Literature on 'accelerated' approach unclear
At the request of my wife, who is a dental hygiene program director, I read, with some bemusement the article titled, "Acceleration in Periodontal Instrumentation," by Kristy Menage Bernie, RDH, BS (September 2002 issue). After further critiquing it with my hygienists and associate periodontists and realizing that a relatively large number of dental hygienists read and perhaps accept Ms. Bernie's "opinion-biased" comments as indisputable scientific facts, I felt compelled in this instance to respond in the interest of evidence-based therapy vs. empiricism.
Let me state first of all that I have no problem with the concept of single-appointment, full-mouth instrumentation. In fact, we frequently offer this option to patients in our periodontal specialty practices, especially those who travel significant distances for treatment or who have trouble scheduling time off from work. We do not, however, usually attempt to routinely decontaminate the mouth via chlorhexidine rinses, tongue scraping, comprehensive subgingival irrigation, etc. because, quite frankly, there is no solid evidence that any of these protocols or procedures makes any clinically significant difference over thorough mechanical instrumentation alone, in the majority of cases. However, again, I have no philosophical problem with one providing those ancillary services, if one feels compelled to do so. One could, however, perhaps debate the issue of charging additional fees for these additional services.
I don't know where Ms. Bernie came up with the idea that "quadrant scaling and root planning represents the gold standard in initial periodontal therapy." This is a nonsensical statement if there ever was one. Further-more, the "challenges" she mentions — insufficient appointment time and multiple office visits, missed appointments, etc. — are only problems if they are allowed to be. Appropriate patient and practice management makes these non-issues. Furthermore, full-mouth therapy won't eliminate missed appointments and insufficient appointment time issues. Assuming adequate time (two to four hours, depending on the difficulty of the case) is scheduled for this therapy, the impact on the daily schedule of a missed appointment is much more devastating. There are potential benefits from multiple appointments, including: minimizing patient and clinician fatigue in difficult cases and reinforcement of home care therapy. Still these issues can be managed as well in the accelerated instrumentation cases, if desired.
Ms. Bernie mentions that "a small body of research" has addressed "the issue of a drawn-out instrumentation process." I assume she is alluding to scaling and root planing on a quadrant by quadrant basis. In point of fact, any periodontist and most third-year dental students can tell you that there is a huge body of literature (the longitudinal studies), which have evaluated scaling and root planning as one form of therapy for periodontal treatment. Whether or not it is accomplished over a period of several weeks, or in one appointment, the most important thing is the thoroughness of the instrumentation in most cases (obviously, some aggressive forms of periodontal disease may not respond to mechanical instrumentation alone). I might suggest that the "hit-and-miss successes seen with initial scaling and root planing therapy" she discusses are more a result of inadequate instrumentation or misdiagnosis of the case type, than reinfection from untreated quadrants. In fact, a number of studies have discounted the idea of rapid reinfection from remote sites to recently treated, healthy sites as described here.
Rather than take my rantings as gospel, I would encourage anyone who wants to have the latest information on full-mouth vs. individual quadrant scaling and root planing therapy, to read the exhaustive review commentary on this very subject by Dr. Gary Greenstein, in the July 2002 issue of the Journal of Periodontology (page 797). Dr. Greenstein, in his usual, leave-no-stone-unturned review style, covers the topic as it stands to date, ad nauseum. He reports, on a comparative basis, that the results of the six to seven studies that have addressed this topic are conflicting. Also, most of the studies are flawed, making their conclusions equivocal as well. He concludes that — although the concept of full-mouth therapy may provide additional clinical benefits beyond scaling and root planing on a quadrant-by-quadrant basis — a definitive answer to this question has not been attained by studies conducted to date. He calls for large clinical trials with sufficient "power" to detect differences in these therapies, with corroboration by different treatment centers to validate the results. Therefore, the statement in Ms. Bernie's article that the "rationale for full-mouth accelerated scaling and root planning is evidence-based" is premature, at least.
Dr. Greenstein did note that several studies reported a significantly higher incidence of post-treatment discomfort in patients who underwent accelerated full-mouth therapy, compared to quadrant-by-quadrant therapy patients. Also, a significant percentage (50 percent in one study) of patients who underwent full-mouth therapy reported elevated body temperatures following treatment, implying significant bacteremia production in these patients (consequence unknown). Another recent study (Journal of Periodontology, September 2002), reported that patients undergoing accelerated scaling and root planing therapy (in this case, four consecutive days) experienced a significant incidence in apthous stomatitis compared to quadrant-by-quadrant scaling over a four week period of time.
In conclusion, my commentary here is not meant in any way to be viewed as a vendetta against Ms. Bernie and her ilk. I do not know her and certainly she is entitled to her opinions. However, I believe that when one publishes an empirically based article such as this, which has the potential to impact clinical practice by many conscientious dental hygiene practitioners, who may obtain their literature updates from magazines such as RDH and who may not be as adept at assessing the validity of literature as others, one needs to be held accountable for these opinions which are being presented here as current standard of care, which they are not.
Clinical research may indeed eventually demonstrate full-mouth therapy to be superior to more traditional quadrant by quadrant instrumentation therapy. Until that time, prudent clinicians will continue to provide nonsurgical periodontal therapy by whatever protocol provides the best clinical results for themselves and their patients, striving most importantly to debride root surfaces and periodontal pockets as thoroughly as possible. Furthermore, the prudent clinician will realize that for many patients, scaling and root planing will not be end-point therapy. Often periodontal surgery is necessary to maximize treatment response.
Benson C. Duff, DDS, MS, MSBA
Grand Blanc, Michigan
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About the cover
The photo shoot started out in a dance studio in the home of Vicki and Tom Ovens. Vicki first put on some country western clothing and went solo in a line-dancing routine. She and her husband switched to swing dancing as shown here.
Everybody then went outside.
"We went to one of my favorite spots where I walk my dogs and used some eight-foot corn stalks and giant sunflowers as background for some photos," Vicki said.
RDH readers, welcome to November!
The Ovens do teach dancing out of their home in Petaluma, Calif., but Vicki, of course, is a dental hygienist. A 1973 graduate from the University of New Mexico, Ovens currently works four days a week for a periodontist and one day a week at a general practice.
She said, "When I graduated from hygiene school, the average career span for a dental hygienist was only seven years. I have quadrupled that!"
Petaluma is in the middle of California's wine country, and gardening is one of Vicki's passions, primarily centered on the 45 rose bushes in her backyard. The couple also have two married daughters and two grandchildren.
Ovens can be contacted at [email protected].