Reader's Forum

Commissions do not affect quality

Dear RDH:

In response to the letter from Connie Sidder of Ft. Collins, Colo., in the June issue, we must take exception to her assumption that hygienists who work on a commission basis are unethical and do not take pride in the quality of their work.

We question her opinion only because of the generalities involved in her statements. It would be the same as a commissioned hygienist saying that all of those who work for an hourly or daily rate drag their feet to do less work for the same pay per day, and we know that is not true.

Having been compensated in both manners throughout our combined careers of 56 years, we have never changed the attention to detail in the patient care we deliver, no matter how we were paid.

We don't know of any dentist, specialist, or medical doctor who doesn't get "paid" based on his or her production per day. This is how the practice Ms. Sidder works in was built, and we're sure she wouldn't work for a dentist whom she considers unethical.

Hopefully Ms. Sidder can take a better view of commissioned hygienists knowing that there are those of us who are as dedicated to our profession as she is.

Donna L. Kelly, RDH, BS
Patricia A. Sedlock, RDH
Moline, Illinois

No ethical dilemma

Dear RDH:

This letter is in response to "No commission and proud of it" that was published in the Readers' Forum section of the June 2002 issue. I work in a practice with a total of five hygienists. And, yes, we are on commission. However, there is not a single one of us who is anywhere near being unethical.

For a fellow hygienist to make a blanket statement referring to commissioned hygienists as unethical is not only completely wrong, but borders on being ignorant. We, too, pride ourselves in the quality of our work as health-care professionals.

Being on commission is not an ethical dilemma. It is a means of motivating hygienists to be more efficient, not less. Also, it is a way for hygienists to be more conscious of their schedules. If a hygienist is unethical, it should be the responsibility of the employer to set the guidelines for their employees. In our office, there are four dentists who are comfortable enough with the hygiene department to allow us to be in control of our own destiny. They do not feel the need to watch every move we make or stand over our shoulders to ensure we are doing our job correctly. Prophy, perio, sealant, and bleaching appointments are all performed with exceptional quality.

Now, let's flip the coin. A dentist in private practice usually works on a percentage of what the office produces, minus office overhead. So, are they unethical too? I think not! The question was asked by this hygienist in Colorado: "Am I the only one who feels this way?" My answer is maybe not, but I would say you are in a vast minority.

Suzanne H. Bedingfield, RDH
Macon, Georgia

Defines 'animal lover'

Dear RDH:

Thank you for another interesting, informative, and thought-provoking issue of RDH. I always enjoy the diversity of topics covered in the magazine.

I usually resist the urge to write to the editor. As someone who "truly" cares for the welfare of animals, I wanted to comment on Joanne Iannone Sheehan's article, "A day at the Farmacy (June 2002)," regarding emu oil. Although I won't argue the possible merits of emu oil as a therapeutic agent, the exploitation (and it is by definition, exploitation ... Alexandra Hall herself describes it as a "company") of innocent animals for profit can in no way meet Ms. Sheehan's assertion that Alexandra Hall is "an animal lover." And as for her contention that the emus meet with a "painless and humane end" at the hands of a deliberate and violent act, well, I think the oxymoron is apparent in that statement. So let's call a spade a spade, shall we?

Because I realize that not every person shares my point of view regarding the humane treatment of animals, I would have found the article acceptable without that paragraph. But I point out the above in the nicest way I can on behalf of "animal lovers" everywhere.

Looking forward to the next issue.

Dean Alcorn, RDH, BS
Grand Rapids, Michigan

Lasers do have a place in perio

Dear RDH:

It is hard to take someone like Dr. Drury seriously when he writes, "First, bacterial decontamination of the periodontium has never been proven to be of therapeutic value (June 2002 Readers' Forum)." Just to be clear, this statement was made by a periodontist. Pray tell, Dr. Drury, educate us all on the causative factors of periodontal disease, if not bacteria, and the lack of therapeutic value from its removal in the pocket.

Dr. Drury then writes, "Even if it occurred, it would be short-lived in an open system." Well, what's the point of discussing the temporal benefits of bacterial removal if there is no therapeutic value in doing it? However, for those of us who read the peer-reviewed periodontal literature, we have concluded, along with researchers and mainstream periodontists, that removal of bacteria in periodontal disease is indeed of therapeutic value. Therefore, let's consider the following evidence on the pulsed Nd:YAG laser's role in terms of bacterial decontamination time frames.

Mary Elizabeth Neill, DDS, MS, and past AAP president James T. Mellonig, DDS, MS, wrote the following conclusion about their pulsed Nd:YAG laser clinical trial: "... these findings suggest a longer lasting effect for the laser therapy in altering subgingival microflora. Clinical significance of these findings may suggest that mechanical scaling and root planing therapy alone may not be the most effective mode of treatment in patients infected with Porphyromonas gingivalis and Prevotella intermedia ... There are several additional areas where the adjunctive use of the Nd:YAG laser may be an advantage over scaling and root planing alone as a mechanical approach to nonsurgical therapy. These include the analgesic effect of the Nd:YAG laser, the hemostatic effect, and the antibacterial potential of laser energy."¹

His comment about the pocket being an open system exposes Dr. Drury's ignorance of laser tissue interactions as well as the published and peer-reviewed literature. That's understandable since Dr. Drury has never actually used a pulsed Nd:YAG clinically or in any laboratory research. Our published works clearly explain that the pulsed Nd:YAG - especially when configured with a "long" pulse duration (for example, 650 microseconds) - allows for creation of a closed system by heating the blood proteins to form a stable thermolytic "soft" fibrin clot at chairside. This is clearly described in our published works on Laser Periodontal Therapy™, a "Step-by-Step Technique" in steps D, E, and F.^{2, 3}

Dr. Drury writes, "The FDA has clearly stated that the laser is not approved for this [bacterial reduction] application or for cross-contamination, ENAP procedures, and periodontal ligament or bone regeneration." Unfortunately, Dr. Drury is wrong about FDA approval for laser bacterial decontamination. The FDA has cleared two near-infrared lasers for their bactericidal effects - one for "bacterial decontamination" and another for "reduction of bacterial level (decontamination) and inflammation."

Besides being incorrect about FDA near-infrared laser clearances for bacterial reduction, Dr. Drury is generally confused about the role of the FDA and what it means for a manufacturer to receive a 510(k) Substantial Equivalence letter. The FDA regulates claims that a manufacturer can make in the marketing of a device after the company has submitted data on both safety and efficacy to demonstrate "substantial equivalency" for a particular "indication for use."

The FDA has cleared for marketing a pulsed Nd:YAG laser for laser periodontal therapy, laser curettage, and laser sulcular debridement to improve the following:

Gingival Index (GI) - improving the quality, quantity, and severity of disease
Gingival Bleeding Index (GBI) - reduce bleeding from the gums
Probe Depth (PD) - reduce the depth of the periodontal pocket
Attachment Level (AL) - increase the level of tissue attachment
Tooth Mobility (TM) - tighten loose teeth

How any dentist chooses then to use that laser in his or her methodology of choice, whether in ENAP-type procedures, or for reduction of bacterial cross-contamination, or periodontal ligament or bone regeneration is entirely legal and appropriate. In any clinical scenario, the FDA does not regulate the use or claims that dentists may make about their own use of a legally marketed device, laser or otherwise.

Therefore, Dr. Cortés is free to use her pulsed Nd:YAG laser for Laser ENAP, bacterial reduction or bone and periodontal ligament regeneration. She is also free to share with colleagues and allied professionals the results of her clinical laser periodontal experiences. That is the point of publishing clinical articles, so that our peers can review the work and make fair comment about it.

The FDA does not ever intend for studies showing substantial equivalency to be the last word on the science. The FDA expects clinicians, academicians, and researchers to conduct additional studies, make observations, and report adverse findings to expand further on the body of evidence about a particular drug or device. Therefore, it is misleading and disingenuous for Dr. Drury and others in the AAP to assert that since the manufacturers have not demonstrated superiority to standard procedures, that the new methodology is somehow invalid, irrelevant, or, worse, dangerous.

Dr. Drury generally complains that red and swollen gums don't need to be treated with a Nd:YAG laser, that there is little support for laser curettage, and that pulps and root surfaces will be damaged by using a pulsed Nd:YAG, especially at the 2.5 watt setting.

These statements are utter nonsense. In our combined 25 years of using pulsed Nd:YAG lasers in the periodontal pocket, we, the FDA, and the California Dental Board simply has not seen the type of damage to bone, root, or pulpal tissues that Dr. Drury and his supporters would like the RDH readership to believe.

If there were patient injuries of the type Dr. Drury and his ilk declare, or damage to root surfaces or pulp tissue, we would have been sued out of existence, and the California Dental Board would not have closed the complaint file that Dr. Drury and his attack pack at the California Society of Periodontists (CSP) filed against us in 1997. Out of frustration, he and the CSP witch hunters wrote, "Unfortunately, the Dental Board's final decision about our complaint was that they needed to see harmed patients before they could pursue our concerns ... Since the FDA and the Dental Board of California refuse to act on the laser until biological damage can be demonstrated on patients, please document and report such cases to CSP immediately."⁴

Lastly, we're certain that Dr. Drury hasn't a clue about laser dosimetry. For example, whether the laser setting is 2.5 or 5.5 watts is not at all relevant to a discussion of laser light dose in the periodontal pocket. What is important is how the energy is delivered to the tissue and in what therapeutic dosage over time. Our research has calculated a light dose of 10 to 16 Joules per millimeter of pocket depth as most safe and effective.2,3 Relatively speaking, it doesn't matter what the wattage on the console reads, only what energy is being delivered at the fiber tip, to the tissue and in what light energy dose.

Dr. Drury and his allies need to stop reporting claims of dire consequences from using the pulsed Nd:YAG laser in the periodontal pocket until they can provide more than anecdotal stories, new theories, and poorly designed lab experiments (for example, irradiating an extracted tooth perpendicular, dry and with 250,000 watts/cm2 of power density) by conducting well-designed, prospective, longitudinal, blinded, multicentered, human clinical trials to demonstrate the damage they allege is taking place. Until they do, the clinical, histological, and scientific data - long on file with the FDA showing no injurious effects of pulsed Nd:YAG lasers on root surface, bone, or pulpal tissue - will have to put this issue to rest for the time being.

Robert H. Gregg II, DDS
Delwin K. McCarthy, DDS
Co-Directors, Institute for Advanced Laser Dentistry
Cerritos, California

The teacher's bias

Dear RDH:

I am writing in response to the letters responding to the statements by Karen Schacher. I am a graduate of a bachelor's program and have been practicing for six years. In those years, I have worked with many different hygienists and can confidently say that hygienists with associate's degrees are great clinicians, sometimes even better than hygienists with bachelor's degrees.

However, in Ms. Schacher's defense, many instructors in bachelor's programs instill an extreme prejudice against associate's degrees. So, hopefully, with a few more years of experience, Ms. Schacher will discover that just because your instructors think one thing doesn't mean that it's true.

Shannon Gleichmann, RDH
Brighton, Colorado

Comparison with 'better' hygienists

Dear RDH:

I would like to respond to some of the responses in the May 2002 Readers' Forum. I received my hygiene license through the so-called (and by some of the responses I read, not-so-good) preceptorship program.

I went through an 18-month course in dental assisting in which I received a degree. I took many of the same courses taken by these "better" hygienists. I, in turn, took the CDA exam and passed with flying colors even though it is not required in my state. I practiced for 10 years as a CDA; six of those years were spent strictly in periodontics. I worked with some of the best periodontists in this city.

After the birth of my daughter, I decided to go back into general dentistry. I worked with the dentist who sponsored me in the preceptorship program for three years before we decided to send me through the program. There were two primary reasons why I chose the preceptorship program:

In my state, at that time, there were only two schools that had hygiene programs - one of which was discontinued and the other had a two-year waiting list.
I could not afford to quit work in order to go to school full-time.

Now, I grant you that while I was in the program there were several ladies who did not belong there. Some did not know anything about dentistry. Some did not know how to sterilize instruments (scary!). Some did not know the anatomy of a tooth or the numbers. I think that they need to screen the students better and require that them to have completed a dental assisting program before entering the preceptorship program.

I educated the dentist whom I work for more about perio knowlege than he knew before. We have had several "better" hygenists who did not know how to do a PSR or know how to use all of the Gracies, and he thinks that I am far better than they are. He has even told me that I am much smarter than most of the dental students that he taught in the dental school. I have to maintain continuing education credits for both my CDA and my RDH. I do not appreciate the fact that just because I aquired my RDH license through a preceptorship program that I am not considered as good as the ones who have bachelor's or associate's degrees. We are all hygienists, and we all are suppose to serve the same purpose in this profession. It does not matter how you got licensed. It matters if you love your job and do it to the best of your ability. You will be compensated in many ways!

Sherri Brooks, CDA, RDH
Birmingham, AL

The real threat

Dear RDH:

I would like to respond to the many letters written by hygienists - graduates with associate's degree and bachelor's degree alike. The way I see our field is like this: We are not governing ourselves. We are at the mercy of dentist who may not always opt for quality care, but go for convenience instead.

We are looking at preceptorship-trained hygienists as a real possibility. We are looking at dentists who would be satisfied just to have "someone" to do hygiene; they are not looking for quality. What scares me about our field of study - and both associate's and bachelor's programs know - is that we have worked very hard to get where we are today.

The on-the-job-trained hygienist is a outright insult! We all know that most dentists do not have time to properly train a quality hygienist. We need to always strive for better, not just getting patients in and out of the chair. Our first priority should be to the public. We need to protect our field from being destroyed!

My husband is a pharmacist, and I have seen his field continually improve. There are now very few bachelor's programs offered nationwide. Pharmacists are moving into a new era; they also govern themselves and protect and improve their field of expertise.

We need to stop arguing about whether we have an associate's or bachelor's degree and go in for the real threat, which is on-the-job-trained hygiene, as well as assistants being allowed to scale.

Connie Elsner, BS, RDH
Elko, Nevada

The root of all evil

Dear RDH:

Each month, I read your magazine faithfully from front to back. Each month, I find the reader's responses to preceptorship in any aspect to be quite passionate. Being a 1996 preceptorship program graduate, these letters and articles are, by far, the most captivating to me. The heated responses in the Readers' Forum concerning the levels of dental hygiene education was exceptionally interesting. I could not resist the urge to be one of the few to speak for those of us educated by the infamous preceptorship program. It amazed me to know how little hygienists actually know about the education that is received in the bachelor's, associate's, or the preceptorship levels of dental hygiene.

I personally feel that I am well-qualified to have the title of RDH behind my name. I know that the validity of my education and experience is reflected in my patients' periodontal treatment results, the behavioral changes in their home dental care, my monthly hygiene production figures, and the consistent praises both my employer and I hear daily about the gentle, professional periodontal and preventive care received while in my chair. I have been in the field of dentistry for 14 years, eight of which were in dental assisting and dental office management and six of which have been in dental hygiene. I have earned a bachelor's degree, and I have kept current my national board certification in dental assisting. I love my profession!

Out of pure curiosity and thirst for knowledge, I researched the bachelor's and associate's degree curriculums for several dental hygiene programs, took these general courses at a local four-year university and passed successfully. The only difference I see in the preceptorship program is one or two years, depending on the level of the degree. The year or two of prerequisites simply has been eliminated in the preceptorship program. In that one year, we attend dental hygiene forums just associate's or bachelor's degree students in their second or third year.

We are tested on paper and by demonstration. We are allowed to perform on patients under the supervision of a dentist and/or licensed hygienist just as student hygienists do in a clinical setting. We also take the state clinical and written exams right along with students who have graduated from an Alabama associate's degree dental hygiene program.

Fellow hygienists, please acknowledge that bad hygienists come from all levels of dental hygiene education. The preceptorship program does have its pitfalls. No, I don't agree that everyone should be able to enter the profession of dental hygiene as easily as the preceptorship program allows. Yes, it has threatened the earning potential when the field becomes saturated. But it meets a supply-and-demand issue in our state, and it made a dream of mine come true after being on numerous dental hygiene program waiting lists.

As for my objective now, I wait patiently for someone to have the courage to allow preceptorship graduates to take the national dental hygiene boards. What do you all have to lose? In my opinion, if we are so uneducated about the job we have "learned," this is one of the ultimate ways to prove this widespread belief. Honestly, what are we really arguing about here? Professionalism ... experience ... credentials ... education? Or could it possibly just be about money? It is sad to say, but I have come to realize that money is the root of all evil among hygienists - no matter what level of education we have obtained.

Kimberly S. White, RDH
Montgomery, Alabama

Lessons of baptism by fire

Dear RDH:

I read both the Schacher letter and the heated responses in the Readers' Forum. I have 28 years of dental experience, six as an assistant working my way through a bachelor's in hygiene and the other 22 in the trenches. All the bachelor's degree did for me was enable me to do a little algebra and quote odd bits of Shakespeare or Shelley. None of these random talents have ever been called upon to help me with some of my more difficult patients or employers! I am, however, more entertaining at cocktail parties, which I occasionally attend to relieve the stress of my worklife.

I am currently back in school to get even more letters after my name, but I will still be the same person and same hygienist I am today. Splitting hairs over degrees doesn't make you a better clinician; the level of experience, focus, and dedication makes one a better clinician - most of which I got from hygiene school and 28 years of on-the-job training that I like to refer to as "baptism by fire."

In view of Ms. Schacher's limited experience, she must be forgiven. She has simply been unable to obtain the extended education that many of her less qualified peers have had out here on the front lines.

Aven C. Coulson, RDH
Houston, Texas

The true issue

Dear RDH:

I am writing in response to all of the issues involving associate's degrees, preceptorship training, and bachelor's degrees. What is the true issue here?

I attended the Alabama Dental Hygiene Program, which allowed me to take my Alabama State Board (and I add that I passed with a very high grade average). Since then, I have been working on an associate's degree, which I have almost completed.

I have worked in the dental field for 13 years and I know from experience some things you cannot learn from reading a book. There is no experience like hands-on experience. You may read it, but you do not actually know unless you have experienced it for yourself.

Like other states, Alabama hygienists are required to pass a state board, which consists of a one-day written exam and a one-day clinical exam. I'm not sure if everyone is aware of this.

In my opinion, what makes a dental hygienist good is not what school she attended or how many years she went. A good dental hygienist is measured by the quality of her work, concern for patients, and the professional manner in which she conducts herself.

Why are the other states so concerned with Alabama? They do not live in Alabama. If other states offered this program, imagine how many would be back-paddling. The bottom line is either you know your job or you do not. So let's display ourselves in a professional manner.

Christa Akins, RDH
Fort Payne, Alabama

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