More on painful hygienists ... By Mark Hartley, editor, RDH

Aug. 21, 2001
In the August 2001 issue, my Editor�s Note was titled, When they stop smiling.

In the August 2001 issue, my Editor�s Note was titled, "When they stop smiling." I referred to an article I had read in the June 2001 issue of DentalTown. A doctor had written DentalTown about patients who complained that treatment provided by his hygienist was a little too painful. The magazine asked for a panel of doctors to respond to their colleague�s letter.

It was my observation that a couple of the panelists were a little harsh in their criticism of the hygienist. I should point out that the doctor who wrote the original letter was overall pleased with her work.

Nevertheless, for primarily business reasons ("hurt" patients find another office), the panel felt the door needed to be slammed shut on the thumbs of hygienists deemed a little too painful.

The last line of the Editor�s Note asked for readers� opinions. Several readers did respond, including the ones below. Although all of the e-mails were "signed" by the writers, due to time constraints I am unable to identify them here. But I think they made some good points and I want to share them with you.

First letter

I was reading through my issue of RDH this month and I was taken back by some of the responses the dentist got when asking how to "deal" with the new hygienist in his office. The first thing I think would have been to look over the patient's chart and talk with the hygienist about the level of disease and whether or not this patient has a history of hypersensitivity.

At this point, the dentist should have talked with the patient about these issues. Let the patient know that she did get appropriate care, although some local anesthetic should have been offered in hindsight and will be offered at subsequent visits until her disease level is reduced or the level of hypersensitivity is reduced.

In an office where this dentist knew that the former hygienist in the office was not scaling adequately, I can't believe that he wouldn't defend the new hygienist for using some elbow grease to get rid of some tenacious calculus. It's possible he hasn't scaled since dental school and doesn't realize how difficult it can be to remove calculus that's been there for years.

In the event that the hygienist used a little too much force when it wasn't called for, then she probably doesn't know she's being heavy-handed. If he just talked with her about it, she may be able to change some of her scaling techniques. I really think jumping to conclusions that this hygienist is a sadist and doesn't belong in practice is not fair at all. To fire her on the spot or to threaten her "to never let it happen again" is a little hasty when you don't have the full story as far as patient history is concerned. I am appreciative that in the state of Maine, where I practice, hygienists are given the opportunity to administer local anesthetic to our patients so we can do our job thoroughly and comfortably.

Second letter

I have just finished reading "When they stop smiling" in my August 2001 issue of RDH. I was glad to see a least one doctor stood by his new hygienist. This doctor understands when a patient�s oral health is compromised by gingivitis or periodontal disease, a prophy or scale and root plane may be discomforting due to the ulceration of the gingival tissues. I am not surprised at the callous response of the other doctors. Unfortunately, it appears their main focus is not on the health and welfare of their mutual patients with the dental hygienist but solely on the revenue generated by these patients. A dental team means the doctor, the dental hygienist, the dental assistant, and the front office. Some offices practice in this manner; however, a good majority does not.

Third letter

I have been a hygienist for over 26 years, and I have had patients tell me that I am the gentlest hygienist they have ever had. Other patients tell me I am the roughest hygienist they have ever had (though not usually directly to me). I have also had many tell me I am very thorough, and a few tell me the opposite.

What I have figured out about the gentleness is that I am very gentle using anything but a new instrument tip. When the tips are new, they are just too thick for any but the loosest gingiva, and people can feel it. So, I only change tips when I must, and I don't share them with anyone. When the tips are very new, I don't do as thorough a job if the patient is sensitive.

After all, the ADA is now encouraging us not to do a thorough cleaning, but a "prophy" (a misnomer if ever there was one -- if it isn't thorough, it isn't prophylactic of anything!) on anyone but the perio patients.

Fourth letter

I've just received the August 2001 issue of RDH. My heart sank as I read your Editor's Note "When They Stop Smiling." The dentist I work for is an excellent care provider, so when he asked me to leave my present job and join him in taking over a retiring dentist's practice, I was honored and thrilled. We have been in this new office for about four months now, and have already had a zillion or so meetings about how to address the roadblocks we've been hitting.

The situation described in the article did occur in our office and does on frequent occasion come close to occurring on almost a daily basis. Without exaggeration, four out of eight people a day comment that: "No one has ever cleaned below my gums before! I can really feel it! I've never had to sit through a cleaning this uncomfortable before!"

This is after a pain-free perio chart (which needs thorough explanation since not one of these patients has ever had it done before) reading 2-4mms average with maybe a couple of 5mms in the far distal. This is my typical patient four times a day. Three patients a day are refered to a periodontist (who can now afford a small country because of our referrals in the past four months) due to the unbelievably high perio pocketing found at six-month recall appointments. At least, but sometimes more, one patient a day is reappointed for scale and root plane procedures.

These patients don't know what periodontal disease is, and, if they do, they were told only that smokers get it. They haven't had anyone tell them to floss or shown them how to floss and why. They come in for a 6-8 month recall system (whenever they were phoned and told it was time), and they have mostly had 'that polish thingy and sometimes the scraper thing.'

I spend hours each day trying to re-educate patients and bring them somewhere close to dental health standards. I butt my head against the wall using conversation, explanation, photos, brochures, gentleness, radiographs, humor, and prayer not to mention the topical and local anesthetic. Going sub-g on someone who hasn't had it before and is scared or sensitive is difficult. I don't know how else to make the person comfortable without giving them valium!

It would take me another 15 pages to detail the lengths we've gone to in order to better understand and comfortably treat our patients. I know my doctor supports me 100% because we've discussed this problem. He's backed me with tough patients, and he's actually let some patients go because we just can't satisfy them. Our gold-mine office of opportunity is a definite challenge but we try to keep positive. We develop new office policies and statement of refusal forms weekly.

Fifth letter

In my 32 years of dental hygiene practice, I have learned how to perform a careful and thorough scaling and prophylaxis, and in the process, am able to keep the patient comfortable and virtually "pain-free." Often, for patients who have left a dental practice because of a "rough" hygienist, I am pleased and humbled that I can be the hygienist who can make a difference for these patients. They leave our office smiling, without dreading the six-month recall any longer.

There are many stories I could relate about hygienists I have worked with, known personally or just heard horror stories about from patients...and the sometimes "brutal" way people are treated, all in the name of dental hygiene, and getting those teeth clean. Lacerated tissues, teeth that are sensitive for weeks afterward, adults being reprimanded and scolded about their hygiene habits ..."Well, if you flossed daily, the cleaning wouldn't have hurt so much."

It's enough to give dental hygiene a bad name! To those hygienists who seem to forget that there is a living, breathing, feeling person beneath those curettes and scalers, I wonder how they would feel if this rough treatment were inflicted on them.

All I know is that it does my heart good when I get a smile, a hug from an apprehensive child, or a sincere "thank-you for being so gentle" from grateful patients.

Sixth letter

There is a wide discrepancy from one hygienist�s skills to the next. Some hygienists are extremely rough because they don't angulate the blade of the instrument correctly. Some hygienists are thorough in their technique, and some hygienists do the spit shine from canine to canine (no such thing as subgingival calculus).

You can't make all of the patients happy all of the time. If a hygienist has been accused of being too rough consistently, she probably is doing something wrong in her instrumentation, her attitude and/or her presentation of the patient�s needs. I, myself, have been told many times by patients that they have never had their teeth cleaned like that before, that I was very thorough. I have also had patients look at me as though they are wondering what I am doing, that is the time to slow down and start explaining a lot. I also quit a practice after two weeks because the hygienist before me had been there for nine years and the patients didn't know what probing was let along scaling.

Fortunately, I had already been a hygienist for 17 years so that I knew the problem wasn't me.

Unfortunately, I am not so sure where dentists are coming from when it comes to the dental hygiene arena. How much are they willing to overlook? Do they know what a comprehensive thorough cleaning is? Or do they want the painless spit shine that keeps patients smiling, perio disease and all? An existing practice where there has not been thorough cleanings is hard to walk into. Probably a high percentage of patients need scaling and root planing with anesthetic. Try presenting that when they have been coming in every six months for regular cleaning and check ups.

Maybe the patients aren't smiling, but neither is the hygienist who really wants to provide the treatment the patient really needs. I have been in this situation numerous times over the years. I have been very fortunate in that the dentists I have worked for have almost always been very supportive of me and my skills personally as well as in front of the patient. Let me re-emphasize again how awkward it is to come into a practice where the patients come every six months and you see the subgingival calculus on years of bitewing x-rays.

This is not an easy job. Trust me, it would be a lot easier to keep the patient smiling rather than doing what you know you have to do.

I hope this enlightens you at least a little bit.

Seventh letter

Dear Mr. Hartley, I enjoyed your article in the August 2001 RDH magazine. I thought I would relate a true story that happened to me about 19 years ago when I first started practicing dental hygiene. Here goes: A man came in to the dental office where I worked and I could tell he was none to happy to be there. It had been many years since his last cleaning and he was really in bad shape.

This was in the days before STM, so it was my job to do the best I could in the time I had. I could tell as the cleaning proceeded that it was uncomfortable for him as he gave me dirty looks and grunts throughout the procedure. When we finished, I promised that, if he came back in six months, it wouldn't be so bad. I could tell he didn't believe me. At the time I was working in two offices in the same community. A few months later at the other office a familiar face came through the door. You guessed it, it was the same man. I didn't say anything when he came in about treating him at the other office. As I promised, this cleaning was much easier. When I finished he looked at me and said, "Well I'll tell you one thing, you're a he-- of a lot easier that the last girl that cleaned my teeth."

I looked back and said, "I was that last girl and I told you it would be easier this time."

If his teeth hasn't of been fastened to him I think they would have hit the floor. Needless to say I made a friend that day and a very faithful patient. I tell this story to people who ask me if the cleaning is going to hurt because sometimes it's not the hygienist's fault if it's a little uncomfortable. I think if you give them some of the responsibility for the discomfort due to their lack of home care they are less likely to be dissatisfied.

Eighth letter

Here are my comments for the thought-provoking Dental town question: How should I deal with patients complaining about my hygienist being rough?

My first suggestion is for the doctor to sit in her chair, and have this hygienist scale his teeth. The next question is: Is she scaling at a prophy visit? Meaning is she doing perio therapy at prophy fees? Is she/they diagnosing periodontal disease? This would be a whole different dilemma.

However, if she is "scaling" subgingivally, the office may want to investigate into a piezo ultrasonic scaler. I have the ProSelect3, and the hygienist could flip right over to fluoride (without getting up) and desensitize the area while she is scaling. These would be some starting suggestions, because a good employees and consistency of a staff is also very important.

Ninth letter

In your article, "When they stop smiling," you questioned the pain patients complained about from their hygienist. Your article does not mention whether a large percentage of patients were complaining or whether it was just one or two.

There will always be those patients who have a very low tolerance for any kind of work that is done on them. However, I have seen hygienists that feel it is their duty to scale every tooth like they are digging to China!

I took over a position where the former hygienist did a poor job of scaling. I had to inform patients of their periodontal conditions, and they were not happy. It took time and effort. Sometimes, on the worst ones, I worked by quadrants at each appointment so as not to cause too much discomfort. Other times I would use anesthesia. Most of the time I found that there were just isolated areas that had to be scaled deep and I informed the patient that it might cause some minor pain.

No one should have to leave a prophy appointment in pain. I once had someone tell me they couldn�t eat for a week after they had their teeth cleaned! If it�s that diseased, it should be called surgery and the hygienist should use anesthesia. Perhaps if a hygienist is getting many complaints about pain, she is too heavy handed. Otherwise it might be better to explain to the patient what is going on and slow down.

My thanks to the readers who took the time to send in the letters above.