The Q- Appointment System: When The Next Appointment is Three Months Away. Dr. James B. Quartey Dental Director Gonzales Community Dental Center 228 St. George Street Gonzales, Texas 78629

Objectives To design an appointment system that takes medical and other “special needs” into consideration when making appointments. Participants will be able to describe the “Q” appointment system. Participants will be able to identify the advantages and disadvantages of the “Q” appointment system. Participants will be able to design and utilize the “Q” appointment system in their practices.

“Q” Appointments: Q is for Quality It is not uncommon for the next available appointment to be three to six months away at community and migrant health centers. This creates a problem for the conscientious dentist or hygienist who knows the optimal treatment for a particular patient will be to see that patient within a month or less. The present appointment system at most community health centers (CHC) is determined by “administration” (i.e., the receptionist gives appointments on a first come first serve basis). Whereas “administrative appointment” system works well in private practice and at CHC’s where appointments are available within a month, they do not serve the patient or the provider well when the next available appointment is routinely a month or more away. The “Q” appointment system is an attempt to correct this problem by reserving one day per week or one week per month, to be filled by the provider based on their patients’ special needs.

SPECIAL NEEDS Cancer Patients Other Major Surgery Candidates Root Canal – early is better Pregnant Women – oral health & pre-term Rampant Caries [or Caries in 3-4 Q] Abscessed Tooth [Antibiotic Resistance] Others (insurance? Travel? Wedding?...)

Standards or Expectation? “The optimum waiting period between appointments or to get a new patient appointment would be less than 6-8 weeks. Emergency patients should be see within 24 hours.” Dr. Jay R. Anderson, Chief Dental Officer, Clinical Quality Improvement Branch, BPHC, HRSA

“Practically speaking, not every patient can get a permanent restoration the day of the RCT. I recommend to patients to get a permanent restoration ASAP, but I feel somewhat comfortable if they have to wait a month.” Dr. Ken Tilashalski, Professor, Department of Diagnostic Sciences, School of Dentistry, University of Alabama at Birmingham

The last day of the week or the last week of every month will be reserved for specific appointments authorized by the dentist. This is to allow the dentist to bring back those patients that had been seen earlier in the month and need follow up appointments as soon as possible. If these slots are not filled up a week before the date, then they revert to “administrative appointment” slots and the receptionist will fill them up “as usual”.

These reserved appointment dates may be used for root canal therapy, surgical extraction, and patients who have several decayed teeth or urgent needs (e.g., extractions before surgery; children, diabetics or pregnant women with abscessed teeth).

It may also be used as a “buffer” to re- schedule patients who have to be cancelled for unforeseen reasons such as a provider calling in sick, employee meetings, or incremental weather, etc.

Patients who have waited three months for an appointment and are cancelled and re- schedule for another appointment three months away may forget the appointment or become discouraged from seeking routine dental care and resort to visiting the dentist only for emergency care.

How it works 1.Each dentist is given a “blank” appointment form on the 15th of preceding month to fill up and give to the receptionist on the 15th of the following month. The blank appointment form already has the time slots printed on it, and three columns for the patient’s name, chart number and type of appointment/treatment.

2. On the 15th of the month, the receptionist collects the completed forms and enters the appointments in the computer. The receptionist fills up any empty slots. [works best for clinic sites with 2 or more dentists.]

3. To avoid any confusion, those dates should be blocked until opened up by the assigned/authorized receptionist. Only one person, per clinic site, should be assigned/authorized to enter these completed forms and open up the blocked slots. After the slots are open, any other person may fill them up.

NOTE: Toothache (TA) and exam slots will still be filled by the receptionist and not by the dentist/hygienist.

Advantages: 1. Persons who need immediate attention, per the dentist’s clinical judgment, do not have to wait for months for the next available appointment [e.g. Need dental treatment before major surgery; have rampant caries and need to be stabilized; patient with cellulites; need RCT; diabetic and/or pregnant patients; need pulp cap].

2. If for any reason, a dentist cannot show up for work or the clinic has to be closed, patients can be rescheduled within a month. 3.Fewer dissatisfied patients.

4. Fewer broken appointments. The closer the appointment the less likely for patients to forget about it. [About one-fourth of appointments will be in a month or less.]

5.Reduces the disease prevalence/germ load (i.e. number of persons with untreated decayed teeth). Since dental caries and periodontal disease are transmittable diseases, this will reduce the number of “carriers” and benefit the community(?).

6.More treatment plans will be completed and at a faster pace (especially for RCT patients). 7.Greater job satisfaction for providers. [Have some direct control over appointments and see more treatment plans completed.]

Disadvantages: 1.Will take longer to get a routine appointment, since open appointments will be reduced. (However, the proportion will not be equal to the number of reduced slots, since some of these patients will be receiving the reserved appointments.) 2.Some dissatisfied patients, because of longer wait for routine appointments.

Software Requirement: A computer system that allows the dental director or an assigned/authorized receptionist to block out the last or first week of every month, and open those appointments as needed.

SIZE MATTERS 1 dentist-clinic – “Q” system a must 2 dentists-clinic – should have system 3 dentists-clinic – may have system 4 dentists-clinic – “Q” not needed, but …

Conclusion: The Q- Appointment System allows the provider to determine which patient has a medical necessity to override administrative appointments. It also provides a buffer for unforeseen circumstances such as absence of the provider for any reason or incremental weather.

Root Canals Torabinejad, Ung & Kettering JOE 1990;16: used root canals obturated with lateral compaction and placed a bacterial mixture over the exposed gutta percha (to simulate bacteria in saliva on a tooth with no restoration). They reported complete bacterial penetration (Staph epidermidis) to the apex in 19 days in 50% of the cases.