Promoting Healing

Q. What is the best way to promote healing after nonsurgical periodontal instrumentation?
A. Dental hygienists have to ensure that the root surfaces are smooth and free of biofilm and calculus following instrumentation, which is the key to optimal healing. They also need to encourage patients to remain diligent with their plaque control at home. The prescription of a chlorhexidine mouthrinse can help patients promote healing at home.

The chlorhexidine mouthrinse should be used for the 4- week to 6-week time period between the initial therapy and the re-evaluation appointment. Patients often do not follow through with using a chlorhexidine rinse because of the taste and the staining that chlorhexidine causes. If the patient refuses a chlorhexidine rinse, an essential oils or other antimicrobial mouthrinse can be considered. If patients can become accustomed to an oral mouthrinse regimen of rinsing morning and night, this can help immensely with the healing process. If the patient has long, open embrasures, dipping an interdental brush into an antimicrobial mouth rinse and then using it interproximally even for the first 1 week to 2 weeks after initial therapy is completed is beneficial.

Q. How long should dental hygienists wait before reprobing or reevaluation?
A. The minimum is 4 weeks. The reepithelialization of the wounds usually takes about 2 weeks. Waiting another 2 weeks at minimum (4 weeks to 6 weeks total from the initial appointment) is important to determine if the initial therapy was successful. This allows additional time for areas that still may be unhealthy and have residual deposits to become evident. At that time, dental hygienists can decide whether they are going to retreat, refer, or try something else. Often the evaluation is performed too early at which point the healing is not representative of the final outcome and the results may be misleading.

Q. Is it normal to see minute spot bleeding at the point of re-evaluation?
A. If the re-evaluation is done too soon, bleeding will be a sign of incomplete healing—not new disease or unresolved disease process. Bleeding on probing after the initial therapy is done and 4 weeks of healing time has occurred is a guiding factor in determining the next step in treatment—whether maintenance, referral, or retreatment will be recommended. Generally some points of bleeding will exist and dental hygienists need to ascertain whether they are due to residual deposits in the pocket or poor oral hygiene. I believe that zero bleeding on probing at the first evaluation appointment is too high of an expectation. After the maintenance phase has been completed where the patient has received scaling and root planing every 3 months for a year, I think zero bleeding on probing can be expected because there have been four other appointments to re-evaluate and rescale the areas that had residual calculus and inflammation.

INITIAL THERAPY

Q. When providing nonsurgical periodontal therapy, including instrumentation of root surfaces, what are the best practice techniques for achieving optimal healing during initial therapy?
A. The first step is to develop a dental hygiene treatment plan for patients based on the information collected during the examination, the clinical evaluation, and the deposits present. Once the dental hygiene treatment plan has been determined, deposit removal can start.

Before beginning, the instruments to be used must be sharp. Many dental hygienists don’t take the time necessary to maintain sharp instruments. Deposit removal will not be efficient both in terms of time management and technical success and calculus will inevitably get burnished onto the tooth surface if dull instruments are used. Burnished calculus is far more work to remove than eradicating the initial deposit. Instruments require sharpening throughout the entire initial phase of retreatment. I recommend ceramic sharpening stones to maintain a sharp edge because they only remove a small portion of the instrument blade material. However, instruments must be continuously sharpened with the ceramic stone during the appointment and if an instrument is allowed to become extremely dull, it is difficult to bring it back to a sharp edge with a ceramic stone. In this case, a coarser grit stone would be needed.

The second step is to detect and assess the calculus deposits. They can’t be removed if the dental hygienist can’t feel them. Remember that, microscopically, the explorer tip used to evaluate root surfaces can be larger than some of the edges of burnished calculus that need to be removed so the use of a very fine explorer tip with a shank that provides access to deep pockets is necessary. Periodontal probing should not be underestimated. It not only measures probing depth but also serves to determine the topographical map of the location of the pockets in need of treatment.

Effective calculus removal depends on the combination of firm lateral pressure and correct angulation of the blade against the tooth. Burnished calculus results if there is inadequate pressure or an incorrect angle is used. To achieve the correct angle, reinforced hand positions as well as extraoral or alternative fulcrums should be considered. These can provide increased power when using hand instruments. More force or power is generated when using an extraoral or alternative fulcrum instead of the regimented process that was once part of dental hygiene education.

Dental hygienists should occasionally do a review of the root morphology to refresh their knowledge on all of the developmental grooves, the heights of contour, developmental depressions, where the CEJ line of contour is, and the general anatomy of the furcations. A strong foundation in root morphology provides a better understanding of where to find the potential challenges to effective instrumentation. All of these tools are important in helping visualize where the instrument blade is and how root surfaces are supposed to look when they are calculus/ deposit free.

Another key point is that dental hygienists need to have a reasonable armamentarium in the operatory. The miniaturization and thinning of instruments really help achieve much better instrumentation in deeper pockets. Also diamond-coated hand instruments and the new different shaped instruments provide additional ways to approach deposits.

Q Does power instrumentation play a role in the initial therapy?
A Definitely. The miniaturization of ultrasonic tips has helped significantly. Ultrasonic tips used to be big and bulky and the probability of gouging root surfaces was high with their use because they are difficult to insert and adapt to the roots in deep pockets. With the thinning and miniaturization of the tips, they have become far more useful and beneficial in removing deposits subgingivally. It is still possible to gouge roots and burnish calculus with power instruments but, at the same time, they have greatly reduced the effort required to remove deposits. However, I do not feel that ultrasonic instrumentation can do the complete job. I strongly believe that follow-up with hand instruments is always required, especially on interproximal surfaces directly under the contact where the small active portion of a sonic or ultrasonic tip is difficult to adapt. Root coverage is very important and only a very small portion of the ultrasonic tip is vibrating optimally for deposit removal. This active portion of the tip must touch the entire root surface to insure thorough deposit removal. A combination of both hand and power instrumentation is the best approach.

MAINTENANCE THERAPY

Q. What are the best practice techniques for maintenance therapy?
A. The goal of maintenance therapy is to remove the bacterial microflora that has re-established since the initial therapy. In the time between initial therapy and the first re-evaluation appointment, inflammation in the pocket wall is reduced and the connective tissue fibers become healthier. As a result, the pocket wall becomes firmer and tighter and a long junctional epithelium forms. Very little actual bone or cementum is being redeposited so the long junctional epithelial attachment is actually a very fragile attachment. As the pathogens recolonize again in about 3 months, inflammation recurs and the tissue becomes looser and more retractable. This causes further loss of the long junctional epithelial attachment. It’s a balancing act—the maintenance appointment needs to happen before inflammation is re-established because when left untreated, there is a risk of continued loss of alveolar bone and connective tissue attachment. Patients need to understand that their pockets haven’t disappeared but rather a nice healthy band of tissue is now hugging around the tooth that can become loose again. They need the bacteria removed from the root surfaces within the pocket. The preservation of their teeth is dependent on it. The debridement and the motivation that dental hygienists provide patients are what will make treatment successful.

The bacterial microflora that has reformed is lightly adhered to the tooth so all that is needed is light instrumentation strokes. Mechanical friction is the method of disorganization of the bacterial biofilm. If power instrumentation is used, fine tips should be used to prevent too much tooth structure from being removed on a very low power setting.

I recommend a different set of hand instruments for initial therapy and for maintenance therapy. During maintenance therapy, it’s almost as if the dental hygienist is brushing the patient’s teeth in those subgingival areas that the patient can’t reach with his or her personal plaque control program.

Whether power or hand instrumentation is used, thorough root debridement is accomplished using a series of careful, close, overlapping gentle strokes so that the entire root surface is deplaqued and detoxified.

Q. Does the root smoothness achieved during initial therapy affect subsequent maintenance therapy appointments?
A. Smoothness of the root surface is the criterion used for immediate evaluation of scaling and root planing. It’s the most successful evaluation tool to determine if there has been complete removal of the calculus and accompanying pathogens. The complete removal of the calculus is necessary for the health of the soft tissue. It gives the tissue the best chance to return to a healthy state. Rough root surfaces are very difficult to deplaque and detoxify. If the root surface is smooth then maintenance therapy can be carried out in a much more efficient manner.

The views expressed in this interview are the author’s.

From Dimensions of Dental Hygiene. November 2009; 7(11): 32, 36-37.