Interventionists A change virus

by Patti DiGangi, RDH, BS, Shirley Gutkowski, RDH, BSDH, FACE, and Cathy Hester Seckman, RDH

Health care reform is fully on the national agenda. The cost of U.S. health care is staggering and predicted to double within the next few years. The high cost is primarily due to the diagnosis and treatment of chronic diseases.¹ (Table 1) Dental diseases are chronic preventable diseases. For too many, health care reform means reform of the method of payment. This is a related issue, but different from other health care reforms, such as electronic records.

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Table 1

Costs of Chronic Disease in the U.S.¹

A second issue getting a lot of media attention is the H1N1 (swine) flu virus. Fear has spread around the world like … a virus. The CDC stated that the virus infected people and spread from person to person, and this sparked a growing outbreak.²

There is another virus sweeping the nation called social networking. Facebook is now the most visited social network, with nearly 1.2 billion visits in January 2009, an increase of 36% over December, and 256% over the previous 12 months. The big winner that many politicians are using to discuss health care reform is Twitter, which jumped from the 22nd most visited social network at the start of 2008, to the third most visited in January, a 1,227% growth in 12 months.³

By overlapping these topics, we’ve come up with a definition of health care reform for dental hygienists — spreading a change virus, infecting dental hygienists to become early interventionists.

In medicine, early intervention is defined as “services given to very young children with special needs, generally from birth until age three. Services include speech therapy, occupational therapy and physical therapy. The hope is that these services, provided early, will address any delays in development so that the child will not need services later on.”⁴ Our dental hygiene services don’t have to be limited to children. Early intervention can go throughout a patient’s life.

An early interventionist should have patience, perseverance, empathy, flexibility, consistency, and a love of teaching. Necessary skills include organization, self-management, and communication.⁵ In a perfect hygiene world, doesn’t this describe an oral health care provider’s function and skill set? Dental hygienists intervene to guide children into caries-free futures, or guide adults into lifelong periodontal health. Dentists, on the other hand, have traditionally been the latecomers, those who put out the fire after it burns down the building. Dental hygienists fireproof the building so it won’t burn down, and the earlier we do it, the better. We can justifiably call ourselves early interventionists. Let’s borrow another term from the medical field — the well-baby visit. We might as well expand the term — the well-person visit. Let’s stop thinking with the old paradigm that dentistry is about repairing diseased tissue. With the tools we now have in our hygiene arsenal, dentistry can and should be about dental wellness. Anytime anything is amiss, diving in at the first opportunity can make a huge difference.

Imagine that wellness can be added to that definition of early intervention. The dental hygienist is already perfectly placed to function as an early interventionist along with speech, occupational, and physical therapists. Imagine further that early intervention can be offered not only to children with special needs, but to all children. Finally, imagine that adults can also be served. Whether we see patients in our dental offices, or move into wellness clinics or the home, we can easily provide patients with the knowledge, tools, and skills necessary to ensure lifelong dental wellness.

Our profession is stuck in the paradigm that if it ain’t broke, don’t fix it. As with any belief, these boundaries block our view. We talk prevention, yet that word is so overused it’s lost its true meaning. You may be thinking that the prevention you provide and teach your patients is working. We ask: How are you measuring prevention/health?

When you are exploring, what are you seeking? Do you find a spot that has cavitated and needs restoration, or lumps of calculus on roots, or soft tissue lesions big enough to make you gasp? When you probe, what are you seeking? Are there pockets and bleeding?

When you take radiographs, is disease advanced enough to be seen radiographically? When you perform head and neck palpation, are there any lumps that might be cancerous? Do you explore enough to find a need for restoring the oral ecology?

Lack of quantifiable symptoms has meant health. Now there’s a circular argument — define health: lack of disease. That definition didn’t work in Public and Community Health class in 1985, and we dare say it shouldn’t work now. Health is a continuum (Graphic 1). Each of the detection modalities listed are looking for moderate to advanced disease shown on the far right side (red arrow) of the continuum. That is where our profession is stuck.

Early interventionists work in a different part of the continuum, the left side (green arrow) portion, when signs are limited or invisible to our most common detection schemes. Working from this end of the continuum means becoming risk factor managers. Risk factor management is discovering risk of breakdown, diagnosing early caries, oral cancer and periodontal disease, and treating infections before they cause damage. It may be time for a special person to be in charge of data gathering. A risk factor manager could perform diagnostic testing, gather data, and put it into meaningful reports for the care providers.

Imagine how we might manifest this level of intervention. A care provider would need to take time to find the causative agents. We cannot badger a person suffering from dry mouth into brushing and flossing, especially if no one takes the time to measure his or her salivary output. Checking salivary output, blood pressure, blood glucose levels, C-reactive protein levels, X-rays, and brush biopsy tests take time. Just completing this partial list of diagnostics necessary for early intervention of caries infections, bleeding gingiva, and oral cancer could take an hour, which doesn’t leave much time for education or prevention.

Viral change means tweaking what we already do, but it doesn’t mean we should throw the baby out with the bathwater. We’ve come a long way the past 60 years. At the start of World War II, the military had standards for military service requiring the presence of 12 functional teeth.⁵ The number of men disqualified for dental reasons far exceeded expectations, and the dental fitness standard was dropped in October 1942. It’s hard to wrap our minds around this. The majority of people applying for military service have traditionally been in their late teens and early 20s, yet back then they could not meet the requirement of having 12 functional teeth.

We’ve come a long way with prevention, yet the biggest mistake is to do more of what we’ve always done because it has always worked. Sound like nonsense? Those very successes can keep us from growing. The emphasis in the past was amelioration of disease; we need to shift to wellness and health. The foundation must be based on the beliefs that caries leads to cavitation, periodontal disease includes gingival diseases, and oral cancers are not inevitable.

Dental hygienists should be the leaders in health care reform based on our educational background. Was that a laugh we heard from some dentists? Most of us have an associate’s degree. How, dentists might wonder, can a person with a two-year technical degree take on this level of health care responsibility? We can take it on because we’re educated and licensed to standards set by the American Dental Association. The ADA knows that most graduates with associate degrees have nearly enough credits for a baccalaureate degree. Some are just a gym class short. Believing we have what it takes to shoulder this responsibility is imperative. Don’t settle for business as usual in your treatment room.

The first step must be the mental leap that a prophy or perio maintenance is not synonymous with the term “hygiene appointment,” no matter the expectations of the patients, dentists, or other staff members. This can be a huge leap for many of us. Often the response is, “The patient wants a cleaning,” or “That is all I have time for.” Patients expect this type of care because dental hygienists have taught them that we’re only in it for the chatting and polishing.

A 2005 Cochrane Collaboration evidence-based review asked, “What are the benefits and harms of routine scaling and polishing for periodontal health, and do these change with different time intervals?” The conclusion was, “The research evidence is not of sufficient quality to reach any conclusions regarding the beneficial and adverse effects of routine scaling and polishing for periodontal health and regarding the effects of providing this intervention at different time intervals.”⁶ This shakes the Holy Grail and rips at the foundation of what dental hygiene has been.

Though there is no science to support any particular time frame, since the 1950s and 1960s the six-month recall virus belief has fully infected everyone, from patients to most dentists, business staff, and even dental hygienists. We’re not saying that no prophylactic or periodontal maintenance procedures should be performed. What we’re saying is those procedures should no longer be the primary emphasis of dental care practice, nor should lack of time be the reason not to implement new health-based strategies.

This is where people start wondering how the bills will be paid if we no longer see patients for hard and soft deposit removal. The idea of a risk factor manager rears its head once again. The real reason our patients come to us is to make sure they are healthy, that they have no holes in their teeth, no cancerous lesions, and no pus pockets. They want to make sure their stomach and eye teeth are in good shape. They want to know if their buck teeth are out too far or their underbite is a problem. They hope we don’t use that pick thing and wonder why we have to leave the X-ray room while they have to stay in there. Our diagnostic tools have been limited to a couple of bent wires on a handle and some E-speed film.

The fact is that those wires are no longer standard of care. They are antiquated. We expect high-end diagnostics when we go to our physicians, and we should deliver no less to our own patients. Saliva testing, for example, cannot only tell us more about caries risk, but also breast cancer risk and be a genetic marker for other issues. In case you didn’t know, medical insurance will cover those tests.

Tests for occlusion before a mouthguard is made should be automatic. Fabricating a mouthguard on the basis of carbon paper dots on the teeth is not acceptable, and the dentist will certainly not be in the winner’s circle if the case goes to court. Orthodontics without an evaluation by a myofacial specialist of the soft tissue is not prudent either. Interventionists will continue to look for ways to find all issues earlier to be able to intervene earlier.

Did you notice this article is written by three authors? This is the virus of change — professionals sharing and growing, and acting synergistically to make the whole more than the sum of its parts.

When it comes to change, there are three ways to handle it:

1. We can fight it and fail
2. We can accept it and survive
3. Or we can lead it and prosper

It’s time for dental hygienists to lead and prosper and spread the virus of early interventionist growth from person to person. Together we can spark an outbreak. What an awesome way to reform our health care system … with a virus.

References

1. Fact Sheet: Preventing Chronic Disease is Critical to Controlling Health Care Costs. U.S. Centers for Disease Control and Prevention National Center for Chronic Disease Prevention & Health Promotion. Available at www.healtheducationadvocate.org/factsheets/chronic_disease_factsheet_2009.pdf
2. H1N1 Flu (Swine Flu) May 12, 2009 Centers for Disease Control and Prevention. Available at www.cdc.gov/h1n1flu/
3. Social Networks: Facebook Takes Over Top Spot, Twitter Climbs. February 9, 2009. Compete.com. Available at http://blog.compete.com/2009/02/09/facebook-myspace-twitter-social-network/
4. Special children: About.com. Available at http://specialchildren.about.com/od/earlyintervention/g/El.htm
5. Southeastern Louisiana University master of arts program in teaching program, Early Interventionist. Available at http://selu.edu
6. Jeffcote G. Dental standards for military service. United States Army Dental Service in World War II. 1955. Available at http://history.amedd.army.mil/booksdocs/wwii/dental/default.htm#cont
7. Bader J. Insufficient evidence to understand effect of routine scaling and polishing. Evidence-Based Dentistry (2005) 6, 5–6. doi:10.1038/sj.ebd.6400317. Available at www.nature.com/ebd/journal/v6/n1/full/6400317a.html

About the Authors

Patti DiGangi, RDH, BS, is a speaker, author, practicing dental hygienist, and director of CareerFusion, www.careerfusion.net, a retreat providing personalized training in all facets of career evolution. She can be contacted through her Web site at www.pdigangi.com.

Shirley Gutkowski, RDH, BSDH, FACE, is codirector of CareerFusion and a practicing dental hygienist. She is coauthor of the best-selling book The Purple Guide: Developing Your Clinical Dental Hygiene Career with Amy Nieves, RDH. She can be contacted at [email protected].

Cathy Hester Seckman, RDH, is a frequent contributor based in Calcutta, Ohio. Besides working in a pediatric dental practice, Seckman is a prolific freelance writer, book indexer, and speaker on dental and writing/indexing topics. She can be reached at [email protected].