Synergy and the patient-provider relationship: The hygienist’s essential role in communication and treatment acceptance

Figure 1 : In the first scenario, the patient makes an appointment for a consultation with the dentist and dental assistant. In the photo, Dr. Goldstein examines the new patient with Christina Via, the dental assistant, who writes down his notes.

Editor’s Note: This article is part one of a three-part series submitted by the authors.The second and third parts are scheduled to appear in the January 2018 and February 2018 issues.

The role that each dental team member plays can positively or negatively influence patients’ perceptions of the practice, their trust in the providers, and their treatment acceptance. Synergy is defined as “the increased effectiveness that results when two or more people or businesses work together.”1 The relationship between the dentist and the dental hygienist, in particular, is one that requires a delicate balance of skill, communication, and collaboration to meet the patients’ needs.

Too many times, the newly hired hygienist and other team members are not given a thorough enough education into the dental practice’s goals and patient management procedures, which can lead to confusion and potential team failure. This symbiotic relationship must consist of mutual respect for one another as well as an understanding of expected clinical procedures, skills involved, ethical expectations, plus the psychological and social practices that each dentist expects. This series will concentrate on the strategies that play an important role in the essential relationship between the hygienist and the dentist.

Featured new dental hygiene products in 2017 RDH magazine

Featured new products in 2017 RDH magazine





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Through their eyes

Mr. Z. was my patient today. He is a 58-year-old male who presented for a recare appointment. He is currently taking cholesterol and oral diabetes medications. I had seen him previously one time only at his initial appointment in the practice. At that time, he was diagnosed with moderate, generalized chronic periodontitis. His radiographs revealed moderate bone loss in the posteriors, with pocket depths ranging from 3-6 mm generally. There was heavy subgingival calculus evident on radiographs.

At the time of the initial appointment, I treatment planned Mr. Z. for four quadrants of scaling and root planning with anesthesia. These were scheduled with the dentist, because he had the time available to get the treatment accomplished sooner. (The doctor takes an active role in nonsurgical periodontal treatment as needed, and is very capable!)

Fast forward to today, 18 months later. I noted on the record that Mr. Z. had opted out of a formal re-evaluation appointment. Today’s visit was his first time back at our office since his quadrant debridement. He informed me that he does not take care of his teeth as recommended, and that we would most likely need to “start again from scratch.”

As I re-evaluated his soft tissue, I could see that the deep scalings had been effective in minimization of most pocketing. However, there was still a fair amount of bleeding with new calculus present in the lower anteriors, as well as generalized biofilm and debris. I asked him if he had changed any of his self care after the quadrant debridement visits? His response was, “No.” He reported that he was still brushing his teeth twice a day “some of the time,” and that he was not using any means to clean his teeth interproximally.

Creating calm: Holistic dental seminar gets ‘off the yoga mat’

As hygienists and oral health professionals, we know that health is not the absence of disease but a state of complete and total well-being. Christel Autuori, RDH, RYT, FAADH, MA, has created a fun, interactive program that moves beyond the traditional oral-systemic connection to the multidimensional perspective that is holistic health. Her program, titled “21st Century Dental Hygiene: An Integrative Practice,” encompasses mind, body, and spirit, and reflects the evolving practice of medicine and dentistry from conventional Western medicine to the integrative approach to health and well-being.

Christel examines mindfulness, staying present in the moment, and how to listen to the body, mind, and soul so that one can become aware of the subtle signs that indicate imbalance. She explores mindfulness techniques, yoga, energy healing, food and herbal preparations, aromatherapy, meditation, guided imagery, Ayurveda, and aspects of traditional Chinese medicine. Participants learn to incorporate healing modalities into not only hygiene treatment plans, but also into everyday life for better health and vitality.

As a certified holistic stress management instructor and certified integrative health coach, Christel presents stress management workshops titled, “Creating Calm in the Chaos,” and “When Life Starts Rocking, You Keep Rolling.” For dental hygiene students and faculty she presents, “Rebalance, Reset, and Respond.” Her experiences as a hygienist and yoga teacher are blended into “Acuyoga for You and Your Patient,” and “Yoga Off the Mat and Into the Dental Operatory.”

The “Creating Calm” program reviews diseases that may result from long-term chronic stress, discusses abdominal or belly breathing, and reviews stress-busting practices. The “Yoga Off the Mat” program is designed to alleviate the neuromuscular imbalances and stresses that clinical practice can produce. All members of the dental team will benefit from Christel’s presentations since patients often ask about herbs, natural products, and other healthy and alternative substances or practices. The dental team should be familiar with these products and approaches in order to advise patients, as well as to maintain their own health.

Product review examines anesthetic gel for gingivitis procedures

Recently launched by Gingi-Pak, GingiCaine Oral Anesthetic Gel is now available in convenient “Syringe Kits.” Each syringe contains 1.2 ml of strawberry flavored gel, formulated to deliver anesthesia directly into the sulcus. For maximum control, use the Gingi-Pak micro needle tips that feature a 7mm gauge mark and rounded end to eliminate the danger of poking or tearing inflamed epithelium.

The 20% benzocaine gel formula has a quick 15-second onset, making it ideal for a variety of procedures, including the new gingivitis procedure (D4346). The gel flows smoothly with no gritty feel and no bitter aftertaste.

The GingiCaine kit comes with 20 syringes and 40 micro tips. For more information, visit or order today by contacting your dental supply representative.

Tooth brushing in 10 Seconds Flat?

Three years ago, Marvin Musialek, founder and CEO of Amabrush, began developing the first simultaneous automatic brushing prototypes with an advisor, Dr. Hady Haririan from the Medical University of Vienna School of Dentistry. The resulting product is a device that brushes all teeth in 10 seconds flat. You read that right, full mouth brushing in 10 seconds flat!

The premise of the Amabrush is to save users time by cleaning all tooth surfaces simultaneously with soft, vibrating bristles. The device consists of a handpiece, toothpaste capsule, and mouthpiece. According to Amabrush, the toothbrush can clean each surface, including the distal of those pesky third molars. The Amabrush does not replace flossing.

The flexible mouthpiece is made of antibacterial silicone and features 3D arranged bristles that are directed in a 45-degree angle toward the gingival margin, simulating the Bass technique. Soft enough to prevent damage to the gum tissue, but strong enough to thoroughly clean the teeth, the mouthpiece can simply be rinsed after each use.

A case study of evacuation valves reveals hidden danger to dental patients

I was asked to perform an informal case study on dental office evacuation valves. This was a challenge in many ways. Several offices I contacted were leery to allow swab testing in their offices even though they said they felt confident of their disinfection process.

My infection control flag went up many times in those practices. If they felt confident, why are they leery of doing a simple swab test? What was the risk to them? One office wanted to check with his lawyer, wanted my license number, and much more seemingly ridiculous information. The offices that were welcoming wanted to know how they could improve their infection prevention protocol. A big benefit was they received bags of disposable valves for allowing testing of their disinfected valves.

A test of evacuation valves confirms need to protect patients from microbial debris

Testing was done to determine if the valves were contaminated even after disinfection. What are the consequences of the unknown invisible organic matter? What pathogens are nesting here? When disinfected, what pathogens are being reduced or present?

As an experienced infection prevention and safety specialist, I performed the swab-testing. After reviewing the results, I was glad I had donned the appropriate PPE. Maybe I should have worn a hazmat suit!

The Down and Dirty Results

I processed 212 valve surfaces and determined they were, yes, contaminated after a routine disinfecting protocol. Discovering the bacterial load on dental unit vacuum valves left me with an uneasy feeling. Are we creating a healthy environment for our patients? Occupational Safety, Asepsis and Prevention (OSAP) has repeatedly stated that dental patients should be in a safe dental environment, which includes the entire dental facility and all the processes.

How dental consultants and hygienists can weigh the scientific evidence about Remin Pro

Show me the science and then show me clinical evidence. I need to see the proof! In 2009 I graduated from Ohio State University, and the educators permanently left an impression on my brain that says, “Show me the science.” I currently hold an active license in Hawaii and Ohio and have an obligation to my profession. This obligation is to continue to educate myself on dentistry’s most recent products.

In this article, I will touch on two different points of view when it comes to the product Remin Pro from Voco—the point of view as a dental hygienist and a point of view as a dental consultant. While the two hats that I wear are very different, they both are heavily rooted in science and evidence. In general, science to a consultant and science to a dental hygienist are the same thing. However, in my experience the two perspectives view evidence differently. When I analyze the evidence as a dental hygienist, my first thought is to request the clinical numbers and to examine the science in detail, under a microscope. I need to see it. When I analyze the evidence as a consultant, I want to see and understand the bigger picture. As a consultant, I need to see before-and-after photos that are compelling enough to tell a story in other practices for their patients with clinical needs.

Figure 1 : Courtesy of Merrillville Family Dental Care in Merrillville, Ind.

As a dental hygienist

Let’s first look at this from my perspective as a hygienist. Remin Pro is a water-based tooth cream with nano-hydroxyapatite, xylitol, and fluoride. It is important to know that the fluoride is sodium fluoride and delivers 1,450 ppm compared to similar products that have a lower fluoride content. It is indicated for patients who have sensitivity or are looking to prevent sensitivity. Because the product contains nano-hydroxyapatite the tooth is protected from demineralization and acid erosion.1

In general, science to a consultant and science to a dental hygienist are the same thing.

Remin Pro is great for patients with previous, past, or current ortho and is what I believe should be an industry standard for all orthodontic patients. It is important to point out that patient compliance is essential—not only at home but in keeping their appointments in office. The following is the protocol for patients with white spot lesions:

  • Take pictures (with Ortho camera and cheek retractors).

Caries management: Simplify product selection to improve compliance and outcome

As dental professionals, we evaluate our patients on a routine basis and continually provide strategies to prevent dental caries. These strategies include caries risk assessment1 and individualized risk management recommendations. There is an abundance of products on the market and it can be challenging for dental professionals to hone their recommendations. In general, caries management programs receive criticism for being time consuming and complicated for private practices. It is essential to streamline and simplify2 caries management for the private practice it can be practiced routinely and indefinitely. The purpose of this article is to discuss simple strategies to get the maximum impact of caries management within the private practice.

Simplify product selection for caries risk management

Getting Started

Before implementing a caries management program, it is vital for the dental or dental hygiene practice to plan and organize as a team. A few items for consideration include:

  • Understanding the caries process. It is essential to become educated in the caries process so that risk assessment and risk management can be tailored for each individual practice.
  • Caries risk assessment. Which team member will provide risk assessment? How will risk be assessed; will a questionnaire be used or will caries risk be assessed using another method?
  • Caries risk management. Who will make risk management recommendations? How will this information be conveyed, verbally or via handouts?
  • Product recommendations. It is important to decide which products will be recommended for patients in each risk category, including toothbrushes, interdental cleaning strategies and topical pastes.
  • Documentation. Documenting caries risk assessment, caries risk category assignment, risk management recommendations and patient’s acceptance of your recommendations is essential. Custom documentation templates within the electronic health record are particularly useful to calibrate different members of the dental team.

The Caries Process

Historically, dental caries was thought to be the result of the interaction of a susceptible tooth, fermentable carbohydrates and time.3 Later research uncovered that the progression of dental caries is multifactorial4 is significantly more complex5. Dental caries is the result of an oral environment that is conducive to the progressive demineralization of the hard structures in the oral cavity. This net loss of tooth mineral is due, in part, to the proliferation of cariogenic bacteria that thrive in a low-pH (acidic) environment.6

Periodontal documentation: Stepping beyond ‘ordinary’ diagnosis

I remember like it was yesterday, even though it was more than 25 years ago. I was attending a dental meeting in Houston with hundreds of other people, but I felt like the speaker was talking directly to me. The periodontist from New Jersey captured my attention with this statement: “If you see bleeding gums in the majority of your patients while cleaning their teeth, the problem is you.”

Certainly, I knew bleeding gums were not okay. But honestly, they had become so “ordinary” in my patients that they had lost their urgency. Then, Van Stevens, DDS, from New Jersey stepped on my toes! Fast forward to today, and I now tell my audiences that I hope they wore close-toed shoes—in case I step on their toes, intentionally.

Let’s address this elephant in the room—periodontal documentation. Already some of you know you can move on to other articles in this publication because this topic won’t apply to you. However, since thankfully I had my toes stepped on and that got my attention, I feel as though I’ve earned the right to address the subject. To have the greatest impact in your practice, dentists and dental hygienists need to read this article and discuss this topic together.

Dentists can defer to the dental hygienists for collection of the periodontal data, but in order for that to become consistent there has to be value for the time required to collect the data thoroughly, as well as explaining the significance to patients. Surprisingly, given all we know about the oral-systemic connection, thorough periodontal assessment and documentation is still an overlooked procedure. Dentists and dental hygienists settle for spot probing, periodontal charts that are outdated, bitewings that don’t show bone levels, and in some cases, no periodontal assessments at all on patients. Right now, I bet some of your toes are becoming a bit twitchy after reading that last sentence.

Gastric ulcers: What is the connection to periodontal disease?

One of the questions on your office’s health history form should ask whether the patient has had any gastric or duodenal ulcers. When a patient responds yes to this question, what follow-up questions do you ask? What concerns you about the patient’s response? Many times, we do not delve as deeply into patients’ medical histories as we should.

One 24-year research study of more than 51,000 male participants found a relationship between gastric and duodenal ulcers and periodontal disease: “In this prospective cohort of men, [the study’s authors] found that periodontal disease with bone loss was associated with an increased risk of gastric and duodenal [ulcers]. The association appeared largely consistent for gastric and duodenal ulcers as well as H. pylori–positive and H. pylori–negative ulcers. These observed associations persisted even after adjusting for putative risk factors, including smoking, alcohol intake, and regular use of aspirin and NSAIDs.”1

The study authors hypothesized that the oral microbiota changes that keep periodontal tissue from healing can also keep ulcers from healing in the GI tract.1

Another study found a possible association between poor periodontal health and H. pylori infection.2 Helicobacter pylori is a gram-negative bacterium that causes duodenal and gastric ulcerative disease. The study authors discovered that this bacteria can be found in deeper pockets of those with periodontal disease and that it can be found in those patients’ saliva and plaque biofilm.2 About 41% of the individuals who had pockets measuring 5 mm or more also tested positive for H. pylori.2 This, of course, does not mean that one causes the other, but it does suggest a link we need to study further.