Plugging In: How Hygienists Can Use Digital Dental Technologies

A digital hygiene practice is the clinical practice of the future—and the now. There are ways that dental hygienists can leverage digital technology in the hygiene room to deliver improved patient care while still providing a return on investment for their dental practices.

Periodontal Diagnosis and Treatment Facilitated by Digital Technology

Katrina Sanders, RDH, a practicing dental hygienist, dental hygiene educator, and international speaker, thinks the best opportunity for hygienists to leverage digital dental technology in the hygiene room is for perio-related diagnostics. Artificial intelligence (AI) changes how patients perceive hygienists' diagnoses regarding periodontal disease.

For example, hygienists diagnose periodontal disease by probing the patient's subgingival tissue, taking a measurement, and observing for signs of infection, aka bleeding gums. However, Sanders says the hygienist might not recommend treatment the first time. So, when the patient returns and the hygienist does recommend treatment, patients feel the gum disease diagnosis is more subjective than it is, or that hygienists are playing a guessing game about when to treat it.

"Quite honestly, it has been us playing a guessing game," Sanders says about when to recommend treatment. "If you ask a lot of dental hygienists where that hard line in the sand is between when we no longer think the free cleaning the insurance covers is enough and that the patient has an active infection that needs a different type of procedure, it's hard to give a definitive answer. We usually hear hygienists say, 'it depends.'"

The problem is that clinicians use X-rays to diagnose critical gum disease. Hygienists learn in school that the X-ray reveals bone loss. However, looking at X-rays alone will miss the early stages of the disease process. Stage I and Stage II gum disease are tough, if not impossible, to see on an X-ray, Sanders explains.

"So, our diagnostic tools have kept us in the dark, so to speak, about what's going on in the patient's mouth," Sanders says. "Using AI technology has revolutionized that."

AI can identify an area on the X-ray that needs further diagnosis. It can detect subtle changes in the lamina dura or the enamel and alerts clinicians. Sanders says AI removes the subjectivity patients feel and increases the clinician's confidence in the diagnosis. She compares it to getting lab results at the doctor's office.

"When a patient feels fine, but the bloodwork comes back with high cholesterol, the patient can't argue with the fact that the bloodwork is telling them this," Sanders says, adding that using AI is like having a colleague confirm a diagnosis. "It helps validate what the clinician sees and provides more clarity than X-rays about those borderline cases. It gives us more definitive guidelines about how to address the disease process."

In addition to using AI technology for diagnoses, Sanders thinks another opportunity for using digital technology in the hygiene room is periodontal endoscope technology. Periodontal endoscopes have revolutionized how clinicians treat periodontal disease, she says.

In the past, hygienists routinely used instruments for scaling and root planing in areas they couldn't see. Hygienists have trained their tactile senses to feel if the tooth surface they cannot see below the gum line is rough with tartar buildup. Hygienists will use instruments there until it feels smooth, Sanders says, even if it means removing tooth structure. However, removing that surface also removes an essential component of the attachment apparatus, making it more difficult for the body to create new healing attachments, Sanders explains.

With the periodontal endoscope, hygienists insert a tiny fiber optic camera into the gingival space to perform visualized scaling and planing. Now, hygienists don't have to feel it; they can see whether the surface has calculus or not. Clinicians can see if there is a root fracture or decay that they missed because they couldn't see it the first time.

"It allows us to have another pair of eyes beyond our radiographs and guessing by feeling alone," Sanders says.

Notice and Wonder with the Intraoral Camera

Most practices have an intraoral camera. But do they use them to their full potential? Tammy Filipiak, RDH, MS, past president of the American Dental Hygienists' Association, says hygienists should use an intraoral camera with every patient. Filipiak, a former educator and clinical leader, thinks an intraoral camera facilitates the patients' participation in diagnosis and engages them in the treatment planning process.

"When working with our team, I talk about 'notice and wonder,' and what that sounds like, 'I noticed you have some staining around this filling on your front tooth. I wonder, does that bother you?'" Filipiak explains. "When we stop telling and co-discover with our patients, it becomes something they want, not just something we're telling them they need."

The intraoral camera is something many dental practices have, and hygienists already know how to use. Filipiak would encourage hygienists to use it to show healthy versus unhealthy tissue, changes in bites, or opportunities for esthetic treatments, like whitening.

"I can't think of something that a dental hygienist couldn't 'notice and wonder' with a patient," Filipiak says.

One of the reasons Filipiak says it is beneficial for patient acceptance rates is that it presents the information in a format that patients recognize, a photo. An X-ray image does not have the same familiarity with patients, so the pictures they produce might not inspire the same reactions. However, a photo shows patients what the hygienists see.

"Starting with a format that patients are familiar with is key to getting case acceptance and whatever the next step is, from perio treatment to some advanced esthetic treatments," Filipiak says.

Be Inclusive with Panoramic X-rays with Bite Wing Capability

Sheri Moore, RDH, Board of Directors, Virginia, West Virginia, Delaware, and Maryland, and Past President for the Virginia Dental Hygienist Association, has 28 years of experience as a clinical dental hygienist. She thinks the panoramic X-ray is one of the critical improvements with digital technology. Her practice invested in one that will take bitewings without a sensor, which she says is a wonderful, inclusive technology for hygienists and patients alike, especially those who cannot open wide enough for traditional bitewings or have a gag reflex that prevents it.

"That's a whole realm of patients we could not do anything for," Moore says. "Those are individuals that have declined X-rays and, 4 years down the road, they need a root canal because they haven't had a radiograph."

For example, Moore has a patient that suffered a head injury that left him unable to open his mouth wide. Getting a toothbrush in his mouth isn't easy, making X-rays an especially vital priority. Moore says that investing in the digital panoramic X-ray with bitewing allowed the practice to include him and provide the diagnostic work he needed.

Moore also likes how the images increase the patients' ownership of their treatment plans. Showing patients what the hygienist sees on the X-rays helps patients trust hygienists' diagnoses, taking the perceived subjectivity out of it for patients.

"Show them on the computer what you see. You have the ability to change the image by increasing the size, change the contrast and density, etc., so that they can see it and say, 'okay, I can see the value of this,' and take ownership of their diagnosis and treatment options," Moore says.

Managing the Practice Management System

When Moore started, there were no paperless systems for patient records. She appreciates how practice management systems changed how hygienists keep records and communicate with the team, patients, and specialists. She enjoys how the software puts patient treatment plans, X-rays, probing, and clinical findings at the fingertips of the hygienist.

"You can also print out their treatment plan and say, 'This amount is how much your insurance is going to cover; this is how much you are responsible for,'" Moore says. "Before, we had to write everything down and give it to them."

Practice management software makes it a lot easier to send X-rays to specialists. Provided that there is encryption for HIPAA compliance, the practice can email the X-rays rather than mailing them or having the patient take a new set at the specialist's office.

In addition, Moore says practice management software allows her to be more inclusive in her patient communication. For example, for patients that have different learning abilities or hearing impairments, she can show them on the computer what she recommends they need and run through the treatment plan that way.

"I also have a couple of patients that have severe dyslexia and cannot read, so for me to hand them a pamphlet on gum disease and say, ‘read this about periodontal disease’ is not possible. But I can use my computer for show and tell. Show them advanced stages of periodontal disease or need for a crown, and then tell them about treatment options," Moore says.

Detect Problems Earlier with CBCT

Emely Perez, RDH, District Sales Manager at Planmeca USA, Inc., says Cone-beam computed tomography (CBCT) allows hygienists to see what is happening with patients' oral health. It also enables hygienists to take bitewings extraorally with tomography, making the patient more comfortable. They can also detect interproximal caries earlier than using an intraoral sensor.

"The lesion has to be 25% penetrated into the cortical bone to see it on a 2D image," Perez says.

In addition, with a CBCT you can view the entire tooth, from apex to apex. This comprehensive view is essential because the clinical team can see if something is going on, even if the patient is asymptomatic, Perez explains. Moreover, the clinical team can show the patient in the 3D rendering view. Seeing is believing, too. Patients see their bone infection, and Perez says that will increase patient acceptance.

"If there is an abscess eating away the bone, guess what? You won't see it on the black and white image," Perez says. "You put the 3D rendering up on that big screen, and the patient can see and visualize in 3D how there is a full-on infection in the bone."

In addition to providing a more comfortable patient experience with extraoral bitewings, CBCT imaging uses less radiation. Carly Zenobi, RDH, Clinical District Sales Manager at Planmeca USA, Inc., explains that Planmeca's Ultra Low Dose® feature means that hygienists can take X-rays for a full mouth through 3D with less radiation than a single Periapical radiograph.

Zenobi also thinks every hygienist should understand CAD/CAM and how it begins with digital scanning.

"Planmeca offers the full digital solution, everything from 2D and 3D imaging to better radiography and providing the ability to treat some of those lesions with CAD/CAM dentistry," Zenobi says.

A foundational part of this workflow is the digital impression. Zenobi thinks digital impressions are more accurate and provide more real-time information than traditional impressions. Digital impressions rarely result in retakes, which is more comfortable for the patients, Zenobi says.

"A repeat impression means more goop for them, and no patient loves that goop," Zenobi says.

Moreover, Zenobi says that Planmeca's digital impression offers more than a regular digital impression. The Emerald® S Scanner takes digital impressions and intraoral pictures. Plus, the new transillumination tip, Cariosity™, detects cracks, fractures, and supragingival proximal carious lesions.

"It's a 3-in-1 solution," Zenobi says.

The ROI from Plugging In

Investing in this technology benefits a practice's bottom line, but more importantly, it addresses a real need in the patient population. For example, Sanders says that gum disease is the sixth most prevalent chronic disease, but its treatment is not widespread. Using AI technology that confirms the need for patient periodontal treatment removes any perceived subjectivity in the diagnosis. The technology also helps borderline cases where patients who might have declined treatment move forward and get the necessary care for their oral health. Moreover, it can confirm bone loss on X-rays, which insurance companies often require to cover treatment.

"There's an incredible ROI because you are going to be able to assess, diagnose, and treatment plan more periodontal cases and optimize case acceptance for your periodontal patients," Sanders says.

With the periodontal endoscope technology, Sanders says this allows patients to get a "Hail Mary" treatment at their regular dental office instead of surgery at a specialist's. In addition, by offering a non-invasive, non-surgical approach to treating disease, there is a better chance that these patients will move forward with their periodontal care before it's too late.

"In addition, we see an excellent response rate. Practices in the US that use this technology often have patients seek them out for it," Sanders says.

Adding these technologies allows dentists to empower their hygienists with treatments that can help their patients. As Sanders points out, this technology investment could be the tipping point for attracting and retaining their hygiene team.

"This is also an investment in the patient health. It's an investment in seeing something greater for your patients," Sanders says. "So, hygienists, if you want to integrate this technology into your practice, you need to talk to the doctor like this is a business investment."

Filipiak says that when patients are part of the discovery process, it helps move them toward case acceptance. More treatments result in more billing codes. Filipiak says that the ROI increases dramatically if hygienists use technology they already have versus buying something new.

However, ROI is not only providing care but also growing a hygienist's practice. More treatment has an excellent ROI, but that increases exponentially with a growing practice.

"Asking for a referral from a patient who is super excited about something we did for them is the best internal marketing we can do," Filipiak says. "There's an ROI that comes from one treatment, and then there is an ROI that comes from having a growing, thriving practice. That happens with an influx of new patients who have heard or seen the good things that we do."

Filipiak says that the more a hygienist uses the intraoral camera, the more efficient they become at it so building the protocol to use the intraoral camera with every patient in the workflow is essential. Plus, it supports the need for hygienists to educate patients about their oral health and give patients the information needed to decide.

"Patients need us to advise, consult, and start the conversation," Filipiak says. "They expect us to do that; we are there as oral health advocates. As a team, there should be an expectation to use the intraoral camera on every patient."

Improved digital radiography also produces an ROI by reducing the practice's overhead tied up in inventory items. For example, traditional X-rays require chemicals and solutions to develop. Moore explains that digital radiography eliminates the need for these supplies among other benefits.

“The greatest ROI with this technology is that patients with special needs, such as limited ability to open wide or a horrible gag reflex, can receive needed diagnostic care,” Moore says. “Gagging in a dental office is humiliating for patients. This eliminates that embarrassment, and patients are your best marketing tool. Trust me when I tell you that they will tell their friends and family about their positive experience at your dental office.”

Regarding practice management, Moore says a well-trained staff can produce ROI in many ways. For example, reporting can show the hygienist how much perio treatment they are doing versus prophy, how many patients are keeping up with regular visits, or even production versus collections.

"That allows the practice and the hygienist to see where we need to focus our attention. ‘Do we need to market? Where are we failing, and where should we invest our resources?’" Moore says. "Your software can do a lot of that for you."

Using digital technology like CBCT is excellent for the patient experience, which also has valuable marketing benefits through word-of-mouth referrals. Perez says patients that experience a more comfortable and informative session with the hygienist will tell their friends and family about it.

"So that's a big deal with patient experience," Perez says.

The digital workflow also produces considerable savings. First, there is no impression material. Also, there are no retakes or pouring of stone and no shipping fees. However, as Zenobi points out, saving time also produces greater ROI over the cost of materials and expenses. Not only for the practice but also for the patient. Planmeca's workflow facilitates same-day relief for restorative cases.

"The patient's time is valued from start to finish," Zenobi says.

"It also opens up another chair when there would have been a second visit," Perez adds. "You open up that chair-time for another type of treatment."

Perhaps the key takeaway from plugging in is that digital technology bridges many communication gaps with patients, leading to more case acceptance. It allows patients to engage more with what's going on in their mouth and make decisions with the same information the hygienist has, Zenobi says.

"From the patient perspective, being able to see what we're doing and understand the why behind it is important," Zenobi says. "It's valuable as a hygienist to offer that value to the patient."