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21st Century Approach to Oral Hygiene Care

by Siobhan Kelleher RDH

Siobhan Kelleher shares her experience of dental hygiene practice by giving us an overview of her tried and tested way of working to improve the quality of dental hygiene care in general dental practice . Her methods optimises the use of the dentist/dental hygienist surgery time in a way that improves the productivity of both parties whilst maintaining a patient centric approach to oral health care.

The 21st Century Approach to Dental Hygiene is about promoting the role of the dental hygienist and dental therapist in dental practice, improving the motivation of the patients, broadening the dental health professionals understanding of the scientific evidence and practical use of debridement tools all aimed at increasing the profitability of the practice.

For too long the dental hygienist has been the Cinderella of dentistry. Dentists and hygienists were and are, often trained in different departments and buildings. As a result of the fragmented training both professionals enter the workforce with very little idea of how to collaborate on periodontal care in practice.

When you ask dental hygienists what they want, they say longer appointment times, utilise our skills, nursing support, respect, an understanding of what we do, up to date equipment and samples for demonstration. When you ask many dentists, they want a dental hygienist to ‘clean their patients teeth’ and do this the lowest cost possible to the practice. Money, on the other hand is way down the list of priorities for hygienists which brings us to the introduction of the combination appointment.

The combination appointment is a maintenance appointment using the ‘hygiene led’ method where the clinicians share the consultation and the patient remains in the hygiene surgery. Often the dentist book is booked up with exam appointments and if we average a dentist exam at fifteen minutes at a cost of £30 this equates to £120 per hour. If a dentist were to free up the book for productive treatments say two fillings in the hour at £120 then the hour doubles the intake to £240 per hour. The average hygienist appointment is 30 mins at an average of £50 per 30 mins. If we add the exam from the dentist book into this time it becomes a 45 min at £80 for the combination appointment. The practice overall becomes more productive and extra revenue would allow investment in new, up to date equipment. Using the Hygiene Led method, the hygienist is guided by the dental hygiene wheel (Fig 1) this wheel is based on a 45 min time slot, ensuring each stage of the appointment is covered. This includes checking the patient medical history, oral cancer examination, restorative examination, Periodontal examination, communicating with the patient, debridement and closing the appointment. The dentist comes through to the hygiene surgery where the hygienist will give a synopsis of their findings. The dentist can coach the hygienist on what they would be looking for in their exam appointment as each practice may have special interests in specific areas. If not working under direct access the hygienist can gather the data and the dentist can then make the final diagnosis.

Assessing/screening, diagnosing, treating or referring, documentation, informing the patient, monitoring, risk factors, BPE and comprehensive periodontal examinations are explored using the co-diagnosis module. Failure to cover each of these steps can lead to medico-legal problems, strict adherence to the full screening process is paramount to the success of this method of working.

In dentistry we all use preventative, therapeutic and supportive hygiene appointments. I have named my maintenance appointments relating to the patient’s treatments e.g. The Implant hygiene appointment, The Orthodontic Hygiene appointment and The Aesthetic Hygiene appointment and it is very successful. Categorising the type of appointments on offer is a valuable way of going out into the community and attracting patients into the practice by offering tailored oral care in a patient friendly descriptive way.

Communication is something I believe is often overlooked. In my presentation about this method of working , The 21st Century approach to Dental hygiene explores some of the different models of behavioural change starting with the COM-B system, ('capability', 'opportunity', 'motivation' and 'behaviour') model. This model recognises that behaviour is part of an interacting system involving all these components. The COM-B model provides a simple framework for understanding behaviour, in which ‘capability’ (physical and psychological), ‘opportunity’ (physical and social) and ‘motivation’ (automatic and reflective) are conceptualised as three essential conditions for behaviour (Michie et al., 2011) (See Fig 2 )

The Visual, Auditory and Kinesthetic (VAK) learning style uses the three main sensory receivers: Visual, Auditory, and Kinesthetic (movement) to determine the dominant learning style. It is sometimes known as VAKT (Visual, Auditory, Kinesthetic, & Tactile). The original VAK concepts were first developed by psychologists and teaching (of children) specialists such as Fernald, Keller, Orton, Gillingham, Stillman and Montessori, starting in the 1920's. The VAK learning styles model suggests that most people can be divided into one of three preferred styles of learning.

I also use and describe the sandwich feedback method consists of praise followed by corrective feedback followed by more praise. In other words, the sandwich feedback method involves discussing corrective feedback that is “sandwiched” between two layers of praise.

There are many personality style models to use and my presentation looks at DISC personality styles because it is a great basic way to understand what works for our patients and indeed our team members. Dr William Marston created DISC and didn’t copyright his work so it is free in the domain to use and explore.

  • D stands for the DOMINANT Type which is OUTGOING and TASK-ORIENTED.
  • I stands for the INSPIRING Type which is OUTGOING and PEOPLE-ORIENTED.
  • S stands for the SUPPORTIVE Type which is RESERVED and PEOPLE-ORIENTED.
  • C stands for the CAUTIOUS Type which is RESERVED and TASK-ORIENTED.

Looking at our hygiene wheel we address debridement and ultrasonics including Magneto strictive and Piezon. There are several different tips for different areas in the mouth and spending time on the left and rights inserts using the available training film clips to show correct adaptation will benefit the clinician in practice. Air polishing is the latest edition to our debridement tools in practice and knowledge on the different supragingival and subgingival powders on the market is vital for patient care. I highly recommend any clinician that hasn’t been on a hands-on debridement course to attend one and update their techniques and knowledge.

Addressing the issues of time, pain, fear and cost for the patient when it comes to patient treatments is an important part of the appointment. If we don’t address the elephant in the room, the patient will leave confused and may not follow up the next appointment.

One of my business tips to teams wishing to adopt this more collaborative and business oriented style of working is to ban the terms ‘Is it JUST a scale and polish’, or ‘Is it JUST an exam’ or we may JUST be telling our patients their dental health is JUST not that important!

Fig 1 The Dental Hygiene Wheel


Fig 2 Combi Model

All references available on request