Nurse-Led Clinics

NURSE LED CLINICSThere are many qualifications that dental nurses can work towards after they have gained their initial dental nursing qualifications, and it is worth considering how we can put these to good use within the dental practice.

In the busy dental practices we see today, it is important for dentists and practice managers to realise the value of a well-trained team and be able to ensure staff reach their full potential. I feel that compulsory registration with the General Dental Council (GDC) has led to many dental nurses wanting to take on extra responsibility – both for patient care and for more 'behind the scenes' roles. Additional qualifications and duties can include (but are not limited to):

  • Oral Health Education
  • Oral Health Promotion
  • Fluoride Application
  • Radiography
  • Sedation
  • Impression-Taking
  • Clinical Photography
  • Suture Removal.

In my practice, our nursing team has all these additional skills, and they are put to good use. This helps the clinicians' appointment books run more smoothly; it takes some work out of their appointment books completely, leaving them more time to treat other patients. Dental practices today seem to constantly get busier, so being able to save time where we can is extremely helpful. I have worked in my current practice for six years and have seen the workload increase greatly in that time. Having well-trained dental nurses who can carry some of the workload makes a real difference in the way the practice can run. An excellent standard of training is vital to ensure dental nurses are confident in carrying out their extended duties safely for the patient and to the best of their ability. My practice has an academy side to the business, training dentists and providing Continuing Professional Development (CPD). As I have recently qualified as a teacher, I am beginning to work with our practice manager and academy to create effective training and CPD for the wider dental team.

Oral Health Education

Generally, in my experience, dentists are terrible at providing patients with oral health education! It is often something they add to the end of an appointment and spend little time on. Placing such little emphasis on it can mean that the patient does not see its importance and therefore will be less likely to carry out any instruction given. At my practice, we feel that oral hygiene instruction should ideally be given when providing patients with a new restoration. This can be one or multiple crowns, bridges, dentures, and implant restorations. If oral hygiene is given immediately after fitting a large restoration, a patient can often be too excited about leaving with their finished restoration to be paying much attention to the advice being given. Similarly, anxious patients may be too keen to get out of the dental chair and leave to be listening to this advice. Booking a further appointment with a dental nurse qualified in oral health education can therefore be extremely helpful. The patient will have started to get used to their new restoration and will be more interested in the aftercare advice given. Anxious patients are often more at ease around a dental nurse than a dentist and so are more likely to be able to take on board this advice. Furthermore, many patients are more honest with a dental nurse than a dentist and may voice problems or concerns they would not have brought to the dentist's attention. If the appointment is booked shortly after the restoration fit, the patient will have had time to talk and eat with their restoration in place, and this can also be an opportunity to discuss how this has felt and any improvements that could be made.

Often, oral hygiene instruction is given verbally by dentists, without any visual demonstration. Patients can then easily misunderstand what they should be doing. An oral health educator can take the time to demonstrate oral hygiene aids and how to use them effectively. These can then be tailored to the individual patient's needs. This may be preferable to the 'one size fits all' approach that many dentists seem to demonstrate. 

With regard to dietary advice, this can be something dentists simply do not have time to address. An oral health educator is often able to spend more time on this with patients, helping them to develop their own knowledge and therefore be able to make healthier choices by themselves when not in the practice. Sometimes, particularly with children, more than one appointment is necessary to reinforce these messages and to ensure that they are fully understood. Again, many dentists simply do not have time to teach patients how to choose a good diet effectively. If your practice offers orthodontic treatment, the role an oral health educator can play throughout treatment is obvious, particularly with the culture of fizzy drinks most children are familiar with.

Oral Health Promotion

Before I gained my oral health education qualification, I completed a short qualification in oral health promotion. I found this extremely useful, and it challenged my knowledge in areas such as how socio-economic differences can affect oral health. Although not as in-depth as the oral health education course, I did feel it improved my communication skills. It is a useful course for any dental nurses considering creating their own resources and literature – such as posters and leaflets – for patients. These can then be used by dental nurses in their clinics where suitable, and can also be taken away by patients for use at home.

Fluoride Application

Fluoride application is most often seen in the appointment book of a dental hygienist, but it is sometimes booked with a dental therapist and occasionally with a dentist. I have recently seen an appointment with one of our general dentists for this. It is easy to see that with dental nurses available to undertake fluoride application, all three of these types of clinician could be carrying out work that is helping patients out of pain, more complex treatments, or treatments of a higher financial value. All of these things are important to a practice. Another advantage of having dental nurses able to carry out fluoride application is that children attending for this type of appointment may be more cooperative with a dental nurse than a dentist, as they may not feel as anxious around them. This can then help build the child's confidence in the dental chair and help them to find any future treatment easier.

Radiography

A very popular additional qualification for dental nurses is the dental radiography for dental care professionals (DCPs) qualification. In my practice, all dental nurses are expected to already have, or be willing to work towards gaining, this qualification. We use these skills on a daily basis. We require radiographs for almost all our new patients at their initial consultation appointment, and often our dental nurses take these along with a set of clinical photographs (discussed later) before the dentist sees the patient. As we are a specialist practice, primarily seeing patients who are referred from their general dentists, we can often assess what radiographic views are required before we see the patient. The fact that our dental nurses are able to do this at the start of an appointment means that all the required information is available to the dentist as soon as they enter the room. This also means that the dental nurse is the first member of the clinical team that the patient meets and can make the appointment seem like an informal chat. This can often put patients at ease more than if their first contact is with a dentist. Of course, in certain cases we will not know which radiographic views are required until after we have seen the patient. This is often the case if a patient is attending on a self-referral basis and we have no prior information. In these circumstances, it is still useful for dental nurses to take radiographs during the appointment, as the dentist can be starting to write their notes whilst the dental nurse is completing this task.

We take radiographs after certain treatments, such as dental implant placements (the surgical appointment) and fitting of implant restorations. Again, dental nurses can be completing this task at the end of an appointment, giving clinicians time to complete their notes.

Another type of radiograph we regularly take is at annual review appointments for patients with dental implants. Currently, one of our hygienists sees the patient for this annual review, and either the dental nurse or the hygienist takes the radiograph at the end of the appointment. We have been discussing more ways to save clinical time in terms of how we arrange these appointments, and one idea is for a dental nurse to use an additional surgery to take radiographs and clinical photographs after the hygienist's appointment. This will mean that the hygienist does not have to rush to do this at the end and will be able to continue on to her next appointment. It will involve having a surgery primarily for a dental nurse who takes radiographs and clinical photographs for clinicians, and it could save a great deal of time throughout the day.

Sedation

At present, only one of our dental nurses has a sedation qualification. Although having a nurse with this skill is very important during procedures in which patients are treated with sedation, it can also be useful prior to appointments. This dental nurse can see patients on her own for sedation assessments to ensure they are suitable for treatment under sedation. Previously, this was another type of appointment that would take time out of a clinician's appointment book; now, this is not necessary. In addition to this, our sedation-trained dental nurse is considering taking a cannulation training course so that she can be responsible for this part of the appointment. Again, this will take some time pressure and responsibility away from the dentist. Further, just like when our dental nurses take radiographs and clinical photographs at initial consultation appointments, it will mean that the patient is ready to begin treatment as soon as the dentist enters the room.

Impression-Taking

Most of our dental nurses have completed an impression-taking course, although most of our impression-taking has now been replaced by digital scanning. Before we began to use digital scanning so frequently, dental nurses often had sessions in which they mainly saw patients just for impression-taking. We have study models for all of our patients who wish to have dental implants. When a patient has decided to go ahead with their implant treatment plan, the first appointment is usually for impressions for these study models and a cone beam computed tomography (CBCT) scan. Our radiography-trained dental nurses carry out a competency log for CBCT scanning, meaning that this initial appointment can be carried out by a dental nurse rather than a dentist if the dental nurse is also able to take impressions.

Impression-taking is also useful in other situations, such as when impressions need to be taken for whitening trays. Our hygienists are usually the clinicians who fit whitening trays, but their appointment books are always full for a number of weeks in advance. It is much easier to find an appointment time with a dental nurse for the first appointment where the only task is impression-taking.

Clinical Photography

As discussed earlier, all of our patients have clinical photographs taken at their initial consultation appointments. As well as forming part of their clinical records, these photographs can be a useful tool when explaining treatment plans to patients, and they can be an aid in case-planning when the patient is not present. Further clinical photographs can also be taken during treatment and are often taken after treatment is completed so that patients have photographs of where they started and how their mouth looks after their treatment is complete. We always take clinical photographs before and after tooth-whitening appointments, and dental nurses can take the 'before' photographs during impression-taking appointments. Our orthodontist takes clinical photographs at every appointment, and although he does this himself at present, we could look into dental nurses doing this for him alongside the photographs for the hygienists if we are successful in actioning this idea.

Suture Removal

A few of our dental nurses are trained to remove sutures after surgical treatment. This is dependent on a clinician reviewing the patient first and confirming all is looking healthy and the sutures are ready for removal. Although this only saves a little time in the clinician's appointment book, it can be another way for dental nurses to build rapport with patients, as they are likely to be the dental nurse who was present at the surgical appointment. 

Additional Duties

There are a few other things that dental nurses can do for patients in the surgery, and many more things outside of the surgery. We have a machine which checks the international normalized ratio (INR) of patients taking anticoagulant medication (such a warfarin and rivaroxaban). All of our dental nurses are able to do this for patients at the start of any appointment where this information is required.

Outside of the clinical area, dental nurses can also take responsibility for carrying out the required audits, and many practices are recognising the value of having a treatment co-ordinator. As we often have large and complicated treatment plans at my practice, our treatment co-ordinator service is very popular with patients who would like certain parts of their treatment to be explained in more detail or who are simply confused by their treatment letters. As I mentioned earlier, I have undertaken teaching qualifications, and I am now looking into ways of training the dental team and devising CPD courses.

Further Considerations

Although all of these ideas can improve the way the practice runs, there are, as always, some barriers to implementing them. In my current practice, the biggest barrier we face is surgery space. We have simply outgrown the practice we are in, and we are hoping to move to a bigger practice next year. Although some of these procedures, such as clinical photographs, can be carried out outside of the surgery, most of them do require the patient to be in the dental chair. Our biggest problem is that our surgeries are almost always being used, and I would imagine this could often be the case in your surgeries too.

However, if this barrier can be overcome, it can have such a positive outcome on both your practice and your dental team. It greatly increases job satisfaction for the dental nurse, frees time for clinicians, and can help patients feel more relaxed and cared for. Although some people may be concerned that patients will feel less cared for than if they were being seen by a dentist, a dental nurse can often make them feel more at ease and also can often allow longer for their appointments. This gives patients an opportunity to chat and discuss any concerns they may have, building rapport and increasing their confidence in the practice. As I work in a private specialist practice, not all of the things we do will be appropriate for general practice, but many of our procedures can be adapted to suit your practice if your dental nurses are adequately trained. Do not let your dentists underestimate the value of a well-trained dental nurse. Perhaps suggest using one session per week for a nurse-led clinic and build from there. Once they see the value of this, they may invest in further training and build in more time for these nurse-led clinics.

 

Author: Katie Booth RDN, CTLLS

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