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“The Changing Face of Dental Hygiene Practice: Expert clinician, skilled motivator and preventive specialist”

Speaker: Lil Caperila, RDH, BSDH, M.Ed. Lcaperila@premusa.com

Course Outline:

MODULE 1: Changing Trends in Clinical Practice

I. Historic trends and changing roles in Dental Hygiene

a. What impacts our future?

b. Skills self-assessment survey (see attached survey - Handout A)

c. Mid-level Providers defined (see attached chart – Handout B)

d. Creating your “E-Portfolio”

i. Qualifications: resume, licensure, professional references

ii. Practice contributions:

1. increased production, use of new products/procedures

2. Thank you notes from patients

3. Employer annual review/positive comments

4. List of technologies you have mastered

iii. Professional Development

1. Continuing education programs you attended

2. Professional membership

3. Association offices held/volunteer opportunities

iv. Community Services

v. Presentations/Publications: to dental programs, K-12 schools, professional journals

II. Role of Technology: Screening and Electronic recording

a. Periodontal assessment, probing and treatment planning

b. Efficiency in exam, post-treatment evaluation and electronic documentation

c. CRA: Caries Risk Assessments (CAMBRA, CDA Foundation and ADA CRA)

i. Source for risk assessment downloads:

Dental Caries: www.ada.org or www.cda.org

Periodontal Disease: www.AAP.org or www.collagenex.com

III. CAMBRA (Caries Management By Risk Assessment)

a. Comparing 2 case studies utilizing CAMBRA to guide treatment decisions

b. Developing Treatment Protocol: (CAMBRA/Guidelines, source: CDA Journal Oct 2010, Vol.38)

New issues – Oct, Nov 2011 CDA Journal – Implementing CAMBRA in Practice

IV. Minimally-invasive - Caries examination

a. International Caries Detection and Assessment System (ICDAS)

i. Assessment of disease activity using visual examination procedures

ii. Reference: Evolution of Caries Diagnosis by Andrea Ferreira Zandona, DDS, MSD, PhD

Dimensions in Dental Hygiene Journal, September 2011 Issue

*Addendum Charts C & D

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b. Caries Detection Technology systems:

i. Diagnodent

ii. Caries ID

iii. Spectra

iv. SoproLIFE

v. CarieScan

vi. Canary System

V. Fluoride & Calcium/Phosphate innovations * See Addendum Chart E

a. Understanding the differences in various product chemistry/efficacy

b. Chart reviews the mechanism of action, bioavailability/solubility and product technologies

i. ACP

ii. CPP-ACP

iii. Novamin

iv. TCP

VI. Expanding Instrumentation Skills

a. Ergonomic considerations for operator positioning and instrument choices

b. Patient Care Set-ups:

i. Diagnostic assessment of patient

ii. Clinical symptoms, pain management and “active vs. recare” protocol

iii. Selecting power or hand instruments?

iv. New designs in scalers, curettes and files

v. Maintaining Implants

View products: www.premusa.com (links to - Dental, Instruments)

MODULE 2: Effective Whitening Strategies for the Next Decade

Dental Hygienist role in guiding esthetic improvements in the practice

a. Demographics and professional guidance for success in safe bleaching

i. Patient choices for success

ii. Predicting best options based on type of stains and shade origin

b. Challenges in OTC versus “in-office” or “take-home” choices

i. Patient compliance

c. Preventing and/or treating sensitivity

d. Enamel microabrasion techniques (when necessary)

e. Practice building and marketing for new patients

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MODULE 3: MOTIVATIONAL INTERVIEWING: A Positive Approach in Guiding Patients to Change!

Reference: “Motivational Interviewing in Health Care” – Helping patients change behavior. Authors: Stephen

Rollnick, William R. Miller, and Christopher C. Butler: 2008 Guilford Press, NY

www.guilford.com

I. Goal: Convey just enough of the essential method of MI to make it accessible, learnable,

useful and effective in healthcare practice

II. Define “Motivational Interviewing”

III. Rationale

A. Shift of “treating acute illness” to “managing chronic illness”

B. How MI guides practitioner in helping patients change behavior/poor lifestyles

IV. Origin?

A. Principles of Carl Rogers but introduced in 1983

B. Chronic illness trials tested MI in 1990’s – for patient behavior changes

C. Activate the patient’s “internal motivation” to adhere to change/treatment

D. Spirit of MI:

i. Collaborative

ii. Evocative

iii. Honor patient autonomy

E. Built on 4 Guiding Principles: “RULE”

i. Resist Righting Reflex

ii. Understand

iii. Listen

iv. Empower

V. How it fits into dental/healthcare practice?

A. Communication styles

i. Following

ii. Directing

iii. Guiding

B. Why MI Guiding works?

C. 3 CORE - Communication skills

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i. Asking

ii. Listening

iii. Informing

VI. Practicing skillful guiding

A. Ask

B. Inform

C. Listen

Understanding AMBIVALENCE:

What do you listen for during patient dialog?

VII. Listening for Change Talk – to BEHAVIOR CHANGE

Cues that imply the following degree of change stages: listen for “wish”, “want”, “like

to” …

A. Acronym for “change talk” is DARN

i. Desire

ii. Ability

iii. Reasons

iv. Need

B. Final 2 stages:

i. Commitment

ii. Take Steps

1. Take gentle small steps and don’t force the change!

VIII. Role Play on Change Behavior in Dental Care

Typical approach to how you discuss these scenarios?

What can you do differently to apply MI principles/skills?

IX. Asking Questions?

A. Open vs. Closed-ended questions

B. Don’t apply “TAG” questions to good open-ended questions

Caries Risk Assessment Form (Age 0-6)Patient Name:

Birth Date: Date:

Age: Initials:

Low Risk Moderate Risk High Risk

Contributing Conditions Check or Circle the conditions that apply

I. Fluoride Exposure (through drinking water, supplements, professional applications, toothpaste) Yes No

II. Sugary Foods or Drinks (including juice, carbonated or non-carbonated soft drinks, energy drinks, medicinal syrups)

Primarily at mealtimes

Frequent or prolonged between meal exposures/day

Bottle or sippy cup with anything other

than water at bed time

III. Eligible for Government Programs (WIC, Head Start, Medicaid or SCHIP) No Yes

IV. Caries Experience of Mother, Caregiver and/or other Siblings

No carious lesions in last 24 months

Carious lesions in last 7-23 months

Carious lesions in last 6 months

V. Dental Home: established patient of record in a dental office Yes No

General Health Conditions Check or Circle the conditions that apply

I.Special Health Care Needs (developmental, physical, medi-cal or mental disabilities that prevent or limit performance of adequate oral health care by themselves or caregivers)

No Yes

Clinical Conditions Check or Circle the conditions that apply

I. Visual or Radiographically Evident Restorations/ Cavitated Carious Lesions

No new carious lesions or restorations in last

24 months

Carious lesions or restorations in last

24 months

II. Non-cavitated (incipient) Carious Lesions No new lesions in

last 24 months New lesions in last 24 months

III. Teeth Missing Due to Caries No Yes

IV. Visible Plaque No Yes

V. Dental/Orthodontic Appliances Present (fixed or removable) No Yes

VI. Salivary Flow Visually adequate Visually inadequate

Overall assessment of dental caries risk: Low Moderate High

Instructions for Caregiver:

© American Dental Association, 2009, 2011. All rights reserved.

Caries Risk Assessment Form (Age >6)Patient Name:

Birth Date: Date:

Age: Initials:

Low Risk Moderate Risk High Risk

Contributing Conditions Check or Circle the conditions that apply

I. Fluoride Exposure (through drinking water, supplements, professional applications, toothpaste) Yes No

II. Sugary Foods or Drinks (including juice, carbonated or non-carbonated soft drinks, energy drinks, medicinal syrups)

Primarily at mealtimes

Frequent or prolonged between meal exposures/day

III. Caries Experience of Mother, Caregiver and/or other Siblings (for patients ages 6-14)

No carious lesions in last 24 months

Carious lesions in last 7-23 months

Carious lesions in last 6 months

IV. Dental Home: established patient of record, receiving regular dental care in a dental office Yes No

General Health Conditions Check or Circle the conditions that apply

I.Special Health Care Needs (developmental, physical, medi-cal or mental disabilities that prevent or limit performance of adequate oral health care by themselves or caregivers)

No Yes (over age 14) Yes (ages 6-14)

II. Chemo/Radiation Therapy No Yes

III. Eating Disorders No Yes

IV. Medications that Reduce Salivary Flow No YesV. Drug/Alcohol Abuse No Yes

Clinical Conditions Check or Circle the conditions that apply

I.Cavitated or Non-Cavitated (incipient) Carious Lesions or Restorations (visually or radiographically evident)

No new carious lesions or restorations in

last 36 months

1 or 2 new carious lesions or restorations

in last 36 months

3 or more carious lesions or restorations

in last 36 months

II. Teeth Missing Due to Caries in past 36 months No YesIII. Visible Plaque No Yes

IV. Unusual Tooth Morphology that compromises oral hygiene No Yes

V. Interproximal Restorations - 1 or more No YesVI. Exposed Root Surfaces Present No Yes

VII. Restorations with Overhangs and/or Open Margins; Open Contacts with Food Impaction No Yes

VIII. Dental/Orthodontic Appliances (fixed or removable) No YesIX. Severe Dry Mouth (Xerostomia) No Yes

Overall assessment of dental caries risk: Low Moderate High

Patient Instructions:

© American Dental Association, 2009, 2011. All rights reserved.

Circle or check the boxes of the conditions that apply. Low Risk = only conditions in “Low Risk” column present; Moderate Risk = only conditions in “Low” and/or “Moderate Risk” columns present; High Risk = one or more conditions in the “High Risk” column present.

The clinical judgment of the dentist may justify a change of the patient’s risk level (increased or decreased) based on review of this form and other pertinent information. For example, missing teeth may not be regarded as high risk for a follow up patient; or other risk factors not listed may be present.

The assessment cannot address every aspect of a patient’s health, and should not be used as a replacement for the dentist’s inquiry and judgment. Additional or more focused assessment may be appropriate for patients with specific health concerns. As with other forms, this assessment may be only a starting point for evaluating the patient’s health status.

This is a tool provided for the use of ADA members. It is based on the opinion of experts who utilized the most up-to-date scientific information available. The ADA plans to periodically update this tool based on: 1) member feedback regarding its usefulness, and; 2) advances in science. ADA member-users are encouraged to share their opinions regarding this tool with the Council on Dental Practice.

Caries Risk Assessment Form (Age >6)

Table 2. Preventative Strategies

EQUIPMENT • Use ergonomically designed instruments (light weight, large handle diameter, texturing that prevents slippage and provides easy grip).12, 13 • Avoid heavy low speed handpieces or tight coils in the lining of the cord to prevent unnecessary pull on the hand, shoulder, and wrist muscles. • Use comfortable gloves that fit properly. Avoid gloves that are too tight or too loose.8,17 • Wear proper fitting eyewear to avoid tipping your head too far forward or downward. • Wear loupes when scaling and root planing to assist, not only with detecting calculus, but also to maintain neutral sitting position.2,3,18

INSTRUMENTATION • Use ultrasonic and sonic scalers as indicated for calculus and stain removal. • When hand scaling, use reinforcements (added pressure against the shank) from the non-dominant hand to assist with the removal of heavy, tenacious calculus.7 • Alter instrument grasp. Use exploratory strokes often and use moderate-to-heavy lateral pressure against the shank only as needed. 8

• Maintain sharp instruments.10

POSITIONING • Avoid prolonged extensions (bending) or deviations (twisting) of the wrist. 11

• Maintain neutral sitting position.12, 13 • Maintain 15 inch working distance.12,13 • Keep head fairly straight.12,13 • Keep shoulders relaxed.12,13 • Keep back straight.12,13 • Keep elbows close to sides.12,13 • Distribute body weight evenly on operator’s chair when sitting; avoid leaning to one side or the other.7 • Avoid prolonged work in one position.

WORK SCHEDULE • Allow brief (5-10 minutes) breaks in your daily work schedule for relaxation, rest, and stretching exercises.8,19 • Alternate scaling and root planing appointments with routine maintenance patients.

PERSONAL CARE • Perform stretching exercises before, during, and after work hours. (See Figures 1-8). 20

• Drink plenty of water (1 quart for every 50 lbs of body weight) throughout the day. • Limit the amount of non work-related activities that cause stress on the wrist, hand, shoulder, and back.

Tavoc T., Gutmann ME. Making the principles of ergonomics work for you. Dimensions of Dental Hygiene Jan 2005; 3(1): 16-18, 20-21.

Seminar Worksheet “The Changing Face of Dental Hygiene”

Describe how you envision a “dental hygienist” in 2026? List the skills you believe we will need to fulfill this model? Can you currently list 3-5 of your greatest skills as an oral healthcare professional?

Do these skills fit the model you envision for the future? What do you see as our greatest impediment in achieving the future hygienist?

Addendum Handout A

ICDAS - Addendum Chart B

ICDAS-Technologies - Addendum Chart C

Technology/ Chemistry ACP

Amorphous Calcium Phosphate ADA licensing

CPP-ACP Casein Phosphopeptide Amorphous Calcium Phosphate

(Recaldent®)

CSPS Calcium Sodium Phosphosilicate (Novamin®)

TCP Beta Tri-calcium Phosphate (Functionalized TCP)

Mechanism of Action

Specialized salt compounds No defined structure or crystalline structure Highly reactive

Casein binds to tooth surface until pH is lowered/ acidic challenge frees ions

Silica binds Ca/P until sodium elevates pH to free CA/P ions

Blended beta tricalcium phosphate is insoluble crystalline form

Solubility and Bioavailability

Rapid delivery Highly soluble & Bioavailable Greater Fluor uptake

Becomes soluble only during lowered pH/acidity

Becomes soluble when sodium elevates and buffers pH

Low to moderate rate of solubility

Professional Products

• ENAMEL PRO: - Prophy paste/formulated to deliver ACP - NaF Varnish & NaF Gel, - Enamelon Preventive Treatment formulated to deliver ACP •Day White/Nite White & Relief gel /ACP • Arm & Hammer Complete Care /ACP Enamel Care / Canada

• MI PASTE MI Paste Plus (fluoride) MI NaF Varnish (containing Recaldent) •Tooth Mousse (International brand)

•NUPRO NuSolutions Prophy paste w/ Novamin TOPEX ReNew

VANISH NaF varnish with TCP Clinpro 950 Clinpro 5000 PREVIDENT Boost 5,000pppm

Addendum: Chart D