Saddened by declining quality of care

I send you this letter so that you can understand my advocacy for better dental hygiene delivery. I have been a hygienist for more than 20 years. I recognized the need for change after I moved to Missouri over 15 years ago. What I was seeing then, and still am seeing, is overuse of gross scale as a concept, absolute total uncoordination between dental hygiene and dentistry on health histories, and no recognizable, informed charts. As a hygienist who took Dr. Zinman`s course, "Malpractice Prophyl

Dear RDH:

I send you this letter so that you can understand my advocacy for better dental hygiene delivery. I have been a hygienist for more than 20 years. I recognized the need for change after I moved to Missouri over 15 years ago. What I was seeing then, and still am seeing, is overuse of gross scale as a concept, absolute total uncoordination between dental hygiene and dentistry on health histories, and no recognizable, informed charts. As a hygienist who took Dr. Zinman`s course, "Malpractice Prophylaxis," nearly 20 years ago, I can tell you there are a whale of a lot of people leaving themselves open for a lawsuit.

I worked in an HMO for nearly a year, and I was continually pulling out black sub calculus on a regular basis. I was so upset that I was determined to find a better solution for these patients. So I went to work for an HMO insurance. I went with the idea that I would go into business or public health. I had the sole intention of better educating the public so that they could make better choices.

The other thing I had to answer in my own mind was why dental hygiene practice is so very different from state to state. I hold California, Washington, and Missouri licenses. I see dentistry advocating preceptorship for dental hygiene, and I am sick at heart over that. Now I understand where this comes from. It is money-oriented certainly, not quality-oriented. I went into dentistry because I loved it and thought that dentists were selfless, caring individuals.

In Washington, we use a lot of anesthesia to make the patient more comfortable during quadrant cleaning. There, I rarely see leftover calculus. In Missouri, I see very firm, tight tissue hunkered down over large chunks of calculus, or veneered on black sub, with little or no bleeding. Yes, they got the plaque, but they left tons of calculus. Very often, chemicals are used to make it heal down more after the gross scale. Can I tell you I have never seen so much hard-to-remove calculus because it`s been on the roots since forever? I see it in the X-rays time after time.

To the Alabama-trained hygienist, I can only say that if you think dentistry trains you well, you ought to go through the training in Washington state. I do not see dentists even using proper instruments to feel for calculus here. Yes, you may have been trained to do what will help you pass the test, but two years of training as a hygienist will give you a much better understanding of why and what you are doing.

And, oh yes, I worked as a dental assistant to my senior student who was doing restorations. I do not mind helping out at all. As a matter of fact, I used to give blocks for my dentist in California. I can do restorative too - everything but remove decay. I`m happy to help.

When I can see patients with absolutely hunkered down tight tissue over yellow calculus over black fine particles, when I run a sharp instrument on that slightly rough surface, I am sickened and saddened. Oh yes, I know root planing is overtreatment, but you ought to try and find the pieces that were half-taken off after gross scale has knocked out the vital information that you need in order to do a proper job.

Is this a conspiracy to eventually drum up more business for periodontists? I`d like to think we are more ethical than that. Well, come get a load of the undertreatment I see. PSRs do not record mobility, recession, furcations, or any other defect. I can`t tell you how many patients here don`t know what a furcation is, let alone that it is in their mouths. Perio charting is necessary and I rarely see that.

Dentists here think that a Panorex or 4 BWs are what is needed on patients. That is not standard of care. I know ... I worked for an insurance company.

Dear Dr. Neiburger, I want you to know that I won`t mind doing faster prophys to help you make more money, but I need to know that these patients are under control first. Most of these so-called easy prophys I see are not under control. When they are bleeding all over the place and they can`t even demonstrate proper brushing technique after 60 times of coming into the office, I think the insurance industry needs to rethink how to make the reimbursement for dental work dependent on how clean the patient keeps his or her mouth, maybe tied to the number of bleeding points.

Health histories? I could write a book about it. I would say that 90 percent of the offices I have been in do not regularly review health histories. And what about blood pressures? Some offices don`t even have a blood pressure cuff.

A better system needs to be developed. As far as I know, to cover myself legally and to care for the patient correctly, complete written OKs in the chart are the only thing that is legally accepted.

Informed consent, at least about perio, is lacking in probably 99 percent of the offices. By the way, the offices I go home to in Washington state are good about this one. I must say that, if you think I`m anal retentive, the office I came from in Washington state does all of the above. If you are taking the only other truly educated person in dentistry in the dental office and saying you can train assistants to do what she does, you most likely don`t realize what she knows or value what she does without your having to tell her.

I can`t tell you how many times I have had to tell a patient, "I`m sorry, but you need more extensive work," or, "This is going to take a little bit longer because somebody before me was rushing through the mouth and left junk all over the place."

Two heads are better than one and teamwork is great, but when you accept less-educated personnel, you do the public a huge disservice. I have to question not only the ethics behind this whole dentistry/dental hygiene fight, but also the attitude of the ADA. I`ve been told that attitude is everything. You tell us over and over why hygienists can`t be out on their own. But when I see you are not doing the right things either, then I am saddened deep into my soul.

We can do better than this. We use managed care as a scapegoat for not doing good care. And the doctor`s desire for faster and faster prophys is not the answer until the patient is truly under control. And that means education of the patient. None of us are perfect, but I think we owe it to our patients to truly do the right kind of care. By criticizing the profession, I hope to make us better at delivery of care.

Donna Rice

Chesterfield, Mo.

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