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Part II: Just Another Day at the Office

Dental Revelations4 Comments
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“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

Dental RevelationsLeave a comment

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

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

Dental Revelations2 Comments
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Zovirax can be used to make the cold sore heal quicker.

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 speed drills have water cooling system and this means there are aerosols in the air when the drill is used. And the aerosols carry pathogens from the patients mouth as far as two metres (about 6,6 feet) from it’s origin.

The nurse noticed that the patient had a large cold sore on a lip. Dentist appeared as if he had not noticed it and asked the patient to sit down in the patient chair. Chair was tilted back and when the dentist put his fingers inside the patient’s mouth the nurse discreetly pointed out the cold sore. The dentist carried on with the treatment and ignored the cold sore.

The nurse was worried. Very worried. And she had all the right to be. She knew the cold sore virus – herpes simplex – can easily spread to her eyes and hands, dentist’s eyes and hands, patient’s eyes and mouth via the aerosols produced by the high speed drill.

Herpes simplex virus in the eye can result in blindness.

Herpes infection on hands (herpetic whitlow) of a dentist/hygienist/nurse might force a career change as one cannot do any treatment on patients when the herpetic whitlow is active.

But the nurse didn’t have any other option but to continue with the treatment as the dentist is considered to be the one who is more educated in the matters of health and carries the responsibility of the treatment. This means the dentist makes the decisions behalf of the nurse and the patient whether to continue with the treatment or not.

Now it might be a good idea to read one of my previous post about integrity of dentists so you understand the motives behind the dentist’s decision in this story.

So on they went with the high speed drill. For an hour and a half.

Less than a week later the nurse developed a bad head ache and the next day she had sores in her mouth. Two days later she had temperature of 40 degrees and the mouth, gums and lips were full of painful sores. The GP diagnosed a primary herpes and prescribed anti-viral medicine. She was off work for a week.

When the patient with the cold sore was seen the next time in the surgery he had small blisters near the operated site.

Cold Sore Aka Herpes Simplex 

Before the anti-viral medication was developed the primary herpes used to be an infection that was often lethal. The doctors treating the patients with primary herpes could only cross their fingers and hope the patient will make through it. Many didn’t.

It can still be lethal but we have medication to treat it.

Most of the people get the primary herpes as a child and it often is asymptomatic. If contracted as an adult the primary herpes can have more difficult symptoms.

The primary herpes can be followed by secondary herpes (recurrent infection) – most commonly as a cold sore on a lip. The most frightening one of the recurrent infection of herpes simplex virus is encephalitis.

Guidelines for Treating Patient’s with Cold Sore

I asked my friend Google and she quickly found me several sites that were unanimous about what us dental professionals should do if we see a patient with a cold sore.

Do not do any treatment that can be postponed!

To convince you I copy-pasted guidelines from couple of sites.

Elective dental treatment should be deferred for patients with active lesions as aerosolization of the virus may occur during dental procedures, placing both the patient and oral health care provider at risk for possible infection or re-infection.

Elective treatment should be postponed until the lesion has healed completely. Though the patient may be comfortable after you have applied a topical medication, there is still the risk of spreading the disease to the health-care provider.

Because herpes is transmittable to patients from dental health-care professionals who have active lesions, there is a risk of spreading this disease. The guidelines from the CDC are clear. Each of us has to keep patient safety and staff safety a priority.

Conclusion

The guidelines are clear. The medical facts are clear. Why do dentists still treat patients with cold sores and risk the health of the nurse and the patient, let alone their own health? They if anyone should know how serious risk it is.

So why?

I’m afraid you might know what’s coming (especially if you read my post Morals in Dentistry). Yes, the only reason for this kind of selfish and negligent behaviour from a dentist is GREED. And perhaps small amount of twisted enjoyment of having power – being almighty in this little world that has two people the dentist can make decisions for.

When the patient walks in the surgery with a cold sore it is simply just not acceptable from the dentist’s perspective to reschedule the appointment even though everyone’s health is at risk. No, no. Profit overrides reason. Shame you who just recognised yourself.

I know there are also hygienists who see the patients with a cold sore. But this is because they don’t either know better or because they are not practice owners. Refusing to see a patient with a cold sore is not considered to be in the best interest of the practice. Plus what can you do if the patient with a cold sore just saw a dentist for a filling and is scheduled to see you for a scaling. How can you say no when the dentist said yes?

It requires lot of self confidence and experience to be able to stand up for you right to decide for your own health. Something the nurses do not have a chance to do. It proves once again how the dentist-nurse relationship is nowhere near about equality as co-workers. Not even in the matters of personal health.

I reschedule the appointment if the patient has a cold sore. And the next appointment won’t be sooner than a fortnight. I also use the opportunity to inform patient about the herpes simplex and ask patient to cancel the appointment next time when he gets a cold sore before the dental appointment.

And seriously (for all the dental professionals):

Applying Zovirax and placing a plaster on top of the cold sore before doing the treatment is just simply bonkers.

Here’s some further reading about the guidelines of seeing a patient with a cold sore.

Remember to share this post if you think there was important information that everyone should know.

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

Google for a Day – Comprehensive Answers about Cold Sore and Dentist
Are Your Dentist’s Tools Clean?