The tissue is the issue: Managing periodontal disease when calculus is absent

In this episode of Fast Facts: Ask the Expert , Katrina Sanders, RDH, addresses a common clinical challenge: signs of active disease in the absence of detectable calculus. While many clinicians are trained to instrument until they achieve a glassy root surface, Sanders explains why this approach may overlook the true source of infection and even cause unnecessary damage to healthy cementum.

This session covers:

• The biological reality of cementum: Why naturally "grainy" root surfaces are normal and how over-instrumenting can lead to tooth sensitivity.

• Tissue-associated plaque: Understanding how pathogens infiltrate the junctional epithelium, creating a soft tissue infection that cannot be managed by tactile instrumentation alone.

• Adjunctive therapy options: Strategies for disrupting biofilm within the tissue, including the use of localized antimicrobials, oxidizing agents, and probiotics.

• Thinking beyond the tooth: When to utilize salivary diagnostics and how to identify systemic contributors like poor glycemic control or hormonal changes.

Episode transcript

Katrina Sanders:

You're listening to Fast Facts: Ask the Expert with Katrina Sanders.

Katrina Sanders:

Hey, everyone, and welcome back to Ask the Expert , the bite-sized podcast for dental hygienists who want to sharpen their clinical edge. I'm your host, Katrina Sanders, and today we're diving into a deceptively tricky situation that most of us have encountered in practice.

And that is: what do you do when the gingiva looks diseased, but you can't find any calculus? Red, puffy, bleeding gums, maybe even some persistent pocketing. Yet when you explore that root surface, it's smooth as glass. Let's unpack what's really going on.

The smooth root surface dilemma

So you've got the patient reclined. You're probing and seeing fives, maybe sixes. Is the tissue edematous , fragile? Maybe it bleeds just upon the lightest stroke. But when you go in with your explorer or even your ultrasonic, the root surface is smooth.

So you pause, wondering, is this really active disease if I can't feel any calculus? So here's the clinical truth bomb: calculus is not always the culprit. We've been trained, some of us drilled, to feel for that glassy, smooth root surface.

But biologically, we know that healthy cementum is not glass smooth. In fact, it's naturally grainy. That's normal, and overtly aggressive root planing to smooth it can cause unnecessary damage and subsequent sensitivity.

Tissue-associated bacteria

So let's shift the focus. If there's no tenacious calculus, what else could be contributing to these clinical signs of infection? And that is tissue-associated bacteria. We know that biofilm isn't just tooth-bound. In chronic periodontal disease, pathogens will infiltrate that cellular and junctional epithelium. And this is known as tissue-associated or epithelial-associated plaque. And it's often invisible, undetectable by tactile means, and extremely pathogenic.

In other words, the tissue is the issue. So when we're seeing signs like bleeding, inflammation, or non-resolving pocketing, even without detectable calculus, we may be dealing with a residual soft tissue infection that oftentimes requires adjunctive therapies to fully manage.

Clinical management options

So let's take a look at some of our clinical options:

• Option one: reevaluate instrumentation expectations. So instead of chasing smooth-as-glass root surfaces, consider prioritizing thorough debridement of detectable deposits without over-instrumenting.

• Number two: introduce adjunctive therapies. So this is where we would consider localized antimicrobials, subgingival oxidizing agents, or tray-delivered gels to disrupt a biofilm in the tissue itself. We may also consider the integration of things like locally delivered or systemically delivered probiotics.

• Step three: consider refractory or resistant pathogens. If a site isn't healing despite adequate debridement, you may need to introduce salivary diagnostics or microbiological testing to understand what kinds of pathogens are still at play.

• And four: think beyond the tooth. Ask about systemic contributors or potential underlying undiagnosed conditions. Things like poor glycemic control, hormonal changes, or immune suppression can all lead to an exaggerated inflammatory response, even in the presence of minimal biofilm.

Closing thoughts

So next time you're scratching your head because that tissue looks angry but the roots feel smooth, remember, it might not be what's under the tooth. It might be what's inside the tissue. Stay curious, stay calibrated, and keep asking the right questions because that's what expert clinicians do. Thanks for tuning in to Ask the Expert . I'm Katrina Sanders, and I'll catch you next time.

Please feel free to reach me on Instagram at The Dental Winegenist or on my website, katrinasanders.com . Cheers! Thank you for listening to Fast Facts: Ask the Expert .

Andrew Johnston:

If you have a topic you'd like one of our experts to answer, simply email me, Andrew, at ataleoftwohygienists.com and we will get it on the air as soon as possible. Thanks for listening.