Readers' Forum

I would like to respond to the false and outdated facts about the Alabama Dental Hygiene Program, which were published in the July 2003 edition of your magazine by Terry L. Mingee, RDH.

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A clarification of ADHP requirements

Dear RDH:
I would like to respond to the false and outdated facts about the Alabama Dental Hygiene Program, which were published in the July 2003 edition of your magazine by Terry L. Mingee, RDH. I'm not sure where he got his information, but it is outdated.

Previously, I felt that your personal bias and uneducated views of our alternative dental hygiene education program did not deserve a response, but I would also like to comment on your editorial article in the same issue.

The political clout that you think the Alabama Dental Association has with the American Dental Association is really just wishful thinking on your part. It is, in reality, an American Dental Association committee charged with the job of studying and visiting the ADHP in 1997 to write a resolution to be presented to the House of Delegates for their consideration. Their findings were that we did indeed have an alternative program to teach clinically competent dental hygienists. As a result, a resolution was presented and passed in the ADA House of Delegates, which stated that the ADHP was an excellent model for other states desiring to look into state dental board administered programs to increase access to care for patients.

I would respectfully request that you make corrections to the false and outdated information you published about the Alabama Dental Hygiene Program.

To be eligible to enter the ADHP class of 2004, you have to have a minimum of 24 months of full-time chairside assisting, be 18 years of age, be a graduate of an accredited high school, or hold a GED certificate. Although prior education and study skills are important considerations, a strong working knowledge of routine dental procedures, terminology, radiographic skills, infection control procedures, medical emergencies, and CPR certification are required for admittance into the ADHP.

The cost of the ADHP program is attainable — however, not for $510 as printed. The cost is over $1,000. There are five required textbooks and a 600-page manual, which the faculty teaches from. The students have to purchase a typodont designed for dental hygiene practice and an instrument packet that provides them with a perio probe and a variety of scalers and curettes. The students are instructed and taught with a hands-on training class, using their typodont and each individual instrument in their packet. This is taught before they are to perform oral hygiene on patients in their clinical setting. An instructional video must also be purchased and utilized throughout the year.

Over 180 hours of structured classroom instruction is taught by faculty members from the University of Alabama Dental School, dentists, and, yes, one RDH with a MS degree. Clinical instruction under direct supervision of a certified dentist instructor with strict guidelines is completed in an office setting.

Students have two to three tests each session to review material covered by each lecturer. They are required to pass with a 75 percent average and to complete 100 prophylaxes on patients with mixed and permanent dentition.

To take the licensure exam in Alabama, you have to successfully complete the ADHP or graduate from a college approved by the board. Passing the national board exam will exempt applicants from having to take the comprehensive written part of the Alabama board exams. Applicants who fail the national board exam are allowed to take the comprehensive written exam and, yes, they have also failed it, as well as the clinical portion of the exam.

As far as the former Alabamians who were quoted, they told blatant lies about the ADHP to the author of this article. ADHP students do not use the hygiene clinic at UAB, opened or closed, except to take the board exam. They do utilize Volker Hall at UAB for classroom lecture. No one is given only two instruments and told to complete 75 prophylaxes before they attend class. That is totally ridiculous and untrue.

I will have to differ with the Alabama hygienists who have a college degree, and blame the ADHP for the low salaries in Alabama. The pay scale for all college degreed professionals in Alabama is the lowest in the country and the ADHP cannot take credit for that. The fees for dentistry in Alabama are about half what they are in other states. I, too, believe that college degreed hygienists should be compensated accordingly. The ADHP does not "suggest that hygienists in Alabama will be forever under direct supervision foregoing the freedoms other states now enjoy." This is misleading because Alabama is not the only state who does not have some type of limited general supervision as you suggest in the "alternative to preceptorship" article. Most states who have general supervision are very limited in what their practice acts allow to be performed under general supervision.

Any conscientious and dedicated hygienist, whether she is college degreed or not, will always take the initiative to continue her education on a daily basis. Alabama requires that dental hygienists have 12 hours of continuing education annually. Clinical dental hygiene treatment in Alabama is as comprehensive as any other state whether performed by an ADHP hygienist or a college degreed hygienist.

Sandra Kay Alexander, RDH, CDA
Rainbow City, Alabama


A response from the editor

As with most letters published in the Readers' Forum, Ms. Alexander's letter to the editor is published in its entirety. She did an admirable job in presenting a viewpoint on behalf of preceptorship.

I do have a response to her letter.

I'm sure most traditionally trained hygienists would disagree about the significance of the equivalent of 20-something days of "structured classroom instruction." I'll let those hygienists speak for themselves as they often have in the Readers' Forum.

The "clinical instruction" — where the candidate completes training under the supervision of a dentist — is where most of the red flags surface, as far as RDH is concerned. There is plenty of evidence that the "strict guidelines" she refers to are worth absolutely nothing, based on direct feedback RDH has received from preceptor-trained hygienists in Alabama.

The politically unmotivated ADA, as she claims them to be, thinks ADHP ought to serve as a model for other states. Due to all of the red flags in the preceptorship part of ADHP, I have little doubt that lawyers will begin receiving telephone calls within 15 minutes of another state adopting a version of the ADHP. There are simply too many risks involved with letting a practicing general dentist handle a critical portion of a dental hygienist's training. Many dentists cannot handle the responsibility — due to either the time constraints of being a revenue producer or ulterior motives (lower salaries).

Ms. Alexander is right about the hygiene salaries in Alabama being among the lowest. The Dental Economics surveys confirm that. We're puzzled by the claim about dental fees, though. According to the same Dental Economics surveys, Virginia, Ohio, Indiana, Missouri, Texas, Iowa, Wisconsin, Minnesota, South Dakota, North Dakota, Kansas, Nebraska, Louisiana, Arkansas, and Oklahoma charge less for a #1110 than Alabama.

If the impoverished residents of Alabama are not saving money by going to one of their state's dentists, and dental hygienists are earning below-par salaries, who's getting the money?

I reject the implication that a dental hygienist who did not buy a specific textbook, or is unaware of the exact location of classrooms at Alabama universities, should not comment on his or her concerns about the ADHP or preceptorship. Alabama's actions toward the dental hygiene profession does foster concern, regardless of any implied endorsement by the American Dental Association.

The ADHP is about money. The ADHP is about decreasing the value of dental hygiene services. However, unlike union members' sentiments toward "scabs," traditionally trained hygienists generally admire the dedication of "preceptors" to oral health. But the ADHP remains dentists' solution to the economics of dental hygiene — nothing else.
— Mark Hartley

No value for the patient

Dear RDH:
In response to Michelle Caldwell's statement (Readers' Forum, October 2003) that she knows "what an 11/12 gracey is used for and the location in which it is used," I would like her to clarify if it is an after five, mini five, SRP, or a rigid gracey because every instrument is site specific and I would not use a rigid SRP when a mini would be more appropriate.

Also, while I appreciate Ms. Caldwell's enthusiasm and passion for dental hygiene, I strongly urge her to attend an accredited dental hygiene program. Working as a preceptorship trained dental hygienist can greatly contribute to the fall and demise of dental hygiene as we now know it. Ms. Caldwell revealed that she has "worked with several (preceptorship trained) who do more damage than they do good."

I will not match my skills against Ms. Caldwell's as she has offered to the readers of RDH magazine. As a professional, I would not place a patient in a possibly harmful situation with Ms. Caldwell or any preceptorship-trained hygienist. I am uncomfortable with not only her lack of training, but also her inability to treat the patient in an appropriate manner as demonstrated by her own personal experiences with preceptorship-trained hygienists.

Good value for one preceptorship degree? Perhaps for the dentist and the preceptorship trained hygienist, but definitely not for the patient.

Beth Kageyama, RDH, BS
Sylmar, California

Evidence-based dentistry

Dear RDH:
Thank you for your recent attention to evidence-based decision-making in dental hygiene practice. We are pleased to have contributed an article addressing this topic (May 2003 issue). We also appreciate a subsequent letter to the editor suggesting how we might have improved our article and pointing out the weaknesses in how the PICO comparisons were structured. The article was meant to introduce the concept of using evidence as part of clinical decision-making rather than to take the reader through the step-by-step process. However, by truncating the discussion to meet the limitations of the publication, and by using general outcomes rather than identifying specific outcomes for an individual patient and intervention, the process itself was not accurately reflected.

As for the respondent's comment on meta-analysis, that term refers to the statistical analysis of the systematic review, which is comprised of multiple studies addressing the same question. Each study included in the Cochrane Collaboration's systematic review on power toothbrushes needed to meet specific, pre-determined criteria to be included as well as the international standards for reporting randomized controlled trials. Meta-analysis techniques minimize the shortcomings from studies with small sample sizes by providing a more valid estimate of the underlying effect. Meeting pre-established well defined criteria explains why a meta-analysis is considered the highest level of evidence, and, yes, the analysis is only as good as the studies that met the criteria for being included in the systematic review.

Systematic reviews and meta-analyses provide a valuable service to clinicians by identifying and summarizing the body of evidence related to the benefits or drawbacks of a particular strategy. It is just as important to know what is statistically and clinically significant as it is to know what works equally well, does not work, or only works well in a particular situation. We agree that the scientific evidence is but one component of the evidence-based decision-making process that also takes into account the experience and judgment of the clinician, the clinical circumstances presented by the patient, and the patient's preferences and values. Together, these components better inform clinical decision-making and maximize the potential for successful patient care outcomes.

Denise M. Bowen, RDH, MS
Idaho State University
Jane Forrest, RDH, EdD
University of Southern California

Options for cancer patients

Dear RDH:
This letter comes in response to the article, "If Only 2" in the August 2003 issue. The article is dramatic and very tragic. Any kind of cancer treatment has a quantity of life vs. quality of life issue that needs to be discussed between the patient and the radiation oncologist and medical oncologist.

It is well documented that radiation therapy causes xerostomia. This has been known for many years. Prior to radiation therapy, a dental prophylaxis and periodontal evaluation is necessary to identify abscesses, infection, and hopelessly decayed teeth. Post-radiation therapies involve dental evaluation every four weeks for the first three months and two- to three-month evaluations for the remainder of the first year, and then follow the patient every three months for the remaining four years.

Fortunately, new techniques and medications are available to help reduce the problem of xerostomia. Intensity Modulated Radiation Therapy (IMRT) can be a parotid gland-sparing technique. Anuj Peddada, MD, stated that the IMRT head-and-neck patients continue to have increased salivary function for one and one-half years following radiation treatment. Pilocarpine (Salagen), amifostine (Ethyol), and Evoxac (on clinical trial) are medications to increase salivary production or act as a barrier during radiation therapy.

The radiation oncologist cannot totally avoid the salivary glands in cancer treatment. The question asked is, "What good is a moist mouth if the patient is dead?" Penrose Cancer Center has been in existence for 50 years. In that time, we have not seen as severe a case as mentioned in the article "If Only2." If the patient complies with our instructions given to him or her and returns for follow-up as directed, then the dentition remains intact.

This article relays the tragedy for the cancer patient and the family and friends of the patient. Fortunately, in 50 years, we at Penrose Cancer Center have not seen this severe a case.

Vickie Mathers, RDH, BA
Colorado Springs, Colorado

Editor's Note: Mathers is a oncology dental hygienist at Penrose Cancer Center.

A testimonial for loupes

Dear RDH:
I am writing in response to your article on equipment ownership (October 2003 issue). Last year, I purchased loupes at the dental convention for myself. It was a last-ditch attempt to alleviate the constant neck pain I was experiencing. I had been in pain for more than a year prior to buying the loupes. I decided I would try the loupes. If that didn't help, I would buy a new chair. If I was still in pain, I would explore new career options.

After a few weeks of wearing the loupes every day, my neck pain was almost completely gone. I was happy and relieved that my hygiene career was not over after only six years of practice.

I work in a large practice with seven dentists. When I bought the loupes, I was the only one who used them. I got a lot of teasing from staff and dentists. I use the flip-down style, and sometimes I walk down the hall with my loupes still flipped up. I still get comments about my "six-eyes."

However, the patients' responses have been entirely different. The patients regularly ask about my glasses. The reactions range from quiet acceptance to enthusiastic approval. I've never had a negative or teasing response about my loupes from a patient. Patients intuitively understand the loupes allow me to do a better job.

One of the dentists now wears loupes, and I suspect more will follow. I feel using loupes has become a standard of care and all hygienists and dentists should use them. It has had incredible benefits for my health, and I know the improved vision has allowed me to serve my patients better.

I recommend the flip-down style of loupes for anyone thinking of buying them. They have a greater angulation than the embedded loupes. This allows the operator to keep his or her head straighter, which puts less stress on the neck.

Laurel Loomer, RDH
Los Gatos, California


About the cover

On this month's cover, three members of the Esprit de Corps synchronized skating team bid you a happy holiday season! All three are also dental hygienists:

Click here to enlarge image

• Penny Williams (left) is a 24-year veteran, who currently practices in the offices of Drs. Cooper, Spiller & Forgosh in Tewksbury, Mass., and Dr. Barry Danzig in Billerica, Mass.

• Linda Gallagher (center) is a 21-year veteran of the profession, and she currently practices in the offices of Dr. Meera Ohri & Associations in Framingham, Mass.

• Debra November-Rider (right) has been a clinical instructor and course director at Forsyth Dental Hygiene Program at the Massachusetts College of Pharmacy in Boston for the past 11 years. In addition, she has been associated with the offices of Drs. Sowles and Trauring in Boston and Brookline, Mass., for the past 13 years.

The three dental hygienists are part of a team of 20 skaters on Esprit de Corps. The team began its season this month with a competition in Bourne, Mass. The competitions lead to Eastern Synchronized Skating Championships in Providence, R.I., next month. The skaters' goal is to compete in the National Synchronized Skating Championship in San Diego next March.

"Esprit de Corps will have competed or performed a total of eight times before our season ends in May 2004," Gallagher said. "We are all looking forward to another fun and successful year. Esprit de Corps is currently the Eastern champions, as well as the national synchronized skating champions for the last three years — something we are all very proud of.

"It is a very special bond and friendship you develop with your teammates, as well as the members of the other teams."

Synchronized team skating is essentially an ice dance, where team members move together in a "Rockette" style performance. Each team consists of at least 14 skaters (a maximum of 20), and the teams execute a series of maneuvers, including "circles, lines, wheels, and blocks."

All skaters must execute each move with speed and precision. The judges consider artistic content as well as the difficulty of maneuvers.

The cover photography was shot by Tom Wehde at the Norfolk Arena in Norfolk, Mass.


To submit letters to the editor for publication in Readers' Forum, send by:

• Mail — P.O. Box 3408, Tulsa, OK 74101
• E-mail — markh@pennwell.com
• Fax — (918) 831-9804
Besides a "signature," letters also must indicate the city and state where the writer resides or practices.

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