Polishing the apple to the core

If it turns out that what we do down there under the gums is saving the lives of our patients, then we must act as if what we do is more than just removing stain.

If it turns out that what we do down there under the gums is saving the lives of our patients, then we must act as if what we do is more than just removing stain.

Shirley Gutkowski, RDH, BSDH

Most people want to save on expenses. Patients do, doctors do, and so do hygienists. So, are our financial goals at odds? Lower practice overhead means the doctors keep more profit. If they can get a less expensive hygienist, that`s more money for them. It sounds logical, right? As employees, one of our goals is to be well paid. Along with maintaining a good reputation and providing health to patients, both doctors and hygienists want to prosper.

Realistically speaking, then, our goals are the same. We simply don`t agree on how to get there. Financial gain for hygienists and, more importantly, holding down preceptorship ultimately comes down to how we are perceived individually and as a group.

The leap over the Grand Canyon

Although we know the mouth is connected to the rest of the body, others fail to recognize this connection. Significant research in the last decade supports the hypothesis that "toxic" chemicals are released into the entire body in the presence of chronic infection that cause systemic diseases. Most people are unaware that periodontal disease, gingivitis, and caries are the most prevalent chronic infections in the world. In most people`s thinking there is a Grand Canyon between the oral cavity and the rest of the body. Recent journal articles have thrown the first shovel full of facts into the chasm of noninformation. So how does this relate to our goals?

If it is ever established that more frequent or complex hygiene appointments will lessen one`s health risks, the public will seek out dentists because the media will tell them to do so. In order to provide these services, dentists will need to seek out hygienists, because it is unprofitable for the dentist to do hygiene functions. This means that more hygienists will be needed in the future. Will they choose a licensed, college-educated health care provider or someone that knows how to run a prophy cup? Generally, patients will not know the difference.

About 50 percent of the population seeks dental care on a regular basis. Probably half of those have no idea of their states` educational and licensing requirements for dental hygienists, or even dentists for that matter. A percentage of these patients may even secretly wonder if dentists just couldn`t make the cut to medical school or hygienists could not handle nursing school. After all, all we do is clean and fill teeth. How we respond to this ignorance is the key to holding off preceptorship.

At the core of all this ignorance is the perception that dentistry is a second-class cousin to medicine. Patients see it that way, medical professionals act that way, dentists practice that way, and hygienists go along with it. To illustrate: only 15 percent of all oral cancers are diagnosed by dental health care providers. The remaining cases are diagnosed by physicians. Patients don`t go to dentists when they have a sore in their mouth; they go to an ENT, GP, or family practitioner.

Even taking into account that only half of the population sees a dentist regularly, that 15 percent figure should make your heart skip a beat. It`s shameful! Consider some other issues:

> 6 percent of the population has oral cancer. How does that translate to your practice referral rate for suspicious lesions?

> 80 percent of the population has some form of gum disease. Is that reflected in your daily schedule?

> 5.4 million people have undiagnosed diabetes; 30 percent of diabetics over age 19 with Type1 diabetes have periodontal disease.

Y Heart disease is the leading cause of diabetes-related deaths. It is two to four times greater than that of adults without diabetes.

Y Stroke risk is also two to four times higher in diabetics

> Paul Harvey tells his listeners that dentists are a primary diagnostician for osteoporosis. Has that ever happened in your practice?

> It took the Surgeon General decades to commission a report on oral health.

Dentistry is not a poor cousin to medicine. In fact, dentistry is a medical specialty, and dental hygiene is a dental specialty.

We all know hygienists that, regardless of their education, provide care as if they were just cleaning ladies (or janitors to be gender sensitive). They don`t follow scientific evidence and are satisfied merely to have a good-paying job and a professional-sounding title. They like the flexibility of the dental hygiene schedule with no nights or weekends. They rarely pick up a professional journal. Periodontal therapy never happens in their treatment room and all the patients know their life story. They never recommend treatment, and they don`t seem to care. Their production is low. If a doctor, office manager, or another hygienist brings up production numbers, this "janitor" gets defensive and accuses the doctor and staff of treating gum disease "for the money."

All hygienists share the same prestige and the same legal responsibility to the patient. In many cases, patients are paying premium prices for mediocre dental services. Ruefully, due to ignorance, the public is not getting equivalent treatment between hygienists. Some providers are just not interested in treating or even referring disease. Doctors, inexperienced in dental hygiene procedures, may not notice until it`s too late for the patient.

Knowledgeable hygienists often try to soften this disparity by thinking, "Well, at least I can sleep at night." They know that their patients are being treated appropriately! The sad truth is that the "other" hygienists never lose sleep either. They often share patients and office space. They also share the same level of respect and salary. They are considered equal to the hygienists who make special trips to the dental library to catch up on new research or those who treat periodontal disease with the latest technologies.

That`s why the doctors are yelling! Doctors don`t want hygiene to be a loss leader. In some cases, hygienists are paid more per day than they produce. Worse yet, hygienists are failing to discuss needed dental treatment or perhaps cosmetic services with patients. They are following some misplaced moral superiority over making treatment recommendations, or because the conversation never got that far, which is wholly unethical.

Between employed, unmotivated "janitors" and offices where good hygienists don`t want to be employed, a shortage seems genuine. But even if the shortage is true, preceptor hygiene is not the answer. Doctors must back up their excellent hygienists, and we, as a group, have to encourage the other dental professionals to strive for excellence. We cannot look at preceptorship as a turf war and scream every time an assistant polishes someone`s teeth. The issue is patient health. Polishing does not enhance health. In order to achieve a win/win situation, we must keep our eye on the core issue. Who better to police hygiene than us?

The heart of the preceptor problem isn`t how much money we make, or who does the polishing or flossing, or the superabundance of hygienists in any given state. It is the perception that dentistry is reparative not medical. It is the perception of dentistry as a luxury for rich people, so they can have the perfect smile. It is the perception that hygienists make a nice living polishing teeth.

If it turns out that what we do down there under the gums is saving the lives of our patients, then we must act as if what we do is more than just removing stain. Science supports this, professionalism demands it, and our livelihood depends on it.

I supposed this commentary will infuriate some and knock others off their chairs. As Walt Kelly`s famous quote from Pogo declares: "We have met the enemy and he is us." I challenge hygienists to provide an excellent role model for those less motivated. Our profession is bound to be more secure if we will be as professional as the title RDH claims we are.

Shirley Gutkowski, RDH, BSDH, has been practicing in Madison, Wis., since 1986. She is a frequent contributor to the internet lists, rdh@egroups.com and sci.med. dentistry and was recently published in Nursing Case Management. Gutkowski presents seminars for nurses and nursing assistants on oral infection control in long-term care facilities. She can be reached by e-mail at shirdent @aol.com.

More in Public Health