The systemic SHOULD of dentistry

October 24, 2019

Knowing the difference between 'should' and elevated patient care is key for hygienists.

I won’t get into the details of it, but let’s just say that the inspiration for this article came from a recent lunch I had with a colleague and fellow dental hygienist. Naturally, between bites of salad and pizza, we were talking shop. As she sipped her sweet tea, she admitted, “I mean, I know we SHOULD be doing blood pressure on every patient, but there just isn’t time for it!”

It got me thinking about that word, should. While I won’t bore you with the dictionary definition, I find the word should to imply that we know better, that we recognize we have a responsibility but that ultimately, we are SHOULD-ing our way out of doing the right thing.

Here’s the problem with should - it will not protect you in a court of law, it will not help you elevate your standards as a clinician, and I implore you to consider that it will also diminish your bottom line.

The transition from hygiene school to 'the real world' was a difficult one for most of us: we learned very quickly that the four hours we had for a prophy are condensed to 60 minutes (if we are lucky) and with that compaction of our schedule comes the potential need for removing standardized assessments and procedures. These procedures are ones we were taught about in our foundational schooling to be of the utmost of importance; procedures like taking the time to gather a comprehensive medical history, gathering vital signs on all patients at every appointment, performing a full head and neck evaluation, collecting comprehensive periodontal charting, and performing counseling services such as tobacco cessation, nutritional counseling, or oral hygiene instruction.

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To be clear, I’m of the camp that there is little in this world that is more glorious than the feeling of inserting a Cavitron tip into the sulcus and liberating a giant piece of black subgingival calculus. There is something so incredibly satisfying about it. But here’s the deal - there is far more to our skills than the debris removal procedures we perform.

As research continues to unpack additional links of periodontal pathogens to the inflammatory processes associated with various co-morbidities, as long as one patient continues to die every hour from oral cancer and until we can address the fact that dental caries is still the #1 childhood chronic disease, we must not only acknowledge, but also actively step into our role as preventive specialists within the dental community.

Gathering a comprehensive medical history during the patient appointment is more than just updating paperwork and SHOULD include more than a simple, “Any changes?”  If we want to change the response of, “I don’t have any medical conditions that affect my teeth,” we must align ourselves as the educators and patient advocates we wish to be. In turn, gathering a comprehensive medical history SHOULD create a dialogue with your patient about the patient-centered conditions and potential genetic influence they present with that may dramatically impact their care.

Taking the time to perform routine vital signs assessment is more than just going through the motions. It SHOULD teach our patients a valuable lesson about the role we, as dental providers, play in the bodily system as a whole. This includes not only evaluation of the blood pressure and heart rate, but also oxygen levels (which may give us a clue about sleep disorders or airway obstruction), as well as HbA1c and point-of-service blood glucose readings for diabetic patients.   Using this information to better inform our patients about their general wellness is an integral step in the provision of comprehensive prevention that aligns with the oral-systemic link.

Performing a thorough head and neck examination means more than just doing a check. It SHOULD show our patients that we are true physicians of the head and neck, as we evaluate everything from TMJ conditions, intra & extra-oral conditions (including variations of normal), thyroid health, occlusal relationships and airway observations including a malampatti classification. It may also help us detect other parafunctional habits such as tight frenulum pulls or ankyloglossia, to name a few. As a hygienist in a periodontal practice, I am fortunate to have the time necessary to perform these comprehensive assessments, and as such, I am saddened by the number of patients who say, “I’ve never had someone do such a thorough exam on me before.”  If we aren’t comprehensively evaluating the tissues of the head and neck, who will?

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Comprehensive periodontal charting SHOULDN’T simply be completed so we have something to submit to your insurance. It is a necessary assessment that helps us evaluate the presence or absence of disease, and this assessment SHOULD go beyond pocket depth readings. Advancement of recession or furcations notes an activity of attachment loss and, subsequently, the advancement of periodontal disease. An increase in bleeding tendency denotes increased activity of disease and clinical observations of erythema and edema provide us with close about the presence of oral inflammation. Without comprehensive assessments, not only are we unable to come to a conclusive diagnosis for our patients, we are also unable to effectively evaluate the advancement or potential movement of oral inflammation and disease over time.

Finally, what is that saying - if you give a man a fish, he eats for a day, you teach a man to fish, he SHOULD eat for a lifetime, right?

We consistently manage diseases that require a life-long commitment to attentive care. Dental decay found in the incipient stage requires consistent remineralization, and although decay may be treated with restorative procedures, we understand that routine examinations, improved diet, plaque control, and continual remineralization therapy helps monitor and prevent the recurrence of a decay episode. Oral cancer identified in its earliest stages are easiest to treat, but one of the greatest risk factors for oral cancer is a previous cancerous lesion. Cancerous lesions identified in Stage III and IV have a far lower 5-year survival rate, and patients with suspicious lesions require consistent monitoring.

Gingivitis is one of the single most influential risk factors in the exacerbation of oral inflammation and subsequent attachment loss, and periodontitis we actively recognize to be an irreversible disease process requiring consistent monitoring, maintenance, and possible re-initiation of active therapy to stabilize.

Despite our best efforts, research continues to identify the ways in which we are still unable to control the manifestations of this disease process, particularly the most recent research from the Centers for Disease Control noting that nearly one in every two Americans have some form of irreversible periodontitis. It is information like this that reminds me that we have a lot of work to do. But more so, we have an excellent opportunity to make an incredible impact and serve our patients through education.

We SHOULDN’T assume that our tobacco-using patients do not want help, and in turn, we SHOULD be prepared to provide tobacco cessation services for our patients. With alternative opportunities for patients of all ages to recreationally utilize various types of tobacco and non-tobacco products, it is imperative to take the opportunity to support our patients through providing the necessary education and support no matter where they are in the cessation process.

We SHOULDN’T assume that our patients don’t care about their plaque control. Perhaps they simply require a different approach. While we quantify aspects of our industry such as vital signs and pocket depth readings, it is very infrequent that patients receive a plaque or bleeding score noted as a percentage. It is through steps such as gathering indices and disclosing biofilm that patients have access to quantifiable and understandable information about their oral condition.

We SHOULDN’T withhold nutritional counseling simply because it is not a covered benefit under dental insurance plans. As we continue to unpack more research identifying the underlying threat inflammation has on bodily systems, now more than ever it's imperative for dental hygienists to step into their preventive role by educating patients on how to reduce systemic inflammation - this goes beyond shoving our scalers into the subgingival space. Counseling patients on the consumption of low-glycemic index, anti-inflammatory food items permits us to truly step into the arena of whole-body wellness. Identifying potential vitamin deficiencies and educating patients on how to improve their nutritional intake elevates the work we do and developing a collaborative nutritional counseling plan alongside the patient takes us to the next level.

Let’s stop “should”-ing all over ourselves and find ways to optimize the work we do. This means working through the barriers we have of time constraints, limited department budgets, uneducated patients, and unsupportive team members and start doing so because optimal patient care SHOULD be our top priority.