Sophie Bracken visited Sarah Gilder, lead hygienist at The Dental Surgery, to discover the benefits of putting hygiene at the forefront of the practice’s services.
It’s widely acknowledged that hygiene is the first line of defence when it comes to keeping patients orally healthy. As such, the dental care profession is shifting its focus towards preventive dentistry and away from the traditional restorative treatment model. The main obstacle to this though, is patient awareness. Tools such as direct access to hygienists and therapists, and improving patient education have a huge role to play in helping patients take ownership of their oral health, but the general practice’s role is equally as crucial, and getting the balance of treatment and education can be tough for the typical dental practice.
One practice that is taking great strides in promoting the oral health message to patients is The Dental Surgery, located in the city of London’s Corn Exchange. The Dental Surgery is the largest independent private practice in the UK, boasting 14 surgeries – with plans to add 10 more. With a team of six full-time hygienists, it’s safe to say that The Dental Surgery’s hygiene programme is hugely important to this monumental practice.
I visited The Dental Surgery earlier this year (‘30,000 patients and counting’, Dentistry 3 March 2016) to talk to the practice’s lead hygienist, Sarah Gilder, to about The Dental Surgery’s successful hygiene programme, and how they achieved it.
Building the team
Sarah began her career over 20 years ago, working in a mixture of NHS and Harley Street practices after qualifying from Guy’s Hospital, before joining The Dental Surgery.
Sarah says: ‘When I started, Shaun had just taken the surgery over from somebody else. Back then there was a minefield of work to do here. The previous people had just skimmed over the top of hygiene, which happens at a lot of practices.
‘A lot of patients also thought of seeing the hygienist just for a bit of a polish, and not understanding that initially our job is to get your mouth healthy.’
The Dental Surgery started with two hygienists, but the team has grown to six full-time staff that have the freedom to work within their full scope of practice, and who support each other fully.
‘We’ve grown massively. Now, people like Emma, our youngest hygienist, have the benefit of placement experience and everyone here supporting her. We do all our own perio work as well. We’ve got a good team here.’
Hygiene at the forefront
When you visit The Dental Surgery’s website – www.thedentalsurgery.co.uk – what is most striking is the visibility and promotion of the practice’s hygiene programme. When navigating the ‘Our services’ section, the hygiene services are first on the list, providing information on why it is important to visit the hygienist, as well as guidance on direct access. Sarah explained why The Dental Surgery’s hygiene programme is a primary focus for the practice:
‘Hygiene is the main thing before any treatment is undertaken here. You can’t have an implant if you haven’t got a healthy mouth. You can’t have restorative work if you haven’t got healthy soft tissue – as we say, you can’t build the house without the foundations.
‘There are very few patients that don’t need a referral to a hygienist, whether it’s a simple maintenance programme, or a periodontal treatment, it’s key. Assessment is the first step, followed by diagnosis, consent from the patient for treatment, treatment and then maintenance. The treatment phase might be a 40-minute hygiene recall, or it could be a two-hour subgingival debridement with local anaesthetic.
‘But it’s all individually tailored. There are 40- 50- or 60-minute recalls. People that have had periodontal work usually have a longer appointment because we need to do a full mouth assessment. A 40-minute recall will usually be someone who has a pretty healthy mouth but needs that maintenance.’
Every new patient at The Dental Surgery undergoes full hygiene assessment, and all patients are either referred by dentists, or visit one of the hygiene team via direct access.
Direct access – a practice grower
Fiona Sandom, president of the British Association of Dental Therapists, recently told Dentistry (‘Putting therapists in the mix’, Dentistry 4 February 2016) that direct access had been a ‘flop’ on a national scale, because of over-regulation of the scheme. At The Dental Surgery however, direct access has been a major success. Sarah explains why.
‘We’re at the front of dental care’ says Sarah. ‘With direct access, we bring patients to the practice. Generally these patients are converted and usually will see someone else here, but that’s how hygienists generate work as well.
‘Too many people are scared of direct access. We’re very lucky that we have a great team of dentists and hygienists here – we have great communication between the team, and direct access has opened our services up to patients a lot.
‘It’s been very successful, and it’s only going to get better. Over the years patients have been told that they can’t see a hygienist unless a dentist has referred them. When the law changed, there wasn’t a big shout about direct access – it was never announced to the public. I think people are reluctant to go to the dentist for a check up because they think it equates to spending a lot of money and they will end up having a procedure done. But when they come and see us we might say, actually there is something you need doing, and they will end up going to see the dentist.
‘I think direct access is the way forward. A couple of my hygienist friends have their own practices, so direct access has opened up doors for that. We can also diagnose within our scope. I think some hygienists are a little scared about direct access. I don’t know whether that’s because they don’t have the backup.
‘I’m part of a Facebook forum for hygienists and therapists – the biggest thing that comes up on there is members that say they’re not understood or not given the recognition that they should have. Here, everyone is brilliant, and the dentists come and ask us things, because we know more about gum disease, that’s a fact!
‘Direct access is a practice builder here and it gets patients in who don’t think they’ve got anything wrong and who just want to have their teeth cleaned, so it helps them out as well.’
The full scope
Not only is direct access a practice builder and a patient education tool at The Dental Surgery, it allows the hygienists to work within their full scope of practice, which in turn, is beneficial to The Dental Surgery’s dentists and the business in general, freeing dentists to take on more complex cases.
‘I don’t know any dentist here that does any cleaning of teeth whatsoever’, Sarah explains. They haven’t spent the years that we have doing the training. We do everything. For a new patient, we conduct a thorough assessment. We talk to them about what they’re worried about, their medical history, smoking history, dental history, family history, their plaque control, full mouth assessment, what their hygiene routine is, any bleeding, gingival appearance, BPE, occlusion, condition of dentine, and we also look at radiographs and make a note of any bone loss, and so on.
‘We then make a diagnosis and discuss a treatment plan. We do that for every new patient that walks through the door, so we’ve got a good understanding of them. We use intraoral cameras and I have a great whiteboard to draw on.
Sarah has undertaken a two-year postgraduate diploma in periodontology, which been extremely beneficial to The Dental Surgery’s hygiene team in terms of using the hygienists’ full scope of practice, and inspiring her team.
‘It was an interesting time, there were 10 hygienists and 10 dentists on the course and it was great – a really good group. I learned a lot on the course, but it also gave me confidence to feel like I could get in and do a bit more. It allowed me to look at the way I work and pass on new ideas to the other hygienists.’
What’s more, Shaun and his partner, Simon Nocton, are very encouraging of the team taking on further education.
‘We’re all busy doing something most of the time’, Sarah says. ‘We all attend most of the big conferences. We were at Europerio last summer and Mary (Foucher, a fellow hygienist) and I are going to Basel to the International Symposium of Dental Hygiene 2016. We’re going to meet up with three of The Dental Surgery’s former hygienists.’
Going further with prevention
In my interview with Shaun, he talked of plans to expand the 14-surgery practice even further, by adding 10 new surgeries. ‘We need more hygienists, like yesterday!’ he told me. I asked Sarah what innovations The Dental Surgery’s hygiene team has recently implemented, and what plans they have for the future, as the UK’s largest private practice continues to expand.
‘We have an implant surgery here, so at the moment we’re working with them more – pre-surgery and post-implant so we can help patients look after their implants. As we have an orthodontist here too, we see the ortho patients; and for restorative patients we might see them for 20 minutes to show them proper oral hygiene incorporating their restoration, just to show how important that is. We need to show people how to look after their £3,000 implant.
‘Little things like this are massively different from 20 years ago. When I first came here, every patient was a 30-minute recall. We then pushed it to 40 minutes, and now we push it to 50 or 60 minutes. That way we can gauge what each patient needs.
‘We also do a lot of deep scaling under local anaesthetic. We wear a surgical gown and we have a dental nurse with us, to make the patient feel like the procedure is important – a proper treatment.
‘We’ve just started using the EMS Air-Flow technique – we’ve had that for the last six months. It’s brilliant. I’ve just used it on a periodontal patient; you can use the nozzle in a deep pocket with a special handpiece. It’s probably the most revolutionary idea in the way we treat patients since I’ve been qualified. It’s less invasive and it’s more comfortable. If you use the Air-Flow first you don’t need to polish or use the abrasive, and you can use it around crowns and implants so that’s changing things in the way we work.
‘In the future, I think we’re going to try to do some courses here, because we have six hygiene surgeries that are all set up with the EMS Air-Flow systems. I ran an ID block course here for hygienists; we’re very lucky that we can run hands-on courses. More courses could be something for the future.’
In addition to all this, The Dental Surgery’s hygienists have the support of dental nurses, allowing the hygienists more time with the patient.
‘We have a team of four nurses – they do all of our changeovers. We don’t do any sterilising and they’re there to assist with suction and charting and things like that. Most hygienists now want their own nurse.
‘If you’re on your own and spend five minutes cleaning down and five minutes setting up, that time comes out of the patient’s appointment time. So in a 30-minute appointment time you’ve actually only got 20 minutes with the patient. Add to that some oral hygiene, so you’re down to 15 minutes. How can you achieve what you want in 15 minutes?
‘I think it’s important to have the support from a nurse, and to not be in a room on your own with a patient. I think that its still going to take a lot of time [for hygienists using dental nurses to become mainstream] because a lot of dentists won’t want to pay for nurses for a hygienist, but we are starting to see it more.’
The Dental Surgery’s hygiene programme is a great model of how a lot of hygienists would like to work, given the resources.
‘When I go home, I can sleep knowing that I have done the best that I can for my patients’, Sarah says. This is especially important now more than ever, given the rise of dento-lagal cases.
‘Mis-diagnosis or non-diagnosis – we see it all the time. Patients that have gone to their local dentist and come to us with BPs of three and four everywhere. But here we’re allowed to work as we want to give the patient the best that they deserve, individually. If you look at our diaries it’s all different lengths of time that we see people, and it’s all tailored for them.’
Tailored education and treatment is one of the keys to the success of The Dental Surgery’s hygiene programme. Support from the practice principals to work within the hygienists’ full scope of practice, and embracing of direct access, has given these hygienists the tools to put oral hygiene education its rightful place – at the forefront dental care.