Incorporate esthetics into recare planning

July 1, 2000
This change in terminology from "recare or maintenance visit" to the "esthetic management session" puts the emphasis on preserving the client`s cosmetic investment.

This change in terminology from "recare or maintenance visit" to the "esthetic management session" puts the emphasis on preserving the client`s cosmetic investment.

Kristine A. Hodsdon, RDH, BS

When designing a care plan, an expanded frame of reference that includes cosmetic and esthetic services provides new dimensions for the dental hygienist. Like a complicated organism, the hygiene care plan and the comprehensive esthetic treatment plan integrate different valuable pieces. However, they only have power when linked together. The totality of the interrelated phases make the hygiene and dental methods of care succeed. Since esthetics is changing our profession, it must be included. As a result, the complexities of the interconnected programs are further challenged.

The esthetic care plan, a component of the complete hygiene care plan, is a written proposal that directs the dental hygienist and the client as they work together to exceed the client`s goals for esthetics. Predominantly, the plan individualizes care, keeps focus on the clients` long-term outcomes for their oral health and smiles, establishes interventions, initiates a sequence of care, and monitors the client`s progress. This is all facilitated while ensuring continuity of care and communication among the oral heath professionals involved.

If the hygiene care is to be effective and successful, the dental hygienist must design and select interventions that specifically address the clients` cosmetic treatments. Interventions such as client education, oral disease prevention, oral health behaviors, health promotion strategies, and professional armamentarium are formulated into the plan.

Professional armamentarium

Since improper professional and client care can adversely affect the longevity and appearance of cosmetic restorations, it`s important to adhere to some basic principles to preserve the substance and beauty of the service. Hygienists have a high degree of proficiency when it comes to the mechanics of instrument sharpening. But few have mastered the clinical artistry or embraced the importance of a sharp curette.

Dull curettes may ditch and/or scratch the surface of a tooth-colored restoration. Research concerning hand instrumentation of tooth-colored restorations concludes sharp curettes offer the tactile sensitivity necessary to debride without scratching the esthetic materials. In addition, a gentle, horizontal stroke - rather than a heavy, up-and-down stroke - should be applied to safeguard the integrity of a bonded margin.

Some of the newer plastic instruments with streamlined shanks and blades may also be considered for debriding. These can be sharpened with material-specific sharpening stones. This new addition is a welcome advantage over the original designs that needed to be thrown out after a few uses and sterilization processes.

Another consideration is, "How sharp is your explorer?" Or a better question would be, "How old is your explorer?" If you are using an explorer during your esthetic, caries, and/or periodontal assessments, it needs to be replaced on a regular basis, since it will not retain its sharpness and diagnostic/tactile properties.

In the arena of high-tech instrumentation, ultrasonic and sonic scalers, as well as air abrasion units, should not be used on or around a tooth with a tooth-colored restoration. Ultrasonic and sonic scalers have the ability to damage the surface or margin of a restoration and the bond to the tooth. Air abrasion techniques can scratch and pit the surface of a restoration, making it more susceptible to plaque accumulation and staining.

The initial research in the areas of hygiene instrumentation and esthetic treatments is encouraging. However, its long-term clinical relevance needs to be further explored. It is my hypothesis that continual inappropriate professional care, as repeated at three-, four-, or six-month recare appointments, are powerful contributors to marginal breakdown and early failure of cosmetic treatments.

Sodium fluoride treatments, delivered after esthetic recare, cosmetic services, and as a part of self-care, should be a component of an esthetic care plan. Acidulated phosphate fluoride and stannous fluoride should not be used in clients with tooth-colored restorations. Acidulated phosphate fluoride has been shown to etch porcelain and may affect the filler particles in composite resins. Stannous fluoride may also cause discoloration of the restorations.

Client education

Change in the health of gingival tissue or migration, as well as increased surface roughness of composite restorations compel us to design home interventions that will support the performance of the new smile.

Based on the current research, what a hygienist can extrapolate and recommend is that the modified Bass technique - while using a frequently changed soft-bristle toothbrush - is the fundamental part of an esthetic self-care plan. Meticulous and proper oral hygiene behaviors should be emphasized. Why? Improper brushing techniques (too fast, scrubbing, excessive pressure, and excessive brushing three or more times a day, for example), along with using an inappropriate dentifrice, may roughen or wear the tooth-colored restorations and irritate the gingival margins.

Although powered-assisted plaque removers are popular, the jury is still out when it comes to esthetic dentistry. Some studies, for example, warn against using sonic toothbrushes with orthodontic brackets since the vibrations may increase the debonding. So is it worth taking the chance with definitive bonded restorations?

The best choice of tooth polish is also unclear. Reports show abrasive wear caused by dentifrices, as well as changes in surface roughness of resin composites. For now, a low-abrasive toothpaste combined with client education that includes behavior modification should be emphasized for self-care programs.

Another challenge is that not all composite materials have the same filler particles and/or weight or composition. Theoretically, microfill composites may be more susceptible than hybrids to abrasive toothpaste slurry. Or what about the ceramic-enamel or ceramic-dentin margins? Are they affected by abrasive pastes and a heavy brushing hand? Additional clinical studies are warranted to further test the abrasiveness of toothbrushes (automatic and manual), dentifrices, and the combination of toothbrush-dentifrice rates on various esthetic materials, especially over the lifetime of the restoration.

Continuing care plans and interventions should be arranged based on the nature of the esthetic treatments and an individual`s needs. Supportive esthetic therapies can be easily incorporated into the "standardized" recare appointment. In a majority of cases, however, esthetic management sessions should be included in the esthetic hygiene plan. This change in terminology from "recare or maintenance visit" to the "esthetic management session" puts the emphasis on preserving the client`s cosmetic investment.

Whether the services performed at such appointments fall under the umbrella of supportive esthetic care, supportive periodontal care, or even a combination of both, the client needs to understand the shift from a "cleaning" to a valued "esthetic session." Clients need to be informed of the necessity of such appointments during case presentations. The fee, proposed schedule, length of appointment time, and services to be provided all need to be communicated to the client and incorporated into the cosmetic financial plan.

References available upon request.

Kristine A. Hodsdon, RDH, BS presents seminars nationally about

esthetic hygiene. Her company, Dental Essence, is based in Hudson, N.H. She can be e-mailed at [email protected].