Diagnosis is a team sport

Aug. 1, 2002
Diagnosis is defined as the "art or act of identifying a disease from its signs or symptoms," Merriam Webster's Medical Desk Dictionary. Yes, hygienists can and do diagnose. Have some fun with the "d" word - don't avoid using it.

Diagnosis is defined as the "art or act of identifying a disease from its signs or symptoms," Merriam Webster's Medical Desk Dictionary. Yes, hygienists can and do diagnose. Have some fun with the "d" word - don't avoid using it. If anyone gives you trouble about it, ask them how many complaints the state board has against hygienists for identifying the signs and symptoms of disease. We need to diagnose to do our job properly. If we don't diagnose, we are setting ourselves up for malpractice charges of "failure to inform."

How can we recommend dental hygiene or periodontal therapy if we don't identify the signs and symptoms of disease? If we are providing dental hygiene services, we need to know when it is indicated, how well treatment worked, and when to retreat or refer. To do that, we identify the signs and symptoms of disease. We diagnose.

What about new graduates taking state board exams? Do they have a dentist select their patient because they are not qualified to recognize the signs and symptoms of disease? You cannot graduate from an accredited dental hygiene program or pass national boards without being able to identify the signs and symptoms of disease. Hygienists diagnose every day, on every patient.

Three-step process

Here's a quick three-step process that will make your job easier, the dentist's job easier, and involve the patient in the process. First, collect the data and diagnose the case; second, present your findings and treatment options to the patient; and third, when the dentist comes in, present the diagnosis and treatment options to him/her, getting additional input and clarification from the patient in the process.

Imagine this situation with a patient in the chair: "That's the most thorough dental hygiene exam I've ever had. It was a bit scary to watch in the mirror as you measured all those 5s and 6s and a couple of 8s and all the bleeding - oh my gosh! You know I've missed several appointments with you recently and I've had a very stressful year and a half. Tell me how bad it is and what we can do about it."

Based on your findings, you have determined the patient has generalized moderate periodontitis with localized areas of severe disease, complicated by Type II diabetes and medication-induced xerostomia, a broken filling with recurrent decay, and several root surface lesions.

If you are avoiding the "D" word, you might say, "You have a few suspicious areas I need to have the doctor check."

What would you think if you were that patient? "It must be so bad, she wants to have the doctor break the news to me." Or, you might wonder why the hygienist is so shy and timid that she can't explain what she just spent 20 minutes checking.

Believe me, your patient isn't going to think, "Oh, that's right, my hygienist is a college graduate with a state dental hygiene license, but the law says she can't use the 'd' word, so she's going to tell the dentist what she found so the dentist can tell me. I know that's true, because whenever he comes in to 'check' he first asks her, 'What did you find?'"

How many of you are such good diagnosticians, that besides identifying the signs and symptoms of disease, you also know your dentist/employer so well, that you know what the recommended restorative treatment is going to be? If you work for two dentists, you can predict a different treatment plan for each dentist, based on their philosophy of practice! Because you know this, you will tell the patient what is going on - give them the diagnosis - and you may also say, "With this much decay, I think the doctor will suggest a crown for this tooth, which will involve..."

Avoid semantics

Dentists and hygienists are a team when it comes to diagnosis and treatment planning. Dentists focus on hard tissue - the teeth - and hygienists focus on soft tissue - the periodontium. Four eyes are better than two, as the old saying goes. When the dentist and hygienist pool their expertise, the patient wins. Playing the semantics game benefits no one. In many offices, the hygienists are the treatment coordinators, working with the dentist on the exams and then doing all of the case presentations.

Some hygienists feel we should change the terminology in the state statutes before we use the "d" word, avoiding the issue and following exactly the letter of the law. My experience with state boards is that something like this eventually will be handled as a simple housekeeping task. Hygienists routinely are diagnosing caries and periodontal disease, using those terms with patients and dentists. After awhile, it is apparent that old terminology needs to be updated to reflect current practice. Not diagnosing (because of the semantics) is self-defeating. Our position as a college-educated, licensed professional is a testament to our knowledge and critical thinking responsibilities, not just the tasks of scaling and polishing.

Those who talk about replacing us with in-office trained personnel believe that hygienists do nothing more than scale and polish. No wonder they think they can train an assistant to do that in a few weeks on the job. If we tie our identity up with scaling and polishing, we do ourselves, those hygienists who have gone before us, and, more importantly, our patients a huge disservice.

Critical thinkers

Just as placing and carving restorations do not define a dentist, scaling and polishing do not define a hygienist. Both professionals provide knowledge and expertise, not unlike an attorney or psychotherapist. We also provide clinical procedures, but critical thinking provides the foundation for our professional services, not scaling and polishing. Understanding basic science, incorporating new research findings, identifying the signs and symptoms of disease and effectively communicating that information to the public are what differentiates licensed dental hygienists from unlicensed auxiliaries.

Don't avoid the "d" word; use it with every patient. Tell them what your diagnosis is. Write the diagnosis in the chart. Tell them what treatment options they have. Tell the dentist what the diagnosis is. Discuss the case together and as a team of three - hygienist, dentist, and patient - make the treatment decisions. Your critical thinking skills are the foundation of dental hygiene care.

Trisha E. O'Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics. The Web site for Perio Reports is www.perioreports.com. She can be reached by phone at (800) 374-4290 and by e-mail at [email protected].