Trisha E. O`Hehir, RDH
As we come to a close on the 15th year of RDH magazine, a look back over the years shows many changes within the field of periodontics which have been documented within these pages. The role of the dental hygienist in the diagnosis and treatment of periodontal disease has evolved and changed over these past 15 years.
What seems routine today was actually questioned and challenged not too long ago. Today, dental hygienists:
- Routinely diagnose periodontal disease.
- Discuss and plan treatment with the patient.
- Use mechanical scalers for periodontal debridement, realizing the potential for overtreatment with root planing.
- Focus therapy as well as disease control on the interproximal areas first.
- Individualize therapy and supportive periodontal care.
Dental hygienists routinely diagnose periodontal diseases and plan their treatment accordingly. Not too long ago, the use of the word diagnosis by dental hygienists was actually forbidden. Instead, we noted suspicious areas and called to the dentist`s attention areas of deep pocketing. Now, hygienists carefully collect the necessary data to determine the periodontal health status of each patient.
Recent findings now enable hygienists to more effectively analyze patient data on an individual basis. Documented changes within the periodontium associated with the hormones of pregnancy provide us with essential information when evaluating the findings of pregnant patients. Vasoconstriction and compromised immune response associated with tobacco use are now considered when evaluating a patient`s periodontal status, as well as when planning treatment. Changes in the periodontal probe, both manual and automated, have enhanced the data collection skills of the hygienist. New diagnostic tests are becoming available, which will further enhance data collection by the hygienist.
Data is analyzed as a whole rather than as separate pieces, providing a complete picture of periodontal status and treatment prognosis. We have seen a transition from a prophy for every patient to four quadrants of root planing for all periodontal patients. The transition includes individualized therapy based not only on the level of disease present but also on the immune potential of the patient as well as their commitment to daily disease control and regular supportive care.
Therapy has shifted from root planing to debridement, a shift necessitated by findings demonstrating the superficial association of bacterial endotoxins and root surfaces. No longer are hygienists instrumenting every surface of every tooth.
Instead, debridement therapy is site specific. Too much instrumentation with curettes can easily lead to root sensitivity, an unnecessary and unpleasant side effect of our best intentions. I know I am guilty of producing my share of sensitive roots.
Not too long ago, thorough removal of cementum was considered essential for periodontal healing. Now, with more information, we know that such diligent instrumentation was not the direct cause of tissue healing. Removal of superficial layers of endotoxin, not cementum itself, results in healthy periodontal tissue (without the risk of root sensitivity).
Despite many years of being relegated to the task of gross scaling, mechanical instruments are now considered the primary tools for removal of bacterial plaque and calculus. The design of new thin tips as well as the development of new mechanical scalers has broadened the scope of use for these instruments. This change is seen not only in practice, but also in dental-hygiene educational programs. Research by dental hygienists will likely decide the future focus and designs of mechanical as well as hand instruments.
The term home care, which some people associate with dusting and vacuuming, was changed to plaque control. However, plaque control focused attention on the plaque and not on the disease caused by the bacteria, so the terminology shifted again to disease control.
Removing visible plaque is not enough to control and prevent periodontal disease. The distinction between attached and loosely attached bacterial plaque has provided a broader focus, one which is based on tissue response as well as removal of attached plaque. The old idea of brushing and flossing for each and every patient has been replaced by an interproximal approach to disease control. Since periodontal problems generally begin between the teeth, hygienists now focus first on that area for debridement as well as disease-control instructions. We must select and recommend to the patient an interproximal tool which best fits their needs and lifestyle.
Floss is still a good choice for prevention in young people, but periodontal patients benefit more from interdental sticks, interdental brushes, or water irrigation.
Supportive periodontal care (formerly termed recall as well as maintenance) has moved away from the six-month interval. Based on research, two-week, three-month, and 12-month intervals are the best choices, depending on the needs of each patient individually. Instrumentation during these visits has changed as well, focusing on subgingival deplaquing with thin-tipped, mechanical scalers, rather than using curettes on all surfaces of all teeth. Individualized attention has replaced the cookbook approach to periodontal care.
A recent innovation which got its start in the pages of RDH is participation of our readers in clinical periodontal research. Several readers collected data on the accumulation of mandibular lingual calculus both before and after instructing patients to brush the lingual surfaces first with a dry toothbrush. Knowing that people generally spend most of their brushing time on the facial surfaces, leaving very little time for lingual brushing, it is clear that simply changing the pattern of brushing would significantly reduce supragingival calculus accumulation on the mandibular lingual surfaces.
Although the outcome may seem obvious to all of us, this information has never been published before, thus, providing an opportunity for our readers to contribute to the future research base of dental hygiene. The data collected by our readers has now been analyzed and the results will soon be published in a research journal, followed by a story in RDH on reader participation in the research project.
Just as we have seen many changes and advancements during the past 15 years, we will look forward to many new and exciting adventures in the future. RDH will continue to provide the clinicians? view of changes and advancements. You may be reading them along with me, or you may be one of those who has what it takes to make the changes and direct the future of our profession. It is an exciting time to be a dental hygienist. I look forward to what the future holds for us.
Trisha E. O`Hehir, RDH, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.