Readers' Forum

To submit letters to the editor, send to: RDH, P.O. Box 3408, Tulsa, OK 74101; [email protected]; or (918) 831-9804 (fax).

Dear RDH:
First I'd like to compliment the editors and staff at RDH magazine for always presenting up-to-date articles and information that are vital to our profession. My colleagues and I always look forward to receiving the next issue.

I must confess, however, that my colleagues and I were a bit dissapointed and stunned by the cover feature on the August 2008 issue. We were not sure what RDH was promoting, for the both background and motif were of Las Vegas and the model depicted was not presented in a professional matter. Until we read the feature page in regards to the model, it appeared that a casino worker or a show girl was posing.

My colleagues and I feel that the angle of the shot and the attire of the dental hygienist was depicted in typical Las Vegas fashion and did not represent the type of professionalism that our profession demands to ensure trust of our public. Perhaps the dental hygienist could have been counseled on her attire at the time of the photo shoot? Or the photo could have been cropped at the shoulders. Either way, we feel that it was in poor taste and lack of judgment to allow this photo to be published on the cover of RDH magazine.
Janet Witt, RDH
Worcester, Massachusetts

Editor's Note: We received several other concerns about the August 2008 cover that were either posted at www.rdhmag.com or did not follow the protocol necessary to be considered as a letter to the editor. So, even though those other comments do not appear here, we know Ms. Witt was not alone with her opinion. We thank everyone for taking the time to contact us about their concerns; it certainly is not our intent to offend dental hygienists with the attire or poses chosen for the cover of RDH.

Dear RDH:

Thank you for sharing Robbie Lerma's (July 2008) adventures with Mercy ships. I found the contrast between her compassionate, caring attitude, and Dr. David Boag's grim and inflexible treatment of patients quite interesting. Dr Boag (May 2008) lacks an essential part of patient care; empathy and compassion. He might do better as a neurosurgeon, where patients don't have many options. Denying patients any level of care because they can't afford or don't want the absolute premium level is showing a lack of humanity. Blaming it on his malpractice carrier sounds fishy; what's the purpose of paying for malpractice coverage if they won't cover you when you are doing standard or above level dentistry? Maybe he should do a trip with Mercy Ships to get some perspective.

Kudos to Robbie and her husband, and to all the others who volunteer their time and money to serve those without access to dental treatment.
Heather Donesky, RDH
Nevada City, California

Dear RDH:

As a dental hygienist and avid reader of RDH, I always enjoy and benefit from Dianne Glasscoe-Watterson's "Staff Rx" column. However, as an animal rescue volunteer, I was pleasantly surprised to see Dianne's analogy of overscheduling and puppy mills in the July issue. Aside from the fact that she was accurate in her comparison, I appreciate the opportunity she took to briefly educate our profession about the cruel practice of puppy mills.

Fortunately, I do not work in a "prophy mill" but seeing the parallel of dental hygiene and animal welfare — two subjects so near and dear to me — was my inspiration for writing. Thanks, Dianne, for helping spread the word.
Sarah Strain, RDH
Indianapolis, Indiana

Dear RDH:
The Staff Rx column titled "Supervised Neglect" has inspired me to reply as no other letter or column has done before. Let me begin by stating that I worked in the group health and dental industry for 20 years before entering dental hygiene, and that I've worked in hygiene for 14 years, in DMO, PPO and fee-for-service practices, so I feel uniquely qualified to respond.

The letter writer said, "The doctor accepts capitation plans, which means she gets money from insurance companies whether she does any dentistry or not. (and) ...I'm not sure how capitation affects the dentistry...".

You're not sure how capitation affects the dentistry? Why not? Why would you take a job in an office that accepts capitation if you didn't know what it was, or how it affects dentistry — or hygiene? For that matter, why would you take a job without asking your potential employer what his or her soft tissue management program was, what your decision making ability was, to what degree you would be able to initiate treatment planning, how long the appointments were, and why the position was open? If your only criteria for accepting a job is that they pay you, then you have only yourself to blame if the position is not a good fit.

But getting back to capitation. Glasscoe-Watterson said, "Capitation plans pay doctors a set amount of money per month to see covered patients, and ... doctors are supposed to provide whatever dentistry is needed by the patients. Doctors who sign on get the capitation payment whether they see one or one hundred capitation patients. In that regard, it seems like a disincentive to treat, in my opinion." Then she goes on to quote an article in the British Dental Journal. The United Kingdom has nationalized health and dental care, and capitation payment to a British dentist is a completely different thing than capitation payment to a United States dentist.

In the United Kingdom, the capitation payment is their salary. They get the same salary if they do a good job or a bad job. They get the same salary if they fill teeth, do root canals, or extract the teeth. They get a raise in salary only when they accept more patients into their practice, but they must demonstrate an ability to treat all the patients they accept, so they must do some kind of dentistry yearly on the patients they are assigned, in order to keep the patients. So clearly, in this system there is no incentive to do more work, or better work, or time consuming, cutting edge work. There is only incentive to add more patients. By the way, this is how nationalized health care works also.

In the United States, it is true that the capitation plans pay doctors a set amount of money per month to see covered patients. That amount is from $2 to approximately $5 per patient per month. A vast sum, as anyone can see, and clearly designed to cover "...whatever dentistry is needed by the patient." Not.

In addition to the "cap," the doctor also gets a copay from the patient on some procedures (paltry, to be sure, in some cases), and can also negotiate additional payments from the insurance company for major work, as opposed to preventative or routine work. It behooves the hygienist to know the definition of preventative, routine, and major, just as the front desk or insurance person knows. Also, the doctor is not "...supposed to provide whatever dentistry is needed by the patient..." The doctor is provided criteria, by each plan, for referring patients to specialists — endodontists, periodontists, orthodontists and pedodontists. In many cases, that criteria is very lenient. The specialists that are on the "cap" plans are paid a larger benefit, by both the insurance company and the patient copay, than the general dentist would get for doing the same procedure. So the dentist can refer those procedures out.

The actuarials who design any insurance plan, including the cap plans, design them so the chances are that the insurance company will not lose money over the long run, and over the entire population being insured. That means they are designed to take in more premium than they pay out in benefit. The doctor who accepts a cap plan accepts some of that risk. The doctor bets that not all of the patients who are assigned to his/her office will ever show up, and that not all of them will need a ton of work. The doctor can manage that risk by accepting a reasonable percentage of cap plans into the practice, in addition to PPO and FFS plans (provided of course, that the employers in the area offer different plans to their employees), and referring out difficult, time consuming treatments/patients. The cap plans then generate the doctor a small but regular and dependable monthly income. Kind of like putting your utilities on a budget plan.

As for the letter-writing hygienist...

So, there are no perio chartings on the patients. How many FFS offices have no perio chartings either? You want perio chartings? Do them! Discuss with your doctor her criteria for instituting soft tissue management. At what pocket depth? On how many teeth? If you've never communicated with her, there is a chance that your definition of perio disease and her definition may not be the same. Or she may assume you know the criteria for referring out perio patients, and is expecting you to be doing that, and doing "prophys" just on patients who do not need to be referred out.

You say, "When I told the doctor I could not do a prophy because the patient had overt perio disease, she fired me." Now, did you say, "I refuse to do a prophy on this patient. He has perio disease (because he is bleeding and complaining that I am killing him and there are chunks of tarter that I cannot get off with this butter knife because I have better things to do than sharpen instruments and besides, any pocket over 4 mm is perio disease)!" I would have fired you, too.

Or did you say, "I did a perio charting which shows BOP on all teeth, 5 to 6 mm pockets on all posterior teeth, with generalized 2 to 4 mm recession, resulting in 7+ mm of attachment loss, and furcal involvment. In addition there is fremitus and Class I mobility on all anterior teeth, with both visible and radiographically evident sub-gingival calculus. I suggest we refer this patient out to the periodontist for evaluation and treatment (because charting and explaining disease took the same appointment time, and generated the same copay as a ‘prophy,' and we only get $18 per quad for SRPs)." Since you "sold" the patient on the need for a specialist and you presented the treatment plan to me logically with an understanding of the insurance, I agree.

And let me spend a moment on your statement that "I have witnessed decay on bite-wings that the doctor tells me to watch..." What kind of decay? Decay on the interproximal that has not penetrated through the enamel? Decay spreading in the dentin? A big honkin hole in the tooth? Again, have you ever discussed with your employer her criteria for restoration, or her reasons for "watching" a tooth? Have you introduced your doctor or patients to remineralization products that can stall or repair decay that is not through the enamel? Do you KNOW that there are remineralization products available?

And as for your assertions that you have seen substandard crowns with excessive margins, and that you believe the doctor needs a "...mental health evaluation...", let me say this: I am sure you are the embodiment of Esther Wilkins, and you have never once in your career run late on a patient, left calculus, skipped polishing, not prediagnosed all dental disorders for the doctor, been unable to get a patient numb, or chopped off a papilla during an SRP. But I still think you might want to heed the admonishment, "Let he who is without sin cast the first stone."
Sue Morrison, RDH
Chicago, Illinois

Dear RDH:

I would like to thank you for doing such a great job in the dental hygienist community. Your articles are informative, easy to read, current and useful for any clinical setting.

I am a dental hygienist from California working in a private practice and as a clinical instructor in dental hygiene school. In my office and at school we always follow very strict infection control and OSHA requirements.

The reason for my letter is that, though your magazine is on the front line of research and implementation of new technology, I sometimes notice on your pages pictures that are not very OSHA-compliant. I mean that sometimes I see a picture of a hygienist working on a patient, but not wearing what is required by OSHA regulations, which serve to protect us from possible liability. I know in California we are supposed to wear lab gowns (not coats or uniforms) that cover the lap while seated, have long sleeves with cuffs and a closed collar. The fabric of this gown should be water/splash-resistant (so if any bodily fluids get onto the gown they will not soak through and touch the skin) and antistatic (to protect against the possibility of electric shock that comes from working with X-ray machine and computers).

I know that sometimes what we ought to do and what we actually do are not the same. I just thought, as a magazine that sets an example for all of us, you need to try to be more careful with posting pictures of appropriate gowns. In the April 2008 issue, on page 72 was an article about hygienists using the newest technology (surgical microscope) to perform procedures. The hygienist was pictured wearing a medical uniform instead of the Personal Protective Equipment we are regulated to wear.

I understand that it can go unnoticed by your editors. I think the main reason why I noticed it is because I recently started my own business in producing OSHA-compliant and stylish dental gowns. For a very long time I had to wear ugly, oversized, uncomfortable and stuffy gowns so I decided to produce a better product. It took a long time and I addressed every problem that I faced while wearing other gowns. My website is www.maano.net.

Please, think of this letter as constructive criticism or just a friendly reminder of something which is sometimes forgotten. I agree with the saying, "Strive for excellence — settle for perfection."
Natasha Tufail, RDH
San Jose, California

Dear RDH:

I am writing in response to Connie Sidder's article "What Are We Teaching Our Patients?" in the August issue of RDH magazine. I was quite taken aback when I read that she discouraged young children from flossing, stating that it could "do more harm than good" only stressing that "parents can help if children get food stuck between their teeth."

Daily, in the pediatric practice where I am employed, I encounter interproximal decay in young children that easily could have been avoided by flossing. Often, due to the nature of deciduous teeth, these areas end up needing crowns. When teeth come in contact with one another, in primary dentition or otherwise, flossing becomes a necessity.

While I am not saying that a five-year-old should have the dexterity and skill to adequately floss, I think we should definitely take a different approach to the issue. I believe it is important to familiarize even our youngest patients with the purpose and importance of floss. More importantly, parents need to be informed and instructed on how to implement this step into the daily regimen at home. This should consist of parental assistance during brushing and flossing. If a child feels that food impaction is the only reason to floss, they are greatly misinformed.
Jacqueline Burgess, RDH
Mt. Juliet, Tennessee

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Editor's Clarification

The June 2008 issue published an article titled, "Dental lasers and the dental hygienist." On page 100, the author attempted to define the scope of practice for dental lasers, focusing on states that have a "written policy" in allowing lasers to be used for dental hygiene procedures.

When the article was being written by the author, the information was accurate. However, by the time the article appeared in print, the information was already outdated. The dental profession is still determining policies on dental laser technology in some states. Reader feedback to the above article reminded us that this is a constantly changing and evolving landscape, and it is difficult to keep up with what is permissible on a national basis.

Without question, laser technology is very relevant to dental hygiene practice. RDH magazine strongly recommends that dental hygienists who are interested in incorporating this technology into routine practice to diligently check with their state board. An alternative is to check with representatives of dental manufacturers who are constantly striving to ensure potential customers are prepared to legally step forward into a new chapter of clinical treatment.