	In 1347, 12 galleys docked at a Sicilian port after a long journey through the Black Sea. In medieval times, ships routinely left port and traveled to faraway lands to trade not just goods, but theologies, philosophies, technologies and culture.

Family members waiting for their loved ones at the port in Messina were met with a devastating reality … half the men on board were dead and those who were alive were dying. Delirious and weak, covered with black boils that oozed pus and blood, the surviving crew had fever, chills, vomiting, diarrhea and terrible aches and pains. Authorities ordered the “Death Ships” out of the harbor, quickly recognizing the malady as the Great Pestilence which was decimating populations along the trade routes of the Near and Far East. In Europe, it became known as the 

 and would kill more than one half of Europe’s population (an estimated 25 million people).

At the time, many believed that the Black Death was a kind of divine punishment, retribution from God who was angered by the hedonistic practices of His children. Eventually modern science identified the culprit as a bacillus called 

 a particularly virulent little bug (one nasty side effect is the development of gangrene in the extremities, which is where the term “Black Death” originated) whose spread was hastened by the vile, unsanitary conditions of medieval Europe where rats (and the fleas infesting them) lived in close proximity to humans. People did not wash regularly, drank filthy water, and buried the dead in mass graves. Once hygiene improved, incidence of the Plague decreased and eventually subsided.

Hygiene: the conditions or practices conducive to maintaining health and preventing disease, especially through cleanliness.

 It is the province of dental hygienists; the foundation of our profession and the theology of a visionary, Dr. Fones, who understood that mouth cleanliness would ensure not just oral health, but general systemic health. His idea to create a new oral healthcare provider who would focus on disseminating information and practices which would remove the disease-causing bacteria and their byproducts, was met with equal parts harsh criticism and ridicule by turn of the century dentists. One hundred years later, oral health professionals across the world are well aware of the pathogenesis of oral disease (i.e., periodontal disease and dental caries).

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 published a consensus report titled, “Principles in prevention of periodontal diseases: Consensus report of group 1 of the 11th European Workshop on Periodontology on effective prevention of periodontal and peri-implant diseases.” It outlines the most current and effective practices in the 

 of periodontal disease. Prevention can be primary and it “refers to preventing the inflammatory process from destroying the periodontal attachment” and “consists of treating gingivitis through the disruption/removal of the bacterial biofilm” and secondary which is “preventing recurrence of gingival inflammation.” In examining all the literature (in fact, the consensus report is a systematic review), the authors’ first recommendation:

Repeated and individually tailored OHI
	is the key element in achieving gingival health

This information is not new but merely a repetition of what has been taught in every single dental hygiene program across the country.

Why, then, do dental hygienists use their time, skill, talent and energies on the utilization of technology/gadgetry as opposed to the teaching of basic oral hygiene techniques and dietary instruction?

a dental hygienist authored an article regarding her frustration at the burnished calculus dental hygienists are leaving behind

. After all, “thorough removal of calculus is the cornerstone to excellent periodontal therapy.” In order to reach this No-calculus Nirvana, any good dental hygienist 

 invest in a perioscope and be quick about it as “our ‘dirty little secret’ has ever more serious consequences than we may fully understand or even think about. We are taught to perform blind root planing, which is an impossible task with no definitive end point.”

Removing the calculus, she contends, would ensure that “biofilms [have] nowhere to flourish and multiply.”

In fact, there is a definitive endpoint. Referred to as the therapeutic endpoint, it is “the restoration of gingival health, a reduction in pocket depth, and a gain in or maintenance of a stable clinical attachment level.”

Evaluation of the therapeutic endpoint is done at the four-to-six-week interval after nonsurgical periodontal therapy (i.e. scaling/root planing). Additionally, biofilms begin to form minutes after even the 

 thorough periodontal debridement and their maturation is wholly dependent on the patient’s ability to maintain cleanliness via plaque removal techniques.

DID YOU SEE? An earlier fierce debate on the value of perio charting

I am aware of the value of perioscopy and do not admonish its users. I am unaware, however, of any good data which advocates its use in the prevention of periodontal disease and the inflammatory process. At best, we can say that removing calculus inhibits the production of biofilm but even that statement can be refuted. If a healthy client brushes his calculus diligently thereby preventing the maturation of biofilm, then no inflammatory response would ensue. No inflammatory response equals no periodontal disease.

Eradicating periodontal disease would require a return of focus to the most basic of all oral health practices: effective, regular removal of plaque biofilm by an individual. Proponents of modern technology may choose to promote 

, perioscopy, scaling instruments created from metals which resist dulling, 

 and any other “gadget,” but none of these, nor the expertise of the clinician, can substitute for the effectiveness of the daily removal of plaque biofilm.

It’s not “jazzy” or exciting and it doesn’t pay much, but using the plethora of good, scientific research which supports disease prevention via proper nutrition and hygiene, dental hygienists can promote 

(the body’s natural ability to heal itself) and improve overall health outcomes, not just reduce the incidence of burnished calculus.

In the end, what we are really interested in is helping our patients maintain health. Good oral hygiene is just as important now as it was in medieval times.

Sasha de la Playa is a registered dental hygienist who works in private practices across New York City. Having graduated from hygiene school in 1995, she considers herself a veteran of the profession and has grown weary of the misinformation and partial truths being shared regarding the practice of dental hygiene. She fully supports the work of the National Center for Dental Hygiene Research & Practice, which seeks to encourage the "translation of research evidence so that it is meaningful and useful in dental hygiene education and practice." Guided by the 

 Code of Ethics, inspired to speak by the current lack of leadership, supported by decades of experience and armed with a keen intellect, she hopes to bring light and a fresh voice to the world of dental journalism. 

Articles

 In 1347, 12 galleys docked at a Sicilian port after a long journey through the Black Sea. In medieval times, ships routinely left port and traveled to faraway lands to trade not just goods, but theologies, philosophies, technologies and culture.

COUNTERPOINT: Technology is great, but education remains the most important thing

	The latest statistics on the prevalence of periodontal disease in the United States are startling. The CDC states that 47.2% of adults aged 30 years and older have some form of periodontal disease. These findings are based on a comprehensive study conducted in 2009 and 2010, and published in the 

, the official publication of the International and American Associations for Dental Research.

According to the findings, periodontal disease increases with age, with 70.1% of adults 65 years and older having periodontal disease. The condition is more common in men than women (56.4% vs 38.4%), those living below the federal poverty level (65.4%), those with less than a high school education (66.9%), and current smokers (64.2%). The classification of disease used in this study does not include gingivitis.

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As eye-opening and indisputable as these figures are, I hear from many hygienists who insist that the majority of the patients whom they treat do not present with periodontal disease, other than gingivitis. A common refrain from these hygienists (and doctors) is, “There is just no perio in our office.” Most of these clinicians site the high socioeconomic status of their patient pool, coupled with the high dental IQ of their community, as being the reason so many of the clients are “healthy.”

However, upon closer inspection and record auditing, we often find that many patients do in fact present with disease. The disconnect is that disease is not being recognized and classified as such. Unfortunately, proper treatment planning to treat existing disease is not being done as a result.

HOT READ: How does your practice stack up with the Perio Percentage KPI?

Even the most talented and experienced clinician will often overlook disease if the proper assessments are not being performed. In the busyness of the day, we can skip the critical assessments that enable a correct diagnosis. Some clinicians consider X-rays and a tour of the mouth a “comprehensive assessment."

While I completely understand how stretched clinicians are for time, there is just no definitive way to know if periodontal conditions exist without periodontal charting that includes identification of bleeding points. Bleeding is the first sign of disease, with pockets forming in later stages. Once bone loss is present on radiographs, it is too late to reverse the course of the destruction.

New patient and recall exams should have enough time built in to allow a comprehensive periodontal assessment if we are to avert and arrest disease. Time to educate patients on their condition, the course of treatment, and the proper home care routine should be included as well. With the prevalence of disease being what it is, it is advised to schedule 90 minutes for a new patient exam, and at least one hour for recalls.

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In terms of “not having any perio” in the office, clinicians are advised to brush up on the risk factors for periodontal disease. In addition to comprehensive assessments, risk plays a prominent role in disease progression, but is often overlooked. Consider the risk factors:

		Underlying immuno-deficiencies-e.g., AIDS

		Taking medications that cause dry mouth

		Female hormonal changes, such as with pregnancy or the use of oral contraceptives

Many, if not the majority of our patients present with one or more of these risk factors.

When they begin to properly assess, many clinicians find their percentage of periodontal cases coming more in line with current statistics. Not only are patients being properly treated with the most conservative measures available, but practice revenue increases concurrently.

Author's Note: Are you ready to improve the periodontal care you provide in your office and increase hygiene revenue? Contact us today at hello@enhancedhygiene.com to learn about our onsite or virtual training programs. 

 The latest statistics on the prevalence of periodontal disease in the United States are startling. The CDC states that 47.2% of adults aged 30 years and older have some form of periodontal disease. These findings are based on a comprehensive study conducted in 2009 and 2010, and published in the Journal of Dental Research, the official publication of the International and American Associations for Dental Research.

The comprehensive assessment is critical in diagnosing periodontal disease

	Warning: What you are about to read will not be candy coated to be politically correct or apologetic about exposing the truth about a dirty little secret that is so widely accepted in the dental profession that it has become an accepted and even comfortable inconvenient truth. The purpose of this article is to shed some light on a defective methodology so pervasive and unchallenged in dentistry it is the gold standard … and yet is not even common sense. It’s time to raise the bar by raising awareness about this dirty little secret.

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The biggest dirty little secret most widely accepted in daily clinical practice is working blindly in one of the most filthy, biofilm-infested areas of the human body … the periodontal pocket. In hygiene and dental schools, we are taught to perform blind root planing, which is an impossible task with no definitive end point (other than the clock on the wall). We are taught to grope around under the gums with various instruments to determine how well we removed calculus. Sometimes it even helps to close your eyes to enhance tactile sensitivity … or so we think. And yet the insanity of this time-honored tradition is that burnished subgingival calculus cannot be detected … even with the most sensitive of instruments.

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The first step to recovery and change is admitting there’s a problem. What we are often not taught or even discuss openly at meetings is that the research is replete with evidence demonstrating that blind root planing is only effective to 4mm. Beyond 4mm, 30-50% of the subgingival root surface is still covered with 

. Rather than discussing this problem openly and hitting it head on, we are taught to learn how to perform blind root planing better. This advice is like telling a blind person to drive better. Instead, we are expected to ignore this foundational issue and to enhance our inept blind technique by using equally blind adjunctive therapies such as air polishing, lasers, or local delivery antimicrobials to more effectively disrupt and alter biofilm, with no mention of the source of the problem … the very home of the biofilm, the

. The foundational problem with all of these BAND-AID methodologies is that mature biofilms will reform within a matter of days wherever subgingival calculus exists. Thorough removal of calculus is the cornerstone to excellent periodontal therapy due to the more permanent removal of, and prevention of, the formation of mature biofilms. Toxic biofilm, growing and changing into an even more toxic soup with every day it goes undisturbed. Toxic biofilm, with complete freedom to infect its hosts systems further through tiny capillaries in the walls of inflamed periodontal pockets with direct access to the entire vascular system, and hence all systems of the body. Our “dirty little secret” has ever more serious consequences than we may fully understand or even think about.

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The idea of thorough calculus removal is such an integral aspect in arresting disease progression that flap surgery often follows blind root planing in order to achieve a definitive end point more conducive to periodontal health. So what is wrong with this picture? Is it true that if we could see into the periodontal pocket that most periodontal surgeries would no longer be necessary (as many leaders in periodontal medicine have suggested through the years)? Is it a conspiracy by dentists and periodontists to keep the dental hygiene profession in its proper place of antiquity and unchanged darkness? Or is it possible that the dental hygiene profession is not taking on the important responsibility of working to change this dirty little secret? Why are 

 collectively allowing this lag in our progressive clinical ability to continue?

Click on the next page for the author's solution...

 out of the darkness. For the first time in history, the subgingival environment could be viewed in real time and burnished subgingival calculus could effectively be removed without surgery. Considering that medicine has incorporated endoscope technology for more than 100 years, it was about time. This led to more than sufficient research demonstrating that visual root planing could result in periodontal health without subsequent surgery … even in advanced cases. Now 99% of burnished subgingival calculus could be removed and biofilms would have nowhere to flourish and multiply. Blind root planing could finally be abolished and replaced with 

root planing. The dental hygiene profession would be able to eliminate its “dirty little secret” and truly have profound clinical and systemic impact in patient care for the first time in history.

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Secrets are no good for anyone. Let’s be honest with ourselves. Who are we serving by continuing to ignore this inconvenient truth? Are we truly serving our patients and our profession in the process? Now is the time to demand more from ourselves and our profession. Make as much noise as possible about the absurdity of not having the proper tools to achieve health in your patients. Tell your professional associations you are fed up with being taught how to perform blind root planing better (a nonsensical idea at its core). Create a buzz and bring this secret into the light of meaningful discussion. There is power in numbers. The only way to create real change is to believe that change is possible … and it is.

Watch videos of residual calculus on roots after blind root planing

https://www.youtube.com/watch?v=ysqfYpBrQQQ

https://www.youtube.com/watch?v=Ow6VYa5cu2o

Learn more about the current research and clinical significance of endoscopic visual root planing over blind root planing

 to listen to the author talk more about this article on the Cross Link Radio podcast.

	Check Out Health Podcasts at Blog Talk Radio with 

Author's Note: We’re anxious to hear your comments! Please post below to voice your opinion about blind dental hygiene practice and our dirty little secret.

About the author: Judy Carroll, RDH, is the founder and clinical director of PerioPeak Innovations, an independent non-surgical periodontal therapy practice exclusively focused on providing Regenerative Periodontal Endoscopy (RPE) and integrative treatment methodologies. Her clients fly in from around the globe seeking her pioneering treatment and comprehensive approach to periodontal care. Ms. Carroll’s 25 years in clinical dental hygiene has fueled her determined focus in providing and teaching definitive clinical treatment strategies and more personalized oral-systemic periodontal medicine.

Ms. Carroll currently lectures and teaches advanced endoscopic techniques and integrative care utilizing multi-disciplinary approach to Periodontists, Dentists, and Registered Dental Hygienists. She offers valuable hands-on and didactic training and is available by appointment for her interesting and informative lectures. She can be reached at 

 Warning: What you are about to read will not be candy coated to be politically correct or apologetic about exposing the truth about a dirty little secret that is so widely accepted in the dental profession that it has become an accepted and even comfortable inconvenient truth. The purpose of this article is to shed some light on a defective methodology so pervasive and unchallenged in dentistry it is the gold standard … and yet is not even common sense. It’s time to raise the bar by raising awareness about this dirty little secret.

modernhygienist.com-2015-06-01

COUNTERPOINT: Technology is great, but education remains the most important thing

The comprehensive assessment is critical in diagnosing periodontal disease

Exposing one of dentistry's dirty little secrets