Featured Image - airway graphic

Most patients are introduced to a general dental practice via a hygiene visit. Typically, the dentists' interaction with the patient is a rushed hygiene and restorative examination.

Is there disease? Is anything broken or may be breaking soon? If we detect an esthetic or functional issue, the hygienist is typically told that we will monitor it. The reasons we monitor? We do not know what to do, we do not want them to think we are only after their money, or we do not think they will trust us.

This creates a practice built on proactive patients which fall below the insurance line. This means that coverage is going to play an important role in their decision-making process.

At Spear Education, we have focused on moving those people above the insurance line or recruiting regenerative patients to the office. These people make decisions based on what is best for them. They may request information about coverage but fully understand that it will not be the deciding factor in care.

Historically, the techniques for creating that shift are all built around Facially Generated Treatment Planning (FGTP). Instead of starting with structural issues and disease — the dentist begins by examining esthetics and function. After gathering data and photographs, a proper diagnosis is made, and a plan of care formulated. The patient is then given a visual tour of their mouth and options for treatment are discussed. This strategy absolutely works.

The key is time with the patient. We need more time than is allowed in a hygiene check to determine what to do, create a unique experience, and demonstrate to the patient that even though their previous dentist monitored the issue, we are to be trusted. You simply cannot achieve this in the hygiene operatory. The idea that there will be a magical day that the patient will trust us enough to believe us as we discuss a rehabilitation in the hygiene operatory is a fallacy. We must get the patient out of the hygiene operatory and into our room for a comprehensive exam.

From hygiene visit to comprehensive care patient

I commonly overhear dentists at our courses saying that the cases that we present are interesting and they would love to do that kind of dentistry, but those patients are not in their practices. While I am lucky enough to receive some referrals from other specialists, the core of my practice is a 55-year-old family dentistry office. As such, I still have a significant number of patients that enter through hygiene.

My message is that the patients are in your office right now and they will be entering your practice next week. If you are not doing complex cases, it is routinely because of your knowledge or system and not your patient base.

For example, in October 2020, four new patients came to my practice. They all entered my office through a hygiene visit and examination. They ranged in age from 29-49, had seen between 2-5 dentists as an adult, they did all the dentistry that had been recommended by their previous dentists — and all of them were on 6-month recall for hygiene with no outstanding diagnosed care. Those 4 patients are currently going through over $100,000 worth of dental treatment. These issues did not just appear in the last 6 months since the previous office's hygiene visit. Their issues were either undiagnosed due to a lack of knowledge or they were detected but the choice was made to “monitor” them.

How did they go from a “see you in 6 months” patient to a very profitable case? My hygienist and I saw enough to elicit an interest from the patient to get more than a hygiene and restorative check.

There are several ways to get the patient to agree to be seen for additional records. Historically, Spear has taught that esthetics and function are the foundation for evaluating the need for restorative care. For example — the teeth are worn from bruxism and erosion and the bite has collapsed. After training on FGTP, these alterations from the norm — even if they are subtle — should be obvious.

Asking patients the right questions

The biggest challenge for me is creating a desire to change — I have always found it difficult to sell ugly. I find it even harder to sell chewing. What has been significantly easier for me is to sell health and wellness.

My hygienist or myself will say, “The damage to your teeth is interesting. It is caused by a combination of reflux and grinding. The newest research is showing us that both of those events can be caused by a poor airway at night when you sleep.” Then I ask either, “How long has your partner complained about your snoring?” or “How do you sleep?”.

I let them answer and then invite them to do a complimentary sleep breathing screening and comprehensive examination of their teeth as it relates to their overall health. We send them home that night with a pulse oximeter that they should wear for 2 nights and return it to us so that it is available for other patients. In lieu of a pulse oximeter, I have used online sleep apps, Fitbit, Apple Watch, or the book “Sleep Interrupted” by Dr. Steven Park. I ask them to read the first two chapters and the additional chapter that is linked to a sign or symptom that they presented with.

The next visit is a comprehensive exam followed by a visual tour of their mouths ending with an outline of possible treatment options. Serendipitously, the esthetic and functional challenges that we face with many of our rehabilitation patients are the same structural issues causing the airway problem. By fixing the smile and bite, we may make our patients healthier.

In conclusion, comprehensive, complex treatment plans are difficult to formulate in the few minutes that a hygiene check allows. Even if you could figure out what to do, there is little to no co-discovery by the patient to generate a desire to proceed. They also have heard from their previous office that they are fine and that they just need a cleaning in 6 months. Why should they believe you?

Airway creates a backdoor for practitioners to get to do more dentistry. People want to be healthier. Everyone wants an improvement in quality and quantity of sleep. If those goals can be linked to their smile and bite, we have their attention.


Jeffrey Rouse, D.D.S., is a member of Spear Resident Faculty.