GENERAL PRACTICE OFFICE OBSERVATION DENTAL HYGIENE

General Practice Office Observation Dental Hygiene

Nichole Gallagher

DH 222 Clinical Dental Hygiene

April 28, 2018

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GENERAL PRACTICE OFFICE OBSERVATION DENTAL HYGIENE

General Practice Office Observation Dental Hygiene

I observed Frankie Holyfield, RDH at Dr. Travis B. Bartschi’s dental office. The office

staff begin their day with a morning huddle ten minutes prior to seeing patients. At the morning

huddle was a dental assistant, two hygienists, one of the front office staff, and Dr. Bartschi. Each

of the office members had their own printout of the schedule for the day. One at a time, each

hygienist began telling the staff which patients required a probe reading, an exam, and which of

their patients had been confirmed. The patients were confirmed by a computerized system. An

automated text and email is sent to the patient a week before, a day before, and an hour before

the scheduled appointment. If the patient has not confirmed the appointment by the day before

the appointment, the front office staff will call the patient. The assistant then started talking

about doctor’s patients and what they were doing for restorative procedures. Then each person

listed how much production they had scheduled for the day. Both hygienists were scheduled six

patients, for an hour, until 1:00 p.m. when it was time for their lunch break.

After the morning huddle, Frankie went to the waiting room and called her first patient to

come back. He was scheduled for a recall prophy maintenance, which is automatically set for a

one-hour appointment. If Frankie needs more than an hour, she is able to modify the appointment

herself and add the extended time she needs. It had been 6 months since his last dental visit. She

walked him back to the operatory and he was seated in the dental chair. Frankie then displayed

the correct autonote on the computer. The practice management software this office uses is

Eaglesoft. Then she asked the patient if he took any medications, and if were any changes to his

medical history. The patient indicated no. She then retrieved the wrist blood pressure cuff and

took the patient’s vitals. Blood pressure was 117/75 and pulse 78. She read the vitals out loud to

the patient and then typed them in the autonote. She then asked him how his teeth were doing

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and if he had any concerns. The patient indicated that everything was fine. She placed the

patients bib and gave him sunglasses to wear. She sat some gloves on the counter for the doctor

to wear when he came to do his exam. She then displayed the patient’s bitewings on the

computer and the perio chart. She indicated that it had been a year since his last periodontal

exam and that she would need to probe today.

She stated that they take four bitewing’s once a year, 3 years for a full mouth series, and

5 years for a pano. If a person is having pain or trouble with a specific tooth then they will take a

periapical. If the patient has third molars that are erupted then they will take a pano and four

bitewings. They do a doctor exam every six months.

On her unit was an instrument cassette for a prophy maintenance that had a Gracey ½,

Gracey 13/14, Gracey 11/12, Gracey 7/8, Barnhart ½, Barnhart 5/6, anterior SH 6/7, 4R 4L,

Marquiz color coded periodontal probe, mirror, 11/12 explorer, air water syringe tip, tooth sloth,

and cotton forceps to help retrieve sterile items with contaminated gloves on. She had a cavitron

with a triple bend tip attached to it. She indicated that every cassette has a tooth sloth in case a

patient expresses that they have a cracked tooth, then she can help indicate which tooth for the

doctor. She laid the patient in supine position. She took off her glasses and put on her face mask,

loops, and gloves. Then she examined the patient’s gingival periodontium and tissues intraorally.

She asked me to record the probing measurements for her. Then she examined mobility with the

end of two blunt instruments, recorded recession, and furcation’s. After she finished, she

retrieved the cavitron and started to debride his mouth. Then she hand-scaled his maxillary and

mandibular teeth with the Gracey ½. She used the Gracey 13/14 on distal of the posterior teeth

and the Gracey 11/12 on the mesial of anterior teeth. After she was finished she began to polish

with fine prophy paste and then flossed at the end.

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She stepped out of the operatory to let Dr. Bartschi know that she was ready for an exam.

She indicated that she lets him know or he will come in when it is convenient for him and she

will stop what she is doing to let him do an exam; or, she will walk into the doorway of the room

that he is in. When he sees her, he knows that she needs an exam. If his back is turned toward

her she will just place her hand on his shoulder to let him know she is ready. They communicate

this all non-verbally. They used to wear headsets but the staff did not like to wear them so they

decided to quit using that.

After a couple of minutes Dr. Bartschi came into the room and retrieved an 11/12

explorer and mirror and examined around the patient’s mouth. He indicated that he looked at the

bitewing radiographs in his office and everything looked fine and everything was satisfactory

clinically as well. He thanked the patient for the effort of making it to his appointment this

morning. He had indicated on Mondays they will have a lot of patients forget and not come in.

After he left, Frankie placed the fluoride varnish. She asked the patient if he wanted mint or

berry flavor. The patient indicated mint and asked if he could drink coffee right away. She

indicated yes, but to not let it be extremely hot. She then grabbed a take home bag and placed a

toothbrush, toothpaste, and floss into it and handed it to the patient. Before she walked the

patient out she asked if he would like to schedule his next six-month prophy maintenance visit.

He indicated yes, and she scheduled him in her operatory and put the codes in the computer for

the next visit. She walked the patient out then came back to the operatory and finished his notes.

In his notes at the top it stated “Adult Prophy.” Then below it said FM probe, Exam, Fl Varnish,

AAP Type: Case Type I Gingivitis, and Caries Risk: Moderate. Below that it had a heading that

said, INFO: where they write something personal about the patient so they remember something

about them to talk about at their next visit, Rev Med Hx; No changes, BP: 117/75 P: 78. Meds;

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none, CC (chief complaint): none, IO/EO Exam: Negative, FM Scale with Cavitron and Hand

Inst., FM polish. OH: which is a description for plaque control and tissue, OHI: what she did for

oral hygiene instruction, Disp: where she notes if she placed any local delivery of antibiotics or if

the patient was prescribed any medication, and lastly NV/WWW (next visit/what will be done,

when, and why).

Then she placed all of her instruments back into the cassette and removed the air/water

syringe tip and placed it into the cassette with the rest of her instruments. She also removed the

triple bend tip. She carried her instruments to the sterilization room and placed them into the

ultrasonic and started it. She went back to her room and removed the barriers. She placed the

air/water and the prophy polisher handpiece into the sink. She grabbed two cavi wipes and wiped

down the unit, the air/water and prophy polisher handpiece, cavitron, counter behind the dental

chair, keyboard, and computer mouse. She indicated that they wipe everything off twice to make

sure that it’s clean. She then placed new barriers, which was a cover over her unit, protective

sleeve covers over the air water syringe, and suction. She placed barriers on the keyboard and

mouse. Then she retrieved a new cassette for her next patient, which was another prophy

maintenance. She placed the suction and air water syringe tip and retrieved fine prophy paste and

about 18 inches of floss. Then she went to go check on the other hygienist to see if she was doing

okay.

She brought her next patient back into the room. She asked the patient if there were any

changes in his health history and if he was taking any medications. The patient replied no. She

displayed the Adult Prophy autonote onto the computer. Then she asked how his teeth were

while she placed the wrist blood pressure cuff onto the patient’s wrist. He indicated that they

were fine and that he wasn’t having any trouble. She read the blood pressure out loud to him

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which was 136/73 and pulse 80. She walks back over to the computer and entered it in. She laid

gloves out for doctor, places the patient bib on, and hands the patient sunglasses.

She indicated that he was due for four bitewings. There is a cupboard between each

operatory with an extended arm and tube head that could be used by both rooms. Each room has

its own sensor. She retrieved the sensor from the cupboard and plugged it in. She placed a

protective barrier over it. Then, she placed the protective lead apron and thyroid collar onto the

patient. She set up the XCP ring and begin to take the radiographs. She started on the left pre-

molar radiograph, then the molar radiograph. She went to the right side and begin with the pre-

molar radiograph, then the molar radiograph. After she had finished, she disinfected the x-ray

equipment, lead apron, and thyroid collar and placed it back into the cupboard. Then she took off

her glasses and placed her mask, loops, and a new pair of gloves. She did not need to do a full

periodontal chart so she did some spot probing around the molars and anterior teeth. She

examined the gingival tissue condition. She retrieved the cavitron and being to debride the teeth.

Then she noticed, in her mirror, where there was trauma to the upper right palate. She said it

looked like a scrape and asked the patient if maybe he scraped it while eating some chips. The

patient indicated that he did not know that it was there or what had caused it. Fankie did not

seem to worried about it and believed that it was caused from food trauma. She then used her

13/14 on the posteriors of his molars, and 11/12 on the mesial of posterior molars. When Dr.

Bartschi came into the room she got up and walked over by the computer. He grabbed the

explorer 11/12 and mirror and did his exam. He indicated that #4 had a DO and #29 had an MO.

She charted these in Eaglesoft. He did not explain to the patient that he had two cavities. After he

was done he walked out of the room. Frankie then told the patient that the doctor found two

cavities and that he could get them filled at his next six mouth re-care visit. She polished and

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flossed his teeth. She placed the fluoride and asked if he would like mint or berry. She explained

no hot and crunchy foods or drinks for up to four hours and to not brush his teeth until tonight.

She set the patient up in the chair. She asked him if he would like to set up his next appointment.

The patient indicated yes, and she scheduled it into the computer in her slot. As she scheduled

the patient she also puts the codes in for the next visit. She handed the patient his take home bag

of floss, toothpaste, and toothbrush. She walked the patient to the front desk and told them about

the restorative work that needed to be done and the front office scheduled him in the computer

for 40 minute composite fillings.

She went back into her operatory and finished her notes, disinfected, re-barriered, and set

the operatory up for another prophy maintenance visit. She went into the waiting room and called

her next patient back into the operatory. The patient had a seat in the dental chair and she asked

if the patient was taking any medications and if there had been any changes to the health history.

The patient indicated no. She asked the patient how his teeth were doing, and he indicated that

they were fine. She placed the wrist blood pressure cuff onto the patient and brought up the

Adult Prophy autonote. She reviewed his vitals and recorded them into the patient notes. She

placed gloves for Doctor, placed the patient bib on, and handed the patient sunglasses. She

placed her mask on, loops, and gloves. She began to spot probe and examined the mouth

intraorally. She complimented the patient on how well he had been flossing and retrieved the

triple bend cavitron and began to debride and used hand instruments. She polished the teeth and

flossed. Just as she was finishing, Dr. Bartschi came into the room and did his exam. He

indicated that there were no cavities. Then she asked the patient if he would like mint or berry

fluoride. He choose berry, and she placed it. She gave him the proper instructions for the fluoride

varnish and grabbed his homecare aids which were floss, toothbrush, and toothpaste. She asked

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the patient if he would like to schedule his next visit and he indicated that he would. She got him

scheduled for another six month prophy maintenance and entered the correct codes in the

computer. She walked the patient out to the front office. She came back to her operatory and

finished her notes, cleaned the room, and re-barriers it. She then went and checks on the other

hygienist to see if she needed anything.

She brought back her fourth patient and asked how his teeth were and if he had any

concerns. He indicated no problems. She then asked if there were any changes to the health

history and if he was taking any medications. He indicated no. She placed the blood pressure cuff

onto the patient’s wrist and recorded the vitals. This patient was a Perio Maintenance but still

came every six months because he had really good homecare. The autonote was exactly the same

as the Adult Prophy except the title of the note stated “Adult Perio Maint.” He needed four

bitewings. She placed the lead apron and thyroid collar onto the patient. She plugged the sensor

in and placed the protective sleeve around it. She took the radiographs beginning with the left

premolar radiograph and continued with the rest of the radiographs. Then she disinfected the x-

ray equipment and thyroid collar and lead apron. She placed the sensor back after wiping it down

with a cavi wipe. She sat gloves out for the doctor on the counter and placed her mask, loops,

and gloves. She placed the patient bib on and handed him sunglasses to wear. She laid the patient

back into the dental chair and began to spot probe areas in the posterior and anterior teeth. She

began to debride with the triple bend handpiece of the ultrasonic. She scaled the anterior teeth

with the Barnhart 5/6. She polished and flossed. She went and let the doctor know she was ready

for an exam. When she came back she grabbed his homecare aids and placed a toothbrush, floss,

and toothpaste into a take home bag. She started to write in the patient notes until Dr. Bartschi

came to do his exam. He came in the operatory and did his exam with the explorer 11/12 and

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mirror. He indicated no cavities and told the patient that he looked at the radiographs in his office

and didn’t see any cavities. After his exam she placed fluoride, giving him the option of mint or

berry. When she was done she sat the patient up and asked to schedule his next appointment. He

indicated yes and she scheduled it into the computer and walked the patient out to the front desk.

She came back to her operatory and finished her notes, cleaned the room, and re-barriered it. As

she was doing this an assistant came into the room and asked if she was ready for the next new

patient. She was still in with the doctor and another assistant in the other operatory.

The assistant had taken the new patient’s radiographs which was a panorex and four

bitewings. Dr. Bartschi had done an exam. The patient came into the room and took a seat in the

dental chair. Frankie introduced herself to the patient and asked if she had any concerns about

her teeth. She pulled up the chart onto the computer screen and saw that she did not have any

decay but had planned to have all of her wisdom teeth extracted. All four of them were fully

erupted. Frankie asked how the wisdom teeth were doing. The patient indicated that they were

fine and not bothering her. Then Frankie started to make some small talk with her about the

patient’s college classes. She did this because on the first new patient visit Dr. Bartschi wants the

staff to be very friendly and get to know the patient. After she was done talking to the patient for

about ten minutes she reviewed the patient’s health history, allergies, surgeries, and asked when

the patients last cleaning was. The patient indicated two years ago. Frankie placed the patient’s

and her personal protective equipment on and then she called out the existing restorations and I

placed them in the computer chart for her. Then she did the periodontal charting numbers,

mobility, and furcation’s and I charted those as well. She indicated that the patient was an adult

prophy. She retrieved the triple bend ultrasonic and begin to debride, hand scale, polish, floss,

and placed fluoride. She verbalized the proper instructions to the patient for the fluoride

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application and explained no hot and crunchy foods, and no drinks for up to four hours and to not

brush her teeth until that night. She asked the patient if she would like to set up her next

appointment for hygiene and the patient indicated yes. She scheduled the patient and placed the

codes in for the next visit. Frankie told the patient that the girls up front will schedule her for the

surgery. She gave the new patient a take home bag of floss, toothbrush, and toothpaste. She

walked the patient up front. She came back to her operatory and finishes her notes, cleaned the

room, and re-barriered it. The notes for a new patient were titled “NP Comp Exam”. Under the

heading it says FMX, PANO, BWX. Frankie then selected PANO and BWX because the patient

had all of her third molars. Below, it said Prophy, FM Probe, AAP: Case Type I Gingivitis,

Caries Risk: Moderate, CC (chief complaint): checkup and teeth cleaned, INFO: patient had

some college classes with Frankie’s son. Med Hx Taken: no concerns, Meds: none, IO/EX

Exam: Negative, FM Scale with Cavitron and Hand inst,, FM Polish, OH: description of tissue

OHI: gave patient toothbrush, toothpaste, floss, Disp: Negative. NV/WWW: September 25 for

six month re-care prophy maintenance.

At the new patient exam, they will take the necessary radiographs and the periodontal

assessment. Then, every six months they will switch back and forth between the radiographs and

the periodontal assessment to save time. Depending on the type of periodontal therapy the patient

needs they will start treatment right away, if it’s an adult prophylaxis, for an hour. If they need

non-surgical periodontal therapy, depending on if there is time, they will either see them that day

or reschedule. Non-surgical periodontal therapy patients are scheduled for two, one and half hour

sessions, doing half the mouth each time.

When the patient is new, they will start the appointment by filling out a medical history.

Then the assistant will tell them about the office by educating that they take digital radiographs

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and what those are, they give the new patient a gift which is usually seasonal such as beach

towels during the summer. They show where the bathrooms are. Then they will ask the patient

what their values are for their oral health, what their barriers are; such as, personal fears. The

assistant will visit with the new patient a little bit and get to know them and find something

personal to talk to the patient about. They record this in the chart so they remember what to talk

with to make the patient feel important at future dental visits. The assistant will then take the

appropriate radiographs and the doctor will come in and do a clinical exam. The doctor will go

through all the tabs on Eaglesoft of the clinical exam which are restorative, TMJ, occlusion,

head, habits, and history.

After the doctor diagnosis what the patient needs he will discuss the treatment with the

patient and explain different options. Then the front office staff will review the treatment plan

with the patient, discuss the financials of the procedures, and schedules the patient. If there are a

lot of restorative needs and big treatment plan they will schedule another appointment for a half

hour to do an consult with the patient. This will involve the dentist, patient, and an assistant. An

assistant is present so that she can write the chart notes for the doctor of what was discussed.

That way one of the assistants will also know what is going on and what was discussed. Before

the patient received treatment for restorative, crown, root canal, surgery, extractions, implants,

and non-surgical periodontal therapy, they sign a treatment plan then a consent form with a list

of procedures listed for the patient, along with describing the risks involved with treatment.

She went to the waiting room and got her last patient before lunch. This patient was an

adult prophy maintenance. She brought the patient back and asked how his teeth have been, if

there were any changes to his medical history, and if he was taking any medications. The patient

indicated that everything was fine and no medications. She took the patient’s blood pressure with

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the wrist cuff and entered it in the patient’s autonote “Adult Prophy” on the computer. She then

asked me to perio chart for her. I recorded the periodontal probing numbers, recession, and

mobility for her. She took the triple bend ultrasonic and debrided, hand-scaled, polished, and

flossed. Dr. Bratschi came into the room to do the doctor exam and asked the patient how his

teeth felt and if anything was hurting or bothering him. The patient indicated that everything was

fine. In the patient’s chart he had an area that had a watch for decay on the DO of number two.

Dr. Bartschi took an explorer and checked the area and told the patient that it had gotten worse

and that he can do the filling at the patient’s next visit. Frankie charted the DO on number two in

the chart. After the doctor exam, Frankie placed the fluoride varnish on the patient and asked to

set up the next appointment. The patient indicated yes and she set it up and handed him his take

home bag of floss, toothbrush, and toothpaste. She walked the patient up front to the office staff

to schedule the patient’s filling. Frankie came back, finished her notes, cleaned the room, and re-

barriered it.

The abbreviations used for services provided by the hygienist and dentist on a daily

schedule are “PX” which stands for prophy maintenance. “PEX”, periodic exam. “PE”,

periodontal exam. “NP”, new patient. “PMPX”, periodontal maintenance. “FMX”, full mouth

series. “BWX”, four bitewings. “PAX”, periapical radiograph. “COCS”, comprehensive oral

cancer screening. “LEX”, limited exam. “SEAL”, sealants. “SRP”, scaling and root planning.

“COMFX”, comprehensive exam. For the doctor they are “COMP” for composite filling, “RCT”

for root canal, “CRN” for crown, “EXT” for extraction, and “IMPLANT” for implant.

The roles and responsibilities of the office personnel are welcoming and checking

patients into Eaglesoft, monitoring the front desk, prepare charts, bill insurance, collect

payments, answering phone calls, scheduling patient appointments, and seating patients. The are

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also cross trained in sterilization. These roles contribute to the team efficiency by being able to

assist the other office staff more. There are three assistants employed there. Their roles and

responsibilities are to prepare patients for dental procedures, provide instructions to patients such

as postoperative, sterilizing dental instruments and equipment, preparing the dental exam room

for use by the dentist by making sure it is stocked and organized, assisting the dentist during

procedures including passing instruments, getting supplies, and using the suction tube to keep the

patient’s mouth dry, assisting with dental radiographs and lab work, and charting patient records

and notes.

The chart entry for an SRP patient states S/RP # at the top. Below the heading it says

INFO: to place a personal comment about the patient as a reminder to talk about at the next visit,

Rev Med HX, Meds, CC (chief complaint), Anesthetic, S/RP # (enters which teeth was

completed) with Cavitron and Hand inst., FM Polish, Sub ging irrig. With Peridex®, OH, OHI,

Disp, and NV/WWW. The procedures utilized were delivery of anesthetic, scaling and root

planning two quadrants at a time. The type of instruments she used were the cavitron with a

triple bend insert for moderate to heavy calculus, files (Orbin and Hershfield), Gracey’s,

Barnhart’s, after fives, mini’s, and 6/7. She will do a gingival irrigation with Periodex®, a full

mouth polish, floss, and fluoride placement.

In four to six weeks she will do a reevaluation appointment. She will determine at this

appointment if there is a need for local delivery of Arestin® or Atridox®. She prefers to use

Atridox® because she believes the placement in easier. She will do a full mouth probing, tissue

evaluation, evaluation of the patient’s home care, ultrasonic, hand scaling, and polishing, doctor

examination as needed, and evaluate the need for a referral. The type of procedures that are

referred for the hygiene aspect are patients with advanced case type four, mucogingival

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involvement one millimeter or less of attachment, or the tissues does not respond correctly to the

non-surgical periodontal therapy.

She has many different inserts for the cavitron. Those are slimline’s and triple bends for

light, moderate to heavy calculus. She has an air-polisher used for moderate to heavy staining,

cleaning around orthodontic bands, or if the homecare is not very good. For hypersensitivity

agents she will place fluoride. For oral irrigation devices she had a syringe that she used to place

the Periodex®.

There are three hygienists that work in this office and the variety of services they provide

are locally delivery of antibiotics such as Atridox® or Arestin®, application of fluoride and

sealants with a curing light, nitrous oxide sedation, laser and gingival curettage, whitening trays,

delivery of anesthesia, intraoral camera for images of a broken tooth or calculus buildup,

intra/extraoral exam, treatment of gingivitis, periodontitis, followed by a re-evaluation and perio

maintenance, diagnostic digital radiographs, assisting patients in managing sensitivity and dry

mouth, instruction of proper home care techniques, documentation of health records, sterilization

and infection control, and assisting the other hygienists and office staff. The only assistance the

hygienists get is when they need to do a periodontal chart. When they need to do one they will go

find as assistant to help them, or the assistant will know to go in at that time because it was

discussed during the morning huddle.

Re-tipped instruments are not used. Instruments are sharpened every week or as needed

after scaling and root planning. They are sharpened with India fine stone. Each hygienist has

their own cassette that are color coordinated. They are responsible for sharpening their own

instruments. The dental hygiene home care aids available for client instruction are manual tooth

brush, floss, proxy brush, soft picks and floss threader. For purchase there are oral B

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toothbrushes. When there is a last-minute change of appointment or “no show” the hygienist will

sharpen between patients when there is down time. Sometimes they call another patient in early,

work on sterilization, prepare more for the day such as the schedule and setting up for

procedures. They also assist other team members with other procedures. The hygienists, office

staff, and assistants all wore scrubs with a long-sleeved shirt underneath. There are two doctors

and they wore dress pants and a long-sleeved button up shirt.

The methods used for infection control were pretty similar to what we do at LCSC. They

use the same autoclavable bags for packaging instruments for sterilization, ultrasonic, and

sterilizer. They only wipe the rooms down with cavi wipes and they do it twice because they said

it insures that everything is clean. They use less barriers than we do such as not placing

protective covers over the entire chair, just on the head rest. They do not change out the

handpiece for polishing after every patient. They will just wipe it down with a cavi wipe to

prevent it from going through the sterilizer less so it lasts longer. At the end of the day the hand

pieces get packaged and sterilized through the sterilizer. When the instruments are stored they

remain in the bag until use.

The overall atmosphere of the office and staff was very friendly and worked well

together. They carried great conversations about vacations or their kids, with the patients to make

them feel welcomed. Everything flowed well. I liked how the hygienists checked on each other

between their patients. It was very relaxing and professional. I feel like they have a lot of regular

patients and each patient that was scheduled for a prophy maintenance or perio maintenance all

rescheduled their next visit at the end of their treatment. I liked the organization of the

appointments and how she entered the codes in right before the patient left and how the autonote

was completed throughout the appointment. My first impression was that it was very welcoming,

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organized, and not hectic at all. None of the staff members seemed rushed and it was a calming

place.

The impressions that I felt the least was that there was no homecare talked about or

shown to any of the patients. I thought maybe she was doing that because most of the patients

she saw were re-care. Although there was a new patient, she still did not discuss homecare. We

were taught in school that homecare is just as important as providing periodontal therapy. If you

are only doing that and not discussing homecare then you are not helping the patient get better.

I thought the standard of care was great. I did not get the feeling that anyone was being

neglected in that way. I felt like this office is doing everything just as we were taught in school,

besides the lack of homecare education. This office is doing a great job for the community

because they have a lot of re-care patients that are well taken care of at this office.

This offices website is https://www.lcsmiles.com/dental-hygiene and phone number is

208-746-2414. Frankie Holyfield, RDH.

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