Reader's Forum

Why school makes a difference

Dear RDH:

I would like to add some personal insight into the problems of preceptorship. I was registered as a dental hygienist in 1985, although my interest in the dental field began many years earlier. I began working as a dental assistant right out of high school in my hometown. After my youngest child started to school, I again worked as an assistant for a small practice for a five-year stretch from 1965 to 1970. Throughout that time, I truly enjoyed dentistry and spent a lot of time studying to be the best assistant I could be.

I was not only the assistant but my work took in all facets of a dental office. I took care of the patient scheduling, billing, some of the lab work, ordering supplies, and keeping the office in order.

In this small town, I was occasionally asked on the street if I would make an appointment for someone, and I would have to remember to do that when I got to the office. To remind myself, I would put my wedding ring on my other finger. My children always thought that was special. During those years, I watched the dentist perform all types of dental work and I leaned over his shoulder so much that I got the idea that I could do many things, for which I had no special training. I am a very dependable employee and take a lot of responsibility for whatever job I do.

In 1983, I was out on my own. Since I was not educated to do anything special, I thought I would go to dental hygiene school. I was surprised and pleased to be accepted into the dental hygiene program at Bee County College in Beeville, Texas. I did not enter the program thinking I knew everything, but I did think I knew something about being a hygienist. That was my first awakening. I knew a little about teeth, but nothing about the detailed work of a hygienist.

The course was very hard, and there were times when I knew I would never be able to complete the program. It really humbled me to come to the realization that, as a dedicated dental assistant I know that part of dentistry, but I had not a clue what it took to know what really went on down in that sulcus area that is our highest interest and responsibility. We learned from each other in the dental hygiene school and learned to work with the patients differently than you would in a private practice setting. There was a lot of teamwork, and we depended on each other in our training.

During the course of my life, I have practiced with several different dentists. From my experience with them, I do not believe they have the time or patience to be a dedicated teacher, at least for what it would take to teach dental hygiene.

Based on my life experiences, I would not recommend that a dental assistant become a dental hygienist through preceptorship. There is no way the assistant could get the quality of education it takes to become a dental hygienist and to serve patients with the quality of care required to fulfill their oral health needs. Unless an assistant goes to an accredited dental hygiene program, she or he would not get the continuous education that would be necessary to practice dental hygiene.

As an assistant for many years and as a hygienist that has practiced as an assistant, I know from experience that one cannot get the consistent training needed from merely watching. For one thing, the dentist has many other responsibilities. It would be nearly impossible to teach hygiene in a way that would give a dental assistant thorough knowledge of what is needed.

I have a friend, whom I have known for years, who was in a class ahead of me in hygiene school. He went on to dental school and is now an oral surgeon in Arizona. He told me as a dental student they had about a week or two of instruction on procedures for scaling teeth. Hygienists have two or more years in preparation for practice. Most patients believe that the dentist knows everything about all phases of dentistry, including periodontics. Dentists know that they have not had the training that a dental hygienist has.

I am currently practicing in a clinic where there are six dentists. Not one of them wants to do the nonsurgical periodontal care. This shows that their knowledge and expertise is limited in this area. With this lack of training, how can they expect to instruct others to become as efficient as a hygienist? The experience gained from working alongside the dentist is valuable, but it cannot replace the dedicated and well-rounded training from specifically qualified educators of oral health in an accredited dental hygiene school.

I have visited with a dentist from Florida who is familiar with the preceptorship program. She thought that many dentists who want preceptor-trained personnel would want to keep them in their specific practices. That might work for that one practice, but who is to know how long one is to stay in a certain place? When the preceptor hygienist moves from that practice, there are serious consequences to face, because one has not received a thorough education in an accredited dental hygiene program.

My insight here is from one who got a late start in dental hygiene, but this profession has taken me places I never thought I would be able to go, or even dream of going. I have traveled from Beeville, Houston, and San Antonio in Texas to Switzerland, Africa, and to north of the Arctic Circle in Kotzebue, Alaska. The dentists I worked with knew I was licensed from an accredited dental hygiene program. I am proud to have a dental hygiene license in Texas, New Mexico, and Alaska.

Wana Milam, RDH
Midland, Texas

The multiple impact of preceptorship

Dear RDH:

A number of very critical issues threaten the continued existence of dental hygiene as a respected and viable health-care profession. An ever-increasing number of hygienists abandon the profession because of physical injuries from cumulative trauma disorders and psychological burnout. But, by far, the most significant issue affecting this profession is the development of preceptorship dental hygiene training.

The health of this nation's unsuspecting and unknowing dental patients is placed at risk when quality educational standards are abandoned in favor of a "quick economic manpower-fix." How can a person that has spent several weekends in a classroom and has been supervised and trained for only one year by a "nondental hygienist" provide the same quality of care as the next candidate, who has taken a minimum of two years of formal and rigorous didactic and clinical training?

Patients trust their doctors to provide quality care, and they also trust that the doctor employs educated licensed personnel. The vast majority of patients are unaware of the extensive training and education of the licensed hygienist. Patients rarely inquire about a dental health-care worker's education or credentials. When confronted with the facts, patients do not want dental hygiene education diluted. If education is our strong point, then surely we have failed to educate our most important potential ally - our patients.

Apathetic hygienists do not believe their employment is at risk, or that preceptorship is a reality. Many hygienists believe that their employer would never consider hiring a less-educated or less-credentialed person to provide so called dental hygiene services. Traditionally educated hygienists in Alabama and Kansas are living through this nightmare day in and day out.

A certain number of dentists view preceptorship as an economic solution to their poor business management skills. If these dentist employers are able to pay an "off-the-street dental health-care worker" half the wages of a professional dental hygienist, educated in a traditional dental hygiene program, they have solved their economic problem.

Preceptoship is an economic issue, an education issue, and an apathy issue.

Anne Nugent Guignon, RDH, MPH
Houston, Texas

Home care instructions

Dear RDH:

Recently, I was made aware of some information which was disturbing to me. I was conversing with my brother on the phone about his prophylaxis. To my amazement, he questioned me about whether or not I floss my client's teeth after a routine prophylaxis. Of course, I replied. My brother said his hygienist never flossed his teeth at the end of the appointment. I started questioning other people about their hygiene appointments and found that seven out of 10 people said their hygienist does not floss their teeth.

As dental professionals, I feel our first priority is to educate and motivate our clients on home care. Although our time is limited, I have found an increase in patient compliance by dedicating some time during each appointment to home care.

I question the client on how many times a day they are brushing and flossing. Surprisingly, some people are only brushing once a day. Most hygienists tell their clients to floss and brush, but if they have never seen their client floss or brush, how do they know if it is being done effectively? I have learned that most clients, if you watch them floss and brush, do not do it effectively.

By demonstrating oral hygiene and watching your clients do this, you can offer some corrective criticism which is very much needed. This is also a good time to recommend a floss aid, a tennis ball, or tape around the brush handle if the client just can not maneuver the floss or the tooth brush.

Clients are usually excited about home care at this point because they realize how dedicated and caring you are. Client's usually say, "Wow! No one ever took the time to show me that." It is important to continue to question the same client at each recare.

I have learned that reviewing oral hygiene once is not enough. If the client is still presenting with plaque and calculus on interproximal and mandibular anterior lingual areas, further oral hygiene is needed. Clients often revert back to their old habits and need more instruction.

In conclusion, if we are telling our client's to brush and floss, do not expect them to do it effectively if they have never been shown how to do it.

Some suggestions:

Ask the client if you can watch them floss and brush.
Time is usually a problem with flossing. Suggest they floss while watching TV, or while sitting and having their morning coffee.
Motivate the client by telling them they will spend less time and money at the dental office.
Tell them it takes time to learn new tasks because you are trying to change years of habits.
Explain that if they do it for a week straight, they won't be able not to do it daily.
Use a mirror to show and explain gingivitis.
Show them how you remove their plaque with a toothbrush in the mirror.

Please take the time to do this. It's worth it and it's our responsibility.

Ava Maria Medellin, RDH
Port Saint Lucie, Florida

Making changes, making a difference

Dear RDH:

I recently read the article titled "Auto Pilot" in the February 2001 issue. I have been in dentistry since 1978, and I have seen many things change over the years. It is just amazing how difficult it can be to get a dentist to make some very small changes in his or her practice. I have been in my current position for 21/2 years. When I arrived the perio charts had not been updated in five to seven years. Everyone I cleaned had a pool of blood.

So I discussed implementing soft-tissue management with my employer, but he was reluctant to allow this to happen. He hadn't heard of this before, and he didn't want his patients to think he was after the money.

So, very slowly, I started implementing this and, within a matter of months, he noticed that his hygiene production was anywhere from $300-$1,000 more per month. Now people were interested in improving their esthetics at the same time. Within the first full year of my employment I had produced $80,000 more than his previous hygienist. He just couldn't believe the difference. Now he even comments that his restorative has improved because he is not trying to keep the area dry.

At the same time this was taking place, I convinced him to bring in an associate to do all of our root canals and extractions, so we did not have to send them out to specialists. So I (the hygienist) found a dentist to hire on a percentage basis, and now he is working two to three days a week.

I have a passion for dentistry and wish I was in dental school. Maybe some day.

Marcia L. Evink, RDH
Grand Rapids, Michigan

RDHAP credentials

Dear RDH:

I was energized to see the article "Beate Gatermann aka Freedom Fighter" in the February 2001 issue. It is truly a happy day when a hygienist elevates the profession, soaring to new heights with the wings of freedom from dentistry and seeing independence as a vision on the path of prevention. However, I am curious to know exactly what credentials are after Gaterman's name on page 50. I was surprised to find her mentioned as RDHAP. My understanding is Registered Dental Hygienist in Alternative Practice (RDHAP) is only designated for a handful of selected RDHs who completed the Health Manpower Pilot Project (HMPP) 139 & 155 in California during the 1980s.

Out of the 45 women in the three classes who graduated, as part of the HMPP's newly created (at the time) postgraduate dental hygiene program taught at California State University-Northridge (CSUN), only 25 of these women became licensed as the official "RDHAPs" in California. Yes, I agree Beate is in alternative practice but RDH magazine cannot arbitrarily just designate her the hard-earned RDHAP credential because she fits the profile. I wonder how many people are aware of these U.S. pioneers breaking ground for the autonomy of oral health in our own nation.

Linda Isis Primus, RDH, MHS
Cheshire, Connecticut

Editor's note: You are correct; we got a little carried away with the alphabet soup. For the record, Gaterman's name is followed with the initials of RDH, SDH.

The evidence behind a shared experience

Dear RDH:

We are writing in regard to an article by Dianne Glasscoe, RDH, BS, published in the October 2000 issue titled, "Going the Extra Mile." First, we want to praise Ms. Glasscoe for demonstrating critical thinking and application of alternative therapies in comprehensive, evidenced-based care. Unfortunately, there are some inaccuracies that need to be addressed.

In the Journal of Periodontology (November 1994) article titled, "Mechanism of Irrigation Effects on Gingivitis," Ms. Glasscoe refers to article in stating that, when used consistently, oral irrigation:

Improves breath
Eliminates gingivitis
Removes toxins from the gingiva
Reduces bacterial concentration.

These statements are not what the investigators concluded about this study, and this is misleading to the reader. First, no measure of breath odor was taken in the study and no statement regarding breath odor is discussed. There is a reduction in inflammation rather than elimination of gingivitis. The only reference to "toxins" is in the opening literature review. This reference annotates a study that suggested that reduction of gingivitis by irrigation may be related to a reduction in specific bacteria within the plaque and/or a reduction in the quantity of toxic products produced by plaque. Finally, while many microorganisms were reduced from baseline, the authors concluded that it was the reduction of the known periodontal pathogen, Prevotella intermedia, that may have had the greatest effect.

Although Ms. Glasscoe states at the beginning that this is a success story and not a scientific study, this does not negate the need for a review of the literature. Although her treatment decisions were prompted by a continuing education course presented by Dr. Larry Burnett, there are numerous studies to support her decision - although not necessarily the use of a syringe. Additionally, the Chaves study used a mechanized pulsating oral irrigation device to deliver the chlorhexidine, which was diluted to 0.04 percent concentrate. Studies have shown that a pulsating oral irrigator can deliver solutions from 50 to 87 percent of the pocket depth and change microbial composition up to 6 mm even when using just water.

If we review the case study, we find that in 1987, the patient, Mr. Davis, presented a 6 mm pocket on the mesial of tooth #30. He was referred to a periodontist and received surgical therapy. Subsequently in 1995, Mr. Davis presented with an 11 mm pocket on the mesial of tooth #30. After Ms. Glasscoe's return to practice and recommendation to irrigate the area daily with chlorhexidine, the pocket reduced to 6 mm in 1998. The probing depth was 6 mm in 1987 and 6 mm in 1998. Perhaps Mr. Davis would have benefited from home oral irrigation over 10 years ago.

Oral irrigation has had its ups and down over the past three decades, but it is one of the few self-care therapies that is evidence-based. It is very important to delineate between the effectiveness of in-office irrigation via an ultrasonic unit, mechanized irrigation device, or syringe and home irrigation. Each has a separate and distinct body of evidence. The evidence is not interchangeable as each protocol has different established results. Home irrigation has repeatedly shown a reduction in bleeding, gingivitis, probing depth, and periodontal pathogens while professional irrigation is inconclusive in its ability to produce better results when combined with debridement versus debridement alone. Additionally, in a recent study by Cutler et al, home irrigation with water significantly reduced prostaglandin E2 and Interleukin 1, which are key factors in the pathogenesis of periodontal infections.

In support of the use of professional irrigation via an ultrasonic, Glasscoe sites Greenstein's review of the use of povidone iodine. Again, she misquotes. For what Greenstein really says in his abstract introduction is: "With regards to patients with adult periodontitis, there is some evidence to indicate that PVP-1 delivered via an ultrasonic device achieves better results in deep pockets than ultrasonic debridement when water is the irrigant." A recently released Academy Report from the American Academy of Periodontology on Sonic and Ultrasonic Scalers in Periodontics concurs and notes that studies using PVP-1 for ultrasonic lavage have had small sample sizes leading to inconclusive results.

Ms. Glasscoe writes that some clinicians report good results with chlorhexidine, Listerine, or salt water irrigation while others like the stabilized chlorine products, such as Oxyfresh. Only chlorhexidine and Listerine have been shown to be effective delivered via an oral irrigator.

Again, Mr. Davis is better off due to Ms. Glasscoe's recommendation and commitment to comprehensive dental hygiene care. She has shared a professional experience, which will help others develop alternative treatment plans or refer to the literature to access additional information. When sharing experiences, however, it is important to discuss accurately and comprehensively the research surrounding treatment decisions as we move toward evidence-based dental hygiene therapy.

Deborah M. Lyle, RDH, MS
Morris Plains, New Jersey

Carol A. Jahn, RDH, MS
Warrenville, Illinois

References

Chaves ES, Kornman KS, Manwell MA, Jones, AA, Newbold DA, Wood RC. Mechanism of irrigation effects on gingivitis. J Periodontol 1994; 65:1016-1021.
Eakle WS, Ford C, Boyd RL. Depth of penetration in periodontal pockets with oral irrigation. J Clin Periodontol 1986; 13:39-44
Braun R, Ciancio S. Subgingival delivery by an oral irrigation device. J Periodontol 1992; 63: 469-472.
Cobb RM, Rodgers RL, Killoy WJ. Ultrastructural examination of human periodontal pockets following the use of an oral irrigation device in vivo. J Periodontol 1988; 59: 155-168.
Drisko CH. Non-surgical pocket therapy: pharmacotherapeutics. Ann Periodontol 1996: 1(1):491-566.
Flemmig TF, Newman MG, Doherty FM, Grossman E, Meckel AH, Bakdash MB. Supragivival irrigation with 0.06% chlorhexidine in naturally occurring gingivitis. I. 6 months clinical observations. J Periodontol 1990; 61:112-117.
Newman MG, Flemmig TF, Nachnani S et al. Irrigation with 0.06% chlorhexidine in naturally occurring gingivitis. II. 6 months microbiological observations. J Periodontol 1990; 61: 427-433.
Brownstein CN, Briggs SD, Schweitzer KL, Briner WW, Kornman KS. Irrigation with chlorhexidine to resolve naturally occurring gingivitis. A methodologic study. J Clin Periodontol 1990; 61: 427-433.
Newman MG, Cattabriga M, Etienne D, Flemmig T, Sanz M, Kornman KS, Doherty F, Moore DJ, Ross C. Effectiveness of adjunctive irrigation in early periodontitis: multi-center evaluation. J Periodontol 1994; 65: 224-229.
Flemmig TF, Epp B, Funkenhauser Z, Newman MG, Kornman KS, Haubitz I, Kaiber B. Adjunctive supragingival irrigation with acetylsalicylic acid in periodontal supportive therapy. J Clin Periodontol 1995; 22:427-433.
Ciancio GS, Mather ML, Zambon JJ, Reynolds HS> Effect of chemotherapeutic agent delivered by an oral irrigation device on plaque, gingivitis, and subgingival microflora. J Periodontol 1989; 60:310-315.
Felo A, Shibly O, Ciancio SG, Lauciello FR, Ho A. Effects of subgingival chlorhexidine on peri-implant maintenance. Am J Dent 1997; 10:107-110.
Jolkovsky Dl, Waki MY, Newman MG, Otomo-Corgel J. Madison M, Flemmig TF, Nachnani S, Nowzari H. Clinical and microbiological effects of subgingival and gingival marginal irrigation with chlorhexidine gluconate. J Periodontol 1990; 61: 663-669.
Fine JB, Harper DS, Gordon JM, Hoviliaras CA, Charles CH. Short-term microbiological and clinical effects of subgingival irrigation with an antimicrobial mouthrinse. J Periodontol 1994; 65: 30-36.
Cutler CW, Stanford TW, Abraham C, Cederberg RA. Boardman TJ, Ross C. Clinical benefits of oral irrigation for periodontitis are related to reduction of pro-inflammatory cytokine levels and plaque. J Clin Periodontol 2000; 27:134-143.
Greenstein G. Povidone-iodine's effects and role in the management of periodontal diseases: A review. J Periodontol 1999; 70:1397-1405.
The Committee on Research, Science & Therapy. Sonic and ultrasonic scalers in periodontics. J Periodontol 2000; 71: 1792-1801.

A highlight of a career

Dear RDH:

Click here to enlarge image

I am a dental hygienist in Maine where I have practiced in the small community of Dover-Foxcroft for 22 years. I was employed by Dr. William Forbes for 15 years and have been employed by Dr. John Clark since his purchase of the practice seven years ago. In 1976, when my youngest of three children entered kindergarten, I entered the dental hygiene program at the University of Maine, a daily commute of 38 miles.

I chose the dental profession because I enjoyed people and discovered that my friend and family dentist, Dr. Forbes, was always looking for a dental hygienist who would remain in a small town in central Maine.

Although I have worked for general dentists, I have had a great interest in periodontal disease. In 1985, I began to use the phase contrast microscope as a motivational tool for my patients to see what micro-organisms were contained in their plaque samples.

I also employed antimicrobial irrigation as part of the periodontal treatment plan before this had become commonly accepted therapy. Continuing education in the area of periodontal disease has been exciting and refreshing for me.

During my dental career I have volunteered in preschool and elementary classrooms to promote good dental health. As you can see by the photograph, making a memorable first dental visit for my 3-year-old granddaughter has been another highlight of my dental career. I have encouraged good dental health in my three grandsons and an looking forward to Abigail's 21-month-old sister's "first dental visit."

Doris G. Coy, RDH
Dover-Foxcroft, Maine

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