With the ball drop at midnight and the off-key vocals of “Auld Lang Syne” bidding farewell to 2019, we enter a time of both reflection on what the previous year brought, as well as turning our sights to the future bringing new growth, new challenges and new opportunities.
As we enter the year 2020 and, subsequently a new decade, it is imperative that the dental hygiene community come together to reflect on where we were, where we are, and where we are going. New Year’s resolutions aside, now is the time to evaluate what it is that we collectively see for the future of our industry and how we can move there, together.
With loupes on, key experts recognize that our scope of practice will become magnified, our clinical savvy will become illuminated and the clarity of the vision of our future, so to speak, is 20/20.
As far back as the 1950’s, history tells us that dental hygienists were managing the sequelae of periodontal disease through the gold standard of scaling and root planing, irrigation with a medicament and performing recall therapy at three, four or six-month intervals.
Despite the advances in technology, equipment and research, many dental hygienists today continue to manage periodontal disease through the same measures, and empirical data indicate that most dental patients are placed on sixmonth recall intervals.
It is safe to say that while other medical industries continue to advance their paradigms to align with the utmost in research, dentistry, in many ways, has remained stagnant with an unclear understanding on how to move forward.
Li, et. al (2010) estimates 55.7% of subjects age 18-90 without attachment loss have a gingival index at 1.0 or higher. Eke, et. al (2016) noted that approximately 45.2% of adults age 30-79 have some form of periodontitis.
By all definitions, one could extrapolate that an average dental practice should find 45.2% of their adult population in either an active or stabilized state of periodontitis, 30.5% of their adult patients have gingivitis at a gingival index over 1.0, and that the remaining 24.3% of patients are healthy or incipient gingivitis patients.
Yarbrough, et. al (2016) noted, however, that nearly 85% of adults aged 19-64 receive a prophylaxis as their hygiene service despite the clear incidence and prevalence of diseases of the periodontium as noted above.
Additionally, increasing prevalence of diseases such as HPV have escalated the risk for oral cancer, and mounting research indicates, on average, one person per hour dies in North America due to complications of oral cancer.
Dental caries remains the #1 most prevalent chronic childhood disease, far surpassing Asthma.
Sleep apnea has been identified as a novel risk predictor for cardiovascular morbidity, airway evaluation in the dental chair may provide key indicators for long term chronic disease, and the new understandings of tethered oral tissues and tongue patterns have demonstrated a parafunctional cascade of symptoms, bringing dentistry further into the medical space.
Research is continuing to unpack diseases that may originate or can be diagnosed by way of the oral cavity, and as such, this research has essentially kicked out a seat for dentistry at the table amongst medical modalities.
Nevertheless, dentistry continues to struggle with the divergency of understanding the breadth, extent and importance of its existence while delicately balancing the general public’s lack of knowledge and perceived value in managing and controlling oral and, of course, systemic disease.
Perhaps it is a culture shift that is needed.
If so, this shift must begin with the dental community.
It seems that nearly every day, a new research article is published highlighting overwhelming conclusive evidence linking the bacteria associated with oral disease or the inflammatory burden as a result of oral infections to systemic disease.
The unending dichotomy between newly evolving evidence and seasoned, unchanging procedures creates the greatest challenge in elevating dentistry to meet the needs of the community. Therefore, let 2020 be the year that you, as a dental professional, identify unique ways to integrate the change our industry and the community so desperately need.
This begins with prevention. Prevention [pre-ven´shun] is defined as the keeping of something (such as illness or injury) from happening. Further definitions in medical dictionaries go on to discuss the inclusion of assessment, disease risk, health teaching, early diagnosis and treatment and screenings as integral parts of the preventive process. As dental hygienists and preventive experts, this is our opportunity to rise and serve our patients.
Our responsibility begins with the gathering of vital signs such as blood pressure, pulse, respirations and pulse oximeter readings, is threaded through comprehensive evaluation of medical, dental, genetic and historical surveys, is tethered to screening for extra and intraoral lesions, airway evaluation, thyroid integrity and risk for oral cancer, is driven by complete and thorough periodontal and caries evaluations, is enhanced by comprehensive oral hygiene, nutrition and tobacco cessation counseling and ultimately driven by evaluation and subsequent implementation of risk assessment.
It is time for the dental hygienist to re-think the hygiene preventive appointment and step into the future as hygienists who understand and practice the value of screening and counseling for life-threatening systemic disease over concerns regarding ensuring we scale the residual stain on the lingual of #27.
Gone should be the days of experiencing incredible head/neck/ shoulder/back pain leading to physical and emotional burnout while struggling to effectively remove all debris due to underdiagnosing a patient with a prophylaxis.
I implore you to consider that the excessive utilization of the prophylaxis code throughout North America is not only not serving our patients, it is also allowing for the slow, gradual and oftentimes silent propagation of diseases of the periodontium. Additionally, the incredible time required to manage the gross amount of debris and inflammation through a prophylaxis rather than therapy of advanced disease poses a distraction to addressing other, more concerning diseases.
Every time we misdiagnose, underdiagnose or skip procedures, not only do we de-value the work we do as professionals, we also put our patients at immense risk for advanced, and oftentimes undiagnosed disease.
Active Therapy requires not only keen assessments and diagnostics but also the right tools, advanced training, and a comprehensive approach.
Periodontal disease is a multifactorial disease, requiring management of various modalities beyond biofilm control to include evaluation of genetic make-up, systemic health, degree of inflammation, immunity, anatomy, salivary flow and content, the duration of biofilm insult, biofilm location, biofilm composition, tobacco habits, utilization of systemic and recreational drugs, the burden of stress, occlusion, nutrition and home care habits, to name a few. (AlJehani, YA, 2014)
Dental caries embody their own set of risk factors inclusive of salivary content and flow, dietary considerations, introduction or lack of remineralization therapy, tobacco usage and early detection and treatment, as significant examples.
Changes to the oral tissues, advancement of suspicious lesions, greater threat from tethered oral tissues, development of airway obstruction and the inclusion of significant risk factors to chronic diseases require advanced training, certifications and screening modalities within the dental office for proper execution.
Unfortunately, the inclusion of these advanced and, some might say futuristic techniques will separate the upper echelon of dental providers from those who choose not to update their protocols, thus remaining in the primitive world with our ghosts of dentistry past. This separation, while creating a disunioned chasm within the dental community, will push boundaries, instill question, challenge the status quo and, ultimately, create a culture shift around the integration of oral health services within the community.
That, my friends, is how we make change, grow and rise.
As data continues to compile around oral and systemic diseases and their threat to our patient population, we recognize that dentistry has several opportunities… no, responsibilities to put on clearer lenses and see the industry for the highlevel, articulate, and comprehensive role it must play in integrative and supportive patient care.
This role, however, must be fulfilled by taking off the dark and blinding shades and refocusing our sights, acknowledging we must become pupils in re-learning how to apply our foundational knowledge while rising up to meet the demands of dental providers in the new decade.