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Patti DiGangi, RDH, BS, believes dentistry is no longer just about fixing teeth. Dentistry is oral medÂicine. Her work helps dental professionals embrace the opportunities and understand the metrics that accurate insurance coding provides. The ADA recognized her expertise by inviting her to write a chapter in its CDT 2017 Companion book and again for its CDT 2018 Companion. She is the author of the DentalCodeology series of easy-to-read, bite-size books. Her latest book, "Teledentistry: Pathway to Pathology" was co-written with Cindy Purdy, RDH, BS. She can be reached at email@example.com.
- "Aging is a risk factor for oral cancer" - "Everyone needs to floss" - "Restorative dentistry restores oral health" What is the truth and current science behind these statements? The automatic answer has a high likelihood of being dated, incorrect or incomplete. The public and many of us believe what happens in clinical dental hygiene practice is based on science. Yet, is it?
For the past decade, the term evidence-based practice (EBP) seems everywhere. Let’s think about this patient in your chair: She lists on her health history Hashimoto’s Thyroiditis. What do you do with this information? What oral health risk might she have? What systemic risk could you cause with unthinking/unexamined care?
Tech-savvy millennials will research online. Do you have a millennial thought process? Pew Research Center has a 14 item quiz and that can tell you How Millennial Are You? You might find it interesting in clarifying how you think and process in our current world (and what the heck, these online quizzes are fun!).
Theory of EBP
Let’s start with the most commonly cited definition of evidence-based practice from Dr. David Sackett, Canadian physician and EBP pioneer: “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” Thanks Dr. Sackett but what does that really mean?
Many hygienists love structure. Good news: The process of EBP is actually quite structured with a bunch of specific steps; it should be easy. Then why isn’t it used? It makes theoretical sense, yet how many practitioners have the time to go through the EBP process when a patient sitting in their chair?
Evidence as hype
On Facebook this week, you remember seeing something about Hashimoto’s so you go back and find the post about a book Hashimoto's Thyroiditis: Lifestyle Interventions for Finding and Treating the Root Cause by Dr. Izabella Wentz. It hit the NY Times Bestseller list for two months in a row. So you link to Amazon.com and the marketing section says, “Hashimoto's is more than just hypothyroidism. Most patients with Hashimoto's will present with acid reflux, nutrient deficiencies, anemia, intestinal permeability, food sensitivities, gum disorders and hypoglycemia, in addition to the typical hypothyroid symptoms such as weight gain, cold intolerance, hair loss, fatigue and constipation.”
You have limited knowledge of Hashimoto’s. How can you examine the information in this book? How much is hype? How much is accurate? You don’t have the time while the patient is in the chair to examine any of it. So is EBP really feasible?
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Evidence as a mallet
Laser-assisted periodontal therapy is routinely performed by many dental hygienists though still controversial in some circles. Codes have been submitted over and over to the Code Maintenance Committee to add to CDT (Current Dental Terminology) for this care. The committee continues to vote “no” to a variety of laser-assisted periodontal therapy submissions (as recently as for CDT 2015). The American Academy of Periodontology (AAP) is leader in this opinion. Is AAP once again using evidence as a mallet? In earlier versions of CDT, there was a code for curettage.
Based on the AAP Statement on Gingival Curettage, the procedure code was removed. If you look at the references to support their statement, there is not a single reference from this century. Okay, so the statement was written in 2002, yet it is still on the AAP website as position they support. The 24 references are from: 1927, 1952, 1954, 1956, 1957, 1958, 1959, 1962, 1966, 1980 and two each from 1981, 1982, 1983, 1987, 1989, 1996, 1997, 1998 and 1999. It looks like the evidence didn’t drive the statement, rather research was found to support a position. Is that EBP?
Evidence as best practices
Clinical treatment guidelines are some of the best and quickest ways for healthcare providers to learn the science behind making the best clinical decisions for their patients. Generally, a panel of experts is convened to review the scientific literature and to create informed treatment recommendations. The experts crafting the guidelines explain which treatments are helpful to the greatest number of people within a certain patient group. Carrying the official backing of established societies, the implications of the release of guidelines are many.
In theory, healthcare professionals review the new guidelines, weigh the scientific evidence, and implement the new best practices. The ADA Center for Evidence-Based Dentistry is accomplishing this process in dentistry. The guidelines have the official backing of ADA and will be considered best practices by insurance carriers and others. What can be of concern to any practice is how the concept of best practices has been used in medicine to limit treatment options and decrease reimbursements. Are you willing to allow ADA to control it all? Is that the direction EBP really going?
What’s your take
We fill these Modern Millennial Hygiene (MMH) articles with more questions than answers because that is true hallmark of a MMH-asking questions and continuing to search for the answers. We’re interested in hearing your take.