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Reader's Forum

Oct. 1, 2002
I am 38 years old, and I have been practicing dental hygiene for 10 years. Before starting a dental hygiene program, I was a CDA for four years.

Shortcuts to professional licensure

Dear RDH:
I am 38 years old, and I have been practicing dental hygiene for 10 years. Before starting a dental hygiene program, I was a CDA for four years. I want to express my thoughts about preceptorship in the dental hygiene profession.

To ask the question, "Why do I need to take one to two years of prerequisites, including the study of English, history, literature, algebra, etc., to practice dental hygiene?" Why not simply eliminate the prerequisites? My answer would be that many of these courses help to build skills of learning, growing, and critical thinking, as well as skills of communication and literacy — skills a professional relies on.

Most dentists are not proficient to deliver hygiene therapy themsleves, much less teach someone else these skills. I have the utmost confidence in my employer's skills as a dentist, but I would not want my employer to give me a prophy much less supportive periodontal therapy or SRP. Most dental students spend four years to learn all of the skills necessary in dentistry as well as hygiene. Hygiene students in an accredited program spend two years just to learn hygiene. Dentists do not have a great deal of time to perfect their hygiene skills. They are too busy providing dental treatment, as it should be.

Some will say there is a shortage of hygienists. However, according to the August 2002 issue of Access, the trend is that there are more hygienists graduating than dentists. If that means there were to be a shortage of dentists, would the dental community be demanding that dental hygienists go through preceptorship programs to become dentists? I believe that the ADA would fight tooth and nail against this.

As for preceptorship itself, I believe it diminishes the profession of dental hygiene. I realize that some people may have a dream of becoming a dental hygienist, but the program should not be diminished to accommodate excuses such as "there is a waiting list," "it is too expensive," "the curriculum is too demanding," "I'm too busy with family obligations," or "the school is not in my area."

These are real concerns, but other professions do not relax their educational standards for these or other valid reasons. Why should the profession of dental hygiene do so? After all, I would not want to be treated by a preceptorship taught dentist, doctor, surgeon, physical therapist, etc. Would you? Even the person that cuts and styles my hair needed to go through an accredited program.

Anyone can learn the skills of a profession, but this in itself does not make the professional.
Roseanne Federico, RDH, BS
Springfield, Oregon

Educating each other about lasers

Dear RDH:
I am writing in response to the article titled, "Demystifying In-Office Whitening" (August 2002 RDH). I realize that the application of lasers still requires a tremendous amout of education. As professionals, we are in a position to educate each other, and then we can educate our patients.

Dr. Doniger did the best she could to clarify the use of lasers in dentistry. She wrote that lasers have a high-intensity output, 700 to 1800 mW/cm2. I have worked with the argon laser, LaserMed 3000, for the past four years. This is a "super glass" fiberoptic laser, and its application goes as low as 150 mW. I use 300 mW of this collimated, directional beam to give minimal surface temperature for maximum results to whiten teeth. I give credit to Dr. Doniger for attempting an unbiased article.

Sooner or later, our dental hygiene and dental schools will bring lasers into the education process. Until that time, let us all keep communicating. Dental hygienists can be a powerful asset in this area, and it is my dream to see soft-tissue and whitening applications with lasers to be a mainstream application in the near future for dental hygienists.
Robyn Cabral, RDH
Temecula, California

Editor's Note: Dr. Doniger responds, "I wish to thank Robyn Cabral for her correction. Yes, an argon laser can function at minimal levels of 300 mW and maybe even lower for dental purposes, such as teeth whitening, with minimal temperature gain or damage. Other, non-dental uses of the argon laser can operate at a much higher mW. In my article, I believe I had indicated a range for mW for all types of lasers."

What's good for pets

Dear RDH:
Your article titled, "Doggie, Open Wide," by Gayle Lawrence (August 2002 RDH) was of great interest to me. I am a licensed registered dental hygienist on staff in the Dentistry and Oral Surgery Service at the University of California Veterinary Medical Teaching Hospital in Davis. This department is directed by two board-certified veterinary dentists and provides a three-year residency program for this speciality.

I am delighted to see articles on the subject of veterinary dentistry because many people are unaware of the importance of good oral hygiene for their pets.

However, I would like to point out some inaccuracies regarding Ms. Lawrence's report.

The teeth of dogs and cats seldom decay like human teeth. Most of their teeth are non-occluding with sharply tapered or conical crowns. The majority of these teeth therefore lack the pits and fissures common to human teeth. In addition, dogs and cats do not snack on sticky, sugary foods that promote the growth of S. mutans and other caries-producing bacteria. However, it is possible an owner may feed a pet inappropriate treats.

Because of the rarity of carious lesions, our patients at the VMTH do not receive topical fluoride treaments to prevent decay, nor do we recommend fluoride products for home treatment. Most pets will swallow fluoridated pastes and rinses applied to their teeth by their owners. Fluoride ingestion may prove to be toxic.

Many cats and some dogs do suffer from painful dental lesions called odontoclastic resorption lesions, often mislabeled as caries. These erosive lesions usually manifest at the CEJ of a crown, continuing to erode root tissue and invade dental pulp. These lesions are not caused by bacteria found in plaque, but are thought to be triggered by small cells called odontoclasts.

However, the etiology of resorptive lesions is not entirely understood.

Ms. Lawrence mentioned the use of a "high-speed handpiece with pear-shaped and pointed polishing burs" to remove calculus. Does any dentist or hygienist scale a patient's teeth with a high-speed handpiece and bur? Is it possible to safely scale subgingivally with this device?

These types of power instruments can damage and remove enamel from teeth as well as mutilate the surrounding attached gingiva. Regrettably, they have been heavily marketed to veterinary practices, and many veterinarians and technicians are using them. Please be aware that these devices are not acceptable to scale the dentitions of veterinary patients, nor would they be acceptable for our own human patients.

The article also stated that "pets do not accumulate plaque and calculus quite as rapidly as humans do." Actually, the etiology and pathogenesis of periodontal disease is very similar to humans. Daily brushing to remove bacterial plaque prevents the development of periodontal inflammation and tissue loss in dogs and cats. Age, body weight, head shape, diet, and chewing behaviors affect the prevalence of disease in individual animals.

I have seen three-year old dogs with a heavy accumulation of plaque/calculus and severe periodontitis. Just as good brushing and oral hygiene habits are important to establish in our young children, it is equally important to begin these same good habits in our pets as soon as possible.

Dental hygienists are truly a wonderful resource for oral hygiene and preventive dental care. As Ms. Lawrence suggested, I urge my fellow professionals to share their knowledge not only with their own patients, but with veterinarians, animal health technicians, and pet owners as well. The same rules of mechanical plaque removal that apply to us are equally helpful for our dogs and cats.
Cheryl H. Terpak, RDH, MS
University of California
Veterinary Medical Teaching Hospital
Davis, California

Use the full arsenal in perio diagnosis

Dear RDH:
I wholeheartedly agree with the central premise of Beverly Maguire's article (July 2002 RDH). Given the extent of periodontal disease in the population and considering that it is the major cause of adult tooth loss, the periodontal exam should indeed be incorporated into every recall appointment.

But how, in this day and age, when it is universally accepted that periodontal diseases are caused by bacterial infections, can you title your recommendations "the complete exam" without even mentioning any of the many tests currently available to determine whether the patient actually has an infection?

Further, the emphasis on probing and bleeding points without any mention of their serious limitations further perpetuates the general perception that these tests are adequate diagnostic tests when they fail the critical test of whether or not they predict future disease. According to the AAP, probing depth measurements are so prone to error, that they are not significant unless the change exceeds 2mm. Even then, it is not predictive of future loss, but only a measurement of past attachment loss.

As for bleeding, it so fails to correlate with disease that the AAP now says that "the absence of bleeding may be indicative of health," i.e. bleeding, per se, is not diagnostic of disease and its absence may or may not be associated with health — hardly a ringing endorsement.

Microbiological tests, in contrast, detect specific markers of disease activity. Commercial culture labs, phase contrast microscopes, and the BANA test can detect the presence of specific disease-associated microorganisms. The TOPAS nucleotide assay tests for serum immunological proteins and the Diamond Probe for elevated sulfide levels associated with anaerobic bacteria.

Any of these tests would provide clinicians with a far greater insight into the risk status of their patients than a reliance on the symptomatic tests outlined in your article. To not even mention them when discussing "the complete exam" is a serious omission.
Bill Landers, president
OraTec Corporation

More reasons not to hunt

Dear RDH:
I would like to respond to Gary Schimelfenig's letter supporting hunting (July 2002 RDH). Sixty million Americans may enjoy "shooting sports" (there are 60 million gun owners in the United States). Of these, only 13.8 million are hunters. Many gun owners never fire their weapons at all. Hunting is a blood sport that is considered unnecessary and cruel by the majority of Americans. Across the nation, hunting is blessedly on the wane. We have approximately 10,000 fewer hunters each year. State wildlife agencies are frantically trying to recruit our nation's children and introduce the very young to the rituals of killing for "sport."

The description of Mr. Schimelfenig's family farm certainly paints a grisly picture. The fact that families had to kill farm animals to survive is understood. Hunters are not killing animals because they are hungry. Their freezers are full. They hunt for the pleasure of the kill and seek this ritual to "bond" with friends and family. I'd like to suggest a nice walk in the woods with a camera instead.

The idea that hunting is somehow more humane than farm-raised animals is ludicrous. Hunted animals suffer hideous deaths from inaccurate hunters who wound and don't retrieve their animals. Hunters even manage to accidentally kill each other on their forays into the woods. Because state wildlife agencies have mismanaged deer herds, we now have a tremendous surplus of deer. This was done to satisfy hunter demands for an "easy kill" and to boost state profit margins. As a result, deer/car collisions have increased dramatically and many human lives have been lost.

The plight of factory-farmed animals has been well documented. They live in filthy conditions and lead miserable, tormented lives until they are finally slaughtered. A visit to a factory farm will change your life forever.

Science dictates that eating meat is unnecessary and possibly quite dangerous. The news is full of stories of e-coli, salmonella, trichinosis, and other lethal bacteria that have invaded our nation's meat supplies. Many have died from consuming these products. Mr. Schimelfenig was correct in stating that hormones and antibiotics are routinely fed to animals. Scientists cannot predict the long-range effects on humans who regularly consume these animals. Please consider that eating animals also increases your risk of heart disease, cancer, and stroke.

Go hunting with you? I think not. "Bless the beasts and the children."
Lynn Donell, RDH
Livonia, Michigan

Editor's note: This all started when we published an article in the March 2002 issue about Julia Egan, who dabbles as a hunting guide. We thought it was an interesting story to tell, and we never intended it to be a comment about the magazine's or the profession's stance on hunting. However, since the article appeared, different writers have voiced their opinions about the "sport." So it's not a matter of a single "fanatic" trying to force his or her opinion on the Readers' Forum. Several people with very strong feelings about hunting — both pro and con — have written letters. We should point out, though, that RDH may publish another 20 years of magazines without a single reference to hunting. It's not our "beat."

Follow risk-management advice

Dear RDH:
Dianne Glasscoe's article on malpractice (June 2002 RDH) is very timely. Risk management has been the focus of my career for a number of years. Over and over, I see sloppy recordkeeping result in problems for the patient and provider.

In addition, we are in the middle of another medical malpractice crisis, and dentistry is certainly not immune. Not only are the number of malpractice suits and the size of settlements rising sharply, but many insurance companies can no longer afford to provide professional liability coverage to health-care professionals.

From the legal perspective, a malpractice suit can be rather lengthy, even if it is settled before trial. This lengthy process can create emotional stress and inner turmoil. Even the best of clinicians begins to question their judgment. What did I do wrong? Why didn't I chart more?

One way that we can protect ourselves and not be overcome by fear is to follow the practical risk-management steps that Dianne outlined. This will enable us to reduce liability, create a safer patient care environment, and focus on quality of care.
Linda Harvey, RDH, LHRM
Jacksonville, Florida

Documentation affects disciplinary action

Dear RDH:
I just had to comment on how happy I was to read Dianne Glasscoe's recent article on malpractice and documentation (June 2002 RDH).

I recently attended a board of dentistry meeting in Florida and sat through the disciplinary hearings portion. It was fascinating, but what I want to emphasize is that all of us, as well as our employers, should read and take heed to what Dianne has shared with us. Proper documentation is essential. If you do not document properly, you are committing malpractice.

The board of dentistry usually will get the complaint and, if the panel finds probable cause it becomes a nasty, long, expensive, and often embarrassing affair. With proper documentation, this can all be avoided.

I strongly recommend that each and every licensed dental professional read their state statutes, be familiar with what the minimum standard of care in their state consists of, how frequently a comprehensive exam of a patient is required, and what is involved in that exam (such as radiographs, periodontal charting, etc.). When entering information on the patient and the particular appointment, be as specific as you can so that nothing can be misunderstood.

What I discovered at the hearings is that about 80 percent of the disciplinary actions were for not meeting the mimimum standard of care due to the lack of proper documentation. This frequently included periodontal charting and current radiographs, as well as a description of what the licensee found the condition of the oral cavity to be.

In my opinion, no one should have to pay the fines that were imposed or have to take the amount of extra continuing education (over and above the required amount; the board required certain courses, so you also lose the freedom to take what courses that truly interest you) that was required within a short period of time. I would expect that dental professionals who have promised to treat our patients to a minimum standard of care would follow the correct protocol in documenting the charts of our patients.

If you did not read Dianne's article, I encourage you to do so ASAP. If you have read it, please take to heart her sound advice and do not find yourself or your employer in the scenarios outlined in the article. All it takes is one dissatisfied patient and incorrect documentation for this to take place.

Thank you again, Dianne, for an excellent article.
Jane Weiner, RDH
Tamarac, Florida

The harsh reality

Dear RDH:
I am a hygienist who graduated from West Liberty State College in May 2000 with an associate's degree. The reason for my letter is that when I read Karen Schacher's letter several months ago (March 2002 RDH) during my lunch hour at work, I was so taken aback by her statement that I spent most of the remainder of the day contemplating what my response letter would say. I didn't respond but when the next month's issue came, I felt an overwhelming feeling of support when most of the letters where as passionate about protecting the associate-degreed hygienist as I would have written. In fact, I felt that these words were taken right out of my mouth.

I would like to comment on what I believe to be the real reason why associate-degreed (not preceptorship-associate degrees) and bachelor-degreed hygienists are so passionate about protecting our integrity. We both have taken what is nationally recognized as a competency test in knowledge and skill via the national board in dental hygiene, as well as the regional clinical exam.

Until the preceptorship-trained hygienist can pass these boards, we will not give you the credibility and/or respect that you think you deserve. You cannot pass those boards without the education. Studying for national boards and stressing over finding the right patient for the clinical exam was not a piece of cake and should not be seen by the preceptorship-trained hygienist as unnecessary. Passing those exams is a rite of passage and, until you can show competency via these exams, please understand that we will and, rightfully so, feel superior to you.

The harsh reality is you did not pass the boards. I challenge every on-the-job trained hygienist to pass these boards; if you are so skilled and there is no difference in quality of care, let's see you pass the test! If preceptorship hygienists feel justified in their practice, I think real hygienists should be able to go through a short program and on-the-job training to practice dentistry. Would you feel comfortable with me picking up a high-speed to cut a tooth? That's how patients should feel when you pick up a scaler.
Dana Rainieri, RDH
Morgantown, West Virginia

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About the cover
Click here to enlarge image

When Shelly Gazette first contacted RDH in January 2001, she was a freshman at a dental hygiene program in Temple, Texas. She was proud of her husband, a practicing hygienist based in Austin, and later sent us a photograph of him on a motorcycle. She thought he would be an excellent choice for a cover model.

We decided to wait awhile.

RDH has featured dental spouses on its cover before, but it's usually a male dentist and a female hygienist. But the magazine has never spotlighted spouses who are both hygienists. So we waited to see if Shelly would successfully make the transition from being a student.

She graduated last May and took her WREB exam seven days later. She is a member of the profession, working part-time in three offices, and so we proudly feature Doug Gazette, RDH, and Shelly Gazette, RDH, on the cover.

Shelly said, "Doug was a constant source of support for me while I was in hygiene school. His knowledge of the material and the dental field was, at times, unbelievable. I think he often got tired of leaning the recliner back in the living room ... with my typodont, helping me practice the proper instrument strokes."

Even with both practicing as hygienists, the conversations continue. "Doug and I compare treatment and talk about the similarities and differences daily. It is really nice to have someone to talk to about dental hygiene."

They have been married since 1994 and have two children, 9-year-old Dalton and 7-year-old Hannah. They met in 1991 while serving in the same dental unit at the Army's Ft. Leonard Wood in Missouri.

The motorcycle is still around; actually, that should be plural. Both ride Harleys for relaxation.

"We ride together whenever we can. We take rides on the bikes just to get away from work," Shelly said. "We both enjoy this very much."