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The Four-Pronged Approach

Dec. 1, 2011
The rapidly evolving role of the dental hygienist requires that we not only treat periodontal disease but also identify risks for the progression of disease ...

Nonsurgical periodontal therapy involves a no-options methodology

by Kimberly R. Miller, RDH, BSDH

The rapidly evolving role of the dental hygienist requires that we not only treat periodontal disease but also identify risks for the progression of disease, as well as medical/systemic or genetic contributing factors that may influence treatment outcomes. Additionally, the patients' willingness and ability to comply and follow through with their responsibilities to the success of treatment must be considered.

Once risk assessment, diagnosis, and prognosis have been completed, the process of treatment planning begins. In order to create effective treatment plans with outcomes aimed at disease remission and disease control, an objective step-by-step approach is essential. Using a four-pronged approach to treatment planning will assist you in pinpointing all the treatment options available to meet the needs of your patient (see Figure 1; this chart can also be downloaded for patient education purposes. Go to and search for "Kim Miller Four Pronged" to download Figure 1).

A four-pronged approach

Simply put, the four prongs of treatment translate to an all encompassing, comprehensive approach to treatment. The standard of care compels us to do everything in our power to assist our patients in controlling their periodontal disease. In keeping with the standard of care, the next time you treatment plan nonsurgical periodontal therapy for a patient, consider organizing the treatment into these four categories.

From the bottom up

Only you, the professional, can get to the bottom of each periodontal pocket in your patients' mouths. One of our primary roles is the mechanical removal of calculus and biofilm. Thorough root debridement can take up to six minutes per tooth and should be carried out with a blended approach that uses both hand instruments and power scaling.

In addition, the clinician may consider subgingival air polishing and laser bacterial reduction for biofilm destruction. The sequence of care would logically be calculus removal, followed by biofilm disruption.

Mechanical debridement of calculus and biofilm is essential to the success of nonsurgical treatment. Although calculus does not cause periodontal disease, its presence on the root surfaces provides greater surface area for the establishment of biofilm colonies and should be removed, to the best of our ability.

When using power scaling for calculus removal, it is important to select an insert or tip designed specifically for that purpose. While the slimmer instruments are very popular and highly effective for biofilm destruction, they are not designed for moderate to heavy calculus removal. When slim inserts and tips are used for calculus removal, the clinician runs the risk of leaving behind burnished subgingival calculus deposits.

Once calculus has been removed, the slim ultrasonic instruments are an excellent choice for the task of biofilm destruction. According to Baehni, Thilo, et al., microscopic counts (of bacteria) following ultrasonic/sonic instrumentation showed a decrease in the amount of spirochetes and motile rods. Their study showed that exposing the biofilm to ultrasonic and sonic vibrations for 30 to 60 seconds yielded the biggest reduction in pathogens.1

The following additional research supports the destructive nature of ultrasonic vibrations on periodontal pathogens:

  • "It is known that ultrasonic scalers operating at high frequencies generate so-called cavitation, a phenomenon known to have destructive effects." (Walmsley et al. 1984)
  • "Gram-negative microorganisms have been reported to be particularly sensitive to ultrasonication." (Leadbetter and Holt 1974, Robrish et al. 1976, Syed and Loesche 1978)
  • "Ultrasonic scalers were shown to have potentially destructive effect on cells. In vitro studies demonstrated these instruments could destroy spirochetes." (Thilo and Baehni 1987)
  • "There are bactericidal effects of dental ultrasound on Aa and Pg." (O'Leary, Sved, Davies, Leighton, Wilson, and Kieser 1997)

Other options for subgingival biofilm destruction include laser bacteria reduction and subgingival air polishing. Laser destroys the bacteria through dehydration; research has shown that the pathogens Aa, Pg, and Pi are significantly reduced when exposed to laser energy.2 Subgingival air polishing kills biofilm using a 25-micron hydrophobic amino acid glycine powder. Subgingival air polishing does not damage the root surface, is gentle on the epithelium, and is safe for use on implants.3 The hydrophobic nature of the glycine powder and the EMS delivery system (Perio-Flow) ensures that no powder remains in the pocket. Both laser bacteria reduction and subgingival air polishing are clinically proven procedures resulting in the destruction of biofilm.

From the top down

Compliance, of course, is the key to daily patient self-care. In order to get the patients' buy-in, make them partners in the treatment. Explain to patients that this treatment is a "four-pronged approach" and that they are completely responsible for one of the prongs. Their prong has a huge impact on the success or failure of the treatment. Ask the patient if they are willing to partner with you in the treatment of their inflammatory periodontal disease.

In addition to standard home care procedures such as power brushing, using a Waterpik, flossing, interproximal stimulation, antibacterial rinses, tongue scraping, etc., hygienists should also discuss smoking cessation (if applicable), a healthy diet, and compliance with any prescribed supplements or medications as part of the patients' responsibility to successful treatment outcomes. It's a good idea to be able to direct your patients to smoking cessation and nutrition programs in your local area.

From the outside in

Specifically targeting bacteria at the site of the infection using locally applied antimicrobials, medicaments, or gel in order to reduce bacterial biofilm colonies is an essential part of every nonsurgical treatment plan. Many patients view the use of these adjunctive procedures as a la carte, when, in fact, the standard of care supports the use of locally applied antimicrobials when managing a patient with chronic periodontal disease.4

Once again, explain to the patient that one of the prongs of treatment is the use of locally applied antimicrobials or specific medicaments to target the bacteria at the bottom of the pocket where they cannot reach. In other words, this is not an optional procedure. All four prongs work together, not independently of one another.

From the inside out

The last prong considers three specific adjuncts: nutritional supplementation, systemic antibiotics, and a collagenase inhibitor. All three fight periodontal disease from the inside out, and using one does not preclude the use of the others. In fact, for many patients, all three adjuncts may be beneficial.

We have always known when treating periodontal disease that nutrition counts! We now know that a relationship exists between low levels of antioxidants and poor periodontal health. This is important data when considering risk factors for the progression and medical systemic implications of periodontal disease. Poor nutrition must now be added to the list of risk factors we consider during the diagnosis and treatment planning of periodontal disease.

We can now screen patients for their antioxidant levels using Raman spectroscopy in a desktop device.5 When a patient under our care has even one risk factor for the progression of periodontal disease, we should be including the recommendation of nutritional supplements targeted to increase antioxidant levels. Most patients cannot achieve the antioxidant levels required to combat free radical damage through diet alone and, therefore, supplementation should be recommended.6

The patient whose salivary DNA test is positive for periodontal pathogens over the threshold may need a systemic antibiotic. OralDNA Labs has done a great job of pinpointing the antibiotic cocktail to best eliminate specific pathogens or groups of pathogens. A short, eight-day course of systemic antibiotics started after the final periodontal therapy appointment will help to eliminate the pathogens in the tissue.

During a subsequent periodontal maintenance appointment, the patient should be retested to be sure the pathogens have been eliminated.

With the same salivary sample, in a separate test, the lab can determine if your patient has genetic sensitivity to periodontal disease. This variable often explains chronically red, inflamed, and bleeding tissue in the presence of very little plaque and very good home care. In this example, the patient may be positive for interleukin-1 beta. In other words, the patient overproduces interleukin-1 beta, which plays a role in bone destruction and host immune response.

In the case of a PST-tested positive patient, consider the use of doxycycline 20 mg, twice per day (Periostat). This subantibiotic dose short-circuits much of the collagenase activity, slowing down bone loss. Patients can safely remain on Periostat for several months. The PST-tested positive patient is a perfect candidate for a two- to three-month interval between their periodontal maintenance visits, as recommended by the ADA.7

Taking a four-pronged approach to treatment planning ensures the consideration of all available treatment modalities, including the patients' responsibility to successful outcomes. Involve your patients in their periodontal care by explaining the "four-pronged approach" to treatment. It's simple and very straightforward; most patients will quickly see the logic and wisdom of this approach, and you will have gained their buy-in to be active participants in the success of their treatment.

Kim Miller, RDH, BSDH, is a partner of the JP Institute and a founder of PerioFrogz. As a graduate from Loma Linda University in 1981, she received a bachelor's degree in dental hygiene. In addition to clinical practice, Kim has been a consultant and trainer with the JP Institute since 1992, coaching more than 500 practices as well as teaching a hands-on curriculum.


1 Baehn T, Chapuis, Pernet. Effects of ultrasonic and sonic scalers on dental plaque microflora in vitro and in vivo. J Clin Periodontol 1992; 19:455-459.

2 Moritz A, Schoop, U, et al. Treatment of periodontal pockets with a diode laser. J Clin Laser Med Surg 1997; 15:33-37.

3 Petersilka G, Faggion Jr. CM, Stratmann U, Gerss J, Ehmke B, Haeberlein I, Flemmig TF. Effect of glycine powder air polishing on the gingiva. J Clin Periodontol 2008.

4 Paquette D, Ryan ME, Wilder R. Locally Delivered Antimicrobials: Clinical Evidence and Relevance. J of Dent Hyg 2008; 83; 6:10-15.

5 Hata T, Scholz T, Ermakov I, McClane R, Khachik F, Gellermann W, Pershing L. Non-Invasive Raman Spectroscopic Detection of Carotenoids in Human Skin. J of Investigative Dermatology 2000; 113, NO..3: 441-448 - For more information about AO screening for the dental office contact [email protected].

6 Chapple et al. The Prevalence of Inflammatory Periodontitis is Negatively Associated with Serum Antioxidant Concentrations. J .Nutr. 137;(3):657.

7 Greenwell H, Bissada N, Wittwer J. Periodontics in general practice: professional plaque control. JADA, Vol. 121, Nov 1990: 642-646.

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