Minimally invasive dentistry in private practice
The term minimal invasive dentistry (MI) should be made redundant as this should be the normative philosophy of all dentists. This paper outlines the pitfalls of integration of MI and how to overcome these along with suggestions for practitioners on how to integrate and apply MI into practice.
For more than a century dentistry has focused on repairing the damage from two rampant diseases – caries and periodontal disease.
In the UK financial reward has centred around ‘items of restorative care’. Each item attracted a different fee. This meant the more items the greater the earning power of the practitioner. This system has permeated the emotions and minds of the profession.
Minimal invasive (MI) dentistry is a model whose philosophy is 180 degrees from the above (Mount and Ngo, 2000). It is centred on preventing disease and repairing rather than cutting lesions where applicable. In addition only ‘the infected caries’ is removed. ‘The affected caries’ is left and remineralised. Enamel E1 and E2 as well as some D1 lesions often do not need to be surgically treated, rather an attempt can be made by the patient with directives from the dental team to harden those lesions (Amaechi, 2017; Hernández et al 2014). Broken pieces of tooth are replaced using adhesive dentistry, with minimal use of the drill (Mackenzie and Banerjee, 2017).
One premolar wall can support a ceramic replacement eliminating the need for root canal treatment in many cases (Desai, 2011; Otto, 2017; Borgia Botto, 2016). Even the full mouth case can be treated much more conservatively through bonding rather than cutting.
The two diametrically opposite philosophies have generated by definition two very different financial models and practice atmospheres.
The journey and pitfalls
This article will be outlining the journey and pitfalls for those who wish to incorporate an MI approach within their private practice.
It might be worth adding that in this authors opinion the term MI itself should be in a sense made redundant as the principles described in this article should just be Modern Dentistry. By giving these principles a separate name the implication is the validation of other outmoded prescriptive approaches in diagnosis and when treating (Figure 1).
All of us should be fully aware of the challenges that change can bring (Kotter, 1996; Covey, 1989; The Relaxed Dentist).
The obvious first step is for the dentist to believe in the principles of MI. Once that belief is total, then comes the next step of evangelical activity to convince one’s staff. Staff must include every member of the team as the third party sale is of vital importance when trying to convince the object of all this change and that is the patient.
Changing the dentist
This is an easier task in ‘a one man band’. Although, practices often have many practitioners with many disciplines. It is vital that a uniform message is conveyed by all the dentists.
The biggest obstacle to change to MI is the perception that it is going to result in financial loss to the practice. For reasons stated above there will by definition be ‘less units’. The model that suits MI best in the opinion of the author is ‘fee for time’ as opposed to the ‘fee for item’.
The latter difficulty is exacerbated by a low fee per item. MI will only work in the long term if it is financially viable. It has proven to be so in our practice through the following areas of gain (Table 1).
Changing the staff
From the perspective of the owner, staff includes associate dentists, hygienists and dental assistants.
Cost effective treatment of disease is often carried out through the hygienists. If the associates are not getting any financial reward for the referral (more specifically for the time spent to persuade the patient to be referred) why should they spend their time with the patient convincing them to see a hygienist? Possible solutions are:
- If they are being remunerated for their time.
- The alternative is for them to quote the patient for the time it would take them to do all that the hygienist will be doing.
- Another possibility is to make sure all your hygienists are ‘direct access’ and to make hygienist’s appointments via the reception thereby bypassing the associates.
- Of course ethically they should be willing to spend the time as it is in the best interest of the patients and that is their role.
They have to take on board the two vital changes in their role outlined in Table 2. Here lies the biggest obstacle of all. The MI ‘description chart’ Figure 1 envisages the treatment of the disease. This is often left to the hygienist. Or is it? No, the answer is that the only person who can treat the disease and stop for example that cavity growing is the patient.
But like the dentists, our hygienists are used to a certain way of life. They show the patients how to brush floss and so on. They tell the patients about the aetiology and then they tell them they have to clean at home.
Showing isn’t good enough because those words in the notes ‘showed patient how to floss!’ are not very helpful. Did they check if the patients could do what they were shown? What we want to see is a trained motivated patient who knows how to floss and brush and beautiful words in the notes like confirmed that patient knows how to floss and so on.
Hygienists in our practice now wear badges (Figure 2). This badge immediately conveys to both patients and hygienists their roles in treating disease.
The second change is that as mentioned above the only one who can ultimately treat the disease is the patient. We come now to the crucial role that we expect of ourselves, the practitioners, as well as our hygienists, and that is, we and they have to motivate our patients. What happens if the patient says I can’t be bothered, or they don’t seem to be able to do what they were shown. Here we rely on our hygienists and for that matter all members of the staff to be skilful motivators.
The reason this is mentioned as change for hygienists is that once again like ourselves they spend too much time talking to patients rather than engaging with them. How many times have hygienists relinquished this vital task of creating a change in their patients attitude and understanding? It is insufficient to tell a patient that they must brush or floss more and get a nod. Here are some valuable tips to ensure success (Table 3).
Conveying the message to the patient
All sorts of ways are available to convey to the patient the message of the necessity for change.
An early attempt by the author was to have all literature that was given to the patient emblazoned with the slogan ‘you and me = health’ (Figure 3).
Another example and technique was to print mini appointment cards (Figure 4). On the outer leaf was the typical appointment card but the front looked like a UK passport in style. On the inside were all the patient scores. These included bleeding index, plaque scores, salivary flow rate, streptococcus count and all the other scores for assessing their profiles and risk.
The motivation for this was that it became increasingly obvious that when the scores are written into patients records the only one who own them is the dental team, whereas the one’s who should be owning them are the patients.
Without question the most valuable asset of any practice are the receptionists (the heart) and the dental assistants (the blood). The first point of contact for any patients is the front desk. The caring approach of ‘we are here for you’ must be instantly recognisable. After all that is one of the fundamental foundations of the MI approach.
- Answer with an ‘IM for you’ tone and language
- He/she has to gauge the level of problem the patient has in order to allocate the correct amount of time
- Explain what the patient is going to get for that time along with its cost. Often persuade the patient of that value
- Assess the patient’s attitude to their dental health so that we the team can be prepared in advance to help this patient.
The dental assistants
Firstly, they are often called upon along with the receptionist to provide ‘the third party sale’ and support the dentists. This can be in the operating area or at the desk.
Secondly, they create a professional attitude in the operatory, which inspires confidence in the patient and creates exceptional customer care.
The first appointment
In our practice, new patients are given 60 minutes for their first appointment (of course there has to be a triage by the receptionist and after discussion it may for example be reduced to 20 minutes for a child). Radiographs are charged and quoted for separately after gaining the patients permission to take them. The exam is offered at a reduced rate compared to the usual hourly rate.
Value has not yet been fully established. The first examination appointment is used to establish this value. It is rare that our patients don’t pass an unsolicited compliment such as ‘I have not had an examination like this before (the details of that examination are not within the brief of this article).
The questionnaire in Table 4 (with a separate medical) is given to the patient to fill in. Either in the waiting room or if the appointment was made in advance it is enclosed with a welcome letter.
Please note the questions are all designed for engagement. The idea is for the patient to do the talking and for us to do the listening with prompting. Through that, we gain valuable information towards our assessment of risk and attitude.
These two factors are powerful indicators of future treatment. In Figure 5 our modified version of the traditional MI chart shows the word attitude in the arrow joining risk and treatment. It goes without saying that the dentist has to have the right attitude but the patient’s is crucial.
Patients with poor attitudes are unlikely to respond to disease controlling home regimes and along with patients who have high risk of disease may result in early surgical intervention.
Consider the following four permutations (Table 5).
Obviously the ideal is low risk with good attitude. Our aim is to ultimately to convert all patients into this grouping. The biggest challenge are high risk and poor attitude. Our assessment is crucial to treatment planning choices. One must always check previous radiographs to see if there has been progression on all the above before deciding to drill.
The questions about oral hygiene are an important requirement at this stage and the dentist should observe all aspects of the patients oral hygiene technique at the first examination. This is done simply by asking the patient to actually go through their regime while you are interviewing them. For brushing they are handed the test drive toothbrush by Oral-B.
One can see the technique they employ and the areas they cover. The same principle applies to flossing or other methods of interstitial cleaning. Table 5 will allow you how to accurately prescribe for the hygienist. The latter will look at this prescription when the patient visits them for their first appointment and set about engaging and training.
Patients with poor attitudes and high risk encourage the use of the drill on all of their lesions. Better to remove the caries when the lesion is small (Figure 7). This is better than waiting for the inevitable caries progression since you are pessimistic that the patient will be able to arrest growth.
This approach can be modified if you feel you have a highly motivated patient in which case you tackle the D2 and D3 lesions and put the rest on probation. This decision involves full hygiene programmes and ongoing regular recalls. The hygienist must report back and confirm the patients high motivation in all areas. This should be accompanied by trying to identify the causative factors. Also, by ascertaining and assessing the patients ability to control these.
Low risk and good attitudes encourage the MI approach to remineralisation. It cannot be stressed strongly enough that this is a crucial call. If a patient is high risk but with a good attitude they can try and control disease. We may suspend surgical judgement on the smaller lesions.
The difficulty in decision making arises with the ‘grey’ middle combinations. One has to assess very carefully whether or not one can change the attitude of the high and low risk patients with poor attitudes. Advice has been proffered on this point under the section dealing with attitude of the patients.
However, it goes without saying that unless we the practitioners are totally committed then we will not be able to convince nor even begin to change others.
The patient sits up and with both of you at the same eye level with the right amount of space between you, and then proceed.
This is not done with a mini lecture which you have said one million times but rather by making the patient ‘do the work’
Engaging, persuading and informing the patient of their role in controlling disease requires tremendous skill and time (The Relaxed Dentist). Here is one of many scenarios that can be used on selected patients to transfer responsibility to them.
Question to patient after having informed them that they have a problem:
Dentist: (delivered with a wry smile) ‘we have two schemes to help you with your problem one costs £80,000 a year and the other is free?’
Patient: The response varies from a wry smile back to a variety of questioning expressions
Dentist: Either me or my hygienist will come around every night at 2300hrs to clean your teeth for you (that’s the £80,000 one) or you do what we would have done (that’s the zero cost one) (Table 6).
After the examination the patient can also be shown the chart in Figure 5. They are engaged through asking them if they understand it. If not we explain that all the work and fees which they are going to need are caused by a disease which will still be present after treatment and how do they feel about trying to treat it. The alternative of course is perhaps more work in a year.
The patient may ‘buy’ one visit or many depending on need and the combination of your persuasive skills and their attitude. Often with resistant patients one visit is an easier ‘sell’. If the patient resists, the notes have to be written up noting their response and treatment may be altered as a result.
Role of dental hygienists
Dental hygienists are our personal trainers and experts in brushing, flossing, diet and motivation.
The patient’s deficiencies in plaque control must be addressed as a priority. The dentist’s prescription must be owned by the patient who should want to learn to remove plaque effectively. This may require many appointments.
In addition if the patient has an attitude of ‘not wanting to bother’ the hygienist has to confront this. They have to find the words, emotions, body language, etc to change the way the patient thinks. One approach is to re-emphasise that the patient’s attitude bothers you as he/she are partners and you are concerned.
Hygienists must take upon themselves the responsibility as an intrinsic part of their vocation of changing the way patients think.
Treatment of caries
This remains the most neglected area in dental practice today. The only care usually given is the surgical approach of removing the damaged tissue. However, we who crave to be called DRs have to treat disease and not only cut away the destruction. In fact ‘we don’t caries!’
Every patient as mentioned above is first triaged by a dedicated and informed receptionist. New patients are asked to fill in a medical and dental questionnaire. The latter is outlined in Table 4.
All these questions are used as a tool to engage the patient (you and me = health). They also act as the first step in risk assessment as outlined above. The first two questions tell you whether there is an active disease process in caries. Question 3 will give you your first insight into whether the patient might have a periodontal problem.
Also, whether they are brushing correctly. Question 4 is an attitude gauge of whether this patient can be motivated. It also acts as a platform for the patient to ask you how you can help them. This works a lot better than you rambling on how you can.
Question 6 is designed to act as motivational tool to get the patient to floss and brush better. This one works far better than a lengthy lecture with pictures on the cause of ‘gum disease’.
Questions 9 and 10 are answered by your patient at the interview. You get them to show you with a piece of floss and test pilot brush how they clean. Table 5 provides the detail prescription for the hygienist on how and where they have to train the patient in OHI. The final question is a further tool to motivate home care and patient responsibility.
The caries risk
The caries risk is also more easily measured by assessing The Strep Mutans count, plaque scores, saliva quality and amount at rest and stimulated, fluoride programme, clinical judgement based on history of caries and diet analysis. The cariogram (Strickland et al, 2017; Richards, 2016) generates a pie chart of the spread of the patients risk an example of which is seen in Figure 6.
This is then manipulated in front of the patient to illustrate how control of the various multifactorial factors influence reduction or increase of disease. By definition if done correctly this will require a number of appointments with the hygienist. It soon becomes apparent that by pursuing the ethical approach this has resulted in your hygienist becoming busier and more productive financially.
It is also useful to have a microscope to show patient the bacteria on a screen which are in their plaque.
Follow up is essential and this has to be owned by the patient. It can be affirmed by making their follow up appointment then and there.
The brief of this article is not to address the surgical aspects of scaling cleaning or restorative care (Karabekiroglu and Unlü, 2017; Meyers and Ann, 2008).
Another area where there can be a struggle is keeping patients in the recall loupe. The most successful way is to make the next appointment on the spot. Some patients need once a month appointments and others every 18 months. We have found that patients often have the best intentions after their initial course of care but somehow disappear thereafter.
Once a few months have lapsed the pressure of life often leads to lapses in OHI and other changes that they undertook.
When phoned they often retort ‘I know but I will call you’. We have to regretfully face the fact that we cannot succeed with all. One tactic that has proven useful in the past is that on that final appointment we say to patients that many do drop out and how would they feel if we phoned them and nagged them. If they say they don’t mind this can be notated on their records. Then, it’s just a nagging exercise when the hygienist has a cancellation.
Looking to the future
At the start of this article it was pointed out that MI can be a very profitable part of practice. If we become committed to the principles then most patients will buy our enthusiasm especially as it is directed to their health. This will generate by definition a full hygienist book and very satisfied patients.
These patients will soon become ambassadors for our way of thinking and refer their friends and family. We also stated that MI should be a redundant term. The implication is that there is another way i.e. to cut a perfectly healthy tooth when at this time there is no proof that that cavity is going to progress.
Furthermore the surgical techniques of minimal invasive dentistry are all directed to the preservation of the maximum amount of tooth substance. By definition if a tooth is left with only two walls which are healthy, why would one want to cut those two down and place a crown? All efforts should be directed to preserve as much of the human body as we can as that will give the greatest longevity.
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