Make evidence an everyday asset
by Cindy Quinn, RDH, BS
Dental meetings exercise my brain. The recent American Dental Education Association meeting (ADEA) was a new experience for me. While there, I connected more dental hygiene dots than usual. The implementation of emerging technologies, federal incentives for electronic health records, and evidence-based decision-making (EBDM) were among the hot topics. I urge dental hygiene professionals to evaluate and leverage the forthcoming changes. Ask yourself the following:
- How can change shore up the assets of professional practice?
- Why embrace change?
- How can I participate in the implementation of change?
It is often said that to understand the future one must look to the past. Look at what has been driving change within the health-care industry during the past 20-plus years — disease prevention, managed care monitoring, cost containment, and corporate management. These factors set the stage for the current information explosion, high-tech mentality, and interest in electronic records. They spawned the need for interoperability. It is up to the dental profession to shore up the everyday assets of interoperability, using technology, electronic health records, and evidence-based decision making (EBDM) for more advanced patient care.
Interoperability in action
At the ADEA meeting, attendees readily admitted that academic institutions have historically accepted change very slowly. However, the tenor of the meeting last spring was refreshing. Professionals embraced the concept of change and active learning through EBDM principles as a foundation for the future. Dr. Dominick DePaola, Forsyth’s president emeritus, summed it up best in his February 2008 Journal of Dental Education article, “If we desire 21st century clinicians, we are obligated to teach students to learn how to learn. We must teach them to practice evidence-based dental medicine. We must teach them to operate as members of interdisciplinary, primary health care teams.” Of equal importance, practicing dental professionals must redirect their mindset to become lifelong learners.
What will this look like, operationally, for hygienists in the future? Using a female patient example, Hygiene Hannah builds active learning into treatment:
MWF, 49 and holding, seeks competent hygienist; has Hashi-moto’s thyroiditis and thyrotoxic myopathy, dry mouth, and periodic cardiac arrhythmia. Takes 13 meds. Desires veneers. Low mileage on amalgams.
Hygienist Hannah examines MWF, reviewing the electronic health record on the chairside computer screen. She updates digital radiographs, locates all side effects of medications, reviews treatment implications for Hashimoto’s thyroiditis and thyrotoxic myopathy, and logs vital signs into the computer as part of her risk assessment. Through the 2008 Merck Manual, Hannah references information on Hashimoto’s and finds the following:
“Hashimoto’s thyroiditis is chronic autoimmune inflammation of the thyroid with lymphocytic infiltration. Findings include painless thyroid enlargement and symptoms of hypothyroidism. Diagnosis involves demonstration of high titers of thyroid peroxidase antibodies. Lifelong L-thyroxine replacement is typically required …
“Patients complain of painless enlargement of the thyroid or fullness in the throat. Examination reveals a nontender goiter that is smooth or nodular, firm, and more rubbery than the normal thyroid …
“Occasionally, the hypothyroidism is transient, but most patients require lifelong thyroid hormone replacement, typically L-thyroxine, 75 to 150 µg po once/day.”
Hannah then reviews fellow hygienist Sandi Roggow’s clinical report titled, “Thyroid disease and oral health,” from the February 2009 issue of Access, and three sections attract her attention:
“The use of epinephrine or other pressor ammines can cause a hypertensive crisis in a patient with uncontrolled hyperthyroidism. These patients can also be at risk for complications of hypertension, cardiac arrhythmias and congestive heart failure. Patients with hypothyroidism need to be well controlled before having dental treatment … Dental treatment modification may be necessary for dental patients under medical management and follow-up for a thyroid condition … The common oral implications in hypothyroidism include macroglossia, dysgeusia, delayed eruption, poor periodontal health, and delayed wound healing. A patient with hypothyroidism is susceptible to cardiovascular disease from arteriosclerosis and elevated LDL. Consulting with the patient’s primary care provider can give you the information needed to determine the patient’s cardiovascular status…
“Common oral findings in hyperthyroidism include increased susceptibility to dental caries, periodontal disease, enlargement of extraglandular thyroid tissue (mainly in the lateral posterior tongue), maxillary or mandibular osteoporosis, accelerated dental eruption and burning mouth syndrome. Patients older than 70 are at risk for anorexia and wasting, atrial fibrillation, and congestive heart failure. In younger patients, Graves’ disease is the main manifestation … Graves’ disease can also put a patient at a higher risk for connective-tissue diseases like Sjogren’s syndrome and systemic lupus erythematosus … There are no major side effects of thyroid replacement medication that affect the oral cavity. A common side effect of many medications is xerostomia …
“When there is excess of fluoride in the body it can interfere with the function of the thyroid gland. Fluoride has been linked to thyroid problems. Patients who wish to avoid the effect of fluoride on their thyroid can utilize a fluoride-free toothpaste such as CariFree, an oral neutralizer gel.”
Additionally, a Web search for “thyrotoxic myopathy” reveals that it is a muscle disease characterized by the gradual loss of muscular function and control, often concentrated in the shoulders, neck area, and hips. Some patients also report muscle weakness in the face and throat that can lead to difficulty in breathing, speaking, and vision, if untreated.
Hannah reviews the health history with the patient, and then taps keyboard buttons that are dedicated to record standardized acronyms onto the paperless chart. She logs tentative restorative findings, the patient’s interest in veneers, and oral health concerns for the dentist’s review during his exam, again using standardized acronyms. Eventually, the computer will compose a full-text handout for the patient from these acronyms, after decisions are secured during the dental exam. Hannah compares today’s digital radiographs with baseline images taken one year ago, highlights areas that have changed, and enters periodontal data on a voice-activated system, including new 5-millimeter pockets in quadrant two.
These tasks take eight minutes. She electronically notifies the dentist of the pending exam, forwarding her findings, and he screens the information. Hannah secures MWF’s signature for informed consent on the screen and begins the prophylaxis. Her patient education includes diet counseling and solutions for xerostomia, a recommendation for CariFree, and modifications to flossing in quadrant two.
At his convenience, the dentist examines the patient and explains the concerns about veneers with periodontally-involved tissue. He prints off a photo, showing veneers with unhealthy surrounding tissue as a motivation to improve her hygiene. He reviews and accepts all the acronyms that Hannah had placed in the chart. This entry automatically produces a treatment plan, with full cost and diagnostic codes in place for administrative staff processing.
Hannah constructs an e-mail to MWF’s patient-centered medical home as a contact with primary care physician, Dr. Casey. No phone calls, phone tag, or staff time is used inefficiently.
Later that day, Dr. Casey reviews the dental diagnosis from her medical practice and learns that her patient might have periodontal disease. This is new information, since she has never checked anything but the tonsils. She also reads that MWF has xerostomia, a common side effect from two of the medications prescribed. She flags the record to change the medications to those that create less xerostomia, rather than refills. She also evaluates available online data concerning the implications that periodontal disease could pose for MWF’s cardiac arrhythmia.
Four months later, Hannah sees MWF for a maintenance appointment and she mentions a “short trip to the ER that was a false alarm.” However, the electronic health record reflects a TIA. The patient’s new medication is a low-dose blood thinner. A month ago, she also began taking aspirin for frequent headaches. Hannah looks up the data regarding dental treatment and is relieved to have current, accurate medical information before complications arise.
This is interoperability in action.
Now, imagine that the entire encounter just described exists through simulation software that is on the market. What an opportunity for upcoming professionals, and those choosing to become lifelong learners!
The scenario just described is an example of the five-step evidence-based education (EBE) process, which was outlined by Del Mar in the 2004 British Medical Journal editorial:
- Ask … Always ask, “Where is the evidence?”
- Access the evidence.
- Appraise the evidence … think it through.
- Apply … make your decision. Be able to justify and account for decisions based on sound evidence.
- Assess … look at the impact of your decision-making based on the available evidence. Was your action correct? If not, what will you change?
The marriage of technology and evidence-based care
When dental professionals embrace change, data-directed evidence, and coordinated health-care efforts, they encourage comprehensive care. That reduces ambiguity and delayed care for patients, while it prompts better treatment outcomes. Point-of-service decisions made with data and pictures that involve patients’ visual and auditory capacity will increase their understanding of the problems at hand. Not only that, electronic health records eliminate the detective work that stems from the “patient’s version” of their health history, minimizing errors and redundancies.
The treatment data generated from monthly practice serve as a comparative with other practices, to access individual office performance to the norm. These data also highlight variations in staff activities or training that need discussion. Finally, aggregate data disclose gaps in knowledge that have the potential to generate funding for research within academic institutions.
Do these dental hygiene dots generate anxiety or excitement? Will you hide or will you take action? Dr. DePaola characterizes dental professionals in the earlier-referenced article, writing, “We understand that change is necessary but continue to struggle with implementing sustained curriculum reform and regulatory reform. Why? Partly because we have not convinced the dental profession and education community that a crisis really exists … Further, we have not provided a compelling vision for the future. Transformation will require a profound reexamination of what we are doing today and what is necessary for survival and sustained growth.”
Embrace change. No one denies that change requires time and effort, but one should recognize that the changes actually create time and reduce effort, in the long run. For dental hygienists, efficient and effective chairside practice in the future requires action today.
The practice of dentistry within ten years
How is change implemented? Actually, many components for integrated dental and medical care already exist in the marketplace. Learning management systems are computer systemized organizers that manage information into tidy pockets of related data that require no paper and filing.
Online learning systems feature Web-based learning opportunities for coursework that are not only digital, but also often interactive or illustrated in 3-D. Faculty members use these online systems to share successful learning materials and methods with the global community. Often, collaborations form, drawing upon the expertise of specific individuals. Consider future applications for online learning within individual dental practices. Think big — think really big!
Personal response systems have infiltrated university-level courses, and they show great promise for interaction and engagement in nondidactic dental courses. In these systems, students use a remote “clicker” to answer questions generated during the instructor’s presentation. They are engaged in active learning. It also enables the instructor to check the level of students’ understanding before proceeding to a new topic, creates an inclusive environment for shy people or those lacking confidence in their knowledge, and it maintains attention to the material. The instructor knows when someone fails to respond. Will this technology funnel down to clinical practice?
Simulation software was showcased at the ADEA, currently for use in dental school. These tools allow budding professionals to practice a procedure and “reset” to the beginning if they make a mistake or want more practice. Haptic devices even enable a clinician to “feel” the technique at the same time. One can also advance one’s level of “play,” similar to video games.
Who ever thought there was a connection between dental practice and virtual reality? It is easy to see that this technology holds the potential to facilitate an objective measure of clinical competencies. Current clinic faculty finds simulation useful because they can observe students’ didactics with an unrestricted view. They also value the opportunity to capture an image and show the student a specific error in real time. It facilitates simultaneous monitoring of four to five students by one clinic or lab instructor, on imitation patients who show up for appointments, do not chatter or move unexpectedly, and do not sue. Imagine learning instrumentation with software that offers feedback on the exact angle and pressure currently applied without concern about patient bleeding or sensitivity. One should expect to see modified versions of simulation software emerge into private practice, as well.
It is easy to assume that dental schools should provide the starting point for change and the advancement of interoperability. But is that realistic? Academic budgets are tight and facilities constrained. Yet, sophisticated computer systems are essential to reduce staff and errors, better track performance, and monitor graduate requirements.
Certainly, dental schools need priority status on learning management systems, online coursework that decreases faculty face time for nondidactic education, and simulation software. However, assigning the responsibility to allied dental health and dental schools really just circumvents the issue. Practicing professionals must unite to embrace change, insist on evidence-based presentations for continuing education, foster informatics use, and swap data source Web sites with colleagues. They should support their alma mater,. Most emphatically, they must refuse to make treatment recommendations based on anecdotal information. Rather, review the data. Incorporate the five A’s of the EBE process into daily practice. Connect those dental hygiene dots and embrace change. This elevates the profession and leverages the assets of professional practice.
Del Mar C et al. (2004) Editorial, “Teaching Evidence Based Medicine” BMJ (329) 989-990.
Roggow S. “Thyroid disease and oral health” The Free Library 01 February 2009. 09 April 2009 http://www.thefreelibrary.com/Thyroid disease and oral health.-a0194963392.
About the Author
Cindy Quinn, RDH, BS, has dental experience as a clinician, corporate manager, nonprofit program developer, and dental hygiene instructor. This gives her a well-rounded view of the industry, including areas of needed improvement. Visit her Web site at RDHwriter.com or contact her at [email protected].
Terms used with this article
- Interoperability — the ability of component parts of a system to operate together successfully
- Evidence-based care — a philosophy of treatment that relies on up-to-date, germane research as its foundation (Mosby’s Dental Dictionary, 2nd edition. 2008)
- Evidence-based dentistry — evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences. (American Dental Association)
- Active learning — learning that takes place as a result of students’ action and thoughts about that action
- Patient-centered medical home — team-based model of care led by a personal physician who provides continuous and coordinated care thoughout a patient’s lifetime to maximize health outcomes. For more information, see www.medscape.com/viewarticle/589670. (American College of Physicians)