General Practice Office Observation and Interview

Chambers Bridge Dental

By Teagan Rubida

Communication:
- Communication between office personnel is mostly verbal. They do end-of-day “huddles”
about twice a week, and a staff meeting monthly.
- Communication between office personnel and patients consists of verbal and written
communication when discussing the treatment plan; the treatment plan is printed and then
Dawn, the care coordinator, verbally discusses the components of the plan and the associated
fees with the patients before getting signed consent. Written consent is obtained every 6
months, and all treatment plans must be signed before treatment begins. There are no separate
NSPT consent forms. Appointments are confirmed with patients via a text and/or email
message through a service called “RevenueWell,” which reminds patients of their upcoming
appointments at 3-week and 1-week intervals, then the day before as well as the day off. If
patients do not confirm the appointment with the auto service, the front office typically calls to
confirm the day before the appointment. The hygienist lets the dentist know she's ready for an
exam by bringing in a sticky note to where the dentist is working with the patient's name, the
type of exam they need (recall or comp), and the hygienist's name so they know which room
to go to.

Records management and scheduling:

- This office uses Open Dental as its management software. They have autonotes for each of the
various types of services, including recall patients, SRP, and nitrous oxide. The autonote
outlines are relatively simple/streamlined and were developed by the hygienists at the office.
- The hygienists schedule their own patients and have the autonomy to adjust the appointment
time as needed, depending on the specific needs of that patient. Generally speaking,
prophylaxes and periodontal maintenance appointments are allotted 1 hour, and SRPs are
allotted 1 hour per quad. New patients are scheduled for 2 hours, in which all of the
assessment procedures are performed and the hygienist may start hygiene procedures if there
is extra time/enough time to do so. The schedule uses different abbreviations depending on the
services being provided. NSPT/SRP patients are denoted as “RPC” with an indication of the
quad being treated or tooth numbers if it’s not a full quad. Periodontal maintenance is denoted
as “PerMaint,” and other services are written as “Adult Prophy” or “Scaling with
Inflammation.”
- The typical chart entry for an NSPT patient contains information about the type and location
of the services being performed, by indicating the quad(s) being treated or the specific teeth if
there’s a localized area of 1-3 teeth. The chart entry lists the patient's chief concern and then
describes the techniques used during treatment, including hand-scaling, ultrasonic, and
polishing. It also describes the anesthetics used, providing details on the types of injections,
the type of local anesthetics and topicals, the amounts used, and the needle gauges. Next, the
note lists the patient's stage and grade, followed by any specific OHI and comments. It has a
 line for PARQ and the next appointment information and finishes off with the name of the
clinician.
- The same autonote is used for adult prophylaxes and maintenance patients. Components of
this note include the services provided, chief concern, intraoral and extraoral exam notes,
periodontal classification/ stage and grade, dental chart, periodontal readings/perio chart,
cancer screening, other abnormalities, and a line for the TMJ. Next, there is a line for notes
from the doctor during their exam, then a line for the recommended treatment plan. Next is a
line for the treatments provided today (ultrasonic, hand scale, polish, etc), then a line for
“other hygiene notes.” This autonote ends in the same way as the one for NSPT, by listing
OHI, comments, PARQ, next appointment, and the clinician's name. There is a separate
autonote that is used for a child prophylaxes, which lists the services provided, the patient's
chief concern, intra/extra oral exam findings, notes from the dental exam, the recommended
treatment, PARQ, the next apt, and the clinicians name.

Patient services:
- New patients always start by seeing the hygienist first for an initial appointment. This 2-hour
appointment consists of all the assessment procedures, including x-rays, perio chart, dental
chart, dental exam, and the development of a treatment plan. The treatment plan is developed
collaboratively by the hygienist and a front desk team member (the care coordinator) and
incorporates input from the dentist who performed the exam. The dental hygiene care plan is
developed by the hygienist and is incorporated into the overall treatment plan. The care
coordinator is ultimately responsible for discussing the treatment plan and associated fees with
the patient and obtaining their written informed consent. Patients who do not have insurance
are given a 10% discount on their bill, regardless of how they pay (cash/card). The office also
has a special for patients without insurance, where they charge $98 for an exam and a CMS.
Consultations may occur for patients with more complex treatment plans/needs. For these
patients, the lead hygienist and the care coordinator discuss the different options for the
treatment plan, then come up with a couple of different treatment plans to present the patient
with and schedule a consultation appointment with the patient to review and discuss their
options.
- For a maintenance patient, bitewings and a dental exam are performed annually, however, if
the patient has insurance or makes a request they will do a 6-month exam interval instead. The
perio chart is updated annually, but the hygienist will spot probe during every appointment. A
CMS is taken every 5 years. Maintenance patients are scheduled for an hour if they are only
due for BWX, and an extra 10 minutes is allotted if they are due for a CMS. The hygienist
typically starts with radiographs, then does probing and any other indicated assessments, and
is sure to leave 10-15 mins at the end of an appointment for the periodic exam. She is typically
able to complete a CMS in 10 minutes, but it sometimes takes 15 minutes if it’s more
difficult.
- The approximate percentage of periodontal maintenance patients is 35%, SRP patients are 6-8/
month, kids are about 15%, and adult prophylaxes consist of about 70%.
- The hygienist receives assistance from the sterile tech throughout patient treatment. The sterile
tech or someone from the front office usually helps record probing depths, especially for
periodontal patients and new patients. However, if no one is available the hygienist will record
probing depths by herself. The sterile tech also assists by helping flip the treatment room
between patients, processing the dirty instruments, and bringing a new tray set up with clean
instruments for the next patient.
- The soft tissue management protocol for NSPT patients varies depending on the individual
patients' needs/periodontal status. For more advanced NSPT patients they do a re-eval after 6
weeks. For more standard NSPT patients they just do a 3 month periodontal maintenance
appointment. Typically patients use a Carifree treatment rinse after NSPT to aid with gingival
healing. They occasionally will perform gingival curettage during NSPT procedures as
needed, however, this is not a service that gets billed out, instead, it just gets performed during
treatment when indicated. No lasers are used.
- There is a variety of equipment available for hygiene services, including:
- There are Cavitron power scalers with bulk debridement, slimline, and triple bend inserts.
Hypersensitivity agents include novamin prophy paste and a desensitizing solution from
Paterson that gets painted on the patient's teeth. They do not have a standard oral irrigation
process at this time. In the past they used Chlorhexidine, but because it inhibits fibroblast
reattachment they have stopped using it. They did recently purchase a rinse called CloSYS,
which is a buffered hypochlorite, to sell as a daily rinse and are considering using this to
irrigate, but they are still looking into the product and have not reached a decision at this
point. They do not use any air-polishers or Arrestin.
- The typical instrument tray setup used for patient treatment includes the following scalers/
curettes: mirror, explorer (exd 11/12), universals (4R/4L and Montana Jack), grayce 11/12,
13/14, 15/16, 17/18, anterior and posterior nevis, and langers. The same instruments are
used for both NSPT and maintenance patients, except langers which are only used for
NSPT patients. Re-tipped instruments are not used. Instruments are sharpened using a
wheel sharpener about 1/week. The two hygienists alternate the responsibility of
sharpening.
- Available home care aids include:
- Carifree products: treatment rinse, maintenance rinse, oral moisturizing spray, Pro Gel
5000, xylitol gum, and breath mints
- Colgates PreviDent 5000
- MI paste and MI paste plus
- Electric toothbrushes: OralB iO brush with 3 different types of heads, and Philips
Sonicare brush
- Waterpik water flosser
- OraCoat: Xylimelts, XyliGel
- Other services provided by the hygienist include sealants, whitening, nitrous oxide sedation,
local anesthesia administration for hygiene services and services provided by the dentist when
the hygienist has free/extra time to help out, and intraoral photos. There are opportunities for
the hygienists to place restorations if they want to, however, the hygienist typically doesn’t
want to so they don’t provide that service.
Patient referrals:
- Patients are commonly referred to a periodontist if the hygienist determines that the patient's
periodontal condition is too involved and the indicated NSPT is beyond the scope of services
they can/should provide. Indications for this referral include pockets that are 8+ mm,
generalized mobility, or a complete lack of tissue improvement at re-evaluation appointments
after initial NSPT.
- Patients may be referred to oral surgeons for complex extractions, such as the root being
located in the sinus, or located too close to the IA nerve.
- Patients are referred to an Endodontist for any/all molar root canals.
- Patients are referred to an Orthodontist for any/all ortho needs.

Office team members:

- Three Dentists/Doctors: Two of the doctors place implants, all of them preform dental exams,
adjust restorations as needed, makes crowns in-house, and diagnose caries.
- Sterile Tech/Assistant: Responsible for processing instruments, performing testing/monitoring
the efficacy of sterilizing equipment, filling in with some assisting duties when extra help is
needed, helping with patient scheduling, flipping rooms, doing laundry, taking out the trash,
getting the trays ready before treatment, closing down sterile, and draining the ultrasonic bath.
- Two Assistants: Assist dentists during all of their procedures and make trays before patient
treatment.
- Care Coordinator: Responsible for developing treatment plans, discussing fees with patients,
and obtaining informed consent.
- Two Hygienists: Help with instrument processing when they have free time or if the sterile
tech is very busy. Hygienists schedule their own patients, appointments are scheduled back to
back. Heather is technically the lead hygienist and has more responsibilities, however, both
hygienists work very collaboratively together and essentially share the responsibilities/do the
same things. Heather is in charge of ordering supplies/instruments for the office. There are no
start of day/end of day duties besides reviewing the patient treatment schedule for the next
day/week to be ready for treatment. In the event of a last-minute cancelation/no-show, the
hygienists help out wherever they can in the office. They do not clock out, instead, they may
help process instruments, organize, clean something, or take a CE course. “There is always
something to do.”
- Office Manager: The office manager is in charge of all the staff and has a lot of responsibility,
especially because the Doctor that owns the practice is only at the office 1 day/week. She is in
charge of instrument payments, payroll, and anything/everything related to money (such as
banking and bill paying). She also manages any interpersonal conflicts with the staff or other
personal issues staff members may have. She helps oversee all three of the practices the
Doctor owns, so she does payroll for all three offices.
- The attire worn by the hygienists includes black scrubs with chambers dental long sleeve
overcoat/open front top. They also wear loupes, a mask, have their hair up/back, and wear
tennis shoes. The hygienists do not wear gowns. The assistants and sterile tech wear the same
black chambers dental scrubs/outfit as hygienists. The dentists wear black scrubs with a gown
over top. All staff members who treat patients wear gloves and masks. The front desk workers
 wear professional but casual street clothes and appear tidy and presentable. in response to the
COVID-19 pandemic, the office implemented a few changes in protocol, including the
addition of air purifiers in each treatment room. They made all the changes necessary to
follow the regulations that accompanied the pandemic, including the use of N95 masks, HVE
suctions during hygiene treatment, taking patients' temperatures, and asking patient questions
regarding being sick or in contact with someone who was sick, but discontinued all of these
practices once they were no longer required. As far as lab coats go, the clinicians wear the
same one throughout the day and they all get washed nightly. There are extra lab coats
available in the back if one becomes soiled and the clinician wants/needs to change. The
dentists and assistants also wear disposable gowns during surgical procedures.

Infection Control:
- Many of the infection control protocols are the same as those used at the LCC clinic, including
practices of changing masks, suctioning the lines, and sterilizing hand-pieces between every
patient. Laundry is done at the facility by the sterile tech every night. Some differences are
that the hygienists do not wear a face shield or double mask during ultrasonic instrumentation
and much fewer barriers are used. There were no barriers over the dental unit light, the nitrous
tanks/tubing, the Cavitron, or the computer; however, there were barriers over the dental chair/
headrest and the tray holder. The room and equipment (Nomad, Cavitron, etc) are wiped down
only once with Cavicide wipes between patients, and all hygiene instruments are sterilized in
pouches. Their OSHA officer is also their office manager, and their lead hygienist also assists
her with OSHA duties. They do yearly OSHA/HIPAA meetings with a representative from
Healthcare Compliance and monthly staff and safety meetings.

General impressions of the style of the practice:

- I found the atmosphere of the office to be very professional and simultaneously incredibly
warm and relaxing. Elements that contribute to this atmosphere include the daily batch of
freshly baked cookies for patients, the caring and thoughtful way the staff members interact
with each other, and the overall team-oriented dynamic of all the employees, who consistently
lend help and support each other whenever they have a free moment. Something that
impresses me is the autonomy the hygienists have over their schedules and treatment plans,
and the mutual respect between all of the employees working in the office. I appreciate the
way they all want to help out with each other's responsibilities even though they are not
“required” to do so.

Office Practice Website:

www.chambersbridgedental.com