Written by Sandra Johnson, RDH Friday, 31 August 2007 19:00
The American Dental Hygienists’ Association (ADHA) defines dental hygiene as “licensed oral health professionals who focus on preventing and treating oral disease both to protect teeth and gums and also to protect patients’ total health.” The dental hygienist healthcare provider may do the following (depending on specific state regulations):
- perform oral healthcare assessment
- expose, process, and interpret dental radiographs
- remove soft and hard deposits both supragingivally and subgingivally
- provide oral hygiene instructions to aid in the maintenance of healthy teeth and periodontal tissue
- offer nutritional counseling.
The dental hygienist is the prevention specialist that focuses on the education, prevention, and therapeutic care of his or her patients.
The ADA recognizes the dental hygienist as an “important member to the dental healthcare team who works with the dentist in the delivery of dental care to patients.” The ADA also acknowledges as significant the services that the hygienist contributes to the practice.
Based on the ADHA and the ADA, it is obvious that a synergistic relationship and team approach within the dental office is essential to establish and maintain best standards and provide the highest quality of care to patients. When the hygienist and the doctor partner as the prevention and restorative specialists, the opportunity for excellent patient care and service is endless.
How is the relationship fostered and how is a dental hygiene program implemented within a dental practice?
DEVELOPING A HYGIENE-DOCTOR RELATIONSHIP
The relationship begins with mutual respect for and recognition of individual skills and expertise. Communication is critical among the entire staff, especially the doctor and hygienist, to ensure that treatment philosophies among the providers are similar. The doctor and dental hygienist must nurture their relationship in order to provide continuity of care to their patients.
A professional relationship and nonconfrontational communication is enhanced by committing to daily morning huddles where scheduled patient care is discussed and treatment opportunities are shared. In addition, it is essential for the doctor and hygienist to set a meeting time monthly, perhaps over lunch, to discuss various treatment issues. During this time, a chart audit may be helpful to examine “how” and “why” specific treatment was performed. This simple act opens the door for open and honest communication and allows each provider the opportunity to share praise and concern regarding specific treatment modalities.
DEVELOPING THE HYGIENE PROGRAM
Once the communication relationship has been established among providers, it is time to begin developing the hygiene program within your office. Obviously, each program will be different based on state regulations and provider preference, but the following is an outline that should aid in the development of a personal, professional, and financially rewarding dental hygiene protocol within the dental practice. In addition, this outline provides the highest standard of care for your patients, which should increase patient satisfaction and personal referrals. During the initial dental hygiene visit the following procedures are recommended to be performed:
(1) Medical history must be updated with the current date and patient’s signature at each and every patient visit to control risk management issues. Due to the hygienist’s role as the prevention specialist, the medical history review provides the hygienist the opportunity to look for systemic, genetic, and medication-induced signs and symptoms that may influence the oral cavity. In addition, Caranza and Perry state that this history aids in the “evaluation of oral manifestation of systemic disease, the detection of systemic conditions that may be affecting the periodontal tissue response, and the detection of systemic conditions that require special precautions and modification in treatment procedures.” During this initial visit the dental hygienist should perform a blood pressure screening and recommend a medical referral if the pressure is 160/115.
(2) Perform and record findings of the intraoral and extraoral cancer examination. This exam should include visual and, where appropriate, tactile examination of the eyes, face, skin, buccal and labial mucosa, hard palate, TMJ, lips, and cervical, occipital, and auricle lymph nodes. The clinician may choose to use chemiluminescent technology to aid in the visualization of dysplastic tissue.
(3) Depending on the dental practice, the dental hygienist may evaluate and document the hard tissues and highlight potential areas of concern for the doctor’s evaluation.
(4) A periodontal evaluation must be completed on every adult patient. This should include a 6-point pocket depth evaluation as well as examination of recession, attachment loss, bleeding, furcation involvement, mobility, plaque, calculus, and stain. Bleeding should be indicated by circling the corresponding site in red; furcation involvement is documented as +1 (just detectable), +2 (vault of furcation is detectable), +3 (instrument is able to pass through and through and is radiographically visible), and +4 (instrument is able to pass through and through and is visible to the naked eye due to recession). Mobility is recorded as M1 (1 to 2 mm), M2 (greater than 2 mm), and M3 (greater than 2 mm and depressible in the tooth socket). This periodontal evaluation should be repeated every 2 years, but pocket depth greater than 4 mm and bleeding sites should be recorded at each visit.
(5) A full-mouth set of radiographs on every adult patient should be prescribed and repeated every 3 to 5 years or as the provider deems necessary. Vertical films aid in the visualization of bone loss, but horizontal films are sufficient in most periodontal cases.
(6) The doctor will make the periodontal diagnosis based on the gathered data. It is helpful to use the guidelines set by the American Academy of Periodontology (AAP) for this diagnosis (Table).
Once the diagnosis is determined, the doctor and hygienist should present the diagnosis and treatment options to the patient as a unified team. Remember, this may be the first time your patient has received a “true” evaluation and notification of his or her oral condition. Therefore, you as the dental professional must be prepared to provide all of the information your patient may require to make an educated, informed decision. This information may include disease progression, oral/systemic relationships, treatment options, repercussions without intervention, professional referral, financial considerations, and payment options. This co-diagnosis and treatment presentation between the doctor and the hygienist will provide the patient with the confidence necessary to take ownership of his or her oral health condition and make a decision regarding the treatment modality.
Should the patient decline the treatment recommendation, the patient should sign an informed declination form. However, be aware that almost all licensing bodies do not recognize a declination form as an excuse for supervised neglect. To avoid a risk management issue, it may be necessary to dismiss the patient from your practice.
Based on the periodontal diagnosis and patient acceptance of treatment, the patient should be scheduled appropriately to provide the therapeutic care. Care may require several strategically planned visits in order to maximize the benefit of healing by eliminating bacterial colonies (biofilm) and creating an environment conducive to tissue regeneration.
If your patient is diagnosed with a healthy mouth, then a prophylaxis, oral hygiene instruction, and an application of topical fluoride should suffice to maintain his or her oral health. This type of procedure can usually be completed within 40 to 50 minutes.
If your patient is diagnosed with gingivitis, then the patient should receive a debridement procedure to remove the hard and soft deposits. He or she should then receive the therapeutic benefits of a subgingival irrigation such as chlorhexidine gluconate. This irrigation acts as an antiseptic agent and is an effective bacteri-cidal agent against bacteria, yeasts, and viruses. Since debridement is not a definitive treatment, it is essential to re-evaluate the oral condition of the patient approximately 2 weeks later and then determine the next step of preventive care. This type of procedure can usually be completed within 50 to 60 minutes.
If your patient is diagnosed with periodontitis, then he or she should receive a series of appointments that may include debridement, quadrant scaling and root planing, subgingival irrigation, placement of a localized, subgingival, time-release antimicrobial/antibiotic agent, fluoride application, and oral hygiene instructions. The dental provider may also choose to implement a host-modulated therapy to aid in periodontal healing. This type of procedure scheduling will be unique to each individual and should be determined based on specific treatment needs.
Table. AAP Classification of Periodontal Disease.
Note: Type V refractory periodontitis is unresponsive to traditional therapeutic methods and may require immediate referral to a periodontal specialist.
Though the initial therapy “jump starts” the healing process, periodontal maintenance is critical for long-term success. The biofilm development begins immediately but matures rapidly and is fully established by 90 days. The disruption and destruction of these colonies must occur repeatedly in order to prevent further periodontal breakdown.
At any time during the patient’s therapy clinical judgment must prevail, and appropriate professional referrals should be established to provide the patient with the greatest opportunity for success. Success may present itself clinically in a variety of ways, and a prudent clinician would be wise to recognize these differences by altering the treatment plan and celebrating successes on an individual basis. As dental professionals, we must remember to set reasonable goals and expectations for nonsurgical treatment intervention. These goals should include the reduction and/or elimination of active disease, reduction of attachment loss, reduced probing depths, and an increase in patient knowledge and personal accountability for their oral health.
Although patient care should be our primary focus, profitability of a dental practice is also an important consideration for a successful dental hygiene program. Dental hygiene patient care is a source of increased restorative treatment, but in itself is an integral part of the dental practice’s revenue. When planning your budget, it may be helpful to keep the following key indicators in mind:
- 85% of all active patients should be in the hygiene program
- hygiene should provide approximately 35% of annual production
- hygiene gross salaries should be approximately 30% to 40% of total hygiene production.
All practices have full patient files, but what is considered an “active patient?”
Active patients are patients that have been seen in your practice at least once in the past 2 years. To determine the percentage of patients that should be in the hygiene program, this formula may be helpful: number of hygiene days worked x number of patients seen by the hygienist x 24 weeks (6 months)/total number of active patients. This number assumes that 15% of your patients will never see the hygienist for preventive care.
The hygiene production should include all procedures completed in the hygiene treatment room. These procedures include, but are not limited to, radiographs, examinations, sealants, fluoride, products, bleaching, and, of course, actual patient therapeutic care. When considering overall hygiene production, be sure that your hygienist is not just “busy.” This scenario may be caused by increasing patient numbers but not patient service. Production is a reflection of patient care, and a wise clinician will work smarter, not harder. This type of environment increases patient and staff satisfaction. A hygienist whose scope of care is preventive and does not include restorative (as in some states) should be producing at minimum (depending on area) $700/day to be profitable.
This production is a direct reflection of the hygienist’s compensation. As mentioned earlier, hygiene salaries should be approximately 30% to 40% of total hygiene production, and this should include bonuses but not benefits. By recognizing the contribution of the hygienist’s treatment and compensating him or her accordingly, the dental practice should reap the benefits of a profitable hygiene department while minimizing staff turnover.
Most dental practitioners prefer to provide direct patient care rather than focus on the business side of dentistry, but unfortunately the business side must be examined in order to provide the best standard of care. By using hygiene monitors the doctor is able to analyze the hygiene program and take action to improve profitability and effectiveness at the first sign of concern. Some simple steps to an effective hygiene program are proper scheduling, morning huddles, adequate number of patients, sufficient marketing, and a proper hygiene salary-to-production ratio.
Regardless of the type of dental practice you own or work in, patient treatment and compensation for that treatment is a reality that must be recognized and respected. By managing your staff, recognizing differences, honoring ethics and morals, and providing the highest standard of professional care, your practice will be well on its way to being a personal and financial success.
American Dental Association. Dental Team Careers: Dental Hygienist. Available at: http://www.ada.org/public/careers/team/hygienist.asp. Accessed on: February 18, 2007.
American Dental Hygienists’ Association. Important Facts About Dental Hygienists. Available at: http://adha.org/careerinfo/dh_facts.htm. Accessed on: February 18, 2007.
American Academy of Periodontology. Guidelines for the Management of Patients With Periodontal Dieases (Academy Report). Available at: http://www.perio.org/resources-products/pdf/management.pdf. Accessed on: February 19, 2007.
Armitage GC. Development of a classification system for periodontal diseases and conditions. Annals of Periodontology. Dec 1999;4(1):1-6. Available at: http://www.perio.org/resources-products/classification.pdf. Accessed on: February 19, 2007.
Carranza F, Perry D. Clinical Periodontology for the Dental Hygienist. Philadelphia, PA: WB Saunders; 1986.
Kaplowitz GJ, Cortell M. Chlorhexidine: A Multi-Functional Antimicrobial Drug [a peer-reviewed CE publication by the Academy of Dental Therapeutics and Stomatology]. 2006:1-13. Available at: http://www.ineedce.com/pdf_files/adts_chlorhexidine.pdf. Accessed August 14, 2007.
Neild-Gehrig JS. Module 21: Advanced probing techniques: four classifications of furcation involvement. In: Fundamentals of Periodontal Instrumentation. 4th ed. Lippincott Williams & Wilkins; 2000:458.
Steele T. Hygiene, Inc.: how managing with statistics can help you turn hygiene into profit. Tyson Steele Dental Practice Marketing Web site. http://www.tysonsteele.com/n-article.phtml/Hygiene_Inc. Published June 2007. Accessed August 14, 2007.
Wilkins EM. Clinical Practice of the Dental Hygienist. Philadelphia, PA: Lea & Febiger; 1989.
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