BY LYNNE SLIM, RDH, BSDH, MSDH
Deciphering science isn't easy, but it has been made a bit less difficult because of the dedicated effort of a fellow dental hygienist. Julie Hawley, RDH, PhD, is making it easier for us to grasp science after two grueling years of editing the first book on evidence-based dentistry (EBD) for dental hygienists. Julie's bio is impressive; she developed and launched the American Dental Association's EBD website and directed their Center for EBD for 10 years. She received a doctorate from Harvard University's biological and biomedical sciences program and has conducted cancer research. Specifically, Julie studied how genetic mutations manipulate cells to cause leukemia.
"Evidence-Based Dentistry for the Dental Hygienist," which is published by Quintessence, arrived in my mailbox a few weeks ago. I have met Julie several times at the ADA headquarters in Chicago while attending the EBD Champions conferences. Julie is very bright and engaging, and the ADA is fortunate to have her on its staff.
In the book's preface, Julie talks about filtering out "noise" in a world in which scientific information is presented to us in increasing volumes and at an ever-accelerating pace. It's a painstaking process and an obligation that is placed upon those who follow the scientific method. But this avalanche of data makes it difficult to separate hard fact from speculation. Using EBD allows us to do our best in addressing this problem.
The book is written in two parts. The first section addresses specific skills required to implement an evidence-based approach to practice. The second section covers current evidence on topics of interest to a dental hygienist. I noticed right away that she selected talented professionals to write chapters - individuals with advanced degrees from fully accredited universities such as professors, researchers, and some with doctoral degrees in public health. Basically, these are individuals Julie has worked with at the ADA over the last 10 years, and she knew them personally. More importantly, these are prudent professionals; many of them have taught evidence-based dentistry modules.
One chapter in the second section was right up my alley and featured application of evidence-based dentistry to periodontal diseases.2 The authors, Gunsolley and Pellegrini, both dental professors at the Virginia Commonwealth University, focused on three topics:
1. Statistical associations among plaque/biofilm, diabetes, tobacco use, glycemic control, and periodontal diseases
2. Strength of the evidence surrounding efficacy of plaque/biofilm control to prevent periodontal diseases including biofilm-removal therapies, tobacco cessation, and SRP as a treatment modality
3. Development of evidence-based dental hygiene treatment plans for patients with gingivitis or periodontitis
The authors did not include preterm birth/low birthweight babies or cardiovascular disease/stroke. These statistical associations are considered weak, and an association is not sufficient to prove that periodontal disease has a direct impact on systemic conditions even though many dental professionals are promoting them as more than statistical "associations."3,4
Evidence strongly supports plaque/biofilm control, tobacco cessation, and glycemic control for diabetes in an effort to control periodontal diseases. All three efforts involve behavioral control.
Here are some important clinical takeaways from this chapter:
• With initial therapy (SRP), meta-analysis of clinical trials provides evidence for the efficacy of SRP, especially when combined with supragingival plaque/biofilm control. Initial therapy is a consistent and effective therapy, and the overall response is greater in sites with more periodontal destruction. There is consistent, clinical evidence to support full mouth (FM) or quadrant approach to SRP. Both approaches result in clinically consistent outcomes and FM has not been shown to be superior to a multiple session SRP.2
• In tobacco users, more periodontal destruction can be attributed to the use of tobacco products than to inadequate oral hygiene.2 Therefore, nonsurgical periodontal therapy should include emphasis on tobacco cessation and control.
• Evidence on efficacy of providing professional plaque/biofilm instruction is disappointing and specific oral hygiene interventions vary in efficacy.2 For example, flossing instruction and motivating patients to floss does not appear to result in improved oral hygiene. Powered toothbrushes, on the other hand, show promise in improving oral hygiene status.2
• Evidence supports the adjunctive use of systemic antibiotics, especially in aggressive cases and results in an additional clinical attachment gain of 0.64 mm. Local delivery antimicrobials (PerioChip, Atridox, or Arestin) provide a small effect for a limited number of sites in chronic adult periodontitis. But for multiple affected sites, a systemic antibiotic would likely be more cost-effective.2
• There is little reliable evidence to determine which interventions are appropriate for treating peri-implantitis. In addition, there are a lot of myths about care and maintenance of implants, including choice of instruments.2
A certain mindset is required to grasp and adopt EBD in clinical practice. I asked Julie what's required of an individual in adopting that mentality. She said it's simply an innate curiosity that, when embraced, empowers you to examine all aspects of life differently. Curiosity is something that can be nurtured and developed, and critical thinking skills follow. Everyday tasks, such as selecting food for your family or making important medical decisions for your children can become more interesting, and you always end up wanting to know more about any given subject.
Adopting EBD and paying attention to external clinical evidence is important to professional growth. The interpretation of scientific evidence changes over time and is no substitute for clinical expertise. Combining both evidence with clinical expertise can transform clinical dental hygiene into more interesting and enjoyable experiences. Adopting EBD in clinical practice is a win-win for clinicians and patients alike. RDH
References
1. Hawley JF. (Ed.) Evidence-Based Dentistry for the Dental Hygienist, Chicago, IL: Quintessence, 2014.
2. Gunsolley J, Pellegrini J. 2014. Application of evidence-based dentistry to periodontal diseases. In: Hawley JF. (Ed.)
Evidence-Based Dentistry for the Dental Hygienist, Chicago, Quintessence. pp. 235-253.
3. Chungie L. Periodontal therapy for the management of cardiovascular disease in patients with chronic periodontitis. Cochrane Database Syst Rev 2014. CD009197.
4. Bobetsis YA, Borgnakke WS, Papapanou PN. Periodontal infections and adverse pregnancy outcomes. In: Glick M. The Oral-Systemic Health Connection, Chicago, Quintessence. 2014. pp. 210-217.
LYNNE SLIM, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the Evidence-Based Dental Hygiene Group (EBDH) on LinkedIn. Evidence-based periodontal therapy will be part of the group's focus, and Lynne enjoys mentoring dental hygienists in EBDH. She can be reached at [email protected] or www.periocdent.com.
