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Getting rid of the cleaning lady image

March 1, 2005
It isn’t “just a cleaning”..or is it?

It isn’t “just a cleaning”... or is it?
by Dee Vecchione, RDH

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“It’s just a cleaning today, right?” Just a cleaning. How many times have we all heard that innocent, yet insulting phrase? Why do patients undervalue the care we provide by consistently using those words?

Is it because we fail to show them otherwise? Is it because hygienists, as well as the rest of the dental team, convey that message to the public? Are we just cleaning their teeth? Are you just a tooth cleaner?

Ask yourself these questions: What type of dental hygiene am I practicing? Am I a true periodontal therapist? Am I a preventive specialist? Am I a “thoroughly modern Millie (or Mike),” or am I still using the same information that I learned in dental hygiene school three to 30 years ago?

Dental hygiene, as well as any other health profession, is not static. It is a constantly evolving science that requires time and education in order to stay abreast of current concepts and treatment modalities. Did you know that there is a movement in this country to separate hygienists practicing at a cutting-edge level from those that are not? Which one are you?

The fact that you are reading this article in a professional magazine shows promise, but how much of what you read do you share with your employer and implement into your practice? Are you a leader, a follower, or still practicing the way you always have?

You do have a choice! You can choose to keep up or fall behind. You can choose to be excited about dental hygiene again, or stay stuck in the rut of yesteryear. Yesteryear ... at first glance, you may be thinking 20 to 30 years ago. Not so! Dental hygiene has changed significantly in even the last two years.

So, let’s see how current you are. Here’s a short quiz to help you determine if you are cutting-edge, or in need of a little sharpening. Ask yourself these questions:

Do I present myself as a health professional or as the friendly neighborhood tooth cleaner?
Friendly conversation has its place in every dental hygiene appointment. After all, our patient relationships are very important to us. However, we must remember that our patients come to us for dental health care, not a social visit. Failing to educate them about the presence of disease is malpractice and betrayal of trust. While we would love to praise and reassure all of our patients, the reality is that 75 percent of the population has dental disease. As care providers, our first priority has to be dental health.

Do I assess and document the periodontal condition of every patient at every appointment?
"“Yes” is the only correct response to this question. Comprehensive periodontal charting should be performed annually for a “healthy” patient, and even more frequently for patients that have attachment loss. This means a complete recording of pocket depth, recession, bleeding points, furcations, mobility, and mucogingival involvement. Probing depth alone is not sufficient in determining the periodontal status of a patient.

At interim appointments, a periodontal screening should be performed and documented. Documentation means more than just writing “WNL.” We all know that WNL means: “within normal limits.” But have you heard of the other definition: “We never looked?” That means you have to go one step further and record your actual findings or use the PSR (periodontal screening and recording) system. Either way, more than just an acronym should be documented.

Do I perform an oral cancer screening on every patient?
Do you skip this vital step in your examination? According to the ADHA, “This year, close to 30,000 Americans will be diagnosed with oral cancer and more than 7,200 will die from it, making it more common than leukemia and melanoma. Yet, 75 percent of those cases are preventable and up to 90 percent are treatable if detected early.”

Hygienists play a key role in evaluating and documenting oral pathology. Before you pick up the probe, perform an oral cancer screening, even if your doctor performs one as well. Two sets of eyes are always better than one!

Do I consider risk factors in periodontal assessment and treatment strategies?
This answer should be affirmative. Smokers, diabetics, and patients with autoimmune disorders are at increased risk of periodontal infection. They also do not respond well to nonsurgical or surgical periodontal therapy because of an ineffective immune system and an impaired ability to heal. Four quadrants of traditional treatment may not be enough for these patients.

Additional sessions of repetitive therapy, locally applied antimicrobials or systemic antibiotics may be necessary to control the infection. In some cases, Periostatshould be considered for host modulation therapy. Other periodontal risk factors include stress, menopause, genetic susceptibility, poor oral hygiene, xerostomia, and medications. Hygienists need to consider all possible risk factors when evaluating a patient’s periodontium and customizing an individual treatment plan.

Do I use ultrasonics on nearly every patient or just those with heavy calculus and stain?
The derogatory term “Cavitron Queen” has been vanquished! With the advent of the slimmer inserts, ultrasonics are rapidly becoming the standard of care. They are time-efficient, ease hand and wrist strain, and create a less stressful work environment. Deep periodontal pockets are more easily accessed with less tissue trauma.

Additionally, plaque is now considered to be a highly complex and destructive bacterial biofilm, and more resistant to antimicrobials than previously thought. It is simply impossible to remove biofilm to the same degree with hand instruments. Alternatively, ultrasonic debridement will remove most calculus, biofilm, and stain, promotes a faster healing response, and is far less damaging to enamel and dentin than hand instrumentation.

Am I still planing the roots of periodontal patients to a smooth, glassy finish?
Root planing is becoming passé. Calculus is no longer considered the causative agent of periodontitis. Research has even shown that cementum is important in the reattachment of the periodontal ligament; so complete removal may actually interfere with that process. Cementum removal also results in uncomfortable sensitivity for the patient.

The focus of periodontal therapy is now root debridement, and the ultimate goal is the removal of enough biofilm, calculus, and toxin to obtain a healing response. The instrument of choice in periodontal debridement is predominantly the ultrasonic scaler, with hand instrumentation employed as needed.

Am I polishing every tooth on every patient with coarse prophylaxis paste?
Prophy pastes can damage marginal integrity and scratch and destroy the luster of composite and ceramic restorations. Recently, several new polishing pastes have become available specifically for the maintenance of these modern dental materials.

Abrasive polishing should never be performed on a caries-susceptible patient, on root surfaces, or in the presence of significant inflammation. Selectively polishing stained or virgin teeth is becoming more widely accepted and grit selection should always be based upon patient need.

Do I perform topical fluoride treatments based upon patient need?
If you’re providing acidulated phosphate fluoride twice a year for patients up to 14 years of age, then it’s time to rethink that policy. Does caries risk stop at the age of 14? Of course not, but we’ve allowed insurance limitations to dictate care! Patients of all ages that have moderate to high caries risk should have topical fluoride treatments twice a year, but carefully choose the fluoride that is applied.

Acidulated phosphate fluorides (APF) should not be used in the presence of composite resins, sealants, porcelain or ceramic restorations, as they will etch the surface and diminish smoothness and luster. In these cases, neutral sodium fluoride should be used instead. Furthermore, patients of any age with a low caries risk may not receive any benefit from topical fluoride. The use of fluoride should not be restricted, nor should it be universally applied.

Were your answers similar to a cleaning lady's

Well, how did you do? These are just a few of the newest concepts being implemented in the modern practice of dental hygiene. There is also plenty of new information about the management of malodor, full-mouth disinfection, laser curettage and disinfection, oral irrigation, ergonomics, magnification, and xerostomia.

It’s up to hygienists to change the perception that a hygiene visit is just a cleaning. Patient education starts with us! Here’s an example: Recently, I noticed that a patient, whom I had never treated, was limping as we walked to my hygiene operatory. When I questioned her, she said that she was going to have knee replacement surgery. Despite prior treatment and frequent recare, her periodontal exam still revealed pocketing and infection. During the examination, I educated her about the need to take a prophylactic antibiotic for up to two years following her joint replacement surgery. Then, I linked the presence of her periodontal infection to an increased risk of bacteremia from simple home-care procedures, and further discussed the systemic effects of periodontitis. She was astonished and surprised that no one had previously mentioned how significant her periodontal condition was to her bodily health. Did she think that I was just a tooth cleaner? I seriously doubt it, since I had just made a significant difference in her health.

Practicing cutting edge hygiene is empowering. It can lift you to heights that you never thought existed. It is exciting, fascinating, and energizing, all at once! When was the last time you felt that way about dental hygiene? When was the last time you bounced out of bed and couldn’t wait to get to work in the morning?

Magnification, illumination, intraoral cameras, caries-detection devices, computerized periodontal charting, and new treatment concepts have all changed the practice of dental hygiene, making it fresh and fun again!

I have been a full-time clinical hygienist for nearly 18 years. Guess what? I still love my profession and I love going to work every morning! I absorb new information like a sponge and pour it into my practice and patient care. Where does my internal drive come from? Well, I am a firstborn, type A personality to begin with, but much of my drive and ambition comes from knowledge and professional camaraderie.

That knowledge is acquired from reading all six of our professional dental hygiene journals. Each is unique and equally worthwhile.

Additionally, in the past two years, I have amassed nearly 100 continuing education credits. I take courses to learn, to stay current, and to stay excited about dental hygiene. It’s actually a lot of fun when you don’t take CE because you have to. I’ve even started traveling outside of my own state in my quest for knowledge, attending a hands-on ultrasonic course in Houston, as well as RDH Under One Roof in Norfolk last year.

In 2003, I finally joined the ADHA. I’m ashamed to admit that I had not been a member since the earliest days of my career. Like many hygienists, I guess I just didn’t perceive the value or feel that I got enough back to warrant the membership fee. Would it surprise you to know that only 25 percent of the profession is represented by our professional organization? That figure is shocking, and the American Dental Association takes full advantage of those statistics! Hygienists need to unite, to support our association, and get involved.

Preceptorship is knocking on the door in Missouri; California has just passed legislation to allow second-year dental students to be licensed as hygienists; and Florida is allowing foreign-trained dentists to practice as hygienists. Our jobs are being taken away, and opportunities are becoming scarcer.

It’s time to defend our profession, and we need membership numbers to do that. Join ADHA now, and protect your future, too!

Finally, I have surrounded myself with hygienists that are equally as passionate about dental hygiene! How am I able to do that when I am the sole hygienist in my practice? It’s called the email community, initiated and managed by Amy Nieves, RDH. This is where over 1,600 of the movers and shakers of dental hygiene can be found sharing ideas and treatment strategies, providing inspiration and friendship, and motivating each other to embrace new concepts and to be more than “just tooth cleaners.”

Join us and leave the tooth cleaning to your patients!

Do I recognize and treat caries as a bacterial infection?
Fluoride therapy is no longer enough for cavity-prone patients. Encouraging more brushing and flossing will only cause frustration, as they continue to form new and recurrent decay. Caries is now recognized as a communicable bacterial infection, which means that treating just one family member may not be enough.

Chlorhexidine mouthrinses and xylitol chewing gum or mints have been found to be extremely effective in controlling the bacterial infection. Glass ionomer sealants and surface protectants, as well as fluoride varnishes, are also of significant value in the prevention and remineralization of early decay. Diagnostic equipment, such as the DIAGNOdent, can actually quantify demineralization and its reversal, thereby permitting progress tracking of patients enrolled in a remineralization/caries control program.

Do I discuss the systemic link between periodontal disease and bodily health with my patients?
If you don’t, then it’s time to start! Periodontal disease has been associated with coronary artery disease, increased risk of heart attack and stroke, preterm, low-birthweight babies, pulmonary disease, and diabetes. Simply educating patients about this new research can significantly create newfound value in the hygiene visit. Does the patient have mitral valve prolapse or heart valve or joint replacements, where bacteremias could place him or her in jeopardy? It is imperative that hygienists think like true health professionals in considering risk factors and systemic implications in the assessment and treatment of periodontal disease.

Dorothy Newcomb Vecchione, RDH, is a 1987 graduate of Camden County College in Blackwood, N.J., and a member of the American Dental Hygienists’ Association. She is the sole hygienist/periodontal therapist for a progressive private practice in Richfield, Ohio, and is an active participant in the email community. She can be reached at [email protected].