A well-trained dental hygienist with sharp instruments and an ergonomically efficient technique can easily do a good scaling and polishing in 10 minutes on most "normal" patients.Speed it up, "girls"Dear RDH:In the July issue, Dianne Glasscoe responded to a letter (Speed Demon) from a hygienist who complained about another hygienist in the office doing a prophy in 10-15 minutes. The remarks concerning this service were negative and Dianne gave a list of 13 items a hygienist should do which would be impossible to do in 10 minutes.
The public, and indirectly, the dentist, are the ultimate sources of what treatment hygienists should do and the level of service and quality that is needed. Today, people want fast food, fast banking, fast gas station fill-ups, and fast dental service. No one likes to wait. No normal person wants to be in the dental chair having his or her teeth cleaned for 45 minutes when the job can be done in 10 or 15 minutes. Patients do not tolerate long procedures and if a quality service is offered at another office in less time, they will take their business to that office. A dental prophylaxis consists of removing calculus and polishing the teeth. The extras mentioned by Dianne (e.g. blood pressure, exam, inquire about dental problems, etc.) does not need to be done by the hygienist and may not be desired by the patient or the dentist. The dentist may want to do this him/herself as is office policy.
A well-trained dental hygienist with sharp instruments and an ergonomically efficient technique can easily do a good scaling and polishing in 10 minutes on most "normal" patients. I'm not talking about someone who has 30 inches of calculus on his lower anterior teeth, but just an average patient who keeps his or her six-month recall appointments. To say it takes more time to do the cleaning and that anyone doing the treatment in less time is providing lower quality treatment is ridiculous. If, after treatment, the mouth is clean and the dentist and patient are happy, then that is success. Do not equate retardation with quality. In today's competitive world, where the consumer dictates the terms, you better provide fast, efficient, quality service. Anything else will result in the loss of the patient, his or her family, and your job. In my and many of my colleague's practices, fast hygienists earn more money and get more respect from the dentists and patients. The slow ones get less. The real slow ones get fired. It's a tough world out there, girls. Are you up to the challenge?
E.J. Neiburger, DDS
The authors of the Scientific American article developed a measuring device for biofilms using a microelectric tip 1/100 of a millimeter across that has provided some surprising information. Bacteria in a biofilm generally constitutes less than one-third of what is in a biofilm. Oxygen concentration can vary radically between locations as close as 5/100 of a millimeter apart. Local conditions vary and a wide range of conditions can permit several bacteria species to live side by side and thrive (one species feeding on the metabolic wastes of another).
Antibiotics and germ-fighting cleansers may fail to pierce a biofilm. Penicillin has great difficulty penetrating biofilms that produce an enzyme known as beta-lactamase, degrading the antibiotic faster than it can diffuse inwards. As a result, it never reaches the inner layer of the biofilm. Another factor enhancing the tenacity of bacteria includes the fact that microorganisms often survive aggressive treatment that would eradicate free-floating cells via differing conditions and bacterial types found in vitro vs. in vivo. Penicillin, which attacks replicating bacterial cells, cannot do anything to fight nonreplicating cells that are found in certain regions of the biofilm when bacteria are shut down due to lack of nutrients. Active and inactive microbes are situated closely together, and servicing bacteria can use dead ones as nutrients. The few cells remaining after antibiotic therapy can restore the biofilm in a matter of hours. Bacteria often can survive most chemical treatments used to control them, and as most of these chemicals are strong (the concentrations used to kill bacteria), they also interfere with collegenation. A well-known periodontist who lectures around the country uses PerioChip and Atridox only on recall patients.
The fact that these bacteria communicate with one another and have quorum-sensing capability shows we are dealing with something more highly developed than attached and unattached bacteria. These biofilm cells can escape and form new bacteria biofilms, plus have new species joining them at all times. Water flows through the biofilm bringing nutrients in and carrying wastes away. When we are debriding, thorough removal of all colonies should be our objective. Daily use of a Water Pik is probably only removing nutrients and waste, and "seeding" bacteria escapes to form new colonies (i.e., just keeping the status quo). I urge every hygienist to read the article as it pertains to plaque. When you find out that biofilm colonies can grow in Povidone iodine, you can begin to appreciate the dilemma.
The fact is that the medical community never has paid much attention to our bacteremias. They may not be aware of how all the new information on biofilms speaks to the issue. We need to educate the medical community about the link between mouth bacteria and heart disease, high blood pressure, strokes, and diabetes. If you photocopy the "Battling Biofilms" article, it may be of great service to your patients and your doctors.
Mosley's Dental Management of the Medically Compromised (all hygienists should own this as it is considered standard of practice) requires 70 percent of the disease processes that we review on a health history to have a physician consult. Legally, I know that physician consults should have a copy of the physician's OK in the chart — for this reason alone better communication between the dental office and the medical office is needed.
When you realize that there are 20 different theories about what causes auto-immune diseases and you understand the implications of the new information about biofilms — "biofilm seeding" — physician consults may be needed to be looked at more thoroughly. Perio surgery is not recommended on medically compromised patients, and doing two and three surgeries also is not recommended. Quickie prophys do no one a service.
Neither does cleaning above the gumline (as advocated by Kansas dentists who advocate assistants doing this). I have experienced an above-the-gumline cleaning where the tissue was so tight I couldn't get the instrument down to the base of the pocket and all flutings had subgingival calculus. It was a good way to make the patient come back for two or three more cleanings, but also took away valuable information as to where the sub was. How would you like it if one dentist did the crown prep and the other seated it? Same idea!
Recently, I admonished hygienists in one of my letters to the editor to pay attention to the chemicals used in antimicrobials. There is a catch-22 in the use of mouthwashes. If used long term, they may kill bacteria, but they also kill the lining of the mouth. Peroxide is a co-carcinogen; chlorine dioxide is cytotoxic (JADA, July 2000). The longer Listerine is used, the more cytotoxic it becomes. It has been recommended that if you are going to use a mouthwash long term to use warm water, salt, and baking soda.
What this letter boils down to is that there is no substitute for "good dental hygiene." Quality prevention demands more education — not less (as the ADA gives our duties away). Unfortunately, the profession of dental hygiene is unable to demand more and better education.
Since the dentist is in charge of our education, we will never be able to "prevent" as much as we need to. Hygienists should be at the forefront of biofilm research (we are up to our armpits in it daily). Research has mushroomed and will continue to, but we have no educational ladder to attain its heights.
Donna Rice, RDH, BS
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We had a wonderful time in Denver this summer. Hygienists from 30 states gathered in the shadows of the Rocky Mountains for the RDH Under One Roof conference on July 27-28.
It was the first time all seven of the magazine's columnists — Kathleen Adams, Dianne Glasscoe, Anne Guignon, Dr. Joen Haring, Kristine Hodsdon, Dr. Chris Miller, and Trisha O'Hehir — spoke in one location at the same time. In fact, two of the magazine's feature writers — Shirley Gutkowski and Cathy Seckman — were seen mingling in the crowd.
Besides working hard to earn CEUs, we played trivia games, socialized during a wine-and-cheese reception, and enjoyed each other's company at the fine restaurants in downtown Denver.
Several members of the [email protected] list attended and one wrote afterwards, "One roof was almost not enough to cover all the wonderful speakers. I have never heard so many fascinating people in two days. Each had their own area of expertise and presented information in an upbeat manner that held your attention. In 30 years of hygiene, this was the best of the best I have ever seen."
Many thanks to the the readers who attended, as well as the sponsors who worked alongside RDH to present the conference: 3M ESPE, John O. Butler, Colgate Oral Pharmaceuticals, Crosstex International, Dentsply Professional, Diamond General, Oral-B, Ultradent, and Young Dental.
Stay tuned for details about RDH Under One Roof in 2002.
— RDH magazine