All of the questions

April 1, 2006
A startling revelation came to me during a recent snowboarding trip with my boys.

A startling revelation came to me during a recent snowboarding trip with my boys. I do not snowboard, or play in the snow at all, but I enjoy watching people. While my daughter and I were playing Parcheesi, a boy of about four or five was bombarding his mother with question after question about everything in the lodge. She didn’t know every answer, but that wasn’t important in my observation. The important fact was the boy had almost every question.

If we had a concrete list of exactly what treatment was needed for every patient along with the exact instructions for providing that therapy, our careers would be so much easier. Instead, our goal must be knowing all the questions to address.

Imagine Danny Whitespots appearing in your chair for treatment. During the intraoral exam, you discover decalcified areas on the buccal surfaces of all posterior teeth. In this situation, knowing the diagnosis is the easy part. Deciding a plan of action can be a bit more complicated. Let’s suppose your treatment plan includes fluoride use. Now the choice becomes in-office application, take-home topical, supplements, paste, gel, rinse or foam - just to name a few. While we may all have our preferences, research into the most effective fluoride for this circumstance is not conclusive.

Now suppose the patient refuses fluoride, or you prefer not to use or prescribe fluoride in your practice. For preventive action, the choices now include Prospec MI Paste, xylitol-containing pastes, and, most recently, pastes that include CaviStat. Also, we can recommend gums and mints that incorporate xylitol and/or Recaldent into the formulation. The scary truth is ... my list is not complete. Available products and treatments change as research results and information become more widely distributed.

Even with the best of products, there is still a good argument for mechanical plaque removal and adequate home care as the best preventive treatment for Danny. Among the myriad of choices in toothbrush designs, there must be at least one that suits Danny’s needs and abilities. Thin or thick handles, flat or varied bristle lengths, and compact or regular heads are only the beginning of the decision-making process. You can now acquire toothbrushes with angled heads and coated bristles.

For the true thrill seeker on a budget, there are now manual toothbrushes that pulse or vibrate. Knowing the problem (decalcification that can lead to decay) is not the end of the battle. Heck, it isn’t even the beginning of the spat.

Now imagine that Debbie Pockets is seated in your operatory. The charting and other data gathered suggests a diagnosis of periodontal disease. Even after consulting the AAP position paper to determine the proper classification of Debbie’s disease and getting the thumbs-up confirmation from the dentist, the diagnosis is still the easy part.

The debate surrounding the benefits of gross debridement is still going strong. Some clinicians feel that an initial full-mouth scaling helps create an environment of decreased pathogens. I have even heard an argument in favor of gross debridement based on the fact that “insurance” will pay for it. Occasionally, a patient will present with so much calculus, bleeding, and debris that an exam cannot be adequately performed. In this case, the need for an initial full-mouth scaling is obvious.

Another decision in treatment planning involves the number and sequence of therapy appointments. I have worked in offices that schedule four quadrant “root planing” appointments for every patient undergoing periodontal therapy. Many hygienists prefer to treat one half of the mouth at a single appointment and still others treat the entire mouth in one sitting.

I enjoy asking clinicians their reasons for each preference, but I do not have the answer on which plan is absolutely right.

Your treatment decisions have just begun at this point. Ultrasonic, sonic, and hand instrumentation all present with their own benefits and limitations. Tip selection in all three categories allows for a multitude of choices. Just understanding how and where to use each of the tips is worthy of a three-CEU course. After plaque and debris removal,the treatment plan might include locally applied chemotherapeutics such as Arestin, Atridox, and PerioChip. Low-dose systemic antibiotics, such as Periostat, are becoming a popular and effective tool in the fight against oral pathogens. We are not just cleaning and

saving teeth anymore, we are fighting pathogens and their effect on the whole body.

Irrigation adds another question to the mix. You can provide subgingival irrigation in-office or recommend an irrigator for home use. For many patients, it is appropriate to irrigate at each appointment as well as suggest daily irrigation at home. There are a number of home irrigation devices to choose from and each has its own advantages.

After selecting an irrigation device, choosing the appropriate solution is just as important. Many patients will benefit from irrigating at home with water. The mechanical action will disturb plaque and biofilm, and water is agreeable to most people. Still other situations call for a solution with antimicrobial action, such as chlorhexidine, iodine, or TheraSol.

Since I have provided questions to facilitate in the selection of an irrigation device and solution, it is appropriate to point out that many practitioners do not endorse the use of any subgingival irrigator technique. Patients in my care have shown significant improvement in gingival health after incorporating home irrigation into a plaque removal routine, but not all researchers share my opinion about positive results.

Recall intervals present another opportunity for treatment planning. Reasons for specific recommendations are varied and need to be customized for each patient’s condition. I cringe when I hear, “Mrs. Soandso just needs the normal six-month recall.” The cringing is even more pronounced when the words come from my own mouth. There is no harm in telling Mrs. Soandso why you are recommending a recall interval of six months.

I have even heard an argument for yearly recall appointments based on the fact that the patient will be due for an exam and “might as well have their teeth cleaned at the same time.”

The time between periodontal recare appointments should be based on more than the fact that the body will be present in the office. Considerations might include the patient’s ability in plaque control, decay risk, or systemic conditions affecting oral health. In all honesty, and at the risk of being ousted from the hygiene world, I have met patients who could go a lifetime without the need for a professional prophy. At the other end of the spectrum, there are people who require monthly professional care to maintain any level of periodontal health. There is no cut-and-dry answer, just more questions to address.

“Philosophy letters” are a great way to introduce your patients to this therapy planning process. A letter explaining periodontal disease, your options, and/ or preferences for treating the disease, along with the expected outcome can prove a vital tool. The patient has access to the information whenever questions arise and is better prepared to ask questions during therapy.

It is imperative to remember that all treatment plans need to include regular health history reviews, nutritional assessment, and thorough head-and-neck exams along with an oral cancer screening. I didn’t even touch on planning for patient education and oral hygiene instruction. Preprocedural rinsing with an antimicrobial and blood pressure checks are another obvious inclusion. The questions are perhaps endless, but answers can be found for each individual situation.

I don’t have all the answers about the practice of dental hygiene; in fact, I don’t even know all the questions. Every step in treatment planning could be a column on its own. It is not too far out on the edge to suggest we are providing the best therapy by asking the right questions and treating the whole patient, not just the mouth.

The author did not receive compensation for products mentioned.