ESMD Secretariat Phone: +370 625 86677, e-mail: [email protected], www.esmd.info Close-Up The European Society of Microscope Dentistry Dear readers, Obviously you all liked the previous CloseUp. In this third edition, we would like to give you an overview of ESMD membership advantages and upcoming ESMD events. Further on, you can read about management issues and about the use of the dental operating microscope in preventive dentistry. I am most grateful for the contributions that have been sent in. These articles make CloseUp a living and growing news- letter. I hope you enjoy! Rebecca Van Audenhove 1 Word of the Editor Issue no. 3, July 2011
David English is an experienced dentist. He obtained an honours degree in Dental Surgery from the Royal London Hospital having previously obtained an honours degree in Human Biology and an MSc in Biomechanics.
He has recently completed an Endo-dontic diploma at the Royal London Hospital. He is an active member of the local Norwich Dentists Study Group and regularly attends many national and international post graduate meetings. He routinely uses an operating microscope to enhance and record treatments.
David English is speaker of the Leuven Autumn School, organized by the ESMD. 2-3 September, 2011.
Website of David English: http://www.davidenglish.co.uk
One area of general practice that is very important to me is prevention. We know that the main dental issues of caries and periodontal disease are caused by bacteria. We are increasingly aware of the complexity of bacterial biofilms. We know that if the right mechanical disturbance is applied to the tooth surfaces where a biofilm exists it can be disrupted and largely removed. We know that this is very beneficial. It works to control and arrest dental disease. We know that some of our patients are more sensitive than others to this biofilm. We know that especially for these people good plaque control is a prime consideration. They need to remove and breakdown this film on a regular basis. Ironically they can be really very good at cleaning their teeth as judged by many life skills. They could be judged 90% efficient in achieving plaque/biofilm free surfaces, even 95%. If we score 95% in an examination we are very likely to be 'top of the class' and by a long way! The sad irony for disease vulnerable patients, and there are many of them, is that this may not be good enough to control their disease. The 5% of tooth surface missed is likely to be in the inter-proximal and cervical margin areas. In these areas the biofilm will effectively remain undisturbed from one end of the year to the next. I may be overstating the percentages a bit, but for these patients they really do need to have their daily plaque control regimes brought up to the highest level. Not many learnable life skills are so demanding... maybe landing aero-planes is also not a good area to under achieve and anyway not so many of us
“Oral health education through the scope and the importance of screen position”
need to learn that one! Most of the time people doing things in their daily lives are not focussed on 100% accuracy.
In these situations I really appreciate using my microscope imaging system to record and explain the issues. I have emphasised that really for some patients it is the detail of the detail in plaque control that will help most. These are some of the things that I have found out.
Not every patient likes looking at pictures of their teeth. We may have to try another approach!
Most patients actually are very curious to see the pictures I have taken. That is once they get over the “Oh my God, are these my teeth?”. For example I can show periodontal measuring probes
I can show the plaque and calculus deposits where this is happening. I can show the 'bleeding on probing' and purple puffy gums.
This is all obvious information to us professionals who deal with this everyday but a revelation to some patients who can't see into their own mouths to notice the problems. I guess I could use an intra oral camera to achieve some of this but it really is much more practical for me using a scope and to have my assistant using a remote control to 'shoot' the images while I have the use of both hands for mirror use and retraction. This camera remote control is used in a disposable plastic bag for hygiene purposes. Another point to note is that not all digital cameras have a remote control option. I think it is important not just for the hygiene aspect but to avoid camera movement when taking images.
I take lots of pictures if only to try different points of focus to get clarity. With the storage capacity for digital images these days why not? I take low magnification views of the whole mouth or quadrant before taking detail 'close up' images to help orientate the patient to where the issue is. This is an important point to consider in the purchase of a microscope. If you are an endodontist you may not need this facility. You may feel that you only need to look at one tooth at a time and be quite happy to save some money by buying a scope with just three higher magnification levels.
I can also do this 'real time' with patients, which would be difficult with just an intra oral camera. This means I need to have viewing screens in the right place. The detail is important.
These photographs show a good position for a screen to allow the patient see what is going on. Good when there is a right handed dentist who tends to work in the 11 o'clock position! For the patient to see well there is a 'window of opportunity' to see the screen shown in the pictures that is not obscured by the microscope or by the operator and assistant too much.
Position of microscope and screen for assistant on the left.
Lengths of white plastic tiling trim placed to indicate general line of sight a patient can have to the screen if it is placed in the correct position.
I also have another screen for viewing when the patient is sitting up. This at the end and to the right of the patients chair. The screens I use have a multi input functionality so I can switch sources and for this 'patient sitting up' viewing screen I can also switch to show radiographic images.
There you have it. Not high powered 'dental eye candy' gingival recons-truction or apical surgery through the 'scope but for me a very useful day to day tool for the basics of dentistry that I really want to try and get right... prevention of disease.
And just in case you were wondering, I also use my operating microscope for other types of dentistry. Especially in diagnosis, general conservation, surgery, crown and veneer preparations and endodontics.
If the screen is mounted too far away from this position the patients will turn their head to see and the mouth will disappear off the screen! I have also been a patient in this operatory and watched my upper left second molar being prepared for a crown. Surreal but very interesting.
For oral hygiene instruction I can show the patient directly where they need to clean and what they need to use. This often comes down to demonstrating the use of colour coded inter-proximal 'bottle brushes'. We can record the images and even send them home with a photograph of which to use and where.
Raising your income seems to be linked to having new patients. But it is equally important to keep your back door closed! Patients might easily escape without you noticing.
In her book 'Win Back Customers' Jill Griffin describes how a customer goes through 3 phases when planning to leave his/her provider. Each phase has its own characteristics and it is important for you to recognize them to prevent problems.
Even if we prefer to call our customers 'patients', they are in essence the same…
Keep an eye on your offices back door!
Phase 1: Depreciation.
Phase 2: Dissatisfaction.
A patient feels like getting less value for his money. This first phase often goes unnoticed by the dentist because most patients do not complain in this first phase. The best way of discovering such patients is to try and bring latent complaints (that are not expressed) to the surface.
Tip:Make complaining easier for patients. Have your staff question a patient who makes a remark such as: 'I did not like this so much last time…' or so. And question often enough to make sure everything is O.K.: 'Was everything going well? What can we improve?...'
Conclusion: Patients in phase 1 find that you don't meet their expectations. You hardly notice. By creating a more accessible complaint procedure, you can prevent worse.
And the more contact you have with the patients, the more likely you will get signals!
In this phase, your patient is less consuming. He/she postpones regular checkups or even planned treatment. Possibly he/she is looking after another dentist. So there still is no complaint coming, and you might be too late in reacting.
How to recognize them? A slow decrease in turnover might warn you, if you have good statistics and follow-up. Your patient will communi-cate vaguely and passively. With excuses
he will put you on 'on hold'. Reactions such as 'I will let you know' or 'things are somewhat difficult now' are often a signal.
Tip: Confront your patient with your feelings: 'I have the feeling you are no longer satisfied, is that so?' …
Now you are almost technical K.O. but you are not exhausted. You can still stand up. Now you hear that the relationship will be broken and your patient will go to another dentist. You are not trusted any longer and you will not hear the real reasons. Your patient is afraid that you might try to re-establish the relation and that would be annoying.
Tip: Try to find out the real reason by asking for his/her evaluation of your office on
1. attention to the patient2. accurate billing3. speed in follow-up4. accessibility5. flexibility and adaptation skills
Phase 3: The breakdown of the relationship.
Eventually give him/her a short list of questions and after that you can look for an opening by asking what really was going on.
Before a patient runs to another dentist, he/she goes through three phases. If you recognize the typical characteristics of each stage, you can quickly take action and thus might prevent the termination of the relationship.
Jennifer de St. Georges is an inter-nationally renowned dental practice management speaker and author. She has spoken at virtually every leading dental meeting in North America and the UK. Her International speaking career has taken her to all parts of the globe. Jenny is a contributing writer to Dentistry Today and the UK journal Independent Dentistry. Her fast-paced, humorous, bottom-line approach to solving management issues in her seminars and education material has earned her a loyal following.
Jennifer de St. Georges was a speaker at the ESMD congress 2012 in Vilnius. Please find her article on the ESMD website:
Question: Hi Jenny, we do not have an office manager, office is "run" by departments - front office, hygiene, assistants. I see friction at times, but have told staff that they are adults and should settle any differences as such, and I, as dentist-owner do not get "involved" unless I see office producti-vity being affected. Comments?
Answer: Doctor. Where do I begin? Firstly thank you for your honesty in stated what a great many dentists think and actually handle their staff in the same manner. It is, however, a recipe for disaster. If staff were motivated enough to do all they should do without direction, input, management, direc-tion etc., they would not be emplo-yees, they would be running their own business, self employed and hiring staff. Staff are staff because 95% of them want and need structure, guide-lines, management and direction. In my opinion, what you have described is a ship at sea, without a captain and no one at the rudder. In this scenario, the strong staff will assert themselves (not always the best ones unfortunately) and the insecure staff will hold back (sometimes the fountain of good ideas).
Am I asking this doctor to change his/her personality? Absolutely not! But I am laying out on the table that when a manager does not provide the team with leadership and direction-there is no team. What one has is a group of people who may turn up at the same time but have different agendas. My last comment is that I am of the school of being pro-active. The #1 goal of holding staff meetings is so there won't
"Ask Jennifer"
Staff interaction
be problems, addressing issues when they are small, so they don't grow and multiple. For the employer / owner / manager to wait until office producti-vity is seen to be affected, is taking the reactive approach. By the time the issue is noticed, it takes much more time and effort to sort out. Another spin off on this management approach is that for the most part, staff unhappy with this managerial approach, tends to give in notice and leave. Almost without exception, even when asked, will they be honest with their reason.
Question: Hi Jenny! Do you have any advice for a new associate coming into an established practice? I would like to become part of the team and "go with the flow" without getting stepped on!
Answer: Congratulations for thinking ahead and planning on taking the proactive and positive approach to your entry into your new practice. To fully answer this question in practical terms, I really would like to know your gender! It actually makes a great deal of difference. A female associate coming into an established practice with a staff which is most probably 99.9 or 100% female needs a different approach than if the associate is male. Please post the information and I will answer, handling both aspects but will approach it first from your perspective.
Question: I asked a patient recently if she had seen the doctor before. She became very upset that I had not remembered her name. How should I have handled her so that I do not upset a patient of record?
Answer: Luckily, this is such an easy problem to solve. The following solution reduces stress for the staff on the telephone and ensures that a well-established patient is never upset again.
Patient: “I 'd like to make an appoint-ment to see the doctor.” Staff: “Mrs. Patient, may I ask when you last saw the doctor?”(came in, had an appointment) If the patient is a patient of record, the answer will be along the lines of…“two weeks, two months, etc.” However if the patient is new, the answer will reflect that. Patient: “Actually I've never seen Dr. Brown before.”
Question: I've heard that one should thank patients for referring patients to the practice. We feel uncomfortable doing this. Any suggestions?
Answer: There is a proven system, which totally allows you to thank your patients of records in two specific ways for their referrals, while, hopefully, remaining very comfortable in the process. Each day, Doctor needs to put out the last five to ten minutes to write a very brief thank you to patients who have referred their friends, neighbors, relatives, and co-workers to your practice that day. Such a note can be limited to two to three sentences i.e. “Mrs. Smith, I’d like to thank you for the confidence you’ve shown in me by referring your sister, Susan, to my care. We will enjoy taking care of her dental needs. Sincerely…”
Be sure to capture each referral source in your computer system. The icing on the cake is to follow up on this note to
Referring patients
patients by actually thanking them again, in person, on their next visit to the practice, (even if it is several months later). Patients constantly express amazement that you actually remembered, thereby encouraging them to continue their referrals. It works.
Question: Is it best for our office to call and confirm appointments?
Answer: My personal research over several years shows, without a doubt, that practices that confirm appoint-ments have a higher no-show rate than practices that do not confirm. There are two specific negatives why this occurs.
1. The confirmation call provides a patient with the opportunity to “cancel short notice.” The patient will comment to the staff, “I am so glad that you called; I have been meaning to call you for days. I don't think that I'm going to be able to keep my appointment tomorrow.” If the practice had not called, the patient would not have been offered this wonderful opportunity to cancel.
2. When a patient can rely on the practice calling to “remind” them the day before, the patient puts the responsibility on the practice to “chase” the patient around town rather that recording the appointment details and making the commitment to keep their appointment without telephone call.
