by Lynne H. Slim, RDH, BSDH, MSDH
My Aunt Alice is a storyteller and I think I’ve inherited her storytelling gene. More than anything, I love to tell stories about experiences I’ve had with patients or strangers, so I’ll tell you a couple of them and try not to bore you in the process. Many years ago, my husband and I relocated from New Jersey to Atlanta. We were thrilled to be able to purchase our first house and like most young couples, we dreamed big dreams. My husband, David, is from England and initially struggled with the Southern culture, but found Southerners to be very friendly and outgoing.
One Saturday while we were working around our new house, the front doorbell rang and I opened the door to a stranger. He was a rather plain-speaking country fellow with overalls, a friendly face, and a booming voice. His rickety old Chevy pickup was parked in the street brimming with firewood. He was anxious to sell us a cord or two, and we obliged him. My husband took a liking to the fellow and he came back a second time with his entire family squeezed into the front of his truck.
David and I were introduced to each family member, and the man was very proud that we took notice of his kinfolk. I noticed during this visit that when he spoke, he sounded like he had a bunch of marbles in his mouth. I got up the nerve to ask him about it. No sooner did I ask when he suddenly, without any warning, stuck out his tongue and I nearly fainted. It was the biggest tongue I’d ever seen, loaded with blood vessels so the entire tongue was bluish purple. I recalled anatomy and recognized it as macroglossia. The sad thing is that the man told me his tongue was growing even bigger and eventually the experts predicted he would no longer be able to contain it in his mouth. Surgery to reduce the size of his tongue at that time was out of the question because he was told he would bleed to death.
My second story relates to this column, so please bear with me as I share one of my success stories with an appreciative patient. About two years ago, I saw a middle-aged, male patient for the first time. Mr. Ed (fictitious name) was friendly, but a bit anxious and ready to tell me his woes. I’m a good listener and was eager to find out what was troubling him. He had already been through two rounds of periodontal surgery and was an active patient with a local periodontist. The periodontist had diagnosed him with aggressive periodontitis, and he was taking Periostat b.i.d. as directed. I questioned him about his home care and he rattled off the usual names of several oral hygiene home-care implements that hygienists associate with good oral hygiene, such as the interdental brush, rubber tip, dental tape, and power brush. This patient was new to me but had been in this particular general dental practice for several years.
I reviewed the recare letters from the periodontist’s hygienist, and she noted that he was maintaining well with good home care on each of about a dozen reports. The patient was very nervous in my chair and was convinced he would lose his teeth in spite of two rounds of full-mouth periodontal surgery. Mr. Ed cried when he told me that he feared losing his teeth, and he wanted me to give him hope. In performing a comprehensive periodontal exam, I noticed immediately that he was still healing from the second round of surgery.
What shocked me the most, however, was my immediate impression that his home care was poor. Upon disclosing, I found significant amounts of biofilm along the gingival margin and interdentally, though he insisted that he was using his brushes and rubber tip according to directions. I told him I thought I could help but that I would need to see him a couple of times for detailed home-care instructions. My immediate thought was to focus on a new home-care procedure that would be easy to implement. So I sent him to the pharmacy for an oral irrigator and told him to purchase a bottle of 10 percent povidone iodine. I also told him to irrigate with a diluted povidone
iodine solution (one part povidone iodine to nine parts water) once a day and return in a month. (I prefer diluted povidone iodine to other antimicrobial agents because of its broad-spectrum antimicrobial activity, low potential for developing resistance and adverse reactions, wide availability, ease of use, and affordability.)
A gamble with povidone iodine
I was a bit concerned about recommending povidone iodine because I had heard it was not approved by the FDA for intraoral use, and its safety as a self-applied adjunctive irrigant was not established. I decided to recommend it for a short time in an effort to heal his surgical wounds. When giving oral irrigation instructions, I always recommend a cannula-type tip for patients with moderate to deep pockets rather than the standard tip that does not penetrate as deeply into the pockets.1
When Mr. Ed returned the next month, there was marked improvement in surgical wound healing, and for the first time in a very long time (I’d say 10 years or so), Mr. Ed felt encouraged. Neither he nor I could fully comprehend the dramatic change from inflamed, bleeding gingival tissues to a healthy and firm condition.
What caused this change in tissues from diseased to healthy in such a short time? Most of us understand that elimination or adequate suppression of periodontopathic bacteria in subgingival microbiota is absolutely essential for wound healing. According to the literature, conventional mechanical root debridement (and pocket reduction surgery repeated twice in this case) does not eliminate all periodontopathic bacteria from the subgingival ecosystem.2 Sites with deep periodontal pockets, grooves, furcations, and concavities are difficult to access with periodontal instruments, and periodontal bacteria can even invade dentinal tubules and live on the mucosa, tongue, tonsils, and gingiva.2
In Mr. Ed’s case, I theorized that the povidone iodine (which is a broad-spectrum antimicrobial) suppressed the bacteria that assist in the formation of soft-tissue biofilms. Supragingivally, biofilms form on a single surface, but subgingivally they form in three areas: on the tooth side of a pocket, on the epithelium lining of the pocket, and within the pocket, which is the loosely adherent plaque zone where the antimicrobial can easily destroy and wash away periodontopathogens that are not caught up in thick intracellular matrix.
I explained to Mr. Ed that we were trying to remove “gum bugs” that make up a sandwich between the teeth and under the gum line. These periodontopathogens live in and around the two slices of bread in a sandwich. (Not very appetizing, that’s for sure!) The tooth side of the pocket is one slice of bread, the pocket epithelium is the other slice of bread, and the loosely adherent plaque is located between the two. You can call it peanut butter or jelly, but make sure the patient understands it’s a layer filled with bacteria.
Comments about home irrigation
Author J. Slots recommends using household bleach for home irrigation at one teaspoon bleach to two large drinking glasses of water, and he recommends irrigating at a high pressure setting.3 If you explain to patients that they will not taste the bleach and that it’s no different from water in a swimming pool, they will be more amenable to trying this antimicrobial as an adjunctive agent.
Should all patients with periodontal diseases irrigate at home? This is a difficult question because many periodontal patients remain stable by adhering to a strict three to four month periodontal maintenance regimen and good sulcular and interdental brushing techniques. Patients with poor oral hygiene will benefit most from home oral irrigation, which also aids in wound healing, like it did in Mr. Ed’s case.
Oral health-care professionals recommend various antimicrobial agents for personal subgingival irrigation, and some insist water alone is useful. The American Academy of Periodontology reports that adjunctive oral irrigation is associated with a significantly greater reduction of proinflammatory cytokines (interleukin 1b and prostaglandin E2) in the oral crevice than oral hygiene without irrigation.4 This is another theory to consider when recommending personal oral irrigation.
For patients with moderate to deep periodontal pockets being maintained nonsurgically, be sure to recommend a good quality oral irrigation system that comes with a cannula adaptor that is long and thin enough to penetrate into deeper areas of periodontal pockets. Teach adult patients with periodontitis to scrub away subgingival biofilm (the sandwich bread) with interdental brushes that are customized for each patient, and use an irrigator to wash away the loosely adherent plaque between (peanut butter or jelly). Rest assured these patients will never be able to eat a peanut butter and jelly sandwich the same way again!
On a lighter note: It was in 1890 in the United States that peanuts were first ground, processed, and packaged as a paste for people with poor teeth who couldn’t chew meat.
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 Boyd RL, et al. Comparison of a subgingivally placed cannula oral irrigator tip with a supragingivally placed standard irrigator tip. J Clin Periodontol 1992; 19(5):340.
2 Umeda M, et al. Effects of nonsurgical periodontal therapy on the microbiota. Periodontol 2000 2004; 36:98-113.
3 Slots J. Selection of antimicrobial agents in periodontal therapy. J Periodont Res 2002; 37:389-398.
4 American Academy of Periodontology: Position Paper: The role of supra- and subgingival irrigation in the treatment of periodontal diseases 2005. E pub: http://www.perio.org.