Presentation on theme: "THE ODTP PROCESS A Case-Based Overview"— Presentation transcript:
1THE ODTP PROCESS A Case-Based Overview Orientation to the Clinical Practice of General Dentistry, Fall QuarterAlan W. Budenz, MS, DDS, MBA
2Heather – a new patient Screened by faculty September 26, 2005 Designated as a 2nd Year teaching case
3I would like a bridge for my lower front teeth Chief Concern (CC):I would like a bridge for my lower front teeth
4The ODTP Process: Step 1 Preparation Pre-appointment preparationReview chartRead screening and/or treatment notesReview health historyReview radiographsMake notesPlan out the first appointment
5The Pacific Health History Questionnaire Form - Comprehensive - Standardized - Translations
6The Pacific Health History Questionnaire Form Section 1: General QuestionsDesigned to elicit general information about the patient’s health, and whether they have seen a physician recently, are currently in pain, or have had any problems with prior dental treatment.
7The Pacific Health History Questionnaire Form Section 2: Signs and SymptomsFocuses on various signs and symptoms that are indicative of medical problems.Signs = indications of disease that can be observed by the practitioner.Symptoms = problems associated with a disease that are experienced by the patient, but cannot be seen by the practitioner.
8The Pacific Health History Questionnaire Form Section 2: Signs and SymptomsNote: No time frame is specified for any of these signs or symptoms.Determining the relevance of the time frame is the responsibility of the practitioner.
9The Pacific Health History Questionnaire Form Section 3: Specific DiseasesConcentrates on specific diseases which have been previously diagnosed by a physician.All of these diseases have a systemic effect.Therefore, all of these diseases have potential ramifications on dental care delivery.
10The Pacific Health History Questionnaire Form Section 3: Specific DiseasesThe patient’s physiology is compromised by their medical problems, and many dental procedures have a significant physiologic impact.Therefore, the dental procedure may need to be modified to insure patient safety.
11The Pacific Health History Questionnaire Form Section 4: TreatmentsDiscusses medical treatments and prosthetic devices which may have a bearing on dental management of the patient.Decisions regarding dental management depend on the patient’s specific situation and the extent of the treatment and/or resultant outcome.
12The Pacific Health History Questionnaire Form Section 5: Medications and DrugsElicits important information on prescription drugs, over-the-counter medications, natural remedies, and any other drugs the patient might be taking.Documents the extent of any problems noted on other parts of the health history, or possibly problems not identified by the patient.
13The Pacific Health History Questionnaire Form Section 6: Women OnlyElicits specific information relative to women uniquely.Pregnancy and the use of birth control pills are especially pertinent to dental care delivery.
14The Pacific Health History Questionnaire Form Section 7: All PatientsConsists of a catch-all question designed to elicit information the patient feels is appropriate to provide, but which has not been otherwise directly queried.
15The Pacific Health History Questionnaire Form Patients should sign and date the health history after initially completing it.The patient should review, update, and re-sign the form at each recall visit.At start of each appointment, ask “Have there been any changes in your health?” Note response in the treatment record.
16The Health History Form In our clinic, the patient fills out a medical questionnaire when they first register.This must be followed up with a verbal interview by the student doctorTo insure that the patient properly understood the questionsTo ask about and obtain a history about any positive responsesTo insure that a negative response was what the patient intended for certain questions.
18The Health History Interview Form The separate interview sheet provides a location for notation of any significant findings and a description of any dental management considerations.It is best not to alter or make notations on the patient’s Health Questionnaire form.The interview sheet is used to ensure that any positive questionnaire responses are followed up and appropriately documented.
19The Pacific Health History Interview Form Includes 6 questions that need to be verbally asked of every patient: Do you have any…Cardiovascular problems?Infectious diseases?Allergies to medicines (or latex)?Bleeding problems?Take any medications?Other medical problems not asked about?
20The Pacific Health History Interview Form The six areas covered by these questions are extremely important to the dentist and it is appropriate to ask them again to insure that the patient properly understands and correctly answers the questions.Cardiovascular problems?Infectious diseases?Allergies to medicines (or latex)?Bleeding problems?Take any medications?Other medical problems not asked about?
21The Pacific Health History Interview Form Cardiovascular problems?Comprise the bulk of medical problems that require dental management considerations.51% of patients with medical complexities have CV problems with the incidence rapidly increasing with age. (Smeets et al, Preventative Medicine 1998)Heart disease is the leading cause of adult deaths in the U.S.Stroke is the third leading cause of death in adults in the U.S.
22Most specifically, patients should be asked if they have any history of “heart problems or heart murmurs”.If “yes”, questions to ask:When was the problem first diagnosed?Did your doctor ever say you should take antibiotics before dental treatment?Did your doctor ever say you don’t need to take antibiotics before dental treatment?For heart murmurs specifically: Was it termed functional or organic? Is there regurgitation?
23The Pacific Health History Interview Form Infectious diseases?Hepatitis is the most common infectious disease with implications for dental complications.HIV+ and AIDS often produce significant oral and systemic changes.Note: All patients should be treated as though they are infectious, i.e. universal precautions are the standard infection control protocol for all patients, with one exception...
24The Pacific Health History Interview Form Infectious diseases?The one exception...Active tuberculosis requires additional precautions, and these patients should generally be treated only in a hospital isolation facility.
25The Pacific Health History Interview Form Allergies to medicines (or latex)?Patients should be asked about allergies to any medications in general, and specifically about possible allergies to:AntibioticsPain medications, including aspirinNarcoticsLocal anestheticsLatex
26The Pacific Health History Interview Form Hematologic, bleeding problems?Has the patient ever had any bleeding problems or do they bruise easily?Positive responses may be indicative of undiagnosed hematologic disease.Referral to or consultation with the patient’s physician may be indicated.
27The Pacific Health History Interview Form Take any medications?Indicates that the patient’s medical problems are severe enough to require medical treatment.Knowing any medications that the patient may be taking allows the dentist to be alert to possible side effects, toxicity, or drug interactions that may occur during dental care.
28The Pacific Health History Interview Form Take any medications?The increasing use of over-the-counter, natural, and herbal medications and supplements may have a significant impact on the delivery of dental care.Patients often fail to disclose these medications unless specifically asked about them.
29The Pacific Health History Interview Form Other medical problems not asked about?This catch-all question asked in a one-on-one confidential setting may elicit significant information that a patient may be reluctant to write down on a form.May also induce the patient to discuss anxieties and concerns they may have regarding dental treatment.Allows dentists to establish a thoughtful and caring rapport with their patients.
30The ODTP Process: Step 1 Medical History Review “Yes” answer to#3: Hospitalized or serious illness (3yrs)Listed: Lung problemWhat questions do you want to ask?
31The ODTP Process: Step 1 Medical History Review “Yes” answers to#4: Being treated by physicianListed: Anemia, GERDWhat questions do you want to ask?
32The ODTP Process: Step 1 Medical History Review “Yes” answers to#37: Stomach problems, ulcerWhat questions do you want to ask?
33The ODTP Process: Step 1 Medical History Review “Yes” answers to#62: Taking medicationsListed: Warfarin, PrevacidWhat questions do you want to ask?
34The ODTP Process: Step 1 Medical History Review “Yes” answers to#63: TobaccoWhat questions do you want to ask?
35Health History Review From your analysis of the medical history: Is the patient’s medical condition controlled and stabilized under the supervision of a physician?Do you need to make any care delivery accommodations because of the patient’s health status?
36Dental Management of Medically Complex Patients Good sources for information on this subject:From the UOP web site:Protocols for the Dental Management of Medically Complex PatientsProtocols for the Dental Management of Patients with HIV DiseaseLittle, Falace, Miller & Rhodus, Dental Management of the Medically Compromised Patient, 6th Edition, Mosby-Year Book, Inc., 2002 (will get in 2nd Year Student kit)
37The ODTP Process: Step 1 Radiographic Interpretation Patient has brought in an FMX dated 4/20/99. Do we need a new FMX?
38The ODTP Process: Step 1 Radiographic Interpretation Complete a Radiographic Diagnosis Worksheet (available in Radiology)
40All of this should be done BEFORE your first appointment with Heather. The ODTP Process: Step 1All of this should be done BEFORE your first appointment with Heather.The better prepared you are, the smoother and faster the appointment will go, and the better the impression you will make upon the patient.
41The First Appointment: D0150 Initial Oral Examination Greet Heather in the waiting room and introduce yourself. Ask her how she is today. Does she have any tooth pain?Give her a brief overview of what you are going to do during this appointment.
42The First Appointment: D0150 Initial Oral Examination Give her a brief overview of what you are going to do this appointment:“Today I’m going to do a very thorough examination of all of your teeth and gums, and then I’ll be able to discuss with you what dental care you need and what treatment options you have. I particularly want to evaluate your lower front teeth.”
43The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs Review the health history with the patient (MH)Take vital signs (VS)Perform intra- and extraoral exams (EOE & IOE)Take diagnostic casts if needed
44The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs Health History: Ask your questions from your Step 1 review of the completed form and record Heather’s responses to your questions on the Health History Interview Sheet.
45Where do you record this information? The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital SignsWhat is significant in Heather’s health history for safe delivery of dental treatment?Where do you record this information?
46The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs Do you still have questions about Heather’s health?If so, how do you get them answered?
47Physical exam (PE) findings: The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital SignsPhysical exam (PE) findings:VS: BP 105/70 – R, pulse 77 reg.EOE & IOE: all WNL
48What questions do you want to ask? The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital SignsThis is a good time to start gathering a dental and social history of Heather.What questions do you want to ask?
49Dental History: HCC: currently asymptomatic. DH: Last dental appt. for delivery of a maxillary partial denture, June 2000.Has had sporadic dental care most of her life.Perio: “deep cleanings” occasionallyOrtho and Endo : noneOS: #1,3,13,14,16 ext. at UOP in 1999;#4,19,30,32 ext. prior, different timesRestorative: moderate restorations: amalgams, crowns, bridge #29 – 31, maxillary removable partial denture (RPD).
50Social History:Grew up in Ireland, lived in Berlin, moved to Arizona in 1985, moved to LA in 1989, moved to SF in 1998.Parents deceased; 2 sisters, 1 brother living in Ireland.Separated from husband who lives in Arizona with their 19 y.o. son.Lives with 3 roommates in SF.Enjoys reading and furniture restoration.
51The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs After completing Step 2, “present” your patient to the ODTP instructor before proceeding to any invasive examination, i.e. perio probing.Faculty will sign your paperwork and “grade” the steps in the computer.
52The ODTP ProcessUse any waiting time during the ODTP appointment to take clinical photographs of Heather.Basic patient intake photographs for chart record (7)Full frontal faceProfile faceFull frontal teeth occludedRight lateral teeth occludedLeft lateral teeth occludedFull upper archFull lower archAdditional images as needed for unique conditions or needs
53The ODTP Process: Step 3 Periodontal Examination Review x-rays, complete full mouth probing and comprehensive periodontal examinationDiagnose periodontal disease statusPlan periodontal treatment therapyPlan follow-up/maintenance care
54The ODTP Process: Step 3 Periodontal Examination Chart all findings in the computer and on the buff-colored Baseline Clinical Examination form
55The ODTP Process: Step 3 Periodontal Examination Periodontal Findings:Recession: generalized 2 – 4 mm w/ 8 mm #25 facialPockets: generalized 3 – 4 mm w/ localized 5 – 7 mmPlaque index: 1 – 2Mobilities: #23 – 25 Class 2, severe vertical bone lossFurcations: Class I & II on all remaining molars, Class I on #5 & 12
56The ODTP Process: Step 3 Periodontal Examination What is your periodontal diagnosis? Does Heather have active or stabilized disease?Since we have x-rays from 1999 and now from 2005, we can compare bone levels, furcas, and defects.
57The ODTP Process: Step 3 Periodontal Examination What is your periodontal diagnosis?Generalized moderate chronic periodontitis with localized severe chronic periodontitisWhat is the etiology?Moderate generalized bacterial plaque and calculus; heavy smoker and moderate alcohol intake.
58The ODTP Process: Step 3 Periodontal Examination What is Heather’s prognosis?Generally fair as is, good if she quits smoking and improves her oral hygiene; prognosis poor for 23 – 25.Treatment plan: 4 quads root planing, ITE, recall interval to be determined.
59The ODTP Process: Step 4 Oral Hygiene Instruction Full instruction customized to your patient’s individual needs.After completing Steps 3 and 4, “present” your patient to the Perio instructor.Faculty will sign your paperwork and “grade” the steps in the computer.
60The ODTP Process: Step 5 Dental & Occlusal Exam/ Problem Listing Charting of restorations, caries, pathologyOrtho/occlusion screeningCaries risk assessmentList all findings and tentative solutions
61The ODTP Process: Step 5 Dental & Occlusal Exam/ Problem Listing Charting of restorations, caries, pathology: in the computerOrtho/occlusion screening: in the computer and on Orthodontic Screening form
62The ODTP Process: Step 5 Dental & Occlusal Exam/ Problem Listing Caries risk assessment: on Caries Risk Assessment form.What is the patient’s risk level and how will we, the patient and you together, manage their caries risk level?
63The ODTP Process: Step 5 Dental & Occlusal Exam/ Problem Listing List all hard tissue findings and tentative solutions: on ODTP Dental Examination Worksheet in detail.List all restorations: if no problem, write WNL; if problem, describe exactly what it is and where.
67The ODTP Process: Step 5 Dental & Occlusal Exam View of Heather’s right lateral side:
68The ODTP Process: Step 5 Dental & Occlusal Exam View of Heather’s left lateral side:
69The ODTP Process: Step 5 Dental & Occlusal Exam Clinical Findings:#1,3,4,13,14,16,17,19,30,32: missing#2: MO amalgam with mesial recurrent caries at ginigival margin#5: MOD amalgam – WNL#12: PFM crown – WNL#15: FVC crown – WNL#18: PFM crown – WNL#21: DO amalgam – WNL#23, 24, & 25: guarded/poor perio prognosis#28: DO amalgam – WNL#29 – 31: FVC 3-unit bridge – WNL
70The ODTP Process: Step 6 Tentative Treatment Plan Determine the ideal treatment options for the various dental problems found.Determine appropriate alternative treatment choices for the dental problems found.Discuss treatment goals with the patient.
71The ODTP Process: Step 6 Tentative Treatment Plan In Heather’s case, her dental problems are:Moderate generalized periodontitis disease with localized severe diseaseCaries on the Mesial of #2Severe bone loss & mobility #23, 24, & 25What treatment options does she have?
72The ODTP Process: Step 6 Tentative Treatment Plan Moderate to severe periodontitisWhat treatment options does she have?4 quadrants of root planingNo treatmentWhat are the risks, benefits, and alternatives (RBAs) of each option?
73The ODTP Process: Step 6 Tentative Treatment Plan Caries on the Mesial of #2What treatment options does she have?M or MOL amalgamFull veneer crown (FVC)No treatmentWhat are the risks, benefits, and alternatives (RBAs) of each option?
74The ODTP Process: Step 6 Tentative Treatment Plan Severe bone loss & mobility #23 – 25What treatment options does she have?Re-evaluate following perio therapyExtract and replace teeth with…?No treatmentWhat are the risks, benefits, and alternatives (RBAs) of each option?
75The ODTP Process: Step 6 Tentative Treatment Plan After completing your hard tissue examination and formulating a tentative treatment plan, “present” your patient to the ODTP instructor.Discuss findings and treatment options with the instructor and the patient.
76The ODTP Process: Step 6 Tentative Treatment Plan After “presenting”, reviewing, and discussing your findings and treatment options with the ODTP instructor and your patient,The ODTP instructor will decide if specialist consultations are needed.
77The ODTP Process: Step 6 Tentative Treatment Plan After completing your hard tissue examination and formulating a tentative treatment plan with your patient and the ODTP instructor,The faculty will sign your paperwork and “grade” the steps in the computer.
78The ODTP Process: Step 7 Treatment Prioritizing/Contract Prioritize and finalize the treatment plan with the patient and review it with the ODTP instructor.Enter the treatment into the computer in prioritized sequence, print it out and have the patient sign the printout.Have the ODTP instructor clinically approve your treatment plan in the computer.
79The ODTP Process: Step 7 Treatment Prioritizing/Contract For Heather’s case, the priorities are:4 quadrants of root planingM amalgam on #2Re-evaluate perio health for status of #24 & 25. Are these teeth salvageable? If not, what replacement options does she have?
80The ODTP Process: The Final Step At the completion of your appointment, or during “down” times during the appointment,Write up your treatment record.
81Treatment RecordsThe quantity of information gathered from the comprehensive patient examination process can be overwhelming.It is therefore essential to have a systematic method for recording and organizing all of the data.
82Treatment RecordsPaperwork can be viewed as a burden, but it is also a necessary fact of life in every practice.Just do it, and get used to it! (It’s only going to get worse!)Learn how to make the paperwork serve your needs.“The palest ink is stronger than the best memory.”
83Treatment RecordsThe treatment record is perhaps the single most important document in the patient chart.It is essential that every aspect of patient care be fully documented.“If it isn’t written down, it didn’t happen.”
84Treatment Records“The complete record contains a description of the patient’s original condition, your diagnosis and treatment plan, progress notes on the treatment performed and the results of that treatment. It should also contain the patient’s personal data, health history information, and informed consent documentation. The record should be organized logically and in language that is comprehensible to all who use it.”(Dentist’s Guide to Keeping Patient Records: Strategies & Solutions, California Dental Association, 1996)
85Treatment RecordsThe patient treatment record is perhaps the single most important document in the patient chart. It forms a running narrative of the diagnostic process, the treatment plan derivation, the delivery of care, care outcomes, and the patient’s involvement in care.This ongoing record is the practicing dentist’s first reference at every subsequent patient visit.
86Treatment Records“The patient record not only serves as the history of the therapeutic and business relationship between dentist and patient, but also it is the most reliable – and most relied upon – defense against a malpractice allegation. Malpractice allegations remain subjective until they can be substantiated, and sound records are an objective and factual measure of the actual treatment provided.”(Liability Lifeline, TDIC, California Dental Association, 1994)
87Treatment RecordsThe patient treatment record is perhaps the single most important document in the patient chart. It forms a running narrative of the diagnostic process, the treatment plan derivation, the delivery of care, care outcomes, and the patient’s involvement in care.From a legal standpoint the patient treatment record has the greatest credibility, and when properly filled out, offers the best defense against litigation.
88Treatment RecordsDocument all treatment visits by chronological order, what services were performed, details of the procedures including what materials were used, and note any complications.Document all instructions, referrals, and recommendations given to the patient with notation of all RBAs discussed.
89Treatment RecordsDocument the informed consent process and any significant questions and comments made by the patient.Document all patient contacts: appointments, telephone calls, letters, etc.Document all failed and cancelled appointments, late arrivals, etc.
90Treatment Records Ten rules for complete patient records: Use a consistent style and standard abbreviations for all entries to foster your professionalism, and thereby your credibility.Use blue or black ink only – colors do not copy well, and pencil smears and fades over time and can be too easily altered, reducing the credibility of your records.
91Treatment Records Ten rules for complete patient records: Use a single line to cross out errors.Do not use whiteout – not only is it messy, but it may be construed as an effort to conceal information.Date and explain any corrections, making corrections as they happen with the true date of the correction entry.
92Treatment Records Ten rules for complete patient records: Write legibly – an illegible record can lead to inappropriate guesswork and suggests a careless, disorganized attitude.Note discussions of treatment options including the risks, benefits, and alternatives (RBAs) – list all options discussed.A handy abbreviation: DWP = discussed with patient
93Treatment Records Ten rules for complete patient records: Express your honest concerns about patient needs – this reflects an understanding of the patient’s needs and documents that the dentist listened to, noted, and possibly addressed the patient’s expressed needs.Record missed appointments and failure to follow instructions, and record your attempts to educate and change patient behavior. This information can be vital for documenting your due diligence in caring for the patient.
94Treatment Records Ten rules for complete patient records: Never write derogatory remarks in the record – this does not mean you should not record negative information, such as a patient’s failure to follow treatment advice, but record all remarks in a dispassionate and objective manner.Adapted from the June/July 1995 New York State Dental Journal
95Treatment Records The SOAP note entry format A clear, concise, and standardized form for recording all patient information and treatmentForms the basis for analyzing all patient data including treatment outcomesIs a universal format for discussing your patient with physicians or specialty practitioners, and for case reports in the dental/medical literature
96Treatment Records The SOAP note entry format S = Subjective O = ObjectiveA = AssessmentP = Plan/Procedure
97Treatment Records The SOAP note entry format S = Subjective What does the patient tell you?IncludesCC = Chief ConcernHCC = History of Chief ConcernMH = Medical HistoryDH = Dental HistorySH = Social History
98Treatment Records The SOAP note entry format O = Objective What are your observations?IncludesPE/VS = Physical Exam & Vital SignsEOE & IOE = Extra- & Intraoral ExamsSummary of appearance of both soft and hard tissuesRE = Radiographic Exam
99Treatment Records The SOAP note entry format A = Assessment What is your diagnosis?IncludesPeriodontal diagnosisCaries risk assessmentRestorative diagnosisAddresses patient’s chief concern
100Treatment Records The SOAP note entry format P = Plan/Procedure What treatment did you or will you provide?Includes complete notes onTreatment plan discussionProcedures done or plannedInstructions, recommendations, referralsPrescriptionsDWP: RBAs
101The Treatment Record: S.O.A.P. Notes For ALL procedures:First line: the date and procedure code and description
102The Treatment Record: S.O.A.P. Notes For ODTP we use an extended SOAP note:10/3/05 D0150 Initial oral exam(S: Subjective)ID: Patient age, sex, etc.CC: Chief ConcernHCC: History of Chief ConcernMH: Medical HistoryDH: Dental HistorySH: Social History
103The Treatment Record: S.O.A.P. Notes For ODTP we use an extended SOAP note:(O: Objective)PE: Physical Exam (VS, EOE, IOE, TMJ)Perio Dx: Periodontal Exam findingsRE: Radiographic Exam findingsHard Tissue Exam findings
104The Treatment Record: S.O.A.P. Notes For ODTP we use an extended SOAP note:(A: Assessment)Periodontal DiagnosisHard Tissue “Diagnosis”Caries Risk AssessmentMake sure the patient’s CC is addressed!
105The Treatment Record: S.O.A.P. Notes For ODTP we use an extended SOAP note:(P: Plan/Procedure)Includes complete notes onDWP: Treatment plan discussion: RBAs – options and decisionsTreatment plan or procedures doneInstructions, recommendations, referrals, prescriptionsNA or NV: Next Appointment or Visit
106The Treatment Record: S.O.A.P. Notes For restorative appts., etc., use abbreviated SOAP note:(P: Plan/Procedure)Treatment progress notes include:Tooth/region and procedureType, dose, location of anestheticsIsolation techniqueAll materials and medications usedShade, occlusion, lab prescriptionPost-operative instructions givenTreatment outcomes
107Treatment Records Patient privacy (HIPPA) Patient privacy must be respected at all timesCharts must be regarded as confidential, privileged informationPatient’s have entrusted their personal information to usWe, as doctors, are privileged to have access to this confidential patient informationTherefore, we must make every effort to preserve chart, and thereby patient, confidentiality at all times
108Patient Presentation A derivative of the SOAP note format The presentation should be a brief summation of significant findings and history.The SOAP note format helps practitioners to organize their thoughtsAnalyze patient dataFrame in an standard sequence
109Patient Presentation S O A P Example: Mary is a 42 y.o. African-American female with a chief concern to have her teeth cleaned and bleached. She has a medical history significant for hypertension controlled with the beta-adrenergic blocker Propanolol and for use of the antidepressant medication Zoloft.Her initial oral exam was completed Sept. 1, 2005 and her perio treatment of 4 quadrants of root planing was completed on Sept. 15th. Her hypertension is controlled today with blood pressure measured at 134/88 on her right arm, and a strong, regular pulse of 72.Tooth #12 has a distal carious lesion with a good restorative prognosis.Today I’m treating #12 with a DO amalgam. I will minimize the use of vasoconstrictor containing local anesthetic in this patient due to the use of non-specific beta-blocker and CNS depressant medications.SOAP
110The ODTP Process: Points to remember: Yes, the ODTP process is time consuming.A well done examination and treatment plan are the key to successful patient care.
111The ODTP Process: Points to remember: The ODTP appointment is an excellent time to build patient rapport.The better prepared you are, the smoother and faster the appointment will go, and the better the impression you will have upon the patient.