by Helen Seubert Forner, RDH, BSDH
According to "Oral Health in America: A Report of the Surgeon General" in 2000, the National Children’s Oral Health Foundation (NCOHF) views pediatric dental disease as the number one chronic childhood disease in America. It is a public health issue compelling dental professionals to find solutions.
Foundations throughout the United States have outlined strategic goals to provide comprehensive dental care to economically disadvantaged children. A number of dentists and dental hygienists are working in mobile dental units providing oral health care to children in rural areas. One school in New Mexico with a dental hygienist on staff has decreased dental disease in many students and has helped the parents of children experiencing constant pain by guiding them through dental care systems. Dentists, hygienists, and assistants periodically volunteer at community free clinics even though the Federal government provides funding for dental care through Medicaid.
Yet, a boy from Maryland still died recently as the result of untreated dental decay. In addition, over the past 14 years, the dental profession has seen mounting evidence linking the bacteria associated with gum disease to heart disease, preterm low-birth-weight babies, as well as an increased risk of weakened immune systems, diabetes, gastric ulcers, osteoporosis, and respiratory disease.
Clearly, while there are promising signs in areas where work is being done, not enough children are being treated overall. That is only compounded by the fact that the medical problems associated with poor oral health are growing.
Could expanding the role of the registered dental hygienist be the missing link to a viable solution? Are our professional assessments a practical tool for medical doctors who are performing routine physical examinations? Can dental hygienists as a group ignite a profession — operating much as it began 93 years ago — transforming it so that it is relevant to society’s current and future needs?
Examining the Roots of the Problem
In 1914, Dr. Alfred C. Fones initiated the dental hygiene movement with his discoveries of how decayed teeth outranked all other physical defects in school-aged children. It is rather astounding to note that as we near the 100th anniversary of our profession, Dr. Fones discovery is still the number one chronic disease facing children.
By today’s definition — one which varies little from that outlined long ago — the process of dental hygiene care involves five steps:
- Assessment — Gathering data.
- Dental hygiene diagnosis — Interpreting the data into a coherent description of a client’s condition in terms that can be addressed by a dental hygienist.
- Planning — Determining the techniques that will solve the problems indicated in the dental hygiene diagnosis and the order in which those techniques will be applied.
- Implementation — Carrying out the plan.
- Evaluation — Determining the effectiveness of the work that was performed.
A Mere Technicality
The second step above, dental hygiene diagnosis, acknowledges that diagnosis is being performed. However, a review of the current CDT Code Book on Dental Procedures and Nomenclature (CDT) in the diagnostic section reveals that the definition of the "Clinical Oral Evaluations" does not acknowledge that dental hygienist have the cognitive skills necessary for patient evaluation.
In fact, the CDT code book defines clinical oral evaluations as: "The codes in this section recognize the cognitive skills necessary for patient evaluation. The collection and recording of some data and components of the dental examination may be delegated; however, the evaluation, diagnosis and treatment planning are the responsibility of the dentist. As with all ADA procedure codes, there is no distinction made between the evaluations provided by general practitioners and specialists. Report additional diagnostic and/or definitive procedures separately."
There are no diagnostic evaluation provisions for the dental hygienist who is working under "general supervision." We collect and record the data necessary to evaluate, diagnose, and treat the patient within the realm of the practice of dental hygiene, but lack the American Dental Association procedure codes that recognize the cognitive skills necessary for diagnosis, evaluation, and treatment.
Consider the impact of these limitations using this scenario, under application of general supervision as it is written today. A six-month recare patient is seen by a dental hygienist. Six months prior to this visit, the patient’s oral health was determined to be healthy.
On this day, however, the hygienist notices that the patient’s oral health has deteriorated. She has subgingival calculus, bleeding upon probing, and generalized four-millimeter pockets with isolated six-millimeter pockets on the first and second molars. There is Class II mobility on tooth No. 15, clicking with the left temporal mandibular joint and suppuration around No. 24 and No. 25.
The oral cancer exam is negative. But the recorded health history reveals the patient has been taking Effexor as a new treatment for anxiety. Her husband died five months previously from an aneurysm and the patient has taken up smoking.
During the examination, the hygienist takes a full series of X-rays, records the findings, reviews the medical history, completes an oral cancer exam, conducts full periodontal charting, and checks for mobility, suppuration, and bleeding points.
Applying the cognitive skills acquired from professional education and experience, this patient would not be treated with a routine prophylaxis. Instead, the patient would be better served with therapeutic quadrant scaling, root planing, and more frequent periodontal evaluation appointments. However, the services rendered for this particular patient visit do not include a fee for this diagnosis.
It is inappropriate to charge a fee for the oral evaluations performed by a dental hygienist under "general supervision" because of the restrictions defining the clinical oral evaluation in the CDT code book.
The Missing Link
Given the public’s overwhelming need for more prevalent and pervasive oral care, the dental hygienist needs a code, a term, and a definition. The key to delivering the oral care to a broader spectrum of the public exists within the very foundation of the ADA procedure codes.
In order to better utilize our skills for the greater good of the community and public health, it is time to expand the role of the dental hygienist. It is of grave importance for the ADA to provide dental hygienists with the diagnostic tools necessary for clinical oral evaluations.
In honor of the dental hygiene profession nearing its centennial anniversary, I present a term, definition, and codes providing a transition to eradicate the oral health-care problems that remain a public health issue today — Dentolytical Analysissm.
Dentolytical Analysis is the application of the cognitive skills used during diagnostic clinical oral evaluation by a registered dental hygienist under general supervision, addressing that which is necessary for proper patient evaluation, diagnosis, and treatment within the realm of the practice of dental hygiene, and includes the recording of the patient’s vital signs. (The latter bridges the gap between oral and medical assessments.)
I propose the ADA board adopt the Dentolytical Analysis (DA) to be included in the diagnostic section of the CDT code book.
It could say: "The DA codes in this section recognize the cognitive skills required of the registered dental hygienist for proper patient evaluation. The collection and recording of some data and components of the Dentolytical Analysis may be delegated; although the evaluation, diagnosis, and treatment planning are the responsibility of the dentist. Under ‘general supervision,’ the evaluation, diagnosis, and treatment within the realm of the practice of dental hygiene are the responsibility of the registered dental hygienist. As with all ADA procedure codes, there is no distinction made between the evaluations provided by general practice hygienists and the hygienists of specialists. Report additional diagnostic procedures separately."
ADA codes that could be devised to include the Dentolytical Analysis are:
- D0120 (DA) — periodic oral evaluation — established patient*
- D0140 (DA) — limited oral evaluation — problem focused*
- D0145 (DA) — oral evaluation for a patient under three years of age and counseling with primary caregiver*
- D0150 (DA) — comprehensive oral evaluation — new or established patient*
- D0180 (DA) — comprehensive periodontal evaluation — new or established patient*
The asterisks above are for the footnote of "will require the recording of the temperature and blood pressure every time the (DA) code is used by the registered dental hygienist under general supervision."
The Benefits of Updated Codes
Expanding both the ADA codes and the role of the dental hygienist would prompt a wide range of positive changes within the dental profession, within the public health sector, and within the community of children. For example, imagine the positive impact of having a dental hygienist in every school in the United States. There are many free clinics and dentists currently offering dental care to the children of Medicaid recipients. However, because many of the children lack transportation, they have no ability to attend scheduled appointments. Dentists, however, are reimbursed for these children regardless of whether the patient shows up for an appointment. A better solution might be for those reimbursement monies to be applied as salaries that fund the placement of a dental hygienist at each school.
The codes would also combat related problems. In an RDH (July 2007) article titled, "Back to School," Christine Nathe reports, "U.S. children experience an estimated 52 million hours lost from school each year to dental related illness." Of course, lost time at school equates to a myriad of other problems. It also points to the tremendous risk facing such children who are suffering from untreated dental caries — not the least of which is death.
Expanding the codes and the role of the dental hygienist within "general supervision" is a win-win situation for all involved. It has the potential to significantly increase professional opportunities for the dental hygienist and transform the profession. It would help to combat burgeoning public health issues that threaten a toll on society, insurance companies, and Medicaid. And most important, it would address the critical needs of children, helping to bridge the gap between their oral health and overall well-being. For all of these reasons, it is time for the ADA to seriously reconsider its current approach and to grant the proposed Dentolytical Analysis code changes.
About the Author
Helen Seubert Fortner, RDH, BSDH, is the creator of the Dentolytical Analysissm. She received her bachelor’s degree in 1983 from the Medical University of South Carolina, Charleston, where she has recently relocated. Helen is known in Virginia Beach and Charleston by her "Pynk" Panther Temporary Dental Hygienist, LLC. The "Pynk" Panther welcomes you to visit www.pynkpanther.com or www.dentolyticalanalysis.com, or send an e-mail to [email protected].