Profile in Oral Health: The RDH’s Approach to Periodontal Therapy: Past, Present and Future by Trisha O’Hehir, RDH, MS Editorial Director, Hygienetown

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.