and also something on soft tissues…”

The dentist walks in the hygienist’s surgery and greets the patient. She puts the gloves and face mask on.

Dentist: When did I do the last check up?
Hygienist: Err, yesterday…
D: And where was it that you suspect a decay?
H: On lower right 6. On the buccal side just below the gum line. There is another one as well but I think it is still in early stages…
D: Where is this?
H: On upper right 2, mesially. I don’t have a fiber optic so I couldn’t check it properly.
D: There is one in my surgery.
H: I know, but the turbine attachment is not working in my unit.
D: Ok then, let’s have a look…

The dentist takes the probe and checks the lower right 6 first while the hygienist stands on the nurses side and watches.

D: It seems to be ok…
H: It’s more subgingivally. You need to push the gum aside slightly.

The dentist feels this unpleasant feeling in her stomach when the probe sinks inside the tooth on the site hygienist mentioned.

D: Yes… yes, you are quite right. This needs to be repaired. Let’s see what we can do about it as it is quite deep… How about the other one. It was the upper left 2?
H: Upper right 2 mesially.
D: You are right it is decay but hard to say without the fiber optic if it’s advanced. I will check it on the next visit.
H: There is also something on the soft tissues I’d like you to have a look. It’s on the cheeks and under the tongue. Could it be lichen planus?

The dentist takes a look.

D: I can see what you mean. Hard to say for sure without biopsy but it does look like lichen.

Then she goes on informing the patient about lichen and asks the patient to book an appointment to decide what can be done to the lower right 6.

The patient looks shaken. Yesterday she got all clear and today she hears there is something seriously wrong with one of her back tooth plus something – possible cancer – on her soft tissues. She is not convinced when the dentist says there’s nothing to be worried about.

The dentist leaves the surgery and feels like going home. Or to the pub. This day is just one of those days she would like to forget. But she must stay to treat the rest of the patients – providing that the suction is fixed before this.

But it is time for a lunch first and she decides to go out for the full hour.

At 2.30pm

The dentist returns to the practice after the lunch break and chats with the receptionist before going to the surgery. The receptionist tells her that the repairman came in and did his magic in 15 minutes. The suction works again. Whoopty doo!

When the dentist reaches the surgery she can see through a glass tile window that the surgery’s lights are off. She opens the door and sees the unit lifted up to the highest position which the nurses do at the end of the day.

“What the hell?” comes out of the dentist’s mouth.

She walks back to the reception to see the PM.

“Why is my surgery closed?”

“Oh is it?” replies the PM and walks to the surgery.

“Oh lord” she says when she sees the surgery, “the temp must have gone home… I thought she went for a lunch!”

“I cannot believe this… this is unacceptable… did I or did I not tell you that I do not want to have this temp assisting me ever again?”

“I’m sorry but I did not have…”

“I don’t care. Your job is to keep the surgery running and I have seen only two patients today which is outrageous. And those two I have had to treat practically alone as the nurse is useless…”

“I understand. I see what I can do… I will try to reach the temp. Maybe she’s somewhere close by. I don’t understand how she thought she could go home.”

The dentist was fuming. She did not want the temp back but she did not have other options if she wanted to see the rest of the patients. But she soon learned that the temp was nowhere to be reached. The PM offers to come in to assist her.

“Well it’s better than nothing” she replies.

After she had seen the first patient for the check-up she was much calmer. She took in the next patient who had just seen a hygienist for a scale and polish.

When the patient opened the mouth she started to get annoyed again. The hygienist had not rinsed the polishing paste properly. It was in every between the teeth, this gritty blue paste.

“Seriously, who uses this much polishing paste!” she thought whilst her cheeks were getting red from the annoyance. You see, this wasn’t the first time. It happened with every patient who came to see her after the hygienist treatment. Soooo annoying!

At 5.30pm

When the day was over the dentist felt like she was the only one in this practice who knew her business. How was it possible that she was surrounded by so many incompetent people? She thought about changing jobs.

But would the patients follow? Some probably. Would it go from bad to worse? Yes possibly. Should she start her own practice? Definitely not, too much stress. Should she quit dentistry? Yes, it would be the wisest thing to do but she wouldn’t afford it as she’s still paying the student loan.

She went home fearing what the next day would bring. One thing she has learned in these couple of years of practising dentistry was not to check the next day’s patients. It was about minimising the stress. But there were so many other things she had no control over that sometimes just felt too overwhelming. Way too overwhelming.


You might also like these posts:

Part I: Is It a Skyskraper? No, It’s Your Ego
Part III: I’m Sorry but I Did Not Get Qualified So That I Can Make Coffee for You

Part I: Is It a Skyskraper? No, It’s Your Ego

Dentalrevelations

On my second post I promised to write about personalities of the staff in dental practices and how they may affect the dental practice and the treatment given to the patient. I’m going to fulfil this promise today. And on my next post. And the next.

I am going to write a series of posts about this topic. Each post will have a viewpoint of one dental professional. Today it will be the hygienist’s.

I’m Not Going to Play with You

As long as there have been dental hygienists there have been dentists who are afraid of losing their living because of them. These dentists either refer only the simple scale and polish to the hygienist or do not refer at all.

They treat the patients with advanced gum disease themselves as it requires more visits. More visits equals more money per patient. And the money is the only motive they have for this silly way of practicing the dentistry.

The problem with these kinds of dentists is that most often the hygienist would have better skills to treat the advanced gum disease than the dentist and this is revealed when the patient sees the hygienist six months later. Often there is subgingival (invisible) calculus still left even though it should have been removed on the first course of treatment. Plus the patient has no clue how to clean her teeth effectively.

Big Ego

It is a fact that the oral and maxillofacial surgeons have a big ego. Or to precise – they have a huge ego. But in my opinion they have all the right to have one. They NEED one to be able to perform all the talent requiring hocus pocus on patients mouth, jaw and face. Plus they don’t use their ego against co-workers or the patients.

But when a dentist has a big ego it rarely is attractive or talent enhancing. I will give you an example from a real life.

A dentist does a check-up for a patient. Then the patient sees a hygienist for a scale and polish. Whilst scaling with curettes the hygienist notices there are potential cavities in three different sites and she checks the patient’s x-rays. The x-rays confirm the suspicion.

The hygienist checks the dentist’s notes for the check-up visit to see if there is a treatment plan to fix these cavities. There isn’t. It appears as if the dentist has missed the cavities when doing the check-up.

The hygienist sends the patient back to see the dentist. When the dentist sees the hygienist’s message about the cavities he acts as if the patient has come in unnecessarily.

“I’m sure there’s nothing there”

he says to the patient. He quickly checks the sites with a mirror, sighs and continues by saying

“One of these suspected cavities is a borderline cavity. We could do a filling for that so that you didn’t come this far for nothing. The other two we can still monitor.”

The hygienist sees a patient for another scale and polish couple of weeks later. She checks the dentist’s notes and realises that only one cavity has been filled. She asks the patient if the dentist has asked her to come back to have the other two to be done. Negative.

The hygienist is baffled. She checks again with her curette the other two suspected cavities. The instrument goes between the filling and a tooth and sinks deep into a soft area – it is a cavity for sure.

The hygienist decides to ask another dentist to come and have a look there and then. The dentist confirms the two remaining cavities and recommends the patient to have them filled.

At this point the patient is very confused. Who is not doing their job properly? Who to believe?

This was just one example. There are plenty more but I won’t write them down as I am not writing a novel. But my point is that when a lower ranking dental professional finds something the almighty dentist didn’t the ego goes before the patient’s best interest.

Not good. Not good dentistry at all and everyone who recognise themselves from this should be ashamed.

But why the dentist did not notice the cavities even from the x-rays? That is completely another story.

Hygienist’s Difficult Role

It is tough to be a hygienist. They often have skills to make the same diagnosis as the dentists but only the dentists have a right to make one. The hygienist must always remember to add a question mark after their findings or the hell will break loose and she is quickly put back to her place by the dentist who kindly reminds her that she has no right to make a diagnosis.

And when she finds something that the dentist missed she will be between rock and a hard place. Especially if the dentist does not agree with her because of the big ego problem. The confused patient often thinks the dentist was right which makes the situation even more difficult.

But the time is on hygienist’s side. She has recorded every finding on the patient’s dental records – with the question marks! She has recorded that she has consulted a dentist. Sooner or later the cavity (or whatever her finding was) will get worse. There will be pain. Or the crown will come off as the cavity has eaten the tooth under it and perhaps so much so that it is beyond repair.

The dentist can only hope the patient do not file a complaint.

Lonely Rider in a Cupboard under the Stairs

Another side of being hygienist is the fact that they are often quite alone in the practice. It is often so that the practice has only one hygienist. This means they don’t have peer support in the practice. Peer support is something that every dental professional would need.

Also the hygienist is given the oldest dental unit in the practice and the smallest room, the one without a window. Or perhaps the room under the stairs. Not sure if the Harry Potter fate has happened for real – perhaps it was just sarcasm from a hygienist that I once knew?

Conclusion

Why do the dentists feel so threatened by hygienists? Why is it hard to be wrong or admit that you have missed something? Why do they need to feel and let others know that dentists are at the top of the command chain?

I’m afraid I do not have the answers. One dentist once said to me that the dentists are non-qualifiers for medical school which means that the dentistry was not their first choice of profession. Are these kinds of dentists letting everyone else suffer for their disappointment?

I will remind you that not all the dentist are like this of course. But in my current workplace two out of four dentists are. That’s 50%. That’s a lot!

I hope practice owners will start to value their hygienist more than before. And get them the brand new dental unit, a saddle chair (or whatever chair the hygienist prefers) and curettes the hygienist wants so that there would be even a small chance to work in an ergonomic position during the treatment. After all they bring in steady flow of cash with very little expenses.

And dear dentists, we are all equal human beings no matter what our profession is.


You might also like these posts:
Part II: Just Another Day at the Office
Part III: I’m Sorry but I Did Not Get Qualified So That I Can Make Coffee for You