by Lynne H. Slim, RDH, BSDH, MSDH
We all have favorite patients and stories to tell about them. Mine are usually elderly and I savor the moments I spend with them, knowing that this month’s visit may be their last. I wish I could name names because this particular gent I’m about to tell you about is a gem; his is a life well-lived and his message to mankind about life’s meaning resonates with me. Mr. “Special,” as I’ll call him, tells me again and again that he has worked hard over the years to develop and nurture a close-knit family. Every week, the entire family (children and grandchildren) gathers together for a family meal or outing, and they all work in the family business too.
This message also brings to mind a book that my son gave me for Christmas; I have been reading portions of it from time to time, and it sits on my bedside table. The Purpose-Driven Life by Rick Warren has a chapter about the value of relationships for every religion, and the time-honored message is this: Life without love is a life not worth living. Relationships suffer in today’s world, and our preoccupation with work is the great enemy of our time. In that regard, the hours I spend with my MacBook can sometimes be a problem for my family and friends. I have to discipline myself to move off the couch and press the “off” button!
It’s expensive for me to travel around the country visiting oral health-care professionals, but it’s a way for me to cement new relationships. A recent adventure in Santa Rosa, Calif., and a visit to the home of Renee Marchant-Turner and family allowed me to do just that. In describing Renee, one adjective is appropriate: she is a successful change agent. When it comes to her professional development, Renee believes that change is essential if you want to get better at what you do. Change requires pushing the envelope, exploring possibilities, and taking risks. In getting to know Renee, I also recognized that she values the relationships she builds with complete strangers, many of whom she meets online in dental-related chat groups or at her ultrasonics course which I recently attended. She is a self-professed continuing-education junkie, who likes to travel to courses outside of California. Renee is also a founding member of a study club that has been meeting for 23 years! Like other hygienists I have written about in my column, Renee is multifaceted, larger than life, and committed to excellence in all aspects of clinical care.
The course I attended took place at the Santa Rosa dental practice of Dr. James Klim, where Renee is happily employed part-time. Believe it or not, she actually describes her job as “dental hygiene heaven,” because she is allowed to provide any and all services she deems necessary for her patients. Dr. Klim is very progressive and wants Renee’s hygiene department to mirror this progressiveness. Fortunately, dental insurance is not a concern in this high-end practice where patients are used to paying for services rendered. Dr. Klim describes his practice as a gallery of fine smile design, and he offers esthetic, rehabilitative, and full-service dentistry in a comfortable setting. The reception area reminds me of an art gallery with life-size, award-winning photos of clients and a black, shiny, upright piano that enhances the high-impact interior design. Renee describes herself as a micro-ultrasonics instructor and a member of the ADHA.
We were a small class of about six students (myself included), and I learned pretty quickly that good clinical positions are hard to come by in the Santa Rosa area since the local junior college opened a dental hygiene program about six years ago. Most of the hygienists who were taking Renee’s course were already using ultrasonics, but they wanted to learn some advanced instrumentation skills and finesse. One student in particular mentioned that she was taking the course because she didn’t want to retire from dental hygiene as a has-been!
Renee is very generous when it comes to sharing her favorite tools of the trade. She loves both her ergonomically designed operatory stool and her loupes, which she says “changed her work life.” She describes them as “expensive little buggers but well worth the price.” In addition to her loupes that she can’t live without, her real KA-CHING! is the combination loupes and an appropriate source of illumination.
Like Anne Guignon, Renee is a big fan of manually tuned magnetostrictive ultrasonics. She insists that the inserts last longer (sometimes up to six years), because the frequency can be adjusted by the clinician rather than the machine. An older insert can be tuned for proper frequency if you have a manually adjustable machine. Automatically tuned machines eventually lose the ability to make an insert vibrate as the insert begins to wear. It’s not necessarily the insert that fails; it’s the inability of the machine to make it vibrate properly for good deposit removal.
The course Renee teaches gives pointers on all types of ultrasonic scalers, including piezo and magnetostrictive. Renee works with the USI and Tony Riso manually tuned magnetostrictive ultrasonic units and the J. Morita piezoelectric ultrasonic unit during the course. The USI is more expensive than the Tony Riso, and the J. Morita piezo is moderately priced like the Tony Riso. Renee points out that Clinical Research Associates rated the USI as number one in the industry in 2003.1
One of Renee’s challenges in teaching ultrasonics to dental hygienists is to get them to lighten their pressure against the tooth and stop fulcruming, using a light finger rest instead. This allows the instrument to remove deposits unimpeded.
Renee begins the clinical portion of her course clad in a pink froufrou costume complete with tiara, announcing that she is proud to be an “ultrasonic princess.” As an added bonus, one of the course participants that day was Jeanne Godett, RDH, who teaches low-level diode laser therapy at the Las Vegas Institute. We were all eager to learn about combining ultrasonic technology with laser pocket disinfection and reduction. Renee uses a diode laser to disinfect pockets in her clinical practice, and she is fast becoming an innovative clinician in this area. She has discovered that mechanical debridement (blended ultrasonic/hand scaling) combined with laser therapy produces better results than mechanical debridement alone. Renee understands that making a change from the current standard of periodontal debridement/disinfection requires a critical review of all the literature, and she is studying and practicing laser periodontal therapy at this time.
Renee has many opinions about magnetostrictive and piezo equipment choices due to her clinical experience with both technologies. Her opinion is that good ultrasonic instrumentation is 50 percent technique and 50 percent equipment. She likes both magnetostrictive and piezo technology and believes each has its place. She has discovered that when working on elderly or other patients who cannot tolerate much water spray, it is advantageous to use a piezo since it does not require water for cooling. Water is part of the treatment as cavitation is beneficial for bacterial reduction in the sulcus, but less can be used when the patient cannot tolerate it. Piezo technology does not generate heat the way magnetostrictive technology does, so the water does not warm up. This can be a good thing, but often patients have root sensitivity, so magnetostrictive technology would be a better choice since the water is nicely warmed by the friction produced in the insert stacks. Piezo requires more wrist bending to adapt the tip properly to the tooth for good deposit removal, which can cause an ergonomic problem. To counteract this problem, the clinician can use the straight, left, and right tips on all patients. This is where a good teacher, like Renee, can help you find the proper equipment to help both you and your patient.
Piezoelectric and magnetostrictive ultrasonic instrumentation are very effective at calculus removal both supra and subgingivally, but root surfaces can be damaged by ultrasonics if clinicians are not coached by someone who understands the nuances of tip designs and tip adaptation. Clinicians can damage root surfaces, especially with diamond-coated inserts, so Renee advises against using them unless the clinician is able to combine root instrumentation with perioscopy. Today’s magnetostrictive and piezoelectric units now have an extensive collection of inserts (wide and precision thin), and both technologies require extensive training and practice just as hand scaling does.
Reviewing the literature in an attempt to compare piezoelectric and magnetostrictive ultrasonic instrumentation, I found that there is no good evidence for choosing one over the other in current randomized controlled trials. Both technologies seem to produce similar results, and it appears that the choice of equipment depends on the operator’s personal preference or availability.
Piezoelectric technology is more popular in Europe and Canada than it is in the United States, but that may be changing now that some of the newer piezoelectric ultrasonic units have a better selection of tips for root adaptation. The missing piece is still a lack of available training in the use of various piezo tips. I’ve yet to see a CD from a modern piezoelectric unit showing the various inserts at work.
When using a piezoelectric unit, tip motion is usually linear, although some curved tip geometries do produce elliptical motion.1 Tip adaptation of piezo is different from tip adaptation with a magnetostrictive unit, with the sides of the tip doing more of the deposit removal. Piezo instrumentation is also more comfortable for the patient when the piezo tip is applied to the tooth.1
Mark Twain once said, “I’m all for progress. It’s change I don’t like.” Is this your approach to your career, or are you like Renee, who sets her mind to improve her skills? Develop your unique gifts and abilities, continue your professional growth, stretch your boundaries, and develop meaningful and lasting relationships along the way. It’s never too late to start.
P.S. You can reach Renee Marchant-Turner at her Web site: www.handsonhygiene.com.
Lynne H. Slim, RDH, BSDH, MSDH, is a practicing hygienist/periodontal therapist who has more than 20 years’ experience in both clinical and educational settings. She is also president of Perio C Dent Inc. (Perio-Centered Dentistry), a practice-management consulting firm that specializes in creating outstanding dental hygiene teams. Lynne is a member of the Speaking and Consulting Network (SCN) that was founded by Linda Miles, and has won two first-place journalism awards from ADHA. Lynne is also owner/moderator of a periodontal therapist yahoo group: http://yahoogroups.com/group/periotherapist. She can be contacted at [email protected].
1 CRA Newsletter reprint. Oct. 2003; 27(10):1-3.