I always enjoy hearing Dr. Connie Drisko speak on periodontics. Dr. Drisko was a hygienist for many years before going to dental school and specializing in periodontics. She wears many hats at the University of Louisville - educator, administrator, researcher, and role model. While giving an update on the latest research findings in periodontics at a recent symposium, she predicted that, in the future, hygienists would open little flaps to access pockets for debridement.
It wasn't her comment that surprised me as much as the reaction of the hygienists in the audience. They found this idea very appealing and quite futuristic. This took me by surprise, since hygienists in Arizona have been doing just that since 1976!
In 1975, Arizona law was changed to allow hygienists, with additional training, to administer local anesthesia, perform scaling and root planing, do surgical curettage and place and remove sutures. This may sound futuristic in states that have not legalized local anesthesia for dental hygienists, but in Arizona, it's been in our practice act for more than a quarter of a century, thanks to a futuristic periodontist.
Estimates in 1969 put the cost of prevention and treatment of periodontal disease at $2.33 billion. With fewer than 2,000 periodontists in the country at that time, it was clear that general dentists would be needed to handle the huge public health problem. However, dentists preferred to do restorative work, not periodontal. Based on those facts, the dental hygienist was considered the primary preventive therapist in periodontics. It was suggested that dental hygiene education needed to change accordingly.
The idea of the expanded functions hygienist was to provide non-surgical therapy to patients in general practice, thus increasing the number of periodontal patients receiving treatment. This concept was the inspiration and hard work of Dr. Perry Ratcliff, a periodontist and Professor Emeritus from the University of California at San Francisco who retired from teaching to practice in Arizona.
I was in the first "expanded functions" class, as it was called back then. Now all of these duties, with the exception of placing sutures, are part of the general duties of dental hygienists in Arizona. But back in the mid-1970s, we were required to take a 10-week, full-time course load to qualify for these duties. We registered for both summer sessions at Northern Arizona University in Flagstaff, where we attended classes from 8 a.m. to 5 p.m., evening classes the first week, plus lots of homework. Most of us had been out of school for quite awhile and found the course work grueling, to say the least.
It was also an expensive endeavor. Most of us were not from Flagstaff. So we had to move into the dorm, go without a paycheck for 10 weeks, and pay tuition, room and board. Despite the great expense, we saw it as an investment in our futures.
I had been teaching in the periodontics department at the University of Minnesota the previous three years, so I was quite confident that I knew at least what dentists knew about perio. Boy, was I in for a big surprise.
Besides courses in histology, perio and pathology, we studied biochemistry and cell biology associated with periodontal pathogenesis. Back in the 1970s, it was quite a novel idea to focus the basic science courses on clinical observations, treatments and outcomes. The instructors were excellent at connecting the dots between concepts like the Krebs Cycle and the breakdown of pocket epithelium.
It was the first truly integrated program I ever experienced, where basic science and clinical experience came together to provide a complete picture. I felt sorry for all those dental students who simply memorized information, never really being given an opportunity to put it all together. No wonder so many dentists have bad memories - or worse yet - no memories of their dental school perio courses.
We began the 10-week program as dental hygienists. But after the intensive perio study, both in the classroom and the clinic, we emerged as periodontal therapists. Despite the fact we did surgical curettage and placed sutures, we were providing "nonsurgical" or conservative therapy. As long as we didn't reflect tissue off the bone, it was considered "nonsurgical."
We instrumented the roots until glassy smooth surfaces remained and the tissue returned to health. Remember, this was in the 1970s, when complete cementum removal was the goal. Surgical curettage was used to open up the interproximal areas, gaining visual access to the root surfaces. Access for instrumentation was easier and we could treat the root surfaces with citric acid to remove the organic matrix, allowing for connective tissue reattachment. We also made a tetracycline paste to put in the pockets. Following these procedures, we sutured the papilla back, using a figure 8 suture to pull the papilla up, rather than flattening them down.
The results were phenomenal. We were able to routinely treat 8 to 12 mm deep pockets. I remember one patient I treated with a 13 mm pocket that reduced to 3 mm. The other hygienists in that first class all have similar stories. Looking back, it is clear that the most important part of this experience was not the course work or even the clinical skills we learned, but the belief Dr. Perry Ratcliff had in hygienists to achieve incredible things. He really believed we could treat deep pockets and get results comparable to pocket elimination surgery. And we did!
His belief in us allowed us to reach goals we never could have imagined. We left that program with the confidence to go back to our practices and change the face of dental hygiene forever. For awhile, we made those changes one patient at a time, but then many of us continued on as educators, spreading the "gospel according to Dr. Ratcliff" both near and far. There are hygienists all over the world who have been influenced by the "Ratcliff Approach" either directly as graduates of the Arizona program, or from the many "Expanded Functions Hygienists" who include this message wherever they give continuing education courses.
2002 marks the 26th year since that first expanded functions program in Flagstaff. A few of us got together in June, and it's surprising how many are still practicing - it never gets boring when your philosophy keeps moving you to greater heights.
One universal experience we all identified is that dentists, in general, don't believe that we can get the results we do because they haven't gotten those results themselves and they've never seen anyone else do it. It only takes a few weeks to totally change that mindset. The first patient the dentist sees for restorative work after receiving this treatment convinces him of its potential. Dentists love to work with healthy, firm tissue that does not bleed.
Knowing that periodontal health can be achieved with conservative treatment is what keeps us going. We did it before the advent of local delivery products - so we know it's what every one of you do with your instruments and with your education. Dr. Ratcliff believed in us, and that made all the difference! I believe in you - you can achieve periodontal health for your patients beyond your wildest dreams. Keep learning, keep trying new things, keep believing in yourself. Don't settle for less than optimal health. It is possible and you can do it!
Trisha E. O'Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter containing news about periodontics for dental professionals. The Web site for Perio Reports is www.perioreports.com. She can be reached by phone at (800) 374-4290 and by e-mail at [email protected].