When It Comes to Hygiene Care, the Clock is Still King

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I chuckle to myself when I say that I graduated from Fones School of Dental Hygiene during the Jurassic period. I took the National and Northeast Regional Board Exam in the 1970s when handpieces were belt-driven, curettes were standard graceys that rolled around on a metal tray and porte polishers were still being used in school settings.

It was hard to feel confident in instrumentation because dental hygiene instruments, including ultrasonic inserts were mostly designed for supragingival calculus removal. I stayed put in one dental practice, full-time in Closter, New Jersey, for 4 years where I worked with my gracey curette sets and ONE Cavitron ultrasonic insert that had a short, bulky tip. Right after graduation, I was scheduled to work in 45-minute increments. There was no such thing as scaling and root planing so we would gross scale at one appointment and fine scale the next.

I enjoyed mixing pumice with mouthwash for heavy extrinsic stains and prided myself in knowing how to remove stubborn tobacco stains. I graduated from Fones not knowing how to take radiographs, so I ended up teaching myself and at that time we were still bisecting the angle as a radiographic technique.

In 2011 I co-wrote a popular article for RDH magazine with Rhonda Jones, RDH, BS, called “The Clock is King”.¹ Around that time, practice management consultants and dental practice owners were starting to experience a downturn in patient numbers with patients foregoing routine dental care. PPOs popped up with discounted fees which meant focusing on efficiency and reducing expenditures and looking for ways to become more efficient.

I say it now as I did back in 2011: “Time management is an important piece of the formula so that patients are not shortchanged.” 1Today’s dental practices are facing challenges like inflation, rising costs and staff shortages and COVID has definitely been a force to be reckoned with. Assisted hygiene is more popular as a model of care, DSOs are here to stay, and time management is more important than ever.

A good friend of mine, Noel Kelsch, RDH, RDHAP, MS, likes to say: “Be the change you want to see” and she’s embodied it in her career. My biggest disappointment with dental hygienists who post online and complain about not having enough time to deliver clinical excellence is this: stop complaining and INSIST on adequate time! Don’t stay in clinical positions where you are compromising care. Re-read the RDH magazine article “The Clock is King” and talk to the practice manager and practice owner before bolting out the door for good. Practice owners don’t always know what your frustrations are unless you address them and sometimes well-meaning practice managers delegate duties to hygienists that belong elsewhere. Patient time, taken away from a hygienist, results in lower hygiene profitability and a frustrated hygienist and patient. Dental hygienists are primary care providers who need assistance, just like the dentist, so they can focus on what they do best: delivering high quality service to patients.

How important is adequate time to perform dental hygiene instrumentation

I am constantly shaking my head when reading dental hygiene posts from someone with a whiny, complaining tone on Facebook. I sympathize, of course, and have experienced some of the same scenarios but I always found a way to wiggle out of it and return to a dental practice that allowed me to achieve clinical excellence and a better work and home-life balance. To those hygienists who have achieved independence in various United States and can work on their own, kudos to you. I’ve written about some of you and I applaud your determination.

I just finished reading a Facebook group post by an experienced hygienist who noticed that the other more recent dental hygiene graduates in the dental practice weren’t removing subgingival calculus on recare patients (seen on bitewing radiographs) and she found herself having to clean up after them. She blamed the situation on the 30-minute adult prophy recare time interval. I’ve rarely worked that kind of schedule but I do recall working a temp day in the 1980s where I was expected to deliver dental hygiene care every 30 minutes. The day flew by, I survived it (barely), but I was an assembly line worker, not a primary care provider. I was paid that day on commission, but I was absolutely miserable. On the drive back home at the end of the day, I vowed that I would never accept a substandard work schedule again. I’d rather earn less money and feel proud of the service I rendered to patients.

When performing an adult prophylaxis, a quick swipe with a sonic/ultrasonic tip on a low power setting to disrupt dental plaque biofilm is not enough! Years ago, I used to write about a periodontist who practiced in California named John Y. Kwan, DDS. John used Perioscopy while scaling so he could visualize the subgingival pocket environment. He only used ultrasonics while scaling but his scope was attached to a probe that guided his ultrasonic tip strokes. Most of us are working BLIND and a quick swipe tooth to tooth isn’t adequate to reduce gingival inflammation and dental plaque biofilm. Let’s take a look at the literature and review some instrumentation principles based on susceptibility to periodontitis.

About 42% of dentate U.S. adults, ages 30-79 years, have some level of periodontitis.² A lot of localized periodontal destruction seems to be the result of inflammation which results from an interaction of the host immune system and a dysbiotic subgingival biofilm which contains “keystone” microbes like Porphyromonas gingivalis and many others.² We have known for several decades that long-term success in treating periodontitis requires a combination of detailed root surface debridement, appropriate periodontal maintenance and patient compliance to recommended oral hygiene measures.²

The cornerstone of nonsurgical periodontal therapy is still scaling and root planing (SRP); however, dental hygienists must insist on adequate time to perform this procedure because it is technically challenging and research has shown that inadequate instrumentation results in faster microbial re-population and re-infection.² No specific instrumentation technique (hand versus powered) has been shown to be superior in removal of biofilm or calculus and the cemento-enamel junction is a common site for residual calculus.² Efficacy of scaling is reduced with the following variables: increased probing depth, root concavities, grooves, restoration contours, degree of furcation involvement, and microbial invasion of root surface irregularities and dentinal tubules.2 Repeated removal of subgingival biofilms at appropriate patient intervals (periodontal maintenance) prevents rebound to pretreatment levels in pockets measuring greater than or equal (≥) to 4 mm.²

Biofilm and calculus harbor bacteria. It used to be thought that calculus was inorganic material but it now appears that there is both an organic matrix with non-mineralized channels and lacunae containing oral biofilms.² Think of the subgingival calculus as a piece of hardened Swiss cheese with biofilms running through it and along its surface.

In closing, I continue to wonder why it is that a non-dental practice manager or front office employee sometimes determines the amount of time allocated to the dental hygienist for a given procedure? If a dental practice is really sincere about the overall welfare of the patient, doesn’t it make sense for the dental hygienist to have some input on time intervals for a hygiene procedure?

The clock is still king but dental hygiene procedures take time. Primary healthcare providers are not robots who can run at peak performance and increase practice profitability at the expense of delivering ethical, quality care.

References

1. Slim, L, Jones, R. The Clock is King. RDH. https://www.rdhmag.com/pathology/periodontitis/article/16408649/the-clock-is-king Accessed Oct. 6, 2022.

2. Cobb CM, Sottosanti JS. A re-evaluation of scaling and root planing. Commentary. J Periodontol. 2021; 92(10): 1370-1378.