The winds of change

May 1, 2004
Progress is inevitable. The more we know, the more important it is that we progress with the new knowledge. Our lives wouldn't be nearly as exciting...

by Shirley Gutkowski

Progress is inevitable. The more we know, the more important it is that we progress with the new knowledge. Our lives wouldn't be nearly as exciting or productive if we still had to pound our clothes on a rock on the shores of a natural body of water.

In agriculture, the United States is feeding the world on a tiny fraction of the farmland settlers cultivated to feed only our one emerging nation. Progress is feeding more people per acre than ever before.

In our little world of dentistry, progress has also made life better. For clinicians and patients, dentistry and dental hygiene have progressed to where most patients need little intervention. Advancements in technology have given us the tools to eliminate the need for subjective reasoning (or guessing), if we use them.

Let's start with the periodontal probe — the instrument upon which dental hygienists base their worth. Dedicated oral health-care providers use this bent wire to determine their value as evidenced by patient health measured in millimeters. Treatment plans are developed and executed on the basis of these measurements. They are really measuring the history of the disease, the effect of the infection, and the bony destruction. There is no way to tell if the disease is active or not by using a probe.

Many readers are now sitting up straighter and screaming at the magazine, "Bleeding on probing, bleeding on probing, you moron! What about that?"

The Academy of Periodontology itself does not accept absence or presence of bleeding on probing as an indication for disease activity or inactivity. It's just the best we have right now ... kind of like a one-ox yoke in the year 1849. We're over-treating disease because the other option is to under-treat and that ain't right.

Up until last year, we had an awesome device that would tell us, in real time, if the disease was active or not. We are left with the DNA probe and BANA testing to determine activity in the pocket. Both are impractical because of the time lag and each site must be tested separately, so we're back to using a probe with the subjective decision made on the presence and amount of blood during the procedure.

Caries detection and treatment have also progressed to a higher level. For too long, we were forced to put all of our decision-making trust into a differently shaped bent wire. Stick or no stick were the parameters for diagnosing decay, then the amount of resistance on the pull after the stick. Pit and fissure anatomy can create false positives and false negatives. I was recently in the audience when a speaker said resistance could be felt when removing an explorer from a door jam and wondered aloud if the door jam had decay.

Caries detection dyes aid in caries detection. Using an explorer gives false positives and negatives at a very high rate — numbers so high that they just don't cut it in today's medical environment.

If all we had available was an explorer like we did 50 years ago, we'd have to live within those confines of caries detection. That's not the case at all. Today, light technology has set us free from the limitations of the explorer. DIAGNOdent is a unit that uses a laser light to give a quantitative reading of the density of enamel. DIFOTI uses light to transilluminate teeth and projects the image on a computer monitor so the clinician can make a determination between disease and health. QLF not only digitally maps decay but it can also discern the difference between cariogenic and non-cariogenic biofilms.

Let's say you use these advanced tools in your daily practice. A question arises that may never have entered your head. That is the question of relaying this advanced information to patients in a way that won't send them running. If they've been going to a less savvy oral health-care team for years and continually were given a clean bill of health, you're sure to find decay if they enter into your diagnostic heaven.

There are dentists who are proud to state that a patient is caries-free even if — or especially if — the patient has just come from an office that employs advanced technology to detect decay or periodontal disease. To put it more bluntly, some dentists cannot identify the level of disease detected by their fellow practitioner down the street. Gleefully acting as a second opinion, using inferior technology, and with a wink to the patient, they infer that the second opinion is saving them money —thank heavens. Happily, they pronounce the patient disease-free, making a friend for life — even though that patient will arrive with surprise decay down the road.

Caries detection dye, magnification, photo energy, digital X-rays, and computers are all ways that allow the clinician to detect decay earlier; however, they may potentially upset patients if the message is relayed without concern for their past experience. If a patient enters into a relationship with one oral health-care team who finds disease, then defects to another oral health-care team for a second opinion, is it fair for the second or third opinion team to use only older technology? Is the first team over diagnosing by using advanced or new technology to objectively determine the absence or presence of disease?

With these new diagnostic technologies comes a new obligation for the practitioner. Decay can now be identified at nearly a molecular level. Treatment options must include some of today's progressive materials. Very early decay can be treated using advanced fluoride therapies, xylitol, Recaldent, and glass ionomer surface protectants. Early detection does not have to mean using a smaller burr.

Next year, ozone therapy will be available to arrest disease and make the tooth more susceptible to remineralization therapies. Detecting disease early at a molecular level paves the way for intervention as opposed to invasion.

All of this advanced detection requires a new level of rapport with patients. If they request a second opinion, they must have a list of questions to ask the new receptionist before making a decision to visit that dentist. Make sure that they ask if the new office uses the same diagnostic equipment and magnification. Help them make a good decision and avoid becoming embroiled in a heated debate between your advanced office and a one-ox yoke office.

Shirley Gutkowski, RDH, BSDH, has been a practicing dental hygienist since 1986. She is a popular speaker and award-winning author. Gutkowski and Amy Nieves, RDH, are the co-authors of "The Purple Guide: Developing Your Dental Hygiene Career," a handbook for graduates from dental hygiene school. Gutkowski can be contacted at [email protected].