As the document states, dental caries is a major global oral health problem, impacting individuals of all ages. In fact, dental caries affects 2.7 billion people worldwide, with low-access populations taking the hardest hit.² The WHO guideline marks a definitive shift in professional philosophy. We are no longer merely managing a clinical condition; we are responding to a global environmental and public health imperative. The new WHO recommendations move beyond a simple substitution of materials. They advocate for a fundamental reorientation toward minimally invasive dentistry. Unlike amalgam, which requires mechanical retention through the removal of healthy tooth structure, mercury-free alternatives support more conservative preparations, preserving the biological integrity of the dentition.

Additionally, the WHO highlights that the most effective mercury-free alternative is prevention. This includes the use of high-concentration fluoride toothpastes, fluoride varnishes, and pit-and-fissure sealants to arrest lesions before restoration is required. Furthermore, the guideline emphasizes nonrestorative interventions. By prioritizing preventive strategies and the arrest of early-stage lesions, the dental community can reduce the cumulative restorative burden. This upstream approach is essential for achieving the equity goals outlined in the WHO mandate, ensuring that the transition to mercury-free dentistry does not exacerbate existing disparities in access to care.

The WHO specifically advises a precautionary approach for certain groups to minimize both mercury and chemical exposures:

• Children and Pregnant Patients: Glass ionomer cements (GICs) are often preferred over resin-based composites in children and pregnant women to avoid potential endocrine disruptors such as bisphenol-A derivatives found in some resins.
• High-Caries Risk: GICs are recommended due to their ability to act as a fluoride reservoir, releasing ions into the surrounding tooth structure to prevent secondary lesions.
• Marginalized Populations and Remote Settings: The use of atraumatic restorative treatment using high-viscosity GICs is promoted for use in settings with limited access to electricity or specialized dental equipment, as it requires only hand instruments.

Our objective is clear: to foster a system in which oral health is maintained through prevention and restored through safe, sustainable, and mercury-free innovation. The roadmap has been provided; our task now is the systematic integration of these standards into every clinic, curriculum, and community. It’s a fascinating time for oral healthcare as we balance high-level environmental policy with day-to-day clinical excellence. That excellence is the heart of the dental hygiene profession.

References

1. World Health Organization. UNEP/MC/COP.6/INF/31/Add.1 – World Health Organization Guideline on Environmentally Friendly and Less Invasive Oral Health Care for Preventing and Managing Dental Caries. Available at https://minamataconvention.org/en/documents/unep-mc-cop-6-inf-31-add-1-world-health-organization-guideline-environmentally-friendly. Accessed March 17, 2026.
2. GBD 2021 Oral Disorders Collaborators. Trends in the global, regional, and national burden of oral conditions from 1990 to 2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2025;405:897-910.

From Dimensions of Dental Hygiene. March/April 2026;24(2):6

Dental caries, a global public health crisis, necessitates continuous evaluation of preventive measures. For decades, fluoride has been the gold standard of caries prevention, recognized for its ability to strengthen enamel and promote remineralization.¹ However, modern concerns regarding systemic toxicity and dental fluorosis have driven interest in biomimetic alternatives, most notably hydroxyapatite — the fundamental mineral component of teeth and bone.^2,3 This article contrasts the mechanisms, clinical efficacy, and safety profiles of fluoride and hydroxyapatite in the context of professional oral care recommendations.

Any discussion of fluoride should recognize that its well-documented benefits overwhelmingly outweigh concerns, particularly when evaluated alongside its strong safety record despite ongoing public debate. Much of the debate stems from concerns about potential systemic effects, perceived overexposure through multiple fluoride sources, and longstanding skepticism toward community water fluoridation programs. Critics argue that population-wide fluoridation may pose risks, such as dental fluorosis or other health effects, while evidence suggests that these risks are generally minimal at recommended levels and are outweighed by fluoride’s proven protective role against caries.⁴

The controversy persists in part because it lies at the intersection of scientific research, public health policy, and public perception, where differing interpretations of fluoride’s mechanisms, dosage, and safety continue to influence public concern despite extensive research documenting its efficacy and safety when regulated according to established guidelines. These concerns have driven the search for equally effective alternatives such as hydroxyapatite.

Fluoride

Dental caries is the result of oral bacteria, such as Streptococcus mutans and Lactobacillus spp., producing an acid that demineralizes the enamel of teeth. Dental decay often progresses asymptomatically in its early stages, as the demineralization of enamel and dentin can occur without immediate pain or noticeable clinical signs. As a result, individuals may remain unaware of the disease process until lesions advance, potentially leading to cavitation, infection, or more complex oral health complications that require extensive intervention.⁴

Dental decay is a prevalent global health concern, particularly affecting children and adolescents.⁴ Oral health professionals prioritize the reduction of dental caries in their patients through effective prevention strategies, which include the use of fluoride. A naturally occurring element found in various minerals, water supplies, and foods, fluoride is available through a variety of sources, including professional applications in dental settings, as well as in toothpastes, mouthrinses, and dietary sources such as food and drinking water.^4-6

Fluoride Benefits

Fluoride can be obtained systemically, through oral ingestion, or topically, a direct application to an intended surface.^4,5 Systemic delivery refers to the intake of fluoride through ingested sources such as food and beverages. Community water fluoridation is an example of systemic delivery; it provides an effective fluoride source due to the frequency with which individuals consume drinking water. Evidence indicates that systemic fluoride exposure during pre-eruptive enamel development contributes to the incorporation of fluoride into the developing tooth structure, promoting the formation of fluorapatite, which enhances enamel resistance to acid dissolution. In contrast, reductions in dental caries observed after tooth eruption are primarily attributed to fluoride’s post-eruptive effects at the tooth surface. Systemic fluoride also provides a topical effect due to saliva containing some fluoride from ingestion. It is continually available at the tooth surface and becomes concentrated in dental biofilm, where it inhibits acid-producing cariogenic bacteria from demineralizing tooth enamel.⁶

Fluoride provides benefits to both the permanent and deciduous dentition. The enamel surface of a newly erupted tooth is not completely mineralized; therefore, the period when the tooth is most susceptible to a carious attack is the first few months after eruption.^6,8 Furthermore, fluoride remains valuable after tooth development is complete, particularly for individuals at high caries risk.^5,6 Fluoride also impedes bacterial carbohydrate metabolism, thereby reducing acid production and limiting the dissolution of tooth enamel.⁶ Fluoride not only prevents dental caries, but when placed on an area of demineralization, can slow or reverse the process.⁹

Fluoride Disadvantages

Fluoride use is associated with certain risks that must be carefully considered alongside its benefits.⁴ One potential risk is dental fluorosis, a condition characterized by hypomineralization of enamel surfaces, resulting from excessive fluoride ingestion during tooth development. Fluorosis can be identified by white or brown lesions on the enamel and can vary from minimal to severe.⁷ Enamel fluorosis occurs exclusively during tooth development; therefore, children whose permanent teeth have fully erupted and adults are not at risk, regardless of systemic or topical fluoride exposure.⁶ Another potential risk is fluoride toxicity resulting from excessive ingestion; however, this risk is not associated with topical fluoride use.⁵

Hydroxyapatite

Hydroxyapatite (HAp) is an excellent alternative to fluoride due to its unique benefits in both preventive and restorative dentistry.^7,10 HAp is the primary inorganic component of human enamel and dentin, comprising approximately 97% and 70% respectively.² Given its biocompatibility and structural similarity to natural enamel, HAp has been widely studied for its ability to support remineralization, protect against caries, and alleviate dentin hypersensitivity. HAp is gaining popularity in dentistry due to its biomimetic properties and potential to remineralize enamel and reduce sensitivity.¹⁰

Hydroxyapatite Benefits

Nano-HAp (nHAp), a synthetic form of this mineral, specifically produced as nanocrystalline particles, ranges from 20 to 100 nm in diameter. This small size is significant because the natural HAp crystallites that compose enamel are around 50 nm in diameter, meaning nHAp particles possess a rod-shaped morphology that resembles those found in natural enamel. The particle size of 20–50 nm in nHAP matches the nano-sized defects caused by acidic erosion on the enamel surface, potentially leading to improved remineralization.¹¹

HAp acts as a source of calcium and phosphate ions, essential for enamel repair.¹¹ Studies indicate that nano hydroxyapatite particles integrate into the enamel matrix, filling microdefects and restoring lost mineral content.⁷ HAp directly supplements the natural enamel composition, leading to enhanced structural integrity.¹²

Similar to fluoride, HAp is effective in occluding dentinal tubules, thereby redirecting fluid movement within the tubules that contribute to hypersensitivity. Clinical trials have shown significant reductions in dentin hypersensitivity with patients using HAp-based toothpaste and mouthrinses.¹²

HAp particles can deposit onto and penetrate into demineralized enamel and dentin, providing a direct source of calcium and phosphate ions to facilitate remineralization.^3,10,11 Some studies suggest that HAp can reach deeper layers of the lesion compared to fluoride, which primarily acts on the surface.^3,10 Clinical trials have shown that HAp-containing oral care products can effectively reduce the risk of dental caries.^{3, 13}

HAp is considered safe if swallowed, making it an ideal substitute for fluoride in oral care products tailored for young children who are more prone to ingesting toothpaste.^{2,3, 11} HAp has also demonstrated anti-adherent and antibacterial effects, contributing to the management of oral biofilms, and nHAp can adhere to both enamel and artificial dental surfaces, potentially disrupting bacterial colonization.^3,7,14

Hydroxyapatite Disadvantages

While promising, HAp-based oral care products also present certain limitations. Although research on HAp is growing, more extensive long-term clinical trials are needed to fully establish its effectiveness compared to fluoride under various conditions.^8,11 Another limiting factor associated with HAp is availability and cost. HAp-based products may not be as readily available or as cost-effective as traditional fluoride-containing products.¹¹

Furthermore, the remineralization potential of nHAp may be concentration-dependent, with studies suggesting an optimal concentration of 10% for efficacy.^{11, 12} Aggregation of HAp particles at higher concentrations could potentially hinder its penetration into carious lesions. This is due to the unavoidable aggregation of particles at higher concentrations, which causes them to clump together and physically block surface pores, which restricts the further penetration of HAp into the deeper regions of the lesion and results in a self-limiting plateau of the remineralization effect.^11,12

HAp’s mechanism of action in caries prevention is primarily based on biomimicry.^11,12 HAp particles dissolve slightly in the oral environment, releasing calcium and phosphate ions that can precipitate onto demineralized enamel and dentin, rebuilding the lost mineral.^2,12 Nano-HAp particles can directly bind to the damaged enamel surface and fill in porous irregularities, restoring surface integrity. HAp can interact with bacterial biofilms, inhibiting their adhesion and growth.^10,11

Better Together

Combining HAp with fluoride enhances enamel microhardness and provides a stronger remineralization effect. Novel research has increasingly focused on investigating the benefits of combining hydroxyapatite and fluoride in oral care products, often exploring synergistic effects.^11,15

Studies have demonstrated a synergistic effect between sodium fluoride and HAp for remineralization.¹¹ Studies have demonstrated that HAp can be purposefully combined with fluoride, among other active agents, depending on the desired product outcome. A harmonious effect between sodium fluoride and HAp for remineralization has been documented.² This combined approach resulted in significantly less demineralization depth when used to prevent enamel demineralization adjacent to orthodontic brackets. Furthermore, the combination of nHAp with fluoride has been shown to provide better enamel resistance to erosion in bovine teeth.¹¹

The inclusion of HAp nanoparticles alongside a high fluoride concentration has also been utilized in experimental dentifrices aimed at managing root demineralization.¹⁵ Moreover, some in vitro results suggest that HAp’s remineralization capabilities may be improved by substituting ions like zinc or fluoride into the HAp lattice, which aids in improving the stability, solubility, and strength of the HAp.¹¹ Additionally, an in vitro study found that a toothpaste containing nHAp along with fluoride exhibited a higher remineralizing effect and greater increase in microhardness on initial dentin carious lesions compared to the fluoride-only control group.¹⁵

Conclusion

Based on an expanding body of clinical and in situ evidence, fluoride-free oral care products containing hydroxyapatite have been shown to be effective and consistently demonstrate noninferiority to conventional fluoride toothpastes in reducing the risk of dental caries across all age groups.^2,3,12 While fluoride remains a powerful anticaries agent whose topical effects are crucial for oral health maintenance, its associated risks of dental fluorosis and potential systemic toxicity, particularly in infants and pregnant women, are unavoidable consequences of systemic ingestion.

Hydroxyapatite offers a clear advantage in safety and biocompatibility, as it is nontoxic if swallowed and carries no risk of fluorosis. Given the growing demand for safe, biomimetic, and multifunctional preventive agents, hydroxyapatite stands as a highly viable and scientifically supported alternative for comprehensive preventive oral healthcare.

References

1. Hung M, Hon ES, Mohajeri A, et al. (2023). A national study exploring the association between fluoride levels and dental fluorosis. JAMA Network Open. 2023;6: e2318406.
2. Pawinska M, Paszynska E, Amaechi BT, Meyer F, Enax J, Limeback H. Clinical evidence of caries prevention by hydroxyapatite: An updated systematic review and meta-analysis. J Dent. 2024;151: 105429.
3. Limeback H, Enax J, Meyer F. Biomimetic hydroxyapatite and caries prevention: a systematic review and meta-analysis. Canadian Journal of Dental Hygiene. 2021;55(3):148–159.
4. Pontigo-Loyola AP, Mendoza-Rodriguez M, de la Rosa-Santillana R, et al. Control of dental caries in children and adolescents using fluoride: An overview of community-level fluoridation methods. Ped Repor. 2024;16:243–253.
5. Bowen DM, Pieren JA. Darby & Walsh Dental Hygiene: Theory & Practice. 5th ed. Philadelphia: Saunders/Elsevier; 2019.
6. Harris NO, Garcia-Godoy F, Nathe CN. Primary Preventive Dentistry. 8th ed. London: Pearson; 2014.
7. Paszynska E, Pawinska M, Enax J, et al.Caries-preventing effect of a hydroxyapatite-toothpaste in adults: a 18-month double-blinded randomized clinical trial. Front Public Health. 2023;11:1199728.
8. Lynch RJ. The primary and mixed dentition, post-eruptive enamel maturation and dental caries: A review. J Int Dent. 2013;63:3–13.
9. Aoun A, Darwiche F, Al Hayek S, Doumit J. The fluoride debate: The pros and cons of fluoridation. Prev Nutr Food Sci. 2018;23:171–180.
10. O’Hagan-Wong K, Enax J, Meyer F, Ganss B. The use of hydroxyapatite toothpaste to prevent dental caries. Odontology. 2022;110,:223–230.
11. Chen L, Al-Bayatee S, Khurshid Z, Shavandi A, Brunton P, Ratnayake J. Hydroxyapatite in oral care products—A review. Materials. 2021;14:4865.
12. Anil A, Ibraheem WI, Meshni AA, Preethanath RS, Anil S. Nano-hydroxyapatite (nHAp) in the remineralization of early dental caries: A scoping review. Int J Environ Res Public Health. 2022;19: 5629.
13. Campus G, Cocco F, Wierichs RJ, et al. Effects of hydroxyapatite-containing toothpastes on some caries-related variables: A randomised clinical trial. Int Dent J. 2024;74:754–761.
14. Meyer F, Amaechi B, Fabritius H, Enax J. Overview of calcium phosphates used in biomimetic oral care. Open Dent J. 2018;12,406-423.
15. Ebadifar A, Nomani M, Fatemi SA. Effect of nano-hydroxyapatite toothpaste on microhardness of artificial carious lesions created on extracted teeth. J Dent Res Dent Clin Dent Prospect. 2017;11:14–17.

From Dimensions of Dental Hygiene. March/April 2026;24(2):9-13

Ultrasonic instrumentation is part of initial nonsurgical periodontal therapy for Stages II and III periodontitis cases (to learn about it’s role in Stage 1 periodontitis, read Part 1 of this article series).¹ Subgingival instrumentation is performed with hand or powered instruments and that choice is based on experience, skills, and preferences of the clinician and patient.²

The stages of periodontitis are subdivided into severity and complexity. Severity is determined by interdental clinical attachment loss (CAL), radiographic bone loss, and tooth loss. Complexity is based on maximum periodontal probing depth and horizontal or vertical bone loss. Grades A to C are the progression rates and associated risk factors.^2-4

The periodontal diagnosis is determined after analyzing full-mouth CAL and periodontal probing depth along with bleeding on probing. Periodontal charting provides a roadmap for scaling and root planing for Stage II and III cases and should be referred to often during instrumentation. Root anatomy, biofilm distribution, and calculus type also are evaluated to determine instrumentation needs.

Biofilm is the main pathology for periodontitis, however, calculus plays a direct role in periodontal inflammation and destruction.⁵ Research shows that 70% of inflammation in deep periodontal probing depth is associated with calculus covered by biofilm and less than 20% of inflammation is related to biofilm alone.⁶ Inadequate calculus removal aids in failed periodontal therapy.⁵

Stage II Periodontitis

Stage II periodontitis is characterized by 3 to 4 mm of interdental CAL, radiographic bone loss at the coronal third (15% to 33%), maximum probing depth of 5 mm, and horizontal bone loss.² For initial therapy, multiple ultrasonic inserts/tips (UITs) will be needed to thoroughly provide nonsurgical instrumentation. Multiple designs are required to adapt to various locations in the mouth, pocket depth, root anatomy, biofilm, and calculus. Calculus size and tenacity are important as calculus of any size can be tenacious.

Standard (ie, traditional, robust) UITs, such as a beavertail, triple bend, or universal design, are utilized first for heavier and tenacious calculus. The beavertail design has a flat surface on the end that is adapted. A triple bend is thought to enhance removal of tenacious deposits because of the concentration of energy around the beveled surfaces. The universal design is most effective for moderate or heavier deposits where access is challenging such as posterior areas and extending slightly subgingival when inflammation permits. Some universal designs are longer and wider than others; therefore, evaluate manufacturers’ options to meet clinician and patient needs. After the larger and tenacious calculus is removed, proceed to remove the lighter deposits in the quadrant, sextant, or half mouth depending on care planning.

For light to moderate subgingival deposits, implement curved right, curved left, and straight designs to meet the needs of deposit removal on line-angle convexities and proximal concavities. These designs, identified as slim, thin, or precision, are usually round in cross section and vary in diameter and length. Refer to the manufacturer’s instructions for recommendations on power settings for UITs; however, strive to use at the lowest power setting possible to enhance comfort and deposit removal, keeping in mind that low power settings may cause burnished calculus.

Early grade furcation involvement (Grade I or II) might be encountered, requiring right and left curved designs ideal for adapting to these defects. The use of only one thin straight tip to save time and effort from changing UITs may negatively impact calculus removal. The narrow and straight design does not adapt well to root anatomy, and a low power setting could result in burnished calculus. Instead, straight thin design should be employed to finalize instrumentation in areas with pocket depth and no furcation involvement.

Adapting the UIT with a vertical orientation (ie, parallel to the long axis and directed toward the pocket base or coronal border of calculus) is used to fracture tenacious, heavy calculus and to reach the base of narrow periodontal pockets (Figure 1 and Figure 2). Tips used for this orientation should be the standard beveled or universal designs for tenacious calculus and thin UITs for narrow pocket depth. Horizontal orientation, which is perpendicular to the tooth, is used most often on proximal surfaces with curved UITs. Oblique orientation positions the UIT on the lateral surface; curved UITs may be used. Implement right and left UITs by either adapting the end that curves toward the mesial surface, adapting the lateral surface of a UIT (Figure 3) or apply the convex back of a magnetostrictive insert tip on the buccal, lingual, and proximal surfaces (Figure 4).

Use mostly light pressure as the tip is always moving in an elliptical motion and should remove deposits without pressure from the grasp and fulcrum. Moderate pressure might be indicated for heavier tenacious deposits. Some ultrasonic units have a boost option to increase the power to enhance removal without adding pressure from the operator. Clinicians should move methodically within the periodontal pocket to completely remove deposit and avoid leaving residual or burnished calculus. Take time to deliberately contact deposits and the root structure in an organized and relaxed manner. Deposits are not removed without contacting the tip; therefore, overlapping, short strokes are paramount.

Furcation involvement exists most likely on the mandibular first molar where the furcation entrance is about 3 mm from the cementoenamel junction (CEJ) on the buccal surface and 4 mm on the lingual. The second mandibular molar furcation entrance can be located 3 mm from the CEJ on the buccal and 5 mm on the lingual. The maxillary first molars could also have a defect located 3 mm from the CEJ on the mesial, 4 mm on the buccal and 5 mm on the lingual (Figure 5). Furcation involvement on maxillary second molar buccal, mesial, and/or distal surfaces is less likely with Stage II cases.

An inactivated, curved, thin UIT may be used to explore the roof (entrance) and the sides (walls) of the furcation. If gingival tissue is present, use a closed angle to avoid unnecessary tissue distention and discomfort. The curvature of the right or left UIT should adapt to the defect; both sides of the tip can be used. Thin ultrasonic tips are optimal for furcation areas because curets are wider in diameter than UITs. Curets are about 1 mm wide, hindering instrumentation within a furcation. The maxillary first molar furcation entrance diameter is only 0.5 mm on the buccal, 0.75 mm on the mesial, and 0.5 mm to 0.75 mm on the distal. The mandibular first molar entrance diameter is 0.75 mm on the buccal and 1 mm on the lingual surface.

Periodontal pocket depth is 5 mm or less and generally will be wide, although localized areas of narrow depth could occur. In these cases, vertical and oblique orientations with fine thin tips are used to negotiate the pocket configurations (Figure 3 and 4). Table 1 reviews adaptation and activation principles.

Stage III Periodontitis

Stage III periodontitis is summarized by 5 mm or greater interdental CAL, radiographic bone loss extending to the middle third of the tooth and beyond, probing depths of 6 mm or greater, and horizontal and vertical bone loss of 3mm or greater.² Tooth loss due to periodontitis can be present (four teeth or less) as well as Class II and III furcation involvement.

For initial instrumentation, multiple UITs will be needed to thoroughly remove tenacious calculus indicating standard larger UITs as described previously. Instrument choice for furcation involvement and deep probing pocket depth could change to thinner and longer right, left and straight UITs as compared to Stage II. The same principles apply for adaptation and activation as with Stage II periodontitis; however, the extent of conditions and instrumentation are greater.

Furcation involvement of Grade II or III is common. Furcation involvement is likely to be on all molars (Figure 6). Also, the maxillary first premolar could have a defect within 7 mm of pocket depth. Ball-ended inserts are designed to adapt to furcation anatomy; however, effective calculus removal should be evaluated. The rounded end is designed to enhance adaptation; although activation might produce burnished calculus. Also, diamond-tipped UITs are indicated for furcations; however, caution is advised due to abrasiveness. They are best used with endoscopic evaluation or surgical procedures. Endoscopy should be incorporated to aid in visualizing the anatomy within the furcation area and deep pocket depth, particularly with Stage III cases.

A systematic review evaluated the efficacy of endoscopy in managing residual periodontal pockets. Randomized controlled trials (RCTs) compared periodontal endoscope-assisted subgingival debridement (EASD) with repeated root surface debridement (RSD). Results showed that EASD demonstrated superior clinical outcomes in managing residual periodontal pockets; however, further high-quality research is necessary to validate findings and assess the long-term benefits of EASD.⁷

Another systematic review and meta-analysis found endoscopy was associated with significantly less residual calculus, longer treatment time, and greater probing depth reduction. Endoscopy use surpassed conventional scaling and root planing alone in calculus removal. Additional RCTs are needed to evaluate clinical outcomes. Periodontal endoscopy is minimally invasive and enhances subgingival visualization, potentially improving the outcomes of periodontal therapy.⁸ Another review concluded scaling and root planing with endoscopy demonstrates superior short-term clinical outcomes compared to conventional scaling and root planing, particularly for subgingival calculus removal and probing depth reduction. However, its long-term efficacy in maintaining periodontal stability and preventing disease progression needs further validation.⁹

Periodontal pocket depth requires long thin UITs implemented with a vertical orientation when reaching the pocket depth (Figure 7). Measuring the length of a UIT with a probe and comparing this measurement to the pocket depth might aid in correct selection and effectiveness of instrumentation, particularly with unfamiliar UIT designs. Every millimeter of the root anatomy should be contacted with overlapping and short strokes (Figure 8). Research comparing ultrasonic and manual subgingival scaling at different probing pocket depths concluded that with 4- to 6-mm periodontal probing depths, the reduction with manual subgingival scaling was superior. CAL results, however, showed no statistical differences between the two means. When the periodontal probing depth was ≥ 6 mm, reductions in probing depths and CAL suggested that manual subgingival scaling was superior.¹⁰

Success of ultrasonic instrumentation depends on patient tolerance, incorporation of local anesthesia, and use of endoscopic technology as well as effective UIT selection, adaptation, and activation. Therefore, clinicians should approach Stage II and III cases with a blended approach of ultrasonic and manual instrumentation. Reassessing instrumentation often with ultrasonic tips and explorers is critical for success.

In summary, initial instrumentation for Stage II periodontitis might resemble Stage I or Stage III instrumentation based on the extent of periodontal conditions. Standard UITs are incorporated first for larger tenacious calculus and then long and thin UITs are used for moderate to light deposits. Stage III periodontitis is complex and demands enhanced knowledge of root anatomy in deep pockets as well as furcation involvement. Varied UIT designs are implemented during Stage II and III ultrasonic instrumentation, particularly as compared to Stage I periodontitis.

References

1. Hodges KO. Mastering ultrasonic instrumentation for stage I periodontitis. Dimensions of Dental Hygiene. 2025;23(2):14-17.
2. Sanz M, Herrera D , Kebschull M, et al . Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline, J Clin Periodontol. 2020;47(Suppl 22):4-60.
3. Tonetti MS, Greenwell H, Kornman K. Staging and grading of periodontitis: Framework and proposal of new classification and case definitions. J Periodondtol. 2018;89(suppl 1):S159-S172.
4. Alkhafaji N, Patel TJ. 2023. Implementing the 2017 periodontal classification system. Dimensions of Dental Hygiene. 2023;21(9):16-19.
5. Harrel SK, Cobb C, Sheldon LN, et al. Calculus as a risk factor for periodontal disease: Narrative review on treatment indications when the response to scaling and root planing is inadequate. Dent J (Basel). 2022;10:195.
6. Wilson TG, Harrel SK, Nunn ME, et al. The relationship between the presence of tooth-borne deposits and inflammation found with a dental endoscope. J Periodontol. 2008;79:2029-2035.
7. King-Lun DH , Fok MR , Li KY, Pelekos G , Leung WK. Effectiveness of endoscope-assisted subgingival debridement versus repeated root surface debridement or access flap periodontal surgery in step 3 periodontal therapy: a systematic review and meta-analysis. Clin Exp Dent Res. 2025;11:70196.
8. Alsharif SB, Hobani N. The efficiency of periodontal endoscopy in non-surgical periodontal therapy: a systematic review and meta-analysis. Front Dent Med. 2025;6:1681020.
9. Zhou D, Lu C. Efficacy of periodontal endoscopy-guided scaling for subgingival calculus removal: A meta-analysis. Current Problems in Surgery. 2025;69:101830.
10. Zhang X, Hu Z, Zhu X, Li W, Chen J. Treating periodontitis-a systematic review and meta-analysis comparing ultrasonic and manual subgingival scaling at different probing pocket depths. BMC Oral Health. 2020;20:176.

From Dimensions of Dental Hygiene. March/April 2026;24(2):16-21

Achieving an esthetically pleasing smile heavily relies on the color of the teeth, which significantly impacts a patient’s appearance and mental well-being.^1,2 Patient expectations often extend be­yond simply addressing the shade of a tooth in need of prosthodontic restoration.³ Bleaching has emerged as a viable alternative to crowning for anterior teeth that have undergone endodontic treatment.⁴

Restorative procedures involved in placing full-coverage restorations can negatively impact oral health due to the necessary removal of tooth structure. Although crowns are often the most appropriate treatment choice, the placement of a full-coverage restoration for a discolored tooth in an attempt to provide a predictable and permanent solution may not always result in a favorable long-term outcome.⁵

Tooth discoloration is either intrinsic or extrinsic. While extrinsic discoloration can be caused by chlorhexidine mouthrinses, stannous fluoride exposure, and iron supplements, intrinsic causes are pulp hemorrhage, pulp deterioration, microorganisms and their byproducts, tetracycline, pulp necrosis, intracanal medications, some endodontic filling materials, and metallic restorations.¹

Several approaches exist for treating discolored teeth. These vary from invasive methods, such as crowns, veneers, and direct restorations, to less invasive procedures, including macroabrasion, microabrasion, and bleaching.⁶ The approach to treating discolored teeth differs between vital teeth and those undergoing endodontic treatment. The cause of discoloration and potential underlying infections must be considered before deciding on treatment.⁷

For nonvital teeth, intracoronal whitening is a minimally invasive treatment option. During intracavity bleaching, the bleaching agent acts directly on the dentin structure.⁸ Stained teeth are treated with hydrogen peroxide, carbamide peroxide, or sodium perborate gels, all of which contain hydrogen peroxide as the active ingredient that whitens the teeth through an oxidation chemical reaction.⁹ Dentinal hypersensitivity is common with the use of bleaching agents and patients must be advised on how to address it in order for the whitening treatment to be successful (Table 1).

The walking bleach technique, also called the thermocatalytic technique, is a noninvasive approach used to whiten a single, discolored, nonvital tooth. The method involves placing a bleaching agent inside the pulp chamber and sealing it temporarily, allowing the agent to work over several days. In the walking bleach technique, proper root filling and establishment of a cervical seal are crucial. The bleaching agent should be changed every 3 to 7 days. The walking bleach approach often uses a lower concentration of hydrogen peroxide to minimize potential changes to the histological and morphological features of the tooth structure.⁷

Systematic Review of the Literature

Our systematic review of the literature on the walking bleach technique resulted in a total of 184 patients with an initial number of 194 endodontically treated teeth. Of these, 172 endodontically treated teeth received bleaching as treatment; 69 were treated with hydrogen peroxide, 101 treated with carbamide peroxide, and two treated with sodium perborate.

The mean patient age was 30.54 years with the youngest being 18 and the oldest being 65.^1,10 The average follow-up period was 12 months. Hydrogen peroxide (five studies) and carbamide peroxide (four studies) were the most commonly used agents for tooth bleaching among the studies we reviewed.

In all reviewed studies, a clinically significant difference in the whiteness of the treated tooth was reported after delivering the bleaching treatment among all participants regardless of the whitening agent used, their treatment protocols, and assigned groups. However, in the randomized clinical trials, no significant difference in tooth whitening was reported between the two groups.⁹

Most studies with a follow-up period of less than 2 years reported satisfactory results using their respective bleaching techniques. However, in a contrasting long-term study, Amato et al¹⁰ reported six failures out of 40 samples over a 25-year period, resulting in the recurrence of tooth discoloration.

The definition of success varied across the studies. The term used as the clinically significant difference was determined based on the tooth shade change, patient satisfaction, and researcher satisfaction after the bleaching treatment.

Clinical Case

A 63-year-old nonsmoking woman complained about discoloration of her right upper central incisor, tooth #8 (Figure 1). On our examination, we did not note any significant dentin loss in the cervical portion, extensive restorations, or visible cracks.

The patient was given the option of internal bleaching after evaluating the tooth both radiographically and clinically (Figure 2). For the bleaching protocol on tooth #8, a mixture of sodium perborate and articaine was used. During the first visit, we removed the composite from the lingual aspect and filled the access to the cementoenamal junction with glass-ionomer restorative.

Next, we placed a mixture of sodium perborate and articaine in the chamber and covered it with glass-ionomer material before light-curing it. We scheduled a follow-up appointment for evaluation after 1 week.

On the second visit, we observed that the gray discoloration on the buccal surface of tooth #8 was no longer visible, but yellow discoloration remained. We placed a new mixture of sodium perborate and articaine in the canal and closed its access with glass-ionomer restorative. We scheduled a follow-up appointment for re-evaluation after 1 week.

During the third visit, we observed that the discoloration had lightened to a light-yellow shade. The patient expressed satisfaction with the shade change, and we scheduled veneer preparation and possible gingivectomy for the next appointment as the patient was not completely satisfied with the final esthetic outcome (Figure 3).

Discussion

The results of our study demonstrated that walking bleaching generally produces satisfactory outcomes in most patients, regardless of the whitening agent and protocol used. The studies revealed varying degrees of shade change after completion of walking bleach treatment, indicating a clinically significant difference before and after treatment. However, shade change doesn’t necessarily reflect patient satisfaction.

When managing discolored teeth, clinicians have several treatment options and combinations at their disposal.⁵ Factors, such as safety and effectiveness, play vital roles in the clinician’s decision-making process.¹²

After reviewing eight articles, it became evident that while different etiologic factors do not significantly affect the outcome of walking bleach treatment, other characteristics can impact the final result. For instance, walking bleaching tends to yield better outcomes in younger patients compared to elderly patients.^7,13 In the case of older adults, the natural aging process leads to the deposition of secondary dentin, affecting the light-transmitting properties of teeth, resulting in gradual darkening.⁷ Furthermore, certain root canal sealer materials are less likely to whiten with internal bleaching; however, bleaching can still reduce the intensity of the grayish color.¹⁴

Dissatisfaction with the outcome is more common in necrotic teeth and those with discoloration caused by root canal treatment sealer materials compared to other discolored teeth.¹⁵

The predictability of the walking bleach result is not completely assured, and it is crucial to consider the expectations of patients. Additionally, the effectiveness and success rate of nonvital bleaching can vary depending on the etiological cause of tooth discoloration.

Our review confirmed that the walking bleach technique tends to yield satisfactory results in most patients, regardless of the bleaching agent and protocol used. Shade change does not necessarily indicate patient satisfaction. The success rates of whitening agents with varying concentrations did not significantly differ. Factors, such as age, tooth condition, and root canal sealer materials, can influence the outcomes of walking bleaching. Longer follow-up periods and the development of protocols for maintaining the bleaching effect are recommended.

References

1. Bersezio C, Ledezma P, Estay J, Mayer C, Rivera O, Fernández E. Color regression and maintenance effect of intracoronal whitening on the quality of life: rct—a one-year follow-up study. Oper Dent. 2019;44:24–33.
2. Machado AC, Braga SRM, Ferreira D, Jacintho FF, Scaramucci T, Sobral MAP. Bleaching of severely darkened nonvital tooth case report — 48 months clinical control. J Esthet Restor Dent. 2021;33:314–322.
3. Kahler B. Present status and future directions – managing discoloured teeth. Int Endod J. 2022;55:922–950.
4. Shillingburg HT, Sather DA, Wilson EL, et al. Fundamentals of Fixed Prosthodontics. 3rd ed. Chicago: Quintessence Publishing; 2014.
5. Poyser NJ, Kelleher MGD, Briggs PFA. Managing discoloured non-vital teeth: the inside/​outside bleaching technique. Dent Update. 2004;31:204–214.
6. Joshi SB. An overview of vital teeth bleaching. Journal of Interdisciplinary Dentistry. 2016;6(1):3-13.
7. Plotino G, Buono L, Grande NM, Pameijer CH, Somma F. Nonvital tooth bleaching: a review of the literature and clinical procedures. J Endod. 2008;34:394–407.
8. Georgieva I. Intracavity tooth bleaching in the aesthetic zone of maxilla using carbamide peroxide gel — case report. Journal of IMAB. 2020;26(3):3223–3225.
9. Bersezio C, Vildósola P, Sáez M, et al. Does the use of a “walking bleaching” technique increase bone resorption markers? Oper Dent. 2018;43:250–260.
10. Amato A, Caggiano M, Pantaleo G, Amato M. In-office and walking bleach dental treatments on endodontically-treated teeth: 25 years follow-up. Minerva Stomatol. 2018;67:225–230.
11. Frank AC, Kanzow P, Rödig T, Wiegand A. Comparison of the bleaching efficacy of different agents used for internal bleaching: a systematic review and meta-analysis. J Endod. 2022;48:171–178.
12. Reitzer F, Ehlinger C, Minoux M. A modified inside/​outside bleaching technique for nonvital discolored teeth: a case report. Quintessence Int. 2019;50:802–807.
13. Knezevic N, Obradovic M, Dolic O, et al. Clinical testing of walking bleach, in-office, and combined bleaching of endodontically treated teeth. Medicina (B Aires). 2022;59:18.
14. Yang WC, Tsai LY, Hsu YH, Teng NC, Yang JC, Hsieh SC. Tooth discoloration and the effects of internal bleaching on the novel endodontic filling material SavDen® MTA. J Formos Med Assoc. 2021;120(1 Pt 2):476–482.
15. Watts A, Addy M. Tooth discolouration and staining: a review of the literature. Br Dent J. 2001;190:309–316.

From Dimensions of Dental Hygiene. March/April 2026;24(2):22-24

For years, many dental practices operated in what could be called the “Golden Age” of dentistry. Throughout the 1970s and ’80s, the field of dentistry was exceptionally profitable and straightforward. Dental insurance had just become a standard workplace benefit and preferred provider organizations had not yet taken over. Even more promising, dental materials were advancing and innovations in technology were not far behind.

Given the rapid pace of technological innovation in the field, one must ask: Why is today not considered dentistry’s Golden Age? Many clinicians are excited by the innovation in the field, but there is a more challenging shift also occurring — the rise of economic pressure. This burden is becoming impossible to ignore and is hitting the dental hygiene department harder than ever before.

Today, practices are caught in a tightening squeeze: labor shortages have increased dental team member wages, while insurance reimbursements continue to stagnate or decrease.

In this environment, the path to profitability or even sustainability isn’t just about seeing more patients, it’s about clinical excellence. The missing link to surviving these economic shifts lies in your periodontal management protocol. Simply put, you cannot afford not to treat periodontal disease.

The Diagnosis Gap: Reality vs Potential

To understand the health of your practice, you must look at the periodontal metrics that matter: The ratio of periodontal codes to total hygiene codes.

• The Healthy Standard: In a healthy performing office, periodontal therapy should account for a minimum of 35% of all hygiene codes.
• The Warning Sign: If your periodontal production is below 20%, your practice needs immediate intervention.

If your practice falls in the metrics of needing immediate intervention, it is the opportune time to realign your hygiene department’s diagnostic philosophy. It is time to recalibrate with your team and start treating periodontal disease.

Falling below these benchmarks is often a sign of underdiagnosing. Many clinicians fall into the trap of performing “bloody prophies.” Treating active infection as standard prophylaxes puts your office at risk. This is more than just a financial leak; it is an ethical and liability issue. Every time infection is ignored, the patient’s health suffers and potential revenue walks right out the door.

Health First, Production Follows

Successful implementation requires a mindset shift: this is not about chasing the mighty dollar, it’s about improving systemic health by implementing a system and educating your patients.

To move the bar, we first must stop diminishing the disease. We have to stop using softened language like “a little bleeding” and call it what it actually is: infection and disease.

Practitioners often hesitate to diagnose out of a fear of patient rejection. But the reality is that your patients have already said yes to you. They are sitting in your chair because they trust your expertise. When you fail to diagnose and treat their disease, you aren’t being nice, you are breaking that trust.

The Root Cause: Why Are We Failing?

If the clinical need is there, why is the diagnosis gap so wide? It usually isn’t a lack of clinical skill or even desire — it’s a lack of systems.

Two of the most common hurdles are a lack of team alignment and prioritizing the time to develop the systems. Often, the dentist and the dental hygiene team are not on the same page regarding diagnostic criteria. The busy days continue and the time is not set aside to align and build these crucial systems. Without a unified standard, the message to the patient becomes muddled, leading to confusion and treatment refusal.

The Perio to Production System

Bridging the diagnosis gap requires a repeatable, structured system for your clinical team.

1. Alignment and education. Calibrate the entire team on what constitutes a periodontal diagnosis. Align on periodontal probing techniques, your verbiage, and how you plan to educate your patients going forward.
2. Outline a periodontal management protocol for your office. Decide what the standards will be for your office when a patient presents in your chair with disease. Be as precise as to the millimeter, so the plan of action is in place and everyone aligns.
3. Visual evidence. Utilize intraoral (IO) cameras. Showing patients their own calculus and active infection bridges the gap between hearing a diagnosis and truly understanding it. Educate patients so they own their disease and understand the need for treatment.
4. Dental hygienists, set the dentist up for success. Before the doctor enters your room for an exam, IO pics and concerns should have already been shared with the patient. Be ready and let that patient hear it not only once, but twice from the clinicians treating them.
5. Clinical coding. Code for the procedures you are actually doing. If you are scaling to remove tartar, infection, or treating periodontal disease, use the appropriate codes (such as D4346, D4355, or D4341/D4342) rather than a prophy code. Ensure clinical notes, X-rays, and IO photos are meticulous to support these codes.

The Financial Backbone

While production is crucial, remember the saying: Production is vanity, collection is sanity. To ensure the practice actually sees the rewards of its work, you must create a bulletproof claim submission and collection system.

And while you’re fully capable of doing all of that on your own, you don’t have to! Dental billing is a million jobs in one, and the systems weren’t built with practices in mind. Instead, they’re often a patchwork of outdated processes, ever-changing policies, and disconnected systems that put the burden squarely on your shoulders. Even when your team is doing everything right, the uphill battle continues.

Outsourcing offers a chance at relief, an opportunity to gain a partner fully committed to making your practice stronger, while simultaneously freeing up your time to focus on your patients and practice.

Support Is Available

Fighting insurance denials is not getting easier. To support your claims in the dental hygiene department, the crucial attachments must be available. Create checklists for which attachments are needed for all periodontal procedures.

A standard scaling and root planing checklist should include:

• Complete periodontal charts with bleeding points, recession, furcation involvement, and mobility
• Current full-mouth X-rays; vertical bitewings are a plus to show 
bone level
• IO photos showing active infection and visible calculus
• Detailed clinical notes that include periodontal grading and staging, any medical concerns, amount of anesthetic used, length or appointment, and need for therapeutic intervention

Success for insurance reimbursement starts with the clinical team. By streamlining the submission process and supplying the necessary attachments to support your claims, you ensure the practice remains profitable despite rising costs.

Treating periodontal disease is the ultimate win-win in dentistry. The patient receives a higher standard of care with better health outcomes, while the practice gains the financial stability needed to thrive in a challenging economy.

Your call to action: Review your numbers today. If your periodontal codes make up less than 20% of your hygiene production, don’t wait. Start calibrating your team and implementing these systems immediately to protect both your patients and your practice.

And of course, if you’re looking for that extra support, Wisdom is here to help.

Wisdom
www.withwisdom.com
314-648-2663

For more tips on building and maintaining systems and habits, check out the ABCs of Dental Billing eBook at www.withwisdom.com/resources.

From Dimensions of Dental Hygiene. March/April 2026;24(2):26-27

The United States Centers for Disease Control and Prevention (CDC) defines intimate partner violence (IPV) as abuse or aggression that occurs in a romantic relationship.¹ IPV can occur within a current relationship or may be initiated and sustained by a former partner. It is also characterized by a partner attempting to exert power and control.

The link between IPV and oral health is well-documented, with those impacted often presenting with dental trauma, facial fractures, and bruising to the head and neck. Oral health professionals are in a key position to screen patients and document and support individuals affected by IPV. Studies have shown strong connections between types of abuse and oral health problems.^2,3 For example, psychological abuse is linked to periodontal diseases, while physical violence often leads to broken teeth. Common dental injuries include fractures (59.1%), tooth displacements (27.2%), and tooth loss (13.7%), usually caused by direct blows without weapons.^2,3,4 These injuries can be extremely painful, affect chewing and speaking, and lower self-esteem.

Abuse-related stress can also lead to grinding teeth, temporomandibular disorders, and chronic facial pain. Table 1 lists other common signs of abuse. Oral health professionals are in a unique position to detect these warning signs during routine visits by carefully examining the head, neck, and mouth.²

Beyond physical injuries, certain patient behaviors may also suggest abuse, such as missed appointments due to a controlling partner, reluctance to speak in front of a partner, or signs of dental neglect.^2,5-9 Oral health professionals should be attuned to patients’ demeanor in the presence of their partners, which may provide important warning signs regarding IPV victimization.²

By remaining observant, empathetic, and supportive, oral health professionals can create a safe space where patients feel comfortable disclosing abuse and receiving the help and resources they need.^2,5

Screening for Intimate Partner Violence

Although domestic violence significantly impacts oral health and oral health professionals play a vital role in recognizing signs of abuse, a troubling gap in screening knowledge remains.² About 75% of physical abuse injuries occur on the head, face, mouth, and neck. Victims who are isolated from friends, family, and social services may seek dental care — either through scheduled visits or emergency appointments.⁶ Knowledge of IPV screening and how to appropriately respond enables oral health professionals to provide compassionate care, communicate with victims more confidently, and address their needs effectively.⁶

Dental practices must identify a screening tool that best fits their clinical setting. In 1992, the Massachusetts Medical Society developed the RADAR model, or Routinely screen, Ask direct questions, Document findings, Assess patient safety, and Review options and refer as appropriate, to physicians in responding to patients affected by IPV. Over time, this model has been adapted for use by other health professionals, including dentists and dental hygienists, to address IPV within the dental environment.⁷

The HITS tool, or Hurt, Insult, Threaten, and Scream, is a brief screening instrument used in healthcare settings to assess the risk of domestic violence or IPV. It consists of four questions, each asking how often a partner engages in these behaviors. Patients respond on a five-point Likert scale (1 = never to 5 = frequently). A higher total score indicates a greater likelihood of IPV.

Because it is short, easy to administer, and validated in multiple populations, the HITS tool is commonly used in medical and dental settings as part of IPV screening.⁸ As awareness of trauma’s impact grows, healthcare providers are recognizing the importance of trauma-informed care. This approach emphasizes understanding a patient’s life experiences to guide treatment and can enhance patient engagement, adherence, health outcomes, and the well-being of providers and staff.⁹

Developing trauma-informed care skills is essential for recognizing and responding to patients who may be experiencing violence. For survivors of sexual assault or IPV, the dental setting can be intimidating and may trigger distress linked to past abuse. Oral health professionals should remain mindful of these triggers and incorporate supportive techniques into daily practice.⁹

A widely recognized and effective trauma- informed approach for addressing such situations is the AVDR method, or Ask, Validate, Document, and Refer/Report. This framework helps guide oral health professionals in appropriately responding to family violence while ensuring that victims receive necessary support and providers fulfill their professional obligations.^7,9,10

Before applying the AVDR method, however, oral health professionals should take foundational steps to prepare for these sensitive encounters. This includes building and maintaining a professional, therapeutic relationship with patients, recognizing the signs of IPV, and becoming familiar with their state’s specific reporting requirements for each type of abuse.⁹

The AVDR approach consists of the following steps:^7,9,10

1. Ask. Initiate a respectful and private conversation if abuse is suspected (eg, Do you feel safe at home?)
2. Validate. Acknowledge the patient’s experience without judgment and express support, (eg, What you’re telling me makes me concerned for your well-being).
3. Document. Record observations and patient statements accurately and objectively.
4. Refer/Report. Provide appropriate resources or make a report as required by state law.

Reporting Intimate Partner Violence

In situations involving suspected domestic violence, oral health professionals have important legal and ethical responsibilities that must inform their actions and guide their decision-making.^2,11,12 A key responsibility in cases of suspected IPV is understanding reporting laws, which can vary significantly by jurisdiction.

Although dental practitioners are generally bound by strict standards of patient confidentiality, laws may require them to report suspected abuse if there is a reasonable belief that the patient is in immediate danger. In such cases, the duty to protect the patient can override the standard confidentiality expectation.²

Oral health professionals must be familiar with the specific reporting requirements in their state or locality to ensure legal compliance. Beyond legal duties, they also face complex ethical considerations. Oral health professionals must carefully balance respecting a patient’s autonomy with the need to ensure his or her safety — an especially challenging task when patients are hesitant to disclose abuse or decline help due to fear, shame, or other personal barriers.^2,11 Creating a supportive, nonjudgmental environment that encourages trust, highlights available resources, and emphasizes the importance of safety and support is the best approach.²

Documentation and Patient Confidentiality

Careful and accurate documentation is one of the most important steps after recognizing potential signs of IPV. Thorough documentation serves as a vital record for future reference, enabling healthcare providers to monitor the progression and severity of abuse over time. This ongoing record supports continual assessment of the patient’s condition and guides appropriate care and intervention strategies.²

Detailed documentation can also help identify patterns or trends in abusive behavior, offering insight into relationship dynamics and assisting in evaluating the patient’s level of risk. To enhance accuracy and accountability, asking a witness, such as a dental assistant or other office staff, to be present during the documentation process is recommended.^2,10

In the dental record, providers should include clear, objective details about the injuries, noting the location, size, color, and any other observable characteristics. Supplementary documentation may include intraoral and extraoral photographs, as well as periapical and panoramic radiographs. Narrative notes must remain factual and unbiased, incorporating precise measurements of affected hard and soft tissues. Any verbal statements made by the patient concerning their injuries should be recorded word-for-word to preserve the integrity of his or her account.^7,11

Best Practices

When IPV may be a concern, how an oral healthcare provider communicates with a patient can significantly influence his or her comfort, trust, and willingness to seek support or intervention. Conversations related to violence or trauma should always be approached using a trauma-Informed framework.

Trauma can affect both the brain and body in complex and far-reaching ways, influencing oral health, overall health, and patient behavior. When oral health professionals are not aware of how trauma may impact patients, opportunities may be missed to promote safety, connect patients to supportive resources, and prevent further harm. Additionally, communication that is not trauma-informed may unintentionally contribute to distress.¹³

Trauma-informed care aims to create safety for people by recognizing the effects of trauma and its close links to health and behavior. Unlike trauma-specific care, it does not focus on eliciting or treating trauma histories, but rather on fostering safe, respectful environments that minimize the potential for harm during healthcare interactions.¹³

Before engaging in conversations related to IPV, oral health professionals are encouraged to learn about how trauma and trauma-related symptoms may affect patients, to create a supportive, nonjudgmental clinical environment. Clinicians should also become familiar with local community resources related to IPV and establish relationships with community partners who can assist with referrals and staff training.¹⁴

When communicating with patients about sensitive topics such as violence, several factors should be considered, including the physical environment and approaches to screening and intervention. Screening should be conducted as confidentially as possible.¹³ This may involve using a private room, drawing a curtain, or checking in about safety and privacy if the patient is accompanied by another person.

Before beginning any screening or discussion related to personal experiences, clinicians should ask for the patient’s permission and clearly explain the purpose of the conversation. Oral health professionals should also address any questions about confidentiality and explain relevant policies or reporting requirements so patients can make informed decisions about what they choose to share.¹⁴

If a patient expresses interest in support or resources, clinicians should avoid directing or prescribing what the patient “should” do. Trauma-informed communication prioritizes patient autonomy and supports individuals in making their own informed choices. During dental procedures, clinicians should clearly explain each step, including what will happen, why it is necessary, and what areas of the face or mouth will be touched. Ongoing communication during procedures can help maintain a sense of control and safety.

When discussing available resources, oral health professionals should offer information about local support services and acknowledge the patient’s strength in engaging in conversation and seeking care.¹⁴

Resources for Suspected Victims

To support victims of IPV, dental office staff should collaborate with other healthcare professionals to compile and regularly update a comprehensive list of local resources. Once a patient discloses that he or she has been a victim, the healthcare professional’s role is to provide safe access to help (Table 2). This means that victims should never be asked to leave the appointment with a physical list of contacts, as a perpetrator could find it and escalate the danger. Instead, patients should be assured that the office has these resources available and that they can call at any time to get a contact number.

The resource list should be created and maintained by the office staff, and every team member must know its secure location. This list needs to include national resources, such as 24-hour hotlines, as well as local contacts for shelters, victim’s advocacy organizations, nonemergency police, crisis lines, and medical facilities.^10,15

Conclusion

Oral health professionals occupy an often underutilized position as frontline responders in the fight against domestic violence. The literature overwhelmingly demonstrates that the oral and maxillofacial regions are primary targets of abuse, with up to 75% of physical assault injuries occurring in the head, neck, and face.^6,16 Given this striking statistic, routine dental examinations that inherently involve a thorough assessment of the head and neck offer a necessary point of contact for intervention that victims may not seek elsewhere. However, the efficacy of this role hinges entirely on standardization. Current data show that a significant gap exists between opportunity and action. Integrating trauma-informed training and mandatory reporting protocols into dental and dental hygiene school curricula and continuing education is not just beneficial, but essential.¹⁶ The simple act of asking, “Is everything alright at home?” can transform a routine check-up into a life-saving intervention.¹⁷

References

1. United States Centers for Disease Control and Prevention. About Intimate Partner Violence. Available at cdc.gov/intimate-partner-violence/about/index.html. Accessed January 29, 2026.
2. Levin L, Bhatti C. The role of dental professionals in identifying, reporting, and supporting domestic violence victims. Dent Traumatol. 2024;40(Suppl 2):3-9.
3. Jones ML, Francisco E. Addressing intimate partner violence. Dimensions of Dental Hygiene. 2014;12(10):63–66.
4. Jailwala M, Timmons JB, Gül G, Esshaki D, Ganda K. See the signs. Dimensions of Dental Hygiene. 2015;13(3):48–51.
5. Garbin CA, Guimarães e Queiroz AP, Rovida TA, Garbin AJ. Occurrence of traumatic dental injury in cases of domestic violence. Braz Dent J. 2012;23:72-76.
6. Parish CL, Pereyra MR, Abel SN, Siegel K, Pollack HA, Metsch LR. Intimate partner violence screening in the dental setting: results of a nationally representative survey. J Am Dent Assoc. 2018;149:112-121.
7. Alshouibi EN. General dentists’ readiness and barriers in intimate partner violence screening: a cross-sectional study in Jeddah City. BMC Oral Health. 2022;22:1-7.
8. Lemich SA, Freudenthal JJ, Neill K, Bowen DM. Dental hygienists’ readiness to screen for intimate partner violence in the state of Texas. J Dent Hyg. 2018;92:47-55.
9. Minnesota Department of Health. IPV Screening Toolkit. Available at health.state.mn.us/docs/communities/fhv /ipvscreentoolkit.pdf. Accessed January 29, 2026.
10. Menschner C, Maul A. Key ingredients for successful trauma-informed care implementation. Available at chcs.org/media/Brief-Key-Ingredients-for-TIC-Implementation.pdf. Accessed January 29, 2026.
11. Futures Without Violence. Compendium of State and U.S. Territory Statutes and Policies on Domestic Violence and Health Care 2019. Available at futureswithoutviolence.org. Accessed January 29, 2026.
12. Maimon-Blau I. Medicolegal aspects of domestic violence against children. Dent Traumatol. 2024;40(Suppl 2):18-22.
13. Wathen CN, Mantler T. Trauma- and violence-informed care: orienting intimate partner violence interventions to equity. Curr Epidemiol Rep. 2022;9:233-244.
14. Mehra V, Family Prevention Fund. Culturally competent responses for identifying and responding to domestic violence in dental care settings. J Calif Dent Assoc. 2004;32:387-394.
15. Health Partners IPVE. A Guide to Support Dental Patients Experiencing Intimate Partner Violence (IPV) and Exploitation. Available at healthpartnersipve.org/wp-content/uploads/2024/06/FINAL-A-Guide-to-Support-Dental-Patients-Experiencing-Intimate-Partner-Violence-IPV-and-Exploitation.pdf. Accessed January 29, 2026.
16. Women’s Advocates. Enhancing Dental Professionals’ Response to Domestic Violence. Available at wadvocates.org/wp-content/uploads/2020/01/DENTAL-AND-DV.pdf. Accessed January 29, 2026.
17. Trindade TF, da Silva MC, Dietrichkeit Pereira JG, Alves da Silva RH. Dentist’s ability to identify and act upon signs of domestic violence against women. Braz J Dent Educ. 2025;25:2450.

From Dimensions of Dental Hygiene. March/April 2026; 24(2):28-31

Oncology treatments, such as chemotherapy and radiation therapy, are essential for combating malignancies but often result in a range of challenging oral side effects. Patients frequently experience complications such as xerostomia, mucositis, and an increased susceptibility to infections.¹ In this context, dental hygienists play a crucial role in mitigating these issues through preventive care, education, and collaborative treatment strategies.

Despite their valuable contributions, the expertise of dental hygienists in oncology care is often underutilized. While it is crucial to maintain good oral hygiene for patients with cancer, many oncology providers may not prioritize this critical aspect in their patient management strategies. However, dental hygienists are uniquely positioned to address the oral health needs of this patient population by conducting thorough assessments, providing tailored oral hygiene instructions, and collaborating closely with oncologists and other healthcare professionals. Improved collaboration among dental hygiene practices within oncology healthcare teams leads to improved patient outcomes and fosters a more holistic approach to patient care.¹

Oral Health Management Before, During, and After Oncology Treatment

The increasing involvement of dental hygienists in public sectors, such as long-term care facilities, community health centers, and hospitals, positions them to treat more diverse populations with more extensive and complicated medical histories.² This is particularly important for patients with cancer diagnoses. As the number of new cancer cases continues to rise, research suggests the importance of recognizing cancer risk factors, conducting thorough cancer screenings, and effectively communicating with patients to gather relevant information about their cancer history.^1,3

Before a patient can begin oncology treatment, a comprehensive dental evaluation must be performed to establish a healthy baseline. This information is used to monitor a patient’s oral health status. Any necessary dental treatment should then be completed as soon as possible due to impaired healing during oncology treatment.⁴ During preventive care, dental hygienists can provide nutritional counseling, emphasizing the benefits of a noncarcinogenic diet, educate about the importance of maintaining good oral hygiene habits, include preventive therapies such as fluoride trays for use at home, and offer recommendations on managing oral side effects related to oncology treatments.⁵

After oncology therapy, a dental hygiene recare interval should be established based on the patient’s assessed risk for recurrent lesions or metastases.⁴ Therefore, dental hygienists must educate patients about their specific needs before, during, and after treatment. While maintaining the oral cavity may not always be prioritized after oncology treatment, dental hygienists should emphasize the connection between oral health and cancer treatment outcomes to motivate patients to maintain their oral hygiene.² Incorporating dental hygienists into cancer care can enhance patient management and improve outcomes for those who have undergone oncology treatment.⁶

Dental hygienists are encouraged to communicate directly with a patient’s oncology team, as they support the patient at every stage of care — from establishing a baseline and maintaining periodontal stability to managing secondary effects.²

Dental Concerns With Oncology Treatment

Oncology treatment exacerbates dental caries and periodontal diseases with a study finding both worsening by 20.8% in patients undergoing cancer treatment.⁷ Caries progression was evaluated 1 to 2 years post-cancer therapy, revealing worsening of existing lesions and development of new ones in previously unaffected teeth.⁷

The number of periodontal bacteria is elevated among patients undergoing cancer treatment.⁷ These bacteria invade oral tissues, enter the bloodstream, and worsen systemic conditions, making them difficult to eliminate.⁸ Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and Tannerella forsythia are the main bacteria associated with the connection between periodontal diseases and cancer.⁸

Oral mucositis — painful ulcerations and erythema, which can significantly impede speaking and eating — is also associated with cancer treatment.⁹ Research shows that laser therapy, professional oral hygiene, antimicrobial agents, and zinc supplementation are the most effective preventive measures.¹⁰ Dental hygienists are well-equipped to administer these preventive strategies. Throughout their education, dental hygiene students undergo extensive clinical and didactic training in which they are evaluated on their proficiency in implementing the prevention methods known to prevent oral mucositis.¹¹

Routine dental care remains essential throughout the diagnosis.¹² Microorganisms predominantly reside in supra- and subgingival biofilm, serving as a reservoir for acute oral infections.¹³ These infections can intensify the symptoms and manifestations of oral pathologies (see Table 1).^1,3,7,10,14 Dental hygienists play a crucial role in effectively addressing etiological factors to optimize patient outcomes during treatment.¹³

Patients treated with radiotherapy should receive preventive care at least 2 weeks before the beginning of therapy to avoid further complications and to minimize the risk of osteoradionecrosis.¹⁵ Osteoradionecrosis, a significant complication for patients undergoing radiation oncology treatment, involves the progressive destruction of bone, most commonly affecting the mandible.¹⁴

Oral hygiene is critical to reducing patient discomfort after oncology treatment with an emphasis on implementing relief strategies, making dietary adjustments, and tailoring treatment plans to each patient’s needs.¹⁶ Dental hygienists deliver personalized oral hygiene instructions, nutritional counseling, and management recommendations. Utilizing their extensive training, they are able to develop patient-specific treatment strategies, guidelines, and goals. While caring for patients undergoing oncology treatment, dental hygienists will naturally shift toward a more interprofessional position.¹⁷

Expanding the Role of Dental Hygienists on Oncology Care Teams

Historically, dental hygienists were primarily viewed as prevention specialists, mainly working in private practices; however, the scope of practice has evolved significantly.^18,19 Changes to legislation and professional advocacy have made it easier for dental hygienists to practice in other capacities, such as public health clinics, hospitals, nursing facilities, and rural underserved areas.^2,20 With the increase in access to care, more medically complex populations can be treated, including oncology patients.

When observing a patient with cancer as a whole, oral complications from cancer treatment go far beyond physical discomfort. Difficulty eating, speaking, or maintaining oral hygiene may lead to social isolation, anxiety, and diminished self-esteem.^21,22 Dental hygienists play a unique role in addressing these emotional and psychological burdens. Their consistent presence, empathetic communication, and personalized guidance offer patients reassurance, comfort, and continuity of care.^16,17,23

This humanistic approach complements clinical strategies and underscores why dental hygienists must be integrated into interprofessional oncology teams. As patients navigate complex treatments, collaboration among healthcare providers, including dental hygienists, ensures that both physical and emotional needs are addressed.

Dental hygienists play a crucial role in preparing oncology patients pre- and post-surgery for the impact of cancer therapies on oral health and helping them maintain their quality of life.³ The dental hygienist’s involvement is in the prevention of painful infections and concerns regarding mucositis. Oral hygiene instructions and dental hygiene procedures prior to, during, and after treatment to reduce pathogens are paramount to a patient undergoing oncological treatment, who will be immunocompromised.³

Research shows that the inclusion of dental hygienists in interdisciplinary healthcare for oncology patients is viewed positively. Warren et al²⁴ found that 96% of 100 nursing and dental hygiene students (64 nursing and 36 dental hygiene) expressed a willingness to collaborate with other healthcare professionals, and 99% agreed that shared learning would help them become more effective team members in the management of oncology patients. The authors surmised that enhanced knowledge, proficiency, and willingness to conduct screenings for patients undergoing cancer therapies are better achieved through interprofessional collaboration. Students in both professions expressed a strong desire for collaboration.²⁴

As previously mentioned, periodontal bacteria are increasingly found in oncology patients.⁷ This finding supports the need for interprofessional collaboration to ensure best patient outcomes. In addition to the patient’s physician, oncologist, and nurse, dental hygienists should be considered valuable members of the patient’s care team.²⁵ However, a lack of knowledge regarding their skill set and gaps in communication between providers have resulted in the underutilization of dental hygienists in multidisciplinary teams.²⁶ Integrating dental hygienists into the interdisciplinary team for oncology patients can further optimize overall health outcomes.³

Oral Health Challenges in Cancer Care: Implications for Dental Hygienists in the Dental Setting

While high-risk bacteria play a significant role in periodontal diagnosis, stringent oral hygiene practices are necessary for the outcome of the patient’s oncology treatment.²⁷ Poor oral hygiene can exacerbate periodontal issues, especially if oncology treatments lead to a decline in a patient’s self-care routine.^28,29 Oncology treatment often results in the deterioration of effective oral hygiene habits, making it even more essential for patients to consult with oral health professionals.²³ Dental hygienists provide strategies to manage oral health routines and reduce bacterial levels through preventive services.^30,31

Dental hygienists can strengthen interprofessional collaboration by reinforcing dietary recommendations made by the nutritionist, emphasizing those that alleviate the oral effects of oncology treatments. This partnership creates a comprehensive approach to patient care.³²

Dental hygienists are exposed to a wide range of patient populations in their practice. By staying current through continuing education courses, dental hygienists are qualified to manage the evolving landscape of oral health complications associated with oncology treatment. A more collaborative, interprofessional approach to care can be achieved by increasing referrals and integrating dental hygienists into settings, such as hospitals, ultimately improving patient outcomes. Interprofessional collaboration and the integration of dental hygienists into oncology care are crucial.³³

Call to Action to Broaden the Impact of Dental Hygienists

To incorporate dental hygienists into these expanded roles, interprofessional relationships must be built at the local level — in hospitals with nutritionists and oncology teams. Through community advocacy, educational seminars, and collaboration, dental hygienists can highlight the value of their profession in oropharyngeal cancer prevention and oncology care.^1,2

These efforts can ensure that dental hygienists are fully integrated into broader healthcare conversations and opportunities as an integral part of the healthcare team. By interprofessional collaboration, dental hygienists will elevate the profession, engage in meaningful dialogue, and improve patient outcomes through integrated, team-based care.¹ Dental hygienists can advocate for their inclusion in oncology teams by initiating collaboration, pursuing continuing education in oncology care, and educating patients and providers about their role.

Conclusion

Cancer treatments, such as chemotherapy and radiation often display manifestations in the oral cavity.¹ To effectively manage these effects, a collaborative care team must be assembled, incorporating various healthcare professionals.³⁴ Dental hygienists are specifically trained to identify cancer risk factors, conduct oral cancer screenings, provide preventive services, offer patient-specific oral hygiene instructions, and manage potential oral side effects associated with cancer therapies.¹¹

Unfortunately, dental hygienists are frequently underutilized in these settings, despite possessing many qualifications that make them highly capable. Ultimately, the goal of all healthcare professionals is to deliver the most effective, patient-centered care possible, tailored to the specific needs and goals of each individual. To close gaps in oncology care, dental hygienists must be fully integrated into the care team.

References

1. National Cancer Institute. Oral Complications of Cancer Therapies (PDQ®)–Patient Version. Available at cancer.gov/about-cancer/treatment/side-effects/mouth-throat/oral-complications-pdq#_29. Accessed February 3, 2026.
2. Dsouza-Norwood R, Kornegay E. Managing patients undergoing cancer therapy. Dimensions of Dental Hygiene. 2021;19(11):36–39.
3. Lanzetti J, Finotti F, Savarino M, Gassino G, Dell’Acqua A, Erovigni F. Management of oral hygiene in head-neck cancer patients undergoing oncological surgery and radiotherapy: A systematic review. Dent J. 2023;11:83.
4. Yong C, Robinson A, Hong C. Dental evaluation prior to cancer therapy. Front Oral Health. 2022;3:876941.
5. Williams K. Impact of diet on oral health. Dimensions of Dental Hygiene. 2020;18(4):34–37.
6. Matsuda Y, Karino M, Okuma S, Ikebuchi K, Takeda M, Kanno T. Proposal of dental hygiene diagnosis for cancer patients based on dental hygiene process of care in acute care hospitals: A narrative review. Healthcare (Basel). 2020;8:217.
7. Soutome S, Otsuru M, Kawashita Y, Funahara M, Ukai T, Saito T. Effect of cancer treatment on the worsening of periodontal disease and dental caries: A preliminary, retrospective study. Oral Health Prev Dent. 2021;19:399–404.
8. Zhou Y, Meyle J, Groeger S. Periodontal pathogens and cancer development. Periodontol 2000, 2024;96:112–149.
9. Bell A, Kasi A. Oral mucositis. Available at ncbi.nlm.nih.gov/books/NBK565848. Accessed February 3, 2026.
10. Daugėlaitė G, Užkuraitytė K, Jagelavičienė E, Filipauskas A. Prevention and treatment of chemotherapy and radiotherapy induced oral mucositis. Med (Kaunas). 2019;55:25.
11. American Dental Education Association. ADEA Compendium of Curriculum Guidelines (Revised edition). Available at csi.edu/_files/pdf/health-science-human-service-department/dental-hygiene/dental-hygiene-program-adea-compendium-guidelines.pdf. Accessed February 3, 2026.
12. American Dental Association. Cancer Therapies and Dental Considerations. Available at ada.org/resources/ada-library/oral-health-topics/cancer-therapies-and-dental-considerations. Accessed February 3, 2026.
13. Kusiak A, Jereczek-Fossa B, Cichońska D, Alterio D. Oncological-therapy related oral mucositis as an interdisciplinary problem-Literature review. Int J Environ Res Public Health. 2020;17:2464.
14. Naseer A, Brennan S, MacCarthy D, O’Connell J, O’Sullivan E, Leech M. Prevention of osteoradionecrosis in patients with head and neck cancer treated with radiation therapy. Head Neck. 2024;47:472–484.
15. Saunders D, Koyfman S, Ismaila N, et al. Prevention and management of osteoradionecrosis in patients with head and neck cancer treated with radiation therapy: ISOO-MASCC-ASCO guideline clinical insights. JCO Oncol Pract. 2024;20:1571–1574.
16. Hong C, Gueiros L, Fulton J, et al. Systematic review of basic oral care for the management of oral mucositis in cancer patients and clinical practice guidelines. Support Care Cancer. 2019;27:3949–967.
17. Winter I, Ingledew P, Golden D. Interprofessional education in radiation oncology. J Am Coll Radiol. 2019;16:964–971.
18. Fones A. The origin and history of the dental hygienists. J Dent Hyg. 2013;87(Suppl 1):58–62.
19. American Dental Hygienists’ Association. Dental hygiene Practice Act Overview. Available at .adha.org/wp-content/uploads/2024/09/Practice-Act-Overview-9-2024.pdf. Accessed February 3, 2026.
20. American Dental Hygienists’ Association. Direct Access States. Available at adha.org/wp-content/uploads/2023/03/ADHA_Direct_Access_Chart_2022-08-1.pdf. Accessed February 3, 2026.
21. Hajek A, König HH. The association between oral health-related quality of life, loneliness, perceived and objective social isolation-results of a nationally representative survey. Int J Environ Res Public Health. 2021;18:12886.
22. Abdullah A, König HH, Hajek A. Oral health-related quality of life and loneliness: results based on a cross-sectional survey. Arch Public Health. 2024;82:114.
23. Qamar S, Rozi S, Sawani S, et al. Oral health related quality of life in head and neck cancer survivors within the first year following treatment: A cross-sectional study in Karachi, Pakistan. Sci Rep. 2024;14:2560.
24. Warren D, Stanek J, Dsouza R, Ciarrocca K, Brame J. Interprofessional collaboration among dental hygiene and nursing students on the oral health of cancer patients. Nurs Educ Perspect. 2022;43:E85–87.
25. Theile C, Strauss S, Northridge M, Birenz S. The oral healthcare manager in a patient-centered health facility. J Evid Based Dent Pract. 2016;16(Suppl):34–42.
26. Imafuku R, Nagatani Y, Yamada S. Complexities of interprofessional identity formation in dental hygienists: An exploratory case study. BMC Med Educ. 2022;22:8.
27. Rapone B, Nardi G, Venere D, Pettini F, Grassi F, Corsalini M. Oral hygiene in patients with oral cancer undergoing chemotherapy and/or radiotherapy after prosthesis rehabilitation: protocol proposal. Oral Implantol (Rome). 2017;9:90–97.
28. Nicolae F, Bennardo F, Barone S, Șurlin P, Gheorghe D, Burtea D, et al. The need for oral hygiene care and periodontal status among hospitalized gastric cancer patients. J Pers Med. 2022;12:684.
29. Lertpimonchai A, Rattanasiri S, Vallibhakara SO, Attia J, Thakkinstian A. The association between oral hygiene and periodontitis: A systematic review and meta-analysis. Int Dent J. 2020;67:332–343.
30. Ishikawa A, Yoneyama T, Hirota K, Miyake Y, Miyatake K. Professional oral health care reduces the number of oropharyngeal bacteria. J Dent Res. 2008;87:594–598.
31. Chhaliyil P, Fischer K, Schoel B, Chhalliyil P. A novel, simple, frequent oral cleaning method reduces damaging bacteria in the dental microbiota. J Int Soc Prev Community Dent. 2020;10:511–519.
32. Kaye J, Lee S, Chinn C. The need for effective interprofessional collaboration between nutrition and dentistry. Front Public Health. 2025;13:1534525.
33. Prasad M, Manjunath C, Murthy A, Sampath A, Jaiswal S, Mohapatra A. Integration of oral health into primary health care: A systematic review. J Family Med Prim Care. 2019;8:1838–1845.
34. Luu T. Cancer patient management: role of multidisciplinary teams. BMJ Support Palliat Care. 2022;12:201–206.

From Dimensions of Dental Hygiene. March/April 2026;24(2):32-35

Understanding terms that patients may use to identify themselves is an easy first step to improving patient care. Lesbian, gay, bisexual, transg­­­ender, queer/questioning, intersex, asexual/aromatic/agender (LGBTQIA+) — with the plus sign referring to any nonheterosexual/noncisgender identities that are not explicitly listed in previous terminology — is a frequently used acronym. These terms are not exhaustive as there are many nuances that continue to evolve as patients’ identities do. These terms serve as a foundation to build an understanding of LGBTQIA+ patients and their identities to facilitate respectful communications (Table 1).

Sexual orientation, biological sex, gender identity, and gender expression are all spectrum-based components of LGBTQIA+ terminology. Sexual orientation describes sexual or romantic attraction to others.¹ Terms used to describe sexual orientation include heterosexual, homosexual, gay, lesbian, bisexual, asexual, pansexual, etc.

Romantic attraction is the emotional connection with another person, while sexual attraction is the physical connection to or arousal from others.¹ Terms used to describe romantic attraction include aromantic, heteroromantic, homoromantic, etc. Biological sex uses an individual’s chromosomes, gonads, hormones, and genitalia to medically categorize them. Furthermore, biological sex is nonbinary due to the variations in the possible characteristics used to determine categorization.²

Cisgender relates gender identity and sex assigned at birth as congruent. Intersex indicates that a person has a mix of male and female chromosomal, hormonal, internal, or external characteristics. Gender identity is how individuals sense their gender. Gender expression is how individuals present their gender.¹ Terms used to express gender identity and expression include transgender (trans), agender, nonbinary, etc.

Members of the LGBTQIA+ community account for approximately 20 million people in the United States, yet studies indicate those that identify as LGBTQIA+ are likely to postpone or completely avoid seeking healthcare due to barriers such as anticipation of discrimination, misgendering, and costs.^3-6 This highlights how widespread fears of discrimination or financial strain contribute to significant healthcare disparities within a segment of the population.

The diverse personal, social, and systemic experiences of gender- and sexuality-diverse individuals, along with documented inequities in access to health care,^7,8 underscore the importance of oral health professionals developing the knowledge and skills needed to address patients’ unique needs and provide inclusive, effective treatment.

Oral health professionals have an ethical responsibility to provide adequate and respectful treatment to all patients, including diverse patient populations such as the LGBTQIA+ community. Dental hygienists specifically play an important role in building the relationship between dental practices and the community as the front line patient educators and preventive service providers.

One study found dental students were less likely than medical and nursing students to express interest in receiving formal LGBTQIA+ health education. Additionally, students across all programs reported feeling unprepared to treat members of the LGBTQIA+ community.⁹ Competence in inclusive and affirming care significantly improves LGBTQIA+ patients’ comfort with oral health professionals.¹⁰

Oral Considerations

When caring for LGBTQIA+ patients, psychosocial factors and individual systemic conditions must be considered. Recommendations should be personalized and delivered with sensitivity to each patient’s unique experiences. LGBTQIA+ populations experience distinct oral health needs resulting from unique social, behavioral, and systemic barriers compared to cisgender, heterosexual individuals. Elevated rates of tobacco, alcohol, and substance use within this community contribute to increased risks of xerostomia, dental caries, periodontal diseases, oral cancer, and bruxism.^11,12 Dental hygienists play a critical role in identifying these behaviors, providing nonjudgmental cessation counseling, and connecting patients with resources to support healthier habits.

Although some quitlines emphasize inclusivity by explicitly inviting LGBTQIA+ individuals to seek support, few demonstrate this commitment through visible acknowledgment on their webpages.¹³ Consequently, dental hygienists serve as an essential, accessible resource for LGBTQIA+ patients by delivering evidence-based cessation counseling, ongoing support and referrals, and reinforcement of cessation messages to improve both oral and systemic health outcomes.

Beyond behavioral interventions, dental hygienists should evaluate patients for signs of bruxism, such as attrition or abfraction, and perform comprehensive caries risk assessments to tailor preventive and therapeutic strategies. Based on these findings, modifications may include the use of occlusal guards, professional fluoride applications, and at-home fluoride therapies. When appropriate, application of silver diamine fluoride offers a minimally invasive adjunctive therapy to arrest active carious lesions and manage high caries risk in patients who may face barriers to restorative care.¹⁴ Recommendations for saliva substitutes, dry mouth products, and individualized self-care aids can further address xerostomia, caries risk, and periodontal concerns for this population.

Among LGBTQIA+ populations, particularly men who have sex with men, higher rates of oral human papillomavirus (HPV) infection may contribute to an increased risk of oral cancer.¹⁵ Dental hygienists are already educating patients on risks and how to perform monthly oral cancer self-exams at home. Recommendations may include looking for persistent abnormalities like red, white, or mixed lesions and assessing areas such as the tongue’s lateral borders, tonsillar pillars, soft palate, and floor of the mouth. In addition, patients should be advised that if they see anything of concern, they should take clear photos of the area (documenting date, size, location, and appearance) and, if the abnormality does not resolve within 2 weeks, call the dental office promptly so the patient can be examined and referred to a specialist for definitive diagnosis.¹⁶ Promoting self-detection and prompt reporting of symptoms is critical to improving oral cancer outcomes in LGBTQIA+ individuals.

Engaging in nonjudgmental conversations about HPV vaccination is important when caring for LGBTQIA+ patients, especially adolescents, to help reduce HPV-associated oral cancers. HPV vaccines are approved for ages 9 to 45, with two or three doses depending on age, and earlier vaccination provides greater protection.^17,18 Dental hygienists are well-positioned to discuss vaccination status and offer evidence-based guidance to promote oral cancer prevention and improve health outcomes.

Mental health conditions, such as anxiety, depression, and eating disorders, are other concerns to consider while treating the LGBTQIA+ community. Transgender individuals, in particular, face a heightened risk of mental health challenges often associated with increased rates of suicide and self-harm.¹⁹ Chronic mental health struggles experienced by LGBTQIA+ individuals may lead to neglected oral hygiene and further anxiety when seeking oral healthcare. Clinicians should carefully observe for clinical signs, such as swelling of the parotid glands and erosion on the lingual surfaces of maxillary teeth, as they can indicate eating disorders.²⁰ When these signs are present, dental hygienists should advise patients who engage in purging behaviors to rinse with water or a baking soda solution and to delay brushing for at least 1 hour to allow saliva to restore pH balance to minimize enamel damage.²¹

Coordination with and referral to mental health professionals when eating disorders are suspected, in addition to tailored oral care plans, are essential to managing these patients effectively and preventing further oral deterioration.²²

Practical Changes for Dental Settings

Dental hygienists, particularly those in managerial roles, can feature diverse images of LGBTQIA+ patients and families on social media platforms or practice websites as a nonverbal signal that the office is a safe and welcoming space. This approach helps to build rapport and create a positive impression as both are essential for providing comfortable, patient-centered care.²³

Additional strategies to foster inclusivity include installing gender-neutral signage for single-stall restrooms and providing LGBTQIA+-inclusive books or magazines in waiting areas. Displaying visible indicators of support, such as Safe Space Alliance signage, at entrances, reception areas, waiting rooms, or operatories offers an accessible and effective way for dental hygienists and office managers to communicate safety and respect.

Dental hygienists can also participate in registries or services that help LGBTQIA+ patients locate safe and affirming providers. Wearing pins or other visual indicators signaling allyship serves as a nonverbal cue that providers are committed to patient safety and inclusion.²³

Normalizing inclusive sexual and health history by asking pronouns, preferred name, and other open-ended questions allows patients to share based on their comfort levels or preferences. Consider training all staff to consistently use patients’ preferred names and pronouns.

Using neutral language and avoiding assumptions based on biases fosters respect and avoid microaggressions, which may decrease healthcare avoidance.²⁴ Fostering an office culture of respect, accountability, and zero tolerance for discrimination can create a consistently LGBTQIA+-friendly environment.

Dental hygienists can encourage language such as “partner” instead of “husband” or “wife” and “parents” rather than “mom and dad” to be used in the office.²⁵ Providing LGBTQIA+ inclusive educational materials and connecting patients to community resources can be included as part of patients’ routine oral hygiene education provided by dental hygienists.

Once a patient has shared pronouns and preferred name, the dental hygienist needs to document and adjust the electronic health record (EHR) to reflect the patient’s wishes. The adjustment in the EHR will further allow other health providers to address the patient respectfully, without forcing the patient to address each provider individually.²⁶

Should the clinician misuse a name pronoun, or gendered term, the best approach is to recognize and own the error, correct the language, and proceed with the conversation utilizing the appropriate vocabulary.²⁷ Drawing excessive attention to the error can increase patient discomfort or embarrassment. Avoid defensiveness when being corrected by LGBTQIA+ individuals and recognize it as an opportunity for growth.

Dental hygienists in educator roles may also be able to seek ally training through their institution to further enhance inclusivity in academic and clinical settings. Ally training can provide dental hygiene educators with specific, personalized, institution accepted ways to improve communications with those of the LGBTQIA+ community in their academic and clinical roles. Dental hygiene educators can also model inclusive language in the classroom to normalize practices with future providers. By modelling inclusive behaviors and fostering consistent institutional support for LGBTQIA+‑affirming communication, educators can help build a culture of respect that future dental providers may carry into practice.²³

Many resources are available to aid dental hygienists in working with the LGBTQIA+ community (visit the web version of this article for a list). Dental hygienists  may want to connect with local centers for community-specific resources and referral networks to best serve their patient populations.

Conclusion

Providing equitable and respectful care is a core principle of the dental hygiene profession. Providing affirming care to LGBTQIA+ patients requires a foundational understanding of cultural competency, inclusive communication, and the unique oral considerations of these individuals.

References

1. LGBTQIA Resource Center Glossary. LGBTQIA Resource Center. Available at https://lgbtqia.ucdavis.edu/educated/glossary. Accessed January 31, 2026.
2. American Society for Reproductive Medicine. Just the Facts: Biological Sex. Available at asrm.org/advocacy-and-policy/fact-sheets-and-one-pagers/just-the-facts-biological-sex/. Accessed January 31, 2026.
3. Stacey L. An updated data portrait of heterosexual, gay/lesbian, bisexual, and other sexual minorities in the United States. Soc Curr. 2024;11:383-400.
4. Kcomt L, Gorey KM, Barrett BJ, McCabe SE. Healthcare avoidance due to anticipated discrimination among transgender people: A call to create trans-affirmative environments. SSM Popul Health. 2020;11:100608.
5. Raisin JA, Keels MA, Roberts MW, Divaris K, Jain N, Adkins DW. Barriers to oral health care for transgender and gender nonbinary populations. J Am Dent Assoc. 2023;154:384-392.
6. Gupta A, Salway T, Jessani A. Cost-related avoidance of oral health service utilization among lesbian, gay, and bisexual individuals in Canada. J Public Health Dent. 2023;83:254-264.
7. Jessani A. Oral health equity for global LGBTQ+ communities: A call for urgent action. Int Dent J. 2025;75:17-19.
8. Wickman J, Mukherjee S, Mintz A, Northridge JL. A social ecological approach to identifying barriers and proposing interventions at multiple levels to improve healthcare for LGBTQIA+ youths in the United States. J Adolesc Health. 2025;76:967-984.
9. Greene MZ, France K, Kreider EF, et al. Comparing medical, dental, and nursing students’ preparedness to address lesbian, gay, bisexual, transgender, and queer health. PLoS One. 2018;13:e0204104.
10. Tharp G, Wohlford M, Shukla A. Reviewing challenges in access to oral health services among the LGBTQ+ community in Indiana and Michigan: A cross-sectional, exploratory study. PLoS One. 2022;17e0264271.
11. Boyd CJ, Veliz PT, Stephenson R, Hughes TL, McCabe SE. Severity of alcohol, tobacco, and drug use disorders among sexual minority individuals and their “not sure” counterparts. LGBT Health. 2019;6:15-22.
12. Fakhrjahani I, Tiwari T, Jessani A. A scoping review of oral health outcomes and oral health service utilization of 2SLGBTQ+ people. JDR Clin Trans Res. 2024;9:199-211.
13. Ramos-Santiago JW, McIntosh S, Orfin RH, et al. Do US quitsites present information related to providing services for LGBTQ individuals? An audit study. Tob Prev Cessat. 2024;10:191457.
14. Santos NML, Tohara H, Rodrigues LKA, et al. The role of silver diamine fluoride as dental caries preventive and management: A systematic review. J Clin Med. 2024;13:4647.
15. Sonawane K, Shyu SS, Damgacioglu H, Li R, Nyitray AG, Deshmukh AA. Prevalence and concordance of oral and genital HPV by sexual orientation among US men. JNCI Cancer Spectr. 2023;7:pkac088.
16. Oral Cancer Foundation. Early Detection, Diagnosis, and Staging. Available at https://oralcancerfoundation.org/cdc/early-detection-diagnosis-staging. Accessed January 30, 2026.
17. Wolf J, Kist LF, Pereira SB, et al. Human papillomavirus infection: Epidemiology, biology, host interactions, cancer development, prevention, and therapeutics. Rev Med Virol. 2024;34:e2537.
18. Kamolratanakul S, Pitisuttithum P. Human papillomavirus vaccine efficacy and effectiveness against cancer. Vaccines (Basel). 2021;9(12):1413. doi:10.3390/vaccines9121413
19. Ziegler E, Valaitis R, Carter N, Risdon C, Yost J. Primary care for transgender individuals: A review of the literature reflecting a Canadian perspective. SAGE Open. 2020;10:1-14.
20. Valeriani L, Frigerio F, Piciocchi C, et al. Oro-dental manifestations of eating disorders: A systematic review. J Eat Disord. 2024;12:87.
21. Rangé H, Colon P, Godart N, Kapila Y, Bouchard P. Eating disorders through the periodontal lens. Periodontol 2000. 2021;87:17-31.
22. Presskreischer R, Prado MA, Kuraner SE, Arusilor IM, Pike K. Eating disorders and oral health: A scoping review. J Eat Disord. 2023;11:55.
23. Braybrook D, Bristowe K, Timmins L, et al. Communication about sexual orientation and gender between clinicians, LGBT+ people facing serious illness and their significant others: A qualitative interview study of experiences, preferences and recommendations. BMJ Qual Saf. 2023;32:109-120.
24. Marchi M, Travascio A, Uberti D, et al. Microaggression toward LGBTIQ people and implications for mental health: A systematic review. Int J Soc Psychiatry. 2024;70:23-35.
25. National LGBTQIA+ Health Education Center. Providing Inclusive Services and Care for LGBT People: A Guide for Health Care Staff. Available at lgbtqiahealtheducation.org/publication/learning-guide/. Accessed January 30, 2026.
26. Grutman AJ. Use of chosen names in electronic health records to promote transgender inclusivity. J Am Med Inform Assoc. 2023;30:1219-1221.
27. Okamuro K, Card A, Barton HJ, et al. Patient and clinician perspectives on misgendering in healthcare. BMJ Qual Saf. 2025:bmjqs-2024-018364.

From Dimensions of Dental Hygiene. March/April 2026;24(2):36-39

Periodontal diseases are the most common cause of tooth loss in the modern world. According to data from the World Health Organization, gingival bleeding and calculus are most prevalent among adults from all regions of the world, while advanced disease with deep periodontal pockets (≥ 6 mm) affects approximately 10% to 15% of the adult population.¹

Periodontitis encompasses a multifaceted interaction between specific bacteria and host factors that results in loss of periodontal attachment structures. The current understanding of periodontitis’ etiopathogenesis describes periodontal diseases as site-specific conditions driven by pathogenic host–microbial interactions that trigger the overproduction of destructive enzymes and pro-inflammatory mediators, ultimately determining the extent and severity of tissue destruction.^2,3 This pattern has assisted oral health professionals to better comprehend the underlying host immune responses and the expansion of innovative treatment strategies that may improve therapeutic outcomes and overall clinical management of patients with periodontitis.

The main goal in treating periodontitis is reducing attached and unattached pathogenic bacteria. Attached biofilm is composed of embedded bacteria in a protective extracellular matrix that protects the pathogenic bacteria from the host’s immune response and antimicrobial agents. Pathogenic bacteria include enzymes and lipopolysaccharides that trigger the inflammatory response and tissue destruction. Unattached pathogenic bacteria can detach from the biofilm and enter the bloodstream during the host’s inflammatory response. Consequently, the unattached bacteria have the ability to colonize in different sites in the oral cavity or reattach to tooth surfaces and restorations, initiating new biofilm formation and propagating the disease cycle.

Periodontitis treatment focuses primarily on the reduction of pathogenic bacteria in biofilm. Nonsurgical periodontal therapy (NSPT) reduces periodontal pocket depth and clinical attachment levels in mild to moderate periodontitis cases in which pocket depths are  < 6 mm.⁴ In the treatment of probing depths > 6 mm, surgical periodontal therapy results in greater periodontal pocket depth reduction and clinical attachment gain.⁴

Chronic periodontal diseases can be arrested and successfully treated by NSPT provided adequate plaque control is maintained throughout the supportive phase of treatment.⁵ Providing NSPT includes mechanical and chemotherapeutic procedures to minimize or eliminate pathogenic bacteria in the periodontal tissues and alter host immune inflammatory responses. Mechanical therapy refers to both supragingival and subgingival scaling and debridement of the root surfaces by hand or power instrumentation to remove deposits such as plaque, calculus, endotoxins, and other plaque-retentive local factors.⁶

Chemotherapeutic agents include antimicrobial therapies that can be used systemically or locally to address changes in the microflora. Host modulatory therapy can be implemented to manage altered host immune response consisting of excessive levels of pro-inflammatory enzymes, cytokines, and excessive osteoclast function that may be related to certain risk factors.⁷

Periodontal diseases are multifactorial, and one or more risk factors are required for disease initiation and progression.¹ Poor oral hygiene, poorly controlled systemic diseases, stress, smoking, genetic susceptibility, and alveolar bone loss are just some of the risk factors that may influence long-term outcomes of periodontal therapy.^1,8

Smoking

Research studies support the correlation between smoking and periodontal diseases. Tobacco smoking destroys periodontal tissues and increases the rate of periodontal disease progression.⁹ Smoking tobacco modifies the host response to the pathogenic bacteria in biofilm. Patients with periodontal diseases who smoke present with diminished clinical gingival inflammation and bleeding compared to patients who do not smoke. Patients need to know that nicotine exerts local vasoconstriction, reducing blood flow and causing edema and clinical signs of inflammation.¹⁰

Smoking tobacco impairs the healing process especially in the gingival tissues and supporting periodontal structures. Smoking reduces blood flow to the gingival tissues, delaying the body’s normal healing processes. Subsequently, smoking weakens the immune system, making it less effective in resisting the pathogenic bacteria that cause periodontal diseases. Smoking also causes hyposalivation, and alters the composition of saliva, decreasing antimicrobial properties and increasing pathogenic bacteria.¹¹ The combined effects of hyposalivation, altered salivary composition, and increased bacterial growth can lead to a higher risk of dental diseases including caries, gingivitis, and periodontitis.¹¹

Diabetes Mellitus

Diabetes has been unequivocally confirmed as a major risk factor for periodontitis.¹² The risk of periodontitis is increased by approximately threefold in patients with diabetes compared to those without.¹³ Diabetes can exacerbate the severity and accelerate the progression of periodontal diseases. Altered wound healing is a common problem among individuals with diabetes. The primary reparative cell in the periodontium (fibroblast) does not function properly in high-glucose environments.¹⁴ Furthermore, the collagen that is produced by fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes, the production of which is elevated in diabetes.¹⁵ Consequently, periodontal wound healing responses to chronic microbial insult may be altered among those with sustained hyperglycemia, resulting in increased bone loss and attachment loss.¹⁶

Cardiovascular Disease

A correlation between oral health and cardiovascular disease has been proposed for more than a century. Oral sepsis and dental extractions were suggested as causes of cardiac tissue infection.¹⁷ Periodontal diseases generate an inflammatory host response that may support the development and progression of cardiovascular diseases.

Research suggests that patients with periodontal diseases may face an increased risk of cardiovascular disease, with greater periodontal severity potentially associated with higher cardiovascular risk.¹⁸ Epidemiologic research has substantiated the link between periodontal diseases and cardiovascular diseases.¹⁹ Although research continues to point to a connection, causality has not yet been established. Shetty et al¹⁹ report an improvement in cardiovascular diseases risk factors after periodontal interventions.

Lasers in Periodontal Treatment

Traditional management of periodontal diseases involves mechanical debridement, oral hygiene education, and, in some cases, adjunctive antibiotic therapy.^20,21 While these methods are effective in managing mild to moderate cases, they have limitations. Deep periodontal pockets (> 6 mm) can be challenging to scale thoroughly with mechanical methods and systemic conditions may impair wound healing and response to treatment.²²

Recent advancements in light amplification by stimulated emission of radiation (laser) technology have introduced new paradigms in periodontal therapy.²³ Lasers create a narrow beam of light in a specific wavelength that produces concentrated energy at a exact location. Research studies revealed developments in laser technology for use in periodontal treatments known as laser periodontal therapy.²²

Laser Safety

Most lasers used in dentistry are user friendly, however, precautions must be followed to ensure safe and effective operation. Lasers used in dentistry require proper training and education. Training and requirements for dental hygiene laser use vary by state. Oral health professionals must keep apprised of state regulations to determine whether laser use is permitted within their scope of practice.

Wavelength protective eyewear must be worn by anyone in the vicinity of the laser while in use.²⁴ The meaning of a safe distance is not standardized as a variety of laser types are used in dentistry. As such, every office should have a designated laser safety officer (LSO) to supervise the proper use of the laser, coordinate staff training, oversee the use of protective eyewear, and remain up to date with pertinent regulations.²⁴ The LSO will determine the nominal hazard zone, which depends on the type of laser used. The Occupational Safety and Health Administration (OSHA) requires the display of appropriate signage in each room in which a laser is used.²⁵ The use of lasers during any dental treatment must be documented in the patient chart.

Clinical Applications of Lasers in Periodontal Treatment

Laser therapy in periodontal treatment uses either soft-tissue or hard-tissue lasers. The choice between these modalities depends on the target tissue and the wavelength of the laser used. The most common dental lasers are carbon dioxide (CO₂) lasers (water and hydroxyapatite); erbium lasers (water and hydroxyapatite); neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers (melanin, hemoglobin and pigmentation); and diode lasers (melanin, hemoglobin, and pigmentation).

The effects of laser energy are wide ranging. Lasers exhibit potential in wound healing, tissue ablation, bacterial reduction, epithelial ablation, connective tissue remodeling, enhanced bone metabolism, hemorrhage control, and enhanced root preparation.²⁵ When choosing the appropriate laser for periodontal treatment, the wavelength, target tissue, type of power, pulsing mode, cooling mechanism, delivery system, quality, and, most important, the training required to safely operate the device are all factors to consider.²⁵

Laser therapy can control bacteremia, remove pocket epithelium, reduce bacteria, and improve periodontal regeneration in animals and humans without damaging the surrounding bone and pulp tissues.²⁶ Erbium lasers demonstrate significant bactericidal effect against Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans.²⁷ Reduction of interleukins and pocket depth have also been reported.²⁷

Soft tissue diode lasers may support new cementum-mediated connective tissue attachment and periodontal regeneration of diseased root surfaces.²⁷ Diode lasers target pigmentation and melanin, use low power, and can be used to excise tissue, kill bacteria at shallow depths, and provide low-level laser therapy.²⁵

Laser bacterial reduction (LBR), a noninvasive procedure, uses a noncutting laser to eliminate bacteria in periodontal pockets as an adjunctive therapy during scaling and root planing or prophylaxis. During LBR, a soft tissue laser is inserted into the periodontal pocket, providing a small amount of thermal energy that decontaminates and eradicates the bacteria in the periodontal pocket. The laser is applied for a short duration, usually 5 to 10 seconds per area, and is moved continuously with apical to coronal strokes to ensure complete decontamination of the periodontal pocket has been completed. LBR likely provides some antimicrobial benefit, but the magnitude of that benefit varies depending on the laser type, clinical protocol, and patient condition. As a result, many researchers conclude that lasers may enhance periodontal treatment when used appropriately, but stronger clinical evidence is still needed to establish consistent, long-term advantages over conventional care.²⁸

Laser-assisted new attachment procedure (LANAP) employs a laser beam for the breakdown of pathogenic bacteria and elimination of damaged periodontal tissues.²⁹ This is accomplished through the sterilization of the compromised areas, promoting tissue regeneration without surgery, regenerating the damaged periodontal tissues, and developing an attachment to the root surfaces of the newly formed connective tissues.²⁸ LANAP may be associated with cementum-mediated tissue attachment and apparent periodontal regeneration of diseased root surfaces.²⁷

LANAP also increases the release of endorphins, diminishes nerve sensitivity, and decreases the perception of pain by blocking pain signals transmitted from the inflamed area to the brain.²⁷ Additionally, LANAP causes vasodilation, which clears inflammation and edema and promotes lymphatic drainages. Through vasodilation, wound healing is accelerated due to better blood flow through new formation of capillaries within the inflamed tissues.²⁷

In LANAP, the laser targets diseased tissue as it presents with darker hues and laser wavelengths are highly absorbed by melanin and hemoglobin. The LANAP procedure usually requires two passes with the laser.²⁷ The first pass of the laser eradicates pathogenic bacteria in the periodontal pocket, followed by ultrasonic and hand scaling to remove accretions on the root surfaces. A second pass with the laser will produce clotting in the periodontal pocket to seal the area, promoting tissue regeneration.²⁷

Evidence shows LANAP works best as part of a comprehensive periodontal treatment plan, rather than as a standalone procedure. Additionally, while some case series and studies show tissue regeneration, results can vary depending on patient factors, operator experience, and disease severity.³⁰

Developing a Periodontal Treatment Plan

After obtaining a thorough medical history, a comprehensive treatment plan is established. The periodontal charting and radiographs are reviewed in order to determine the periodontal stage and grade. The patient’s assessment is used to determine whether laser therapy is an appropriate option. If the patient presents with deep periodontal pockets and/or chronic inflammation, LBR or LANAP may be beneficial in the comprehensive periodontal treatment plan.

Once it has been determined that laser therapy will be incorporated into the comprehensive periodontal treatment plan, the patient must give informed consent. Informed consent includes explaining the assessment and proposed treatment, benefits and risks of the treatment, and alternative treatment options, including the consequences of not treating the periodontal condition. Treatment should not commence unless the patient has signed the proposed treatment plan.

The evaluation of laser therapy’s efficacy in periodontal treatment involves an assessment of clinical outcomes, comparisons with traditional treatments, and analysis of various studies and clinical trials.²³ Laser therapy is not a substitute for traditional methods of periodontal treatment but may be a helpful adjunct. Its efficacy varies depending on the type of laser used, the severity of the periodontal disease, and individual patient factors.²³ Mills et al³⁰ report that current evidence is inadequate to conclude laser therapy alone is either superior or comparable to conventional periodontal therapy in terms of clinical improvement in probing depths in the treatment of moderate to severe periodontitis.

In dentistry, laser therapy has become more prevalent as an adjunctive method to periodontal treatment. Conventional scaling and root planing may not always allow thorough access to the periodontal pockets during treatment. Lasers may offer bactericidal and detoxification effects, as well as removal of the epithelium lining and granulation tissue.³¹ Lasers in the periodontal treatment plan focus on bactericidal and disinfection of periodontal pathogens while aiming to diminish the etiology of periodontal diseases.

References

1. Bhansali RS. Non-surgical periodontal therapy: An update on current evidence. World Journal of Stomatology. 2014;3(4):38-51.
2. Ryan ME, Preshaw PM. Host modulation. Carranza’s Clinical Periodontology. 11th ed. Philadelphia: Saunders; 2012:275-280.
3. Kirkwood KL, Cirelli JA, Rogers JE, Giannobile WV. Novel host response therapeutic approaches to treat periodontal diseases. Periodontol 2000. 2007;43:294-315.
4. Heitz-Mayfield LJ, Trombelli L, Heitz F, Needleman I, Moles D. A systematic review of the effect of surgical debridement vs non-surgical debridement for the treatment of chronic periodontitis. J Clin Periodontol. 2002;29 Suppl 3:92-102.
5. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. Results after 6 years. J Clin Periodontol. 1981; 8:239-248.
6. Drisko CH. Nonsurgical periodontal therapy. Periodontol 2000. 2001;25: 77-88.
7. Ryan ME. Nonsurgical approaches for the treatment of periodontal diseases. Dent Clin North Am. 2005;49:611-36.
8. Albandar JM. Epidemiology and risk factors of periodontal diseases. Dent Clin North Am. 2005;49:517-532.
9. Zini A, Sgan-Cohen HD, Marcenes W. Socio-economic position, smoking, and plaque: a pathway to severe chronic periodontitis. J Clin Periodontol. 2011;38:229–235.
10. Jensen JA, Goodson WH, Hopf HW, Hunt TK. Cigarette smoking decreases tissue oxygen. Arch Surg. 1991;126:1131–1134.
11. Sever E, Božac E, Saltović E, Simonić-Kocijan S, Brumini M, Glažar I. Impact of the tobacco heating system and cigarette smoking on the oral cavity: a pilot study. Dent J (Basel). 2023;11:251.
12. Khader YS, Dauod AS, El-Qaderi SS, Alkafajei A, Batayha WQ. Periodontal status of diabetics compared with nondiabetics: a meta-analysis. J Diabetes Complicat. 2006; 20:59–68.
13. Mealey BL, Ocampo GL. Diabetes mellitus and periodontal disease. Periodontol 2000. 2007;44:127–153.
14. Willershausen-Zönnchen B, Lemmen C, Hamm G. Influence of high glucose concentrations on glycosaminoglycan and collagen synthesis in cultured human gingival fibroblasts. J Clin Periodontol. 1991;18:190-195.
15. Golub LM, Lee HM, Ryan, ME .Tetracyclines inhibit connective tissue breakdown by multiple non-antimicrobial mechanisms. Adv Dent Res. 1998;12:12-26.
16. Mealey BL. Periodontal disease and diabetes: A two-way street. J Am Dent Assoc. 2006;137:S26-S31.
17. Miller WD. The human mouth as a focus of infection. Dent Cosmos. 1891; 33: 689– 713.
18. Alwithanani N. Periodontal diseases and heart diseases: a systemic review. J Pharm Bioallied Sci. 2023;15(Suppl 1): S72-S78.
19. Shetty B, Fazal I, Khan SF, et al. Association between cardiovascular diseases and periodontal disease: more than what meets the eye. Drug Target Insights. 2023; 17:31-38.
20. Batchelor P. Is periodontal disease a public health problem? Br Dent J. 2014;217:405-409.
21. Ramesh T, Sundar M, Ranjani SS, Kurian B. Efficacy of scaling and root planing with and without adjunctive use of diode laser or tetracycline fibers in patients with generalized chronic periodontitis: a comparative study. J Investig Clin Dent. 2017;8: e12188.
22. Kwon T, Lamster IB, Levin L. Current concepts in the management of periodontitis. Int Dent J. 2021;71:462-476.
23. Al Asmari D, Alenezi A. Laser technology in periodontal treatment: benefits, risks, and future directions-a mini review. J Clin Med. 2025;14:1962.
24. Verma SK, Maheshwari S, Singh RK, Chaudhari PK. Laser in dentistry: An innovative tool in modern dental practice. Natl J Maxillofac Surg. 2012;3:124-132.
25. Linden E. Laser basics. Dimensions of Dental Hygiene. 2016;14(4):56–59.
26. Romanos G. Current concepts in the use of lasers in periodontal and implant dentistry. J Indian Soc Periodontol. 2015;19:490-494.
27. Elavarasu S, Naveen D, Thangavelu A. Lasers in periodontics. J Pharm Bioallied Sci. 2012;4 (Suppl 2): S260-263.
28. Patel S, Awan KH, Freitas CMT, Bhandi S, Licari, FW, Patil S. Diode laser targeting red-complex bacteria in periodontitis: a systematic review. Eur Rev Med Pharmacol Sci. 2023;27:11806-11816.
29. Bechir ES. The clinical and microbiological effects of LANAP compared to scaling and root planing alone in the management of periodontal conditions. Diagnostics (Basel). 2023;13:2450.
30. Mills MP, Rosen PS, Chambrone L, et al. American Academy of Periodontology best evidence consensus statement on the efficacy of laser therapy used alone or as an adjunct to non-surgical and surgical treatment of periodontitis and peri-implant diseases. J Periodontol. 2018; 89: 737–742.
31. Aoki A, Sasaki KM, Watanabe H, Ishikawa I. Lasers in nonsurgical periodontal therapy. Periodontol 2000. 2004;36:59-97.

From Dimensions of Dental Hygiene. March/April 2026;24(2):40-45

At the core of Profisil Plus is 5% sodium fluoride, providing a high concentration of fluoride ions to support remineralization and increase enamel resistance to acid challenges. Upon application, fluoride occludes the dentin tubules, allowing for sustained fluoride availability and enhanced uptake over time. This prolonged exposure is particularly beneficial for patients at elevated caries risk, those with enamel erosion, or individuals experiencing post-scaling or post-whitening sensitivity.

The Modern Solution

What differentiates Profisil Plus from traditional fluoride varnishes is its dimethicone-based gel formulation, which eliminates the need for rosin (colophony). The absence of rosin eliminates the tacky, sticky residue often associated with conventional varnishes — improving patient comfort and reducing complaints related to unpleasant mouth feel.

From a clinical standpoint, the rosin-free formulation also prevents clogging of suction lines and minimizes varnish buildup on instruments, contributing to smoother operatory workflow and reduced maintenance concerns.

Profisil Plus is additionally allergen-free and alcohol-free, making it suitable for medically sensitive patients and those with known sensitivities or prior adverse reactions to rosin-based products. It’s truly unflavored formulation is especially valuable for patients who struggle with strong tastes or oral sensory triggers, including pediatric, geriatric, periodontal, and special-needs populations.

Another practical advantage is the varnish’s clear application. Because Profisil Plus dries transparent, it does not obscure tooth surfaces, allowing oral health professionals to perform a comprehensive exam immediately after application without visual interference. This supports efficiency during recare appointments and facilitates seamless collaboration between the dental team.

The “Plus” formulation further enhances preventive benefits by incorporating calcium phosphate and hydroxyapatite, which work synergistically with fluoride to support enamel repair and reinforce weakened tooth structures. This chemistry-driven approach not only addresses immediate hypersensitivity through surface protection but also supports long-term enamel health.

Applied chairside in seconds to wet or dry teeth, Profisil Plus offers dental hygienists a scientifically grounded, patient-centered fluoride varnish option that enhances comfort, supports fluoride uptake, and integrates effortlessly into preventive and periodontal care — demonstrating how formulation chemistry can directly impact clinical outcomes and patient experience.

If your office is looking to increase fluoride acceptance and provide an exceptional product that patients actually like, now is the time.

Kettenbach
kettenbachusa.com
877-532-2123

From Dimensions of Dental Hygiene. March/April 2026;24(2):25

A systematic review by Silva et al¹ investigated whether brush-floss or floss-brush is more effective. It assessed randomized control trials to determine which sequence (brush- floss or floss -brush) resulted in a reduction in dental plaque. The authors found no difference between the two approaches, however, the systematic review included two articles with a small sample size of 60 participants.

A randomized control trial by Mazahari et al² that was included in the Silva systematic review examined the effect of brushing and flossing sequence on interdental plaque. Researchers noted the presence or absence of interdental plaque in 25 adults. Reduction in interdental plaque in the floss-brush group was statistically significantly higher than in the brush-floss group. The authors also found higher interdental fluoride concentrations in the floss-brush group than in the brush- floss group.

Another study with 35 adult participants found that flossing and brushing had the greatest reduction in periodontal indicators, but only in men.³ Using a crossover design, the authors assessed bleeding on probing and dental plaque to assess the efficacy of the brushing and flossing sequence.

While this research indicates that the floss-brush sequence may be superior, the sample size in all of these studies was small. More research is needed to confirm these findings.

To address the question of rinsing or not rinsing with water after brushing with a fluoride product, Nazzal et al⁴ conducted a randomized control trial with 17 caries-free and caries-prone children: a total of 32 participants. When examining the residual salivary fluoride concentration, the authors found an increased fluoride concentration when no water rinsing was performed after brushing. In contrast, Opydo-Szumaczek et al⁵ examined salivary fluoride concentration in 14 volunteers finding that the concentration of the fluoride product had a greater influence on residual salivary fluoride concentrations than did post-water rinsing or no rinsing. In another randomized control trial, the authors found no post water rinsing had a greater anticaries effect and increased fluoride retention.⁶ This 8- to 9-week study was conducted on 20 adolescents with orthodontic bands. Again, the research is inconclusive due to the limited number of studies, the small sample size, and the short length of the studies.

Using an evidence-based approach, advising patients to floss and then brush and avoid rinsing with water appears to be reasonable. However, this recommendation is based on limited scientific evidence.

References

1. Silva C, Albuquerque P, de Assis, et al. Does flossing before or after brushing influence the reduction in the plaque index? A systematic review and meta-analysis. Int J Dent Hyg. 2022;20:18-25.
2. Mazhari F, Boskabady M, Moeintaghavi A, Habibi A. The effect of toothbrushing and flossing sequence on interdental plaque reduction and fluoride retention: A randomized controlled clinical trial. J Periodontol. 2018;89:824–832.
3. Torkzaban P, Arabi SR, Sabounchi SS, Roshanaei G. The efficacy of brushing and flossing sequence on control of plaque and gingival inflammation. Oral Health Prev Dent. 2015;13:267-273.
4. Nazzal H, Duggal MS, Kowash MB, Kang J, Toumba KJ. (2016). Comparison of residual salivary fluoride retention using amine fluoride toothpastes in caries-free and caries-prone children. Eur Arch Paediatr Dent. 2016;17:165-169.
5. Opydo-Szymaczek J, Pawlaczyk-Kamieńska T, Borysewicz-Lewicka M. Fluoride intake and salivary fluoride retention after using high-fluoride toothpaste followed by post-brushing water rinsing and conventional (1400-1450 ppm) fluoride toothpastes used without rinsing. Int J Environ Res Public Health. 2022;19:13235.
6. Al-Mulla A, Karlsson L, Kharsa S, Kjellberg H, Birkhed D. Combination of high-fluoride toothpaste and no post-brushing water rinsing on enamel demineralization using an in-situ caries model with orthodontic bands. Acta Odontol Scand. 2010;68:323-328.

From Dimensions of Dental Hygiene. March/April 2026;24(2):46