By Anne Nugent Guignon
Hand scaling is hard work — meticulous and time consuming. Decades ago, hand scaling was considered the gold standard. The periodontal disease model was rooted in calculus. "Real hygienists" hand scaled.
Hand-scaling snobs like me have historically looked down their shortsighted noses at hygienists who dared to use an ultrasonic scaler on a patient — unless that patient was loaded with calculus and stain. I believed this machine was reserved only for the worst cases.
Did these "Cavitron Queens" understand something the rest of us did not question? While some hygienists must have felt it was quicker and easier, I suspect the "CQs" understood that power scaling was kinder to people's bodies. Some of these hygienists also observed amazing soft tissue results.
Today's research is shifting our thoughts about periodontal disease. The disease model is built on the complex interactions of plaque biofilm and a person's susceptibility or resistance to disease — a real global tug-of-war between bugs and body immunity. Research also tells us that ultrasonic scaling can destroy these biofilms, and that patients who use the more sophisticated powered brushes effectively at home can disrupt plaque biofilms.
When I graduated from dental hygiene school in 1971, I believed that bleeding meant disease and that brushing, flossing, and good plaque control were the cornerstones for stable oral health. Life was simple when these were the prevailing thoughts.
There were few non-steroidal anti-inflammatory drugs and few medications that contributed to increased bleeding. Hygienists rarely had to worry about the confounding effects of the drugs patients took other than aspirin, coumadin, Motrin, and Dilantin. This is in contrast to today's patients, who can self-medicate with over-the-counter NSAID's in any dose they feel is necessary, or who can take handfuls of herbal remedies with the incorrect belief that "natural" equals no side effects.
Early in my career I experimented with every home-care regimen known to man, and still some of my patients continued to bleed. During my first couple of years, I noticed that stressed patients had more gingivitis.
Other things also caught my attention. Some patients' teeth were so loaded with plaque and calculus that it took a veritable excavation exercise to unearth their teeth, yet they often had no other signs of disease. Other patients had teeth that appeared clean but were getting looser by the minute.
Life was simple, and 35 years ago science told us:
• There were only three types of periodontal disease: periodontitis, periodontosis, and ANUG
• Bleeding meant disease
• Getting rid of calculus equaled getting rid of disease
• Periodontal disease was generalized throughout the mouth
• Patients with periodontal disease went progressively downhill
• Diabetics had a higher risk for gingivitis
• Pregnant women normally developed gingivitis
• Osteoporosis was not related to periodontal disease
• Toothbrush abrasion caused gingival recession and notching at the CEJ
• Power brushes and oral irrigators were just fancy tools.
The simple science of four decades ago didn't match what I was observing. I saw isolated periodontal defects. I saw periodontal patients go in and out of remission. Stressed patients had more active disease sites. Premenstrual and post-menopausal women had more active disease at certain times of the month. Patients who used irrigators appeared to have less active inflammation. Older women bent over from osteoporosis often had no mandibular ridge, which made it impossible to keep their lower dentures in place.
When nothing explained the inflamed tissue, I often asked patients to get a complete physical. I remember being astonished at the number who returned and told me they had been diagnosed with conditions such as diabetes, colon cancer, or ovarian cancer. I clearly remember their names and faces, and I remember thinking that the condition of gingival tissue was like a crystal ball that gave clues about their futures. It felt very eerie.
My observations conflicted with everything I had learned during my dental hygiene education. Out of sheer frustration I developed this hypothesis: Some people are highly allergic to their own plaque.
I didn't have a fancy way to test this, but I did observe that patients who more frequent dental hygiene visits tended to be healthier. Periodontists were beginning to recommend three-month recall intervals, so I followed suit and began to encourage patients in my practice who appeared to be high risk to visit more often than every six months.
That took guts 30-plus years ago.
The results? A number of patients agreed to more frequent recall intervals, and, for the next 15 years I saw the disease process in these patients slow down.
By the mid-1980s the dental community was beginning to understand that host resistance, hormones, and stress have a profound effect on the progression of periodontal disease.
We were beginning to understand the disease was more than plaque and calculus, more than brushing and flossing. Life was no longer simple. According to today's science my working hypothesis was wrong, but my recommendation was right on the mark.
In 1988, I moved to another dental practice. A remarkable number of patients followed me. My new employer was dumbfounded that most of these patients were on three to four month intervals and had been so for years. He asked me point-blank, "How did you figure this out?" I answered, "Nothing else seemed to work."
Was I smarter than other hygienists who had gone to school at the same time? I don't think so. But I do know that I used my brain, observed and recorded my findings, and trusted my gut. I remember how good it felt when science finally caught up with my recommendations.
The biggest payback I received for going out on a limb came four years ago when I returned to my original practice. The patients were still there, and so were their teeth. Most were still on short recall intervals and didn't want it any other way. Many of these patients should have lost their teeth — they smoked and drank, were stressed, or were pregnant. Some had so many risk factors it's amazing they had a tooth left in their mouths.
Life was simple 30 years ago. It's been amazing to go back and read the documentation I so unknowingly recorded in pencil at the time. I am now grateful for my untraditional thinking. It's my own personal comfort zone. Thirty years later we have so much more to offer our patients, but it is still up to us to observe each condition and consider all of the alternatives.
Daring to be different can be scary. One must be ready to pay the price if your ideas fall short of the mark. But I can't imagine anyone faulting you for using your brain. Hygienists are well educated. It's our responsibility to make use of our observations and act accordingly. If you use your brain and follow your heart you will find your own comfort zone.
Anne Nugent Guignon, RDH, MPH, practices clinical dental hygiene in Houston, Texas. She writes, speaks, and presents continuing- education courses on ergonomics and advanced ultrasonic instrumentation through her company, ErgoSonics (www.ergosonics.com). She can be reached by phone at (713) 974-4540 or by e-mail at [email protected].