Policy Manual Final_2016

I

Clinical and Administrative Policies and
Procedures for the Dental Office

Second Edition

Gregory P. Heintschel D.D.S., M.B.A.

ISBN 978-0-692-56328-1
Copyright 2016
All rights reserved. No part of this publication may be reproduced or transmitted in
any form or by any means, without permission in writing from the author.

Foreword

This text is the second edition of a formal compilation of notes, continuing education, practical
experience, and formal education related to management of the dental office. These sources have
been considered on the promulgation of clinical policies and procedures that have been utilized and
refined by My Community Dental Centers Inc., and can be incorporated into dental operations small
and large. These concepts are the culmination of the insight of many individuals from all aspects of
a dental operation. This text integrates thoughts not only from the viewpoint of the practitioner
and the administrator, but most importantly, the patient. The systems and policies incorporated
within this manual have been time-tested within the facilities of My Community Dental Centers
(MCDC) for their merit and inclusion. This edition further refines and expands upon earlier
systems.

MCDC has grown to be the largest not-for-profit, non-governmental organization in the
country providing dentistry in the public health sector. In no small part, it is the result of the
information contained within this work that has nurtured the growth and success of the
organization.

The sections of this text are organized by grouping related concepts together. It is recommended
that this text be initially reviewed in its entirety as it serves as the basis for a comprehensive
system of administration and practice. The system functions optimally when all individual
components are in place and being utilized. Once that context is obtained, the table of contents
provides for a ready reference to individual components for quick review, integration, and training.

Section 1 serves to provide a context for the provision of dentistry in the public health realm,
and an understanding for the underpinning of public health.

Section 2 includes material which would be useful to the office relative to its internal systems.
This section contains material which would be helpful in the administrative tasks of the
operation. Specifically included is information with regard to the conduct of meetings, which
provides a critical link in establishing clear and effective communications.

Section 3 includes material on one of the most basic and yet controversial aspects of
administering a dental clinic: scheduling. In this section the reader will find content related to
all aspects of scheduling, including the new patient visit, emergency patient visit, multiple family

appointments, and how to manage broken appointments. If one section of this manual would
provide for the greatest sustainability for any facility, it would be Section 3.

Section 4 includes information regarding patient finance issues. This section is minimized as so
much of dental public health is contingent upon a wide disparity, eligibility, and availability of
group dental care programs. Also adding to the potential for lack of standardization in this area
are the requirements made upon the operation for what patient population it is required to
provide care for and under what conditions.

Section 5 directly relates to the clinical rendering of care and patient management. It is assumed
that in all cases the provision of care is rendered at a minimally acceptable standard of care. It is
the duty of the administrative staff to trust this minimal level of care is provided and verify that
it is. Exceptional organizations will take one additional step and work towards creating a
culture of ever-improving quality. In this section the reader will find a wide range of content
related to making best use of treatment time in a safe and effective manner.

Section 6 expands upon our knowledge of safe, effective and patient-centered office
management and maintenance protocols.

Section 7 serves as an addendum for material referenced throughout the text. It also provides
more in-depth content of presented material for deeper reflection and consideration.

Section 8 shares with the reader many of the forms and templates for forms that offer guidance
for the creation of office-specific policies and procedures. Some of these forms can be directly
copied for immediate use in the practice.

New material is also included in this edition regarding dental ethics. This growing issue in
healthcare is well worth studying.

The success of any dental operation may often seem like a puzzle. I invite you to peruse this text
as it will offer much guidance. Commonly asked is: what is the best way to piece together the
provision of an ever-improving level of clinical care, providing an exceptional patient
experience, while maintaining an acceptable margin? Putting all these pieces together, including
both art and science, can often seem beyond our grasp and a mystery. It is the mission of this
text to add clarity and to demystify.

It is my sincere hope that the material contained within will not only provide a firm foundation
upon which to build a successful dental health facility, but to additionally energize and give
direction to all your team. Enjoy the journey ahead of you.

Gregory P. Heintschel D.D.S., M.B.A.
President and Chief Executive Officer
My Community Dental Centers
Boyne City, Michigan

Acknowledgments

First I need to make the disclaimer that this text does not represent a body of work with a heavy
reliance on references and other published works. Rather this effort represents a body of
knowledge gained over a lifetime of education and experience, including both success and
failure. The policies and guidelines published here represent the incorporation of a myriad of
different viewpoints and strategies. For those seeking further depth and detail, one need only to
reference any one of the other excellent written sources or search the Internet via your
computer and favorite browser. With a discerning eye the internet can provide a plethora of
information for your further study and reflection.

It is also vitally important that no policy should replace common sense and compassion. Nearly
every manual carries a disclaimer and this one is no different. Clinicians and caring staff should
always be empowered and authorized with some level of discretion in individual circumstances.
This manual does not replace the individual practitioner’s responsibility in using common sense
and best clinical judgment and skill when rendering clinical care. The provider alone maintains
responsibility for the care rendered and the manner in which it is conducted.

I wish to acknowledge several persons and organizations that have made this second edition
possible. First and foremost is the founding CEO of MCDC Dr. Thomas Veryser. It is his guidance
and direction that provided for an expanded vision for what the potential is for public health
dentistry. I also want to thank Dr. David Murphy and Dr. Amanda DesJardins, also of MCDC, as
the voice of the clinical professionals in putting together this administrative text. Credit must
also be extended to Cheryl Tackett, who provided countless hours of effort in assembling this
text. Others from the organization who have made significant contributions to this work include
Nicole Murray.

I also want to thank my colleagues and friends outside of MCDC, which have so heavily
influenced my perspective on all aspects of dentistry. Specifically I would like to acknowledge
Dr. Roger Levin and Dr. William (Bill) Dickerson. Credit must be given to the American College
of Dentists who contributed and allowed for its publications to be used in this text in the section
related to Dental Ethics. I am most appreciative for their allowance of materials in this work and
their relentless pursuit of heightening the stature of the profession by raising the bar for all.

Finally, thanks to my wife, Dayle, whose support and counsel allowed for continual growth
throughout my career. Her blessing and support allowed dentistry to become my passion and
vocation and not just my work.

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Section 1 – Public Health
Dentistry and Dental Public Health
Summary ………………………………………………………………………………………………………………………..1
Dental Public Health as Practiced by Michigan Community Dental Clinics, Inc………...................2
Business Statements: Mission, Culture, Vision and Values………………………………………………….2

Section 2 – Internal Systems of Excellence
Excellence in the Dental Office
A Venn Approach ……………………………………………………………………………………………………………5
Ten Commandments of a Great Dental Office…………………………………………………………………….8
Best Practices and Standardization…………………………………………………………………………………..9
Dental Office Ethics………………………………………………………………………………………………………….9

Section 3 – Communications Contributing to Excellence
Communications in the Dental Office
Internal Office Communications……………………………………………………………………..………………12
Daily Morning Huddles………………………………………………………………………………….……………….12
Weekly Team Meetings.........................................................................................................................................14
Monthly Team Meetings………………………………………………………………………………………………...14
Effective Communication with Patients………………………………………………………………………..…15
Patient Communication Materials
New Patient Orientation Packet……………………………………………………………………………………...17
Value-Building Statements……………………………………………………………………………………………..17

Section 4 – Scheduling and Appointment Management

Basic Scheduling Principles
Efficient and Effective Scheduling…………………………………………………………………………………..19
Procedural Time Studies………………………………………………………………………………………………..20
Emergency Scheduling…………………………………………………………………………………………...………21
Initial New Patient Call……………………………………………………………………………………………..……23
Appointment Slips and the Tickle File……………………………………………………………………….…….24
Scheduling an Appointment…………………………………………………………………………………….……..24
Family Scheduling……………………………………………………………………………………………….….……..25
Block Scheduling……………………………………………………………………………………………………………25
Patient Reminder of Appointment………………………………………………………………………………..…25
Late Patients………………………………………………………………………………………………………………….26
Office Running Behind……………………………………………………………………………………………………27
Broken Appointments………………………………………………………………...………………………………….27
Patient Cancellations and No Show Policy for the Existing Patient…………………………………...29
Patient Cancellations and No Show Policy for the Potential Patient…………………………………30
Non Discrimination Policy……………………………………………………………………………………………...31
Management of Patient Exams
Initial Adult Patient Visit………………………………………………………………………………………………..31
Policy Regarding Initial and Periodic Evaluation and Periodontal Status………………………….32
Comprehensive Exam and Charting………………………………………………………………………………..33
Initial Child Patient Visit………………………………………………………………………………………….……..34
The Re-Care, Hygiene, or Preventative Visit…………………………………………………………………….35
Radiographic Exam Guidelines
Best Practice Policy on Taking Radiographs .............................................................................................. 37
Radiographic Exam Standard of Practic.......................................................................................................37
Quality Control Chart Review Guidelines
The Complete Clinical Note…………………………………………………………………………………………….38
Chart Audit Guidelines.........................................................................................................................................41
Retreatment Policy................................................................................................................................................44

Section 4 – Patient Finance
Finance
Background .............................................................................................................................................................. 46
Patient Financial Brochure……………………………………………………………………………………………..46
Financial Management of Emergency Patients………………………………………………………………...46
Case Presentation
Being a Patient Advocate for Treatment……………………………………………….…………………………47
Hygienist Case Presentation of Soft Tissue Management………………………………………………….48
Hygienists Case Presentation of Required Dentistry
Hygienists as Advocates for Treatment…………………………………………………………………………...49
Treatment Plan Presentation – Verbal Skills…………………………………………………………………...49
Treatment Plan Presentation – Enthusiasm…………………………………………………………………….50
Treatment Plan Presentation – Obtaining Commitment…………………………………………………..51
Patient Financial Options Scripts…………………………………………………………………………………....53
Medicaid Co-Payments (Varies by State)………………………………………………………………………...54
Medicaid Co-Payment Collection Flow Chart…………………………………………………………………..56
Cash Handling……………………………………………………………………………………………………………….56
Insurance Write-Offs……………………………………………………………………………………………………..57
Refund Policy………………………………………………………………………………………………………………..58

Section 5 – Patient Management
Pain Management
The Concept of Pain Control …………………………………………………………………………………………59
Local Anesthetic……………………………………………………………………………………………………………59
General Local Anesthetic Dosage Recommendations……………………………………………………….60
Nitrous Oxide Sedation…………………………………………………………………………………………………..61
Nitrous Oxide Sedation in Children…………………………………………………………………………………63
Complications of Nitrous Oxide Sedation………………………………………………………………………..63

Containdications of Nitrous Oxide Sedation…………………………………………………………………….63
Billing and Insurance Coverage for Nitrous Oxide……………………………………………………………64
Prescriptions and OTC Medications
Prescribing Policy…………………………………………………………………….……………………………………65
Analgesic Medications……………………………………………………………………………………………….......65
Treatment of the Pregnant Patient
To Treat or Not to Treat ………………………………………………………………………………………………..66
Dental Treatment Guidelines for Pregnant Patients…………………………………………………………68
Considerations as to Timing Treatment in the Pregnant Patient………………………………………69
Drug Administration and Drug Categories in Pregnancy…………………………………………….……69
Drug Administration During Pregnancy and Feeding………………………………………………………70
Caring for Children in the Dental Office
Policy Statement for Children’s Care.............................................................................................................71
Guidelines for the Care of Children in the Hospital Setting……………………………………………….71
Treatment of Patients with a Medically Compromised Status
Patients and Systemic Health………………………………………………………………………………………….72
Bleeding Problems and Patients on Anticoagulents………………………………………………………....72
Patients with Cardiac Problems, Heart Murmurs, and other Adverse Cardiac Effects………..74
ADA Prophylactic Infective Endocarditis Guidelines..............................................................................74
Standard AHA Regimen………………………………………………………………………………………………….76
Treating Pateints with other Cardiovascular Disease and Related Problems.............................. 77
Blood Pressure Classification and Dental Treatment Recommendations…………………………..78
Central Nervous System (Seizures, Stroke)…………………..…………………………………………………79
Diabetes………………………………………………………………………………………………………………………..81
Immunosuppresion……………………………………………………………………………………………………….82
Infectious Diseases………………………………………………………………………………………….……..………84
Kidney Problems……………………………………………………………………………………………………………87
Liver Problems………………………………………………………………………………………………………………88
Pregnancy……………………………………………………………………………………………………………………..88

Prosthetic Joints………………………………………………………………………….…………………………………90
HIV Compromised………………………………………………………………………………………………………….90
Protocols for the Dental Management of Patients with HIV Disease ...............................................69
Treatment and Management of Common Oral Diseases
Fungal Infections Including Oral Candidiasis…………………………………………………………………..92
Viral and Herpetic Infections………………………………………………………………………………………….94
Recurrent Apthous Ulcers………………………………………………………………………………………………95
Oral Mucosal Disease – Erosive Lichen Planus………………………………………………………………..96
Xerostomia……………………………………………………………………………………………………………………97
Bacterial Infections - Necrotizing Ulcerative Gingivitis…………………………………………………….99
Palliative Treatment for Oral Lesions…………………………………………………………………………...100
Management of the Patient with a Medical Emergency
Basic Considerations ......................................................................................................................................... 100
CPR Certification………………………………………………………………………………………………………….101
Emergency Equipment…………………………………………………………………………………………………102
Management of Adverse Reactions to Anesthetic Injections or Any Dental Material
Anaphylaxis…………………………………………………………………………………………………………………102
Delayed Allergic Reaction…………………………………………………………………………………………….104
Syncope (Fainting)………………………………………………………………………………………………………104
Cardiopulmonary Arrest……………………………………………………………………………………………...105
Shock………………………………………………………………………………………………………………………….106
Hypotension……………………………………………………………………………………………………………….106
Hypertension………………………………………………………………………………………………………………106
Angina and Myocardial Infarction………………………………………………………………………………...106
Seizures………………………………………………………………………………………………………………………106
Hypoglycemia……………………………………………………………………………………………………………..107
Restoring the Definition in the Public Health Setting
Cavity Preparation in the At-Risk Population………………………………………………………………..107
Restorative Materials for Posterior Teeth................................................................................................ 108

The Indirect Pulp Cap........................................................................................................................................ 109
The Stainless Steel Crown ............................................................................................................................... 109
Requirement for Rubber Dam Use .............................................................................................................. 110

Section 6 – Office Management and Maintenance
Taking Pride in the Office………………………………………………………………………………………..……111
Preventative Maintenance Program ........................................................................................................... 112
Daily Maintenance Schedule………………………………………………………………………………………...112
Weekly Maintenance Schedule……………………………………………………………………………………..113
Dental Equipment Preventative Maintenance Guide………..………………………………………….…115
Infection Control ................................................................................................................................................. 116
Occupational Exposure in Dentistry ........................................................................................................... 116
Recommended Quality and Patient Safety Protocols .......................................................................... 116
Disinfection and Sterilization Protocols……………………………………………………………….……….118
Inventory Control System…………………………………………………………………………………………….122
Ordering Protocol………………………………………………………………………………………………………..123
Fire Safety and Evacuation Protocol……………………………………………………………………………..124
Medical Waste Management and Amalgam Recycling
Developing a Waste Management Plan…………………………………………………………………………126
Medical Waste Management by Category………………………………………………….…………………..126
Segregation and Handling Procedures....................................................................................................... 126
Storage of Medical Waste ................................................................................................................................ 128
Decontamination Methods.............................................................................................................................. 128
Team Training on Medical Waste Issues................................................................................................... 128
Amalgam Waste Management & Recycling
Mecury Containing Dental Waste................................................................................................................. 129
Amalgam Compliance Measures – Evacuation Systems ..................................................................... 129
Best Practices for Handling Dental Waste................................................................................................ 131
Recruiting and Hiring Process

Recruiting............................................................................................................................................................... 133
Interviewing.......................................................................................................................................................... 133
Making Job Offers................................................................................................................................................ 133

Section 7 – Addendum
Protocol for Complaint Resolution.............................................................................................................. 134
Exposure to Blood Borne Pathogens Incident Checklist .................................................................... 135
Risk Management Tips for Clinics................................................................................................................ 136
Authorized Dental Laboratories................................................................................................................... 137
Abbreviated Note Version of the Michigan Medicaid Provider Manual....................................... 137
Medicaid Provider Manual Short Notes..................................................................................................... 144
Multi-Codes in the Dental Office................................................................................................................... 157
Multi-Code Groupings for Dental Procedures......................................................................................... 158
Abuse and Neglect .............................................................................................................................................. 159
Commonly Used Dental Acronyms for MCDC ......................................................................................... 160
State of Michigan Delegable Dental Procedures for Auxillaries ...................................................... 161
Levels of Supervision for Delegated Duties ............................................................................................. 162

Section 8 – Forms
Annual OSHA Training...................................................................................................................................... 163
Objective Assessment of Patient Care Rendered by Dentist............................................................. 165
Objective Assessment of Patient Care Rendered by Hygientist ...................................................... 169
Complaint Survey................................................................................................................................................ 172

Ethics Handbook for Dentists .................................................................................................................................. 178

Legal Note

This text has been prepared to provide the reader with recommendations, suggestions, and examples of
the types of policies that can be incorporated into each organization’s policy manual. There are numerous
federal and state laws, rules, and regulations, which would be considered when preparing your own
policies and manuals. These laws and rules do vary from state to state, and thus it is important to have
your own policy manual reviewed by an attorney experienced in such matters.

Clinical and Administrative Policies and
Procedures for the Dental Office

Second Edition

Section 1

Public Health

Dentistry and Dental Public Health

Summary

Dental public health programs and initiatives have only a recent history in our country. As a matter
of record, the first dental public health program in the United States was established by the
Tennessee Department of Health in 1936. This was followed up less than ten years later with what
the CDC has referred to as one of the greatest achievements in public health in the 20th century: the
fluoridation of public water supplies. This was achieved in 1945 in Grand Rapids, Michigan when it
adjusted its water supply to 1.0 ppm of fluoride. Similar programs now reach more than 72% of the
population served by public water systems. Fast forward to 2000, the Surgeon General of the
United States issued the first-ever report on the “silent epidemic” of dental and oral diseases that
burdens some population groups and called upon a national effort to improve the oral health
among all Americans. Dental public health continues to evolve over time.

It is of value to understand that dentistry as practiced in the public health sector has both
similarities and disparities with dentistry as practiced in the private sector. Public dental health
programs range from individual health department facilities, to government programs like the
Indian Health Services, to Federally Qualified Health Centers, to private and public for-profit
operations, and finally to private not-for-profit organizations like Michigan Community Dental
Clinics, Inc.

Dental public health is one of the nine specialties of dentistry recognized by the American Dental
Association. It has been defined as the “…science and art of preventing and controlling dental
diseases and promoting dental health through organized community efforts.” It is a form of dental
practice which serves the community as a patient rather than the individual. It is additionally
concerned with the dental health education of the public, the application of dental research and the
utilization of group dental care programs, as well as the prevention and control of dental diseases
on a community basis. Public health dentistry as defined within our organization is: “Dentistry
which provides the most good to the greatest numbers, given the available time and treasure.” We
view every interaction with a patient in this regard.

Given the public health model perspective, policies and procedures as to the conduct of dentistry
may differ from that of the private practice sector. Public health focuses on the community while
the private sector is focused on the individual. This manual includes many of the best practices of
dental public health so as to offer the greatest chance of success for the organization at maintaining

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sustainability, while providing appropriate care for the individual which enhances the health of the
local community.

Dental Public Health as Practiced by Michigan Community Dental Clinics, Inc.

Michigan Community Dental Clinics, Inc. (MCDC) had its first full year in operation in 2007. At that
time the organization had 10 clinics with 29 doctors and 121 total employees. In a mere eight years
the organization has grown to 30 clinics, offers outpatient services in over 10 hospitals, has 76
doctors and a total staff of nearly 400. MCDC provides care to nearly 100,000 unique individuals
with 250,000 patient visits. MCDC continues to expand its partnerships, open new dental facilities,
and incorporate new models to meet its mission.

Through this growth MCDC has experimented with incorporating many of the best practices of both
the private and public sector, solo and group practice. In entrepreneurial fashion the organization
has created a truly unique model in the delivery of dental services. This model has come about by
taking a laboratory approach in testing new systems and policies and then modeling and
standardizing the best of those in facilities across the entire organization.

As the organization has grown, the culture has shifted. The culture we aspire to is one in which the
needs of the patient (being the community) come first. This culture is one which is widely
cultivated by the Mayo Clinic, allowing it to become one of the most admired service organizations
existing today. MCDC and its employees aspire to a similar reputation by believing in a continual
effort of improving the quality of what we do and how we do it. We make every effort to maintain
the belief that the needs of the patient are of paramount importance. MCDC continues to explore
strategies to encourage and reward this culture among our entire team. MCDC is continually
striving to improve all aspects of its operation with maintaining a patient-centered culture.

Business Statements; Mission, Culture, Vision and Values

Business statements carve out the rationale and help determine the marching orders for any
organization. These statements provide the basis for the ongoing strategy of the organization and
may change over time. As such, a critical crafting of these statements by key personnel of the
organization is vital to its success. The business statements of MCDC provide for dental public
health based upon our unique perspective and bias. Every operation and organization needs to
look internally into the development of their own statements. They should be uniquely reflective of
the business and its employees. At MCDC the approaches we take in the operation of the dental
clinics are predicated upon the following business statements:

Mission Statement, Why We Exist:

To improve the lives of our patients and enhance community health by setting the highest standard of

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oral health care.

When we speak of high-value dental care, we mean to achieve a goal where the quality of care that
is rendered is higher than what is traditionally practiced at a price point that is lower than that
commonly charged. Our emphasis is not on treating or fixing teeth. Rather our emphasis is on the
improved quality of life and health that follows a sense of well-being and improved self-esteem.
This can often follow comprehensive dental care which is provided in an environment focused on
exceeding the patient’s expectations and incorporating her values.

Culture, the Way We Do Things:

“Continuous improvement in a patient centered environment.”
What we do and how we do it shall always be in the interest of the patient. As William Mayo stated,
“The best interest of the patient is the only interest to be considered.” This is a paradigm shift for
many within the profession in which so many of the decisions have been focused on what is best for
the organization of the doctor. We further understand that continuous improvement is a journey,
not a destination.

Vision Statement, What We Hope To Accomplish:

An improved quality of life for our patients which enhances and benefits the local communities we
serve. We believe our vision can be achieved by caring for one smile at a time.

 Increase access to high-value oral healthcare (exceptional care at fees below the market
average).

 To provide oral healthcare in a manner consistent with improving the quality of life for the
patients we serve.

 The ability to recruit and retain exceptional health care talent.

 Foster an environment which encourages the personal and professional growth of our team.

 Develop and train future dental professionals with our educational partners.

 Lead the dental profession toward continuous improvement and patient safety.

 Cultivate an environment of political and social relevance with regard to the needs, outcomes,
and benefits of dental public health.

 Collaborate with all healthcare professionals to create an awareness of the importance of oral
health.

Value Statements, What We Believe:

“Transforming and improving lives and our communities’ health and wellness – one smile at a time.”
We accomplish this by:

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 Social Entrepreneurship - We believe that visionary innovation and creative thinking will
improve upon the delivery of dental services.

 Respect - We respect all individuals and demonstrate it through consideration, appreciation,
empathy, inclusion, and compassion.

 Excellence – We strive for continuous improvement to exceed the expectations of our patients,
staff and the community.

 Honesty – We are transparent in our actions by being real, credible, and free of deception.
 Learning - The pursuit of education strengthens our ability to make well-informed decisions

and prepares us to embark upon the best course of action.
 Engagement – We understand that none of us is as smart as all of us. Given that, we will be

engaged in our work to the benefit of the organization, our patients, and each other.

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Section 2

Internal Systems of Excellence

Of

Excellence in the Dental Office
A Venn Approach
The pursuit of excellence, continuous improvement, and patient-centered care are all catch phrases
used with ever-increasing frequency within our profession. The questions for the dental teams
become: What are we pursuing in becoming excellent? What are we improving, and just what does
patient-centered mean? To answer these questions, the dental office operation needs to be broken
down into its most basic parts. In this respect, those basic parts include just four areas. The first
three (core components) include clinical competency and standards, patient satisfaction, and
margin (profitability). Overlaid on these would be the fourth component, which is the underlying
ethos practiced in the pursuit of the first three. Generally these topics are presented as disparate
entities without much interaction considered between them. Some presentations have gone so far
as to say it is improbable that an office could achieve all components. “Determine which of the two
you want to achieve” has been a message delivered. The purpose of this article is to give a rationale
for achieving all components. To that end, the concept of Venn is introduced for the benefit of all
dental industry stakeholders, dental professionals, practice owners, and patients.

Simply stated, Venn is a diagram introduced in 1880 by John Venn in his attempt to diagram all
possible logical relations between finite collections of sets. In relation to a dental operation, a Venn
diagram provides a framework in which we can define and balance the components of excellence.
Through this approach, it can be determined where the operation needs to emphasize or de-
emphasize certain aspects to obtain balance. It also provides a method to evaluate and monitor
ongoing operations. The incidence of unintended consequences of our actions is minimized.

Venn also is used as an intentional play on words with Zen. When we achieve Venn, a natural
consequence is often Zen in our office. Peace, harmony, enlightenment, and balance are all aspects
of Zen. These are all highly desirable qualities in the practice and administration of a dental
practice. Figure 1 illustrates a Venn diagram using the three vital components of a dental
operation.

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Note that while each component is an
independent variable, a picture starts to
materialize as we overlay each component
onto each other. When looking at the
epicenter of the diagram we are viewing the
scope of what is referred to as the “sweet
spot” of the operation. It is in this range
where balance and harmony between the
patient experience, clinical quality, and the
margin or profitability of the operation is
obtained. It is also in this area where our
office Zen can be fully realized.

Figure 1

As this diagram is studied, it is possible to imagine the nearly infinite set of logical relations
between these components. As an example, consider a dental office which makes the concerted
effort to emphasize the incorporation of the highest standards of technical and clinical quality.
What may happen to profitability and the patient experience with this type of directed effort?
According to Venn, overstressing or emphasizing clinical quality would come to the detriment of
both the patient experience and our office margins. Think back on that absolutely perfect crown
that one attempted to achieve on that central incisor of a family member or other loved one. How
much more time was involved than a traditional preparation? Did that not affect our margin? Did
that extra time we took in attempting the perfect restoration make our patient a little more
uncomfortable with the procedure? Did that extra time also negatively impact the patient
experience and satisfaction with the procedure? We have come to accept, as reported in patient
surveys, that the second most important aspect in achieving patient satisfaction with patients is
respect of their time.

Understand that an argument is not being made against stressing a highly desirable clinical process
or outcome. But one should come to understand the ramifications of making this conscious
decision. Left unchecked, stressing clinical competency without regard to the other components of
Venn can lead to disastrous results. Most of us know, or know of, an exceptional clinician with
equally exceptional clinical competency who failed in maintaining the sustainability and viability of
his or her office.

In contrast, consider an operation that overly stresses or emphasizes profitability. The stressor of
putting profits over people would be likely to negatively impact the clinical standard of care and
patient satisfaction. Again, if left unchecked over time, this could result in disastrous consequences
for the office and likely the patient. As an understanding of the Venn model improves, it can be
used to great advantage in determining the culture, policies, and processes within the practice. A

6

Venn approach minimizes surprises and can help negate unintended consequences of our actions.

In a more holistic manner, a Venn approach also helps develop an appreciation for defining just
what is meant by excellence in the dental office. Excellence is defined differently by doctors and
patients. When patients speak of excellence, they have an entirely different meaning and
understanding than that of the health care giver. Patients don’t talk about numbers or outcomes,
but of their own human experience. Thus, really two parameters exist: that of the patient and that
of the learned health professional. A Venn approach encompasses and balances the expectations of
each.

It was earlier mentioned that overlying the three core components of Venn is a fourth component
which is the ethos practiced—that is to say, the character that is used to guide beliefs, behaviors
and morals. Without a strong moral character attached, all actions can come into under scrutiny.
Figure 2 provides a Venn diagram with the visual overlay of an office ethos on the three core
components. Through this visual it is apparent how an organizations ethos is to be ingrained in all
actions.

As mentioned, generally all actions and decisions have
some layer of ethical consideration attached to them.
Contemporary dental ethics often calls for the practice
beneficence. With the practice of beneficence we are
called upon to not inflict harm, prevent harm, remove
harm, and do or promote good. To put it in a patient
perspective: do the right thing, for the right reason, and
at the right time. With this practice, actions and
decisions become less parental in nature, and more
aligned with advocacy on behalf of the patient. As
balance and advocacy for patients become
commonplace, their response is highly favorable.

Figure 2

By maintaining Venn with the patient experience, it is found that patients are more likely to abide
by office policies such as keeping appointments, paying their bills, and accepting recommended
treatment. They also are more likely to take responsibility for their oral health and maintain the
dental services received. Finally, patients who feel satisfied have fewer complaints and increased
loyalty. Coupled with satisfaction of our patients, employee satisfaction commonly aligns. We all
feel better about ourselves when patients are satisfied and show their appreciation. This sentiment
is contagious in the office and can lead to employees feeling more appreciative, more highly
engaged and fewer staff turnovers. This all leads to an increased caliber of the dental team over
time.

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In evaluating our clinical competency, paying heed to appropriate and high standards, we find that
our individual patient’s health will improve over time. We find fewer incidents in their treatment.
Our personal benchmarked standards, and those of the profession, will improve over time. Costs
for required treatment decline over time. As a benefit of improved health the dental team can focus
more on complex rehabilitation, cosmetic enhancements, and other advanced procedures.
Remaining costs shift from treatment to prevention. On a larger scale, as individual health is
improved, the health of the communities we live and work in similarly improves.

Not to be minimized is our ability to do all this in a profitable fashion. Profitability lends to our
ability to provide for a better life for our family and the families of our employees. It adds comfort
to the viability of our operations and our livelihood. With higher levels of profitability we can make
needed investments in our operations to maintain our technological edge, and to provide that
world-class environment in which our care is rendered. With higher margins, some level of mission
can be incorporated. As Sister Irene Kraus has stated, “No margin, no mission.” The dental
profession is blessed with so many serving to a higher purpose. With improved financial results we
can increase our ability to provide care for those without the financial ability to do so.

Ten Commandments of a Great Dental Office

In following the dogma of a patient-centered practice it is helpful to be continually reminded of
whom we serve. Doing the right thing, for the right reasons, at the right time are paramount to this
philosophy. These commandments can be used in numerous ways to build a culture of being
patient centered. Be creative and consider sharing your culture in patient communications,
marketing materials, and in employee meetings. Here are the Ten Commandments in achieving a
great dental office:

1. A PATIENT is the most important person in our dental office.

2. A PATIENT is not dependent upon us – we are dependent upon her.

3. A PATIENT is not an interruption of our work – she is the purpose of it.

4. A PATIENT does us a favor when she calls upon us – we are not doing her a favor by
serving her.

5. A PATIENT is our mission – she is not an outsider.

6. A PATIENT is not a cold statistic – she is a human being with feelings and emotions like
our own.

7. A PATIENT is not someone to argue or match wits with, but to seek to understand.

8. A PATIENT is one who brings us her needs and wants – it is our job to educate her as to
her options, and to be her advocate and help her make an informed decision.

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9. A PATIENT is deserving of the most courteous and attentive treatment that we can
provide.

10. A PATIENT is the reason we exist in each and every one of our dental offices.

Best Practices and Standardization
Every operation will hopefully consider benchmarking most, if not all, aspects of the operation.
Through benchmarking we can determine levels of success. When success, or heightened success is
obtained (best practice), that success can be mirrored to achieve improvement (standardization).
So in utilizing a best practice we will employ methods and techniques which show results
consistently superior to those achieved by other means. This provides for a new benchmark to
strive for. It is important to note that no practice is best for everyone in every situation, and no best
practice remains best for very long as people continue to work toward and find better ways of
doing things.

To most efficiently incorporate best practices, standardization of the process into the system is
required. Standardization is simply the process of developing and agreeing upon a set of standards.
Note that some standards can be voluntary while others may be mandated. The process leads to
outcomes, but the outcome should be of primary concern.

Dental Office Ethics

Follow impulses and leaderships that represent ideals; that point the way to your professional destiny; that
express integrity, fidelity, service, and lofty purposes—the finest that is in you individually and professionally!

William J. Gies July 11, 1937

Those words were spoken nearly 80 years ago and still should inspire today. The American College of
Dentists is the pinnacle organization to dental ethics as is practiced today, and serves as a valuable
resource. As mentioned in the Acknowledgement of this text, many thanks to the College for its
contributions to this section of this work. Any material reprinted here is with permission.

Ethics are the moral principles or virtues that govern the character and conduct of an individual or a
group. Ethics, as a branch of both philosophy and theology, is the systematic study of what is right and
good with respect to character and conduct. Ethics seeks to answer three fundamental questions:

 What should we do?

 Why should we do it?

 When should we do it?
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The object of ethics is to emphasize spirit (or intent) rather than law. Dental ethics applies moral
principles and virtues to the practice of dentistry and encompasses activities of both judging and
choosing. Ethics affects relationships with patients, the public, office staff, and other professionals. As a
dental professional, numerous decisions must be made. Some decisions are straightforward and easy;
others can be very difficult. Ethics are inextricably linked with these decisions and with the day-to-day
activities of the office.

When ethics are ignored, one risks making unethical or less ethical decisions. Unethical decisions can lead
to unethical conduct. At a minimum, unethical conduct seriously compromises your service to patients
and undermines your ability to function as a professional.

Ethics are critical to being a professional. An emphasis on ethics and ethical conduct clearly distinguishes
one’s standing as a professional. Without a solid ethical foundation, one simply cannot be a true
professional.

A professional is a member of a profession. Four qualities have been attributed to those who practice a
profession:

 A professional has respect for people

 A professional is competent

 A professional has integrity

 A professional’s primary concern is service, not prestige or profit

These qualities are consistently reflected in the decisions and actions of a professional. To act
professionally is to act as a true professional—to comply with the duties and obligations expected of a
learned professional. In this vein every dentist is called upon to participate in service—the chief motive
being to benefit mankind, with the dentist’s financial rewards secondary.

While dentistry is first a profession, the practice of dentistry usually involves financial compensation for
professional services. Such compensation necessitates, by its very nature, some form of business
structure to accommodate these transactions. Since dentists are in a position to gain financially from their
professional recommendations, they are at risk of having a conflict of interest, whether actual or
perceived. The patient is the beneficiary of the dentist’s services. If the dentist is being compensated for
professional services, then the dentist is also technically a “beneficiary” of his or her recommendations.

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The issue is not whether there is a conflict of interest. Additionally the level of financial gain to the dentist
must never be a consideration in any of the dentist’s professional recommendations. A patient’s ability to
pay for services may be a consideration in these recommendations. If the patient’s relevant and best
interests are always considered, the profession of dentistry can ethically exist within a business structure.

The “best interests” of our patients means that professional decisions by the dentist must consider
patients’ values and personal preferences. This requires that dentists carefully communicate with their
patients, and listening is of paramount importance. Sometimes patient desires conflict with professional
recommendations. Patients must be informed of possible complications, alternative treatments,
advantages and disadvantages of each, costs of each, and expected outcomes.

Together, the risks, benefits, and burdens can be balanced. It is only after such consideration that the
“best interests” of patients can be assured.

Finally there are times when a dentist may face the decision to compromise quality. This may be because
of the limited financial resources of the patient, reimbursement restrictions imposed by dental insurance
plans, patient values or preferences, or other factors. Compromise must not occur simply because the
dentist is willing to “cut corners.” These limitations or restrictions may divert the direction of the overall
case from “ideal,” but they should never affect the quality of the separate components, comprising the
final treatment plan. The goal should be to perform each treatment step to its highest standards. For
example, if the final decision, considering all limitations, is to place a less costly type of restoration instead
of a more durable or esthetic (but more expensive) restoration, then the dentist is obligated to place the
less costly restoration competently. The dentist is also obligated to collaborate with the patient during the
decision-making process. It is unethical to knowingly provide substandard care.

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Section 3

Communications Contributing to Excellence

Communications in the Dental Office

Internal Office Communications
The fast pace of a typical dental office environment proves a daily challenge with regard to effective
communications; and it all starts with communicating. Paramount to an effective operation is
effective and timely communications. It is important to remember that attempts at communication
are rarely perfect and can generally be improved upon. Through experience it has been learned
that this improvement can be enhanced by incorporating a multifaceted approach. This approach
could involve one-on-one, email, phone, social network media, fax, “snail” mail, electronic bill
boards, white boards, and other forms. The more important the message, the more avenues in
sharing the communication should be considered. The manner in which we evaluate ourselves for
effectiveness should be determined both in internal and external communications. This is
definitely one area that we need to take time away from the practice to work on the practice. The
following are policies and protocols internal to the office. Many of these are directed at positively
impacting internal and external communications.

Daily Morning Huddles
Often unexpected situations arise throughout the day, which may slow us down, keeping the team
late, making patients wait, delaying needed treatment for our patients, and costing the office
production and patients needed treatment. The morning huddle is designed to review the day’s
schedule in order to identify bottlenecks and potential patient, team, and scheduling
inconsistencies. Once identified, we can minimize the unexpected and discuss a solution or
alternative. There are also times when opportunities may present for further patient treatment and
increased office production. As time allows, individual patients and their pending treatments,
including new patients, can be discussed. Finally the team meeting allows for daily feedback on the
office’s achieving its goals. This is also a time to recognize employees who exhibit and demonstrate
actions which build the team and put the patient first.

The personnel responsible for morning huddles would be the Office Administrator (manager) or
other designated team member. It is often good policy to rotate this responsibility among the
entire team. All team members, including the doctor(s), should be present during this time.

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Meetings should be conducted every morning in the immediate 10-15 minutes before the first
patient is seen, and should conclude promptly at patient appointment times. Promptness is
expected at the meetings. These meetings are not a coffee clutch, nor should they result in a delay
in seeing patients at their appointed times. It is required that everyone be seated and ready one
minute prior to the beginning of the meeting. The following should be included as a minimum in
every huddle:

 Start each meeting with a reading of the mission statement and one vision or value
statement of the organization.

 Share a positive statement regarding the previous day about the team’s behavior, a team
member, or an appreciative patient.

 Business Staff:
o Communicate the next opening in the hygiene department.
o Flag patients scheduled that day with potential collection or financial concerns.
Identify who is to speak with the patient on this concern.
o Reflect on the office production goal, and discuss opportunities to meet or exceed it.
o Share personal info regarding today’s patients; for example, death or birth in family,
birthdays, achievements, etc. This creates an opportunity for patients to feel as
though they are special in our environment.
o Share new patient information.

 Clinical Staff:
o Insure that all expected lab cases are present in the office and, if not, take the
appropriate actions.
o Review any special treatment to be performed.
o Following individual state law, indicate opportunities where local anesthetic needs
can be administered by an RDH, or other licensed professional.
o Review and make accommodations for potential problem areas in schedule,
whether they involve openings or being overbooked.
o Identify opportunities to exceed patient expectations and satisfy them

 Hygiene Department:
o Review the potential to dovetail hygiene patients into the doctor’s schedule if
changes to the schedule occur during the day.
o Indicate required FMX’s needed that others may assist with.
o Indicate sealants needed that other licensed professionals may have the opportunity
to complete or assist with.
o Review patients who are staying for restorative who could have local anesthetic
administered by the RDH.

This may seem like much to cover in 10-15 minutes, and it is. It is critical that adequate preparation has
been done by all individuals prior to the meeting. In general, all staff should be aware of what is
happening throughout the office throughout the day. Anticipate the needs of others; don’t wait to be
asked to help. Also don’t wait for others to volunteer their help. Ask for it based upon a team member’s

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availability. Remind the team at the conclusion of each meeting that we are stronger together than
individually.

The meeting should conclude prior to the first scheduled patient, no exceptions! Remember,
patients first, and a respect for their time should always be a most pressing priority.

Weekly Team Meetings

The content of weekly team meetings can vary dramatically based upon organizational need and
identified opportunities for improvement. In keeping with a culture of continuous improvement
improved frequency for meetings is likely to result in improved results for our office and outcomes
for our patients. Suggested weekly team meeting times could vary from 30 to 60 minutes. The
meeting times are suggested to be outside of hours in which patients are normally seen. Consider
the opportunities for improvement in the area of exceeding patient expectations to be an area of
primary discussion.

Monthly Team Meetings

The monthly meetings are essential to allow the office to continue to grow as a team and to
continuously improve our patient and business skills. Central to the meetings are improvements in
patient treatment, increasing production, decreasing overhead, building team skills, and training on
office procedures and policies. These meetings are not to be used as a forum for employee
grievances. Team members should understand that these meetings are scheduled to be highly
productive. It is important to recognize that while we work in our individual operations daily, we
do need to take time away from that to work on improving the operation. Facilitators for the
meeting would include the Clinic Administrator or Manager. The recorder for the meeting should
alternate among employees from meeting to meeting.

The timing and frequency for the meeting should be set by each individual practice. It should be
held the same day and time of the month and be scheduled at the discretion of the operation, but
should be approximately one hour. The meeting should not conflict with normal clinic hours in
which patients are seen.

The procedure and the agenda for the meeting may vary from month to month, but should
generally be aligned with the following format:

 Discussion of old business.

 Discussion of new business to include review and implementation of policies, patient
satisfaction, team building skills, communication skills improvements, marketing, review of
practice performance, and the review of an agenda that is written by the team members and
approved by the doctor or office administrator (manager) throughout the weeks in between
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meetings.

 Any work assignment emanating from the meeting should be clear as to who is to be
responsible and accountable, and a deadline for completed action.

 Minutes for the meeting should be recorded. Minutes should be available to staff and
forwarded to immediate superior administrative personnel where applicable. This should
be completed within three business days of the meeting.

 Collection/Production goals should be reviewed.

 New procedures in the office should be addressed.

 Number of new patients and patients that have left the practice should be discussed.
Emphasis should be on why are people leaving, and why people are coming to us.

 Improving customer service should be discussed.

Benefit statements should be part of every meeting so that all team members are aware of the
purpose and hopeful outcomes of the topics discussed.

Effective Communication with Patients

Effective communications begin with an understanding of our audience. In the dental office our
audience is the individual patient and her family. When we have an understanding of the patient
we can tailor our communications to be more effective. The most basic understanding to hold is
that the average U.S. citizen has an average literacy rate between 7th and 8th grade. This would be
the average patient entering a private practice setting.

In contrast to the private setting, those practicing in the public health are particularly challenged.
Typically, the literacy rate of an underprivileged adult, in public health, is that of a second or third
grade elementary student. More disturbingly, the Literacy Project Foundation reports that 3 out of
4 people on welfare can’t read. This can be an obstacle to effective communications between the
learned professional, who may have 20-plus years of formal education, and the patients in this
demographic. There is a tendency to talk to the patient above their level of literacy or attempt to
somehow educate them to our level. In reference to an article which appeared on the AP Newswire,
Alan Alda made the remark, “There is no reason for the jargon when you’re trying to communicate
the essence of the science to the public, because you’re talking what amounts to gibberish to them.”
This is indeed a true challenge for both the health professional and the patient.

Clear communication between the patient and the dental team will greatly improve the level of
trust and confidence from the patient. Every reasonable measure should be taken to develop and
maintain a strong partnership with the patient and transform the patient experience.

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Utilization of a patient satisfaction survey can provide invaluable insight into the patient
perspective and experience. A survey should provide the patient the opportunity to provide honest,
anonymous feedback.

Example of potential survey topics:

Your Appointment
1. Length of time between calling for an appointment and being seen by the dentist
2. Helpfulness of the person who scheduled your appointment
3. Availability of your dentist
4. Length of wait before going into the treatment area/exam room

Dentist – Patient Interaction
1. Explanation of your options for treatment
2. Amount of time the dentist spent with you
3. Dentist’s concern for your questions and worries
4. Caring shown by the dentist
5. Thoroughness of exam and treatment
6. Your confidence in this dentist
7. Degree to which the dentist talked with you using language you could understand

Dental Team
1. Teamwork shown by the dental staff
2. Friendliness/courtesy of the dental assistant
3. Friendliness/courtesy of the dental hygienist (person who cleaned your teeth)

Facility
1. Comfort of the reception room
2. Cleanliness of the facility
3. The infection control features used in the exam room

Personal Issues
1. Our concern for your comfort
2. Information provided on ways to avoid future dental problems

Payment Issues
1. Information provided on cost of treatment
2. Degree to which the care provided was worth the money charged

Overall Assessment
1. Likelihood of your recommending this dentist to others
2. Overall rating of the skill of this dentist
3. Overall rating of care provided by this dental office

The feedback provided from a patient satisfaction survey can be used to identify opportunities for
improvement. Transparency with the survey results is necessary to facilitate change and foster an
environment that encourages continuous improvement.

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Additional strategies to consider in improving oneself in this area would include studying
emotional intelligence, coming to an understanding of the DISC Personality Profile System, and
reviewing our individual practice’s patient demographics to better understand patients.

Patient Communication Materials

New Patient Orientation Packet
The front desk personnel, or a member of the contact center team, are responsible initially in
providing information on practice policies and services to the new patient. These polices can be
reviewed during each patient interaction to keep patients educated and reinforce the policies
required to maintain sustainability of the operation. This information can be shared verbally and in
a new patient mailing.

Orientation doesn’t just end with the initial interaction. It is important that a continual
reinforcement and encouragement of patient adherence to office protocols be conducted. This
responsibility shifts to the back office during patient treatment. At this time all appropriate clinic
guidelines including matters of finance and maintaining appointments should be discussed.

Recommended Scripts:
Hello Mrs. Jones. In order to introduce you to our office and services I would like to take a few
moments to review information in our patient information packets. Please keep this
information so you may refer to it in the future. (Team member reviews each page of the new
patient packet) Now that we have reviewed this information, do you have any questions?

Value-Building Statements
All team members are responsible for adding value to the patient appointment. The purpose of
having value-building scripts is to provide a way for all team members to consistently convey to
patients the value and benefit of both the time and treatment that are offered to them.

It is highly recommended that at least one benefit statement is shared every visit, by every team
member the patient comes into contact with. Multiple statements can be utilized to place value not
only on the patient’s time, but on our time. Recall that things of value are also scarce. In that regard
we should emphasize the scarcity of provider time to increase compliance with appointments.

Statements are to be utilized in the course of conversation which would elevate the doctor and the
team to instill trust and confidence in the patient’s dental office. Bringing these statements into the

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conversation must come naturally and not feel forced.
Recommended Scripts:
Hello Mrs. Jones. We place great value on your time. I want you to know that we will make every
effort to begin your treatment within 10 minutes of your appointment time. To honor that for
you and all our patients I need you to extend the courtesy of arriving at the office to begin your
treatment at your appointed time. Do you foresee any obstacle to arriving in enough time for the
appointment we extended to you today?

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Section 3

Scheduling and Appointment Management

Basic Scheduling Principles

Efficient and Effective Scheduling

It is proper scheduling, more than any other aspect of managing a clinic which can provide for a
smooth and efficient operation. It can also provide for a chaotic, stressful, and inefficient operation
without proper systems. Generally too little time and attention is dedicated to this aspect of the
operation. Many offices fall behind schedule on a daily basis, to the point where both staff and
patients have come to accept the practice as the norm. The thought process includes: if only the
doctor were faster, if only the hygienist didn’t need all those exams, if only my assistant could turn
the rooms over faster we would stay on schedule. Proper scheduling needs to take all these facets
and challenges into consideration. In general a good scheduling system should provide for the
following (the goal):

 Patient treatment is initiated within 10 minutes of the appointed time.
 The schedule allows for a production or revenue goal to be met.
 Patients with emergent needs can be accommodated on a daily basis.
 Stress level is minimized for all staff of the office.
 Maximize treatment rendered on any given appointment.
 Minimize the number of treatment visits required to complete a treatment plan.
 Allow for flexibility to accommodate changes in the schedule and individual treatment.
 Enough time is allocated for a quality patient interaction.
 Sufficient time is allowed for the provider to render care at an acceptable standard.
 Longer and more productive appointments take priority for morning time slots.
 Staff maintains control of the schedule.
 All appointment requests are directed by the provider.
 Generally patients are to be scheduled with “their” doctor, unless a suitable reason is

evident. Establishment of a patient home is critical in ongoing care. Patients should
routinely be scheduled back in the next available opportunity with their established
provider of record.
 Providers can only be in one place at one time, and should not be double-booked.
 Scheduled appointments should accurately reflect the times each team member is required
to be in the room at any given time. This would include the dentist, assistant, the registered
assistant (or expanded duties auxiliary), and hygienist.

The last bullet point indicated a concept that requires further reinforcing. The general policy is that
the owner of the schedule is that of the office, and not the patient. To achieve the stated objectives
above, the office must maintain that control. All too often we abdicate that control to the patients

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making statements like, “Mike, what would be the best time for you to come back to for this
appointment?” Making a statement like this puts the patient in control of our schedule and not only
disadvantages the office, but very likely other patients. By taking control of the schedule we may
now make a statement like, “Mr. Smith, I know the doctor would like to see you as soon as practical.
I have Tuesday at 10 a.m. available or Thursday at 2 p.m. Which would work better for you?”

Remember the office should make every attempt to schedule patients for an appointment as
requested by the provider (in concert with the patient), for the time allotment requested, at a time
which maximizes the office efficiency.

Procedural Time Studies

Before one can schedule effectively, it is of paramount importance to determine clinical time
requirements for procedures to be scheduled. Procedural time studies should be performed to
achieve the average total chair time and doctor/assistant time for the most frequent and productive
procedures. It is critical that this time be established so as to maximize the efficiency of the clinic,
and to allow for cross-scheduling of patients among all providers within the facility. When time
studies are conducted they should be by the dental assistant in conjunction with dentist. Times
can be conducted for the following:

 Endodontics
 Quadrant operative care
 Crowns and other fixed prosthetics
 Multiple extractions
 Removable prosthetic appointments

As dentists hone their skills it is recommend that once every 12 months the dental assistant, in
conjunction with the dentist, perform a minimum of 12 evaluations for time in reference to the
appointment types listed above. To obtain standardized times follow the protocol below:

 Choose procedure to be timed.
 Begin timing when the patient is seated and continue until patient leaves the operatory.
 Determine total chair time.
 Determine doctor time.
 Determine assistant time.
 Repeat above steps a minimum of 12 different times on a similar procedure. Add all times

and then divide by 12 to obtain the average times for the provider. This can also be divided
by the number of surfaces restored or teeth extracted to get a unit time per extraction of
surface of restoration. This will generate the mean time.
 Time study information should be shared and agreed upon by all providers within a facility.
This information should be available to all clinic personnel as to provide for uniform
scheduling among all.

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 As team members mature in their practice, they become more efficient. In this regard it
may be necessary to visit time studies on an annual basis.

Emergency Scheduling

A dentist should be available, within reason, to address acute dental conditions. A person with an
emergent dental condition should be examined and either treated or referred for treatment. In such
situations, the patient’s health and comfort must be the dentist’s primary concern, not compensation or
convenience. If a dentist cannot accommodate the patient’s emergent needs, a reasonable effort should be
made to have the patient seen in a timely manner by someone capable of treating the condition.

It is important to understand that there are two general groups of patients with emergent
problems. They are existing patients of record and new patients to the organization. In most states
there is a legal requirement to see patients with emergent issues within a set time frame. Persons
calling who are not existing patients have no legal requirement to be seen. However, every attempt
should be made to accommodate these individuals as it is the right thing to do, especially within the
public health sector. Individuals who are not patients of record should be very clearly informed
that the office will see them. It should be made evident to them that this is a one-time opportunity.
Should they wish to continue to receive services in the clinic in the future, they must become an
established patient and return for a traditional new patient visit. Should they fail to do so, they will
need to seek future emergent care elsewhere. While this is policy, it should be remembered that
policy should not replace compassion and common sense.

Patients with emergent issues are perhaps the biggest challenge to maintaining a schedule. There is
no fool-proof system in existence which meets with all the parameters of a good scheduling system.
The protocol outlined here has been in service within the MCDC system for several years and has
proven very successful when appropriately integrated. The general principle to follow is there is no
good place to schedule these patients, so don’t look for a place, simply follow this protocol.

To ensure that patients with an emergent need are offered an opportunity to be seen, and to
provide minimal disruption to the office, efforts should be made to provide palliative treatment
when definitive treatment is impractical. It should be noted that attempts of any person, outside of
the dentist, to triage may be both illegal and unethical. While there are many duties a clinician may
delegate, this is arguably not one of them. However, patients will self-triage when queried properly
utilizing the three questions outlined here. Statistically there is a 50% affirmative response rate to
each of the three questions, and all three require an affirmative response to require action on the
part of the clinic. As an example, if an office fields 20 suspected “emergency” phone calls, on
average only two or three will meet the self-test to be seen based upon affirmative responses to the
three questions. Patients with a negative response to any of the three questions should be directed
to call the facility at the earliest opportunity tomorrow. At that time the three questions are
revisited with the caller.

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The questions are:
1. Do you feel as though this is a problem you need to be seen today for?
2. Are you able to come right over to be seen?
3. Given the doctors already filled schedule, would you be willing to wait between five minutes
and four hours to be seen?

With this policy patients are offered the opportunity to immediately visit the office after self-
triaging with the three questions which are indicated in the script below. Once properly screened
via the three questions, the patient should be instructed to immediately proceed to the dental office.
Upon arriving at the dental office the first available clinic personnel shall seat the patient, review
medical history, take the patient’s chief complaint, obtain the appropriate X-ray, and inform the
doctor of the findings. The most efficient scheduling involves teamwork that has openly
communicated all aspects of the patient visit and has been determined to be within the comfort
level of the doctor and with state law. Conservation of time is critical in being able to accommodate
these patients into an otherwise fully scheduled day. Team members should obtain and report
information to the doctor utilizing a SOAP format.

As a review, the information which should be contained in a written and verbal SOAP report
includes:

 S-Subjective. Report the chief complaint, or what the patient is telling us, to the doctor.
Example: “The patient reports the upper right has been hurting for three days and the
swelling and redness is increasing.”

 O-Objective. Report what is observable of the chief complaint to the doctor. Example: “The
upper right cheek is visibly swollen to the lower orbit of the eye. The patient has a tooth #3
that is tender to the touch, and has a temperature of 102. There appears to be an apical
radiolucency associated with #3 which has extensive coronal decay.”

 A-Assessment. Give the doctor the impression of what might be the problem. Example:
“Doctor, it appears as though tooth #3 is badly decayed and abscessed.”

 P-Plan. Give your impression to the doctor as to what needs to happen. Example: “Based
upon your previous direction, I have indicated that the options you may present are an
extraction or endo and crown. Given your lack of time to perform either today, I am ready
to assign the appropriate prescriptions and schedule the patient back for definitive
treatment.”

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Recommended Scripts, The Three Questions:

Question 1 - Is this a problem you feel that you need to be seen today for?

Question 2 - Do you have the availability to come right over to be seen?

Question 3 – Given the doctors schedule is completely full today, do you have a willingness to
wait between 10 minutes and 5 hours to be seen today?

Mrs. Jones, I understand you are having a problem. Do you feel as though this is a condition that you
need to be seen today for? (Patient- yes) Do you have the availability to come right over to be seen?
(Patient – yes) I need to inform you that our schedule is completely full for the next few months.
Having said that, I am sure our doctor will want to see you to determine how she can best help. Your
wait time may be minimal, but quite honestly it could be some time before you are seen as we have a
very full schedule today. We would ask your patience as we attempt to help you with your problem.
Are you willing to wait between 10 minutes and 5 hours to be seen today? (Patient – yes) Mrs. Jones,
given the information I have shared with you, please come right over and I will inform our team to
expect you very soon.

If a patient has any objections to these three questions they should be informed to call the next day at
the earliest opportunity and repeat the three question tactics. Do not schedule an emergency visit.
Initial New Patient Call

You only have one opportunity for a first impression. The front desk staff or contact center
members are usually the ones that have the opportunity to create a positive and lasting first
impression. Always consider the viewpoint of putting patients first when conducting this initial
conversation with patients. It is this first contact that often sets the tone for the following series of
appointments. An initial call not properly managed can result in an appointment not being made,
or possibly an antagonistic relationship between patient and clinic staff.

The purpose of this script is to allow consistency when speaking to a new guest who calls our
practice with a dental problem and shows interest in becoming an established patient. Most often
the front desk team member of the contact center will field these calls. Scripting is vital to ensure a
consistent and positive first image is created for the patient.

Recommended Scripts:

Team Member: Thank you for calling “clinic name.” This is ____. How can we help you today?

New guest: Are you accepting new patients?

Team Member: Yes, we are always happy to have new guests in our office! Are you having any
particular concerns at this time?

New Guest: No, I just need a checkup.

Team Member: That is great! May I take a moment to tell you about our new patient
appointment?

New Guest: Yes

Team Member: We allow 70 minutes with one of our hygienists and the doctor. During that 23
appointment they will complete a very thorough examination, including a complete set of
necessary X-rays.

Appointment Slips and the Tickle File

Appointment slips should be used for every patient on every visit. Completing an appointment slip
ensures that we are giving the provider the proper resources for the next appointment. The doctor
should be controlling the patient’s treatment and thus holds the responsibility for indicating the
requested care for each appointment. Approximately 80% of all patient treatment visits should be
scheduled from the rear office, or treatment room.

Each patient of record should either have an appointment within the appointment scheduler or an
appointment slip within the “tickle file.” The tickle file is created by appointment slips which were
not scheduled, but placed into an index card box with calendar tabs. The tickle file serves as our
methodology to follow up with patients on care which has not been scheduled. Patients no longer
are lost or fall through the cracks in the system with this method.

Requested Ideal Appointment Time:

Requested Provider

Times should be indicated on the appointment slip in Patient Name
units on the X. The top box of the X is where the
requested assistant time is designated, to the right of the Requested Procedure(s):
X the doctor time is indicated, and at the bottom of the X Alternative Appointment Time:
is any additional assistant time required to complete
services with the patient. To the right is one suggested
example of what an appointment slip might look like.

Scheduling an Appointment

It is critical that the general scheduling principles be followed when appointing patients. All staff
maintains this responsibility on a continuous basis.

Appointment requests are to be directed by the doctor to include what treatment is requested, the
units of time requested, which team member will be required and during what portion of the
appointment. Two alternative appointment times should be offered to the patient. The offered
times should allow for maximum office efficiency.

Recommended Scripts:

Mrs. Jones, the doctor has requested an appointment for the treatment the two of you discussed
today regarding your next visit back with us. The appointment request is for 90 minutes. Please
remember our no-show policy as we schedule this appointment. Generally missing an
appointment without 24 hours’ notice may result in your dismissal from all of the offices of the
organization. Given that information would Tuesday at 10 a.m. or Thursday at 2 p.m. work better
for you?

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Family Scheduling

When multiple family members are scheduled at the same time, a number of situations can occur
which may cause all appointments to be broken when a problem exists with just one of the family.
Our guidelines are in place to reduce and eliminate the schedule from being violated and the time
going unused.

When a patient requests to schedule an entire family, apply the guideline that we offer up to two
appointments per family per day.

Recommended Scripts:

Mrs. Jones, I understand how you feel in this situation. It would be a very unusual circumstance to
offer more than two appointments per family at one time. Other mothers have had a similar
concern with everyone’s active life schedules. What they have found is that by bringing the kids in
two at a time, it helps out with sports schedules, etc., and actually reduces the possibility of having
to reschedule. Also, the appointments are interchangeable. If it turns out that Jodi can’t come this
week, just let us know and we can make arrangements for you to bring one of the children that are
scheduled in the future.

Block Scheduling

Block scheduling is a modification to maintaining a traditional schedule. Block scheduling helps to
ensure office goals are met and provides a flow to the day with a variety of procedures that, by
design, reduce stress and maximize services rendered. The minimum goal for achieving daily
production and revenue goals should be to achieve 60% of that goal prior to a designated lunch
break, or upon the completion of one-half of the work day.

To achieve this, the early appointments are generally reserved for longer appointments, which
often equate with productive appointments. Examples would be six or more extractions, fillings, or
a root canal and crown. Minor appointments should be highly discouraged from this time frame
and generally only be allowed when not able to be filled with the more productive appointments.

Patient Reminder of Appointment

These are not confirmation calls, as we should believe that the appointment was confirmed when
first placed. With a confirmation call, by definition we are creating an opportunity to change the
appointment or cancel it altogether. For that reason, we do not confirm appointments; we merely
remind patients of previously confirmed appointments. To increase the efficiency of the office
through patient utilization, reminder calls will be made to increase patient compliance 48 hours
prior to their appointment. Calls are generally made by front office personnel, clinical staff when
available, and contact center team members.

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The reminder call will be made 48 hours prior to the scheduled appointment. Re-care cards should
be mailed six weeks prior to the due date and re-care calls should be made two weeks prior to the
due date.

Recommended Scripts:
Hi, Mrs. Jones. This is Sally calling from your dental office. I am calling to remind you of your
appointment Wednesday at 8 p.m. If you recall, the doctor wanted to see you at this time and he
wanted me to reiterate the importance of your keeping this appointment. We look forward to
seeing you at that time.

Late Patients
The protocol for late patients is in place to respect not only the time of other patients, but the team
members as well. This system also allows a diplomatic way of emphasizing to the patient that a
specific amount of time is reserved just for them. Generally the front office team member will
administer this policy.

If a patient arrives late, notify them in a courteous manner that they are late for their appointment
and express concern at being able to accomplish all for them which was scheduled. After 20
minutes being late, check with clinical team to determine if patient can be seen. In most cases
where the patient can be seen, see the patient.

Recommended Scripts:
Less than 20 minutes late: Mrs. Jones, we were hoping to see you at____. We’re glad you’re here
and I hope everything is OK. Please understand that as a result of a late start we may not be
able to accomplish everything we previously planned for. Please make yourself comfortable
and I will let them know you’re here.
More than 20 minutes late: Mrs. Jones, we were hoping to see you at____, and it is now____. The
OtfifmiceewReusnentiansgidBeewhiansdspecifically reserved for you, and a good portion of that time has now
passed. Please make yourself comfortable and we will check with the clinical team to
determine if we can accomplish anything with the time that is left.

All team members are responsible to communicate when the clinical team is behind to a degree that
it will affect other scheduled patients. Our goal is to treat patients within 10 minutes of their
appointed time.

It is important to communicate changes in the schedule to ensure that our patients may be notified

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and their time respected. This is merely a common courtesy to the patient as we in turn would like
the courtesy of a call if a patient were running late for their appointment. This philosophy is
utilized to foster a mutual respect for each other’s time. We also communicate so that the team can
be prepared to handle the circumstances.

The clinical team should notify the front office whenever a scheduled patient can’t be seated and
treated within 10 minutes of their appointed time. The front office team member in turn notifies
the individual. The procedure may look like this:

 Clinical team member notifies front office if running more than 10 minutes behind.
 Front office communicates delay to patient and offers to let them use the phone if

needed. Also, they are given the opportunity to reschedule if the office is significantly
behind schedule.

Recommended Scripts:
Benefit statement: Mrs. Jones, so that you are aware, we want to let you know that the clinical
team has experienced a delay. It will be approximately ______minutes before they are able to see
you. Is there anything we can do to make you more comfortable while you are waiting? Please
be assured they will give you their undivided attention as soon as possible.

Broken Appointments
Broken appointments are extremely disruptive to the functions and morale of the office. Broken
appointments greatly increase the cost of providing dental care and limit our ability to treat those
truly seeking our care. Broken appointments stress our ability to meet our mission and obligations
to the community. Our guidelines are in place to reduce stress and eliminate the schedule from
being violated and the time going unused.

Maintaining the importance of the appointment when the appointment is made, by all clinic
personnel, is critical in keeping the proper patient perspective for the time that was reserved solely
for them. Patients need to be continually informed of policy in this regard.

The procedure for managing broken appointments would be the following:

 First and foremost, the importance of keeping the appointment must be made when it is
scheduled. To increase “buy-in” to the appointment, it should be made by the provider who
will be seen, or if unavailable, by an available clinical member. The front office team should
only be scheduling appointments when impractical in the operatory for reasons of
cost/insurance and time constraints. Eighty percent of appointments should be scheduled
in the op.

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 Secondly, patients should be informed that they must give us 24 hours if they cannot keep
their appointment. This is a courtesy to open their reserved time to provide treatment to
another. Failure to provide 24 hours to the clinic may result in dismissal of the patient from
the clinic(s).

 Broken appointments must be entered in the appropriate patient file.
 All patient co-pays must be made at the time the appointment is made. Exception is

Medicaid co-pay. Medicaid recipients are not obligated to pay to create an appointment but
they can be asked.
 Special consideration with great reservation should be given to scheduling patients without
a phone contact. A generally high failure rate is seen among patients where a phone service
has been disconnected.
o Patients should be informed that they may be dismissed after one broken appointment;

however a second opportunity will be provided to them in this event.

o Patients will be dismissed from the clinic system upon a second broken appointment.

o The dentist should be notified when a patient will be dismissed so that an appropriate

decision can be made based on treatment and when it is in the best interest of the

patient and the clinic’s operation. Ultimately it is the prerogative of the clinic dentist to

allow for select and limited exceptions to the rule. Generally all patients are to be

dismissed following a third broken appointment which would have been originally

authorized by the treating dentist. Any exceptions should be noted in the dental

software with a patient alert and include the dentist’s name and reason for extending

additional appointments.

o Children may have dental requirements for attending school. Effort should be made to

contact a responsible party (i.e. Head Start) to assist in alleviating any barriers that the

family may be facing.

Recommended Scripts:

Mrs. Jones, we want you to know that your next visit with us is extremely important in
maintaining your dental health. Please understand that, due to high demand, we are extremely
busy and if something were to happen to keep you from keeping this appointment, it may be quite
some time before another appointment could be available to you. We would ask that you contact
us 24 hours before your appointment if it becomes absolutely impossible for you to maintain the
appointment time that you asked us to reserve for you. Please remember our policy that you may
be dismissed upon a broken appointment without giving us 24 hours’ notice.

Patient Cancellations and No Show Policy for the Existing Patient

The protocol in managing patient cancellations should emphasize eliminating the cancellation.
When this is not practical every effort should be made to utilize the open time. This will help
maintain office productivity and render treatment to others. While this policy is not intended to
replace compassion and common sense, patients may be considered for dismissal from the clinic
system after the second broken or no-show appointment as outlined here. The assumption is made
that the office has a very clear policy in this regard that has been communicated to the patient.

If a patient fails to show for the first time for a scheduled appointment, all future (if any)

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appointments scheduled should be cancelled. It is recommended that the dental office NOT call the
patient for explanation. Often patients are vague in their responses, and a call puts them in a
defensive posture. Rather, a note sent indicating their missed appointment and our concern for
them is warranted. If they wish to continue dental treatment in our office, the responsibility is with
them and our communication would direct them to call and reschedule the missed appointment.
An effective policy is to require 24 hours’ advanced notice. With this notice the appointment is not
considered a broken appointment. Without 24 hours’ notice, the appointment is considered a
broken appointment. Depending on the nature of the cancellation, any combination of failing to
give adequate cancellation notice, or not showing for two appointments may likely result in
dismissal from the office and any offices of the organization. Dentists of the practice should
routinely be informed of patients the office deems appropriate to dismiss. The dentist should also
hold the ultimate authority for making exceptions to this policy.

Dental clients who have been dismissed from the clinic for either broken appointment or
cancellation reasons should be notified by certified letter and will be seen for emergency care only
for 30 days from the date of the dismissal letter. State dental board law does vary. Check with your
state on requirements for patient dismissal from the practice.

The procedure for effectively handling potential broken appointments includes:

 When a patient calls in an attempt to cancel an appointment, concern should be expressed
about not receiving the needed treatment. Every attempt should be made to influence the
patient to keep the reserved time.

 If the person is giving 24 hours’ notice, thank her for the notice and reschedule the visit.

 If the patient is calling with less than 24 hours’ notice, and it is the first broken
appointment, reaffirm policy of dismissing, but as a courtesy offer another opportunity, if
the patient believes she will keep the appointment. The appointment must be documented
as broken in the patient file, or dental software, and a patient alert should also be entered.

 It should be reinforced that if this appointment is broken, the patient will be dismissed
from the system. If the person has other broken appointments, and has been informed of
the dismissal policy, she should be formally dismissed with a certified/return receipt letter.
In extreme, extenuating circumstances a third appointment may be offered only with
approval and authority of a clinic dentist. Ultimately, it is the prerogative of the clinic
dentist to allow for select and limited exceptions to the rule based on treatment and what is
in the best interest of the patient and the clinic’s operation. Remember, policy does not
replace compassion and common sense.

 Children may have dental requirements for attending school. Effort should be made to
contact a responsible party (i.e. Head Start) to assist in alleviating any barriers that the
family may be facing.

 To not disadvantage children, a policy does not dismiss families but dismisses individuals.

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Patient Cancellations and No Show Policy for the Potential Patient

The potential patient is one who has displayed an interest in becoming a patient of the office,
scheduled an appointment, but has not completed the initial comprehensive appointment and
established the doctor-patient relationship. In this instance the office needs to have a firm
understanding of the latitudes it is willing to grant to patients, and consider the boundaries of respect
that are required by patients. Consideration as to whether the potential patient should be extended
another opportunity to schedule should be discussed. Making allowances in this regard has a way of
working itself through the community and may result in ever-increasing frequency of broken
appointments.

Recommended Scripts:
With 24 hours’ notice: Mrs. Jones, I am sorry you will not be able to keep the appointment
time you asked us to reserve for you. I know the doctor will be disappointed in not being able
to provide your much-needed treatment in a timely manner. I would like to thank you for the
advance notice so we may provide treatment to another patient.
Without 24 hours’ notice (first time): Mrs. Jones, we appreciate your call but are concerned
that you cannot keep the time you asked us to reserve for you. Our staff had that time
dedicated just for you, and at this late notice we will probably not be able to utilize it to treat
another deserving patient. Please understand that another broken appointment will result in
dismissal from our clinic system. We would like to offer another time for you that you would
be able keep. May we make that appointment for you now?
Without 24 hours’ notice (more than once): Mrs. Jones, we appreciate your call but are
concerned that you cannot keep the time you requested we reserve for you. Our staff had that
time dedicated just for you, and at this late notice we will probably not be able to utilize it to
treat another deserving patient. Because this is a multiple occurrence I will need to inactivate
you as a patient in our clinic system. We will see you for emergency care for the next 30 days,
and after that you will need to find another dentist. Are you sure you cannot keep this
appointment?

NON-DISCRIMINATION
The provision of services to individuals based on race, color, sex, national origin, disability, religion,
or sexual orientation should never denied services. Accommodations will be made for individuals
who have the inability to pay due to verifiably insufficient income.

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Management of Patient Exams

Initial Adult Patient Visit

The initial patient visit is extremely important in the cycle of an organization’s patients. This
appointment is an opportunity to present a great first impression of the clinic and staff, educate
patients regarding systemic and oral health through a medical history and clinical exam, and
finalize a treatment plan with appropriate options to regain and maintain oral health and function.
This appointment is also the ideal opportunity to present patients with important communications
regarding policies and procedures of the office.

It is understood that there are differing philosophies on how the initial exam is conducted. One
method is to improve the clinic system efficiency by scheduling the new patient for a full diagnostic
and preventative appointment with the hygienist. At this visit the initial prophy or debridement
can be accomplished along with the comprehensive exam and radiographs. Other arrangements
allow for the patient to be scheduled in the doctor’s schedule with the effective utilization of a
dental assistant. Preventative or periodontal treatment can be discussed with the patient at this
time with a full disclosure of the cost of therapy. This protocol will insure that we are taking the
greatest advantage of patient time, maximizing the initial visit, and utilizing our staff for greatest
efficiency.

Primary Performance Objectives to be completed for patients scheduled with the doctor and
assistant include the following:

 Update patient health history and all required information in patient clinical chart, and
obtain all necessary signatures of the doctor and patient.

 Question patient regarding problems and personal desires with dental treatment.
 Complete dental charting of existing restorations and missing teeth.
 Take and record patient’s blood pressure.
 Perform an oral and head/neck cancer screening.
 Conduct a TMD screening.
 Take digital facial and smile photographs if required.
 Take and diagnose all appropriate X-rays per organizational policies.
 Complete all aspects of a thorough exam including the full documentation with the current

dental software or patient clinical chart.
 Present initial findings and, in consultation with the patient, advocate for the appropriate

treatment.
 Confidently answer patient questions regarding any proposed treatment.
 Enter treatment performed and treatment plans in the patient record.

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 Triage and sequence treatment while in the dental operatory. The doctor alone, in
consultation with the patient, maintains responsibility for dictating the desired treatment
and appointment time required for the next visit.

 Sequencing of treatment may only be modified by, or with the approval of, the dentist. This
most often needs to occur due to a change in a treatment plan or the financial inability of the
patient to move forward with the proposed treatment.

 Complete Periodontal Screening and Reporting (PSR) charting.
 Complete next appointment slip and schedule the initial hygiene visit, and/or dental

treatment visit in the operatory.

The primary performance objectives for patients scheduled with the hygienist include all of the
above, plus the following:

 Either an adult prophy or a full mouth root debridement will be accomplished.
 Periodontal Screening Record (PSR) completed and a Comprehensive Periodontal

Evaluation (CPE) completed or treatment planned as indicated by the PSR Score.
 If charting leads to a diagnosis of periodontal disease, follow office Periodontal Therapy

Protocol (PTP). Discuss patient options for treatment of the disease and the outcomes if
disease is not treated. Periodontal treatment discussions are to be entered into the patient
clinical chart.
 If no disease is suspected as indicated by the PSR, periodontal probing is not indicated.
Chart note should be made “Periodontal status within normal limits, no probing indicated at
this time.”

Policy Regarding Initial and Periodic Evaluation of Periodontal Status

To help maintain a healthy dentition, a complete dental exam requires an evaluation of the
periodontium. A Periodontal Screening and Recording (PSR) exam should be considered as a
requirement for all adult patients (those 20 and over). The PSR is an effective and efficient
screening tool for the detection of potential periodontal concerns. When utilized, the PSR can be
conducted at the initial visit and annually at re-care visits thereafter.

The PSR score is recorded on a scale of 1 to 6 as established by the American Academy of
Periodontology by sextants; i.e. UR,UC,UL,LL,LC,LR. The clinical note should indicate the PSR score
at the initial and all re-care appointments.

A complete periodontal charting/probing is indicated when a PSR reveals any two sextants with a
score of 3, or any one sextant with a score of 4.

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Comprehensive Exam and Charting

The purpose of the comprehensive exam is to establish a foundation of health/disease through
dental charting, provide a conclusive look at the conditions in the patient's mouth to make an
appropriate diagnosis, and in conversation with the patient establish an appropriate and acceptable
treatment plan. The comprehensive exam should be a requirement in establishing the initial doctor
patient relationship. Emergency exams for first time visitors should not be construed to establish a
doctor-patient relationship.

The comprehensive exam charting likely will take place during the new patient appointment. The
charting is to be recorded by the assistant or hygienist. The doctor then directs the diagnosis to the
dental team member to be included in the patient record. The diagnosis should always be in
conversation with the patient and be reflective of the concerns and values of the patient.

A comprehensive exam is useful and appropriate at other times for patients. This exam could also
occur when an existing patient has not had a periodic exam in over three years. It may also be
appropriate if there have been major changes between any periodic exam periods.

The information to be obtained during the comprehensive exam include: PSR and full periodontal
probe readings (where indicated), existing restorations and missing teeth, occlusal class,
temporomandibular joint abnormalities, oral cancer screening, and other soft/hard tissue findings.
Before beginning, the team member will explain the need to obtain and record the information and
how it will be done, using any recommended scripts. Emphasis should be made with the patient as
to the thoroughness of the exam they are about to be involved in.

The primary objectives of the comprehensive exam appointment include the following:

 Update patient health history and all required information in computer. Obtain appropriate
signatures of the doctor and the patient.

 Question patient regarding problems and personal desires with dental treatment. The
appropriate question is not, “What is the matter with you?” but should be, “What matters to
you?”

 Dental charting of existing restorations, missing teeth, and other oral conditions.
 Periodontal (PSR or full) charting.
 Take and record patient’s blood pressure.
 Obtain appropriate intra-oral and extra-oral photographs.
 Obtain the appropriate and diagnosable set of radiographs.
 Present initial findings and recommend appropriate treatment.
 Confidently answer patient questions regarding any necessary treatment.
 Enter treatment performed and treatment plans in the computer.
 Triage and sequencing of treatment completed by the providers in the operatory.

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 In conversation with the patient, the doctor will direct the next appointment as to treatment
and time requested at the conclusion of the appointment.

Recommended Scripts:

Periodontal Charting: Mrs. Jones, the next part of your appointment is the gum examination. I
will be using this instrument to measure the depth of the pockets between your teeth and gums.
You will feel a little pressure. Let me know if at any time this becomes uncomfortable for you. In
healthy tissue this is completely painless; discomfort is an indicator of a possible gum infection.
You will hear me calling out some numbers. Anything within three or below is considered
healthy. Four or above indicates that gum disease is present. Five and above indicates more
serious disease which may put you in jeopardy of keeping your teeth if not treated. (Explain
what gum disease is as you conduct the exam.)

Occlusal Class: I would now like you to bite together to obtain information on how your teeth
come together. This can affect the jaw joint in terms of pain and headaches. Do you suffer jaw
joint pain or headaches?

Initial Child Patient Visit

The initial patient visit is extremely important for both the patient and the patient’s parents or
guardians. This appointment is an opportunity to present a great first impression of the clinic and
staff, educate patients and their parents/guardians regarding systemic and oral health through a
medical history and clinical exam, and finalize a treatment plan with appropriate options to regain
and maintain oral health and function. There are differing philosophies on how the initial exam is
conducted, but it is generally recommended that the initial child visit experience occur with the
hygienist, with subsequent examination by the dentist.

The primary objectives of the initial child visit include the following:

 Update patient health history and all required information in computer. Obtain appropriate
signatures of the doctor and the patient.

 Question patient regarding problems and personal desires with dental treatment.
 Dental charting of existing restorations and missing teeth.
 Take and diagnose appropriate X-rays.
 Complete all aspects of a thorough exam including full documentation of all aspects of the

exam in the patient chart.
 Present initial findings and recommend appropriate treatment.
 Confidently answer patient and parent/guardian questions regarding any necessary

treatment.
 Enter treatment performed and treatment plans in the computer.
 Triage and sequencing of treatment completed by the providers in the operatory.

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 Sequencing of treatment may only be modified by the dentist. This can be done following a
discussion with patient, based upon the patient’s financial status and desire.

 In conversation with the patient, the doctor will direct the next appointment as to treatment
and time requested at the conclusion of the appointment.

The Re-care, Hygiene, or Preventative Visit

The hygiene visit is an important part of the routine care required to maintain the oral health of
patients, educate patients, evaluate for the presence of disease, and advocate for their treatment.
Hygiene visits run the gamut from a dental prophy appointment, to the placement of sealants, to
periodontal scaling and root planing. Through standardization of the appointment process we can
both standardize times allowing for improved efficiency and improve outcomes.

The primary objectives at the hygiene visit include the following:

 Initial meet and greet with patient.
 Obtain and record blood pressure reading on all patients 19 and older.
 Discover what patient concerns may be, if any.
 Obtain appropriate radiographs.
 Update dental/clinical chart.
 Update PSR and CPE as indicated by the PSR Score.
 Apply disclosing solution to act as a visual aid in patient education. This process also

speeds the subsequent polishing.
 Perform patient education regarding oral hygiene. Use a supportive approach.
 Polish dentition with prophy cup and angle.
 Provide ultrasonic instrumentation of dentition.
 Utilize remaining time to remove any remaining debris using the most appropriate tool for

the patient’s needs, i.e. ultrasonic or hand, or both.
 Floss.
 Obtain an exam by a dentist if not previously completed. Note that this exam can be

conducted at any point during this visit depending upon the availability of the dentist.
 Direct the next patient appointment with the appropriate treatment and requested time.

Inform the patient as to the importance of keeping the next re-care appointment.

Guidelines on Dentistry Provided in the Hospital

In some instances it is not possible to render quality care in the office setting to children and adults
that may have mental or emotional challenges that cannot be adequately addressed in the
operatory. In this scenario the patient is best referred for treatment in the hospital setting.
Generally for Medicaid and other insurance carriers to extend a benefit for hospital care, it is
usually required that a documented attempt was made to treat the patient in the operatory of the

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