Th 70157

A beacon in ultrasonics

Sept. 1, 2001
Dr. Tom Holbrook's innovative modifications on ultrasonic scalers have revolutionized the way hygienists practice and saved many careers — including the author's.

Dr. Tom Holbrook's innovative modifications on ultrasonic scalers have revolutionized the way hygienists practice and saved many careers — including the author's.

by Anne Nugent Guignon, RDH, MPH

Dr. Tom Holbrook holds a plaque engraved with a lighthouse that was presented to him by his "ultra-sonic disciples" last year.
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"Imagine how many teeth could be saved ... imagine how many careers could be saved." This simple mantra represents the core vision of Dr. Tom Holbrook, a Tampa periodontist. Even if you've never heard of Dr. Holbrook, he has touched your career. He has affected the way each one of us practices dental hygiene today.

Have you ever had an experience that totally altered the way you think, dramatically changed how you operate day in and day out, challenged tradition — yet left you refreshed and energized? The changes that Dr. Holbrook has pioneered have salvaged the careers of many hygienists, including mine.

Dr. Holbrook is a pioneer, changing the world of power-driven scaling for every practicing hygienist. His ideas and techniques have changed the way we utilize power-driven scalers to deliver patient treatment. Just who is Dr. Holbrook? Let me introduce you to this remarkable man who has helped save so many careers, and so many teeth.

When Dr. Holbrook was studying dentistry at the University of Michigan in the early 1960s, ultrasonic scaling was an emerging technology. After graduation, Dr. Holbrook became fascinated with the mysterious ultrasonic scaler sitting in the corner of the Air Force dental clinic where he was stationed. Convinced that power-driven scaling had something special to offer in patient care, the ever-curious Dr. Holbrook began to experiment with this new tool.

Dr. Holbrook left with his wife Sandy (far right). Kim Herremans (second from left), and the author.
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When he completed his tour of duty, Dr. Holbrook enrolled in the post-graduate periodontal program at the University of Kentucky. The program had one power-driven scaler. Six graduate students were expected to share the one tool, but it was soon apparent that only Dr. Holbrook was interested in using it. This ultrasonic scaler quickly became a permanent fixture in his cubicle. He began modifying thick P-10 tips, making them slimmer, and also experimented with the frequency and amplitude settings on the machine.

Dr. Holbrook quickly determined that the longer, slimmer tips were much more comfortable for patients and allowed access to areas that curettes could never reach.

After finishing the program in 1968, Dr. Holbrook opened a periodontal practice in Tampa, Fla. With one foot still planted "in the box," he continued to study the differences between hand instruments and ultrasonic scalers. He conducted experiments using a split-mouth design — half the mouth was scaled with hand curettes, the other half with his new modified ultrasonic tips. When he examined the teeth later during surgical procedures, the results were clear. Quadrants that had been scaled ultrasonically had far less calculus and much better soft-tissue resolution.

Dr. Holbrook began to wonder if he just didn't have "the hands for curettes." He visited noted periodontists around the country, watching in awe, observing the meticulous hand-scaling with a tray full of Gracey curettes and other hand instruments. When these cases were opened surgically, however, he also saw all the deposits that remained.

Dr. Holbrook returned to his modest Tampa office convinced that ultrasonic scaling could transform dental hygiene procedures. Though it was hardly his nature to "buck the system," Dr. Holbrook instinctively knew that ultrasonic scalers were the right way to go.

Armed with rotary stones mounted on slow-speed handpieces and a handful of orthodontic pliers, he continued to thin down and reshape inserts. In the early days, Dr. Holbrook used the big P-10 inserts and experimented with different insert sizes and shapes until he found a configuration that really worked. He also shortened the external water conduit, allowing the water to flow over the tip without interfering with instrumentation.

Through the years, Dr. Holbrook met with manufacturers about ultrasonic tip designs. He asked them to make thinner tips with external water conduits. Time after time his ideas were rebuffed. Finally, the Tony Riso Company produced the first commercially available ultra-slim inserts; now a number of other manufacturers produce reliable inserts.

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Dr. Holbrook joined forces with Dr. Sam Low. They authored a chapter about ultrasonic scaling in the 1991 edition of Clark's Clinical Dentistry and gave joint presentations at a number of dental meetings. The revolution had begun. Manufacturers began to make inserts with thinner tips, and the word started to spread. Ultrasonic scaling could now be considered a comprehensive treatment, rather than just blasting off debris. We were finally able to debride periodontal pockets that we were only able to probe before.

From the beginning, Dr. Holbrook trained his hygienists using his modified inserts in the original Cavitron 660 manually tuned ultrasonic scaler, considered a dinosaur by many. He quizzed his protégés relentlessly on root anatomy and radiograph interpretation, while constantly modifying and perfecting the inserts even more. He also taught his hygienists and a handful of other clinicians how to reshape and re-contour inserts that were just too thick for scaling deep, narrow pockets.

While the dental world moved on to the increasingly popular automatically tuned machines, Dr. Holbrook stood firm in his conviction that manually tuned scalers gave clinicians a much wider range of scaling options. Manually tuned units allow clinicians to determine the frequency of each insert. As a result, we can use the thinnest of insert tips and customize the treatment for each clinical challenge. Manually tuned scalers also require less water, giving the clinician improved visibility. Patients rarely require anesthesia, even in the most complex debridement cases. Today, Dr. Holbrook and his hygienists use a tunable scaler called the USI 25 MPLC that allows them to control the frequency of the insert as well as the power setting.

Dr. Holbrook also broke down another barrier. How could he keep new dental hygiene employees from reaching for their tried and true hand instruments? He made a deal with the hygienists. He told them they could have their hand instruments back in three months — if they really wanted them. Initially, Kim Herremans thought she would want hers back on the 91st day, but quickly found that the ultrasonic scaler helped her more than she had ever imagined!

Seven dental hygienists in this country have become serious Dr. Holbrook disciples. Each of us travels around the country teaching hygienists and dentists to work with manually tuned scalers and the latest of the ultra-thin tips. Kim Herremans, RDH, Michelle Mooney, RDH, and Mary Kerger, RDH, each learned this special technique firsthand from the master. Each of them has been fortunate to practice dental hygiene in Dr. Holbrook's periodontal practice; each has made a unique contribution in the world of ultrasonic education. They have produced articles, textbook chapters, workbooks and videos about ultrasonics that highlight the Holbrook technique.

Herremans enrolled in the master's program at Old Dominion University after working with Dr. Holbrook for several years. She conducted original research about the benefits of ultrasonic scaling for her master's thesis. The key elements of her research can be found in her chapter, "Ultrasonic periodontal debridement." in the 1998 textbook, Concepts in non-surgical periodontal therapy.

In 1995, Mooney and Dr. George Bailey collaborated on a videotape, "Tunable ultrasonics with modified tips," which is available through Clinical Research Associates. Home Study Educators publishes an 8-credit hour course written by Kerger titled "Ultrasonics in periodontal therapy: The Holbrook concepts." Both Kim and Mary's publications contain extensive bibliographies on this complex subject. Michelle's video also has excellent close-up footage of this technique.

The rest of us came to know Dr. Holbrook in a variety of ways. In 1988, Dr. L.K. Croft secured an audiotape of a lecture that Dr. Holbrook gave about this technique. Drs. Croft and Holbrook were graduate school classmates and had kept in touch through the years. He was convinced that Dr. Holbrook's ideas regarding periodontal therapy had merit. Dr. Croft also worried about the toll hand scaling was taking on his hygienists' hands. He had seen them massaging their hands at the end of a busy day, trying to get rid of the pain. Dr. Croft could also see potential ergonomic benefits to using power scalers.

Masters of the Holbrook Technique
(left to right) Anne Guignon, RDH; Sandy Holbrook; Patti Parker, RDH; Dr. Tom Holbrook; Mary Kerger, RDH; Nancy Miller, RDH; Michelle Mooney, RDH; Donna Skaggs, RDH; Kim Herremans, RDH; Lana Crawford, RDH; Dr. L.K. Croft
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Dr. Croft and his hygienists, Lana Crawford, RDH, and Donna Skaggs, RDH, traveled to Tampa for a long weekend. They spent three days absorbing these new ideas and working side by side with Dr. Holbrook, Herremans, and Mooney. When they returned to Dallas, word spread that they were using a new ultrasonic technique. Patients learned that their debridement appointments were more comfortable. Lana and Donna were thrilled with how much better their hands felt, how much more comfortable the patients were, and how much more thorough their debridement procedures were. Dr. Croft, Crawford, and Skaggs have spent the last decade giving lectures and teaching hands-on courses about the Holbrook technique. Croft has also published an article on this technology.

Initially, Nancy Miller, RDH, was skeptical about these new ultrasonic concepts. She worked in a periodontal practice. In the fall of 1988, her doctor went to a conference in Atlanta and heard Drs. Holbrook and Low speak. When he returned to Wisconsin, he announced that there were going to be some changes in the practice. In 1988, root planning was the standard of care; without warning Nancy learned "they were no longer going to use hand instruments on patients — just ultrasonics!" Miller felt she needed to see this technique first-hand, so she traveled to Dr. Holbrook's office. Miller returned a convert to this new technology. She began to develop hands-on courses and lectures embracing the Holbrook concepts and filmed a very useful instructional video in 1995 titled, "Advanced ultrasonic instrumentation for periodontal debridement."

More than a decade ago, I met Michelle Mooney, who was living in Houston at the time. I listened to what Michelle had to say but it was hard for me to believe that complex scaling procedures could be performed without anesthesia, with compete clinician comfort, and superior clinical results. Michelle's remarks resonated within me. Too many smart people believed in this technology; I needed to learn about it myself.

It took four years to convince my doctors to purchase the recommended scaler. By this time, Michelle had returned to Florida; I didn't know anyone else that taught this technique. I kept asking the manufacturer questions and he patiently answered many of them. I knew this machine could deliver a better outcome, but I needed to learn from an experienced clinician. Suddenly, I remembered that I had met Kim several years before at the American Academy of Periodontology Meeting. I called and scheduled a phone conference with Herremans. She began to mentor me over the phone ... definitely not the ideal way to learn about technology!

In August 1996, I decided to leave an established dental practice. Temporary dental hygiene practice was a scary concept, but I was much more concerned about having to return to hand scaling. I purchased my own scaler. It quickly became clear that it was important to contact each office before I showed up with my ergonomic chair, magnification, headlight, and scaler!

Several years ago, I wrote my first article on advancements in power-driven scaling. Dr. Holbrook and Kim offered many constructive comments during the process.

Dr. Holbrook sensed that I had fallen in love with ultrasonics and suggested I come to Tampa and spend some time in his office. Even though there are excellent inserts available commercially, I wanted to learn how to modify inserts myself. Dr. Holbrook spent an entire morning trying to teach me. Kim Herremans and Mary Kerger joined in on the session.

It looked so easy ... a little bend here, just a little more metal off the other side! He was so patient. I returned to Houston, convinced that I had spent time with the father of modern dental hygiene.

Last fall, Mary Kerger decided to host a two-day course on the Holbrook technique in St. Petersburg, arranging to have Kim, Michelle, and Lana assist with the didactic and clinical portions. Word spread quickly via e-mails and phone calls about "The Dream Team Course." We knew that Dr. Holbrook would be around for some portion of the course. Dr. Croft, Donna Skaggs, Nancy Miller, and I all made plans to join this event. How could we resist spending two days with the finest minds in ultrasonics? Jim Feine, the manufacturer of the USI ultrasonic scaler, and Patti Parker, RDH, from Hu-Friedy also made plans to be in Florida. It quickly became apparent that Mary's CE course was going to be much more than an ordinary one.

For the first time, we would all be together for two days. We would each have an opportunity to personally thank Dr. Holbrook for his contributions. Dr. Holbrook is an avid photographer with a special affection for beacons and lighthouses. Lighthouses adorn his home and office. So, during the opening session, we surprised him with a special award: a plaque engraved with a lighthouse. The weekend was an event that celebrated Dr. Holbrook's dedication to his patients and our profession. You could not erase the smile off of his face.

Afterwards, we met for dinner at an upscale restaurant on the pier. Dr. Holbrook's wife, Sandy, and his son, David, joined us for this special celebration. Each one of us recounted a funny or touching story about our relationship with Dr. Holbrook. The depth of the stories was amazing. At the end of the evening, we presented Dr. Holbrook with a bag filled with lighthouse mementos. Individually wrapped Lifesaver candies filled the bottom of the bag. As the festivities began to wind down, Dr. Holbrook presented each one of us with a piece of candy — announcing that we were all lifesavers!

Historically, visionaries have been ridiculed, labeled as kooks, or dismissed by the mainstream. Many visionaries never experience the joy and validation they deserve for bringing us forward into a better place and time. Truly, the soft-spoken, self-effacing Dr. Holbrook epitomizes the word "visionary." I will treasure that small piece of wrapped candy forever!

Author's note: Tom Holbrook, DDS, and Mary Kerger, RDH will be presenting an all day program "21st Century Ultrasonics in Periodontal Therapy" on October 13, 2001 at the ADA Annual Session in Kansas City, Missouri. For more information check or phone (312) 440-2500, or fax: (312) 440-2800.

Anne Nugent Guignon, RDH, MPH, is the author of the Comfort Zone column in RDH. She can be contacted at [email protected].