As I get good questions like the one below, I try to answer them in a way that is helpful to many by turning them into blog posts. This has the added benefit of enabling others to join in the conversation because I know for sure there are a lot of smart people reading this who may have better answers than I do. In fact I got permission from the one who wrote the question and he is excited as well to see what many who read this might think.  So here was his question to me:

“Dear Ben,

After careful discussions with my great hygiene team they feel that I am asking too much in 1 hour although I feel this to be very reasonable. I have listened to them and I know there is still great resistance. Did you have a way to change the instrument-at-all-times culture to an examination-and-explain culture or did you initially give your team more time?”

For those who may not know, he is referring to the SPT series (Supportive Periodontal Therapy) I wrote how supportive therapy is not a cleaning appointment, per se. Rather, it is an evaluation appointment with a cleaning component to institute treatment as needed, but at as low an impact as possible.

Although I get the essence of the situation, I also know that the abbreviated question may not be the deeper question or concern. So let me make a few observations and I hope they help. Ultimately I am confident that this dentist and his team will figure this all out in a way that best works for them. I base my optimism on the fact that they are having the conversation and attempting to understand one another.

A number of years ago, when I had just come out of the military and had been in private practice for about a year, I made a business arrangement with anther periodontist in town. He wanted to move to another city but wasn’t in a real hurry and so was willing to work with me for about a year. Because he had a more established practice, but I had the newer office, he moved in with me and brought his dental hygienist and one dental assistant. They continued to work with me after he left for many years.

As soon as he settled in, I had the brilliant idea that it would be good for me to see the Supportive Periodontal Therapy patients as part of their next hygiene visit. Immediately, meaning after one or two attempts at doing this, I discovered that the patients were not happy with this plan. They didn’t know who I was or why I was “barging” in to see them. Quickly I made an adjustment. I told the dental hygienist to simply point me out to the patient if I walked by. Also, if it seemed reasonable, introduce me to the patient as they were leaving, but don’t change anything else. If the patient really needed to have a periodontist check something, inform the patient that you will try to get their periodontist to see them first and then ask if they would be willing to see me if the other one is not available? In this way we were giving patients space to adapt. Already they were a little annoyed to have to find a new dental office, even though they were seeing most of the same faces as before.

We are all creatures of habit.  As much as possible we want to walk through our days with as little disruption as possible. This is true for patients, dental hygienists and even ours truly.

The lesson I learned from this experience is to change as slowly as possible without stopping all together  whenever change involves a lot of people and the majority are used to another system. There are a lot of ways to do this. First, we can change one thing at a time. Second, we can step back and train at a deeper level. That is to say, if we are going to get resistance on implementing a technical change, perhaps we don’t have buy-in with the more basic principles involved.

In this particular case the dental hygienist evidently believes the most important element of the appointment is the cleaning, OR the hygienist believes the patient believes this. How do we change these deeply entrenched beliefs?

Answer: Patiently provide new factual information. Show the patients and/or the dental hygienists how and why this is in their best interest to change. There are problems with over-instrumentation for example. We don’t want to harm people even though they may expect an aggressive cleaning at every visit – so we have to constantly educate.

Starting with the patients, perhaps the first thing to do is to tell each patient about a new system being implemented into the office – or review why the systems are the way they are. When people are coming more frequently, the purpose is not to clean more often, it is to evaluate more often and institute treatment to turn back or control periodontal disease without damaging oral structures.

Frankly, the benefit to the dental hygienists is that they have less physical labor involved with SPT than with most prophylaxis procedures. It’s a change in instrumentation, not a reduction in care. The documentation also is important and keeps us on top of what is going on with patients.

Perhaps a good compromise in this situation would be to add 15 minutes to first appointment AT THE END when the dental hygienist can explain the changes to the program. Later, my hope would be that for some patients the time requirement for SPT would come down. Also, this is a fluid process. Each SPT appointment should determine what needs to happen next and it isn’t always another SPT. Periodically the patient needs repeat root planing or radiographs and a general restorative examination, etc.

Note that I added the explanation of change at the end of the patient’s appointment. Remember I said people don’t like change? Patients don’t like sitting and talking when they think they came for a particular procedure. Give them what they came for and then they are more open to listen to what you have to say. If you spend the beginning of the appointment talking, they may conclude you are just being lazy. After they have received what they came for, they are in a sense relieved and appreciative — they no longer are waiting for anything unpleasant that may be coming. This is a good reason to provide short oral hygiene instruction at the end of procedures, not at the beginning. Also the instruction can be tailored to specific findings encountered during the procedure.

I think I’ve said enough. Anyone else have any thoughts or suggestions?