Some days are diamonds

May 27, 2005
Hygienist in a rural setting reflects on how her familiarity with residents helps her remember which days are diamonds. In fact, she can't even remember the stones.

By Sheri French, RDH

One of the pleasures of practicing in a small town is that most of your patients are your friends and neighbors. On many days I will recognize all of the names on the schedule. When someone is a new patient, I always strive to prove that even though we may be located in a small town we are able to provide very high quality oral health care. In fact, a couple that moved to town just a year ago expressed their delight in finding such good dental care in such a small town. They doubted its availability and had been prepared to drive some distance to a metropolitan area if our office wasn't satisfactory. I know that patients' perceptions may have little to do with quality of care, but I was glad we passed their test. That felt like a diamond of a day.

A recent newcomer to the community is George, a 56-year-old retired military nurse anesthetist. George made several comments to the office administrator as he was filling out the initial paper work that she passed on to me. Things like "I don't want any x-rays taken; I just want my teeth cleaned." "I've had that scaling done before." "I know my teeth better than anyone." He seemed to have a rather defensive attitude, but possibly just wanted us to know that he would be in charge of this visit.

Once in my chair, I reviewed his medical and dental history I asked why he didn't want x-rays since they were an important part of the diagnostic process. His reply was that "he had not had any decay in years and as for the bone level being evident ... There was nothing I could do to restore that, was there?" He reported having previous scaling and root planing done — twice. I was curious as to just how well George did know his mouth so I asked him if he was aware of any areas of permanent bone loss and where they might be. He indicated that I would find a great deal of bone loss in several areas of his mouth.

Since our operatories are so open the rest of the staff could easily hear our conversation and the doctor chose this moment to come in and introduce himself to George. He asked if he could take a quick look. I commented that I had not gathered much data yet. The doctor did a cursory visual exam and told George that he would be surprised if "she can get all that off today." George's comment was that "they always have before." You see, even though George reported using a Sonicare toothbrush for two minutes morning and evening, flossed daily, used an oral irrigator and interproximal brushes he had a moderate to heavy accumulation of supragingival calculus, especially on the lower anteriors. I did a comprehensive periodontal charting which revealed several 6 and 7 mm probing depths, areas of 3 and 4 mm of recession, furcation involvements and mobility as well as a muco-gingival defect. I also provided an oral cancer screening.

I decided to communicate with George as a fellow professional and used correct dental terminology when advising him of my findings. Nothing I told him was surprising but I wanted to make sure that he had a complete picture of his periodontal status. I used some chairside pictures to indicate the level of disease that I could observe with the data I had at hand, minus the radiographs. Then I did as thorough a debridement as I possibly could using an ultrasonic scaler on medium power and a universal tip, followed by a slim tip on lower power. Luckily, my next patient cancelled so I had a bit of extra time to spend scaling. The calculus was not tenacious since it wasn't that "old" and came off quickly and easily. I told George he would be better served to be under the supervision of a periodontist and offered him a referral to one of two periodontists that we use. We discussed the differences in their approach to treatment and which approach he would generally prefer.

To my surprise, once we got started George was an easy patient to work on. He was appreciative of the service I provided and complimented me to the dentist saying he had never had such thorough scaling. He then accepted our referral to a periodontist. The doctor asked me what I had done to achieve such a dramatic turn around in George's attitude. That day started out like it was going to be a stone, but it turned into a diamond.

I always enjoy seeing Joyce, we have children the same age and she has been a regular patient for the past 10 years. On a recent visit as we caught up on news about the kids she reminded me of how special our first encounter was to her. Joyce's husband had recently retired from the military and they were "back home" for good.

She brought her almost 15-year-old daughter in for her preventive oral health visit. Kassi was shy and not thrilled to be at the dental office. As our appointment together progressed it became obvious that she had been chastised thoroughly and often for her poor oral hygiene habits. Kassi was a Class II, Division II occlusion with severe crowding and rotation in the anterior region. She had just plain ugly teeth! When I accompanied her to the reception area after the procedure I asked her mother if they had ever considered orthodontics for Kassi. I knew nothing about this family's financial situation yet or the parents' dental IQ either.

The mother advised me that every dentist they had seen had told them they would not do braces until Kassi "grew up enough to keep her teeth clean." I sensed that the mother also had been frequently castigated for her daughter's lack of motivation in caring for her teeth. Regular dental care was evident. My response was that there was no way Kassi could possibly keep her teeth clean with the situation she was in.

Orthodontics was absolutely a necessity and, though it would be difficult, we could work together on improving her home care, using home fluoride to minimize decay. "In my opinion Kassi will never be able to adequately clean her teeth, until they are straightened and if she were my daughter I would have it done now." Joyce was visibly relieved and grateful for my comments and a referral was made.

That was a diamond day. I wish I could tell you that Kassi turned into a highly motivated model patient, but she really didn't. Home care improved, but was never optimal. Well, some days are stones. Like I told Joyce, we both did the very best we could and now it truly was up to Kassi to continue as a young adult.

Lisa showed up for her regular hygiene care with her 3-month-old baby in tow and no one with her to babysit. I greeted Lisa in the reception area and thanked her for bringing the baby for us to see, commented on how beautiful he was etc. I told her I'd love to hold him but I never hugged my own children with my scrubs or lab coat on because of the germs I pick up all day. I've been seeing Lisa since she was in high school and we've always had rapport. It was winter and cold season. I explained to Lisa my concern about having the baby in the operatory with us. Even though the baby couldn't move around and touch things, there were aerosols full of germs from whoever's mouth was back there. Even though a healthy person could tolerate the atmosphere with no problem I expressed concern that it might not be the best environment for the baby.

About that time someone coughed and it was perfect timing. Lisa quickly volunteered to run the baby to a friend's house and return and was so grateful that I was looking out for the baby. Fortunately, it was close by and I was able to accommodate the delay by running just a few minutes into lunch. I knew Lisa's homecare was immaculate and she would be very easy. I felt like I had educated a young mother just a little on disease prevention. That is what I consider a diamond day.

When I first moved to this town with its one traffic light I didn't know what to expect as far as patients and their dental knowledge. I've found it similar to that in the metropolitan area with this exception. Many of the first patients I saw not only knew what a dental hygienist was, they knew the dentist had been without one for awhile now and that a dental hygienist was needed and why. They expressed appreciation for what I was doing and were glad that I was moving to the area so they could depend on me staying in the practice for some time. I have stayed with the practice for 12 years. Like other relationships there have been great times and times of struggle and challenge. The office is too small and there are lots of new technologies that we have not incorporated into every day use, but our dedication to our friends and neighbors who entrust us with their oral care is optimal. That is what keeps me coming back.

I began this article with the old John Denver song ringing in my ears. "Some days are diamonds, some days are stones..." The more I think about it, though, I guess the days I remember are the diamonds. I just can't remember the stones.

Names have been changed to protect privacy.

Sheri French, RDH, has enjoyed a variety of roles in dental hygiene, including administrator, change agent, educator, and clinician. She has spent the last 12 years in a small town practice treating her neighbors and friends. Sheri welcomes comments at [email protected].