Working in Dental Practices

The Working Day in a Dental Practice (Points of Stress and Advice on How to Manage):

Developing your dental career and working in a dental practice can be both stressful and rewarding. Our aim for you is to have the balance-scale weighted towards the latter.

Here are some common points of stress and advice on how to deal with them:

• Patients are often anxious, nervous or scared: Explaining the procedures to them in a gentle and reassuring manner will help, but will not work for all patients and referral to a sedation clinic or hospital may be needed. Clinical dental procedures require the highest level of precision and accuracy and sudden movements from the patient must always be considered and prepared for. Patients who are very scared can move in ways which are unexpected and sudden. Always have a finger and/or palm rest on the patients' jaw, cheek-bone or tooth so that you can stabilise instruments and hand-pieces while also being able to detect and react to any movement immediately. Nurses can rest the aspirator tips on patients teeth but should never rest it on their gum. Nurses should not be offended if the clinician temporarily takes control of the aspirator tip...the clinician may need to suction the vestibule on the left side which is impossible for the nurse to see or may need to retract the tongue or cheek was is very difficult for the nurse to do. Nurses who are able to use both hands (in order to achieve "four-handed dentistry") can significantly improve their team-work with the clinician.

• Patients can be mistrusting or suspicious of clinical opinion or diagnosis: Unfortunately, some patients will not be trusting of what a health professional says and they are free to refuse or ignore the advice given to them. It is important to document refusal of any advised treatments in your notes. 

• Patients complaining that the cleaning done by a dentist or hygienists makes their teeth and gums worse: There is NO situation where keeping something dirty would be a good decision or a solution to a problem. The reason why people get bleeding and pain when getting their teeth cleaned at a dental practice is because their oral hygiene needs to be improved and their gums are infected and tender to touch and pulling away from the teeth which is exposing the more sensitive dentine on the root surface underneath the enamel. The tartar that builds up on the  teeth (especially on the gum-line and between the teeth) acts as a coat and covers these sensitive root surfaces. This does not however mean that you should leave this tartar on your teeth as it is the very reason why your gums have receded in the first place. People that get pain and bleeding when they brush their gum-line then avoid brushing that area altogether under the flawed assumption that they must be doing something wrong. This then allows the problem to worsen. Plaque (the accumulation of bacteria/germs held together in a biofilm) builds up on teeth hour by hour and if left for even a day or two the calcium in the saliva will calcify (harden) it to the point where it can no longer be brushed off and a professional cleaning will be needed by a dentist or hygienist. Patients must accept the bleeding and slight discomfort (which can be helped by providing anaesthetic, but this introduces its own type of discomfort) and subsequent sensitivity as this will be temporary and will only last a few days. This can be improved by the patient applying toothpaste on the root surfaces each night and leaving it there while they are sleeping. Unfortunately, the gum and bone loss which results from gum disease is irreversible, but can be stabilised. However, without the dentist/hygienist cleaning every 3-6 months and the patient's improved daily brushing and interdental cleaning (demonstrated by the dentist/hygienist) they are guaranteed eventual loss of these affected teeth.

• Patients can be rude or overly-demanding: Patient's attitudes and expectations must be reined in. This is easier said than done and dealing with such patients can be one of the most demanding aspects of the job. We all deserve to be treated with respect and understanding. Having a supportive manager/principal is vital in dealing with such patients in the long-term.

• The workload can seem overwhelming: Ultimately, it is the clinician's decision as to how long they want for their appointments and how much work can be done on a patient at any given appointment. No one else should be able to override this decision.

• Running late: Time-management by the clinician and allowing enough time for each patient and between patients, including not taking on too much non-urgent treatment in a single visit, is essential to keeping on-time throughout the day. This will keep the majority of your patients, nurse and receptionists happier and reduce your own stress levels throughout the day. 

• Standing or maintaining an uncomfortable position for prolonged periods of time: Nurses should always sit down during treatments on a chair that can be adequately raised high with an arm rest available. Dentists should practice a straight back and neck posture. Dental loops can help magnification and aid in maintaining this posture without affecting visibility. 

• Treatments failing: This improves with experience and training. Root Canal Treatments on molar teeth that have been heavily filled for many years (older adults) are some of the most difficult for success-rates and patients should warned that best efforts will be made, but there is no guarantee of success and patients can be referred to Private Specialist Endodontists. There are also NHS options for referral, but acceptance rates are variable. 

• Difficult Extractions: Being able to extract RCT'd, brittle and heavily restored teeth which are firm in the mouth with strong bone support takes experience. I always try to avoid Surgical Extractions as the Buccal/Labial Bone Removal will never fully regrow and healing time is much more prolonged. Instead, Segmentation of Molar Roots and using a Surgical Bur to remove a small amount of surrounding bone while still keeping the cortical bone and use of Elevators often avoids the need for Surgical approaches. Loose Root Fragments deep in the jaw bone can sometimes be removed with a K-flex file screwed into the canal, rather than using Elevators which will cause more bone compression and prolong healing-time and increase post-operative pain. 

• Difficult Diagnosis: Some problems can be associated with Atypical Pain, TMJ Dysfunction, MyoFacial Pain, Stress, non-Dental or Systemic problems. These patients often need referral to a Dental Hospital if your efforts have not significantly improved the patient's symptoms. Do not be tempted to jump into RCTs or Extractions if things do not seem to add up for you...treatments started too hastily can end up with the patient feeling no relief (and sometimes feeling worse) and having unnecessary treatment done or even loss of sound teeth.

• How to improve the service for patients?: In addition to improving your clinical and communication skills, it is important to keep comprehensive notes of each of your appointments with your patients and what is discussed as well as what is done. This includes Oral Hygiene Instruction (OHI) provided, Basic Periodontal Examination (BPE) and Periodontal Status, Tobacco/Paan use and Alcohol consumption and associated Oral Cancer Risk (OCR) assessment, their Medical History (MH) and General Medical Practitioner (GMP) details, Dental History (DH) and Social History (SH). Using a Template for your Examinations can help to remind you to include these details. Having clear and concise notes is essential as you will not be able to remember all details about each and every patient. This means initially having to look through all the notes and X-rays, including those from previous dentists at the practice, and bringing everything together in an accurate summary, which may need updating from one examination to the next, but ultimately it will save you time in the long-run. Before the patient enters the surgery you can quickly view the notes from the most recent Examination and course of treatment to remind yourself of what has been happening with the patient dentally, medically and personally. This will greatly improve your relationship with your patients and allow you to provide them the best continuity of care. It will also protect you against possible future cases of litigation. 

• How can I get my patients dentition to stabilise? Dentists can often concentrate too much on treatment and not spend enough time on prevention. Time must be taken to explain to patients how to keep their teeth clean and why it is important. Why is it important to brush in the morning? Brushing is not just removing food from your mouth, it also serves to remove plaque which builds up on an hour to hour basis irrespective of whether or not you have eaten. This plaque is made worse by the dry mouth conditions present when you are asleep. This plaque causes gum disease and softens your teeth, making them more liable to pick up staining, fracture, wear away or become decayed in the presence of carbohydrates. In the absence of plaque, carbohydrates by themselves would not cause tooth decay. Why is it important to brush before going to sleep? The build up of plaque and food must be removed before you go to sleep, otherwise the dry conditions present when you are asleep will leave the plaque to run rampant and feast on the carbohydrates present in the food debris still in your mouth. Should I rinse my mouth after brushing? There is a lot of advice from reputable sources stating that you should not rinse after brushing. However, I would advise you to rinse after brushing and flossing as you will find that dislodged pieces of food debris and plaque will come out with rinsing. The advice comes from the benefit you gain from leaving a thin layer of toothpaste on your teeth while you sleep, but you can have a similar and better effect by reapplying a small amount of toothpaste back on your teeth (especially the root surfaces along the gum-line) after you have rinsed. Any excessive toothpaste can be spat out to leave a thin coating still on your teeth. Should I brush my tongue? In healthy individuals the saliva normally washes away any buildup on the tongue, but there is no harm in brushing your tongue and for those in poor health or who suffer from dry mouth there is a benefit to brushing the tongue. Be careful not to go too far back as this will make you retch. Flossing or use of Tepe brushes needs to be done at least nightly and patients must be shown the proper technique so as not to damage their gum. 

• Constant learning and CPD: As you move through your career you will instinctively pick up on parts of your work that you need to improve upon. This continuous self-development will make you better and happier at your workplace. Some of these changes can be done by just making small adjustments to how you do things and finding more effective techniques for overcoming reoccurring problems. Other learning may need the advice of colleagues or extra training. There are now many online CPD resources which are both economical and allow you to study in your own time. 

• Health concerns about daily exposure to blood, saliva, potentially harmful substances and radiation: It is mandatory for clinical staff working in the surgeries to be vaccinated against Hepatitis B. Nurses need to follow correct cross-infection control, disinfection and sterilisation procedures. Dentists need to follow good Hand Hygiene protocols, As Low As Reasonably Possible (ALARP) guidelines and be responsible for the disposal of sharps. Employers and Managers need to adhere to the Health and Safety at Work Act, the Regulations for the Management of Health and Safety at Work, the principles of the Control of Substances Hazardous to Health (COSHH), Ionising Radiations (IRR), Ionising Radiation Medical Exposure (IR(ME)R), Personal Protective Equipment at Work, Sharp Instruments in Healthcare, Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR), Fire Precaution, the General Dental Council (GDC) Standards and those from the Care Quality Commission (CQC). In daily practice, it is the nurse and dentist who implement these requirements. This includes frequent cleaning, disinfection and sterilisation, hand washing and understanding the differences between clinical and general waste, disposing of all sharps and anaesthetic cartridges in the sharps bin and unused amalgam and those from extracted teeth in the sealed amalgam pot. As a result of all these safeguards and precautions, staff and patients are extremely safe in dental practice settings and coming to any harm in a dental practice from blood, saliva, harmful substances or radiation remains exceedingly low and cases are few and far between. The employer also has responsibilities outside of the workplace and must adhere to the Environmental Protection Act and Special Waste and Hazardous Waste Regulations.

• Treating elderly patients or those in poor health: Certain patients must be referred to Hospital for Invasive procedures such as Extractions, including Organ Transplant patients and Cancer patients actively receiving treatment. You must also be vigilant to check if patients are taking Immunosuppressant Medications for autoimmune conditions such as Inflammatory Bowel Disease (Crohns’ disease or Ulcerative Colitis), Osteoporosis, Psoriasis, Psoriatic Arthritis, Rheumatoid Arthritis and Lupus. Many patients do not know the names of all their medications and do not carry a list around with them (although this should be recommended to them) or mispronounce the names of their medications or remember only the brand name and not the empirical name. They may also not understand or remember their diagnoses. When in doubt always get them to call back with a full list of their medications and double-check any unfamiliar medications before proceeding. Medications to be wary of include long-term Prednisolone, Tacrolimus, Sirolimus, Azathioprine, Cyclosporine, Methotrexate, Bisphosphonates (such as Alendronic Acid and Risedronate), Rituximab, Infliximab, Adalimumab Ustekinumab, Secukinumab, Tofacitinib and Etanercept. These patients are at increased risk of post-extraction complications such as Osteonecrosis and are better referred to a Hospital setting. If this is not possible, such as occasions when urgent treatment is needed for acute pain, patients can have Pulpectomies or RCT's done until they can get to see the Hospital. If patients insist on invasive treatment within the dental practice it would be prudent to contact the Dental Hospital Clinicians or Consultants for clarification of the updated guidance for the treatment of such patients. Some patients are in poor health, but can still have Invasive treatments such as Extractions within the dental practice, but this must be done for only 1 or 2 teeth in a single visit and further time allowed between appointments for proper healing. Such patients include the elderly and frail who do not have the conditions listed above, those on blood thinners (such as Heparin, Apixaban, Rivaroxaban, Clopidogrel or Aspirin and even Warfarin...which has become less popular in recent years...if INR has been stable between 2.5-3.5) and those with uncontrolled High BP or uncontrolled Diabetes. If teeth become mobile and there is significant swelling in the absence of significant periodontal disease or bone loss you should be wary of the fact that there may be some other underlying cause. These patients should be referred to the Dental Hospital for definitive diagnosis rather than having teeth extracted within the dental practice. Cleanings, Fillings and RCTs are not considered invasive procedures and can be done on all patients in a dental practice setting.

• Treating pregnant women: Local Anaesthetic and X-rays are to be avoided unless absolutely necessary during Pregnancy, particularly during the first trimester. If treatment is needed to relieve severe pain, Lidocaine LA can be provided for Extirpations and permanent treatment delayed until after pregnancy. Amoxicillin would be a safe antibiotic to prescribe, unless the patient is allergic to this. 

• Concerns regarding the prescribing of antibiotics and medicines: The most common antibiotics to be prescribed by dentists is Amoxicillin, Metronidazole and Erythromycin. Care should be taken with Allergies, where Amoxicillin is the most common. Note that Amoxicillin can also interfere with the Oral Contraceptive Pill. Metronidazole is great when used in combination with Amoxicillin for Abscesses, but is to be avoided for pregnant or breast-feeding women and for anybody on Warfarin. Alcohol cannot be consumed when taking it. Erythromycin is an alternative to Amoxicillin, but is to avoided with patients on Simvastatin (although this has also become less common in the last few years). Miconazole is also to be avoided with patients on Warfarin. Difflam is an anaesthetic, but clove seeds or oil applied locally is also a good natural remedy. Duraphat is effective for patients suffering from sensitive root surfaces, but re-applying normal toothpaste over the root surfaces after brushing, flossing and rinsing and leaving it there overnight is also an effective remedy. 

• Communication issues between team members within a dental practice: This can be a difficult problem to overcome and may take time and effort to build and improve relationships. Working together in a stressful setting can bring out the best or worst in us all. Issues are better dealt with directly between the individuals involved. Only when continued attempts to remedy the situation have failed should the Manager then become involved. Ultimately, the Manager and Principal have control over the running of the dental practice and if you remain unhappy despite your best attempts and compromise, it may be the deciding factor in whether or not you decide to stay or leave that dental practice.

• Dental Receptionists having difficulties with patients and other team members: It is essential that the Receptionists are able to build good relationships with the patients and all team members. Reception should never be giving clinical advice or suggesting what treatments will or will not be happening at any of the appointments as this is down to the individual clinician to discuss with the patient privately. When booking patients as emergencies with other dentists that are not the patient's regular dentist it should be stressed to the patient that treatment cannot be guaranteed and the patient will ultimately need to return to their regular dentist for continuing care and review. 

• There is no Manager: Some practices do not have a manager and it is often up to the receptionists to take on a lot of the burden of management duties. This can be overwhelming, but also a great opportunity to learn and show the employer/principal that you are the right person to take on the position of a manager. Indeed many dental practice managers used to be receptionists! However, you cannot count on this happening as some employers/principals will never want a specified manager. 

• Practice Managers dealing with difficulties between clinicians and patients and amongst staff members: The Practice Manager must listen to all sides of the situation first before making their judgement and be able to resolve an issue in everybody's best interests. 

Why Do Associates and Employees Stay in a Dental Practice Where They Are Unhappy?

There can be several reasons why someone might choose to continue working in an unhappy workplace:

• We all have bills to pay and rely upon the income and benefits our job provides us. This makes it difficult to leave a place of work without a suitable alternative. 

• Candidates may wrongly believe that opportunities elsewhere are scarce or not aligned with their skills and experience levels and so are apprehensive to make the move. 

• Fear of the unknown, resistance to change and preferring the comfort of routine could keep them in a familiar but unsatisfying environment. 

• Personal obligations or commitments and family, societal, or cultural expectations could make it challenging to transition to a new workplace. 

• They might endure the current situation believing that it might improve over time, either through internal changes or personal growth or that it might eventually lead to career advancement or better opportunities. 

• Low self-esteem or self-doubt can also prevent them from seeking better options. 

Is Working in a Dental Practice Rewarding?

Working in the dental profession is an extremely rewarding and satisfying career for the vast majority of our colleagues:

• Dental practices, their associates and staff all contribute towards helping patients improve their oral and general health, self-confidence, relieving them of pain and discomfort and improving their biting/chewing function, allowing them to enjoy their food and live their life to the best. Our primary goal is to help others, and this by itself is incredibly rewarding and important. 

• Having patients be thankful and show their appreciation and being able to see that our contribution has improved their quality-of-life is a great joy. 

• We have a better chance of forming meaningful long-term relationships with our patients, more than any other healthcare provider. 

• Our patients span the whole gamut of diversity in our communities and in any given day you can attend to the needs of a family with six or more children, a professor of a university, a curator of a museum, a doctor of a medical practice, a nurse from the Intensive Care Unit of a Hospital, a specialist firearms officer, a fireman, a business owner of a start-up company or one with decades of experience, a budding actress or an established celebrity. We are in a privileged position to be able to speak with so many different types of people. This diversity keeps our conversations and our minds lively, interested and knowledgeable. 

• We work closely with our team members, always trying to improve the service to our patients, which fosters a sense of camaraderie and collaboration. 

• We use a wide array of equipment in our workplace and have a broad spectrum of experience, effectively working as mini-hospitals. We can perform surgical procedures with the patient fully conscious. If working in a sedation clinic we can also get to work alongside an Anaesthetist to perform treatments under IV Sedation. 

• We develop amazing dexterity and hand-to-eye co-ordination skills and our work involves artistic expression when we replicate the morphology and appearance of teeth, blending it in with the patients natural dentition while having health and function as our guiding principles. 

• We learn to read psychological cues and become experts in diagnosis. 

• Career growth for GDPs in dental practice is not just about learning how to place Implants or provide clear-aligner Orthodontic treatment or even to study for a Specialisation, it can be as simple as improving and expanding upon the services that are already within their remit by improving techniques and procedures to yield better results. 

• The GDP must be a Jack-of-all-trades including providing Fillings, Splinting in Emergencies, Root Canal Treatments (RCTs), Pulpectomies, Extractions, De-Coronation, Surgical Extractions, Crowns, Bridges, Dentures, Gingivectomies, Frenectomies and Surgical Exposures. The variety of services provided keeps the work interesting. 

• For Nurses, working with different Dentists and Specialists is a great learning curve and valuable in their career progression.

• For Receptionists and Managers, finding that perfect balance of how to communicate with patients and work with team members is pivotal to improving the dynamics and morale in the practice. 

• Job security is great in the dental profession. There will always be a demand for our experience and expertise, not just throughout the UK but in all countries around the world.  

• We work with different Specialists and colleagues with different experiences and can liaise and learn from them. 

• We have the opportunity to mentor newer colleagues, helping us to build upon our skills and assets and make a lasting impact on fellow workers. 

• We can develop close and long-lasting relationships with our colleagues. This is particularly so with the relationship between a clinician and their dental nurse or amongst receptionists as they work shoulder-to-shoulder with each other throughout the day. 

• Many members of staff and associates work part-time so that they can achieve a better work-life balance. 

• Dental careers often come with competitive salaries and benefits, in recognition for the valuable services we provide. 

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