... Try some variation of the current quadrant approach to instrumentation.
Trisha E. O`Hehir, RDH, BS
A patient who was apprehensive about undergoing conservative periodontal therapy pleaded with me to do it under general anesthesia. "Impossible," I told him, having never even considered such a possibility before. Since he was scheduled with the oral surgeon to have third molars extracted, the impossible became a reality. He talked with the oral surgeon, who was interested in the approach and agreed to the combined treatment.
After extraction of the third molars, I stepped in and did a full-mouth subgingival debridement. Since the patient was under general anesthesia, aerosols were not an option. Most oral surgeons use electric handpieces, not air-driven, so a sonic scaler was out of the question. The work needed to be done with hand instruments and in record time.
I felt like an Olympic scaler! With the help of two assistants, the instrumentation was completed in well under 30 minutes. Picture this:
> No air.
> No water, except what can be dripped from a hand-held bulb.
> A dry working environment with an efficient assistant using surgical suction. Great visibility.
> Total patient cooperation - the assistant moved his head to any position. No stopping for rinsing, spitting, or questions.
> Total anesthesia.
It was a dream! The original treatment plan included four, two-hour appointments, which had been condensed into less than half an hour. I was sure that I had missed huge deposits of calculus and plaque! The big surprise was yet to come.
When I saw the patient a few weeks later, I couldn`t believe the healing! He looked better than any of my traditionally treated patients! For years, I wondered why his results were so good. I thought perhaps the blood clots left in all interproximal areas provided a healing stimulus. He took postoperative antibiotics, but so had other patients, so it couldn`t be just that. I remained puzzled by it.
It wasn`t until I began following the research of Dr. Marc Quirynen in Belgium that I found a possible explanation. Dr. Quirynen and his colleagues wondered if doing subgingival instrumentation one quadrant at a time allowed the untreated quadrants to reinfect the treated ones. To test this theory, they developed the "full-mouth disinfection" approach to conservative periodontal therapy. They now have very interesting, long-term data on a couple of groups of patients. These results may change the way dental hygienists plan and carry out treatment. It definitely gave me some ideas about why my first experience with full-mouth instrumentation was so effective.
There are really two parts to the "full-mouth disinfection" approach. First, all subgingival instrumentation is completed within 24 hours - half the mouth on one day and the other half on the next day. Secondly, chlorhexidine is used immediately after treatment and daily for several weeks thereafter. I don`t mean just rinsing with chlorhexidine.
There also is 10 minutes of subgingival irrigation of the pockets with chlorhexidine gel, tongue-brushing with chlorhexidine gel, and tonsil-spraying with chlorhexidine. All of this is done in addition to twice daily rinsing with chlorhexidine. The subgingival irrigation is done by the clinician, but the rest is done daily by the patient.
The results are quite impressive! Compared to traditional weekly appointments for quadrant instrumentation, the Ofull-mouth disinfectionO approach was far superior. Although both groups showed significant healing, those receiving full-mouth disinfection experienced greater pocket-depth reductions, more gain in attachment, less bleeding upon probing, and greater reductions in bacteria. In the Ofull-mouth disinfectionO group, pocket-depth reductions for single- and multi-rooted teeth were 3.7 millimeters and 2.9 millimeters, respectively. Patients treated in the traditional quadrant approach showed reductions of 1.8 millimeters and 1.3 millimeters, respectively. Pocket depths were reduced an additional millimeter, almost two millimeters more using the Ofull-mouth disinfectionO approach compared to the traditional approach.
Now, the question you probably are asking ? was it the full-mouth instrumentation within 24 hours or the extensive use of chlorhexidine? That we don?t know. Other studies are needed to determine the effects of each part separately. Until those questions are answered, it?s worth trying all or part of the approach with your patients. Make your own comparisons.
Let?s see how this might work in practice. Next time you think about scheduling four quadrants of debridement therapy, try a couple of two-hour appointments on consecutive days. Or, do all four quadrants in one day. You?ve probably already had patients ask for that if they?ve had to travel some distance to your office.
Now, about the chlorhexidine use. In Europe, chlorhexidine is an over-the-counter product sold in many forms, including rinses, sprays, and gels. Our choices in North America are quite limited in comparison. Compounding pharmacies are on the increase, so you might be able to have these products made for you. Use chlorhexidine as the irrigant in your power-scaler. Be creative.
I would encourage both clinicians and dental hygiene students to try some variation of the current quadrant approach to instrumentation. You might be very pleased with the results. I?m sure patients would be happy to complete the therapy in a single day or two long appointments, or two days in a row, rather than stretching it out over several weeks.
With this new information on Ofull-mouth disinfection,O I wonder if my success with the patient under general anesthesia was due primarily to the lack of potential reinfection? It doesn?t seem likely that general anesthesia will become part of dental hygiene therapy any time soon, but the Ofull-mouth debridementO approach certainly is a possibility. These new findings have the potential to not only change the way we provide conservative periodontal therapy, but also the results we can expect. What do you think?
On another note E if you have worked in Switzerland ? or know of someone who has ? please get in touch with me for details on the June reunion in Colorado. Call me at (800) 374-4290.
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. Her e-mail address is trisha@perioreports. com.
