Thrilled as I am to have the power of the Surgeon General`s office presenting an action plan ... I feel an urgency to initiate a health epidemic of my own ...
Beth A. Thompson RDH, BS
Surgeon General David Satcher, MD, PhD, has delivered his report on dental health concerns to the nation. The report hopefully will serve both the public and the profession synergistically. Acknowledgment of the medical impact that oral diseases have on overall health - and ultimately on life expectancy - has given dentistry an elevated health importance, as well as a challenge to meet.
The primary goal of the recent Surgeon General`s Report on "Oral Health in America" is to enhance health promotion and disease prevention programs. His main message is that oral health is essential to general health and well-being. Since oral health is integral to general health, one cannot be healthy without oral health.
This 311-page report acknowledges that caries and periodontal disease are the two leading dental diseases that remain common and widespread. These progressive and cumulative diseases affect nearly everyone at some point in life. Most adults show signs of periodontal disease, and older adults have a higher incidence of severe periodontal disease.
The report stresses that the social burdens of oral problems are extensive and that integration of oral and general health programs is lacking. This has the highest impact on some population groups and constitutes a "silent epidemic."
As a result, the Surgeon General is calling for the development of a National Oral Health Plan. Since professional care is necessary for monitoring oral health, that plan would involve changing the perceptions of the general public, policy makers, and health providers. Although dentists, as primary care providers are uniquely positioned to play an expanding role in the detection, early recognition, and management of these diseases, all health-care providers should contribute to enhancing oral health.
As an example, the Surgeon General is recommending that an oral examination be included as part of a general medical examination. Using what criteria? What tools? What follow-up?
This report has challenged me to determine how I would hope the role of the dental hygienist would be utilized and perceived within the scope of general health care. Since my pharmacology class in dental hygiene school, I have been intrigued by the words "synergy" and "potentiate." According to Meriam Webster`s Medical Dictionary:
Y Synergy - something that increases the effectiveness of another agent when combined with it.
Y Potentiate - to make more effective or more active; also to augment the activity synergistically.
As my hygiene career has evolved, I have sought to practice synergistically, utilizing technology and knowledge to deliver the best treatment available and elevate the overall health awareness of my patients, family, and myself. This challenge has not diminished over the years. The complexity of dental care delivery, though, has changed significantly - what dentistry has to deliver, what patients expect, and what patients have learned.
Advertising has increased consumer awareness about brushing longer and more effectively, as well as about how gingivitis, tartar, periodontal disease, and, now, breath malodor can be effectively treated.
Press releases and the Internet have vastly increased the public`s access to all knowledge. The term "Internet time" was proven to me as press releases prompted patients to inquire about the introduction of Periostat(tm) by CollaGenex They asked, "Will it prevent/cure gum disease, and should I take it?" Their questions were asked literally within hours of my learning of the product`s availability.
From 25 years of teaching patients about the progress and prevention of periodontal disease - including during the days when patients did not know they had gingiva - to today`s patients asking about volatile sulfur compounds associated with periodontal disease and breath malodor, I have experienced a positive shift in the care expectations of patients.
I had not expected to personally sense any impact of Dr. Satcher`s report for some months to come. However, just last week I had my yearly physical. During the interview about my overall health, I was asked how often I see my dentist. Had I been diagnosed with any gum disease or decay? Following the questions, my mouth was inspected.
What were they looking for with a light and a tongue blade? If disease were suspected, would a referral be made for care? My mind raced through the possibilities of additional opportunities for a hygienist in the health-care arena.
Thrilled as I am to have the power of the Surgeon General`s office presenting an action plan to influence better diagnosis, treatment, and education of professionals and the public about dental disease, I still feel an urgency to initiate a health epidemic of my own - one to empower oral-health care providers to take the initiative and have the courage to elevate our caregiver status within the medical field and the public. Our knowledge and this report have created an opportunity for positive synergy.
My initial (evolving) suggestions for our action plan:
* Become legally recognized as Licensed Oral Care Therapists. The terms "registered" and "hygienist" do not convey to most people our education and care provider competency.
* Be accountable. Take the fact that we are licensed seriously. Accept only those employment positions where our influence is welcome and we can show respect for the health of our patients, as well as where we can make decisions about how to best deliver treatment, including choosing the equipment we will use.
* Rethink your classification of periodontal disease. Traditional standards for diagnosis reflect the history of damage present, not the current disease activity. Furthermore, the qualifiers of "slight," "moderate," etc., do not consider the progression of the infection, which may be active.
Too often, I hear colleagues tell me that they are not allowed to purchase or utilize technology because the office doesn`t believe in XYZ, or that the office doesn`t budget adequately for "hygiene" instruments. Recently, a friend interviewed for a position in a very upscale office in the Boston area. When she inquired about how perio patients were diagnosed and treated, she received no response. After repeating her question three times, she was told that "patients don`t like to hear about periodontal disease, and that the doctor doesn`t like to upset the patients." I wish I could say that I was shocked. I am proud that my friend ended the interview right then. However, we know that someone took that job.
During my career, I have had the pleasure of being able to create my position within the dental office, and I have never had to beg for top-quality treatment and diagnostic tools. Often, I obtain equipment on a trial basis, and I have made many investments of my own when I am determined to practice at the level I desire.
Furthermore, I have been rewarded by my commitment to my ideals. During an interview, the discussion of compensation is very different when your professionalism and contributions are above the norm and set a new standard for the office. Plus, I surround myself with other professionals who are endlessly curious about how we can improve our skills and the benefits we provide to our patients.
With new opportunity and challenges before us, how do we want to recreate our clinical world?
The Surgeon General`s report specifically states that caries and periodontal diseases are bacterial infections. It reinforces the documented position of the American Academy of Periodontology and its studies, which have demonstrated an association between periodontal disease and diabetes, cardiovascular disease, stroke, and pre-term births. Immunocompromised and hospitalized patients are at greater risk for general morbidity progression and to manage oral diseases as any other infection.
Only recently are medical doctors calling dental offices for an oral "all clear" prior to surgeries. Patients have additional sources to confirm when we tell them that bleeding gums are not an isolated symptom of "not flossing." We can test for oral pathogens and be reimbursed through medical insurance. How long before medical and dental insurance merge to honor the health relationship of the entire body?
We have used color, contour, bleeding, probing, radiographs, etc., in our dental health assessment. All of these signs show us the history of the mouth, although nothing truly indicates present disease activity. For some patients I culture sites of apparent disease, and have even recommended antibiotic therapy based on the results.
I recently have started using the Perio 2000 probe manufactured by Diamond General Development Corp. With it, I can measure both pocket depth and record sites where disease activity is present, even prior to pocket-depth change. We all have seen 2 mm pockets change into 4 to 5 mm pockets, and that is when many offices treat or refer. Now, I can treat proactively, monitor, educate, and better choose sites to culture. The probe looks and functions like a regular perio probe, connected to a device that detects VSC (volatile sulfur compounds) produced by bacteria related to perio disease. The unit is calibrated to detect VSC byproducts from only those pathogens. Activity is indicated by an audible tone.
This independent feedback has made my chairside consults progress with greater ease and focus. Patients have increased priority for their soft tissue management treatment. Additionally, we submit the fee for pathogen detection to our patient`s major medical insurance carriers and receive reimbursement - further recognition of the importance of oral health to overall health! Thus, we are being compensated for periodontal probing and obtaining more information from the periodontal exam. I predict that routine oral pathogen detection will become a standard of care in a very short period of time.
Current standard of care in treatment of gum tissue is the use of ultrasonics to deplaque, disinfect, detoxify tissue, and remove calcified deposits. Hand scaling alone only removes hard deposits - without the effective and efficient bactericidal benefits of ultrasonic therapy. Most of my patients who are new to ultrasonics only need to hear that there are no sharp edges; I run the active tip over their thumbnail as a demonstration of safety and sensation. Ultrasonic technology has evolved to offer a wide variety of tips to clean prosthetics, very sensitive areas, and deliver antimicrobials.
The Surgeon General`s report supports the diagnosis of pathogens, efficient deposit removal, and the use of antimicrobial agents.
To quote a friend of mine, Bev Maguire, RDH, whose editorial appeared here in RDH last year: "I say it`s time for us, as trained professionals, to facilitate the transition within our profession from prophy-based, schedule-driven cleaning departments to that of diagnosis-driven perio hygiene co-therapists."
As dental hygienists, we have long sought to be recognized as primary health-care professionals. We assertively defend our licensure and the public`s protection from undereducated dental employees. We have the power of synergy to potentiate our professional integrity and care delivery. Let`s do it.
Beth A. Thompson RDH, BS, practices in Boston. Thompson has written and presented dental continuing-education courses for the past 18 years. She has worked for several dental manufacturers and is current owner of her own consulting company, The Dental Connection. She can be contacted at [email protected].