April 1, 2001
by Lisa Philp, RDH
Fortunately for the profession of dental hygiene, the days of “pick and flick” and “buff and shine” are gone forever. We are no longer the “cleaning ladies” of the dental practice. The evolution of research with respect to periodontal disease has created a major change in preventive and periodontal care. Traditionally, hygiene was a procedure-based profession; we would schedule 30 to 40 minute appointments twice a year regardless of the patient’s status of oral health. During that appointment time, it was expected that we would accomplish a series of disconnected tasks combined with the usual lecture on flossing. Our patients viewed the 6-month recall in a similar manner to getting their hair or nails done. The profession of dentistry had trained patients to perceive hygiene services as a routine “pick and flick” and “buff and shine.” It’s no wonder that hygiene departments across North America experience 10% – 40% downtime from last minute cancellations and invalid broken appointments!
The beliefs and evidence upon which hygiene services were determined have dramatically changed over the last 20-30 years. There have been three main eras that have determined patient care. The first was the “non-specific plaque theory,” initiated by Harold Loe’s classic paper declaring that plaque was bad, caused gingivitis, and equaled disease. At this time it was generally perceived that gingivitis progressed very slowly to periodontitis. The quantity of plaque was thought to influence the progression of disease.
It was a relatively simple time to practice periodontics; a number of very basic techniques were used to treat all forms of periodontal disease. If patients didn’t respond favorably to those techniques, the patient was blamed for not performing home care adequately. Never was the treatment technique or etiology of the disease questioned. Failure went unchallenged and was accepted for what it was — “unexplainable”.
In the late 1970’s research revealed the “bacterial specificity” era. This theory was based on the identification of different bacteria and their relation to disease. Research proved that supragingival plaque was different from subgingival plaque and that quality, rather than the quantity, influenced the progression of disease. The dental world began to question their accepted beliefs regarding periodontal disease.
In 1985 scientists began to look closely at the way in which the host and bacteria interact. This time period is referred to as the “host bacteria inter-relationship” era. Further research suggested that while specific bacteria was important, it was the response of the host (immune system) that determined the progression of disease. This has led us to the current standard of care with the focus now on over- all health and wellness.
It’s only natural to adapt the profession to support patients through new findings in research. As such, dental hygiene is progressing through a metamorphosis. That metamorphosis began with the realization that the dental hygienist needs to possess more than the technical skills required to perform deposit removal, they also need to have the ability to be critical thinkers and problem solvers with advanced communication skills.
The term used to identify the current model of care is the “Dental Hygiene Process.” This model reflects a systems approach and conceptualizes dental hygiene practice as a problem solving process, not merely the performance of a series of disconnected tasks. The dental hygiene process is comprised of four distinct, but interrelated phases, assessment (preceded by a screening phase), planning, implementation, and evaluation.
The acronym that makes it easy to remember the hygiene process of care is S.A.P.I.E.
The screening phase is performed using the PSR system (Periodontal Screening and Recording). PSR is convenient and easy to incorporate into the existing recare appointment for healthy adult patients (PSR is not deemed appropriate for patients who have shown signs of past history of disease). Performing the PSR takes approximately 3-5 minutes and is of no extra charge to the patient. The PSR technique addresses all sites in the oral cavity (it is not a spot probing) and it is not meant to measure the depth of pockets. It is crucial that the proper WHO probe be used, otherwise the screening is confused with the assessment. The screening probe has a black band from the 3.5-5.5mm range. The clinician “walks” the screening probe around 6 sites on each tooth in a sextant. Each sextant is assigned a code number between 0 and 4. The code is based upon whether the black band is completely visible, partially visible or completely invisible. The results of the PSR tell the clinician and patient two things.
— Is the patient at risk for breakdown of the supporting structures of their teeth?
— Does the patient require further data collection?
There has been great success in using this tool to reward healthy patients and by identifying when they have developed signs of risk. If the results of the PSR indicate two code 3’s or one code 4, the patient needs to move into the next phase of the process, which is the Assessment phase or the Comprehensive Oral Examination (COE).
The Assessment phase of the model consists of a Comprehensive Oral Evaluation that includes the collection of data from a procedural perspective combined with behavioral discovery. The procedural component includes medical/dental history, extraoral and intraoral cancer screening, restorative conditions, occlusion, gingival assessment, pocket depth measurements, recessions, clinical attachment levels, furcations, bleeding, mobility, home care analysis, radiographs and intra-oral pictures. The behavioral component is often overlooked especially with a patient of record; it is vital in nurturing relationships with patients. The behavioral information includes documentation of the patient’s perceived problem, dental I.Q., their motivators and goals, their expectations, personality style and the degree of behavior modification necessary with respect to self-care.
The Planning phase of the model focuses on the extent of periodontal disease and the necessary periodontal and restorative treatment. This is the time to determine the number of visits, what treatment will be delivered at each visit, the patients’ role in treatment and what the financial investment will be. The course of action taken for the periodontal treatment plan is based on the level of infection in the patient’s mouth (Case Type). The restorative treatment plan includes a comprehensive lifetime strategy for needs, and elective dentistry.
The implementation part of the model is the actual treatment phase of repetitive periodontal therapy. It includes making sure that the patient takes ownership for their role in the treatment, delivering current concepts of ultrasonic debridement, delivery of chemotherapeutics and “self-care instruction” with self-assessments.
The Evaluation phase occurs 4-6 weeks following the completion of active therapy and is crucial in determining the healing results and success of treatment. Was the treatment successful; or does it need modification? Does the patient require referral to a specialist; or have this patient’s needs been met within the scope of our practice? What is the appropriate maintenance interval to support the patient in maintaining this status? The evaluation appointments include full documentation of the periodontal status and self care progress.
Dental Hygiene is the heartbeat of the dental practice. The entire practice depends upon the effectiveness of the hygiene process of care. Your commitment to the integration of new concepts into your practice will change your patient’s perception of value, therefore increasing production, reducing downtime and increasing case acceptance. Change is a normal part of life; as much as we resist it, it doesn’t go away. DPM
Lisa Philp, RDH and president of Transitions Consulting Group, Burlington, ON.