Evolution of Nonsurgical Periodontal Therapy Part 3: Future Outlook

Periodontitis is largely preventable, but access to affordable periodontal care—especially for older adults—is woefully lacking. A 2012 study published in the Journal of Dental Research found that 47.2% of adults 30 years and older have some form of periodontal disease.¹ The Centers for Disease Control and Prevention reports that periodontal disease increases with age, and 70.1% of adults 65 years and older have it.² About one-third of adults forego dental care.³ Among elderly patients, 29.2% have dental insurance and 65.5% had a dental visit in the past 12 months.²

Nonsurgical treatment of periodontitis by a dental hygienist is time consuming if done well, and periodontal care is viewed as a “profit center” in many general practices.⁴ Hygienists on social media often cite inadequate time and instruments for periodontal and other procedures. Because such complaints are not seen on dentists’ blogs, it appears that hygienists are sometimes stuck with inferior equipment and insufficient time simply because they are employees who do not make these decisions. It also may indicate that some dental practices may not value clinical excellence and good outcomes the way they should.

Subgingival Biofilm and Calculus Removal

Sottosanti and Cobb, both periodontists, emphasize the complete removal of subgingival calculus to resolve inflammation but state that in recent decades clinicians and educators have diminished its significance in favor of a “’biocompatible root surface’ as a necessary requirement to eradicate the periodontal disease process.”⁵ They compare calculus to a porous, spongelike material, mineralized and dry, that allows periodontal pathogens to live within its framework. Further, Sottosanti and Cobb say multiple studies show a relationship between calculus and inflammation of the adjacent soft tissue wall of the periodontal pocket. The pathogens living in biofilm that also live within the calculus may over time release toxins into the periodontal pocket, causing the disease to progress.⁵

For dental hygienists to remove as much subgingival calculus as possible, they need time and effective instrumentation. In addition, hygienists need patient cooperation and a working knowledge of root anatomy, including furcations. There are 3 main ways calculus attaches to a root surface.

1. The cemental surface of a root has a rough surface with tiny mounds as seen under a powerful microscope. As pockets deepen, each mound is a former insertion site for periodontal ligament fibers. Sticky pellicle layer forms on the surface of cementum and as early subgingival microbes accumulate, they form a biofilm that thickens and calcifies, often surrounding bacteria-filled channels and spaces. According to Sottosanti and Cobb, these mounds are easily removed by overlapping strokes of sharp curettes and ultrasonic scalers.⁵
2. Root surfaces with lacunae (cavitations) are defects that sometimes penetrate cementum into dentin and may lock in calculus to these undercuts.⁵

1. Calculus can be directly attached to the crystalline structure of cementum. When removed, some will remain, becoming residual and undetectable. This happens because the attachment of the calculus to cementum is stronger than the calculus itself. This smooth, residual calculus fuels future pocket increases and ultimately tooth loss. Burnished calculus is the main reason periodontal diseases progress after scaling and root planing.⁵

The goal of scaling and root planing is to remove subgingival calculus and biofilm, but it is a very demanding procedure for even the most accomplished clinicians.⁶ The cementoenamel junction (CEJ) is a common site for residual calculus.⁶ Following subgingival instrumentation, microbial colonization begins almost immediately, and posttreatment bacterial counts can return to pretreatment levels within a week.⁶ Intervals necessary for the site to return to pretreatment levels of subgingival microflora depend on disease severity, thoroughness of debridement, and supportive care including meticulous self-care and appropriate intervals of repeated removal of subgingival biofilms during periodontal maintenance.⁶

Instrumentation

In a 2021 CE by Rethman, et al, the authors summarize studies comparing manual to ultrasonic instrumentation with or without surgical flaps.⁶ Combined use of sharp curettes and ultrasonics appears more effective than either method alone and experienced clinicians do better in removing subgingival calculus.⁶ Residual calculus is usually found in furcations, CEJ, interproximal root flutings, in deeper pockets, and in multirooted teeth.⁶ Air powder polishing using glycine or erythritol powders combined with manual and ultrasonic instrumentation seems to provide better outcomes.⁶ Periodontal endoscopes, when used by a skilled clinician, provide visualization of the root surface while scaling, reducing the need for traditional periodontal surgeries.⁷

Future Outlook

Demand for health care professionals like registered dental hygienists (RDHs) will grow, according to the US Bureau of Labor Statistics.⁷ This is mainly due to an aging population that will have greater need for health care services. During the pandemic and postpandemic have seen a lot of health care services move into patients' homes. In addition to the pandemic, an aging population and renewed focus on preventive care may shift nonsurgical periodontal therapy and maintenance by RDHs into on-site primary care facilities connected to senior housing. As individuals age, chronic health care problems multiply and it is common for seniors to have anywhere from 4 to 8 such issues.⁷ As more senior living facilities offer primary care, consumers are demanding that senior housing deliver and manage that care, including dental services.⁸

Economic conditions during COVID-19 have affected the delivery of dental hygiene services. During the first wave of the pandemic, dental practices were forced to close. When they reopened, stringent infection control measures increased overhead costs and patients were reluctant to return. As patients return and as practices get busier, patients are still avoiding regular preventive recare. After a year of disrupted dental care and treatment there may be less demand for dental care, especially with inflation rearing its head. With inflation and COVID-19 come higher cost of doing business and lower profitability.⁹

Most RDHs in privately owned dental practice settings or dental service organizations are employees working under general or direct supervision. They are not business partners but licensed providers hired to perform a service to patients as nurses do. Running a successful dental practice means providing a high standard of care and investing in a top-notch dental hygiene department. Present and future dental hygiene departments will require meeting patients’ expectations that support their well-being. The future outlook and successful delivery of nonsurgical periodontal therapy is a critical component of care and clinical excellence will drive revenue goals. Here are some positive ways to achieve a healthy future outlook.

1. Be sure to diagnose gingival and periodontal diseases using the new classification system. Diagnosis and treatment planning must be accurate and can only be made by a thorough evaluation of data collected. Future malpractice claims will continue to include failure to diagnose and treat/refer periodontal diseases.¹⁰ In many general dental practices, only probing depths are recorded even in patients at high risk for periodontitis. Use the American Academy of Periodontology comprehensive periodontal evaluation checklist and give it to the patient to follow along as you collect data.
2. Refer to a qualified periodontal specialist when limited periodontal care under the facade of a full scope of periodontal treatment fails to control inflammation and unnecessary tooth loss.¹¹
3. Nonsurgical periodontal therapy in general dental practices should exceed the norm, including reevaluation and periodontal maintenance.⁶ RDHs and periodontal specialists are trained with the equipment needed to perform this service and educated to attain therapeutic endpoints consistent with a pattern of health.¹¹
4. There are no shortcuts to the delivery of effective nonsurgical periodontal therapy.¹¹ Manual and ultrasonic instrumentation take adequate time and hand curettes must be selected based on access to root anatomy. Ultrasonic equipment and scalers must be checked regularly for wear with a wear guide.
5. Continue to invest in technological systems like Perioscopy to achieve consistency and improved clinical outcomes. This minimally invasive periodontal endoscope allows clinicians to see magnified details of root anatomy; the unit and component parts will become more affordable over time.
6. Don’t call biofilm and dental calculus “buildup on teeth.” Managing biofilm subgingivally is necessary to promote healing of periodontal pocket wounds. Wound debridement protocols, like those used in medicine to eradicate chronic wounds, will continue to change based on biofilm research on hard-to-heal chronic wounds.

The future of nonsurgical periodontal therapy remains challenging, given the overall percentage of adults who cannot afford private dental care. Comprehensive periodontal treatment regimens are ideal but unattainable for many, especially older adults with limited incomes and little to no dental care under Medicare. Dental benefits for low-income Medicare recipients would help, especially as thousands of Baby Boomers are losing company-sponsored dental benefits. Oral health improvements occur when there is better access to dental care and when financial barriers are removed. Maybe someday, dental care, including periodontal care, will become essential in US policy.

References

1. Eke PI, Dye BA, Wei L, et al; CDC Periodontal Disease Surveillance workgroup. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914-920. doi:10.1177/0022034512457373
2. Periodontal disease. CDC. Updated July 10, 2013. Accessed April 1, 2022. https://www.cdc.gov/oralhealth/conditions/periodontal-disease.html
3. Reinberg S. Even before pandemic, one-third of U.S. adults went without dental care. U.S. News & World Report. July 9. 2021. Accessed April 19, 2022. https://www.usnews.com/news/health-news/articles/2021-07-09/even-before-pandemic-one-third-of-us-adults-went-without-dental-care
4. Seidel-Bittke D. Six steps to making the dental hygiene department a profit center. DentistryIQ. February 22, 2013. Accessed April 1, 2022. https://www.dentistryiq.com/dental-hygiene/career-development/article/16355072/six-steps-to-making-the-dental-hygiene-department-a-profit-center
5. Sottosanti JS, Cobb CM. Guest editorial: dental hygienists play a critical role. Dimensions Dent Hyg. 2021;19(6):14-15. https://dimensionsofdentalhygiene.com/article/guest-editorial-dental-hygienists-play-critical-role/
6. Rethman MP, Cobb CM, Sottosanti JS, Sheldon LN, Harrel SK. The importance of effective scaling and root planing. Dimensions Dent Hyg. 2021;19(8):40-44. https://dimensionsofdentalhygiene.com/article/importance-effective-scaling-root-planing/
7. Healthcare occupations. US Bureau of Labor Statistics. Updated April 18, 2022. Accessed April 19, 2022. https://www.bls.gov/ooh/healthcare/mobile/home.htm
8. Silverstein J. 4 reasons why onsite primary care is mission-critical for senior living. Senior Housing News. January 31, 2019. Accessed April 1, 2022. https://seniorhousingnews.com/2019/01/31/4-reasons-why-onsite-primary-care-is-mission-critical-for-senior-living/
9. Huot RA. Inflation affects both dentists and patients: prepare your practice now. Ontario Academy of General Dentistry. August 23, 2021. Accessed April 1, 2022. https://www.agd.org/constituent/news/2021/08/23/inflation-affects-both-dentists-and-patients-prepare-your-practice-now
10. Tipton P. Dental negligence and the rise of litigation. Lawyer Monthly. Updated March 31, 2020. Accessed April 1, 2022. https://www.lawyer-monthly.com/2020/03/dental-negligence-and-the-rise-of-litigation/
11. Slim L. Periodontal referral gone awry. RDH. March 1, 2012. Accessed April 1, 2022. https://www.rdhmag.com/pathology/periodontitis/article/16405895/periodontal-referral-gone-awry