Patient care is number one
Long gone are the days of a ‘dental assistant’ who just aspirates. Being a qualified and confident nurse to assist during implant and surgical work is essential.
Thorough planning and the use of protocols are vital to ensure the smooth and safe running of the appointment. At Botanics Dental Care, where I work, patient care is always the priority, so when it comes to implants, as with any other treatment, the highest standards must be maintained.
I would like to provide a brief overview of the basics involved for the dental nurse during these procedures, training tips and what is expected of the dental nurse.
Pre-operative patient care
Before the patient is in the chair, it is common for them to express their concerns to the dental nurse. Will it hurt? Can I drive today? How do I care for my mouth after? It is during this uncertain time for the patient that a well-trained and compassionate dental nurse can really help ease the patient’s apprehensions. In my experience, this is truly appreciated – somebody taking the time to sit with them and answer their concerns gives all the reassurance they need.
It creates a feeling of security for the patient and shows that their wellbeing is of the utmost importance. We discuss pre and post-op instructions in a non-clinical environment and provide the patient with a written copy. The nurse should be confident in raising all these points with the patient and should have enough time to discuss them.
Taking the time to get to know your patients is very useful, it instils trust and co-operation. Even if you have a patient who has no nerves about the appointment or is used to having the procedure, it is still good practice to have a quick chat with them prior to the appointment to find out how they are. As we are well aware, some patients don’t like to tell you how they are really feeling.
A quick chat and a hello will make the patient feel that their procedure is important and their emotions are being taken into consideration. For the dental team it could be just another appointment in the day, but for the patient it is an event, one that may have required some planning, time off work and considerable investment.
The set up
Well in advance of the appointment, all consent forms, medical histories, implants, healing abutments, augmentation materials and lab work should be checked. If there is any doubt, then this should be clarified prior to the appointment. When first starting out in the world of implants, all of the different components, systems and small items of equipment can seem daunting. Nurses who are new or relatively new to this kind of work should review equipment and procedures prior to the appointment with a more experienced staff member. Creating protocols for every procedure and having a photo set up checklist for instruments and equipment can save time and aid with training. It provides a quick reference for nurses to refer to if they are struggling with the set up.
This provides piece of mind for the nurse and the dentist and minimises the risk of errors.
The stringent nature of the infection control policies means that everything must be standardised and any small error could have a big impact. Placing a dirty, non-sterile pair of gloves on a sterile area could mean a complete new set up process.
There are two different roles for the dental nurse during implant surgery: sterile and non-sterile. Both of these roles are of equal importance, working closely together during the set up to keep things as sterile as possible. This requires practice, communication and training within the team to work effectively.
The idea of surgical asepsis is important to all surgical procedures. Protocols for preparation, sterilisation and correct storage of instruments should be followed at all times. The dental team have to aim to reduce the number of micro-organisms in contact with the surgical site, utilising strict protocols. A surgical hand and forearm scrub should be undertaken by all members of the team. This is a very important step in reducing the risk of infection. Only then should the team don a surgical gown, sterile gloves and hat. All team members in sterile gowns will remain in the sterile zone at all times.
The purpose of surgical hand scrub is to:
- Remove visible debris and micro-organisms from the nails, hands, and forearms
- Reduce the microbial count
- Reduce growth of micro-organisms.
The procedure for the timed five-minute scrub consists of:
- Removal of all jewellery and nail varnish/false nails (rings, watches, bracelets)
- Washing hands and arms with soap. Ensure the correct temperature – excessively hot water is harder on the skin, dries the skin and is too uncomfortable to wash with for the recommended time
- Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for two minutes
- Proceed to scrub the arms, keeping the hand higher than the arm at all times. This prevents bacteria from contaminating the hand
- Wash each side of the arm to the elbow for one minute
- Repeat the process on the other hand and arm, keeping hands above elbows at all times
- Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow
- Finished, hands and arms should be dried using a sterile towel and aseptic technique. You are now ready to don your gown and sterile gloves.
The sterile area will be set up with everything that could possibly be needed for the procedure, including surgical instruments, sterile gauze and extra suction tips (these can easily get blocked when carrying out surgical procedures). The sterile nurse should be providing adequate retraction and moisture control at all times as well as being acutely aware of the areas of the surgery that she can and cannot touch during the procedures.
Another thing to consider is the use of non-latex products. This will benefit the team and the patients as the number of latex sensitivities and allergies is on the increase. It is best practice to aim to be latex free to reduce the chance of an allergic reaction.
All dentists will have their own preferences when it comes to instruments, but below is a basic list of surgical instruments (figure 1).
- Minnesota retractor
- Cat’s paw retractor
- Tissue tweezers
- Needle holders
- Mitchell’s trimmer
- Periosteal elevator (small)
- Periosteal elevator (large)
- Periodontal probe
- Blade handle
- Spencer-Wells forceps.
The use of local decontamination units are making all dental care professionals aware of ‘zoning’ techniques, a useful skill to have when working with implants.
Nurses who are non-sterile are responsible for maintaining the clinical area outwith the sterile zone. This can include changing programme settings on equipment, opening pre-sterilised packets for the sterile nurse, drafting a surgical report for the dentist, recording drill usage charts and keeping a copy of implant labels.
By no means should the non-sterile nurse be considered to have the ‘easy job’. Making the most of the time available and forward thinking should reduce the need for a nurse to be standing waiting and make the appointment more efficient.
For more advanced procedures involving sinus lifts, block grafts or augmentation, there is a whole new set of procedures and equipment to learn. The excellent advanced nurse’s course run by the ADI was very useful for expanding my knowledge and skills in this area. I would urge all team members involved in implant dentistry to join.
Having a practice set of surgical drapes and gowns is a good idea to use for training new staff members and honing the skills of the more experienced team members. Implants may not be an everyday occurrence and having the items to practice with can really help boost confidence on the day.
Useful training tips
- Good planning prior to the appointment – know what to expect and what you need. Be prepared for the unexpected as quite often it happens!
- Create check lists and photo guides to aid set up
- Regular ‘dress rehearsals’ using a spare drape kit and gown
- Reflective learning. After the appointment discuss with the rest of the team how it went, is there anything to be learned from what happened? Did it go well? How can we improve?
- Engage with the patient – possibly have a dedicated nurse for the whole implant journey that the patient can get to know and call if they need advice
- If in any doubt seek advice, don’t be afraid to ask
- Join a professional body, such as the ADI, to keep up to date with protocols and training.
Dental nurses have been granted professional status, which is fantastic for our profession. We have worked hard to get where we are now. I am fortunate to work within a team who fully appreciates the role that a dental nurse plays. I have been lucky enough to have been supported initially by an experienced nurse from another practice who has a wealth of experience on the subject, along with excellent help from implant company reps, dentists and fellow nurses.
Implants may seem daunting to the inexperienced, but they are not something to be feared. There is always the opportunity to learn more and gain more experience and that is what I aim to do. We are now in an environment where patients are much more informed and have a better idea of what is expected from their dental care professionals.
Training and CPD must be at the forefront of everyone’s minds and it is important that dental nurses are aware of the implications and the risk to their GDC registration is they do not follow procedure. It is now essential that we not only have these procedures and protocols in place, but that we are also able to demonstrate that we have followed them for each and every case.
About the author
Tara Crabtree has worked as a dental nurse for six years and qualified with her national certificate in 2010 with a merit pass. She has been involved in implant work since 2009 when joining Botanics Dental Care in the west end of Glasgow, working with Dr Colin Gardner.
After completing several implant training courses and attending the ADI team conference in 2010, Tara decided to join the ADI as a DCP member to keep her knowledge up to date. She recently attended the ADI Advanced Nurse’s Course in Edinburgh.