The value of a dental hygiene appointment

So far 2020 has brought unexpected downtime and many challenges to our industry. As clinicians cautiously returned to their operatories, many felt frustration, fear, and a sense of charting unfamiliar territory. During this time I was struck by the thought that society still does not know the value of what a dental hygienist provides. Furthermore, I wondered if we in dentistry had forgotten as well.

Of course, many patients do value their dental hygiene visits. Take the patient who follows you from one practice to another because you “saved” their teeth by providing periodontal therapy. Or take the type-A perfectionist who absolutely loves the process of a dental hygiene appointment and comes to see you every three months—even though he is the model of oral health. What exactly is it that these patients value? If most of the value is due to their slippery smooth teeth at the end of their appointments, then perhaps we need to help them envision their appointments a little differently. 

During this time, we as dental hygienists are experiencing major shifts in the industry. Some of us are experiencing the fear of going back to work, some of us have been told by our employers that hygiene schedules have been cut, or perhaps we are lucky enough to have longer appointment times with our patients. As time goes on, it becomes easier to get lost in the changes and forget our purpose.

Just recording accurate vital signs alone can be lifesaving to a patient who is unaware of underlying medical conditions. 

I would like to take this time to reflect and remind the dental community of our immense value within the dental team. A dental hygienist’s value does not solely come from removing calcified deposits from teeth, or from removing stain and providing that wonderfully clean feeling that patients love so much. No, our value lies far deeper in areas that are not acknowledged by billable codes. And because of this, the other vital health-care services we provide may not be perceived as valuable. Let’s take a closer look at these and remember.

Health history assessment and vital signs

A thorough medical and dental history assessment satisfies several fundamental aspects of initial care that are central to a successful appointment. It is an opportunity to build rapport with patients and obtain an overview of their concerns and the main objectives for their visits.^1,2 However, on a much deeper level, the dental hygienist is taking this time to consider the relationship between patients’ systemic health and their oral health. They are taking inventory of possible oral implications related to medications and systemic conditions, as well as noting allergies and any risk of the occurrence of a medical emergency. The dental hygienist assesses patient concerns, takes notes, and plans for any alterations to care that may be required due to a systemic condition, mental health issue, or disability. Additionally, the dental hygienist screens for an elevated temperature to minimize the risk of spreading infectious diseases, and records blood pressure, pulse, and respiration.^1,2 Just recording accurate vital signs alone can be lifesaving to a patient who is unaware of underlying medical conditions. 

The dental hygienist incorporates interprofessional care by contacting various health-care providers and therapists regarding uncontrolled systemic conditions and physical or behavioral issues that are affecting the patient’s oral health. The amount of critical thinking and patient-centered care that takes place in these first few minutes is really quite astounding.

Extra/intraoral examination

With an estimated 53,000 Americans receiving a diagnosis of oropharyngeal cancer this year alone, the value of this screening to our patients is certainly not in question.³ According to the Oral Cancer Foundation, oropharyngeal cancer kills one person an hour.³ With more than 150,000 registered dental hygienists in the United States who each see roughly eight patients per day, that presents a huge opportunity to provide this lifesaving service.⁴

As we know, the earlier oropharyngeal cancer is detected, the higher the survival rate.^3,5 Therefore, every time you visually scan and palpate your patients’ tissues, you are giving them the gift of expert eyes. Dental hygienists understand what the normal environment looks like; therefore, abnormalities stand out easily. Dental hygienists cannot diagnose, and oral cancer requires a biopsy for confirmation. However, patients benefit from dental hygienists identifying their risk factors—both modifiable and nonmodifiable—alerting the doctor, and referring the patient to an oral surgeon or physician. Dental hygienists may be the only health-care providers who ever perform this screening. Patients visit their physicians routinely for mammograms, prostate screenings, and PAP smears. Screening for oral cancer is just as important. None of our patients would choose to reduce the risk of one type of cancer but not another if they were educated on the topic. 

Periodontal assessment 

The periodontal assessment could be the most valuable information collected by a dental hygienist during an appointment. Most dental hygienists could not imagine initiating treatment without a current periodontal assessment. At minimum, this is conducted once a year for healthy patients and as often as every visit for patients with active or stabilized periodontal disease. Dental hygienists understand the value of a current periodontal chart.¹ The act of gently probing around each tooth provides information about the subgingival world that is not available in any other format. Even dental radiographs can hide bony defects or present them inaccurately due to variations in clinician technique. Furthermore, radiographs do not reveal buccal and lingual bone levels adequately unless there is furcation involvement. However, the value of the periodontal assessment is not always relayed to the patient, and aspects of this assessment may be neglected by dental hygienists for a variety of reasons, such as time restraints or patient sensitivity. 

The dental hygienist has a prime opportunity to integrate interprofessional collaboration by locating a nutritionist or a dietitian and discussing ways to support the patient's needs.

A complete periodontal assessment should include recording probing depths, bleeding upon probing, amount of recession, total clinical attachment loss, furcation involvement, mucogingival examination, and mobility.^1,2 Oftentimes, an experienced dental hygienist will mentally take note of how much calculus is present while gathering this information. 

What are the benefits to the patient that result from this assessment gathering? We all have had patients who let us know they don’t like it when we “go poking around their gums.” They may not realize that there is a genuine purpose to probing. We say the oral cavity is a window to the body, and this assessment provides valuable information to determine oral and systemic health and disease. The vital information gathered can reveal issues ranging from mild forms of gingivitis clearly related to a lack of biofilm control to the early signs of an irreversible inflammatory disease process. Additionally, assessments can divulge clues to an underlying systemic condition that is directly affecting the mouth, even in the presence of good oral hygiene care. We also know many of the diseases in the oral cavity are “silent,” and often pain is present only when destruction is severe. The periodontal assessment provides an opportunity for patients to understand their health or disease status, both orally and systemically.

Nutritional counseling

According to the American Dietetic Association, nutrition is a central component to oral health.⁶ There are many facets of oral health and nutrition that overlap and synergize. Consider oral manifestations of malnutrition, the need to chew fibrous and nutritious foods as we age, the systemic effects of poor nutrition on inflammatory diseases, or the acid attacks that take place every time we eat or drink fermentable carbohydrates.^1,6 

Nutritional counseling is very much within the scope of the dental hygienist’s practice, but it is often not utilized due to time restrictions or not feeling adequately prepared to broach this topic in depth with our patients. However, the dental hygienist has a prime opportunity to integrate interprofessional collaboration by locating a nutritionist or a dietitian and discussing ways to support the patients’ needs. The dental hygienist can resolve to make nutrition an important part of an appointment. Value is easily increased if the hygienist prepares a few key points to provide a patient. It doesn’t have to be 20 minutes of discussing nutrition; however, you might find a few patients who could benefit tremendously from this counseling and are grateful for the knowledge you have to share. Having this information on hand or being a resource for your patient to find a nutritionist, wellness coach, or diabetic educator holds a tremendous amount of value, and it is directly linked to oral health.

Smoking/vaping cessation

Today, a greater number of young people are choosing to use electronic cigarettes over traditional tobacco cigarettes.^7,8 Between 2011 and 2015, e-cigarette use among US middle and high school students increased 900% before decreasing for the first time from 2015 to 2017.^7,8 According to the CDC, in 2019, 27.5% of high school students reported using electronic cigarettes.^7,8 However, it is not just nicotine and tobacco that dental hygienists have to be educated about in order to discuss this topic with patients. Studies indicate that in 2019, 14% of high school seniors admitted to vaping marijuana. Additionally, 3.9% of eighth graders report having vaped marijuana.⁹

During this time of COVID-19, when respiratory health and risk factors are on the front pages of news outlets and social media platforms, dental hygienists are perfectly poised to assist their patients in smoking/vaping cessation. This can be accomplished by asking patients about their use and readiness to quit. Dental hygienists can advise their patients by providing the latest information on tobacco use, vaping, and e-cigarettes, as well as the overall health risks. Finally, dental hygienists can refer patients to other resources for quitting, including websites, physicians, or counselors. 

Though there is much to learn about COVID-19, one thing that seems consistent in the research is that underlying medical conditions, such as asthma, COPD, and serious heart conditions, are increased risk factors for severe forms of COVID-19.¹⁰ Our understanding of the relationship between these conditions and smoking/vaping is an invaluable resource to share with patients. 

Sharing the information that has come out recently in regard to e-cigarette or vaping-associated lung injury (EVALI) adds value to the services we provide our patients. Furthermore, this is a service—along with nutritional counseling and oral hygiene education—that can be provided to patients entirely through teledentistry. 

Conclusion

As clinicians, we know much of this already; there are really no great revelations here. But I do believe we forget the importance of all that we provide during the hustle and bustle of a busy workday. We don’t talk with our employers about these valuable services. We tend to get busy and just focus on the billable codes for prophylaxis, scaling and root planing, fluoride, and other therapeutic modalities. As a result, the emphasis and the importance get placed on calculus and stain removal, and this perspective is often shared with patients. 

But as you can clearly see, if we never picked up a scaler and treated disease or provided a prophylaxis, dental hygienists would still be providing invaluable, potentially lifesaving services to patients. And why is that? Because dental hygienists are disease preventers and educators first and foremost. That is where our value lies, but it has been discounted because those essential services are not typically reimbursed by insurance. 

Now that we have reflected on our value, what can we choose to do about it? During this time of adjusting to the new realities that COVID-19 brings, when there is so much fear and change, I believe there is much we can do. Instead of being fearful, we can choose to harness proven technologies such as teledentistry. We can remember who we are and where our value lies. We can demonstrate our skill of being great patient educators and screeners of disease. We can take this time to remind our employers of this fact as well. I challenge you to put your superhero cape back on and spread the oral health message you are so expertly qualified to share. We are a mighty group of healers and prevention specialists, and we will move through this time together as we establish our new normal and systems of care, while improving the lives of our patients. 

References

1. Darby ML, Walsh MM. Dental Hygiene Theory and Practice. 4th ed. Elsevier; 2015.
2. American Dental Hygienists’ Association. Standards for clinical dental hygiene practice. 2016. https://www.adha.org/resources-docs/2016-Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf
3. The Oral Cancer Foundation. Close to 53,000 Americans will be diagnosed with oral oropharyngeal cancer this year. 2020. https://www.oralcancerfoundation.org/research/  
4. American Dental Hygienists’ Association. Oral health fast facts. https://www.adha.org/resources-docs/72210_Oral_Health_Fast_Facts_&_Stats.pdf
5. Tax CL, Haslam K, Brillant M, et al. Oral cancer screening: knowledge is not enough. Int J Dent Hyg. 2017;15(3):179-186.
6. Touger-Decker R, Mobley CC, American Dietetic Association. Position of the American Dietetic Association: oral health and nutrition. J Am Diet Assoc. 2003;103(5):615-625.
7. Centers for Disease Control and Prevention. Youth and tobacco use fact sheet. 2020. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
8. E-cigarette use among youth and young adults. A report of the Surgeon General. Centers for Disease Control and Prevention. 2020. https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/pdfs/2016_sgr_entire_report_508.pdf
9. New report: marijuana vaping rising among teens. Get Smart About Drugs. Dec. 19, 2019. https://www.getsmartaboutdrugs.gov/news-statistics/2019/12/18/new-report-marijuana-vaping-rising-among-teens
10. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). People with certain medical conditions. September 11, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html