Value Based Dental Practice

transcript

The Exceptional Patient Experience T h e Va l u e s B a s e d D e n t a l P r a c t i c e

William T. Brown, D.D.S.

Friday, February 22, 13

Introductions

2Friday, February 22, 13

Introductions

Introduce yourself and

Introductions

Introduce yourself and

What influenced you to go into the Dental Profession?

Bill Brown

Bill BrownWho am I?

Steps in achieving workshop goals:

“IS”

“WAS”

“IS”

“WAS”

“MIGHT BE”

My Goal is that Each of You Will:

Identify some change you want to make

Understand COHC

Develop & use your philosophy as a communication tool.

Understand COHC

Conduct exams that influence attitudes & monitor oral health.

Understand COHC

Conduct exams that influence attitudes & monitor oral health.

Have you leave with an idea of your next step.

BRAINSTORMING

For Change:

Change

“Everyone thinks of changing the world, but no one thinks of changing himself.” - Leo Tolstoy.

An EXPERIMENTAL ATTITUDE

Key Elements:

Core Beliefs that are understandable & repeatable by staff & patients.

Key Elements:

Establishing Effective Doctor-Patient Relationship.

Key Elements:

Involving Patients in a Health Story.

Key Elements:

Involving Patients in a Health Story.

Dental Metrics to Monitor Patient Progress.

A Personal Story

Diagnosed with gingivitis at age 28

A Personal Story

I was shocked!

I thought I had a healthy mouth

A Personal Story

I thought I had a healthy mouthThis revelation caused me to change

A Personal Story

I thought I had a healthy mouthThis revelation caused me to change I needed to find the cause

A Personal Story

From My Own Life,My Conclusions:

Interruption of a disease process

Patients were responsible for their oral health

And not “Objects of Treatment”

NEW SYSTEMS NEEDED

The Result of My Learning & Influences”

c o m p r e h e n s i v e o r a l h e a l t h c a r e

Knowledge is Empowering

Critical Issue

Studied causes of my problem

Bacterial plaques

Mechanical removal

Bacterial plaques

Mechanical removal

Unmanageable areas manageable

Bacterial plaques

Mechanical removal

Unmanageable areas manageable

The cause of man’s most common disease was bacterial plaques

Dr. C.C. Bass

Dr. C.C. Bass in his dental laboratory

Bacteria settle on the teeth and organizes to cause disease

What He Found Out:

Dr. C.C. Bass in his dental laboratory

I incorporated the Bass techniques personally, and my periodontal disease was controlled in less than a month

Dr. C.C. Bass

I incorporated the Bass techniques personally, and my periodontal disease was controlled in less than a month

This personal experience and epiphany was a revelation that I knew I had to share with my patients

Dr. C.C. Bass

Comprehensive Oral Health Care

Resulted from experience & influences

Dentistry is a dynamic evolving science

Shift from techniques to dental team

The Five Components of COHC

humanistic

Humanistic

Humanistic- Importance of patient involvement in oral health care

- What a patient does every day is more important than what is done in the dental office two or more times a year

- Avoid treating patients as objects

humanistic

biologic

Biologic

Biologic- Understand basic biology

- Oral Cavity-Organ System

Health Plans Expand Dental BenefitsStudies Linking Gum Disease To Health Problems Spur New Focus on Preventive Treatments

The Future

Picture a world where dentists are the entry point in the health care system.

The Future

Relationships between Perio Disease and :

The Future

• CV Disease

The Future

• CV Disease

• Diabetes

The Future

• CV Disease

• Diabetes

• Pre-Term and/or Low Birth Weight Babies

The Future

• CV Disease

• Diabetes

• Pre-Term and/or Low Birth Weight Babies

• Salivary Diagnosis

humanistic

biologic

humanistic

biologic

diagnostic

Diagnosis

Diagnosis is the reason for professional education

Diagnosis

Diagnosis is based upon COE

Diagnosis

Diagnosis is based upon COE

humanistic

biologic

diagnostic

humanistic

biologic

diagnostic

therapeutic

Therapeutic

- Importance of providing the patient with comfort, function and a good appearance

Therapeutic

- Importance of providing the patient with comfort, function and a good appearance

- Therapy is based on the information gathered in the examination/diagnostic phase.

humanistic

biologic

diagnostic

therapeutic

humanistic

biologic

diagnostic

therapeutic PHILOSOPHY

Philosophy:

The “glue” that holds the components of COHC together

Philosophy:

Used as a communication & management tool with staff and patients

Philosophy:

- Should be easy to explain & repeatable by patients & staff.

Philosophy:

- Should be easy to explain & repeatable by patients & staff.

- Can be a roadmap.

Comprehensive Oral Examination

PHILOSOPHY

c o m p r e h e n s i v e o r a l e x a m i n a t i o n

This is NORMAL

The Gold Standard!

Bleeding Is Not Normal

This is average, but not normal

System development

- Baseline data

System development

- Baseline data

- Quantify monitoring progress

Benefits

- Involves patient in a HEALTH STORY

Benefits

- COE is what’s best for your patients

Benefits

- COE is a powerful non-verbal communication tool you’re thorough

Benefits

- Co-Dx can break the “preoccupation barrier”

Benefits

- Co-Dx can break the “preoccupation barrier”

- Check list - Don’t land with wheels up! Friday, February 22, 13

Additional benefit: what’s best for the patient

What would you do for a member of your family?

Additional benefit

- Change in dentist’s image

Yields benefits to patient and practitioner

A powerful nonverbal communication of your sincere desire to be thorough and complete in your procedures

Instantly communicates to your patient that your practice is exceptional

Establishes a new rapport

Is the only method:

- To find all the patient’s needs

Is the only method:

- To find all the patient’s needs

- Dentist’s moral, legal obligation, and responsibility

Can you imagine a physician’s Physical Exam:

Without measuring blood pressure

- Without weighing you

- Or listening to your heart and lungs

Preposterous for “RD” to perform the above procedures, but not record them

As many procedures as there are dentists

- My procedure evolved over many years

- You decide what might work for you

- My COE can serve as a matrix or outline

- COE is culmination of many different sources

With COE:

Baseline data allows us to determine patient progress.

Barkley, Kohn, and Burns

Dr. Robert Barkley, DDS

Elements of COE

Orientation

Elements of COE

Orientation

Clinical

Elements of COE

Orientation

Clinical

Radiographic/Digital (CBCT?)

Elements of COE

Orientation

Clinical

Treatment planning

Elements of COE

Orientation

Clinical

Treatment planning

Consultation

Elements of COE - Orientation

Medical / DentalHistory

Non-ThreateningEnvironment

You are what the patient experiences

Non-ThreateningEnvironment

Interview

Philosophical Agreement

- not byacquiescence

PatternedInterview

How can I help you? _______________________________________________________Review medical history. ___________________________________________________Age of first dental appointment. ___________________________________________Any history of bad experiences. ___________________________________________Was care regular? __________ How much care was needed?__________________Are parents living? _______________________________________________________What is parents’ dental condition and care habits? Edentulous? _____________What is / was brothers’ / sisters’ dental condition and care habits? Edentulous? ________________________What is / was spouse’s dental condition and care habits? Edentulous? ______________________________What is / was children’s dental condition and care habits? Edentulous? __________________________________How would you describe your present dental health? Good Fair PoorWhat has the past five years’ care been? ____________________________________Do you think your dental disease is active or controlled? ____________________Have you been taught to control it? ________________________________________How do you feel about ever losing your teeth? ______________________________Two main goals of practice? _______________________________________________Any problems to handle today? ____________________________________________

Orientation - Dental History

Mantra for new patients

“We have unconditional amnesty for dentist evaders.”

Specific comments:

- How can I help you?

Specific comments:

- Review medical history.

Specific comments:

- Age of first dental appointment.

Specific comments:

- Any history of bad experiences?

Specific comments:

- Was your care regular? How much was needed?

Specific comments:

- Was your care regular? How much was needed?

- Are your parents living? Parents dental conditions & habits? Edentulous?

Specific comments:

- What is/was your brother’/sisters’ dental condition & care habits? Edentulous?

Specific comments:

- What is/was your spouses’ dental condition & care habits? Edentulous?

Specific comments:

- What is/was your spouses’ dental condition & care habits? Edentulous?

- What are your children’s dental condition & care habits? Edentulous?

Specific comments:

- How would you describe your present dental health? Good, Fair, Poor?

Specific comments:

- What has the last five years’ care been?

Specific comments:

- Do you think your dental disease is active or controlled?

Specific comments:

- Have you ever been taught to control it?

Specific comments:

- Have you ever been taught to control it?

- How do you feel about ever losing your teeth?

CRITICAL POINT

Two main goals of practice:

CRITICAL POINT

Two main goals of practice:1. Never lose your teeth.

CRITICAL POINT

Two main goals of practice:1. Never lose your teeth.2. Ultimately lower the incidence

of dental repair

CRITICAL POINT

Orientation accomplishes:

- Agreement on the basics before proceeding - not by acquiescence

- Establish common reference point - agree philosophically

- New doctor patient relationship

- Personal dental health awareness

- New insight and understanding

Establish a Relationship

Elements of COE - Radiographic/Digital

Digital Radiographs, Digital Images

and Models

Co-Discovery

Digital Imaging for Co-diagnosis

Clinical

Co-diagnosis

Elements of COE - Clinical

Exam Form

Dental

Record on the tooth chart.

Missing teeth, why lost, position of remaining teeth and replacements No. ________________________________________________

Chart all other variations from normal, (see symbol sheet)

Palpation over the gingiva and roots of the teeth to determine bone form _______________________________________________________

Extension of the lips and cheeks for the observation of frena and muscle attachments, position of the gingival margin, and width of the attached gingiva.

Probe for pocket depth and furcation involvement.

Son of a Dentist

Attached Gingiva

Dental Form

Soft Tissue

Buccal Mucosa

Examination Form

TMJ (Temporo- mandibular Joint)

Exam Form

Occlusion 0 - none 1 - slight 2 - moderate 3 - extensive

___ Premature centric contacts No. __________________________

___ Biting stress mobility No. _______________________________

___ Right working contacts No. ______________________________

___ Right (left) non-working No. _____________________________

___ Left working contacts No. _______________________________

___ Left (right) non-working No. _____________________________

___ Protrusive contacts No. ________________________________

___ Right dec. chewing efficiency ____________________________

___ Left dec. chewing efficiency _____________________________

Non-Working Interferences

Occlusion

Exam Form

Habit Signs 0 - none 1 - slight 2 - moderate 3 - extensive

Tongue ThrustTongue ThrustReverse swallowingLateral indentationsFungifuorm enlarge

BruxismBruxismFacetingOcclusal wearHyper masseter

MouthbreathingMouthbreathingLack of nasal flareGingival changesNail biting

TemporomandibularTemporomandibularRight painRight crepitusLeft painLeft crepitus

AmelogenesisImperfecta

Tooth Mobility

Periodontal Pocket Depth

Probing

Periodontal Pocket Depth

Probing

Probing in Six Places

Why periodontal disease can’t be diagnosed with x-ray only

Cadaver

Cadaver Lingual View

Enamel Projection

Enamel projection

Elements of COE - Treatment Planning

Exam Form

Complete the remainder of the form after the patient is dismissed.

General condition of mouth ___________________________________

State of active disease

Caries _____________________________________________________

Perio _____________________________________________________

State of bacterial control _____________________________________

State of manageability _______________________________________

Pt’s attitude during exam - Interested Casual Disinterested

Fears and dislikes of potential treatment possibilities _____________________________________________________________

Hope and desires about future dentistry ______________________

_____________________________________________________________

Initial Status

FacialFacialFacial

1-5 6-11 12-16TEETH NO.

CALCULUS

BLEEDING

SUPPURATION

GINGIVAL TEXTURE

GINGIVAL FORM

EXTOSTOSES

PLAQUE (DEBRIS)

PalatalPalatalPalatal

16-12 11-6 5-1

FacialFacialFacial

17-21 22-27 28-32

LingualLingualLingual

32-28 27-22 21-17

Date TM Occl Sul Ging Perio Calc Debris Irritant

INITIAL

RE-EVALUATION

SIX MONTH

ONE YEAR

TWO YEAR

THREE YEAR

Etiology ______________________________________________________________________________

Diagnosis _________________________________________________________________________

Prognosis __________________________________________________________________________

Treat Plan _________________________________________________________________________

__________________________________________________________________________________

Initial Status

Patient Status

Section 1. First appointment. (Orientation)Observations about patient.

Section 2. Second appointment. (Examination)Summarize medical history (questions 1-55)Additional dental history information obtained during examinationSummarize dental history (questions 56-105)Basic physical findingsSummarize diet history (questions 106-115)Synopsis of historical findings

Section 3. Oral ExaminationComplete soft tissue examination (quanitate changes 0-3)Complete occlusal examination (quanitate)Habit evaluationReview of radiograph findingsDental examination (complete charting of all restorative and periodontal needs - absolutely must probe all pockets)

Section 4. Review of findingsQuantitation of the periodontal condition at initial examination. Quantitation of periodontal findings with progression of treatmentTM - Tooth Mobility; Occl - Occlusion; Sul-Pocket Depths; Ging - Gingival Status; Perio is average of means of TM, Occl, Sul, GingCalc - Calculus; Debris - plaque; irritant is average of calc, debris

Explanation of Examination

Initial Status with Numbers

from Exam

FacialFacialFacial

1-5 6-11 12-16

2 1 23 2 21 0 12 2 22 2 20 0 02-3 3 3

TEETH NO.

CALCULUS

BLEEDING

SUPPURATION

GINGIVAL TEXTURE

GINGIVAL FORM

EXTOSTOSES

PLAQUE (DEBRIS)

PalatalPalatalPalatal

16-12 11-6 5-1

2 1 22 2 21 0 11 2 11 2 11 0 13 3 3

FacialFacialFacial

17-21 22-27 28-32

1 2 12 3 20 1 02 3 22 3 20 0 03 2 3

LingualLingualLingual

32-28 27-22 21-17

2 2-3 23 2 31 0 12 2 22 2 20 0 03 3 3

Date TM Occl Sul Ging Perio Calc Debris Irritant

1 2 2.6 2 1.9 1.7 2.9 1.8INITIAL

RE-EVALUATION

SIX MONTH

ONE YEAR

TWO YEAR

THREE YEAR

Etiology ______________________________________________________________________________

Diagnosis _________________________________________________________________________

Prognosis __________________________________________________________________________

Treat Plan _________________________________________________________________________

__________________________________________________________________________________

Initial Status

Patient Status

Explanation of Assessing Periodontal

Status: Quantization of

Periodontal Condition at

Initial Examination

SCORING CALCULUS

Score 3Score 2Score 1Score 0

heavy calculus (supra sub)moderate calculus (mainly sub)slight calculus (mainly supra)none

SCORING BLEEDING

bleeds easily with probingbleeds moderately with probingbleeds slightly with probingnone

SCORING SUPPURATION

pus readily appears with probingpus moderately appears with probingpus slightly appears with probingnone

SCORING GINGIVAL TEXTURE

considerable swellingmoderate swellingslight swellingnormal

SCORING GINGIVAL FORM

considerable enlargement alterationmoderate enlargement alterationslight enlargement alterationnormal

SCORING EXOSTOSIS

considerable exostosismoderate exostosisslight exostosisnone

SCORING PLAQUE (DEBRIS)

most of tooth coveredabout 1/3/ of tooth coveredless that 1/3 of tooth coverednone

Simple or complex

Departure from normal

Simple or complex

We see mostly “average” not normal

Simple or complex

We see mostly “average” not normal

Complex may require “team approach”

Patients comment:

“Do you do this for everyone?”

Radiographic Exam

Case Planning

Digital Metrics for COHC

DentMet Excel Spreadsheet

Digitizing Dental Metrics

• Code can be written in Microsoft Visual Basic

• Metrics can be coded with oral commands through voice activation module

• Dental metrics can be statistically analyzed for an overall sum of patient’s health

• Dental metrics can be linked to existing practice management software

Potential Digital Metric Partners

Digital Images and Models

Elements of COE - Consultation

Consultation Can:

Allow you to stop feeling you have to badger people into accepting treatment.

Consultation Can:

Help you find out what the person wants in a dentist

Consultation Can:

Find out what the person dreads about dentistry.

Consultation Can:

Help you replace resistance with collaboration.

Consultation Can:

Keep you from feeling like a salesman.

Consultation Can:

Keep you from feeling like a salesman.

Allow you to have a productive conversation about the patient’s wants and needs.

Consultation IS:

Based upon COE & Diagnosis

Consultation IS:

The highest productivity of the Dentist

Consultation IS:

A critical issue for the patient

Consultation IS:

Variable (Simple, Complex, etc.)

Consultation IS:

Not a “batting average”

Consultation IS:

Not a “batting average”

The embodiment of your practice philosophy

Summary of COE

How COE can solve problems

Summary of COE

Make money (can only treat what you know to look for and find)

Summary of COE

Stay out of trouble

Summary of COE

Stay out of trouble

Do what’s best for your patients

Patient Who Did Her Own Surgery”

After Meticulous Home Care:

Before Plaque Control

Two Weeks Later

Disease Processes Differ

The Mount Rushmore of Dentistry

• G.V. Black

• C.C. Bass

• G.V. Black

• C.C. Bass

• Robt. Barkley

• G.V. Black

• C.C. Bass

• Robt. Barkley

• Sumter Arnim

• G.V. Black

• C.C. Bass

• Robt. Barkley

• Sumter Arnim

• Per Branemark

• G.V. Black

• C.C. Bass

• Robt. Barkley

• Sumter Arnim

• Per Branemark

• Michael Buoncore

• G.V. Black

• C.C. Bass

• Robt. Barkley

• Sumter Arnim

• Per Branemark

• Michael Buoncore

• Dr. Bob Margeas

What changes do I want to make?

How do I make them?

What You Want:

LIST FOUR THINGS YOU WANT YOUR PATIENTS

& STAFF TO SAY, BELIEVE, FEEL ABOUT YOU AS

A DENTIST AND YOUR DENTAL PRACTICE.

Extensions for successful change

Control your own oral disease, if you haven’t already.

Require your office staff to have their oral disease under control.

Develop an examination form which includes components that you feel are necessary to accomplish COHC.

With a colleague, conduct a thorough examination on one another.

Conduct a thorough exam on a few selected patients (family, staff, patients) and solicit their reaction.

Write your philosophy of oral health care and share it verbally with your staff. Solicit their reaction.

Solicit the oral health care philosophy of your staff. Is it the same as yours?

Review patient records to see if you can make specific observations on patient progress.

Provide a small, select number of patients with a written and (or) verbal diagnosis. Solicit their reaction.

Analyze with your staff the ways that your office and dental practices contribute to changing the dental behaviors of patients.

Discuss the ideas shared here, and get their reactions.

You’ve Been Shown:

How systems were developed.

And how you can develop you own unique program.

My system isn’t perfect.

Your system will have shortcomings.

The process will enhance your goal

Comprehensive Oral Health CareT H E G O A L O F D E N T I S T RY

Patient Communications

need a section on pt. relations: Green Notes, office satisfaction surveys, mystery patient, staff feedback, focus groups, cleanliness (office, staff, Doctor) e.g. spots on glasses, blood spatters on gowns, breath odor, personal grooming.

The car you drive and How you drive it.

The way you dress.

Value Based Dental Practice

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