by Lynne Slim
I once read a newspaper article about a high school teacher who discovered that nearly one-fifth of her biology students had plagiarized their semester projects from the Internet. Instead of ignoring the situation or merely deducting points, she wasted no time, and gave the sophomores a grade of zero. She had the full support of the local school board, which agreed that it was plagiarism, and that the students should receive a failing grade for the assignment. When parents complained to the school board, the principal insisted that she go easier on the students. Instead, the teacher resigned in protest in an incident that was perceived as a national decline in integrity.
Today’s dental hygiene clinicians are routinely asked to make decisions about patient care, including assessments of a patient’s periodontal status. In years past, periodontal assessment was not emphasized in dental hygiene school and clinic grades were, for the most part, determined by a student clinician’s ability to remove subgingival calculus and plaque. Even in private practice, hygienists would spend a considerable amount of appointment time double-checking the lingual surfaces of mandibular anterior teeth for stain and calculus. Dentists who reviewed the hygienist’s work would typically wave the mirror (like a magic wand) behind the same teeth and declare that the hygienist did an excellent job!
Early diagnosis of gingival and periodontal diseases is the responsibility of the dentist/hygienist team. In today’s practices, responsible management of a patient’s periodontal status must begin with a comprehensive examination and full documentation. In examining new adult patients, either the dentist or hygienist must have adequate time to perform and document exam findings. It is no longer acceptable for the new patient to see the hygienist “first’ for a “routine cleaning.” Believe it or not, some practices still tell new adult patients that the hygienist sees the patient initially for a prophylaxis, at which time the gums are “conditioned.” Is gum “conditioning” an acceptable and ethical clinical procedure, or does it obscure the disease process? Looking at it another way, does it make sense to create healthy gingival margins while ignoring pocket infection and inflammation?
Before we go any further, let’s back up a minute and talk about integrity. A person who has integrity is literally “whole” or “well-integrated.” We think of such a person as being upright, principled, decent, and trustworthy. In A Little Book of Dental Hygienists’ Rules, Dr. Esther Wilkins mentions one particular rule: “Honesty and integrity are the most important characteristics of a professional person.” In other words, the daily decisions that we make in patient care determine our level of integrity and our adherence to a professional code of ethics.
As dental hygienists assume more responsibility for nonsurgical therapy within the confines of general dental practices - or, in rare instances, in their own practices - a clinician’s integrity often comes into play. For example, do you assume the role of a periodontal therapist because you are motivated by money more than providing care that is in the patient’s best interest?
In reading articles on nonsurgical therapy, we are bombarded by perio/hygiene discussions for the 21st century, which emphasize productivity of the dental hygiene department and profit-driven therapy. With the advent of high-tech diagnostic tools and equipment for dental hygienists, clinicians and patients are presented with an overwhelming array of diagnostic and adjunctive services such as:
• Automated and voice activated periodontal charting systems
• A fiber optic probe (microendoscope) that illuminates the root surface and detects subgingival calculus
• Ultrasonic/air polishing devices with sterile irrigation systems
• Host modulatory therapy, and systemic and local delivery antibiotics.
How does an honest professional adapt to this new and challenging practice environment? Hygienists with integrity stay abreast of new skills and professional advances. They take continuing education courses not because they have an obligation to meet minimum state requirements, but because they wish to raise their professional standards. These hygienists recognize the need to be “profitable” as an integral part of practice economics, but they don’t “sell dental hygiene and dentistry” based solely on a profit motive.
One way in which hygienists can improve therapeutic outcomes is through evidence-based dentistry and medicine (EBDM). The success of this approach in patient care decision-making depends largely upon the willingness of hygienists to adopt an unbiased approach to therapy. For instance, how do we know when or if subgingival irrigation is warranted? Should we irrigate before or after debridement, and how do we evaluate the various antiseptics that can be placed in an irrigator? Do we rely upon our colleagues for answers to these questions, or do we ask pharmaceutical sales representatives who stop in for an occasional visit? Do we turn down the really “hot” sales rep who buys us a mouth-watering pizza or deli sandwiches?
EBDM does not mean that you have to give up your good relationships with sales reps. What it does mean is that you weigh scientific evidence against tried-and-true clinical judgment and patient preferences. Finding scientific evidence to support what you do is the tough part, and there are different ways of going about it.
For starters, we can now gain access to large volumes of research on a particular topic, such as professional irrigation, through reviews of the literature called systematic reviews. These systematic reviews are popping up in various places and hygienists now have several resources for evidence-based information. Let’s say that you are trying to make a decision about what type of antimicrobial irrigant to use in your new, self-contained ultrasonic system. Where would you find a systematic review of professional irrigants?
You have a few choices for evidence-based information on this subject:
If you’re really feeling intellectual and studious, you can conduct a Web-based search by visiting the Cochrane Collaboration. The Cochrane group is an international, nonprofit organization that provides evidence-based health-care databases, including the Oral Health Group.
Now that you’re thoroughly confused, let me explain where this odd name originated from, and how you can “google” to get there. The Cochrane Collaboration originated in England. Archie Cochrane (1909-1988) was a British medical researcher who understood that scientific evidence originating in carefully controlled research trials was more likely to provide reliable information, than other sources of evidence.
To read the various systematic reviews that pertain to periodontal therapy, go to www.cochrane.org, and then click on the section called “Cochrane Reviews.” From there, click on “Review Groups” and you will then find the Cochrane Oral Health Group. The Cochrane Oral Health Group lists systematic reviews that have been completed and those that are also in progress.
The American Academy of Periodontology (AAP) publishes various position papers on topics. To find the AAP website, go to www.perio.org. In addition, the AAP has completed its first series of systematic reviews, which can be found in a publication called Annals of Periodontology, Vol. 8. This publication is the result of a workshop that included periodontal researchers, educators and clinicians, who came together in 2003 to conduct an evidence-based review of the most current information, on a variety of topics. Anti-infective agents (which include professional irrigation, systemic and local delivery antibiotics and host modulation therapy) are some of the many therapies that were evaluated.
There are several reputable evidence-based dental and health care journals that hygienists can subscribe to, such as: The Journal of Evidence-Based Dental Practice, Evidence-Based Dentistry, Evidence-Based Medicine, and Evidence-Based Healthcare. Above all, remember that evidence is only as good as the quality of the information presented and the unbiased nature of the evidence-based recommendations.
Today’s clinical practices are strikingly different from those of yesteryear, and our profession is ripe to tackle new, unprecedented challenges and opportunities wherever they occur. In making therapeutic decisions for new and established patients, don’t forget to keep your level of integrity intact ... in fact, don’t enter the office without it, and always let your conscience be your guide.
Lynne H. Slim, RDH, BSDH, MSDH, is a practicing hygienist/periodontal therapist who has more than 20 years experience in both clinical and educational settings. She is also President of Perio C Dent Inc. (Perio-Centered Dentistry), a practice management consulting firm that specializes in creating outstanding dental hygiene teams. Lynne is a member of the Speaking and Consulting Network (SCN) that was founded by Linda Miles and has won two first place journalism awards from ADHA. Lynne is also owner/moderator of a periodontal therapist yahoo group: http://yahoogroups.com/group/periotherapist.