July 1, 2007
by Dental Practice Management
Today’s reality of dental hygiene care is recognition of it being a strategic contributor to influencing the quality of life our clients can experience. Our profession serves to not only improve lives but actually save lives. That is an awesome opportunity and responsibility as well as a testimony to the culmination of our efforts.
Technology, evidence-based research and consumer driven demands of dentistry have all served to shape the face of our profession. Evidence based decision making has provided an innovative model for the efficient determination of the dental hygiene treatment plan. A review and analysis of literature is essential to substantiate clinical choices and treatment selection. With the advent of evidence-based research our profession is now privy to a wide variety of literature and studies to advise and direct our treatment decisions.
The last decade has seen the emergence of several technologies and conclusive scientific studies that have impacted the way we deliver care; how we present the dental hygiene treatment plan and how we view the disease we are dedicated to fighting.
As clinicians we have been quite effective in our treatment to date, however not without its limitations. This is not necessarily related to our lack of skill or effectiveness, but more so related to our lack of understanding of the disease process. A profound transition has occurred from viewing the etiology of the disease to being solely bacterial to the current awareness of a second factor. We now recognize the role of the host response to inflammation and the impact this response may have on the periodontal tissues. With our current model of pathogenesis we can now treat our client more effectively.
The focus on integrating technology into the dental hygiene practice has provided many positive spin-offs to our profession. When addressing the bacterial component of the disease, technology has further aided us in providing an opportunity to offer more effective therapy, healing, root preservation and detoxification with the introduction of laser assisted periodontal debridement.
There are numerous types of lasers that have been proven effective for varying clinical procedures. Each laser is identified by a specific wavelength, target tissue and active medium. A laser that is attracted to hemoglobin such as the diode would have a varying array of applications as a soft tissue laser. It is particularly useful for surgical procedures, however has its limitations in regards to calculus removal. In in vivo studies with diode lasers, large amounts of calculus remained after treatment and there was significant structural damage to root surfaces.1 The differences between the in vitro and in vivo studies may be attributed to the presence of blood in vivo, which may influence the amount of fluorescence radiation reaching the calculus.2
Since its first application in the late 1980’s, the Er:YAG laser is the most commonly studied laser for use in periodontal debridement. It has a very high rate of absorption in water and hydroxyapatite. Because of its high rate of absorption in water, the Er:YAG laser ablates hard tissue though “microexplosions” rather than heating the tissue, resulting in minimal thermal side-effects.3
The KaVo KEY 3 Laser is an Er:YAG laser in combination with a unique diagnostic system. The KaVo KEY 3 Laser performs automatic therapy using its integral feedback system to identify and selectively remove infectious calculus. Its ability to distinguish between calculus and root cementum is accomplished by a significantly stronger fluorescence in subgingival calculus than in cementum due to the water content. This provides a higher degree of protection and preservation of the root cementum (Fig. 1).
Along with the contribution of technology, science has presented considerable advances in our understanding of the tissue-destructive mechanisms involved in periodontitis which ultimately affect the dental hygiene treatment plan. Possessing the knowledge that adult periodontitis has the combined causative factors of periopathogens and destructive enzymes (host response), any management should include therapies that address both effectively.
Education is key as it is the primary determinant of the success of any therapy (Fig. 2). The far reaching effects of the chronic inflammatory response need to be clearly understood before initiating the treatment. The constant production of inflammatory mediators such as fibrinogen, C-reative protein and collagenase pose numerous threats to the entire body. We also need to recognize that a prolonged host response is largely responsible for the localized tissue destruction, namely, degradation of the periodontal ligament and resorption of alveolar bone.4
Extensive clinical trials carried out by Dr Lorne Golub, D.M.D., M.D. et al in SUNY Stony Brook’s School of Dental Medicine, have resulted in the introduction of sub-antimicrobial dose doxycycline as an effective means of reducing destructive matrix metalloproteinases derived from the host. This is the result of a collaboration that began over 30 years ago. Doxycycline at the sub-antimicrobial level has proven to inhibit the activity of the enzyme classified as a matrix metalloproteinases (MMP), collagenase from causing further destruction to the periodontium.
In 1998, the US Food and Drug Administration approved Periostat for use as an adjunct therapy to the conventional, non-surgical standard being scaling and root planing in the treatment of adult periodontitis.
Periostat is a twice daily dosing of 20 mg. doxycycline referred to as host modulation therapy. Caton, et al5 found this dosage of doxycycline to facilitate the reduction of periodontal disease progression in placebo controlled studies. Compliance is excellent once a client is aware of the host derived destructive nature of the disease. There is self-empowerment knowing that there is a shared responsibility in the management of the disease.
The enzyme-suppressing technology behind Periostat and its systemic effects have led the Stony Brook investigators and others to explore and identify its therapeutic potential in a wide range of medical disease that share a similar etiology with periodontal disease.6
Along with addressing adult periodontitis is the opportunity to identify cancerous lesions which if left untreated may pose a life threatening risk. Oral cancer is presently the sixth most common cancer in males in the U.S. Unfortunately the survival rate for oral cancer has remained unchanged for decades even thought there have been significant advancements in the treatment of other cancers. If oral cancer is detected in the early stages through screening devices, there is a significant increase in the 5-year survival rate from 52% to over 80%.
A recent survey7 conducted and presented at the 2006 annual session of the American Dental Hygienists’ Association reported that of 1,505 subjects surveyed, only 453 reported having been examined for oral cancer. Of that same group, 506 indicated that they did not have an examination, and 532 were not sure whether or not an oral cancer examination was performed.8 As dental hygienists we are in a unique position to positively address this area of education with our clients and translate this knowledge into application.
Technology has once again risen to the task facilitating a non-invasive, pain free method of identifying lesions at the basement membrane. Through the use of a visible and safe blue light (400 – 460 nanometres), the clinician is able to clearly see the distinction of normal (Fig. 3) vs. abnormal tissue through a variance in fluorescence. Using histology as the gold standard, a novel handheld device (VELscope by LED Dental Inc. White Rock, BC), achieved a sensitivity of 98% and specificity of 100% in a high risk population when discriminating normal oral tissue from severe dysplasia/carcinoma in situ or invasive cancer.9
The light will excite the tissue from the surface of the epithelium through to the basement
membrane and into the stroma beneath causing it to fluoresce. Typically healthy tissue emits a bright green glow while suspicious regions appear dark due to a loss of fluorescence. (Fig. 4)
As Director of the dental hygiene program at Canadian College of Dental Health, I feel very strongly that it is a mandate of the curriculum to ensure that dental hygiene students emerge having knowledge of evidence based advancements which will shape the way they practice. There are numerous advances which could be represented by volumes of text that are having a phenomenal impact on our profession. Technology and science have married together resulting in a re-energizing of our profession. Enjoy!
1. Kreisler, M, Meyer C, Sterider E, Daublander M et al. Effect of diode laser irradiation on the attachment rate of periodontal ligament cells.; an in vitro study. J Periodontol 2001; 72(10):1312-7.
2. Chantaboury, R, Irinakis, T. The Use of Lasers for Periodontal Debridement: Marketing Tool or Proven Therapy? JCDA 2005; 71(9):653-7
3. Gasoirc B, Skaleric U. Morphology, chemical structure and diffusion processes of root surface after Er:YAG and Nd:YAG laser irradiation. J Clin Periodontol 2001;28(6): 508-16
4. Golub LM, Wolff M, Roberts S, et al. Treating periodontal diseases by blocking tissue-destructive enzymes. J Am Dent Assoc. 1994;125:163-171.
5. Caton, JG, Ciancio SG, Bileden TM, et al. Treatment with sub-antimicrobial dose doxycycline improves the efficacy of scaling and root planing in patients with adult periodontitis. J Periodontol. 2000;71:521-532
6. Resnick, Nicole. Dental Research Yields Powerful Product in the Fight Against Periodontal Disease. 25 Innovations That Changed the World. 2006;24:109-112
7. Hein C, Kunselman B, Frese P. Preliminary findings of consumer-patient’s perceptions of dental hygienists’ scope of practice/qualifications and the level of care being rendered. American Dental Hygienists’ Association Annual Session. June 2006.
8. Gurenlian, J. The Role of the Dental Hygienist in Oral Cancer Screening, Education, and Management. The Inside Summit on Oral Cancer Discovery and Management 2007;3(2):21-2
9. lane, P.M., Gilhuly, T., Whitehead, P., et al. Simple device for the direct visualization of oral-cavity tissue fluorescence. J Biomed Opt. 2006 Mar-Apr;11(2):024006
Jo-Anne Jones is the Program Director for the Dental Hygiene Program at Canadian College of Dental Health in Burlington, Ontario. Jo-Anne has lectured extensively across Canada and internationally focusing on clinical excellence and client care. Jo-Anne remains active as a lecturer, author and educator.