BY LYNNE SLIM, RDH, BSDH, MSDH
When I was a child, my grandma loved to tell a story about her neighbor who would circle around his mailbox twice before collecting his mail. He would walk out to the crooked box and smile broadly at it — almost as though he were greeting a long-lost friend. Next, he would walk around it twice, returning to the front of it and stare at it once more. Finally, he would reach out and pull open the rusty metal door and retrieve the mail. After telling the story, my grandmother would wipe the tears of laughter from her eyes, tuck the tissue back into her sleeve, and say, “Different strokes for different folks.”
No one seems to know from where the above proverb originated, but we know it means that different things appeal to different people. The same can be said for dental hygiene protocols and subgingival instrumentation.
I belong to a couple of perio chat groups on LinkedIn, including one called the Perioscopy Forum. It is there that I read some posts by Nancy Kiehl, RDH, MS, who received the 2012 ADHA/Hu-Friedy Master Clinician Award. Nancy is a Perio-scopy devotee and is currently working in two periodontal practices, both of which use Perioscopy to visualize the subgingival environment.
I recently read an article online where Nancy discusses subgingival instrumentation and biofilm/calculus management, and I’d like to discuss this topic from Nancy’s viewpoint and from an evidence-based perspective.1
I’ve already written many times before about the dental endoscope, and my last article on the subject featured Suzanne Newkirk, RDH, and Dr. John Kwan, a periodontist. Both train dental hygienists, dentists, and periodontists in Perioscopy.2
Both Suzanne and John view the subgingival environment while scaling, and they are both insistent that aggressive, blind scaling frequently hacks up roots. Using 25/30K magnetostrictive ultrasonic units with 25K inserts, Suzanne and John use micro-ultrasonic tips (the size of a perio probe) for supra- and subgingival debridement while viewing the tooth and root endoscopically. John doesn’t use any hand instruments for debridement, and Suzanne uses very few (her favorites are American Eagle’s sharpen-free XP technology Barnhart #5/6 and an XP technology sickle scaler for anterior teeth). Right and left inserts are preferable to straight inserts to better fit concavities and furcations in posterior teeth.
With the right technique and instrument adaptation, John insists you can get great results using ultrasonic instruments only.
Nancy, in contrast to Suzanne and John, is a big advocate of hand instrumentation, and she prefers hand instruments for debridement procedures for improved maneuverability and tactile sensitivity. She uses ultrasonics with Perioscopy (agrees with Suzanne and John about the advantages of visualizing a pocket habitat) but prefers to remove subgingival calculus with a hand instrument when she cannot see what she is instrumenting. She often employs the “view, instrument, view” technique with hand instruments because there isn’t enough room in the pocket even with a micro mini curette. She gets excited about working her way around the root surface with an appropriate hand curette before visualizing her results with the endoscope. Sometimes, if the pocket is shallow, she can scale with a hand instrument while viewing through the endoscope, and she prefers to view the area while scaling.
Nancy admits that a thin ultrasonic insert is better at removing tiny spicules of calculus that are embedded in cementum and she believes it’s a good idea to teach students to hand instrument first and then finish with an appropriate ultrasonic insert. Nancy is proud of her mastery of hand instrumentation and she calls it “precision.” Nancy agrees that any instrumentation — hand or ultrasonic — can be damaging to the root when the clinician can’t visualize it. She also agrees that endoscopic root debridement is the least damaging and most thorough procedure available for root debridement. Nancy uses thin ultrasonic inserts/tips and micro mini curettes for instrumenting difficult-to-access furcations and concavities. In other areas where access is limited (for example, distal of second molars), she will “view, instrument, view” there, too.
Scaling and root planing is an inaccurate, tired term that was based on the traditional belief that root planing was required to remove diseased cementum to produce a smooth tooth surface devoid of bacterial endotoxins.3 More recent studies have found instead that periodontal health can be achieved without the removal of infected cementum. Unfortunately, however, meticulous debridement to remove as much calculus as possible includes cementum removal. It has been suggested that the primary therapeutic advantage of root planing is that it facilitates the removal of biofilm/plaque and calculus root irregularities.3
It turns out that large amounts of endotoxins can be removed by fairly nontraumatic and gentle procedures such as ultrasonics. Excessive hand instrumentation — such as what Nancy, Suzanne, and John warn about — can and should be avoided. Micro-ultrasonics on a low-moderate power setting is perfect for passing lightly over root surfaces to remove light calculus and subgingival bacterial biofilm.
Numerous studies have shown that manual and sonic/ultrasonic instrumentation are equally effective in treating periodontal disease and both result in a similar healing response.3 Sonic/ultrasonic instrumentation, however, is more time efficient with many ergonomic benefits.4
We now know that a single session of debridement can significantly reduce the pocket bacterial bioburden, even though residual calculus often remains in areas with limited access.3 According to the research, surfaces with small deposits of remaining calculus following instrumentation in the absence of bacterial plaque/biofilm can be compatible with a clinically acceptable level of gingival wound healing, indicating that plaque/biofilm has a greater pathogenic potential.3 On the other hand, residual calculus has the potential to increase the detrimental effect of plaque/biofilm (as a plaque-retentive factor) so the removal of calculus with overlying plaque/biofilm is an important factor in therapeutic outcomes.
As the U.S. economy continues to struggle, dental practices are also struggling. To economize, some dentists are performing dental hygiene services. General dentists receive only about 295 clock hours in periodontics — compared to 2,700 hours for the dental hygienist — and it’s unclear whether or not dentists spend adequate time on periodontal instrumentation. Hygienists are sometimes working with broken ultrasonic units, worn, unusable ultrasonic tips/inserts, and dull curettes. In some practices, dental hygienists receive inadequate time for instrumentation.
Compare this scenario to that of Nancy Kiehl, Suzanne Newkirk, and John Kwan’s instrumentation protocols and it’s clear that theirs is solidly evidence-based and their actions clearly serve the welfare of their clients. Dental professionals are a lot like our crazy neighbors — different strokes for different folks — and there are clear consequences for our clients when personal goals/economic factors outweigh professional obligations.
My grandmother and her neighbor used different processes to gather their mail. Although different, they achieved the same results. Nancy Kiehl, Suzanne Newkirk, and John Kwan each took slightly different paths to achieve successful outcomes. The common denominator throughout was the meticulousness of their efforts coupled with a foundation of a scientifically valid foundation of evidence. As I reflect on their differences, I can hear my grandmother now exclaiming, “Different strokes for different folks.” RDH
References
1. http://www.dimensionsofdentalhygiene.com/ddhright.aspx?id=11940#.UFD610KhBCg
2. http://www.rdhmag.com/articles/print/volume-31/issue-5/features/let-it-shine-or-do-it-blind.html
3. Apatzidou DA. Modern approaches to non-surgical biofilm management. Front Oral Biol 2012; 15: 99-116.
4. http://www.rdhmag.com/articles/print/volume-30/issue-1/feature/ultrasonics-amp-ergonomics.html
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 periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.
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