A personal, high-tech tutor

May 1, 2002
When I worked in Switzerland, my periodontist employer would call me into his operatory to see the results of my instrumentation.

When I worked in Switzerland, my periodontist employer would call me into his operatory to see the results of my instrumentation. In a quadrant undergoing flap sur gery, he would point out all the pieces of calculus that I missed. As a young, inexperienced hygienist, I was sure I was the only one missing so much calculus.

Although a humbling experience, my clinical skills did improve with this form of tutoring. It took me awhile to figure out that, despite this tutoring, I would never see a quadrant undergoing surgery with no calculus. If I were that good clinically, the patients wouldn't need surgery!

Besides my Swiss periodontist tutor, I've watched, worked with, and learned from many clinicians and educators during my career. Clinical study clubs provide an environment for improving our clinical skills. Patients themselves are great tutors, without even realizing it.

I've also had the opportunity to tutor several hygienists preparing for state board examinations. The very idea of taking a state board several years after graduation will prompt hygienists to seek tutoring.

Most of my tutoring time is spent teaching hygienists to find deposits, rather than remove them. If we find the calculus, we can figure out a way to get it off. Good instrumentation skills are of no use if the calculus remains undetected. Find ing it is the first step.

Periodontal instrumentation is performed blindly by hygienists, using only our tactile sense to detect subgingival deposits. Some hygienists are better at this than others, as you would expect. Some of us just figure that if we spend enough time and the surface feels smooth, we're bound to be successful. If we've spent the time and the pocket doesn't heal and the tissue continues to bleed, we conclude it's time to place a local antimicrobial or refer the patient for surgery.

Now, here is an interesting finding in the research on this topic. Local drug-delivery systems are tested on perio patients with pockets and bleeding remaining after instrumentation. The control quadrants receive additional instrumentation and no drug placement. These areas always show clinical improvement! Because we're working blind, we never know if the cause of the infection is removed. That's why reinstrumenting areas that have not healed can result in further healing. It would be interesting to compare local drug delivery to improved clinical skills through tutoring. If simply reinstrumenting sites results in some healing, what would the clinician be able to accomplish with improved clinical skills?

Some of you have probably worked with a tutor, coach, or consultant to improve your clinical skills. All hygienists could benefit from the advice of a tutor now and then. The problem is there are not enough tutors, coaches, consultants, or clinical study clubs to go around. So let's look at a high-tech alternative.

Just imagine being able to see what's in a pocket. Imagine having a camera on the end of your probe, curette or power-scaler. Imagine looking at a magnified image of subgingival surfaces, actually seeing the calculus and our instruments at work, watching to see if the blade has been adapted and checking to be sure the stroke you are using really removes the deposit. It seems like science fiction, but it's not. For less than the price of other high-tech tools in your practice right now, hygienists can have subgingival endoscopy. It's like having a personal tutor all the time!

Industry uses endoscopy to check pipes and machinery, saving millions of dollars by early detection of problems. Medicine has used endoscopy for many years, looking into various orifices and moving the tiny camera over what seems to be miles of our internal highways and byways. My own experience with it is limited to the obligatory sigmoidoscopy after reaching my 50th birthday. It wasn't the most pleasant procedure, but watching the screen as the lining of the colon was evaluated was fascinating ... well, at least I thought so!

Now, endoscopy has moved into dentistry, specifically for hygienists, with the Perioscopytrademark System from Dental View (www.dentalview.com). Dental View has been working on it for several years, refining the camera and screen and adapting the camera to different instruments. After all these years of performing periodontal instrumentation blindly, it's just amazing to see what you're doing in a pocket!

The Perioscopy System is not used for all your routine instrumentation, but recommended for areas that haven't been resolved with traditional therapy. In the past, we've offered nonsurgical therapy as a preliminary step before periodontal surgery for pocket elimination. We've been able to eliminate pockets in some areas, reducing the need for surgery. Now, we can predictably offer a successful alternative to pocket-elimination surgery.

To achieve consistent success, we need the help of a tutor or coach to improve our instrumentation skills. Perioscopy is the high-tech tutor we need to achieve success each time we offer nonsurgical therapy as an alternative to surgery.

When you provide nonsurgical therapy, what is your treatment goal? My goal is to eliminate pockets and reduce bleeding - no measurements over three millimeters and no bleeding points. That's my goal. I don't always achieve that goal, but the closer I come to it, the better I feel. I don't give up until I eventually reach that goal.

The Perioscopy system gives us the technology to predictably reach those goals. When sites measure four millimeters or more and bleed, something needs to be done. The first step is a Perioscopy evaluation of the pocket to determine the cause of the infection. The camera/probe allows us to look at the root surface, into furcations, and to evaluate the pocket wall. Looking at a screen, the image is enlarged 24 to 48 times. Both hygienist and patient now can see the cause of the infection and discuss treatment to eliminate the problem.

Two-hour treatment appointments are suggested with the Perios-copy System, allowing enough time to achieve clean surfaces. It isn't an attempt to remove all the cementum - as we used to do with root-planing - but, the calculus is removed and all bacterial biofilm is removed. This isn't the traditional goal of smoothing root surfaces, but achieving a surface smooth and clean when viewed at 48 times magnification.

Gail Myers is the hygienist expert with this technology. Not only has she been instrumental in guiding the changes in design, she has completed and presented research on this technology and designed the clinical-training program new purchasers go through to make the most of their investment. With this new technology, she's moving the profession into an entirely new dimension. The potential is quite exciting. Just imagine ellipse future students will learn subgingival instrumentation with direct vision - no more blind scaling!

I'm looking forward to seeing the Perioscopy System adapted to the O'Hehir Debridement Curettes, currently available from Thompson Dental, Hu-Friedy, and Hartzell. These tiny spoon blades are like having just the toe of the curette, without the unused portion of the blade that makes subgingival access so difficult. You probably think I'm making a fortune every time you buy a set, but that's not the case - having my name on the curettes is payment enough. Although a bit biased, I'm sure these instruments will be perfect with the Perioscopy System.

If you want to move your clinical skills to the next level and provide predictable, successful nonsurgical therapy, consider your options. You can join a clinical study club and learn from other hygienists, hire a tutor or consultant who can evaluate your clinical skills and refine your technique, or you can look into the purchase or lease of a Perioscopy System ... and have your own full-time tutor!

Trisha E. O'Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics. 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].