Changing paradigms

Dear Dianne, I received the July 2006 RDH today and your "Disparaging Remarks" advice column caught my eye.

Dear Dianne,

I received the July 2006 RDH today and your “Disparaging Remarks” advice column caught my eye. I am disappointed with some of your advice concerning dental hygiene.

I have been practicing dental hygiene for 21 years. I received a very unique dental hygiene education in that I completed four years of clinical dental hygiene education. I earned my certificate of dental hygiene from Forsyth School for Dental Hygienists, and received my BSDH through a post-certificate program at the University of Southern California. I arrived at USC assuming I would do didactic course work only to earn my bachelor’s degree. After my skills were evaluated, I was required to see only advanced periodontal patients for the next two years. Wow, what a difference those extra two years in clinic made in my clinical skills! I now believe that the profession of dental hygiene would advance and receive more respect from the dental community if it had a four-year clinical component requirement.

Afterwards, I earned my master’s degree, specializing in clinical education. I have taught dental hygiene ever since, and I have worked part-time in private practice to maintain my skills. I am very committed to staying current in the latest evidence-based trends in dental hygiene patient care. The program where I currently teach is the only program in my state to have the DentalView® Perioscopy system.

Back to my disappointment. The focus of perio maintenance remains the same whether power or hand scaling is used - the removal of calculus and biofilm are mandatory for healing. If the patient has new or residual calculus from incomplete instrumentation, the dental hygienist has the responsibility to remove that calculus. Even though low power feels better, it does not remove calculus. There are times when dental hygiene instrumentation hurts, no ifs, ands, or buts about it. I agree that pain control must be used to keep the patient comfortable, but gentle instrumentation instead of definitive calculus removal is malpractice in my book!

I work in a state where periodontal instrumentation is not taught to a standard that benefits periodontally infected patients. It is my experience that there are varying degrees of instrumentation skills taught in dental hygiene programs throughout the United States, and therefore not all dental hygiene graduates receive a “similar” clinical education. Students will only be as clinically competent as those who teach them, and I have seen lots of incompetent clinical instructors who can’t feel calculus, let alone remove it. So I beg to differ from your determination that dental hygienists are educated equally. Sorry, but that is what I’ve seen for 21 years, and it is only getting worse with the increase in community college programs that exist outside of dental schools.

The dentists in my state constantly remind my state dental hygiene association that dental hygienists receive only two years of hands-on patient care and dentists receive four. My dream is to open a dental hygiene program with a four-year clinical component and make a bachelor’s degree entry level mandatory for the profession. Time will tell.
Concerned Hygiene Instructor

Dear Concerned,

Your clinical experience early in your professional journey gave you some valuable training that many of your peers never have the opportunity to obtain. Additionally, Perioscopy is truly cutting edge technology that the vast majority of hygienists have never experienced. As with any new technology, there is a learning curve, and it doesn’t feel very user friendly in my hands (albeit my very limited experience with it). My opinion is that the parent company must work out some of the bugs, especially cost, if it is to become mainstream technology.

Further, I agree that all hygienists would benefit from an expanded educational component, both clinical and didactic. It really saddens me to hear about four-year programs closing. Besides my associate’s degree in dental hygiene, I have a bachelor’s degree in human resource management, which fits well with my consulting business. So I actually have six years of college.

I graduated in 1978 from hygiene school, several years ahead of the “soft tissue management” curve. However, I distinctly remember when that concept hit the scene, and hygienists were just learning how to treat periodontal disease in a non-surgical manner in a general office. Treating only one

quadrant per appointment with the patient being anesthetized was a new and radical concept in the early ‘80s.

The doctor I worked with then was very progressive. After attending a course in Chapel Hill taught by a periodontist, we implemented our first periodontal program. It was such a success that the doctor and I were amazed! It kindled a fire in me, a love of treating periodontal disease that came from the professional satisfaction of taking a patient from a state of disease to a state of good health. The doctor and I could see the dramatic change in the tissues, but most of all, patients were amazed and very appreciative of our efforts. So, my “expanded clinical education” came from baptism by fire in Thomasville, N.C., a virtual periodontal “Mecca” at the time.

One other noteworthy item is that this was the same time that Thomasville Furniture Industries introduced dental insurance benefits to its vast group of employees. Dentists all around the Thomasville area were slammed with new patients who had never visited a dentist unless they had a toothache.

Did my great results happen because I removed all the calculus? Was it “back-slapping, atta-girl” time because I was such a good scaler? Maybe that’s what I thought at first. But the fact is, we don’t ever get it all off, but we get some mighty good results even when we don’t!

We know now that periodontal disease is a bacterial (yeasts, fungi, and viruses have also been associated with it) disease, and controlling those bacteria is the only way to get the disease under control. The calculus is secondary, in that it does not cause disease but provides a sanctuary for pathogens. We also know that the outermost layers of the calculus are bacteria-rich, so removing those layers provides some benefit. Again, I’m not saying burnishing should be an endpoint (heaven forbid!), but the fact of the matter is, we often cannot detect calculus that has been finely burnished with a probe or explorer.1 Plus, plenty of microscopic evidence says our well-intentioned hand scaling roughens and gouges cementum and makes surfaces, even if calculus-free, a nidus for bacteria. Research often suggests we need to preserve the cementum. Very few hygienists today have the benefit of Perioscopy.

What about when we inadvertently remove cementum that opens up dentinal tubules right into the pulp, allowing bacteria to enter the pulp area? Could we be responsible with our overzealous hand scaling for the sequelae of nerve contamination or death in some teeth? Some researchers think so.2

Now, that doesn’t give license to hygienists to be sloppy with their scaling. We should remove as much as we can, but we can also cross the line into over-instrumentation of the root surface to cemental removal, which is detrimental to any hoped-for fibroblast reattachment. We’ve all seen those “hour-glass” shaped roots that have been over-instrumented from aggressive hand scaling.

Another great shift in nonsurgical treatment/maintenance has come with the improvements in power scalers, such as the thin tips that allow for greater access into the pocket. I agree that these tips are “wimpy” at removing tenacious calculus deposits. But they have been shown to be superior to hand scaling in deplaquing and removing biofilm in pockets, particularly deep pockets.3

Additionally, new technology is changing how we treat our periodontal patients today. On the cutting edge (couldn’t resist the pun!) are lasers. A search of the peer-reviewed journal, the Journal of Periodontology, reveals 10 citations in the top 30 in a search of the keywords “hand scaling.” My feeling is that as science catches up with technology, the use of lasers in treating periodontal disease will become more commonplace.

In treating the periodontal maintenance patient, the hygienist should be vigilant about removing new and residual calculus. However, if the patient is on a strict three-month or less disease control interval, there shouldn’t be a lot of new calculus deep in the pocket if the scaling was thorough initially. The emphasis should be on debriding/deplaquing the deep-pocketed areas where the anaerobes thrive that the patient cannot clean thoroughly. Power scalers are great for this. I beg to differ with your statement that low power ultrasonics cannot remove calculus. The new calculus is rather soft and easily removed with ultrasonics, even at low power. Dr. Esther Wilkins calls it “pre-calculus.”

Current thinking (Rams, Socransky, Loesche) is that specific microbes trigger the immune system. This, in turn, produces a cascade of inflammatory cellular products. The influx of inflammatory white blood cells and enzymes, not toxins or calculus, is responsible for the destruction of the periodontium. Therefore, removal of and controlling pathogens is the thrust today. Power scalers greatly assist with this task.

I taught in a dental hygiene school for a few years as well. I considered all my fellow instructors to be excellent clinicians and respected their gifts and abilities. Maybe my experience has been different from yours in that regard.

I maintain this premise: Any hygienist who thinks he or she gets all the calculus off while treating an advanced periodontal patient deludes him/her-self. Even periodontists who have the ability to lay the tissue back surgically will admit that they don’t get it all off.

One last point is that the hygienist who wrote me in the July RDH article was frustrated because another hygienist in the perio office disparaged the treatment protocol used in the general office and caused the patient - who was caught in the middle - concern and confusion. The periodontal hygienist behaved unethically. It is never acceptable to disparage another health-care provider to a patient, and the general practice hygienist had every right to be upset. This kind of thing happens too often. We need to support and collaborate with each other, not tear each other down.

I hope your dream of expanded education for hygienists becomes a reality. Thanks for writing. I really do appreciate your comments. I have no doubts that your clinical skills are impeccable, and your students are fortunate to have you.
Best wishes, Dianne

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or e-mail dglasscoe@northstate.net. Visit her Web site at www.professionaldentalmgmt.com.

References

1. The effectiveness of subgingival scaling and root planing. I. Clinical detection of residual calculus. J Periodontol. 1990 Jan; 61(1):65-6.

2. Aggressive Scaling Effects on Tooth Vitality. J Clin Periodontol. 1993 Oct; 20(9): 673

3. Comparative effectiveness of ultrasonic and hand scaling for the removal of subgingival plaque and calculus. J Periodontol. 1987 Jan; 58(1): 9-18

More in Periodontitis