Hygiene instrumentation shortcuts: are they wise?

June 20, 2018

Hygienists often feel pressured to take shortcuts to beat the clock, but it may not be in the best interest of the patient.

In chatting with my RDH friends and colleagues, we share our angst and successes in clinical practice. Yesterday, I told an RDH friend I wanted to write more about the frustrations RDHs share when it comes to getting assistance from a dental assistant who’s been assigned to us.

This particular friend works one column of patients in a large group practice and is expected to share another column of patients with a second hygienist. Both hygienists have a couple of treatment rooms at their disposal and a dental assistant (hygiene assistant) has been assigned to assist them by taking radiographs, breaking down and setting up the room, etc. This is a large group practice owned by a couple of dentists and there are practice managers on site who are supposed to make sure the entire operation is seamless. The reality is that the hygienists only get assistance when the hygiene assistants feel like it.

I asked my RDH friend how she deals with this situation and she said, “I’ve given up asking for help. I take shortcuts like everyone else. It’s sad, but it’s the only way to survive and stay on time.” She also said, “Production and time management suffer when we have no help with the small tasks like taking X-rays, room turnover, etc.”

How many of us feel this frustration? I’ll bet it’s a large number of practicing hygienists, and even I’ve felt it from time to time. Whose fault is it when hygienists are compelled to take shortcuts like performing a PSR (periodontal screening and recording system) instead of a comprehensive periodontal exam (not just probing depths) or skimping on instrumentation time. The answer to this question is not always clear, but the owner of the practice sets the tone for his/her practice. Job descriptions need to be in place and monitored regularly with the end goal being a robust and effective dental practice with happy employees and patients.

Instrumentation shortcuts

I’ve heard of hygienists performing scaling and root planing (SRP) in 30 minutes for two quadrants with no assessment of time needed during diagnosis based on case type. Picture yourself sitting next to a patient with severe chronic periodontitis with huge spicules of proximal calculus on radiographs, heavy bleeding on probing (bop). Not only do you have to administer local anesthesia, but you have about 15-20 minutes for instrumentation. An ethical RDH will only attempt one quadrant of debridement, but your head still pounds when you try to figure out what to do. Personally, I’d do nothing in that situation and reschedule the patient, but how many practicing hygienists have the option to make that choice?

How important is meticulous debridement and how is it defined?

There’s no good answer to this particular question. Research on scaling and root planing outcomes is dated and there isn’t anything noteworthy since the late 1990s. The late Connie Drisko, DDS, a legendary leader in periodontics, stated that scaling and root planing requires skill and time to achieve the desired outcome.¹ She also reiterated that periodontal debridement results in the maintenance of attachment levels over time and is the gold standard for the treatment of inflammatory periodontitis.¹ In their study to determine the effectiveness of SRP, Nagy et al. actually scaled and root planed 15 minutes per tooth.² Indirect evidence shows that effective SRP does, indeed, take time and can’t be rushed.

John Y. Kwan, DDS, a diplomate of the American Board of Periodontology and clinical Professor at the UCSF School of Dentistry, division of periodontology, is a periodontist whose professional opinion I respect. I contact him frequently with questions about nonsurgical periodontal therapy, and I’ve observed and written about his and his hygiene team’s nonsurgical periodontal protocol several times over the years. Dr. Kwan and his hygienists in private practice don’t work BLIND in the periodontal pocket; instead, they use a minimally invasive dental endoscope to magnify the details of the root anatomy called Perioscopy.³ I asked Dr. Kwan several questions about periodontal pocket debridement and we discussed the trend to turn periodontal debridement procedures into a profit center for the dental hygiene department in general dental practices. He shared with me his concerns about hygienists and dentists debriding periodontal pockets in a rushed appointment, working blind. Dr. Kwan was generous enough to answer my questions in writing:

“Current evidence suggests that therapies intended to arrest and control periodontitis depend primarily on EFFECTIVE ROOT DEBRIDEMENT.

Can this be adequately done in a 30-minute debridement appointment, regardless of the type of instrumentation? Can this be done given any amount of time? There is certainly a better chance given more time. However, with the absence of visualization, chances are lower with tactile endpoints.*

Periodontal debridement endpoints always reflect in the patient’s response. The predictability of response relates to effective root debridement. When closed debridement results in inadequate disease control, visualization is necessary to increase predictability. The visual endpoint can be confirmed with surgical open flap debridement or nonsurgical endoscopic debridement. Endoscopic debridement is teaching us a lot about how to achieve health, especially in patients who are not the best candidates for surgery due to medical, pharmaceutical and/or physical factors.

The trend of minimization of periodontology and periodontal therapy in dental hygiene and dental education, inadequate attention to clinical skills and reduction of treatment appointments will unfortunately help to ensure that epidemic levels related to moderate to severe periodontal disease in this country continue or grow.** This amounts to a continuation of “disease care” versus “healthcare” for an ailment that can be prevented and that has a significant link to systemic disease via inflammatory pathways.”

*Sites with probing depths over 5mm High Probability of Continued Disease Inflammation and Attachment Loss, Kadahl, Kalkwarf, et. al. J Perio 1988; Becker, Becker, et. al. J Perio 1988; Kalkwarf, Kadahl, et. al. J Perio 1988.

*SRP not adequate for removal of plaque and calculus greater than 3mm from: FURCATIONS, ROOT GROOVES, and other SURFACE IRREGULARITIES, Caffesse, Sweeney, et. al. J Clin Perio 1986; Rabbani, Caffesse, et. al. J Perio 1981; Fleischer, Mellonig, et. al. J Perio 1981.

**CDC estimates more than 35 percent of adult Americans 30 years and older have moderate to severe periodontal disease.

References:

1. Drisko CL. Periodontal debridement: still the treatment of choice. J Evid Based Dent Pract. 2014 Jun; 14 Suppl: 33-41.

2. Nagy RJ, Otomo-Corgel J, Stambaugh R. The effectiveness of scaling and root planing with curets designed for deep pockets. J Perio 1992; 63: 954-959.

3. http://www.zestdent.com/index.php/products-perioscopy.