Past 1960-1985
Scientific Basis for Periodontal Treatment
Calculus was considered the cause of periodontal disease in
the 1960s. It was viewed as a mechanical irritant to the tissue
and removal was considered the primary treatment for periodontal
disease. This was followed by the "non-specific plaque
hypothesis" that suggested plaque was the primary etiological
factor and all plaque was bad plaque. It was the amount of
plaque that caused disease. No research was able to prove this, as
some patients had so much plaque they deserved disease, but
didn't have any pockets. And others had very little plaque on
their teeth, but the connective tissue and bone seemed to be
melting away.
Plaque was considered "white sticky stuff " on the teeth
made up of bacteria and it was stained red to show patients
where they missed with brushing and flossing. It wasn't until
dental offices in the 1970s began using Phase Contrast
Microscopy that clinicians actually saw the bacteria as living,
growing, multiplying creatures. This enhanced the clinician's
view of plaque, captivated some patients and frightfully scared
others. It changed the focus from just calculus removal to the
importance of daily plaque removal. It was in the 1960s when
Dr. Bass, having lost a tooth to periodontal disease, studied and
published his findings on the importance of daily plaque control
using his Right Kind toothbrush and dental floss.
Next came the "specific plaque hypothesis" that suggested
just one bacteria was responsible for periodontal disease. In the
1970s it was widely believed that the identification of a specific
bacteria responsible for periodontal disease would be discovered
and a vaccine would be developed to eliminate both periodontal
disease and the dental hygiene profession. Who would need
hygienists if periodontal disease no longer existed? During the
1980s, periodontal researchers were on a quest to identify
pathogens within plaque. Each month the periodontal research
journals heralded the discovery of yet another pathogen thought
to be the "one" responsible for periodontal disease. Identification
of bacteria within plaque was done with Scanning Electron
Microscopy. Plaque samples are placed on a slide, dried, sputtered
with gold and evaluated to identify bacteria. As the
months grew to years, it became known as the "bug of the
month club" as more and more pathogens were identified.
Periodontists identified six to eight potential pathogens among
500 identified species in plaque and research never confirmed
one specific bug responsible for gingivitis or for converting gingivitis
to periodontitis.
With a top-10 list of bacteria identified as the virulent
pathogens, the research turned to the episodic nature of the disease.
Periodontitis was characterized as having periods of quiescence
and periods of disease progression.
Dental Hygiene Education
Dental hygiene education in the 1960s focused on supragingival
deposit removal. Periodontal disease was identified by
holding the radiographs up to the light to determine bone loss.
Severe, generalized bone loss on the radiographs was a conclusive
diagnosis of periodontal disease and these patients were
referred to the periodontal department where periodontal probing
was done. Probing was not done in the hygiene department.
Hygiene students did see periodontal patients for calculus
removal, since calculus was the enemy and had to be removed.
Power scalers were used only on the toughest cases, followed by
extensive hand instrumentation to achieve glassy smooth root
surfaces. Power scalers were used for a single pass around the
mouth to remove only gross deposits. The bulk of the instrumentation
was done with curettes. The importance of calculus
removal carried over to the state board examinations requiring,
still today, removal of a specific number of calculus deposits. In
the 1960s calculus was considered a mechanical irritant that
caused periodontal disease.
Treatment
Treatment of periodontal disease by dental hygienists
included scaling and root planing performed with primarily
curettes and scalers but also some power scalers used prior to
hand instruments for gross supragingival deposits. The curettes
were generally Gracey and Columbia designs. The Gracey
curettes were designed by Dr. Clayton Gracey in the 1930s to be
used during flap surgery, not for closed instrumentation as they
are used by hygienists even today. But since these were the only
instruments available to hygienists to remove subgingival
deposits, they became the standard. These site-specific curettes
adapt well to root surfaces when the gingival tissue is reflected
back during flap surgery, but when used by hygienists to access
subgingival deposits, they presented unique problems and challenges
to effective deposit removal.
Present: 1985-2013
Scientific Basis for Periodontal Treatment
Calculus is no longer thought of as the cause of periodontal
disease, but the result of periodontal infection in the tissues. The
introduction of Laser Confocal Microscopy by engineers studying
biofilm changed the focus of the dental world from identification
of specific bacteria within a biofilm to identification of
the structure, composition and function of the polysaccharide
slime that housed the bacteria in a biofilm. Instead of drying
out a plaque sample to view it using a Scanning Electron
Microscope, the oral bacteria were allowed to form a biofilm in
a fluid environment on a stage of sorts. Digital images are taken
as slices through the living biofilm and digitally assembled to
provide a video film of living biofilm in action. Learning more
about the way bacteria live and function has changed the view
of periodontal disease. Periodontal pathogens within a biofilm
release toxic waste products that pass through the junctional
epithelium and trigger an immune response from the body. It is
this immune response from the body that destroys connective
tissue and bone, not the bacteria directly.
It's not just about the bacteria either, as smoking and diabetes
were the first recognized risk factors observed to interfere
with periodontal healing. Today, epigenetic differences, changes
in gene expression due to environmental factors, stress and diet
impact the disease process and healing. Although basic DNA
doesn't change, how the genes are expressed does change and
this impacts periodontitis, cancer and other inflammatory diseases.
Eliminating the stressor, nutritional deficiency and bacteria
can reverse alterations in gene expression, or they can remain
and be passed on to future generations with potential detrimental
effects. Research is focusing on the link between the oral cavity
and the rest of the body. Periodontal disease doesn't cause
systemic disease, but oral and systemic health are linked.
Today bacteria in oral biofilm are identified by genetic testing,
with estimates that only 50 percent of pathogens can be culcultured.
Today genetic identification of bacteria estimate the
mouth is home to more than 800 genetically different species.
Bacterial species are grouped by colors denoting their virulence
from red, the worst, to orange, yellow, blue and green.
Antibiotics, both systemic and locally delivered, are used to
fight the pathogens of periodontal disease. Systemic antibiotics
will effectively target bacteria that have found parking spaces
within the ulcerated epithelial pocket lining. They are not effective
against pathogens within the biofilm on the root surfaces, as
these surfaces are outside the body. Locally applied antibiotics
and antimicrobials target bacteria on subgingival root surfaces.
Dental Hygiene Education
Both assessment and diagnosis of periodontal disease provide
the foundation of periodontal education for dental hygienists
today. Hygienists need to recognize the signs and symptoms
of periodontitis and distinguish between gingivitis and early,
moderate and severe periodontitis. They must also identify risk
factors and devise a dental hygiene treatment plan to bring a
patient back to periodontal health and keep those who are periodontally
healthy, just that: healthy.
Treatment
Hygienists still provide non-surgical therapy today, and
nearly all hygienists are now licensed to provide local anesthesia,
no longer needing to wait for the dentist to anesthetize their
patients. Power scalers are used as the instrument of choice for
access and removal of subgingival deposits. Hand instruments
supplement the primary work done by power scalers. New
instrument designs provide some minor alterations in blade and
shank length for Gracey curettes. New instrument designs are
being introduced to access subgingival areas more effectively and
with no tissue trauma from the offset blade of traditional
curettes. The O'Hehir curettes have a tiny scoop blade, with no
offset blade and provide easier adaptation to narrow subgingial
areas as well as supragingival sites. Lasers are now used by
hygienists in addition to power and hand instruments.
The endoscope was introduced and is still used by many
hygienists to "see" the subgingival root surface and tissue wall
magnified up to 46 times. Endoscopy allows hygienists to effectively
remove all subgingival deposits associated with pocket wall
infection. Although the perioscope is no longer being produced,
prototypes of advanced endoscopes are being developed to further
enhance subgingival instrumentation. Soon blind subgingival
instrumentation will be a thing of the past.
In addition to instrumentation, the patient's immune system
is enhanced with nutritional supplementation. Several products
specific to periodontal tissue health are now available that contain
vitamins, minerals and herbs. Salivary testing is also available
to determine exactly which bacteria dominate the bacterial
biofilm. In some cases, systemic antibiotics are recommended.
Mechanical disruption of bacterial biofilm is still the primary
focus of patient oral hygiene activities.
Future: 2014 and Beyond
Scientific Basis for Periodontal Treatment
The focus until now has been on treatment of periodontal disease
with scaling and root planing. Moving forward the focus will
be on early intervention for prevention. Why wait until the damage
is done to find effective preventive methods? Today's research
shows that dental disease is completely preventable, and it is also
clear from the research and from the level of disease still seen
today that brushing and flossing do not effectively prevent dental
disease. The future will provide patients with the tools and coaching
they need to effectively manage their oral biofilm. More will
be available than mechanical disruption of plaque biofilm.
Adding xylitol to the diet five times daily results in a 50 percent
reduction of biofilm. That's better than toothbrushing, which is
shown to reduce plaque by 42 percent in the hands of patients.
Oral probiotics will change the balance of bacteria in oral biofilm,
leading to a healthy microflora rather than a flora conducive to
disease. Mouth breathing will be addressed to shift people back to
nose breathing, which protects oral tissues, but also promotes
regenerative sleep, better brain development in children, ideal
palatal growth and optimal airway development. The pH of the
oral cavity determines which bacteria dominate the bacterial
biofilm. Acid levels will encourage acid-producing bacteria while
alkaline levels will discourage acid-producing bacteria. Since disease
begins on interproximal surfaces first, the focus will now be
on cleaning in between the teeth with things other than string
floss. Flossing with water or using various interproximal devices
are easier to use and more effective than string floss.
Dental Hygiene Education
Oral health coaches will be RDHs with a Master of Science
Degree in Oral Health Promotion. They will be experts in the
science, business and communication of oral health practices
and interventions. They will work with both fee-for-service
coaching contracts with individuals and families, as well as with
medical insurance companies focused on the financial bottom
line, recognizing the cost savings on many levels from optimal
oral health. The science supporting new approaches to prevention
will be the foundation of this education, along with skillbuilding
in the business of dental hygiene and effective
communication. Education of the future will not be based on
structured courses, but rather reflective and inquiry learning
that ask questions about what they are doing now to promote
oral health and how effective it is. Reflective learning and action
research will guide RDHs in their development of new work
opportunities focused on oral health promotion.
Treatment
Treatment in the future will still require subgingival removal
of bacterial biofilm and calculus within the dental office setting
as it is provided today with non-surgical periodontal therapy in
general and periodontal practices. The use of endoscopes will become the standard of care in the future, looking at the subgingival
area rather than providing treatment blindly. Subgingival
treatment will be done with lasers and instruments designed for
easier subgingival access.
The future will also bring diagnostic codes to be used in conjunction
with treatment codes. This will bring clear delineation
between health, gingivitis, early, moderate and severe periodontitis.
With detailed diagnostic codes come the necessary treatment
codes to eliminate the problem of treating gingivitis and
early periodontitis with a preventive procedure, a prophylaxis, as
is the case in many dental offices today. Specific treatments
codes will be created for the various clinical procedures provided
by dental hygienists.
In the future, effective preventive services will be provided in
settings other than the dental office. Oral health coaching will
become the approach that succeeds in preventing initial disease
as well as preventing recurrence of disease after successful treatment.
RDHs will go to the consumers rather than the consumers
coming to the dental office. They will bring their prevention
message to the general public through family practice medical
practices, OBGYN practices, breathing and myofunctional therapy
centers, schools, nursing homes, hospitals, senior residential
centers, homes, sports clubs, shopping malls and wherever consumers
find oral health coaching convenient. Today's dental
patients have invested time and money for cosmetic dentistry
that requires significant daily attention to prevent root caries and
periodontal disease. Three- to six-month maintenance visits in a
dental office without adequate steps taken on a daily basis to
address biofilm formation, salivary pH, nutrition and immune
response will fail. Dental hygienists are needed to provide weekly
coaching visits for these individuals and families.
Parents report difficulty "brushing and flossing" their children's
teeth. With so many more tools now available, RDH oral
health coaches will be hired by families to come to the home on
a weekly basis to ensure effective biofilm control, salivary pH
control, nutritional counseling, remineralization when necessary
and daily xylitol use. These visits will also address mouth breathing
and tongue positioning to ensure optimal oxygen reaches the
brain for restorative sleep and optimal brain development for
growing children.
Brushing and flossing will no longer be the mantra of prevention.
Instead, control of the biofilm environment and the
salivary pH will be the focus of weekly oral health coaching visits.
Xylitol-containing products, oral probiotics, nasal breathing,
tongue position and nutritional supplementation will be used
to achieve and maintain oral health, not just with periodontal
health, but with overall health. All of these preventive
approaches provided by the future RDH oral health coaches will
prevent more than just periodontal disease; they will begin with
infants and children to set them on the right path to optimal
growth and development and prevention of dental diseases over
their lifetime.
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