Flipping the referral process – starting with a hygienist workflow

itero elementClaire Berry explores how to flip the referral process by using hygienists and the Itero Element scanner to help educate patients.

Earlier this year, I underwent Invisalign treatment and talked about my journey, both as a patient and as an oral health expert. I detailed how myself and colleagues developed a robust prevention programme pre-Invisalign treatment to ensure that patients’ oral health was optimal at the start and throughout their treatments.

As part of this pathway, I experienced digital scans with the latest Itero Element 5D Plus intraoral scanner. I realised how much the technology helps with patient engagement. As well as how it can educate patients about what’s happening in their mouths.

As a preventative dentistry advocate, I was particularly keen to trial one of the scanner’s unique features called near infrared imaging (NIRI) technology. I wanted to see how we could incorporate the concept into the hygiene workflow.

NIRI can aid in the detection and monitoring of interproximal caries lesions above the gingiva without using harmful radiation. The NIRI functionality is contained within the Itero Element 5D wand. And once configured, it is really easy to use.

Hypothetically, if the scanner was used at each hygiene visit, we could detect early inter-proximal carious lesions and refer our patients for necessary treatment much sooner than waiting for periodic X-eays. Even at that, bitewing X-rays only detect carious lesions beyond approximately 30% demineralisation. Whereas NIRI 5D scans can reveal its presence much earlier.

Patient education

Up to now, we have mainly seen the Itero Element scanner as part of a patient’s Invisalign treatment journey.

I work at a very busy private practice where I see Invisalign patients on a daily basis for oral health optimisation (oral health optimisation being the name we give my treatment as a hygienist, in order to get them to optimal oral health before moving on to restorative or cosmetic treatment).

The more I thought about this concept, the stronger I felt I could use this technology on every patient on a regular basis.

Delving deeper into the idea of introducing this into a hygiene work flow, is it possible to use this concept to also initiate behaviour change in our patients? Could it help get the message across that patients need to change their behaviour and attitude towards oral health in order to prevent disease?

Visually seeing their susceptibility to disease in such a clear way could make the message hit home more effectively.

The health belief model in the psychology of behaviour change states: ‘A patient needs to know they have a susceptibility to disease to make the necessary changes’. If they don’t feel they have susceptibility for disease, they won’t take our messages on board. They will remain in a pre-contemplative stage of change.

Seeing early caries when using the NIRI wand or seeing intraoral images using scans as part of the hygiene workflow can really help bring that message home.

Experiencing the Itero Element scanner

I was professionally and personally curious to have a NIRI 5D scan with the Itero scanner to check for inter-proximal caries. I’ve had periodic X-rays with nothing noted. I’ve checked them too of-course. And I have no restorations.

But low and behold the NIRI 5D scan revealed…I have an early enamel lesion on my LL7 – I was devastated!

This information gives me a chance to possibly arrest it and change my behaviours to prevent the need for treatment.

What really struck me though, was the exciting (or scary), anticipation to see if something was there. Anticipation causes a release of dopamine, the reward is the collection of new information about something that piqued my curiosity. This makes it an experience I’ll never forget.

These are all the qualities we need to heighten the ability to take on information, learn something and remember it. Dopamine increases focus and the ability to learn and remember. Anticipation and curiosity causes dopamine to rocket. So by involving a patient in the interpretation of their scan, they are more susceptible to any information we give them in that moment.

As a result, our oral hygiene advice, talking about biofilm control and the explanation of caries or other diseases will sink in more than it ever did before.

The prospect of creating memorable experiences to increase learning and change behaviour is tantalising.

In just one scan, you get Invisalign outcome simulations. And with the Itero Element 5D scanner; you can detect interproximal carious lesions using the NIRI technology; and you can monitor changes over time in tooth surface loss (abrasion and erosion) with a tool called the Timelapse programme. You can also access intraoral images and the occlusogram to map and measure the patient’s occlusion.

Sharing information with patients

I was interested to learn you can download detailed screen shots. Clinicians can then send these to the patient or referral specialist.

By sending them to the patient you are putting them in control of their own health and oral health status. Rather than just storing it on our systems for us to use.

This is a useful way of putting their disease in their hands. And making it a team effort, not just leaving it to dental professionals to maintain. We can’t maintain or stabilise disease if they’re not a team player.

Introducing this system of bringing the Itero 5D scanner into a DCP workflow could increase practice revenue. This could mean:

  • Increasing referrals for the treatment of caries when diagnosed using NIRI
  • Performing the necessary treatments or topical applications to arrest early lesions
  • Having discussions about alignment to reduce disease risk in patients with imbrication and crowding
  • An increase in patient retention and recall.

The use of intraoral imagery is also a great tool for the treatment and monitoring of periodontitis. Imagery is something I’m using a lot more in my practice when treating patients with gum disease.

The cost of periodontitis

The European Federation of Periodontology (EFP) recently commissioned the Economist Intelligence Unit (EIU), a provider of forecasting and advisory services, to perform an analysis on the financial and human cost of periodontal disease.

Dental Tribune, which published the findings, states: ‘The prevalence of periodontitis has remained largely unchanged over the last 10 years. Awareness of the disease among the general public and non-oral healthcare professionals is poor.

‘Few studies have modelled the economic burden of periodontitis and return on investment (ROI) of treatment. Particularly across different countries.

‘The EIU analysts developed a model to examine the ROI of prevention and management of periodontitis.’

The findings showed that in the UK:

  • Projected savings over a 10-year period: €24.68 billion (£21.16 billion)
  • ROI of every euro invested in eliminating gingivitis: €23.92 (£20.50).

This is obviously on a larger scale and focuses solely on gingivitis and periodontitis. But how can investing in prevention in general be beneficial on a practice level?

Itero Element benefits

Delegating more to DCPs and utilising them within their full scope of practice can free time for the GDP to continue with high earning treatments. Less time on fillings, more time on cosmetic treatments, for example.

Find lesions earlier, less extensive or lengthy treatments. More ethical, increase patient retention/practice builder. Use DCP’s time for Invisalign scans, but at the same time also gather other vital information.

As a patient I would 100% choose a practice that has this capability for my preventative care now I’ve experienced it.

As a DCP, I can’t wait to see technology flip the referral process and integrate a hygiene workflow into every patient journey. The future is exciting!


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