Shirley Gutkowski, RDH, BSDH

	Imagine my surprise when I heard someone talking about an interdisciplinary team comprised of the receptionist, dental assistant, practice manager, dentist and dental hygienist. I suppose that’s right but a true interdisciplinary team refers to medical disciplines, like dentistry, cardiology, respiratory, chiropractor, oncology and pediatrics to name a few. That’s the best way to treat the whole patient.

	Recently I was going through my charts for the day and noticed a health history that just didn’t match the view of the tooth chart on the computer. Although the patient was born in the 1970’s, they had a number of crowns, a root canal and new areas of decay waiting for treatment. The health history listed a thyroid condition, some medications for thyroid and nothing else. There was a total mismatch. If this had been 2013, I would have had nothing to offer that patient other than more frequent recare appointments and a xylitol protocol. Now I ask questions about the airway.

	The patient presented with comments about restless sleeping, snoring, and sinus problems that were not apparent when she filled out the form years ago so she didn’t think to add it. Visual inspection revealed an enlarged uvula, mandibular torus and maxillary exostosis. We started talking more about her sleeping and breathing and it became more and more apparent that she needed a sleep study. 

	The mismatched health history and dental history has never been so revealing as it is today. So many conditions are exasperated by poor sleep or hypoxic events during sleep that new questions need to be asked. Flossing won’t cure those problems.

	Working together with other medical teams are what’s called for today. In this case a sleep (aka airway) dentist, a dental hygienist, a myofunctional therapist, sleep physician, chiropractor, naturopath, and others from different disciplines. Whether there’s a causal relationship between oral health and systemic conditions or not, there’s enough evidence today to force a new way of looking at our patients. 

	For more information on sleep disorders and the interdisciplinary team, visit www.AAPMD.org 

	For more information on OMT or for introductory classes visit www.aomtinfo.org.

	To refer virtual clients for OMT contact Shirley Gutkowski at PrimalAirOMT@gmail.com

Articles

Imagine my surprise when I heard someone talking about an interdisciplinary team comprised of the receptionist, dental assistant, practice manager, dentist and dental hygienist. I suppose that’s right but a true interdisciplinary team refers to medical disciplines, like dentistry, cardiology, respiratory, chiropractor, oncology and pediatrics to name a few. That’s the best way to treat the whole patient.

Who is on your interdisciplinary team?

	"Darwinian dentistry has been providing evidence that the volume of the sinus and oropharyngeal complex is decreasing in size in generations as opposed to that level of change over tens of thousands of years. We’re at a crisis stage."

	In the coming months and years, the idea of chewing and learning about the mechanics of chewing will become all the rage. The physiological benefits of chewing have been understood for a while. However, the magnitude of the benefits in the context of epigenetics is a game-changer.

	Many dental hygienists across the country visit schools during the academic school year to teach youngsters about oral hygiene. It may be time to teach chewing instead, especially to the younger kids and particularly to young and expectant mothers. A few of the valuable benefits of chewing are listed below.

	1. Chewing can be affected by insufficient nasal breathing (due to enlarged lymph tissue like tonsils and adenoids) and impacts the function of the following:

	e. Neurological or genetic disorders such as strokes, hemiparesis, hemifacial  microsomia, and traumatic brain injury

More from the author: What Modern Millennial Hygienists need to know about allergies

	2. Excessive chewing of gum leads to hypertrophic masseters and often to TMJ disorders and facial pain. Excessive gum chewing occurs with gums containing extended flavor times.

	c. Inefficient breaking down of the food particles

	d. Poor salivation and food residues in the mouth after swallowing

More from the author: 4 reasons that Modern Millennial Hygienists need to track their numbers

	4. Poor chewing increases the viscosity of the bolus, impacting swallowing

	5. Nuts, seeds, dried fruit, kale, raw spinach, carrots, raw cabbage, raw fennel, raw broccoli, apples with peel, and meat are some foods that promote good chewing.

	To chew properly, one must have balanced muscles, teeth that occlude, and a working airway system that comes from the nose/sinus complex. Today’s foods are soft. Think of a burger from a fast food establishment. Imagine chewing it without teeth. No problem, right? Children with airway issues choose, or demand, foods that are easy to masticate, bolus, and swallow. Inquiring about food choices should be part of the discussion with children age 3 and over when they’re in the dental hygiene chair.

More from the author: Hey hygienists, it's time to stop blaming the patient

	The study of the facial musculature is called orofacial myofunctional study. An OMT is a therapist who works with the structures of the face and mouth to balance and teach the owner how to use them to the best effect. Darwinian dentistry has been providing evidence that the volume of the sinus and oropharyngeal complex is decreasing in size in generations as opposed to that level of change over tens of thousands of years. We’re at a crisis stage. Baby lead weaning and using actual foods instead of traditional baby foods will help increase the need for chewing and increase the size of the airway complex, including the mandible, maxillae, anterior sinuses, and the oropharyngeal complex. This type of activity will start to nullify the epigenetic effect of the child’s grandparents’ diet.

	Are you interested in learning more? The first congress of the Academy of Applied Myofunctional Science is meeting September 9-13 at the Biltmore in downtown Los Angeles. International speakers will speak on sleep apnea, breathing, and posture. Learn more about it by visiting 

	Shirley Gutkowski, RDH, BSDH is the owner of Cross Link Presentations, integrating oral and systemic health in presentations to dental, medical, and consumer groups across the country. She has contributed to dental textbooks, journals in multiple disciplines, and consumer publications about the links between oral and systemic health. Her podcast, Cross Link Radio, deals with these topics as well and remains the only health podcast that highlights the mouth as a contributor to good overall health. Learn more at 

. Gutkowski also guides a dental hygienist mastermind focusing on helping hygienists build or improve on their oral systemic practice.

Get support and assistance in developing a caries management protocol that works for you, your office, and your patients.

In the coming months and years, the idea of chewing and learning about the mechanics of chewing will become all the rage. The physiological benefits of chewing have been understood for a while. However, the magnitude of the benefits in the context of epigenetics is a game-changer.
Many dental hygienists across the country visit schools during the academic school year to teach youngsters about oral hygiene.

The importance of proper chewing and its relationship to health

	One of the big mysteries of dental hygiene practice is how some hygienists are highly paid and some are not.

	Even people from the same class with the same grades have a per-hour discrepancy that defies logic. We bet there isn’t a dental hygienist reading this post who thinks he or she is overpaid. So, really, what does being overpaid mean?

	Practice management consultants say a hygienist should be paid one-third of their production. This might work if you are producing as much as the dentist-otherwise a third of production is too high. What the what? We’ve heard this happen to many high caliber dental hygienists. One hygienist paid a commission of 33 percent of collections had her portion reduced to 27 percent by the practice consultant. If looks could kill, that practice management consultant would have assumed room temperature years ago. The other side of this argument is how one-third became the magic number.

Related reading: Hey dental hygienists, it's time to stop blaming the victim

 protocol development is important as it establishes a dental hygienist’s value to the practice. The best time to do protocol development is during down time at the practice and not during your family time at home. How are you using your down time? What is protocol development?

	Develop protocols based on the dental conditions of the practice patients. For instance, using topical agents and/or a locally delivered antibiotics to control periodontal disease in patients is a protocol. There are usually a set of guidelines the practice follows for placement of this aid. The missing piece to the protocol is tracking how the treatment is working practice-wide and not just pocket by pocket. If a dental hygienist is not doing the evaluation phase, it could be argued he or she is overpaid.

	Hygienists who only do screenings on high risk patients may also be overpaid. All patients can be screened for caries, airway, oral cancer and periodontal disease. All that screening will pay off in treatments from the dental hygiene, or restorative, side and the dental, or prosthetic, side. It may take a while to get all the screenings done (a few months), but the effort will pay off. Writing a newsletter announcing the screenings can be another use of time to increase the dental hygienists' value to the practice.

	The third way to evaluate overpayment is to gauge your value without benefit of the rose-colored glasses. You deserve days off, use of the restroom, hydration and adequate compensation. That compensation will decrease when a hygienist decides keeping up with the times or production numbers is too much work.

More from DiGangi and Gutkowski: 3 ways to participate in the dental practice without employees

	Every now and again, we run into a dental hygienist who has all his or her perio numbers in check. All the patients are in a system, and the rapport is awesome.

	Increasing value to the office is taking the next step into dental health management. Start by getting up to speed in the airway. Can your perio patients breathe? Is that contributing to their periodontal condition? How much is their systemic health contributing to their oral health? Can you incorporate systemic support?

	There are new products that support the reduction in inflammation system-wide that may improve their periodontal health substantially. Obviously, this article is too short to list them all, but we believe that with a little ad reading and investigation, any hygienist can find the list of reasons dental hygienists are overpaid doesn’t apply to them.


	Running from patient to patient without time to take a potty break doesn’t make you a valuable employee. President Obama doesn’t skip potty breaks. Keeping current, protocol development and tracking, investigation of products and proposal presentations make a hygienist an incredibly valuable and underpaid part of the practice. We want to hear from you. Do you work with people that are overpaid? Are you?

3 baked-in-the-cake patient-enabling behaviors

Listen to a podcast from DiGangi and Gutkoski on this topic below:

	Check Out Entrepreneur Podcasts at Blog Talk Radio with 

One of the big mysteries of dental hygiene practice is how some hygienists are highly paid and some are not.
Even people from the same class with the same grades have a per-hour discrepancy that defies logic.

Dental hygienists, here are 3 ways to know you are overpaid

Stories on all types of media question whether victims of sexual harassment, rape, bullying, poverty and more are at least partially to blame for their circumstances. How often do oral health professionals do the same-blame the victim for new or continuing conditions?

An article in Psychology Today says blaming the victim is not just about avoiding culpability or responsibility; it’s also about avoiding vulnerability. Many of us have read or at least heard of the 1970s book, When Bad Things Happen to Good People.

The reality of life is bad things do happen. We like to see the world as a safe and happy place. There is no argument that how you see the world contributes to personal happiness. When our sense of the world is upset by someone else being vulnerable, our own sense of well-being can be threatened. We like predicable consequences. If this can happen to this person, how vulnerable am I? So the thinking then becomes: That person must have played a role in his or her own problems e.g. the woman’s clothes were too sexy so she set herself up for rape. This is not usually a consciousness thought process.

This subconscious thinking can play out in our relationships with patients. When a patient presents for a dental hygiene appointment, most often there is an automatic assumption of what is needed. We have taught the patient to expect scraping, polishing and lecturing about flossing. This expectation is deeply ingrained; it isn’t questioned by anyone. Care is performed with everyone believing it is preventive. When the patient presents with breakdown and disease, they are seen as the one at fault. They must not have been flossing; they must have a poor diet, they must have ... Blame the victim.

We hear your arguments already, but ask yourself what really might have happened here. Was an accurate risk assessment, as well as a disease evaluation, performed prior to care? Have you used any systemized way to measure oral dryness/hydration (hyposalivation screening tool)? Does the person have any breathing issues or sleep apnea (Malipati Score or Epworth Sleepiness Scale)? Did you take vital signs (normal ranges)? Did you confirm his or her medications just by asking if anything has changed (e-prescribing)? Are the medications her or she is taking genetically compatible? There is a simple way to test that evaluated prescription and dosing decisions based on individual genetics (DNA DrugMap). Is his or her saliva healthy (Saliva-Check BUFFER)? Is the pH level healthy (pH2OH)? Was autofluorence technology used to determine a caries infection (Spectra or SOPROCARE) or did you just use a bent metal wire to find an obvious hole? These are just a few of the evaluations and risk assessments that are not the patient’s responsibility; they are the professional responsibility of the oral health provider.	 	 

Another version of this blame game often plays out in organized groups. Membership recruitment, retention and participation, volunteer management and fundraising are necessary elements for the survival of voluntary organizations. Falling membership dues and stagnant membership numbers continue to be of concern whether it’s a church, union or dental hygiene group. Once again, it must be the fault of nonmembers. Don’t they feel any loyalty to contribute to the professional organization? The answer for many is no.

Millennials are the most diverse generation in U.S. history, as was pointed out by Pew Research Center’s Millennials in Adulthood survey. They come from so many backgrounds and have different upbringings than previous generations. What appeals to them is often very different yet rather than shift thinking, often dental hygiene groups just do more of the same and see those who aren’t participating as apathetic, noncaring people just out for the money. This couldn’t be more wrong. Once again, blaming the victim is evident. The biggest blunder occurs when associations blindly accept what they were doing, offering and even that which brought the most success in the past is no longer working.

It isn’t just millennials who are no longer interested in association membership. Gen X and Baby Boomers are just saying no, too. If associations don’t become the answer for multigenerational membership, then extinction is imminent.

The big picture is the answer, and then change, adapt and innovate. Membership is not a duty; it can be seen and experienced as a joy and what someone wants. Organizations need to accurately determine the needs of those they serve and then brainstorm creative ways to meet them. There isn’t a one-size-fit all for your patients nor is there one solution that will appeal to everyone to participate in an organization-diversity is the name of the game.

1. Social media influences all. An associations needs to have a social media presence. This is not limited to Facebook and Twitter; Instagram, Tumblr and a whole host of other social media platforms are available to engage potential members. Who can you find to help manage it? Millennials and those who behave as Modern Millennial Hygienists.

2. Encourage leadership by stepping away. Often, leaders don’t know when it is time to step down. No matter how creative or innovative, leadership is tiring, which can lead to tired ideas and a lack of energy and enthusiasm. It can be experienced when the leader's attitude says, "been there, done that." New leaders can’t step up unless previous leaders step down.

 3. Make engagement personal. We live in a digital world, as you are experiencing reading this article. In the digital realm, engagement needs to become personal. This means sending out interactive newsletters, emails and social media posts regarding your organization’s progress so you can get real-time feedback from both members and, more importantly, nonmembers. Do this not once a year but routinely.

One of life’s hardest lessons to learn is that you can only change yourself. Some people spend inordinate amounts of time and energy upset, angry or frustrated by other people’s thoughts and behaviors and blame the victims. Save yourself some frustration and try to learn to stop trying to change others. Focus instead on looking at yourself and your contribution to the outcome, and you may find yourself living a happier and more peaceful life.

What do you think? Did we make you crazy once again? If so, we are doing our job. Your thoughts, contributions and disagreements are important to success. Please share your thoughts below.

Hey dental hygienists, it's time to stop blaming the victim

	Most businesses today, including dental practices, are run using a factory assembly line-model.

Active participation makes so much more sense. This means, as a dental hygienist, there at least three (and probably many more) ways to be active, productive and financially well-compensated while making meaningful contributions to patients and, more importantly, your own health.

, talked about this idea as he revealed the ways businesses should be run by stakeholders. This is not a simple shift in term but rather a major shift in attitude.

Businesses making this shift have posted gains of 120 percent on the SP 500 over the last decade. The top few, the good-to-great companies, posted gains of about 320 percent. Companies shifting from managers to leaders and employees to stakeholders and posted gains of more than 1000 percent! These are huge numbers in which each person participating gained. Stakeholders actively participate in decision-making and exert pressure on the traditional top-down organizational structures. The audience listening to Chuck’s revelations consisted of dental practice management consultants, which can be good news for dental hygienists.


	Dentists have to work both on their business and at their business. Dental hygienists can be co-captains. Using a body metaphor for the business organization can help visualize this idea

maybe right and left ventricles of the heart, right and left hemispheres of the brain or the skin and the lungs, which cannot function without each other. Each is interdependent on the other.

Here are three ways a dental hygienist can act more like a stakeholder in the practice:

1. Focus on dental hygiene, what you were hired to do. 

Stakeholders work in small, natural groups where leaders appear and are not appointed. Down time? Focus on building the dental hygiene part of the practice. Is calling patients from the dead file really a good use of time, or is it better to rehab a perio protocol? Is it better to run personal errands or calculate the dollars lost from not offering patients higher options for their oral health?

 Whether the vision is for the owner to retire at 57 or stop doing fillings, dental hygienists should strive to be a part of the vision. Having a dental hygiene vision that supports the dental practice vision is also a good way to use some downtime. Are you philosophically aligned with the practice owner? Do you feel the same obligation to avoid dental diseases as the practice owner and/or dentist?

Related reading: The truth about alternating codes D4910 and D1110

 There’s really only one way to chart progress. Don’t like dollars? Keep track of how many of anything and watch for trends or fluctuations in the numbers. Go dig out info from last year and see if its less now.  If you believe dentistry is only necessary when dental hygiene fails, see if you’re failing, measure it and strive to make it better.


	Is that all there is? No, it’s a logical easy way to start. Perhaps you are a leader in the practice and others will follow you. In a participatory style business, there is no top down or no bottom up, everyone falls into an alignment. The ladders of attainment can illustrate this for the health care and dental hygienists.

The ladder shows how patients become part of their own solution depending on their education. The bottom rung, manipulation, is best illustrated by a patient being told  their teeth are soft and they need to brush more often or floss more diligently. For the dental hygienist in practice, that rung is occupied by dental hygiene students. More autonomy is earned and offered by the dental hygienist and dentist-business owner respectively as appropriate until the dental hygienist has total control over the department.

More from DiGangi: 5 things your dental practice needs to know right now about Medicare


	Can you imagine a dental practice with no office hours, unlimited vacation and profit sharing for everyone? Maybe not at this moment yet re

imagining what can be is part of this thinking. You can be part of the 1000-percent growth for the practice you’re participating in.

Can this model work in traditional dental practices? Let us know what you think by commenting below.

	Check Out Management Podcasts at Blog Talk Radio with 

More from DiGangi and Gutkowski: Bleeding on punching in the nose: Thoughts on bleeding on probing

 Most businesses today, including dental practices, are run using a factory assembly line-model.

3 ways to participate in the dental practice without employees

	Have patients ever said they missed an appointment because you didn’t remind them?

How about the patients shopping for home care products in your office to take home by the bag full at no charge? Then there are the confessors asking for forgiveness and absolution for not flossing. Dental hygienists themselves have created or contributed to these behaviors in both overt and subtle ways. Dental hygienists, like the loved ones in a family, can unwittingly become the codependent enablers for the patients they serve.

Many of the behaviors and choices in our clinical practices are baked-in-the-cake, meaning they are such an integral part of the clinical tradition, we don’t question them. Look at these three simple everyday behaviors:

		Preschedule appointments and send reminders

Each behavior is usually done with a desire to help and be of service to our patients. Yet they create codependency because the hygienist and/or practice becomes the responsible party-not the patient. It’s time to examine and question these behaviors to understand why they exist and if they should continue.

Codependency is a term most often used to describe the family members and other loved ones of a chemically dependent person. The family enabler, in a desire to help the person with the addiction, ends up owning the problem instead of the person with the addiction. Enabling is removing the natural consequences of the addict's behavior. Professionals warn against enabling because evidence has shown addicts experiencing the damaging consequences of the addiction on their own lives have the most powerful incentive to change. 

People with a predisposition to be a codependent enabler often find themselves in relationships where their primary role is that of rescuer, supporter and confidante. Studies show codependency is often considered an addiction in itself. Many health care providers become codependent enablers. The same desire to help and serve others can easily go over the line and create patient dependency.

For many years, it has been a tradition in dentistry to preschedule the patient’s next appointment. The reason is to ensure the patient comes back. However, it really means we don’t trust our patients to care for themselves. We need to be the person responsible. So in whose interest is prescheduling? If we dig a bit deeper, we’ll see our own business security rests on having a full schedule. This is codependency at work again.

Customer service is the act of taking care of the customer's needs by providing and delivering professional, helpful, high quality service and assistance before, during and after the customer's requirements are met. Customer service is meeting the needs and desires of any customer and defined by the customer. Prescheduling and reminders can be a customer service behavior if that is what the customer wants. But we don’t have customers; we have patients. What is the difference? Perhaps it lies in the word we so often seek from our patients: compliance.

		the act of conforming, acquiescing or yielding;

		a tendency to yield readily to others, especially in a weak and subservient way;

Do those sound like healthy behaviors? We don’t think so. A healthy relationship is interdependent. This means each person in a relationship takes care of themselves. Have you ever found yourself going through a half or full day without going to bathroom? Are you taking care of yourself so you can be in healthy interdependent relationships?

Do you give out a toothbrush, floss and other items to your patients each time you see them? You probably have patients that only change their brush when they get a new one from you, and they can probably sell you back floss by the case. Do you question why you do this? Where did you learn that behavior? Should it continue? Customer service or enabling?

More from DiGangi and Gutkowski: Evidence, hype or manipulation?

Rather than answering those questions, we want to give you food for thought and discussion. How do you feel when you think about the possibility of being an enabler in codependent relationships? You are a caring, helping professional. Yet has it gone over the edge?

We fill these Modern Millennial Hygiene (MMH) articles with more questions than answers because that is true hallmark of an MMH-asking questions and continuing to search for the answers. We’re interested in hearing your thoughts and ideas.

Listen to DiGangi and Gutkowski's podcast on this topic below:

	Check Out Business Podcasts at Blog Talk Radio with 

 Have patients ever said they missed an appointment because you didn’t remind them?

	Millennials in almost any arena except dental hygiene know entry level is a bachelor's degree. Many dental hygienists have an associate’s degree but have paid for a baccalaureate in time, energy and cold, hard cash.

	The only people who don’t know it are recent grads, non-dental people and registered dental hygienists that just ignore this cold, hard fact.

	Once hygienists learn they’re gypped out of an undergrad degree, it’s usually too late. Physical limitations start to become evident, and working chairside becomes increasingly difficult.The only way to change it is to talk about it.

, who started her own university for dental hygienists with associate's degrees. Trish was motivated because of the disdain she saw between orofacial myofunctional therapists (OMTs) trained via the speech pathologist route to those on the dental hygiene route.

More from DiGangi and Gutkowski: The truth about alternating codes D4910 and D1110

	They said hygienists weren’t educated enough.Trisha sat down and counted all the credits associate's degree hygienists earn before finishing the 90 they earn for their degree. It turned out hygienists have more credits than speech pathologists.

	One of the dark days Shirley had as state DHA president was hearing a dentist in a legislative hearing tell the legislators that dental hygienists had only a technical school degree and could not be loosed onto the unsuspecting public. Patti sat in a legislative committee hearing in 2015 in her state when it was said a dental hygienist with only cursory education does not have the skills to review health history.

 has emphasized the need for advanced practitioners yet the majority of the currently practicing professionals don’t have the degree needed to even consider this.The ADHA says in its 

 (page 23), “the American Dental Hygienists’ Association declares its intent to establish the baccalaureate degree as the minimum entry level for dental hygiene practice.”

Free on-demand webinar: Understanding medical billing and its relationship with 3D

	Unfortunately, the ADHA has no direct standing, authority or say-so in the credentialing of a school or setting the standards of education. The ADA requires students to take courses and hire people who are schooled to only work in a

dental office. Today, there are 50 or more applicants to every chairside opening. The more experienced clinical hygienists cannot move out of their clinical position; they don’t have the education they need to work in any other health care field. The new, need-to-practice hygienists can’t find an empty chair to sit in. In addition, the hourly wage of an employee is about 2/3 of what it was 15 years ago.

	Even worse is the decreasing number of four-year schools offering a dental hygiene baccalaureate program and the price of the two-year non-transferable degree that costs the same and has the same credit outcome of a four-year degree.

	This education system is so broken it’s hard to imagine a repair. The fox guarding the hen house is costing the country billions of dollars. People need access to dental hygienists at every life stage. In long-term care alone, billions of Medicare and Medicaid dollars are wasted because oral care is delegated to a nursing assistant with a higher comfort level with the end of the alimentary canal without teeth.

	Here hygienists are like battered spouses still willing to work with the very people who have had a foot on hygienist’s neck for the last 75 years. 

 was right when he said hygienists are necessary to help patients learn how to care for their teeth.

	The current educational system is a double-cross, and we need to sound an alert-Patients and legislators need to know. Dental hygienists are uniquely qualified to care for the mouth-the center of the person, the most innervated area of the body, the center of health and disease, love and communication. Our Boomer, Xer, and Yer, compatriots may be able to look to our Millennial co-workers to set this system right. Let’s get out of the way and let them try.

	We want to hear from you on this issue. This is huge for the future as well as anyone looking for employment right now. Please post your thoughts below.

	Check Out Training Podcasts at Blog Talk Radio with 

	Millennials in almost any arena except dental hygiene know entry level is a bachelor's degree. Many dental hygienists have an associate’s degree but have paid for a baccalaureate in time, energy and cold, hard cash. The only people who don’t know it are recent grads, non-dental people and registered dental hygienists that just ignore this cold, hard fact.

Once hygienists learn they’re gypped out of an undergrad degree, it’s usually too late. Physical limitations start to become evident, and working chairside becomes increasingly difficult.The only way to change it is to talk about it.

They said hygienists weren’t educated enough.Trisha sat down and counted all the credits associate's degree hygienists earn before finishing the 90 they earn for their degree. It turned out hygienists have more credits than speech pathologists.

One of the dark days Shirley had as state DHA president was hearing a dentist in a legislative hearing tell the legislators that dental hygienists had only a technical school degree and could not be loosed onto the unsuspecting public. Patti sat in a legislative committee hearing in 2015 in her state when it was said a dental hygienist with only cursory education does not have the skills to review health history.

Unfortunately, the ADHA has no direct standing, authority or say-so in the credentialing of a school or setting the standards of education. The ADA requires students to take courses and hire people who are schooled to only work in a

Even worse is the decreasing number of four-year schools offering a dental hygiene baccalaureate program and the price of the two-year non-transferable degree that costs the same and has the same credit outcome of a four-year degree.

This education system is so broken it’s hard to imagine a repair. The fox guarding the hen house is costing the country billions of dollars. People need access to dental hygienists at every life stage. In long-term care alone, billions of Medicare and Medicaid dollars are wasted because oral care is delegated to a nursing assistant with a higher comfort level with the end of the alimentary canal without teeth.

Here hygienists are like battered spouses still willing to work with the very people who have had a foot on hygienist’s neck for the last 75 years. 

The current educational system is a double-cross, and we need to sound an alert-Patients and legislators need to know. Dental hygienists are uniquely qualified to care for the mouth-the center of the person, the most innervated area of the body, the center of health and disease, love and communication. Our Boomer, Xer, and Yer, compatriots may be able to look to our Millennial co-workers to set this system right. Let’s get out of the way and let them try.

We want to hear from you on this issue. This is huge for the future as well as anyone looking for employment right now. Please post your thoughts below.

 Millennials in almost any arena except dental hygiene know entry level is a bachelor's degree. Many dental hygienists have an associate’s degree but have paid for a baccalaureate in time, energy and cold, hard cash. The only people who don’t know it are recent grads, non-dental people and registered dental hygienists that just ignore this cold, hard fact.

Do you have an associate's degree but paid for a bachelor's?

	Since 1991, people have had questions about alternating codes 

Even those who think they know the answers don't quite understand the why. It all comes down to dental-medical necessity. Not sure what that is? 

 series of books to help professionals understand the process and use critical thinking, which is more important than knowing a bunch of code numbers.


	Coding should not depend on what a benefit package will cover. It should be based on the individual dental-medical necessity determined at each visit. Dental-medical necessity is a thought process and terminology not well known in dentistry. Yet, as a dental hygienist, you know and probably document it daily. Dental-medical necessity documentation simply requires recording the reason a procedure is needed. In other words, treatment is based on the documented risk assessment and the diagnosis.

, there are parameters used for periodontal treatment coverage. Though the parameters vary policy to policy, let’s consider a current example from 

, which states, “To be considered for a benefit, diagnostic materials must demonstrate the following, consistent with professional standards:

		Clinical loss of periodontal attachment and/or

		Radiographic evidence of crestal bone loss or changes in the lamina dura and/or

		Radiographic evidence of root surface calculus …” –Revised 1/16/15.

The third parameter of root surface calculus is based on the philosophy that calculus is the cause of periodontal breakdown, a theory that has not been supported in periodontal research since the 1960s. Waiting for bone loss is somewhat akin to waiting for a heart attack before treating someone with high blood pressure.

The second parameter, bone height, must be evaluated to determine if there is loss. What is a normal bone height measurement if measured from the alveolar crest to the CEJ? One would think that every professional instantly knows the answer. Yet, as we asked the question around the country, the opposite is more often true. Very few dental hygiene professionals seem to know the answer is 1.5-2mm. This measurement can only be taken on radiographic images.

The first parameter, clinical loss of periodontal attachment, involves a measure of periodontal attachment. This is a derived measurement combining probing depth and distance of the gingival margin relative to the CEJ. Suppose we are evaluating tooth No. 2, and the sulcus depth measures 3-2-3. That sounds okay, yet what if there is recession? Would it make a difference the recession is 3-3-3 or 3-2-3 or 1-1-3 or 3-3-1 or 3-2? Each of those a distinctly different levels of attachment and same tooth. If inflammation is noted in an area with 3mm AND 3mm of recession, how clinically significant is it? The parameters of this carrier seem to count it toward something-Do you?


	Many times, hygienists have been told the insurance company said it was okay to alternate D4910 and D1110. What must be understood is the carrier can only say what would be covered under the policy. This does not mean this is accurate coding.

What if patient comes back for her three-month appointment and her periodontal condition is stabilized? Can she go back to D1110? 

 has said it is a matter of clinical judgment of the dentist. It is appropriately reported as D4910, but if the treating dentist determines the patient can be treated with routine prophylaxis, D1110 may be appropriate. D1110 can be used, but later you cannot go back to D4910 without a new diagnosis and treatment of an active periodontal infection with bone loss. The words of the D4910 state, “…if new or recurring disease occurs…” The problem, as we have discussed before, is 

Follow-up care for a patient who has received active periodontal therapy can receive the D4910 code. Again, a carrier can only say what is covered under a policy. This does not mean this is the correct coding. Back in 2006, a dentist from the ADA Dental Benefits Office said, “D1110 and D4910 are not interchangeable and should not be alternated. The dentist must make the diagnosis, but then the proper code for the procedure provided needs to be used. It does appear that you could choose one code or the other, based on the diagnosis, but it would never be appropriate to alternate them.”

A narrative can be added to a claim form stating, “If periodontal maintenance (D4910) is not available for reimbursement, please provide the alternative benefit of (D1110) prophylaxis.” This is different than changing the code. Purposely changing a code for the purpose of increasing reimbursement can be considered fraud.

More from DiGangi and Gutkowski: Be part of the oral cancer change


	The challenge in understanding alternate coding is based on past thinking confusing current choices. Dentistry has so long been accustomed to thinking directly about the treatment and often skipping over documenting risk assessment and diagnosis. When those steps are routinely documented, coding is much simpler. No games need to be played. The coding is clear-cut. Fraud is no joke to anyone holding a license. Taking the time to understand coding leads to success.

What do you think? Have any ‘war-stories’ to share? Let's help each through this mine field.

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 Since 1991, people have had questions about alternating codes D4910 with D1110 for follow-up of periodontal care.

The truth about alternating codes D4910 and D1110

	Over the years, the idea of bleeding on probing has been a tightly held tenant in 

 and in practice. New studies on treatment benefits measure both bleeding and the decrease of bleeding on probing sites. Does anyone even know what that means?

Back in December 2014, we authors caucused in the beautiful snow/mud covered hills of the Wisconsin Dells to create our tentative editorial calendar. Written in pencil, the calendar illustrated which of our pet projects we’d highlight each month. Of course, BOP was one of those. The authors have both written previous articles on the fallacy of BOP as an indicator of disease, but the notion is so entrenched in the practice that fresh new dental hygienists are taught to regard BOP as an indicator of the severity of 

, and the idea is brought into the fold of nearly every dental office in the land.

Anyone remember how much pressure to exert on the probe? Ms. Ryan told us in 1985 to apply light pressure-so light that someone could pull the probe out of your hand as you’re holding it. In 2009, the 

 taught us that probing requires about 15 grams of pressure. After speaking around the country and asking groups, large and small, how much pressure they put on a probe, I got more blank looks than a group of 4-year-olds being asked who ate the cookie. Super funny–all the studies measure the pressure in Newtons not grams. What’s a Newton?

One Newton is the force needed to accelerate one kilogram of mass at the rate of one meter per second squared. It is based on Newton's second law of motion where F=ma. F is the force applied (the hand), m is the mass of the object receiving the force (the base of the pocket) and a is the acceleration of the object.

Alright, fun’s over. The seriousness of this problem comes into play when dental hygienists, who don’t trust their Newtons and therefore don’t trust the BOP indicator, allow what’s now commonly called a bloody prophy. Much like a punch in the nose elicits bleeding so does dental hygiene treatment. Since our first patient ever, our husband, boyfriend or mother, we know that bleeding is part of the patient’s prophy experience. Here’s where it gets to be super crazy: The difference in one study between bleeding on probing or not around dental implants was 0.15N. That’s 15 grams, the exact amount of pressure you’d use if you were applying the appropriate pressure as you were measuring pocket depths.

Increasing the probing pressure by 0.1 N from 0.15 N resulted in an increase of BOP percentage by 13.7% and 6.6% for implants and contralateral teeth, respectively. There appeared to be a significant difference of the mean BOP percentage at implant and tooth sites when a probing pressure of 0.25 N was applied. A significantly deeper mean PPD at implant sites compared with tooth sites was found irrespective of the probing pressure applied.

The results of the present study demonstrated that 0.15 N might represent the threshold pressure to be applied to avoid false positive BOP readings around oral implants. Hence, probing around implants demonstrated a higher sensitivity compared with probing around teeth.

For the purposes of this article, I think this reference is a good one. There are tiny fractions in Newtons of pressure between bleeding and not bleeding in healthy tissue. Let’s get over it already. For the type of tissue at the base of the pocket, fractions of a Newton really is the difference between squeezing a pimple on the nose and getting punched in said nose. We would NEVER accept these kinds of lame diagnostics from our medical providers, and, if patients knew, and they do, what we were doing within some unmeasurable tolerances, they would clean their own teeth. Start demanding real diagnostic tools. Our profession demands it!

Straight Talk: Revisiting a controversial article and the importance of the Modern Millennial Hygienist

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More from DiGangi and Gutkowski: Breaking the law dental hygiene style

 Over the years, the idea of bleeding on probing has been a tightly held tenant in dental hygiene education and in practice. New studies on treatment benefits measure both bleeding and the decrease of bleeding on probing sites. Does anyone even know what that means?

Bleeding on punching in the nose ... Thoughts on bleeding on probing

? Five years ago, University of Texas, MD Anderson 

 care and research, changed its logo to indicate its intention to strike out 

. This idea can be seen in ads, PSAs, signage in airports and more. TV and radio ads bleep the word 

. It’s time for dentistry to bring these type of innovative ideas from other successful 

 awareness groups to make finally start seeing positive changes in the mortality and morbidity of oral 

Huge strides have been seen based on the passion of women through the work of multiple breast 

 Awareness month, it seems the world gets 

. We see shirts, hats and bracelets. Professional football players wear pink shoes. There are even energy drinks branded pink. The statistics show since 1990, breast 

 mortality has decreased by 34 percent. This decline is due to improved breast 

 treatment and early detection. Awareness didn’t happen with just one group, it took the efforts of many. It’s time for dentistry to take a similar approach with a variety of groups, people and efforts.

Statistics show that 42,000 newly diagnosed with oral 

 since last year’s awareness month. Fully 40 percent of those individuals will be lost to the disease by the year 2020. One person dies from oral 

 every hour, 24-7-365, which adds up to 8,760 people died since our last awareness month. The unfortunate news is we have a seen a change in the rates of oral 

r-a negative change. There has been a dramatic increase being driven by a virus. The HPV 16 virus is replacing tobacco as the primary driver of the disease with healthy, young non-smokers dominating those newly diagnosed.

Never before has opportunistic screening and public awareness been more important. Insanity is to continue to the same things over and over thinking we will get a different outcome. It’s time to learn from others success. The Oral 

 Foundation asks each of us to be part of the change. The ways you can make a difference are many and varied.

As a Modern Millennial Hygienist, you LOVE the recognition and opportunities provided by OCF. They say it this way:

"One group of individuals is uniquely positioned to be in the forefront of the early discovery paradigm; members of the dental hygiene community. With over 150,000 hygienists working in communities across the U.S., they have the numbers to have an impact. With a hygiene professional seeing approximately 10 patients per day, they see a huge segment of the American population in their practice every year. Most importantly, they spend a large amount of time at each patient visit looking at the soft tissues of the oral cavity, where the early manifestations of oral cancer occur. Lastly, their training gives then an existing skill set to identify suspect tissues, and refer them upwards in the dental community for confirmation (general dentistry), biopsy (oral surgeons and periodontists), histopathology and diagnosis (oral pathologists)."

Ways to Be Part of the Positive Change in Your Practice

Another organization we can learn from is the American Red Cross. They had slogan a few years back, ‘If not you, then who?’ Starting can begin in the practice or practices in which you work. You can call for an oral 

 screening calibration session. First update yourself on current knowledge of oral 

Once again, April has arrived with thoughts of spring, flowers and a new beginnings change perceptions and outlooks. Did you think, hey, it’s also Oral Cancer Awareness month?