Treatment modules that have beome a standard of care
by Karen Donaldson, CDA, RDH, BS, EFDA
Every dental hygienist has spent hours studying nonsurgical scaling and root planing, both during initial hygiene education and later as part of continuing education requirements. The technique has not changed much over the years, but research about the cause of the disease has strengthened our responsibility to patients and helped them make educated decisions about treating the disease, and hopefully maintaining treatment with diligent home care.
Nonsurgical technique for treating mild to severe periodontal disease is an important skill for all dental hygienists to master. When I was in school, our clinic had two Cavitron scalers. If I wanted to use one with my patient of the day, I had to arrive at work as the doors opened. Most of the clinicians did not bother to use one for periodontal treatment. I chose to use one, even if a patient had normal pocketing. This allowed me to remove calculus faster and shorten the already long appointment for the patient. This is where I began to focus on what is now considered the standard of care in dental hygiene, using ultrasonics to provide a thorough removal of calculus, but also to create an oxygenated lavage within the periodontal pocket where anaerobic bacteria thrive.
Dr. Tom Holbrook was just becoming a household name among progressive dental hygienists when I graduated in 1989. I quickly caught on to this progressive method of pocket debridement. We were told never to use an ultrasonic tip subgingivally when I was in school. Today we know that subgingival scaling with ultrasonics is an important part of successful nonsurgical periodontal therapy.
What other treatment modules have become standard of care? Many products in the dental office have added to success for some and been ineffective for others. Of course the most common adjunct was chlorhexidine gluconate, Peridex. This product was used as standard of care in treatment for periodontal disease in Europe for 30 years before the FDA approved its use in the United States. The biggest holdup in approval was its staining factor. The U.S. manufacturer finally resolved the staining problem. Most hygienists learned from networking and seminars that instead of having patients rinse with the product, they should have them brush with it to reduce staining even more.
Chlorhexidine gluconate is routinely used for subgingival irrigation into the pockets post-SRP and sent home with the patient for home irrigation, utilizing a Waterpik with a Pik Pocket tip. During the mid 1990s, many research groups presented data showing chlorhexidine gluconate ineffective in home use because patients could not effectively get the rinse into the base of the pocket where it was needed. Even with this data, most hygienists continued to use the product in in-office irrigation and carefully taught patients how to effectively irrigate at home. As research for periodontal pocket response to chlorhexidine gluconate continues, the data is more positive than negative, giving this product sound support as a home-care recommendation.
Another form for delivery of chlorhexidine gluconate is PerioChip. Each chip is a small orange-brown rectangle, rounded on one end to allow for easy placement into the periodontal pocket. Each PerioChip weighs approximately 7.4 mg and contains 2.5 mg of chlorhexidine gluconate in a biodegradable matrix of hydrolyzed gelatin, glycerin, and purified water. Placement of the chip sometimes proves difficult; therefore the product is not very popular with hygienists.
The product also received warnings from the FDA for not providing risk factors in their ads.
Some offices recommend Listerine oral rinse as part of a nonsurgical program. Listerine is available over-the-counter and is composed of a fixed combination of essential oils: thymol (0.064%), eucalyptol (0.092%), methyl salicylate (0.060%), and menthol (0.042%). However, it contains 21.6% to 26.6% ethanol depending on the product. This level of alcohol is considered toxic for gingival tissues when used in abusive amounts. Listerine does have an alcohol-free product, but the ethanol is the bacteriostatic ingredient considered to help fight periodontal infection. It should be noted that for ethanol to be toxic to bacteria it must be used at 40%. This is highly toxic for gingival tissues, and no OTC product contains this percentage.
Another homecare technique that was introduced in the 1970s and gained support in the 1980s from many periodontists was the Keyes Technique, developed by Dr. Paul H. Keyes (rhymes with skies) of the National Institute of Health. His then revolutionary treatment for periodontal disease was simply brushing with baking soda, but he added hydrogen peroxide to provide a foaming sensation. Most patients that used this maintenance care had improved pocket depth. However, over time gingival exposure to concentrated hydrogen peroxide created problems by developing pyogenic granulomas, ulcerative gingivitis, and gingival tumors. In the mid 1980s the American Academy of Periodontology recommended not using this technique for treating periodontal disease.
Research has shown that the baking soda, when added with water, is less abrasive and has the same benefits. Hydrogen peroxide is routinely discussed as being harmful to gingival tissues when used as a rinse or added to baking soda. It is wise to tell your patients not to use this combination.
The newest version of the Keyes Technique is Periogen. This product is available in many chain stores and on the Internet. Its main ingredients are sodium bicarbonate with citric acid, fluoride .04%, sodium tripolyphospate (antioxidant), and tetra potassium pyrophosphate (emulsifier). This product is said to dissolve both supra- and subgingival calculus. It is added to water, used with a Waterpik, and irrigated into the pocket. No studies are available on this product and the FDA has not approved it.
Actisite fiber therapy was promoted heavily during the late 1990s but quickly lost favor among clinicians due to difficulty placing it into the pocket, the necessity of keeping it in the pocket for 10 to 14 days, and then having the patient come back to the office for removal. The fibers contained tetracycline hydrochloride, the antibiotic of choice for fighting the anaerobic bacteria that causes periodontal infection. It was taken off the market in the U.S. due to product difficulty.
Next to irrigating chlorhexidine gluconate, Arestin is the most widely used adjunct to SRP therapy. Arestin contains minocycline, a tetracycline derivative. Its use is contraindicated in children and pregnant women due to the staining effects to developing teeth from tetracycline. Arestin comes in a premeasured cartridge that is dispensed in a stainless steel syringe. One cartridge is used for each pocket.
The product congeals when it comes in contact with crevicular fluids, which helps the product remain in place. There is a small learning curve in placing it into the pocket.
One adjunct treatment not readily used by general dentists is oral antibiotics after nonsurgical therapy. A combination of metronidazole and amoxicillin over seven days is considered normal. However, the abuse of antibiotics in medicine today might interfere with results if a patient has taken these drugs regularly over time.
Dr. Jefferey Hillman has developed one of the latest and most promising treatment modalities available. A probiotic lozenge contains three forms of streptococcus that actually act as antagonists against bacteria that cause periodontal disease. EvoraPro and EvoraPlus by Oragenics contain Streptococcal uberis and Streptococcal oralis, both antagonistic to periodontal pathogens. The third bacteria, Streptococcal rattus, acts as an antagonist to Strep mutans but does not make high levels of lactic acid. It eats sugar and blocks the introduction of Strep mutans into the cycle of sugar molecule reduction. This product promises to fight periodontal infection and caries in adults and adolescents that drink sugary sodas and power drinks.
The question becomes, with all these adjunct treatment modes to increase success with nonsurgical periodontal therapy, why are we still reluctant to recommend treatment? Most offices are still charging a 0110 ADA code for adult patients and "just doing what they can" to treat deep pockets. Meanwhile over 90% of our regular six-month patients have some areas of pocketing. With all the research on periodontal disease and the relationship of oral health and heart disease, diabetes, pneumonia in the elderly, and chronic inflammation related to other systemic diseases, we must develop strong verbal communication with patients regarding the need for nonsurgical therapy to establish a healthier oral environment.
The Internet is blanketed with all types of valid information that patients can access to explain the importance of aggressively treating oral infection. It should be our responsibility to direct them to the correct information, and to develop a strong relationship so that they’ll follow our recommendations for treatment.
If your office does not have a strong nonsurgical therapy program, work with other hygiene staff and the doctor to develop one. Many practice management companies have standardized programs as part of their guidance. It’s easy to set a standard for treatment so all patients are treated the same by all hygienists. Determine what adjunct care will be recommended to your patients and what levels of disease will receive them. Put all this into a written plan with appointment sequencing, and what data will be sent to insurance companies as part of filing the treatment. If the hygienist is the one to present the treatment plan, make sure you are ready to answer questions patients have concerning treatment and insurance coverage.
Nonsurgical therapy can be successful for patients and rewarding for the office if everyone approaches it positively. How you educate your patients will determine a large part of that success. Learning the newest techniques to provide high-tech care in the 21st century is part of the success with any nonsurgical program.
The treatment of periodontal infection is the same as it was 30 years ago – remove the bacteria and debris causing the infection, allow for healing of the gingiva and reattachment of the periodontium, and immaculately remove plaque every 24 hours. Today’s methods are far superior to those used years ago. We now know that setting up our patients for successful infection treatment is a major factor in their systemic health, and depends on our knowledge of the latest treatment modalities.
So what are you waiting for? Start today and breathe new life into your profession by developing a positive approach to nonsurgical periodontal therapy. You will be amazed at the improvement in your patients’ homecare and your attitude toward a job that has become monotonous. Perhaps you will set the next standard of care with your own ideas.
Karen Donaldson, CDA, RDH, BS, has worked as a dental hygienist since 1989 when she graduated from the University of Southern Indiana as a nontraditional student. She graduated magna cum laude in 1990 with a bachelor’s degree in health sciences with a geriatrics and social services emphasis. She also holds certification from DANB as a Certified Dental Assistant and has had expanded functions training. Karen practices clinical dental hygiene in Northwest Arkansas.
References
- O’Hehir TE. "Eating Bacteria for Health." Hygienetown. April 2010: 1.
- Napoli M. "How to Avoid Tooth Loss." Medical Consumers. Aug. 18, 2010. http://medicalconsumers.org/2010/08/18/how-to-avoid-tooth-loss.
- Rawal SY, Claman LJ, Kalmar JR, Tatakis DN. "Traumatic Lesions of the Gingiva, a case study." http://www.ncbi.nlm.nih.gov/pubmed/15212360 2004.
- Ryan ME. "Nonsurgical Approaches for the Treatment of Periodontal Disease." http://www.gcds.org/Upload/Documents/Dr.%20Ryan%20(pm).pdf 2005.
- Vernino AR, Gray J, Hughes E. The Periodontic Syllabus. Baltimore, MD: Lippincott Williams & Wilkins, 2008.
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