Readers' Forum

I was delighted today when I picked up my August 2003 RDH and saw an article pertaining to the link between Crohn's disease and the oral cavity.

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A personal experience with Crohn's disease

Dear RDH:
I was delighted today when I picked up my August 2003 RDH and saw an article pertaining to the link between Crohn's disease and the oral cavity. I have been wondering for a number of years why there has been nothing mentioned about this, either at seminars or in educational magazines.

In 1998, my daughter, Elisabeth, was diagnosed with Crohn's disease. Looking back on it, I believe she had early symptoms of this damaging disease for several years prior to diagnosis. One of those symptoms was chronic aphthous ulcers. Being a dental health professional, I felt helpless to do anything but treat the pain with various ointments, have her switch toothpaste, and even have her stop taking a chewable vitamin C, thinking the ascorbic acid might have been irritating her mouth.

When she went off to college, her other symptoms became worse. She experienced cramping after eating, rectal bleeding, weight loss, and generally looked malnourished and felt fatigued. While doing her six-month prophy, I was shocked to see how much enamel had been eroded from her molars. She had no cusp tips on any of them! I started thinking bulimia (even though the erosion was only on her molars and not the linguals of her anteriors), but when she would come home for the weekends, I would watch her eating habits carefully and never noticed her going into the bathroom shortly after eating to purge. I was worried and puzzled as to what might be going on with her.

I want to note that for two years, she was under the care of an internist who treated her bleeding as internal hemorroids and the cramping as stress. I happened to mention her symptoms to my gynecologist who was shocked that she had not been referred to a gastrointerologist. I made an appointment for that week. The doctor himself didn't think she had Crohn's, but wanted to do an endoscopy and a flexible sigmoidoscope. Through a biopsy of two small nodules in her lower colon, she was diagnosed with Crohn's! Later, they did a colonoscopy and found the inflammation where the small and large intestine join. Also, the erosion of her enamel was due to severe reflux, not bulimia.

I know this letter is long, but I want all registered dental hygienists to understand what a role we can play in making sure a patient who might exhibit these symptoms gets the proper medical attention. I have been practicing since 1971, and I think of all the patients I have treated who complained of chronic aphthous ulcers. Now, I am much more vigilant about questioning my patients with this problem, and have alerted the rest of my staff about this link.

Last year, I had a new, male patient in his 30s who told me that all his life he had suffered from recurrent aphthous ulcers. Upon my questioning him further, he said he also suffered from diarrhea and fatigue for as long as he could remember. He had been told by his mother that "this was just the way his whole family was." I encouraged him to see a GI doctor, and told him Elisabeth's story. Six months later, he came back and told me he had been diagnosed with celiac disease, another digestive tract disease. He is now on a gluten-free diet. He no longer has RAUs, is no longer depressed (which he said he had also experienced most of his life) and has lots of energy. This made me feel so good that he had taken my advice!

Please continue educating us. I feel that oral health is so often indicative of a patient's overall health. Thank you for what I consider to be the best dental hygiene publication on the market today! Keep up the good work.

Fran McWilliams, RDH
Conyers, Georgia.

Premedication protocol

Dear RDH:
In your August 2003 issue, Shirley Gutkowski addressed the need for premedication in her column "The Pressure of Premeds." I think she did a great job in accurately portraying the ethical dilemma that any practitioner faces when patients have either forgotten medication or the necessity of premedication is unclear. At the same time, there were a few issues Ms. Gutkowski discussed that need further clarification.

First, (and I believe this is an oversight or typographical error) the current guidelines from the American Heart Association (AHA) were issued in 1997, not 2000. I would recommend that every dental hygienist have a current copy. It can be easily downloaded from www.american heart.org by clicking on Science & Professional>Library>Statements and Guidelines> Endocarditis.1

Second, regarding discussion on the elimination of premedication, antibiotic overuse is an issue. The reason that we should be concerned about it is because we must keep in mind that giving someone an antibiotic is never risk-free. It is not uncommon to hear health-care professionals justify premedicating someone "to be on the safe side." Considering that any patient at any given time may have side effects ranging from gastrointestinal upset, skin rash to death from anaphylaxis, particularly from drugs derived from the penicillin family, no such safety net exists.2,3,4 However, it is not just overuse that is the concern. An emerging issue in premedication is the fact that the link between dental procedures and infective endocarditis (IE) is speculative — one linked through events in time and not concretely determined.2 A 1998 population-based case-control study concluded that dental treatment was not a risk factor for IE, even in those with cardiac valvular abnormalities, and that few cases of IE are preventable with premedication.5 Others have noted that about 40 percent of patients who develop IE have no known risk factors.4

Thirdly, Ms. Gutkowski notes that giving the antibiotic within two hours after the procedure was an animal study and is not acceptable. This is correct. But what is important about this fact is that most procedure-related bacteremia is short-lived. The highest onslaught occurs within the first 30 seconds and the blood is considered sterile 15 to 30 minutes after the completion of the procedure.2,4 Therefore, it is difficult to imagine a significant preventive impact when a drug is given "after the fact."

Premedication is not just a medical issue but a legal one as well. Despite current research and opinion that dental procedures may not be causal for IE, the 1997 AHA Guidelines still remain as current protocol. If there is any doubt about complying, keep in mind that if a patient contracts IE, there is a high risk of morbidity and/or mortality. And even though the current guidelines state they are not intended as a standard of care,1 to knowingly not follow protocol would surely be difficult to defend in a court of law.6

Finally, if this really is happening to you weekly, as Ms. Gutkowski implies it is for some, please schedule time to speak with your employer about developing guidelines on how to handle this situation. No one needs to be repeatedly put into an unethical and legally challenging situation. Schedule all new patients for an exam only on their first visit so that there is no "wondering" about that "little murmur" any longer. When confirming appointments with patients already scheduled, speak with the patient personally to reiterate the necessity for premedication. Finally, if there is a need for a medical consultation, let's keep in mind that nurses as well as physicians can often confirm the medical history and premedication need of the patient, rather than only trying to speak with the physician.

Carol A. Jahn, RDH, MS
Education Programs Manager, Waterpik Technologies

References
1 Dajani AS et al. Prevention of bacterial endocarditis: Recommendations by the American Heart Association. Circulation, 1997; 96:358-366.
2 Durack DT. Prevention of infective endocarditis. N Engl J Med, 1995; 332(1):38-44.
3 Imperiale TF, Horowitz RI. Does prophylaxis prevent postdental infective endocarditis? A controlled evaluation of protective efficacy. Am J Med 1990; 88(2):131-136.
4 Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically compromised patient. Periodontol 2000 1996;10:107-138.

Editor's Note: Shirley Gutkowski, the author of the "Thinking Sharply" column in RDH, adds the following message to the letter writer above: "Thank you for your thoughtful response to my column. The topic of premedications is a complex one, difficult to address entirely within the confines of a single column. Your insights helped answer additional questions about understanding what is studied, and how or why it can be incorporated into our daily routines."

Additional observations about avulsed teeth

Dear RDH:
Your article, "Nice play, but does it hurt?" (August 2003 issue) nicely summarized several issues about dental traumas, but a few key points regarding avulsed teeth deserve greater emphasis.

First, speed is paramount, particularly for adolescents and young adults. An avulsed tooth must be treated quickly; chances for success are optimized if the tooth is replanted within two hours. During this time, the tooth must be kept wet to minimize loss of periodontal ligament (PL) viability. The dessication from even a few minutes of drying significantly reduces the chance for successful replantation. Therefore, in the flurry of activity following an injury, place the tooth immediately in saliva (patient drool, not the buccal vestibule), which is usually available. Do not store the tooth in saliva longer than 30 minutes because of its hypotonicity. Only use water as a last resort and for less than 15 minutes while another long-term storage medium is found.

The preservative value of storage mediums depends on time, temperature, and isotonicity. Tooth rescue devices such as the EMT Toothsaver™ and Save-A-Tooth™ contain buffered salt solutions that mimic physiological fluids (similar to tissue culture medium). These pre-prepared devices provide immediate convenience in an emergency. Because the tooth is easily visualized in these solutions, handling trauma can also be reduced. Furthermore, some studies suggest that these solutions may lengthen the time period permitting successful replantation of avulsed teeth without requiring refrigeration. In emergency situations, these reduced time and temperature constraints can ultimately improve patient outcome.

At room temperature, milk is only acceptable for short-term use. When iced or refrigerated, milk should only be used to store an avulsed tooth for about 90 to 120 minutes. However, an avulsed tooth may not be easily visualized in a container of milk. Neither water nor Gatorade should be used for long-term storage, as both substantially reduce PL cell viability within a few minutes.

Finally, many teachers, athletic trainers, and physicians are unaware of the importance of the expedient and appropriate treatment of avulsed teeth. Because one-third of dental injuries occur during sports activities, parents must insist that responsible individuals receive appropriate education and training, and that protocols are established to provide guidance. Moreover, the use of protective mouthguards should be mandated, as these offer the best solution — prevention.

Curtis P. Hamann, MD
Pamela A. Rodgers, PhD
SmartHealth

Acupuncture remedy strikes a chord

Dear RDH:
I just finished the article in your August issue titled, "Her answer was acupuncture." What a great story! I have been in the dental business for 22 years, first as a dental assistant and then as a dental hygienist for the last 17 years. Recently, I graduated from "acupuncture school" and was thrilled to see that Pamela Newhouse finally got relief from her occupational injuries through acupuncture.

After experiencing first-hand the occupational hazards associated with our field, I, too, became quite concerned about continuing in a field that could cause such pain and discomfort on a daily basis. I also cut my hours down to part-time. But after my divorce five years ago, I was forced to re-evaluate how I was going to, first, survive on a part-time hygiene salary, and, secondly, whether I really wanted to compromise my health working full time. That's when I decided to go back for my master's degree and become an acupuncturist. Not only is this old/new field "up and coming," it is much less taxing on my body. The joys of learning such a fine art are also truly rewarding!

I look forward to helping my fellow hygienists/colleagues realize and finally resolve their pain.

Nancy A. Fisher, RDH, LAc
Huntington, New York

Supervised neglect for delicate sensibilities

Dear RDH:
Cathy Point of California has a very good definition of what it's like to perform such a tiring routine. I know this, because like many of us hygienists, this is a daily and ongoing work regimen praised by the employer's collections and loathed by the hygienist.

Unlike the softer side of patient care, this side demonstrates and exemplifies the frustrations caused by weariness, fatigue, and the desire to withdraw from denistry. Forever.

I'll wave my hand and say that it's my fault for allowing such a system to excel in the practice that I've been at for over 13 years. The former dentist began the shorter appointment times, because he felt I needed to see more patients so he could pay me. I learned to adapt and he appreciated the revenue that system produced. Naturally. Did I make any more money? No. Did I receive any bonuses? No. Did I have to stay an hour after closing — when everyone else had left? Yes. Was I an idiot? You bet!

Could anything get worse? Why, heck yeah! Since the former dentist retired, I see an average of 10 to 12 patients a day. Sometimes, I have 15. No, I'm not telling you a story. It's true. Do I still stay late? Yes. Do I get paid any overtime? No. Do the collections love me? Oh, yeah. Am I stupid or just too delicate to revolt? Yes, I guess that I am stupid, but I have been known to throw little temper tantrums from time to time. This does allow me a few weeks with a moderate schedule and some time to build up frustrations before the next tantrum.

Currently, I work for a trust fund for three kids, attorneys and who knows what else. Do they appreciate my "too many patients" schedules that's accomplishing their bank accounts and futures? Probabaly not. Do they care? Ditto.

What was that all about, you ask? Remember the Clara Harris case? Yes, that's right. You got it. Talk about stupidity and delicate sensibilities.

Someone recently told me to get out and do something else. That advice was not without merit. When I attend continuing education, all I hear are complaints on one side and how hygiene is the most rewarding career on the other. There's also my favorite: How to love your job again subject, not to mention the "would you suggest a career of hygiene to others?" No, I don't want to love it. I've seen the worst and, honestly, I've learned that for the most part; it's not worth it. For career suggestions, become a registered nurse or anything else but a hygienist.

For those of you hygienists who love your job, career, employer and staff, that's awsome ... and bravo! But, there really are a lot of us out there who have been unable to suppress a true dislike of dysfunctional offices. Regardless, whether or not it was our own doing and for what ever reason, we can't seem to remove ourselves from our current position of dedication and loyalty. Or stupidity.

Lisa Morgan-Huff, RDH
Baytown, Texas

The underlying problems

Dear RDH:
I'd like to respond to Cathy Point, the hygienist from California who thinks we all ought to "unite and demand" one hour per patient (Readers' Forum, August 2003). Are all patients created equal in California? All hygienists created equal? And every practice the same?

I think this viewpoint grants us the "prima donna" title we all hate to hear. I guess I have been fortunate to work my 19 years in practices that allow me to "ask" for the amount of time I need for that patient's individual needs. This is where we need to agree, assigning time by the patient's individual needs. (Does the doctor take the same amount of time for a single crown prep as for six? Does he schedule the same for a deciduous extraction as for molar root canal?) In the practices where the doctor saw the new patients first, even the time needed for them has been assessed, and I didn't have to cram all that the patient might need into one appointment.

I think most times when hygienists feel they are asked to do too much in an appointment, the real problem is they feel unappreciated for what they do. The doctor feels his highest paid employee is just that — overpaid. The rest of the staff feels the hygienists make so much more than they do that they don't care to help the hygienist with their schedule.

With all due respect to RDH's annual salary survey, I would like to see questions concerning satisfaction. I think that hygienists are more likely to leave a job due to being unappreciated as they are to leave due to pay disputes. And even when pay is given as the reason for leaving, often the hygienist felt her efforts were taken for granted — and, then, any amount of time or pay is not enough.

Marsha McNutt, RDH, AQP
Mansfield, Ohio

Control issues

Dear RDH:
I sympathize with Cathy Point's letter to the editor "Shortcuts are also called supervised neglect." I, too, suffered from a lack of authority to work as I saw to be in the best interest of my clients and myself. I spent my first three years in this profession searching for an office that had the right fit for me and another six years to find a place where I could adjust some aspects of the office to fit me. Cathy hit the point of the problem that dental hygienists face almost everywhere.

Dentists have too much control of the dental hygiene profession, resulting in a conflict of interest. Dentists can have larger profit margins when dental hygienists' work is paid for through dentists' establishments and is done quickly and at poorer quality. Far too many employers take advantage of that situation. This is why there is an ethical principle, which the American Dental Association claims to support, that all professions should regulate themselves.

I don't agree with Cathy's answer to the problem, however. She should definitely have the right to decide how long she needs for each client, but just as I do not feel a dentist should be imposing time constraints on dental hygienists, I do not feel our profession should do so. Instead, I hope Cathy and the rest of our profession will unite in demanding the more basic principle of self-determination for our profession, its members, and its clients. This will occur when regulatory boards that regulate dental hygienists have more dental hygienists than any other profession, legislators listen to dental hygiene lobbies on dental hygiene issues, and dental hygienists have the legal and recognized authority in making clinical decisions about the conditions and recommendations we present to clients.

We can accomplish the goal of self-determination through membership in the American Dental Hygienists' Association and activities on its behalf, being an active part of the political process, educating clients about the politics that affect our work, educating advertisers that fail to mention dental hygienists as the primary resource for home care advice and preventive therapies, and refusing to take jobs where the work or environment makes us second-class citizens.

Howard M. Notgarnie, NCTMB, RDH, BA
Aurora, Colorado

Clueless guinea pigs

Dear RDH:
I just moved from Alabama and I witnessed the ADHP in action as a certified dental assistant. I have developed the desire to become a dental hygienist while I was living there. I refused to even attempt to begin training on live patients who had no clue that they were being used as human guinea pigs.

I would have had no idea that I was doing anything wrong until it was too late. That whole situation is horrible and unbelievably wrong. It is so true concerning the dentist and why they choose to have a short-cut trained "hygienist" to work cheap in their office. I mean being certified didn't mean a thing either. I am surprised that they managed to sneak in an accredited school in Hanceville, Ala., at all. I hope that some day there will be a national outcry about this and it will be illegal to do such a thing to unknowing patients. Thank you for allowing me to speak my thoughts on that whole pitiful training program.

Tanya Burney, CDA
Eielson AFB, Alaska

Tired of being degraded

Dear RDH:
I realy enjoy reading your magazine and it is real helpful at times. What I do not enjoy is in nearly every issue since I started receving them in 2001, there is always some article degrading preceptor-trained hygienists. I am one of these non-"college trained" hygienists and I do not appreciate being degraded and put down on how I chose to obatin my degree when I pick up your magazine.

I decided to go through the preceptorship program instead of the two-year course because:

• There was a waiting list to get into the only two-year program we have.
• I have a family to support and I had to keep my day job.

I could not have given up my assisting position in order to go work at Wal-Mart in the evening for $6.25 an hour. I worked as a certified dental assistant for 10 years. Yes, I was a college-educated dental assistant before I went through the hygiene program at UAB.

The article in your July 2003 issue pertaining to this issue needed to be researched a little more. For example, we were trained by a well-known Birmingham periodontist all through the course on how to scale and root plane properly. If we were not trained for it, then why does the board require us to find a patient who had mainly subgingival calculus that shows up on a radiograph in order to take the board exam?

The course cost me, not includng books, nearly $800. I had to pay for it out of my own pocket, not the dentist. All of these "college" trained hygienists who write all these articles and put "preceptors" down need to take a good look in their own "college" pool. I have met and worked with several who needed to take a step back and go over what they were trained to do because they were not doing it.

With both types of hygienists, you have some who do not live up to the title of RDH. So why is it that the only ones I see getting any heat about their job performance are preceptors? We all work in the same profession and do the same thing every day, and it would be so great to quit putting people down.

I am hoping that I do not read through this great magazine to find a degrading article anymore. I am sure that RDH can find something more educational to put in those spots.

Sherri M. Brooks, CDA, RDH
Birmingham, Alabama

Good value for one preceptorship degree

Dear RDH:
I agree with "The defense of a speaker " statement (August 2003 Readers' Forum). I also have heard Anne Guignon speak recently and feel like she is a great motivator for our profession. The real shocker should be: I am a hygienist from Alabama. However, I was very disappointed in the article, "The value of a degree in Alabama" — not that I did not agree with some of the statements made. I also went through the preceptorship program after five years of dental assisting.

My complaint is this: Mrs. Henderson and the overall article made us sound ignorant to our patients and our profession. I have patients who come from other states such as Florida, South Carolina, Georgia, etc., who have had their teeth cleaned by more educated hygienists, but still once a year to every six months come to the office I work to have their teeth cleaned by me.

I also think the article made a harsh statement toward our Alabama citizens. We have professionals such as doctors, lawyers, government officials, and, yes, even educators who come get their teeth cleaned and oral health needs met by us, the preceptorship hygienist. And, no, they are not ignorant about how we obtained our degree.

I also know what an 11/12 Gracey is used for and the location in which it is used. Anyone in this profession who does not know needs to rethink their career decision. I am all for education and support it highly, and hope one day things will change. I take continuing education classes outside of the state, as well as in the state of Alabama, and would match my skills against anyone's.

I have those certain patients who keep coming back. Yes, we get paid less but sometimes when you love what you do and the people you do it for it's not about money; it's about your love for the patients, the doctors, and, yes, even your state!

I'm not saying that all preceptors are wonderful at what they do or even do what they do the right way. I have worked with several who do more damage than they do good, and that is very hard to deal with.

But there are also some educated hygienists who do the same, and I'm sure that Mrs. Henderson herself is aware of this fact. When I am in another state for seminars or continuing education classes along with more educated hygienists, I do not feel insecure. I admire them like anyone else who tries to better themselves. I get along just fine with all of them because we share the same passion and love for the career we chose and the state we chose to practice in.

Michelle Caldwell, RDH
Alexander City, Alabama

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.


About the cover

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Brynne Poore resides in the rural part of Nebraska — as if more cosmopolitan readers from California and New York can imagine a populated section of the state — in a town called Scottsbluff, which is about 20 miles from the Wyoming border. Her introduction to dental hygiene "late in life" is a story worth repeating. A secretary for the local school district, she had wanted to expand her associate's degree in psychology into a bachelor's degree, but the only options that did not involve relocation were teaching and nursing. She was not interested in those fields. However, a colleague in her office announced one day that the University of Nebraska was opening a dental hygiene program in Scottsbluff.

"The minute I heard about this dental hygiene program, I knew it was what I wanted to do," Poore said.

So the 36-year-old set about fulfilling science requirements and re-taking the ACT. "It's pretty humbling to sit next to your son, his old high school sweetheart, the quarterback of the football team, etc., and take a test like that at my age. You can also imagine the hassle it was contacting my old high school to have my records forwarded to UNMC! I'm sure there was a lot of dust and a few spiders in that box."

The university, however, experienced funding problems with the distance-learning program. By that point, though, she was bitten by the dental hygiene bug. After consulting with her family, she moved to Lincoln (six to seven hours away) for two years to finish her degree.

"I have now been out of school for five years and have never regretted the decision. I love this profession," she said.

She continued, "I think the greatest compliment I received was from my youngest son when he started at the university. He was struggling with a class and was frustrated one day. He said he was about to give up when he remembered what I had done and how hard it had been for me. He said he knew he couldn't give up when he thought of me moving to Lincoln all by myself and finishing what I'd started."

In her spare time, Poore enjoys creating "100 percent computer-generated scrapbook pages" and hanging out with colleagues at Amy's RDH Yahoo group (http:// groups.yahoo.com/group/RDH).

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