A different point of view

Sept. 1, 2003
Problem solving requires a good working knowledge of the facts and potential solutions. Problem solving can take a lot of work. Often, it requires a willingness to look at a situation from another point of view.

By Anne Nugent Guignon

Problem solving requires a good working knowledge of the facts and potential solutions. Problem solving can take a lot of work. Often, it requires a willingness to look at a situation from another point of view. If a problem revolves around a patient's health status, then his or her viewpoint raises the stakes a bit higher.

If you were facing carpal tunnel ligament release surgery on your dominant hand, would you want to know if your surgeon operated with a microscope? Granted, it is arthroscopic surgery and it only takes 15 minutes, but it is your hand and microsurgery means the surgeon should be using a microscope. I asked this very question last spring. I sought a surgeon that used a microscope. My hand and my career were at stake, and I wanted a doctor that operated well above the standard of care. If he wasn't using a microscope, then he wasn't going to be my surgeon.

We expect our health-care providers to use equipment and techniques that increase the chance of a successful outcome. Should our patients receive care from us at any lesser level? Are we content to provide services and treatment utilizing techniques that haven't changed in years? Here is where the different point of view comes in.

Think about it this way. Magnification loupes have been around for a long time and more and more clinicians are wearing them. Are they the standard of care, and, if not, should they be? If you haven't practiced with loupes, then you don't know what you are missing — and believe me, you are missing a lot! Is that an arrogant remark? No. It is the truth. Magnification enlarges the image, allowing us to see most, if not all, of the oral cavity with a three to five inch depth of field.

It allows us to see more pathology — soft tissue lesions, defective restorations, fractured teeth, and subtle changes in gingival architecture. Magnification does give a different point of view. If you don't believe me, ask any hygienist or dentist who wears loupes what they would do if theirs broke. You'll see a look of sheer panic come over their faces ... unless, of course, they have a second pair. Notice I didn't even mention anything about the ergonomic benefits of loupes. I'm focused on the diagnostic benefits.

What if you add a headlight to the loupes? Will that change your point of view? Imagine being able to see where you are working with a clean beam of light following every move you make. If the working area is more evenly illuminated, will your clinical skills improve? I hope so. None of us would ever consider driving in the dead of night with only our parking lights on. If you transfer that thought process into the treatment room, doesn't it make sense to consider illumination when you provide patient care? One word of advice: If you choose to wear illumination, then always have a spare bulb, because — once you have seen the entire oral cavity this way — you'll never want to go back.

What about the patient's point of view? Many patients have no clue what is going on in their mouths and the intraoral camera gives them an opportunity to see what words just cannot describe. A fractured tooth or heavy calculus buildup looks amazingly real on the monitor. It's much harder for a patient to deny obvious pathology when we present them with an image from their own mouth.

We know what disease looks like and we know what health looks like. If we want patients to accept treatment, then it is much more powerful to show them the big picture (no pun intended) rather than have them rely on our word alone. Information like this can either render a patient speechless or asking how soon they can get the problem fixed as they dig in their pockets for a calendar to schedule treatment. Yes, it takes time to use the camera, but the payoff is big when patients have a better understanding of their needs. There is another unexpected bonus if you or your doctor finds a problem that was missed on earlier inspection. All of us who use an intraoral camera have had this humbling experience.

Technology brings us even more devices that can change our point of view. Many of us wish we could crawl down into the periodontal pocket and see what was really going on, or peer inside the nooks and crannies of every tooth surface to assess the stability of the tooth structure. I distinctly remember an engineering-geek patient of mine imagining a tiny camera at the end of a periodontal probe. While the idea was intriguing, I wasn't sure I'd ever see the day when we'd be able to do things like that.

Fortunately, I was wrong and those with bigger imaginations than mine have brought us technologies that give us some extraordinary insights into the health of our patients. Today we have the four "D's" to help us with disease detection: digital radiography, the DIAGNOdent, the Dental View Periodontal Endoscope, and the Diamond Probe. Each device gives us more information than we ever had before, allowing us to evaluate our patients' relative state of health or disease at a higher standard of care.

Digital radiography

Ten years ago, digital radiography was appearing on the horizon. I remember the first course that I took discussing pixels and all of the other intricacies of digital radiography. The speaker mused on whether digital radiography would be routine in dental offices during the next decade. At the time, the machines were extraordinarily expensive and rarely found outside of the academic walls.

While digital radiography is still the wave of the future, to some it is rapidly becoming the standard of care. Several years ago, someone took a set of digital bitewing X-rays on me. I was floored to see early bone loss on the mesial of tooth No. 5. This bone loss was not evident on traditional films. My office is installing digital radiography this year, and I can't wait. I know it will help me be a better clinician and will help us provide better patient care.

Caries detection

The DIAGNOdent and the Diamond Probe are easy-to-use devices that allow us to detect caries and active periodontal disease sites much earlier than we ever imagined. These are the ultimate prevention/early detection machines.

My February 2003 column in RDH contains an in-depth discussion of the Diamond Probe. It is a fascinating diagnostic tool that allows clinicians to focus their efforts on the sites that have high levels of volatile sulfur compounds (VSCs), the by-products of periodontal disease bacterial activity. If you have not read it, grab your old issue or look it up in the archives at www.rdhmag.com.

The DIAGNOdent is the caries detection counterpart. This class two laser caries detection device gives us an opportunity to peer deep inside the tooth and assess the relative strength of the enamel and dentin and detect occlusal carious lesions at a much earlier point. The DIAGNOdent gives a reading that reflects the relative soundness of the hard tooth structure. Low readings indicate a strong tooth that can benefit from well-documented remineralization and preventive therapies such as sealants, fluorides, xylitol, and Recaldent. In addition to these methodologies, emerging research indicates that a new argenine calcium carbonate/bicarbonate compound called CaviStat provides enhanced tooth remineralization when applied as a dentifrice. Higher DIAGNOdent readings indicate a need for surgical intervention.

Now you may think that you are doing just fine with a mirror, explorer, and radiographs; but think about what you are missing. What if the occlusal pits and fissures are so narrow that your explorer can't penetrate? What if caries are developing on the fissure walls? Research indicates that this is often the case. What if there are microscopic breaks in the enamel, creating a virtual freeway for bacteria and acids to enter the dentin? By the time occlusal caries show up on a radiograph, the tooth is in real trouble.

Research has shown every one of these situations exists, calling these conditions hidden caries, caries that are not detectable with the conventional methods that we all learned in school. In addition to all of these dilemmas, we have done such a good job of getting our patients to use fluoride that the outer surface of the enamel is rock hard. The still vulnerable dentin is just below and any void in the enamel sets the stage for disaster.

Ask your doctor how many times he or she has opened up an occlusal surface thinking that the restoration will be small and found a lesion that is nearly a pulp exposure. While the DIAGNOdent is not intended to be the only diagnostic tool, it does give dental professionals quantifiable and reproducible information. In addition, the DIAGNOdent has an audible tone that alerts both the clinician and the patient to areas that have less density. Now the patient receives a treatment plan that is based on additional science rather than the limitations of a visual and tactile examination.


When the Dental View Periodontal Endoscope first came out, I was fortunate to spend an afternoon seeing how it worked. While it looked fascinating, I kept hearing that it was really technique-sensitive. I continued to take courses and became convinced that this device did have a place in our future. What would we be able to see? Would we finally be able to see those elusive subgingival fractures or some complex root anatomy? And if we could really see what we were up against, would we be better clinicians?

While I wanted to learn as much as I could about the Dental View, I was afraid that it would be hard for me to use. For some reason, intraoral cameras make me nuts. I love the view they give, but I always seem to be going in the wrong direction and thought that the Dental View would be just as difficult to use. And I was worried that I would not be able to identify the images on the monitor.

Well, I was wrong. One of my friends has her own Dental View. Several months ago, I spoke in her state and she challenged me to try this technology. She even arranged to have a periodontal patient available for this adventure. Well, I was successful. The images on the monitor made sense to me. It is amazing to see biofilm, fractures, crown margins, and calculus magnified at 24x-48x.

A different point of view can be exciting for you, your doctor, and your patients. If you think that new technology is just one more thing to pack into your already crammed-full dental hygiene appointment, please stop and consider that these devices can be fun to use and bring a new spark of excitement to your practice. If you are excited about the new services that you can provide, then your patients will get excited about these advancements. They will want to know how technology can help them stay healthier.

You will look like the smart person — and that is a nice comfort zone to spend time in.

Anne Nugent Guignon, RDH, MPH, practices clinical dental hygiene in Houston, Texas. She writes, speaks, and presents continuing- education courses on ergonomics and advanced ultrasonic instrumentation through her company, ErgoSonics (www.ergosonics.com). She can be reached by phone at (713) 974-4540 or by e-mail at [email protected].