By Anne Nugent Guignon
I travel a lot. With very few exceptions, flying is my most frequent method of getting from one place to another. Sometimes I think my Saturn could drive itself to the Houston Intercontinental Airport all on its own.
Since I try to get a lot of writing done while I'm up in the air, flying time is my own private think-tank time, and it would be a very rare event to choose who sits next to me. Fate holds these cards, but fate has been very, very good to me. Sometimes I strike up a conversation with the person seated next to me, but not always. However, I have met some amazing folks this way.
On a recent trip to Reno, I sat next to a man who was flying back from Peru. It turned out his sister is a hygienist in Albuquerque. It was bound to happen sooner or later. We all have relatives somewhere, but that was not the real story. My seatmate was a geologist who works for a company that mines gold all over the world. Yes, it is the same gold that we use in dentistry. I asked him how geologists determine the location of rich gold deposits, ones that are worth going after. His answer stunned me. They look for the presence of sulfur. High levels of sulfur indicate significant gold deposits.
The wheels in my head started turning. Sulfur, that same kind of stinky stuff that gives people bad breath and is found in periodontal pockets, is a marker for one of the most precious metals on the planet. So how does gold mining relate to periodontal disease?
A few years ago an innovative diagnostic tool, called the Diamond Probe, came on the market. The inventor of this probe knew that people were suffering from periodontal disease in epidemic proportions. He also knew that sulfides are released when bacteria metabolize proteins. These sulfide waste byproducts can be found as the bacteria destroy proteins, such as collagen-containing connective tissue. So he theorized that if a diagnostic device was available that could detect high sulfide levels, perhaps bacterial activity responsible for periodontal destruction could be identified sooner and therefore treated earlier. After extensive testing and documentation, the Diamond Probe received FDA clearance to market as a device for use in detecting periodontal bacterial activity.
Even though the Diamond Probe has been around for a while, only a handful of dental practitioners have known about it. The company is small and their advertising budget is even smaller. As clinicians have begun to use this device, their clinical lives have begun to change dramatically right before their very eyes. The Diamond Probe has altered the way I practice and the way that I think about disease. Before I discuss how my clinical life has changed, let me share some other thoughts with you.
Three concepts, floating around in my dental hygiene universe, have suddenly collided, making my thoughts about periodontal disease reach a critical mass. First is the newest research on plaque biofilms — the thriving, living masses of communicating bacteria that resist so many of our therapeutic efforts so successfully. Secondly, the advances in microultrasonics using tunable ultrasonic scalers, especially with ultra-thin tips, are astonishing. Finally, the ability to determine high-risk sites in areas that look perfectly healthy clinically, regardless of sophisticated magnification loupes, is exciting. These areas, teeming with billions of pathogenic organisms organized in a bulging, slimy mass, have been invisibly seething in the place just below the gingival crest.
These concepts, along with our more profound understanding of host resistance to disease, are causing a cosmic collision of the first magnitude concerning the future of clinical dental hygiene practice. Wow! From my vantage point as a clinical hygienist, the practice of dental hygiene is changing faster than we ever thought possible, and those who are unwilling to explore these advances or new technologies will be left in the dust.
Let's step back into the reality of the hygiene treatment room. Is the Diamond Probe just one more device that will chew up my precious clinical moments? No, I think it is rather the door to the gold mine.
For example, as I begin my preliminary hygiene assessment, I explain that there is new technology that will help me assess periodontal disease bacterial activity at a much earlier stage than ever before. As the discussion continues, I point out that this probe allows me to gather traditional information like BOP (bleeding on probing) and pocket depth, but it also tests for the presence of high levels of sulfides. Yes, I explain that not only are sulfides found in the sulcus, they are also the substances that create bad breath. Jokingly, I tell my patients that I am using the probe to check for stinkbugs. They giggle at this, but each time the probe tip is inserted into an area that tests positive, the machine beeps. As the dialogue continues, patients become more and more concerned about the location and number of beeps, and every time the machine beeps the probe tip must be decontaminated in a special water cup. If there are a lot of active sites, I kid my patients that I am going to get carpal tunnel syndrome from all of the beeping.
Preliminary research now indicates that high levels of sulfides may actually be an earlier indicator of bacterial activity than traditional methods of BOP, redness, suppuration, and edema. I relate these thoughts to my patients along with the idea that pocket depths are simply a history lesson and that BOP may not indicate active disease, but rather may be indicative of heavy handed probing or even something as obscure as the confounding effects of a medication like an NSAID. Along with this information, I let patients know that the beeping sites are full of infection.
Additionally, the information derived from the Diamond Probe is a lesson in current events. It tells me exactly where I need to focus my efforts with my ultrasonic scaler. It tells me where the greatest numbers of pathogenic bacteria are hiding. Now I can get busy and blow up these bad bugs with my power scaler.
Every one of us has had patients who zone out when we begin to discuss pockets or bleeding. They have heard it before and unfortunately glaze over quickly. But I have seen a complete behavioral transformation in some of the most resistant patients as soon as they start to hear the beeps. It gets their attention in a new and different way. Patients don't want to hear that they have an infection, especially one caused by stinky bacteria. Now, I'm not the one telling them about the infection — the Diamond Probe has taken over that job.
Patients usually want to know what can be done about the high levels of bacteria that have been found. With the opened door, we can successfully propose the appropriate hygiene therapy, focusing on treating their disease, not just performing a prophy that should be performed in the presence of health. If we provide the appropriate treatment, we are entitled to the appropriate fees — therein lies the gold. Our practices are compensated financially and our patients are diagnosed more accurately.
Patients who accept that they are at high risk for periodontal disease love the Diamond Probe. They appreciate the fact that I can spend my time and efforts using my ultrasonic more appropriately in areas loaded with bacteria. Active sites must be retested before the end of the appointment and if retesting shows that the areas are not clear, then it is important to continue instrumenting with the ultrasonic scaler. This technology holds me accountable to my patients and they know it.
I have also been amazed at how much more seriously patients take their disease once they have been evaluated with the Diamond Probe. Patients regard it as a report card. It tells them where to focus their efforts at home and it measures their success. Over time, with shorter recall appointments and more effective home care, I have seen many patients completely transform their mouths. Patients are more motivated, schedule appointments more readily, and are much more reluctant to miss or change an appointment at the last minute.
These positive changes make our practices run much more smoothly. We all know how costly last minute changes in the hygiene schedule can be, not to mention the stress that it places on the entire dental office.
Every time I worked with one particular patient, there were fewer and fewer active sites. When I probed her entire mouth at a recent visit, there were no beeps until the last site. I thought she was going to dissolve into tears because she really wanted to be beepless! I tried to comfort her with the idea that she had just gotten a 99.99% on her test. Three months later her probing was completely negative.
I have worked with the Diamond Probe for nearly 18 months. I have been humbled by how this machine has helped me become a better clinician. Would you give any extra attention to an area that appeared to be clinically normal? An area that did not bleed, nor have any visible edema or redness? An area that measured 3 mm or less with no detectible hard or soft deposits? It never would have occurred to me to treat this type of area in any special way. After all, I was taught to look for the traditional signs of infection and areas with a history of disease. We have all been taught this way.
Now what would happen to your thinking if you had a Diamond Probe in your treatment room today and suddenly you found high levels of sulfides in areas that appeared to be normal? And how would you feel if you probed into areas that were 5 or 8 mm deep and the machine was silent? What would you think if a 1 or 2 mm area on the facial of number eight continued to test active even after you had spent more than five minutes with your ultrasonic scaler in this area? I have had each of these types of experiences over and over. If they had only happened once, I am sure that I would have dismissed them as false readings. Eventually, it became clear to me that this technology is just one more piece in the puzzle for successful periodontal evaluation and treatment.
When I first started using the probe I never expected that my thinking would be so dramatically altered. Now more than ever I understand how complex periodontal disease can be, how easily we can be fooled about where the bacteria are really lurking, and that it may take more effort than we ever thought to destroy these evil-doers.
New technology is often very difficult to introduce to the dental market. There are practitioners who are comfortable to practice exactly how they were taught, regardless of when they graduated from college. Once we couple scientific principles with our skilled deductive reasoning, we can begin to embrace what technology has to offer, and this can help us get more excited about practicing every day in the 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].