Value Based Dental Practice

The Exceptional Patient Experience T h e Va l u e s B a s e d D e n t a l P r a c t i c e

William T. Brown, D.D.S.

Friday, February 22, 13

Introductions

2Friday, February 22, 13

Introductions

Introduce yourself and


Introductions

Introduce yourself and

What influenced you to go into the Dental Profession?


Bill Brown


Bill BrownWho am I?


Bill BrownWho am I?


Bill BrownWho am I?


Steps in achieving workshop goals:



“IS”



“IS”

“WAS”



“IS”

“WAS”

“MIGHT BE”


My Goal is that Each of You Will:





Identify some change you want to make




Understand COHC




Understand COHC

Develop & use your philosophy as a communication tool.




Understand COHC


Conduct exams that influence attitudes & monitor oral health.




Understand COHC


Conduct exams that influence attitudes & monitor oral health.

Have you leave with an idea of your next step.


BRAINSTORMING


BRAINSTORMING

For Change:


Change


Change

“Everyone thinks of changing the world, but no one thinks of changing himself.” - Leo Tolstoy.



An EXPERIMENTAL ATTITUDE


Key Elements:


Key Elements:

Core Beliefs that are understandable & repeatable by staff & patients.


Key Elements:


Establishing Effective Doctor-Patient Relationship.


Key Elements:



Involving Patients in a Health Story.


Key Elements:



Involving Patients in a Health Story.

Dental Metrics to Monitor Patient Progress.


10

A Personal Story


10

A Personal Story

Diagnosed with gingivitis at age 28


11

A Personal Story



11

A Personal Story


I was shocked!


I thought I had a healthy mouth

12

A Personal Story


I thought I had a healthy mouthThis revelation caused me to change

12

A Personal Story


I thought I had a healthy mouthThis revelation caused me to change I needed to find the cause

12

A Personal Story


13

From My Own Life,My Conclusions:


13


Interruption of a disease process


13



Patients were responsible for their oral health


13




And not “Objects of Treatment”


13




And not “Objects of Treatment”

NEW SYSTEMS NEEDED


14

The Result of My Learning & Influences”


14

The Result of My Learning & Influences”

c o m p r e h e n s i v e o r a l h e a l t h c a r e


Knowledge is Empowering

Critical Issue


16

Studied causes of my problem


16


Bacterial plaques


16


Bacterial plaques

Mechanical removal


16


Bacterial plaques

Mechanical removal

Unmanageable areas manageable


16


Bacterial plaques

Mechanical removal

Unmanageable areas manageable

The cause of man’s most common disease was bacterial plaques


17

Dr. C.C. Bass

Dr. C.C. Bass in his dental laboratory


Bacteria settle on the teeth and organizes to cause disease

18

What He Found Out:

Dr. C.C. Bass in his dental laboratory


I incorporated the Bass techniques personally, and my periodontal disease was controlled in less than a month

19

Dr. C.C. Bass


I incorporated the Bass techniques personally, and my periodontal disease was controlled in less than a month

This personal experience and epiphany was a revelation that I knew I had to share with my patients

19

Dr. C.C. Bass


20

Comprehensive Oral Health Care


20


Resulted from experience & influences


20



Dentistry is a dynamic evolving science


20



Dentistry is a dynamic evolving science

Shift from techniques to dental team


The Five Components of COHC



21

humanistic



Humanistic



Humanistic- Importance of patient involvement in oral health care




- What a patient does every day is more important than what is done in the dental office two or more times a year




- What a patient does every day is more important than what is done in the dental office two or more times a year

- Avoid treating patients as objects



23

humanistic



23

humanistic

biologic



24

Biologic



24

Biologic- Understand basic biology



24

Biologic- Understand basic biology

- Oral Cavity-Organ System



25

Health Plans Expand Dental BenefitsStudies Linking Gum Disease To Health Problems Spur New Focus on Preventive Treatments


The Future


The Future

Picture a world where dentists are the entry point in the health care system.


The Future


Relationships between Perio Disease and :


The Future



• CV Disease


The Future



• CV Disease

• Diabetes


The Future



• CV Disease

• Diabetes

• Pre-Term and/or Low Birth Weight Babies


The Future



• CV Disease

• Diabetes

• Pre-Term and/or Low Birth Weight Babies

• Salivary Diagnosis



27

humanistic

biologic



27

humanistic

biologic

diagnostic


Diagnosis


Diagnosis

28

Diagnosis is the reason for professional education


Diagnosis

28


Diagnosis is based upon COE


Diagnosis

28


Diagnosis is based upon COE



29

humanistic

biologic

diagnostic



29

humanistic

biologic

diagnostic

therapeutic



30

Therapeutic



30

Therapeutic

- Importance of providing the patient with comfort, function and a good appearance



30

Therapeutic

- Importance of providing the patient with comfort, function and a good appearance

- Therapy is based on the information gathered in the examination/diagnostic phase.



31

humanistic

biologic

diagnostic

therapeutic



31

humanistic

biologic

diagnostic

therapeutic PHILOSOPHY


Philosophy:


Philosophy:

32

The “glue” that holds the components of COHC together


Philosophy:

32


Used as a communication & management tool with staff and patients


Philosophy:

32



- Should be easy to explain & repeatable by patients & staff.


Philosophy:

32



- Should be easy to explain & repeatable by patients & staff.

- Can be a roadmap.


Comprehensive Oral Examination

PHILOSOPHY

c o m p r e h e n s i v e o r a l e x a m i n a t i o n


34

This is NORMAL

The Gold Standard!


35

Bleeding Is Not Normal

This is average, but not normal


36


System development


36


System development

- COE


36


System development

- COE

- Baseline data


36


System development

- COE

- Baseline data

- Quantify monitoring progress


37


Benefits


37


Benefits

- Involves patient in a HEALTH STORY


37


Benefits


- COE is what’s best for your patients


37


Benefits



- COE is a powerful non-verbal communication tool you’re thorough


37


Benefits




- Co-Dx can break the “preoccupation barrier”


37


Benefits




- Co-Dx can break the “preoccupation barrier”

- Check list - Don’t land with wheels up! Friday, February 22, 13

38



Additional benefit: what’s best for the patient

38



Additional benefit: what’s best for the patient

What would you do for a member of your family?

38



39



Additional benefit

39



Additional benefit

- Change in dentist’s image

39



40


Yields benefits to patient and practitioner



40


Yields benefits to patient and practitioner

A powerful nonverbal communication of your sincere desire to be thorough and complete in your procedures



41


Instantly communicates to your patient that your practice is exceptional


41


Instantly communicates to your patient that your practice is exceptional

Establishes a new rapport


42


Is the only method:


42


Is the only method:

- To find all the patient’s needs


42


Is the only method:

- To find all the patient’s needs

- Dentist’s moral, legal obligation, and responsibility


43


Can you imagine a physician’s Physical Exam:


43



Without measuring blood pressure


43




- Without weighing you


43





- Or listening to your heart and lungs


43





- Or listening to your heart and lungs

Preposterous for “RD” to perform the above procedures, but not record them


44


As many procedures as there are dentists


44



- My procedure evolved over many years


44




- You decide what might work for you


44





- My COE can serve as a matrix or outline


44





- My COE can serve as a matrix or outline

- COE is culmination of many different sources


With COE:

Baseline data allows us to determine patient progress.


46


Barkley, Kohn, and Burns

Dr. Robert Barkley, DDS


47

Elements of COE


47

Elements of COE

Orientation


47

Elements of COE

Orientation

Clinical


47

Elements of COE

Orientation

Clinical

Radiographic/Digital (CBCT?)


47

Elements of COE

Orientation

Clinical


Treatment planning


47

Elements of COE

Orientation

Clinical


Treatment planning

Consultation


Elements of COE - Orientation

48

Medical / DentalHistory



49

Non-ThreateningEnvironment



49

You are what the patient experiences

Non-ThreateningEnvironment



50

Interview



51

Philosophical Agreement

- not byacquiescence



52

PatternedInterview

How can I help you? _______________________________________________________Review medical history. ___________________________________________________Age of first dental appointment. ___________________________________________Any history of bad experiences. ___________________________________________Was care regular? __________ How much care was needed?__________________Are parents living? _______________________________________________________What is parents’ dental condition and care habits? Edentulous? _____________What is / was brothers’ / sisters’ dental condition and care habits? Edentulous? ________________________What is / was spouse’s dental condition and care habits? Edentulous? ______________________________What is / was children’s dental condition and care habits? Edentulous? __________________________________How would you describe your present dental health? Good Fair PoorWhat has the past five years’ care been? ____________________________________Do you think your dental disease is active or controlled? ____________________Have you been taught to control it? ________________________________________How do you feel about ever losing your teeth? ______________________________Two main goals of practice? _______________________________________________Any problems to handle today? ____________________________________________

Orientation - Dental History



53

Mantra for new patients



53

Mantra for new patients

“We have unconditional amnesty for dentist evaders.”



Specific comments:



Specific comments:

- How can I help you?



Specific comments:


- Review medical history.



Specific comments:



- Age of first dental appointment.



Specific comments:




- Any history of bad experiences?



Specific comments:





- Was your care regular? How much was needed?



Specific comments:





- Was your care regular? How much was needed?

- Are your parents living? Parents dental conditions & habits? Edentulous?



Specific comments:

- What is/was your brother’/sisters’ dental condition & care habits? Edentulous?



Specific comments:


- What is/was your spouses’ dental condition & care habits? Edentulous?



Specific comments:


- What is/was your spouses’ dental condition & care habits? Edentulous?

- What are your children’s dental condition & care habits? Edentulous?



Specific comments:

- How would you describe your present dental health? Good, Fair, Poor?



Specific comments:


- What has the last five years’ care been?



Specific comments:



- Do you think your dental disease is active or controlled?



Specific comments:




- Have you ever been taught to control it?



Specific comments:




- Have you ever been taught to control it?

- How do you feel about ever losing your teeth?





57

CRITICAL POINT



57

Two main goals of practice:

CRITICAL POINT



57

Two main goals of practice:1. Never lose your teeth.

CRITICAL POINT



57

Two main goals of practice:1. Never lose your teeth.2. Ultimately lower the incidence

of dental repair

CRITICAL POINT



Orientation accomplishes:




- Agreement on the basics before proceeding - not by acquiescence





- Establish common reference point - agree philosophically






- New doctor patient relationship







- Personal dental health awareness







- Personal dental health awareness

- New insight and understanding



59

Establish a Relationship


Elements of COE - Radiographic/Digital

60

Digital Radiographs, Digital Images

and Models


Co-Discovery

61

Digital Imaging for Co-diagnosis


Clinical

62

Co-diagnosis


Elements of COE - Clinical

63

Exam Form

Dental

Record on the tooth chart.

Missing teeth, why lost, position of remaining teeth and replacements No. ________________________________________________

Chart all other variations from normal, (see symbol sheet)

Palpation over the gingiva and roots of the teeth to determine bone form _______________________________________________________

Extension of the lips and cheeks for the observation of frena and muscle attachments, position of the gingival margin, and width of the attached gingiva.

Probe for pocket depth and furcation involvement.



64

Son of a Dentist



65

Attached Gingiva



66

Attached Gingiva



67

Dental Form



68

Soft Tissue



69

Buccal Mucosa



70

Examination Form



71

TMJ (Temporo- mandibular Joint)



72

Exam Form

Occlusion 0 - none 1 - slight 2 - moderate 3 - extensive

___ Premature centric contacts No. __________________________

___ Biting stress mobility No. _______________________________

___ Right working contacts No. ______________________________

___ Right (left) non-working No. _____________________________

___ Left working contacts No. _______________________________

___ Left (right) non-working No. _____________________________

___ Protrusive contacts No. ________________________________

___ Right dec. chewing efficiency ____________________________

___ Left dec. chewing efficiency _____________________________



73

Non-Working Interferences



74

Occlusion



75

Exam Form

Habit Signs 0 - none 1 - slight 2 - moderate 3 - extensive

Tongue ThrustTongue ThrustReverse swallowingLateral indentationsFungifuorm enlarge

BruxismBruxismFacetingOcclusal wearHyper masseter

MouthbreathingMouthbreathingLack of nasal flareGingival changesNail biting

TemporomandibularTemporomandibularRight painRight crepitusLeft painLeft crepitus



76

AmelogenesisImperfecta



77

Tooth Mobility



78

Periodontal Pocket Depth

Probing



79

Periodontal Pocket Depth

Probing



80

Probing in Six Places



81

Why periodontal disease can’t be diagnosed with x-ray only

Cadaver



82

Cadaver Lingual View


Enamel Projection


Enamel projection


Elements of COE - Treatment Planning

85

Exam Form

Complete the remainder of the form after the patient is dismissed.

General condition of mouth ___________________________________

State of active disease

Caries _____________________________________________________

Perio _____________________________________________________

State of bacterial control _____________________________________

State of manageability _______________________________________

Pt’s attitude during exam - Interested Casual Disinterested

Fears and dislikes of potential treatment possibilities _____________________________________________________________

Hope and desires about future dentistry ______________________

_____________________________________________________________



86

Initial Status

FacialFacialFacial

1-5 6-11 12-16TEETH NO.

CALCULUS

BLEEDING

SUPPURATION

GINGIVAL TEXTURE

GINGIVAL FORM

EXTOSTOSES

PLAQUE (DEBRIS)

PalatalPalatalPalatal

16-12 11-6 5-1

FacialFacialFacial

17-21 22-27 28-32

LingualLingualLingual

32-28 27-22 21-17

Mean

Date TM Occl Sul Ging Perio Calc Debris Irritant

INITIAL

RE-EVALUATION

SIX MONTH

ONE YEAR

TWO YEAR

THREE YEAR

Etiology ______________________________________________________________________________

Diagnosis _________________________________________________________________________

Prognosis __________________________________________________________________________

Treat Plan _________________________________________________________________________

__________________________________________________________________________________

Initial Status

Patient Status


Section 1. First appointment. (Orientation)Observations about patient.

Section 2. Second appointment. (Examination)Summarize medical history (questions 1-55)Additional dental history information obtained during examinationSummarize dental history (questions 56-105)Basic physical findingsSummarize diet history (questions 106-115)Synopsis of historical findings

Section 3. Oral ExaminationComplete soft tissue examination (quanitate changes 0-3)Complete occlusal examination (quanitate)Habit evaluationReview of radiograph findingsDental examination (complete charting of all restorative and periodontal needs - absolutely must probe all pockets)

Section 4. Review of findingsQuantitation of the periodontal condition at initial examination. Quantitation of periodontal findings with progression of treatmentTM - Tooth Mobility; Occl - Occlusion; Sul-Pocket Depths; Ging - Gingival Status; Perio is average of means of TM, Occl, Sul, GingCalc - Calculus; Debris - plaque; irritant is average of calc, debris


87

Explanation of Examination

Forms



88

Initial Status with Numbers

from Exam

FacialFacialFacial

1-5 6-11 12-16

2 1 23 2 21 0 12 2 22 2 20 0 02-3 3 3

TEETH NO.

CALCULUS

BLEEDING

SUPPURATION

GINGIVAL TEXTURE

GINGIVAL FORM

EXTOSTOSES

PLAQUE (DEBRIS)

PalatalPalatalPalatal

16-12 11-6 5-1

2 1 22 2 21 0 11 2 11 2 11 0 13 3 3

FacialFacialFacial

17-21 22-27 28-32

1 2 12 3 20 1 02 3 22 3 20 0 03 2 3

LingualLingualLingual

32-28 27-22 21-17

2 2-3 23 2 31 0 12 2 22 2 20 0 03 3 3

Mean

Date TM Occl Sul Ging Perio Calc Debris Irritant

1 2 2.6 2 1.9 1.7 2.9 1.8INITIAL

RE-EVALUATION

SIX MONTH

ONE YEAR

TWO YEAR

THREE YEAR

Etiology ______________________________________________________________________________

Diagnosis _________________________________________________________________________

Prognosis __________________________________________________________________________

Treat Plan _________________________________________________________________________

__________________________________________________________________________________

Initial Status

Patient Status



89

Explanation of Assessing Periodontal

Status: Quantization of

Periodontal Condition at

Initial Examination

SCORING CALCULUS

Score 3Score 2Score 1Score 0

heavy calculus (supra sub)moderate calculus (mainly sub)slight calculus (mainly supra)none

SCORING BLEEDING


bleeds easily with probingbleeds moderately with probingbleeds slightly with probingnone

SCORING SUPPURATION


pus readily appears with probingpus moderately appears with probingpus slightly appears with probingnone

SCORING GINGIVAL TEXTURE


considerable swellingmoderate swellingslight swellingnormal

SCORING GINGIVAL FORM


considerable enlargement alterationmoderate enlargement alterationslight enlargement alterationnormal

SCORING EXOSTOSIS


considerable exostosismoderate exostosisslight exostosisnone

SCORING PLAQUE (DEBRIS)


most of tooth coveredabout 1/3/ of tooth coveredless that 1/3 of tooth coverednone


90


Simple or complex


90


Simple or complex

Departure from normal


90


Simple or complex


We see mostly “average” not normal


90


Simple or complex


We see mostly “average” not normal

Complex may require “team approach”


Patients comment:

“Do you do this for everyone?”



92

Radiographic Exam



93

Case Planning




Digital Metrics for COHC


DentMet Excel Spreadsheet


Digitizing Dental Metrics



• Code can be written in Microsoft Visual Basic




• Metrics can be coded with oral commands through voice activation module





• Dental metrics can be statistically analyzed for an overall sum of patient’s health





• Dental metrics can be statistically analyzed for an overall sum of patient’s health

• Dental metrics can be linked to existing practice management software


Potential Digital Metric Partners













98

Digital Images and Models


Elements of COE - Consultation


Consultation Can:


Consultation Can:

Allow you to stop feeling you have to badger people into accepting treatment.


Consultation Can:


Help you find out what the person wants in a dentist


Consultation Can:



Find out what the person dreads about dentistry.


Consultation Can:




Help you replace resistance with collaboration.


Consultation Can:





Keep you from feeling like a salesman.


Consultation Can:





Keep you from feeling like a salesman.

Allow you to have a productive conversation about the patient’s wants and needs.


Consultation IS:


Consultation IS:

Based upon COE & Diagnosis


Consultation IS:


The highest productivity of the Dentist


Consultation IS:



A critical issue for the patient


Consultation IS:




Variable (Simple, Complex, etc.)


Consultation IS:





Not a “batting average”


Consultation IS:





Not a “batting average”

The embodiment of your practice philosophy


102

Summary of COE



102

Summary of COE

How COE can solve problems



102

Summary of COE


Make money (can only treat what you know to look for and find)



102

Summary of COE



Stay out of trouble



102

Summary of COE



Stay out of trouble

Do what’s best for your patients



Patient Who Did Her Own Surgery”


After Meticulous Home Care:


Before Plaque Control


Two Weeks Later


Disease Processes Differ


The Mount Rushmore of Dentistry





108

• G.V. Black



108

• G.V. Black

• C.C. Bass



108

• G.V. Black

• C.C. Bass

• Robt. Barkley



108

• G.V. Black

• C.C. Bass

• Robt. Barkley

• Sumter Arnim



108

• G.V. Black

• C.C. Bass

• Robt. Barkley

• Sumter Arnim

• Per Branemark



108

• G.V. Black

• C.C. Bass

• Robt. Barkley

• Sumter Arnim

• Per Branemark

• Michael Buoncore



108

• G.V. Black

• C.C. Bass

• Robt. Barkley

• Sumter Arnim

• Per Branemark

• Michael Buoncore

• Dr. Bob Margeas


109

What changes do I want to make?

How do I make them?


What You Want:


What You Want:

LIST FOUR THINGS YOU WANT YOUR PATIENTS

& STAFF TO SAY, BELIEVE, FEEL ABOUT YOU AS

A DENTIST AND YOUR DENTAL PRACTICE.


111

Extensions for successful change


111


Control your own oral disease, if you haven’t already.


111



Require your office staff to have their oral disease under control.


111




Develop an examination form which includes components that you feel are necessary to accomplish COHC.


111




Develop an examination form which includes components that you feel are necessary to accomplish COHC.

With a colleague, conduct a thorough examination on one another.


112


Conduct a thorough exam on a few selected patients (family, staff, patients) and solicit their reaction.


112



Write your philosophy of oral health care and share it verbally with your staff. Solicit their reaction.


112




Solicit the oral health care philosophy of your staff. Is it the same as yours?


112




Solicit the oral health care philosophy of your staff. Is it the same as yours?

Review patient records to see if you can make specific observations on patient progress.


113


Provide a small, select number of patients with a written and (or) verbal diagnosis. Solicit their reaction.


113



Analyze with your staff the ways that your office and dental practices contribute to changing the dental behaviors of patients.


113



Analyze with your staff the ways that your office and dental practices contribute to changing the dental behaviors of patients.

Discuss the ideas shared here, and get their reactions.


114

You’ve Been Shown:


114


How systems were developed.


114



And how you can develop you own unique program.


114




My system isn’t perfect.


114





Your system will have shortcomings.


114





Your system will have shortcomings.

The process will enhance your goal


Comprehensive Oral Health CareT H E G O A L O F D E N T I S T RY

Q & A


Patient Communications

need a section on pt. relations: Green Notes, office satisfaction surveys, mystery patient, staff feedback, focus groups, cleanliness (office, staff, Doctor) e.g. spots on glasses, blood spatters on gowns, breath odor, personal grooming.

The car you drive and How you drive it.

The way you dress.


Documents

Value Based Dental Practice