BY DIANNE GLASSCOE WATTERSON, RDH, BS, MBA
Dear Dianne,
I graduated from hygiene school three years ago, and I have worked in the same office full-time since passing my boards. Another full-time hygienist has been working in the office for 20 years. The problem is that the other hygienist leaves calculus all the time. I have seen a number of her patients, and I almost always find deep subgingival calculus that she missed.
I just don't know what to do. I've thought about going to the doctor about it, but he seems very fond of her. She has many patients that have been seeing her for years. If someone needs to reschedule, that patient may wind up on my schedule. Then I have to dig out what she has been missing and get labelled as "rough." The office manager has told me that some patients have complained about me and have requested not to see me again. Please help me sort this out. I need my job.
Thorough RDH
Dear Thorough,
One thing I know is that there is no harsher critic of a hygienist than another hygienist.
Here's another newsflash! Rarely, if ever, does anybody ever get all the calculus off. Many studies have borne out this truth. Kepic et al. published a scientific article titled, "Total Calculus Removal: An Attainable Goal?" (Journal of Periodontology, Jan 1990, Vol. 61, No. 1, Pages 16-20). Using scanning electron microscopy, they found "that complete removal of calculus from a periodontally diseased root surface is rare."
Additionally, I've presented a number of "gift" seminars for periodontists who hire me to provide continuing education for their referring dentists and hygienists. In discussions about calculus removal, periodontists have shared with me that even when the tissue is laid back and the root is completely exposed, it is sometimes impossible to remove all the calculus that has become deeply embedded in the root surface without doing serious damage to the root. My point is that no one - not even periodontists - gets all the calculus off all the time.
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One embarrassing moment for me was when a tooth (No. 2) that I had root planed about a month earlier had to be extracted. The prognosis was questionable all along, but the doctor told me to scale it anyway. After the extraction, he brought the tooth to me to show me the remaining calculus. I had burnished the calculus so well that it could not be felt with an explorer, but all the same, there was still significant calculus on the distal root of the tooth. He didn't show it to me to make me feel badly, and it really was good for me to see what I had left. That day, I learned I was not "Super Hygienist Woman."
We know that calculus removal is an important aspect of professional patient care. Your dental hygiene training focused on teaching calculus removal techniques, and you got points counted off if you left one little spicule that could be detected with air drying or an explorer. In fact, your training may have made you so calculus oriented that you feel it is the benchmark of high-quality care. That's a problem.
Calculus does not cause periodontal disease. Calculus is an inert material that is actually secondary in the periodontal breakdown process. It gives microbes a nice, rough place to take up residence. However, microbes will stick anywhere in the sulcus. They do not prefer calculus over cementum. Microbes can be found on the root surface, free-floating in the sulcus, embedded in the epithelium, in the connective tissue, and even on the surface of the bone. In fact, patients can still have periodontal disease in the absence of calculus.
Please understand that I'm not making excuses for your coworker, and in an earlier time, I might have felt exactly like you feel under the circumstances. Time is a great teacher, and over the years I've learned a few things that might help you in the future. I've learned:
1. Hygienists do not intentionally leave calculus as a rule. I've never met a hygienist or dentist who thinks he or she does substandard work.
2. Calculus removal is far more difficult when hygienists use dull instruments. Far too many hygienists do not know how to sharpen effectively. Some that know how to sharpen don't do it often enough. It is much better to use instruments that actually stay sharp for a long, long time, such as those made by American Eagle (am-eagle.com).
3. It is important to remove as much calculus as possible, but it is also important to realize that complete calculus removal is often not achievable, especially in sulci deeper than 6 mm.
4. Implementing comprehensive strategies aimed at controlling microbial populations in patients with periodontal disease involves much more than just removing calculus. Microbial control is as important (if not more so) in the big picture as calculus removal.
5. Just because you get most of the calculus off does not mean the patient will get better and stay better. In fact, there is nothing the clinician can do that will overcome what the patient will not do.
6. Nobody is perfect. Even the most skilled clinicians unintentionally leave calculus.
While it is commendable that you are astute about calculus removal, you stated that some patients have complained about perceived "rough" treatment from you. When one patient complains, rest assured there are 10 more who feel the same way but didn't complain.
In my opinion, you should be far more concerned with perfecting your own technique so that you don't hurt people than stressing about a coworker's deficits in calculus removal. People do not enjoy experiencing pain at the dental office.
You should not hurt people in any of three ways: emotionally, financially, or physically. We cause emotional pain when we make people feel stupid or inadequate. We cause financial pain when we unpleasantly surprise a patient at the front desk with a fee that he or she was not expecting. We cause physical pain when we use improper instrumentation techniques or fail to use anesthesia as needed. Use whatever means are necessary to make sure your patient stays comfortable while in your chair. There are good topicals available to use in the sulcus, such as Cetacaine (Cetacaine.com), or your patient may need a local injection in order to allow you to be thorough.
I do not advise you to go to the doctor in this situation. The other hygienist has significant longevity, and I seriously doubt the doctor would have continued her employment if he felt her work was not adequate. Also, if enough patients complain about your treatment, no matter what your intention, your job will be in jeopardy. There aren't too many things that will upset a dentist more than complaints from patients about a staff member.
If your coworker's skills are lacking and you discover calculus from time to time, do your best to remove it without causing patients unnecessary pain. I urge you to try to be less critical of her work and more in tune with what patients perceive when they are in your chair. And keep in mind that after you've been scraping teeth for another 17 years, you might unintentionally leave some calculus too.
All the best,
Dianne RDH
DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. Dianne's new book, "The Consummate Dental Hygienist: Solutions for Challenging Workplace Issues," is now available on her website. To contact her for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her website at www.professionaldentalmgmt.com.
