In early August, I had the pleasure of attending the International Symposium on Dental Hygiene (ISDH) in Dublin, Ireland. It was held at the world-class Dublin Convention Center, which sits across from the harp-shaped Samuel Beckett Cable Bridge that spans the Liffey River. It was thrilling to see so many of the young members of our profession, as well as rub shoulders with some of the long-time greats in dental hygiene.
Equally thrilling during this 3-day event was learning about the newest trends, recent developments, and just-published scientific studies in the field of dentistry and dental hygiene. In my opinion, one of the more interesting trends in the dental hygiene world is air polishing. The new air polishers blast off plaque biofilm using glycerin or erythritol and appear similar to the older prophylaxis polishers that used baking soda and calcium carbonate to achieve stain removal. Air polishing provides an alternative to rubber cup polishing for supragingival biofilm removal. Uniquely, air polishers can be used subgingivally to cleanse the periodontal sulcus of biofilm. Subgingival biofilm removal has traditionally been done using hand instruments or ultrasonics.
When I overheard two British dental hygeenists (this is how they pronounce hygienist in the United Kingdom [UK]), asking why American dental hygeenists haven’t joined the air polishing biofilm removal revolution, I chimed in. I expressed my opinion with a question: Do I want to spend my chairside time removing biofilm that patients can remove on their own or do I want to spent time removing calculus deposits that patients can’t remove themselves? This is the question I struggle with.
In my opinion, calculus is the more important deposit because periodontal health will not be reached if it remains and patients are unable to remove it. Plaque biofilm will grow back within 24 hours and needs to be removed by patients once they leave my chair. We carried on a lively conversation discussing the pros and cons of air polishing. Time will tell if air polishing takes off in the US.
Hand Vs Ultrasonic Instrumentation
I attended as many of the presentations at the symposium as time permitted and most were fascinating. I found one paper particularly interesting. It involved the proverbial war between hand and ultrasonic instrumentation. The focus was on the systemic responses of instrumentation. The research, which appeared in the Journal of Clinical Periodontology in 2020, reported that serum C-reactive protein increased at day 1 following debridement with no difference between hand and ultrasonic groups.1 The takeaway here is that care must be given when treating patients who are susceptible to an increase in inflammatory response. What struck me was the conclusion that ultrasonic instrumentation resulted in shorter treatment time than hand instruments with comparable clinical outcomes.
It was explained that clinicians in the study finished debridement faster with ultrasonic instruments vs hand instruments. I wondered how did they know when they were finished? Determining completion was not discussed. During the question period, I asked how the clinicians determined when therapy was complete. I was told that determining completeness of debridement was subjective and that there was no definitive way to assess when it had been finished. The presenter said clinicians used an explorer to determine when therapy was compete. I piped up to say that a dental endoscope could have been used to view the root surface under magnification, providing the clinician with the ability to visually inspect the root surface to help determine when the procedure was complete. To this, the presenter commented that dental endoscopes were controversial and still under investigation. I found this surprising because the dental endoscope is approved by the United States Food and Drug Administration for treatment in dentistry and is fully backed by scientific research. Numerous studies verify dental endoscopy’s legitimacy.2–7
I have been using a dental endoscope for 12 years and my former employer, a periodontist, owns seven of them. The use of a calculus explorer is the most common way dental hygienists determine when they have finished root debridement, but this is because most do not have access to a dental endoscope.
With a dental endoscope, I have watched my removal of subgingival calculus deposits daily using ultrasonic instruments for the past 12 years and it is not a fast procedure. My usual time to complete a quadrant of root debridement with a dental endoscope ranges from 2 hours to 3 hours. It takes time and patience for vibration to dislodge embedded calculus from roots. You can only know this if you have seen it. The benefit of watching is to know when calculus and biofilm have been completely cleared, thus preventing excess root structure from being removed. Dental hygienists experienced in dental endoscopy can achieve results following debridement that are comparable to surgery.
I am not convinced that ultrasonic instruments are faster than hand instruments. Perhaps roots feel smooth after ultrasonic instrumentation because of the way it removes calculus in layers, leaving a flattened sheet of glass-like deposit that can go undetected when using an explorer in a closed procedure. I am looking forward to more research exploring the question of which provides shorter treatment time: hand or ultrasonic instrumentation. I am also looking forward to the next ISDH in Korea in 2024, and encourage all of those clinicians who are able to attend. To learn more about the IFDH and ISDH, visit: ifdh.org.
- Johnston W, Paterson M, Piela K, et al. The systemic inflammatory response following hand instrumentation versus ultrasonic instrumentation—a randomized controlled trial. J Clin Periodontol. 2020;4:1087–1097.
- Kuang Y, Hu B, Chen J, Feng G, Song J. Effects of periodontal endoscopy on the treatment of periodontitis; a systematic review and meta-analysis. J Am Dent Assoc. 2017;148:750–759.
- Osborn J. Role of the dental endoscope in calculus detection. Dimensions of Dental Hygiene. 2016;14(2):40–44.
- Osborn JB, Lenton PA, Lunos SA, Blue CM. Endoscopic vs. tactile evaluation of subgingivalcalculus. J Dent Hyg. 2014;88:229–236.
- Blue CM, Osborn J, Lenton P, Lunos S, Poppe K. A pilot study comparing the outcome of scaling/root planing with and without Perioscope™ technology. J Dent Hyg. 2013;87:152–157.
- Checchi L, Montevecchi M, Checchi V, Zappulla F. The relationship between bleeding on probing and subgingival deposits. An endoscopical evaluation. Open Dent J. 2009;28:154–160.
- Wilson TG, Harrel SK, Nunn ME, Francis B, Webb K. The relationship between the presenceof tooth-borne subgingival deposits and inflammation found with a dental endoscope. J Periodontol. 2008;79:2029–2035.
From Dimensions of Dental Hygiene. January 2023; 21(1)12-13.