Different strokes ...

Oct. 1, 2001
Different strokes ...

... it's the way this hygienist explains her methods to patients that is infuriating. She tells patients that she doesn't need to "scrape" their teeth anymore because the new technology is better.

Dear Dianne,
I work in a large group practicethat employs three doctors and five hygienists, all of whom are full-time. Recently, a new hygienist came to work in our office. She practices very differently from the rest of us, using the ultrasonic scaler exclusively. She never uses curettes and rarely uses a sickle scaler.

This hygienist's methods are in complete opposition to the way I practice. I use hand instruments almost exclusively and rarely use my ultrasonic scaler. My tactile sense is better with hand instruments, and I do a better job for my patients. Besides, I don't like dealing with the water spray and sensitivity issues that are inherent with ultrasonics.

But it's the way this hygienist explains her methods to patients that is infuriating. She tells patients that she doesn't need to "scrape" their teeth anymore, because the new technology is better. The other hygienists and I worry that patients may misunderstand and think we are not utilizing the latest technology. We all feel that it is sometimes necessary to "scrape" the teeth and root surfaces to rid them of plaque and calculus. In fact, this was the basis of my dental hygiene education. I was taught that ultrasonics are used only on patients with heavy calculus.

I don't want to initiate a confrontation. However, our treatment methods are so different that patients are bound to notice. And I am concerned that patients are not getting good care. Who is right? How can we bring our treatment paradigms into closer alignment?

Hand Scaler in Hattiesburg

Dear Hand Scaler,
You asked who is right — you, or the new hygienist. The answer is: Neither! Much of what you feel to be the best treatment for your patients comes from when you graduated from hygiene school. Those of us who graduated before the 1990s were taught to be hand-scaling purists. Instructors placed a heavy emphasis on perfecting hand scaling techniques; ultrasonics were reserved for removing heavy deposits of calculus. The ultrasonic tips back then were big and bulky, and could only reach into the sulcus about 3 mm.

Several years ago, there was a general consensus that the mechanical irritation from calculus caused periodontal disease. Removing every speck of subgingival calculus was considered absolutely necessary, as was a glassy, smooth root. We even did a procedure called "root planing" that involved removing some of the cementum from the roots in order to eliminate bacterial endotoxins. We held that a competent clinician should be able to detect any and all subgingival deposits with an explorer and subsequently remove them.

We now understand that many of these old beliefs are myths. We know that periodontal disease occurs when bacterial pathogens overwhelm the host immunity. Calculus is merely a sanctuary and breeding ground for bacteria. Modern modalities for periodontal therapy focus on bringing the periodontal pathogens under control through debridement and adjunctive therapies. A clinical study from 1990 demonstrated that skilled clinicians were wrong 50 percent of the time when attempting to detect residual calculus on root surfaces after scaling (Sherman, P.R. et al., The effectiveness of subgingival scaling and root planing. Clinical detection of residual calculus, J. Periodontol, 1990, 61:1, p. 3-8).

We also know now that ultrasonic instrumentation is as effective as hand instrumentation. The new slimline and ultra-thin tip designs allow access into areas (such as furcations and deep crevicular areas) that were inaccessible before. Ultrasonics have several advantages:

  • Minimal iatrogenic damage to root surfaces
  • Detoxifies the pocket through the cavitational effect of the tip
  • More effective in removing plaque in the pocket.
  • Less stress on the hand
  • Less tissue trauma and faster healing time
  • No sharpening needed

Adjusting the power setting to a lower range can usually eliminate ultrasonic sensitivity. Patients can be just as sensitive with hand instrumentation, especially if cementum has been removed previously.

Hand instrumentation, however, still should have a place in the treatment of periodontal disease. To deliver the best care to our patients, we should use a combination of hand instrumentation and ultrasonics. In hygiene school, our students are taught that the two go together, and that both are necessary for thorough debridement.

Periodontal maintenance patients benefit significantly from ultrasonics, especially those with pockets 5 mm and above. Ridding all sulcular areas of periodontal pathogens in both loosely attached and unattached plaque provides greater benefit than hand scaling alone. The thin and ultra-thin tips are excellent for this purpose.

You mentioned water spray as a hindrance. Of course, there are ways to cut down on splatter. A dedicated assistant providing high-evacuation suction is the ideal method of splatter control. Hygienists can also reduce spray by setting the lavage at the proper level.

Face towels with a two-inch hole in the center are also available. These towels are machine washable and have a see-through mesh across the patient's eyes; they are also wonderful for protecting a female patient's make-up [Practicon, Inc. (800) 959-9505].

Your concern that patients may misinterpret the new hygienist's communication is valid. Every team member within a practice needs to be on the same page; no one should say anything that suggests one hygienist is providing better treatment than another. I propose that the hygienists in your office have a calibration meeting about patient communication. Tactfully let the newcomer know your concerns. However, be willing to incorporate some of her treatment strategies into your own protocol. The best treatment for our patients comes from a combination of hand scaling and ultrasonics.


Dianne Glasscoe, RDH, BS, is an adjunct instructor in clinical hygiene at Guilford Technical Community College. She holds a bachelor's degree in human resource management and is a practice-management consultant, writer, and speaker. She may be contacted by e-mail at [email protected], phone (336) 472-3515, or fax (336) 472-5567. Visit her Web site at http://www.professionalden talmgmt.com