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.

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Alcohol – The Feared Subject

Dental Revelations Blog-1044

About 60 year-old man came to see me one morning and complained that every once in a while a layer of skin comes off inside his mouth and no-one has been able to tell why. He was concerned and felt that it was happening at that very moment as well.

I took a look at the soft tissues before the treatment and asked if he had used a mouthwash the same morning or the night before. Negative. I asked if he had drank wine last night. The patient’s face went serious and he said he had been drinking whiskey last night. I went on telling without any judgement how alcohol effects the mouth and body – the risks in mouth and the age related risks. He looked like he had eureka moment and was very happy but also shaken as he realised that his alcohol use could be damaging his health in more ways than just one.

Now, this blog post is full of information for dental professionals but there are links that are useful for the patients as well. I will give advice to the patients at the end of this post so move on over there if you want to skip the professional part.

Fear of Asking

Us professionals seem to find it hard to discuss about patient’s alcohol consumption. For some reason we think that alcohol consumption is too personal question to ask. Sometimes also the patients think the same which makes it even more difficult question to ask. But we ask about illnesses, smoking, diet and oral hygiene habits. Why not about alcohol?

Everyone knows that smoking can cause oral cancer. But not so many know that alcohol does the same. And even fewer knows that alcohol and cigarettes combined raise the risk of developing oral cancer many times higher. So dental professionals are on the frontline of preventing oral cancer. This means that asking about alcohol consumption should be a routine thing to do and I’m going to help you with that.

  1. When interviewing the patient about his medical history, oral hygiene routines and smoking, continue without hesitation How about alcohol? Do you use alcohol? Keep the same tone of voice as if you were asking did you watch the footie last night?

This is how the conversation continues:

Patient: Yes, sometimes.
You: How often would you say you drink per week?
P: When we go out after work.
Y: How often did you go out last week?
P: Last week we went out almost every night.
Y: What do you normally drink?
P: Beer.
Y: How many do you drink on your regular night out?
P: Normally 3 or 4 pints and on weekends it can be a lot more…

When you engage patient into discussing about alcohol consumption you are kind of evaluating the patient’s attitude towards the subject. Is he co-operative or defensive? If the latter, you need to advance with very small steps. A piece of information here, a piece there. Whenever the patient is ready to take in information about alcohol.

If the patient is co-operative (you would be surprised how many are!), you can move on to sum up the alcohol units the patient consumed the last week and then give information about how it affects his health. Before you can do this you need to know the facts.

2. Learn the numbers and facts behind the risks of excessive alcohol consumption

The recommended low risk (of developing an alcohol related illnesses) daily units are:

healthy women 0-1 units
healthy men 0-2 units
65+ year-olds no more than 0-2 units (no more than 7 per week)

Learn these by heart or print them out (please note, that the recommendations can vary in different countries).

The oral cancer’s death rate is nearly 50%.

Alcohol is an aldehyde and it is metabolised by oral bacteria to acetaldehyde which is carcinogenic in humans.

This is very short but effective list. With this little information you can have a significant impact on patient’s alcohol consumption.

3. Be a therapist if needed

More than once I have been in a situation with a patient when the patient opens up about his life when we discuss about alcohol. There have been patients who have thought by themselves that they are drinking too much. Some tell the reasons behind them. All they need at this point is that someone listens.

But if you feel like the patient needs more advice and guidance, remember to ask
Do you mind me giving you an advice?

People generally respect you more if you don’t offer advice without asking. Especially when it is about alcohol. Have phone numbers at hand for local AA and offer them if needed.

4. If you didn’t ask about alcohol consumption

Do ask about alcohol every time when

  • there is no improvement on oral hygiene routine despite a great effort, especially if there is lot of plaque every time
  • the soft tissues are bright red and the patient is not using mouthwashes (and even if he is, mention also that alcohol can irritate the soft tissues no matter how it enters the mouth)
  • the mouth is very dry and no other reason is found for it

Reminder to All Dental Professionals

Do check the soft tissues and tongue every time you see the patient. It doesn’t take long and you might be saving somebody’s life. No matter if you are a nurse, hygienist or dentist. All of us can tell if something is normal or not and it doesn’t matter who points out the abnormality in the first place.

Have a dental camera or DSLR with macro lens at hand. Learn to use them so that when you see something suspicious, you are able to take a photo of it and compare it the next time.

This is an area in our profession that is too often neglected.

Information for the Patients

You are in good hands when you are interviewed thoroughly on your very first visit and  and every time when you have your check-up done. If you only needed to fill in a medical history form and no-one asks further questions, it’s not a very good sign. The professionals treating you are not looking after you very well.

Please do take our questions as they are. They are questions for your best interest and health and for good quality of treatment. We need to repeat these questions over and over again every time you come in for your regular check-up.

We will ask about subjects (like alcohol consumption) you would rather not discuss with anyone but please do not hide anything or lie. Most often we can see from the patient’s mouth if we were not told the truth about certain subjects like:

smoking
alcohol consumption
how often you clean between the teeth
do you brush your teeth regularly
certain illnesses

So be honest and don’t be afraid of a judgement. It is not our job to do.


Please click here to see the repost of this same post. It includes forewords worth reading.

It’s ok to swallow, it’s only water… Or is it?

Sandbox-4950

You feel the water lever rising in your mouth while you are having a treatment done at the dentist. Your natural instinct raises an alarm in you mind.

I’m going to drown…

I’m choking…

Your eyes open wide and you raise your both hands to make a gesture that you want to get up to empty your mouth. The nurse quickly takes the suction to remove the water but there’s always some left, isn’t there? Your hands are still reaching the spittoon next to the dental chair but the nurse lays a hand on your shoulder and says gently

It’s ok to swallow, it’s only water.

Well is it?

Dental Unit (= the Chair) Waterlines Causing Infections?

The water in dental unit waterlines should match the same standards as safe drinking water. In short this means that the bacterial count (colony forming units, CFU) in the water should not exceed certain safe level (if interested to find out more in depth, please visit here). The standards vary in different countries. The countries I have worked the CFU/ml regulations vary from 100-500. Now here comes the nauseating fact:

In practice the CFU/ml levels can be as high as hundreds of thousands of all sorts of nasty bacteria, including the ones of human origin. Needless to say that it is enough to cause problems.

The problem with the dental units is that many of them are old and do not have the latest technology for waterline cleaning. Renewing the dental units is slow as they are expensive and practices want to use the existing ones as long as possible.

Dental units without waterline cleaning system have a slow flow in the waterlines, the water is warm and the water stands still during off-surgery hours (nights and weekends). Sounds like a very bad combination, eh? The old dental units do not have preventive valves in the waterlines to stop suck back of the patient’s saliva into the lines.

So as a result the waterlines in the dental units are lined with biofilm (a mass or layer of live micro-organisms attached to a surface) that should be removed regularly.

Who Is at Risk?

The healthy patients should not worry much. But to be honest, I do not like to swallow the water myself. It’s gross.

The patients whose immune system is impaired are most at risk. The elderly, the young children, medically compromised people and everyone with immunodeficiency. In worst case scenario the visit at the dentist can be lethal.

Of course us professionals are at risk as well. There are lots of aerosols in the air during the use of the dental unit. A bacterium to raise the biggest concern is the Legionella that causes Legionnaires’ disease. So do take care of the unit waterlines.

Advise for Professional to Improve the Water Quality

Use water source that meets the standards for drinking water.

Run the water from the unit waterlines (handpieces, ultrasonic scalers, air/water syringes):

10 minutes after the weekend
3 minutes in the morning
30 seconds after every patient

Use an efficient waterline treatment product recommended by the unit manufacturer. Use it regularly. Running the water as I advised will get rid of the free flowing bacteria but not the biofilm, it needs an effective disinfectant. The most effective product for getting rid of the biofilm are the ones containing:

hydrogen peroxide
hypochlorite
superoxidized water

Invest in new dental unit (do not go to the cheapest option – you only go from bad to worse) with the latest technology. It’s only humane thing to do.

Conclusion and Cause for Worry

In my experience the dental unit waterlines are not looked after as they should to maintain the good quality of the water.

I have seen that instead of cleaning the waterlines the dental professionals have stopped using the water e.g. when using the slow handpiece (the drill that feels like a street drill). Now I must mention that this happened only in the other country I worked at. I never found out why they actually do this (please enlighten me on comment box below!) but perhaps it was because of the water quality problem? When I used a slow handpiece there, I was naturally worried about overheating of the tooth and tried to get water flowing but it was made impossible.

I have seen a dentist performing implant surgery using a water from air/water syringe (it wasn’t the only thing that was wrong with that treatment – imagine dentist’s tie hanging loose and contaminating everything it touches. Sterile surgical coat was nowhere to be seen). Implant surgery if anything needs an absolute clean environment and wearing your personal clothes and using unit’s water supply simply is not up to the standards.

I know for a fact that many dental nurse neglect running the water as described above. It is appalling thing to do. Honestly.

What does this tell about us professionals? We should be the ones that are looking after the patient’s best interest and health. Doing all the fancy and immaculate maneuvers inside the mouth is not enough to fulfil our purpose.

Are we too busy making money and forgetting the basics?

Advise for the Patients

Seek out a modern dental practice with modern equipment. If you are unsure what modern dental unit looks like, here‘s one example (unfortunately I don’t get paid for advertising this site).

It is ok to ask the nurse or the dentist if the waterlines are regularly disinfected and if the nurse runs the water after each patient.

 

 

Soap Opera of the Dental Practice

Sandbox-3239
Sometimes colleagues act like kids in a sandbox. On a frosty day.

The next time you lay back on dentist chair to have either check-up or treatment done, instead of concentrating on squeezing the handles in a fear of the pain and unknown, pay a close attention to the chemistry between the dentist and the nurse. If you are lucky, it can be very entertaining to watch and listen, and you forget the whole business of being nervous.

Ideal Dentist-Nurse Relationship

An ideal relationship between a dentist and a nurse is such where mutual respect prevails. They are two human beings, professionals working together for the patient’s health and earning their living. Both of them understand that one could not work without the other (at least without seriously compromising the safety of the patient) and especially that they could not work without the patient. They may be good friends that go beyond the working day.

Dentist-Nurse Relationship from Hell

It can be a sign of a non-working relationship if it is the nurse that calls your name at the waiting room of the dental practice. Not always, but often it is so.

Why? Because normally it is the nurse who has more to do after the previous patient than the dentist. The nurse spends long time wiping surfaces (should do), equipment, patient chair with a disinfectant, sterilizing instruments and preparing the room for the next patient.

Meanwhile the dentist chats with the previous patient, records the visit (takes couple of minutes, sometimes even less if the dentist is not bothered to write anything else than check-up and adding a sign that tells us professionals that nothing special was found) and checks the next patient’s treatment plan, which she should have done already in the morning. All this often takes less than what the nurse needs to do.

A revelation:

Some dentists feel that they are too highly educated to walk the aisle of the surgery to call the patient in. It is the nurse’s duty even if it meant that the dentist has nothing to do while the nurse is finishing with disinfection business (well, she can always have a cuppa while waiting).

Here is an example of this. I have witnessed a very highly educated specialist taking a seat in the front of the computer every time the nurse walks out to call the patient in. And when the nurse returns with the patient, the specialist is looking intensely at the computer screen looking all important and wise for few seconds and then almost like apologetically getting up (for not noticing that the patient arrived) and rushing to shake hands. This happened with e-v-e-r-y patient. Honestly.

But.

There are nurses that prefer to call the patient in from their own will. In this case any of the following won’t happen in the surgery. So keep reading!

Once you have taken a seat in the dental chair, the nurse gives you the safety glasses and a bib to cover you shirt and tilts the seat down. Here comes the next battle of the non-working relationship between the dentist and the nurse.

The ergonomics are very important in dental profession. It means early retirement or occupation change if you work in wrong positions for many years. In a good healthy working environment the dentist and the nurse have tried and tested the positions of the patient chair that is good for both of them (there will be exceptions e.g. when very large patient or heavily pregnant patient comes in).

So the nurse placed the seat down and sits beside you. The dentist washed her hands (hopefully) and puts on the face mask and gloves. She moves her chair beside you and starts adjusting the patient chair’s hight and tilting-angle. If you see the nurse moving hastily further away from you or standing up, you know they do not work well together. The dentist has just adjusted the seat so that the nurse is not able to find an ergonomic position.

If they have worked together like this for years, there is lots of anger and resentment from the nurse’s side. You might be collateral damage in this war, I’m afraid. If you feel like your mouth is filling up with water, you need to swallow it a lot (by the way, you can swallow it, it’s just a tap water, is a lie and I will write about it later on this blog) or it pours out from the side of your mouth on to the dentist’s lap, it might be a silent demonstration against the dentist’s tyranny over the position of the patient chair and the patient’s head.

Twisted, but that’s how it goes.

Other Signs of Non-Working Dentist-Nurse Relationship

  • they don’t chat while treating you
  • they don’t make jokes to try to ease you fear
  • you hear lots of clatter from the instruments (they are thrown in the tray)
  • they reply cynically to one another (normally nurse to the dentist and in non-funny way e.g. as soon as I have time)
  • they argue about treatment, equipment and materials. How they should be used or should they be used at all – the dentist wins these arguments as they are the higher educated ones and cannot be wrong. Especially not in the presence of the patient
  • the nurse sits like a statue after the dentist has requested for an instrument. Just before the dentist is about to renew his request the nurse rolls her eyes and slowly reaches for the instrument

Definite Sign of Non-Working Dentist-Nurse Relationship

The nurse walks out of the surgery.

Conclusion

Just imagine what it is like to work as a pair and the chemistry does not work. It is simply and utterly torture for all including the patient. And it is very common in dentistry.

If you, a dental professional recognised yourself from the above, please start working towards a better relationship. It starts from the respect.