by Dianne Glasscoe Watterson, RDH, BS, MBA
I work in a very blue-collar practice, and many of our patients smoke. Many people have substandard oral hygiene, refuse to floss, have 4 mm to 5 mm pockets, and present with moderate bleeding.
Recently, another hygienist in the practice saw a patient I had seen previously. She claimed there was so much subgingival calculus that it took her two visits to complete the patient. Now my boss is questioning my work. I always take bitewing X-rays at the beginning of the appointment when needed so I'll know if there is radiographic subgingival calculus. Is there any way to know how old calculus is when it shows up on X-rays?
This incident has me questioning my abilities as a hygienist. What do you think I should do?
Frustrated and Hurt in Wisconsin
Since I lived and worked for many years in a small town in central North Carolina (the tobacco capital of the world), I understand blue-collar practices very well. However, gingivitis and periodontal problems are not confined to this population. I have also worked in upscale practices, and the main difference I have observed is that upper class clientele are easily offended if I mention the need to improve something about their oral hygiene, as if their wealthy status precludes them from having the usual oral problems that stem in large part from substandard oral hygiene.
The approach to helping people achieve better oral hygiene should not be influenced by a person's status in life. My role is to help people get better and maintain good oral health through 1) customizing my instructions to their level of understanding, 2) becoming their ally, not their mother, and 3) finding what works for each patient individually, and this may not include using floss. Don't let complacency hamper your efforts to help people.
I have to disagree with you about when you take radiographs. You mentioned you take them at the beginning of an appointment. Actually, you should perform all the necessary assessments, complete the tour of the mouth, and then decide if radiographs are needed based on the patient's risk factors. The ADA guide to radiographic frequency states, "Radiographic screening for the purpose of detecting disease before clinical examination should not be performed." You may view the entire guide at http://www.ada.org/sections/scienceAndResearch/pdfs/topics_radiography_examinations.pdf.
Please understand that if you can see calculus on radiographs, the calculus is very large. Sheet calculus that forms on root surfaces is rarely, if ever, evident on radiographs. Think about the limitations of radiographs. Through a radiograph, you are viewing a three-dimensional object (a tooth) on a one-dimensional plane. Radiographs are important and have their place in good patient care, but we should not rely on them to tell us where calculus is hiding.
Now let's get to your problem. It seems your coworker made a big deal about needing two appointments to treat a patient that you formerly treated in one visit. According to the report, she indicated that there was so much subgingival calculus, allegedly left over from previous visits, that it took an extra visit to complete the patient. Evidently she brought it to the attention of the doctor, who is now questioning your abilities.
Without having seen the patient, I have some questions. Why did your coworker make it a point to tell the boss? Why didn't she come to you with this information first? Were there changes in the past six months that caused the patient to build more calculus? Is the patient taking some new medication? Has there been a change in the patient's level of homecare due to some outside factor? Is the coworker being too critical of your work?
It's easier to see the dirt in someone else's kitchen than our own. Seriously, some people are so insecure that the only way they can feel good about themselves is when they make someone else look bad. There are two facts I'd like to point out:
1) Every root surface roughness is not calculus. The former endpoint of glassy smooth roots has been proven invalid. People actually need their cementum, and we can do great damage by over-instrumenting root surfaces. I'm not saying that it is acceptable to leave calculus, but the calculus is secondary in the periodontal disease discussion. The pathogens are the real problem.
2) Nobody ever gets ALL the calculus off, especially when patients have a propensity to build root surface deposits. Closed debridement has many limitations, chief of which is the inability to directly view the root surface for the presence of deposits.
The age of calculus is sometimes evident by its tenacity. Very old calculus becomes hyper-calcified as the lacunae fill up with dead cells and calcify and then become embedded in cementum. Newer calculus is easy to remove because it hasn't had time to become hyper-calcified.
Let's agree that none of us are perfect. We all leave deposits from time to time. Sometimes we burnish subgingival deposits so well that those deposits are imperceptible to an explorer or probe. Some of us are better at scaling than others. If your coworker really had your best interests at heart, she would have come to you privately and said, "I don't mean this in a bad way, but I thought you'd be interested to know that Mr. Smutmouth who you saw six months ago had so much calculus that I needed an additional visit to complete his scaling."
Here's what I'd do. I would face this head on with the other hygienist.
"Mary, I've been giving this some thought, and I have to tell you that I have been very concerned about the allegations against me that I have not been thorough with my scaling. I'm not perfect. I do not purposely leave calculus, but there are probably times when I miss something. You've probably missed something too. So in the future if you feel I have not served a patient well, I want to see for myself. And when I find calculus that you left, I will offer you the same consideration. I don't think you'd like it if I put doubts in the doctor's mind about your skills, so I hope you understand where I'm coming from."
Here's my take on the situation. If I'm leaving so much calculus that my coworker feels it is necessary to involve the doctor, I want to see it for myself. If I need to improve for the good of the patient, so be it. Maybe I need to seek out a good hands-on course to improve my techniques. If not, my coworker should either put up or shut up. How can I fix something if I don't know it's broken?
Don't let this coworker's criticism get the best of you. If need be, tell the doctor that you see this as a wake-up call, and you are more determined than ever to serve the patients well. Just remember that some people are legends in their own minds.
Dianne Glasscoe Watterson, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe Watterson for speaking or consulting, call (301) 874-5240 or e-mail [email protected]. Visit her Web site at www.professionaldentalmgmt.com.
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