Desired Outcome:  Thorough evaluation of the patient�s oral health needs and the complete provision of necessary hygiene treatment in a manner that maximizes treatment outcome while maintaining patient comfort.  The restoration of the patient�s oral tissues to the best state of health possible for the individual and the education of the patient to maintain or improve upon this state in the future.

 

Measurement:  Feedback from the patient. Review of the patient�s chart. Oral examination post-treatment.

 

1.   Introduction of the patient to hygiene procedures:

A.  Greet the patient by name and escort to the operatory.

B.  Introduce yourself to the patient by name and position.

C.  State the general purpose of this visit to the patient.

D.  Update the patient�s information sheet.

1.  Verify the patient�s address, phone number, and insurance.

a.  Make changes on the information sheet and circle �yes� in changes section on the fee sheet/rate slip.

2.  Review their medical history with the patient and note current health problems and medications.

a.  Determine implications of such medications to the systemic health of the patient and to possible dental treatment.

3.  Ask the patient how long it has been since their last dental cleaning and if they�ve experienced any problems with previous treatment.

4.  Confirm that the patient has taken antibiotic premed, if prescribed.

a.  Make notation on chart.

E.  Prepare patient and yourself for treatment.

1.  Secure a bib on the patient.

2.  Put on your mask, gloves, and glasses.

3.  Recline the patient�s chair to the optimum position.

                        4.  Offer audio headphones, a blanket, or lumbar to a patient at the appropriate time during the appointment.

     

2.   Evaluate the patient�s dental hygiene treatment needs:

   A.  New patient or patient long overdue for recall

1.   Explain to the patient that you will be doing a visual and tactile examination of the mouth to determine what dental hygiene treatment is needed and how it can best be provided.

2.   Examine the patient�s mouth and confirm the doctor�s treatment plan, including the type and number of visits needed, the necessity of local anesthesia, and the corresponding fees and insurance coverage.

3.   Explain your findings and diagnosis to the patient and obtain this verbal consent for the prescribed treatment, making sure that the patient understands the treatment plan, its ramifications, and the fees to be charged (patient should already have fee estimate, so clarify that).

 

        B.  Routine recall patient

   1.  Examine the patient�s mouth to verify the nature of the appointment.

   2.  Discuss oral health changes since last appointment with the patient and advise the patient of any additional treatment needed.

       

3.   Provide dental hygiene treatment

A.  Administer local anesthesia, if indicated.

   1.  Obtain assistance from the dentist, if needed.

B.  Perform a complete and thorough root planing or prophylaxis for the removal of all deposits on the teeth resulting in clean and smooth surfaces and tidy gingival margins, through the use of ultrasonic scaler, hand instruments, and laser and slow-speed handpiece polisher, in the best sequence and combination of equipment required.

   1.           Explain the procedures, equipment, and tools as procedure progresses.

   2.  Monitor and maintain the patient�s physical comfort through observation and direct inquiry.

a.  Provide medicaments and/or additional local or topical anesthesia.

b.  Maintain optimum saliva/blood control with water syringe and vacuum system.

c.  Show consideration for the patient�s TMJ comfort.

   3.   Monitor and maintain the patient�s emotional comfort through observation and direct inquiry.

a.  Offer open acceptance of the patient�s questions and concerns.

b.  Avoid disturbance of the patient from visual negatives such as blood and syringe.

   4.         Perform complete dental probing at each visit and record on the chart, including the date.

   5.         Advise the patient of the prognosis of administered treatment and point out any problems that will need additional treatment.

   6.         Document in the charts:

a.   A complete description of the patient�s oral tissues

b.   The treatment you provided

c.   Medications and equipment used

d.   The patient�s response to treatment

e.   The patient�s concerns

f.    Important and/or interesting personal information about the patient

g.   Any patient education given including what plaque control aids were demonstrated and given to the patient

h.   Date and initial all of the above on the chart

     

4.   Patient Education:

A.  Explain the patient�s oral condition, treatment, and equipment and tools used, pointing out problems to the patient with the hand mirror, before, during and after the treatment.

B.   Explain periodontal disease, its causes and results, treatment needed, and the patient�s responsibilities to his/her future oral health.

 

C.   Demonstrate needed plaque control aids and make certain the patient understands their purpose and use.

1.  Evaluate and tactfully correct the patient�s plaque control techniques.

D.  Give the patient a �mouth map,� with problem areas marked and advice given.

1.  Ideally, make a copy and have the patient initial it.

2.  Give the original to the patient and put the copy in the chart.

3.  Record in the chart that a mouth map was given.

4.  Explain the mouth map�s purpose and use by the patient.

E.  Recommend home-use products for desensitization and plaque control, such as toothpaste, rinses, fluoride products, etc.

F.  Give the patient post-operative instructions such as saline rinsing, desensitizing, etc.

      

5.     Determine the next treatment needed:

A.  Evaluate the treatment just given, the resulting condition of oral tissues, the patient�s response to the treatment, and the patient�s plaque control skills.

B.   Advise the patient of optimum time lapse until next appointment with hygienist.

      1.  Example: Additional root planing appointments; prophy recalls at 3, 4, 6 months; periodontal recall vs. routine prophylaxis.

C.   Explain our recall notification system.

D.  Necessary restorative work should be noted on the chart, flagged for back office notice, and discussed with the patient, if appropriate.

      

6.     Patient dismissal:

A.  Make sure the patient has the opportunity to ask final questions.

B.  Verify the patient�s expectations regarding future treatment.

C.  Give the patient plaque control aids and literature.

D.  Tell the patient to call you with any questions or concerns.

E.  Escort the patient to the front desk and clearly indicate when and why the patient should return.

1.       Charting should be complete, including prescribed future treatment and recall recommendation.

2.       The fee schedule (or routing slip) should be marked.

3.       Notes for routing to the dentist should be prominently affixed to chart.

 

7.     Treatment follow-up:

A.  Consult with the dentist regarding problems or recommendations for additional treatments.

B.   Phone root planing patients the following day to inquire about their comfort, problems, or questions they may have.

 

   Samples from Standard Operating Procedures for All Dentists
(Contains over 470 pages + software)