Trisha E. O`Hehir, RDH
Have you ever been in a situation where your knowledge of periodontics has been challenged? Where someone has stated, for a fact, something you have never heard before? When someone in your dental community has pointed out to you a technique or situation you have never heard of before? Do you begin to question your own knowledge of periodontics, thinking this person surely is an expert and should be believed? It has happened to us all, at some time or other.
My suggestion in this situation is to remember your position as the periodontal expert in your practice. You can always add new information to your knowledge base, but that doesn`t mean that others always have the answers and you don`t. You are, after all, the perio scholar in your office!
You may be wondering how you suddenly became the perio scholar in the practice. Some of you took on the position willingly. Others feel the position is delegated to them by the dentist. Others may not even realize that the position is an opportunity for them right now.
The dental hygienist in the general dental practice is the most likely person in the office to read periodontal news and research, as well as to attend continuing education courses on periodontics. The hygienist is also the one providing the majority of periodontal care in the office. Therefore, the hygienist is the most appropriate person in the office to be considered the perio scholar and should be the one to share that knowledge and experience with the rest of the practice. The dental hygienist is the primary source of periodontal information for their practice.
The lessons of time can be cold, hard facts too
Our dental hygiene education has provided a strong knowledge base upon which we can build and add new information. Being a perio scholar requires continuous reading, learning, and questioning. And it`s lots of fun! Besides all the hard, cold facts about periodontal disease, we must learn to trust our intuition and our experience.
After all, research findings are sometimes years behind the experience of clinicians. The link between tobacco use and periodontal disease is a good example. Long before research confirmed the link and identified the cell-level changes attributed to tobacco use, hygienists knew from experience that smokers and smokeless tobacco users had fairly pink tissues, less bleeding than usual, but more periodontal disease than usual.
Hygienists also knew from experience that tobacco users were poor healers. These facts were confirmed over and over with each visit by a tobacco user. It was no surprise to hygienists when research studies finally confirmed the strong links between tobacco use and periodontal disease, as well as the associated compromised healing.
As perio scholars, we must also learn to question new information, especially when it doesn`t fit the picture. Before we assume the validity of someone`s statements, questions must be answered.
Here`s an example. A lecturer told a group that ultrasonic scalers should not be used on pregnant women. Before accepting this statement and incorporating it into practice, ask a few questions. Why does the person making this statement believe it to be true? Next, is there any proof? What studies have been done on the subject? What were the findings?
Here is a catch. The absence of research does not necessarily make a statement true. Since ultrasonic scaling research does not include pregnant women or children, it cannot simply be assumed that these instruments should not be used on these two groups of people.
It can also be argued that there is no documented research to support the use of ultrasonic scalers on pregnant women and children. However, we can use our knowledge, experience, and yes, even intuition in this case. On how many pregnant women and children have you used a power scaler without apparent problems? How many pregnant patients have you followed for several years without the appearance of delayed problems? How many pregnant patients have actually benefited greatly by the use of an ultrasonic scaler? Several research studies confirm an increase in subgingival bacteria during pregnancy, suggesting the importance of effectively deplaquing subgingival areas.
Next, what about the medical use of ultrasound on pregnant women?
Of course, medical ultrasound is not exactly the same as our power scalers, but the fact that ultrasound is used as part of routine evaluation of pregnant women provides us with some information. In children, ultrasound has been used experimentally to enhance bone healing around orthodontically moved teeth. We must put together what we know on a subject and then ask more questions.
Let the questions flow
Here is another example. You may have heard someone say that the pulsed-flow oral irrigation is better than direct-flow irrigation, based on the Bernoulli Principle. Before you take this idea and tuck it into your bag of perio tricks, ask several questions. Be sure you are convinced, one way or the other.
First, ask why the person making the statement thinks this is so and then ask for the research to support the claim. You may also want to look up the Bernoulli Principle in a reference book.
In the meantime, ask yourself if the principle makes sense, based on your knowledge and experience. How does it fit with what you already know? This is not to say that you won`t add to your knowledge, but first check your current knowledge base.
See what you already know on the subject. Chances are it is quite a bit! We know that oral irrigation does not remove attached plaque, but it does remove loosely adherent plaque from subgingival areas. We also know that subgingival irrigation reaches, on average, 80 percent of the depth of a pocket.
The most common oral irrigator is the Water Pik, which uses a motor and produces pulsed-flow irrigation. The Water Pik has also been used most often in the research. Based on that fact, we cannot simply assume the findings from a pulsed-flow irrigator can be equally extrapolated to a direct-flow irrigator. It appears that we need more research in this area. It would be interesting to repeat the classic irrigation studies with a direct-flow irrigator to see if the results are different. My guess is they would be quite similar.
It has been suggested that pulsed-flow irrigation has the potential to draw bacteria out of the pocket better since the breaks between pulses of water create a vacuum.
Sounds good, doesn`t it? Now the first question - is it true?
If it is, does it apply in this case? If it does apply, is it clinically better than direct-flow irrigation? We use direct flow with both power scalers and in-office irrigation. Is direct-flow irrigation adequate for removing subgingival loosely adherent bacterial plaque, or is pulsed-flow irrigation far superior? If pulsed flow is better, why has it not been adapted to other procedures? And why is there no research to confirm this advantage?
I don`t have the answers to all these questions, but based on what I know and what I`ve read, there are more reasons to use power scalers on pregnant women than to avoid it. The same is true of subgingival irrigation. Whether it is pulsed flow or direct flow, subgingival irrigation provides tremendous benefits to the patient.
Questioning the information source may reveal an underlying fear of legal action. Some statements are made simply to prevent the possibility of being sued. In the past, power scaler companies made statements restricting the use of ultrasonic scalers to supragingival areas, a statement based on legal advice, not scientific evidence.
It seems to me that being a perio scholar also means being a detective. Every time you answer one question, it leads to two more. There are always more questions than answers.
Remember, you`re the expert! Trust your knowledge, experience, and intuition. And then start asking questions.
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.
At any point in a tube through which a liquid is flowing the sum of the pressure energy, potential energy, and kinetic energy is constant. If p is pressure; h, height above a reference plane; d, density of the liquid, and v, velocity of flow,
p + hdg +1/2 dv2 + a constant
Is direct-flow irrigation adequate to remove subgingival loosely adherent plaque, or is pulsed-flow far superior?