The control of biofilm is probably the most important factor in a patient’s oral health. The control of biofilm is probably the most important factor in a patient’s oral health. Yes, you read that twice because it is that important; however, as dental professionals and patients, we tend to use the same mechanical methods of controlling biofilm. Brushing, flossing, and professional cleanings are not helping us to decrease periodontal disease. As our patients age, we see a rise in gum disease: up to 70% over the age of 65 and in almost half (47.2%) of adults over the age of 30. From this, we can conclude that we have to equip our patients with better tools to help regularly reduce biofilm, which is one of the main factors contributing to the progression of poor gum health and systemic health. A rinse can be this tool to help! 

WHAT IS BIOFILM, AND WHY SHOULD WE CARE?

Biofilm is an assemblage of surface-associated microbial cells that is enclosed in an extracellular polymeric substance matrix. In the mouth, we call this dental plaque. Biofilm formation is an important adaptation and survival strategy commonly employed by bacteria. Bacteria in the biofilm are protected from adverse environmental factors and immune responses.

Compared to free-living cells, cells in a microbial biofilm are much less susceptible to antimicrobial agents. This decreased susceptibility has a considerable impact on the treatment of biofilm-related infections. Biofilm formation is often considered to be the underlying reason why treatment with an antimicrobial agent fails. As an estimated 65% to 80% of all chronic infections are thought to be biofilm-related, this presents a serious challenge.

Over the past 10 years, more and more data has emerged linking oral biofilm to systemic illnesses, either causing them to begin with or making them worse. The patient’s health must be viewed as a whole-body system, with linkages that may start in the mouth and influence different parts of the body at different times.

Oral biofilm micro-organisms and their by-products have been linked to several aspects of systemic health. These include rheumatoid arthritis; diabetes; lung conditions; and prostate, colon, and pancreatic cancers, and they also include erectile dysfunction, Alzheimer’s disease, and preterm pregnancies.

In the oral cavity, biofilm has a major role in many oral diseases, such as dental caries and periodontal disease. Biofilm can be found in easy-to-reach places like the surfaces of the teeth and in tough-to-remove areas, like a gingival sulcus.

MECHANICAL VS THERAPEUTIC METHODS

Whether with home care or professional cleanings, our only method of fighting biofilm is mechanical. We diligently educate our patients on brushing and flossing and hope they do so on a regular basis. However, even when they do brush and floss, it is still only mechanical. Perhaps you’re lucky and have patients who are great brushers and flossers, but even then, they are really only cleaning about 22% of their mouths. If they just brush (like most patients I know), you can essentially cut that number in half and deduct that only 11% of the whole mouth is being cleaned. They only brush half of the tooth, leaving areas for biofilm to proliferate. These mechanical methods are simply detaching some of the biofilm from the tooth, adding it to our saliva, mixing it with some toothpaste, and then spitting it all out. It doesn’t do anything to help the patient fight an active infection, nor does it kill any microbes that cause disease, and it does nothing to prevent more biofilm from forming.

Therapeutic products (rinses) work differently. Most just focus on killing the bacteria, which has little effect on biofilm. Professional rinses try to break up or penetrate the biofilm, kill the bacteria, and prevent biofilm from forming. There are clinical studies that suggest that rinsing can be 4 times as effective as flossing. However, it is important to note that the criteria for choosing rinses should be rigorous because not all rinses have all of these abilities, nor can they all be used long-term. For example, chlorhexidine is great at killing bacteria but does nothing to break up biofilm or prevent biofilm from forming. In fact, chlorhexidine, because of substantivity, can actually increase biofilm buildup.

THE TRIAD

To properly fight biofilm, you must have these 3 criteria: You must break up/penetrate the biofilm, kill the bacteria and other microbes in the biofilm, and prevent new biofilm from forming. The product OraCare addresses all 3 by combining chlorine dioxide and poloxamer 407. Let’s take a look at both of these compounds and how they work to fight biofilm. 

CHLORINE DIOXIDE

Chlorine dioxide is a powerful, selective oxidizing biocide. It attacks micro-organisms by disrupting the cell’s ability to create essential proteins. This oxidizing property makes chlorine dioxide an efficient and effective antimicrobial that is used for a variety of sterilization, disinfection, and decontamination purposes in the food, beverage, water disinfection, industrial water treatment, and agriculture markets. First discovered in 1811, its antimicrobial properties have been known since about 1900, and it has been used in the United States to disinfect public drinking water for more than 70 years. Chlorine dioxide kills many strains of bacteria, viruses, and fungi, all of which can be found in biofilm, and has a role in oral health diseases.

Chlorine dioxide has a superior ability to break down the toughest micro-organisms and biofilms without corrosive action or negative impacts on the oral environment. Its efficacy is not impacted by the condition of the environment, most notably in regard to pH levels and the presence of organic matter. Chlorine dioxide is effective against bacteria, protozoa, viruses, and fungi on inanimate objects and is considered more effective against microbes than other chlorine solutions. Unlike other products, chlorine dioxide starves and kills micro-organisms by disrupting the transport of nutrients across their cell walls.

Chlorine dioxide is used in many industries to “break up biofilm,” but what it really does is penetrate the biofilm and inactivate the bacteria that are producing the biofilm, stopping the production of biofilm at the source.

Chlorine dioxide may be the perfect compound to fight oral biofilm because it is a very selective oxidizer that penetrates biofilm, kills microbes, and prevents biofilm from reproducing.

POLOXAMER 407 

Poloxamer 407 is an FDA-approved polyoxyethylene polymer and a hydrophilic non-ionic surfactant. It is made up of 2 blocks of hydrophilic polyethylene glycol on either side of a central hydrophobic polypropylene glycol block. It reduces its surface tension, thereby increasing its spreading and wetting properties.

The poloxamer works with chlorine dioxide to make the surfaces of the oral cavity “slicker,” preventing biofilm from taking hold. This combination has yielded excellent results in clinical studies and clinical cases.

CLINICAL STUDY

Salus Research conducted a 6-week, randomized, examiner-blind clinical trial to evaluate the safety and efficacy of OraCare Health Rinse compared to tooth brushing alone (Table 1). One of the 4 areas evaluated was biofilm reduction using OraCare vs brushing without OraCare. We will focus on the results of this area.

Salus Research evaluated multiple surfaces of the teeth, the whole mouth, gumlines, and interproximal areas. OraCare saw an amazing 225% decrease in biofilm vs brushing alone and an astounding 307% reduction interproximally. Here is the clinical summary:

• The active treatment provided very positive outcomes toward gingival health over the 6-week period, with about 6 times the improvement seen for the control group.
• The active treatment increased healthy MGI sites to about 20 compared to less than one site for the control group.
• The active treatment provided very positive outcomes toward plaque biofilm removal over the 6-week study, with a 22% improvement in the whole mouth compared to no improvement for the control group.
• The active treatment showed a 15-times improvement in the periodontal pocket depth compared to the control group.
• The active treatment rinse showed superiority for every endpoint evaluated compared to the control group.

What this study shows us is that the combination of mechanical and therapeutic techniques far exceeds just mechanical aids.

CASE REPORTS

Case 1

The patient in this case was seen continually on a 3-month recall. The patient always had calculus buildup and inflamed gingiva. This was documented in Figure 1 on January 4, 2018. This was consistent with how the patient’s oral health looked during the 3-month recalls. After a periodontal maintenance appointment on January 4, 2018, the patient was given OraCare and was instructed to rinse twice a day. The patient returned on March 5, 2018, with considerably less calculus and inflammation (Figure 2). The only change in the patient’s oral hygiene was the addition of OraCare twice a day.

Figure 1. The patient was seen continually on a 3-month recall. The patient always had calculus buildup and inflamed gingiva.

Figure 2. The patient returned for 3-month perio maintenance after incorporating rinsing into the daily routine. The patient returned with less calculus, less inflam- mation, and increased comfort during cleaning.

Case 2

The patient in this case presented with inflammation, bleeding, moderate plaque buildup, and sensitivity due to a lack of good oral hygiene (Figure 3). If left untreated, this patient would have developed a more severe form of gum disease. Like many patients, the dentist and hygienist stressed good oral hygiene at previous appointments, including instructions on proper brushing and flossing techniques. Due to a lack of improvement, the dental team discussed the need for a potential gingivectomy. In a final attempt to improve the patient’s home care, the patient was given OraCare. After just 5 weeks of use, the patient saw a significant reduction in inflammation, bleeding, plaque accumulation, and sensitivity (Figure 4). This rinse provided the benefits that the dental team had been unable to achieve with traditional methods in a short window of time. The patient had higher compliance with rinsing compared to brushing and flossing. With this simple additional step added, the dental team decided not to move forward with the gingivectomy and continued having the patient use OraCare to aid in improving the patient’s gum health and general health.

Figure 3. The patient presented with inflammation, bleeding, moderate plaque buildup, and sensitivity due to a lack of good oral hygiene.

Figure 4. The patient returned for re- evaluation after 5 weeks of using rinse. These were the results seen in that period of time.

Case 3 

Many patients struggle with home care. They often consume staining liquids and foods like coffee, tea, fruits, red wines, and more that cause discoloration to build over a period of time. Even with more frequent recare appointments, the stain can be heavy and hard to remove. The patient in this case had been seen at 3-month intervals for an extended period of time (Figure 5). Each time, he presented with a heavy amount of stain due to his diet. The dental team counseled him on good brushing and flossing techniques and changes that would need to be made in his diet, but the staining persisted. To help prevent the accumulation of stains, the patient was given OraCare. OraCare helps to reduce plaque. Since plaque is a sticky film of bacteria that forms on the tooth surface, it can trap pigmented substances from food and beverages, leading to discoloration or staining of the teeth. With the regular use of OraCare twice per day, this patient had little to no staining upon his return at his next 3-month recare appointment (Figure 6). 

Figure 5. This patient has been seen on 3-month intervals for an extended period of time. Each time, he presented with a heavy amount of stain due to his diet. The patient is not a tobacco user.

Figure 6. The patient returned to the office after 3 months of using OraCare with an incredible reduction in stain.

Figure 7. This is the same patient as in Figures 5 and 6 but with a view of the lingual area of the mouth.

Figure 8. After 3 months of using OraCare daily.

On the same patient, we view another problematic area for many to keep clean at home. The lingual of the mandibular anterior teeth is a common place for calculus to form due to the area being hard to reach and the plaque being able to mature and harden into calculus (Figure 7). This is a common place for calculus and stain to collect. The patient admitted to only brushing once daily and did not floss but began using OraCare twice daily. Notice the reduction in stain and calculus formation in just 3 months (Figure 8).

Case 4

As seen in Figure 9, this patient also struggled to clean the lingual of the mandibular anterior teeth. The patient is seen every 4 months due to heavy bleeding and calculus formation. The patient was brushing twice per day using an electric toothbrush in the morning and a manual toothbrush at night. The patient had also been using an over-the-counter mouthwash in an attempt to help with buildup and bleeding. Due to a lack of results, the patient was given OraCare with instructions to use the rinse every morning and every night. Figure 10 shows the results after 4 months of incorporating OraCare into a daily routine. There was noticeably less calculus and a reported reduction in bleeding because of the rinse’s ability to kill bacteria and break up plaque in this problematic area.

Figure 9. The patient is seen every 4 months due to heavy bleeding and calculus formation. The patient was brushing twice per day using an electric toothbrush in the morning and a manual toothbrush at night and had also been using an over-the-counter mouthwash.

Figure 10. The following visit. The patient continued to brush 2 times per day with an electric/manual brush and floss daily. The patient replaced the over-the-counter rinse with a professional rinse, which resulted in less plaque and calculus accumulation.

CONCLUSION 

Biofilm is a menace when it comes to the human body, especially the oral cavity. It is a constant battle and one that we are losing when you look at the public’s general oral health. Mechanical removal of biofilm is just not enough for most people. Our hygienists do a great job of removing calcified biofilm (calculus), but patients do not brush and floss adequately. That is a fact. Most patients brush for 30 seconds or less, and many do not floss. We must give them help, and that comes in the form of a rinse that breaks up the biofilm, kills the microbes, and prevents new biofilm growth. Studies and clinical cases prove that rinses work. As stated in the beginning, control of biofilm may be the most important factor in your patients’ oral health. Incorporating rinses in their home care may be one of the best and easiest things you can do in the continued fight with biofilm.

ACKNOWLEDGMENTS

The author would like to thank Wohlers Family Dentistry and Cloudland Dental for their contribution to the cases mentioned in this article. 

ABOUT THE AUTHOR

Dr. Martino earned his DDS degree from the West Virginia University School of Dentistry. Following dental school, Dr. Martino practiced dentistry in the Bridgeport and Buckhannon areas of West Virginia. He now owns and operates 7 dental practices in West Virginia, presiding as CEO of Wilmar Management Company. In 2012, Dr. Martino co-founded Dentist Select and helped launch OraCare. He is currently CEO. In 2013, Dr. Martino founded Freedom Day USA (freedomdayusa.org), a national movement to thank our active military and their immediate family members, along with our veterans. He can be reached via email at robertmartino@wilmarmanagement.com.

Disclosure: Dr. Martino reports no disclosures. 

WEBINAR

Dr. Martino will present a FREE CE WEBINAR on August 26, 2024 expanding on this article’s topic.

CLICK HERE TO REGISTER.

Bacterial plaque, as well as the formation of calculus on teeth and around the gingiva, has been intricately linked to the development of oral diseases such as caries, gingivitis, and periodontitis.² Hence, plaque and calculus control are considered crucial to the effective self-management and prevention of oral disease development. Clinicians often counsel their patients to carefully remove plaque via the physical action of tooth brushing; however, the chemistry of plaque, calculus, enamel, dentin, and saliva constitute an intricate relationship. Only a handful of elements are present at the tooth surface that allow plaque to accumulate. Calcium is one of those elements. It plays a vital role in the development of both dental biofilm and calculus³ (ie, when calcium is in the wrong place at the wrong time) while also serving as the main atomic building block of enamel and dentin (ie, when calcium is in the right place at the right time). 

Both hydroxyapatite (HA) and the substances that form upon it contain the same 2 molecules: calcium phosphate and hydroxyl ions. Even if the teeth are completely free of plaque, calcium ions in the dental enamel are continually removed and added in a dynamic demineralization-remineralization process known as the “demin-remin cycle.” This cycle occurs because food and drinks contain corrosive, calcium-depleting acids that give the food and drinks flavor. Fortunately, humans have saliva to protect enamel and replenish the healthy calcium and phosphorus diminished by that corrosion. Salivary proteins ensure that saliva is supersaturated with calcium phosphate; armed with an excess of these mineral ions, healthy saliva drives remineralization by replenishing calcium and phosphate lost from the tooth surface. Healthy saliva also creates what is called the “acquired enamel pellicle,” which serves to further protect the enamel and acts as an ion diffusion barrier.

While some intraoral bacteria can form a mutually symbiotic, healthy biofilm that confers resistance to disease, oftentimes, the biofilm that is closest to the tooth surface becomes detrimentally acidic, thereby creating an environment that dissolves tooth structure. Without chemical neutralization or the removal of that acidic biofilm, the tooth surface becomes dysbiotic and may begin to demineralize, creating an initial caries lesion.

Unremoved non-acidic plaque has an opposite, though still detrimental, effect. When it is bathed in calcium- and phosphate-rich saliva, the non-acidic plaque calcifies due to the ions deposited within it. Thus, both acidic and non-acidic plaque damage gums and play key roles in the development of receding gums, gingivitis, and periodontitis.⁴

Anti-calculus agents are used extensively in toothpaste to delay and interfere with dental plaque calcification. The most common anti-calculus agents are metal chelators.¹ Chelation is a chemical reaction in which ions and molecules (ligands) become bonded to metal ions; this bond involves the formation or presence of 2 or more separate coordinate bonds between a polydentate (multiple-bonded) ligand and a single central metal atom. Essentially, the chelator is a molecule designed to grab onto a metal ion. 

The most common anti-calculus chelators include ethylenediaminetetraacetic acid (EDTA), sodium hexametaphosphates (SHMPs), and pyrophosphates. They all work with essentially the same mechanism: Each has a high affinity to HA surfaces thanks to an interaction with calcium ions (Ca²⁺) in the hydration layer. In this interaction with HA and enamel surfaces, chelators reduce the protein-binding capacities of these surfaces. They also have the ability to inhibit calcium phosphate formation.⁵ Essentially, chelators get in the way of the calculus-hardening process: Like adding bowling balls to a brick wall, the calculus structure becomes wobbly and weak and thereby slower to accumulate and easier to remove.

Some chelating processes occur naturally in nature, such as in serum or biological tissues. Chelators have also been developed as tools for a wide range of industrial applications, including water softening and food preservation. Their ability to bind to and remove metal ions, especially unwanted calcium, means that chelators also have many important medical applications, as chelating effects can be achieved at a near-neutral pH.⁶ Chelators are already commonly used in dentistry; endodontic instrumentation relies upon chelators to facilitate canal cleaning by binding to calcium to assist in its removal. In addition, chelators are often the active ingredient in tartar-control toothpastes, where they bind to excess salivary calcium ions in order to prevent those ions from precipitating and forming dental calculus.¹ It is important to note, too, that the efficacy of chelators in tartar-control toothpaste is predicated upon the fact that one usually brushes twice a day for roughly 2 minutes, which means that chelators from toothpaste are only active in the mouth for about 4 minutes in an entire day. This relatively brief timespan ensures the safety of chelating agents in that they are not removing too much calcium from the mouth, allowing the vast majority of calcium ions necessary for oral health to remain (Figures 1 and 2).

Figure 1. A low-caries-risk adult male refrained from oral hygiene for 24 hours. A disclosing agent was applied (GC TriPlaque ID Gel [GC America]) to visualize the plaque.

Figure 2. The maxillary teeth were brushed for one minute with an over-the-counter, fluoride-containing toothpaste (control). The mandibular teeth were brushed for one minute with LIVFRESH Dental Gel (Livionex) (test). The LIVFRESH gel resulted in a lower plaque score after brushing compared to the control.

There are differences in the amount of chelation achieved by the various leading chelators used in tartar-control toothpastes. The most commonly used chelators for calculus control are pyrophosphates, SHMPs, Gantrez (a copolymer of maleic acid), and EDTA. Each of these compounds is safe and effective in binding to calcium and other metals. Each chelator has its own affinity for metal ions (this affinity is a measure of its ability to hold on to a metal ion once it is bound). Table 1 shows the varying levels to which these chelators reduce the rate of calculus formation.

Studies have shown that pyrophosphates reduce the rate of dental calculus formation by around 30%, while SHMP reduces it by up to 50%.⁸

Colgate Total with Triclosan contained 2% Gantrez, a maleic acid copolymer.³ Gantrez is used in dentifrices and is described as a “bioadhesive polymer”⁴ that adheres to oral surfaces. According to Ashland Corp, it “function(s) by chelating metal ions….Calcium phosphate occurring naturally in the mouth normally forms a pre-calculus or tartar seed on the teeth….[Gantrez] attacks the tartar seed and the seed dissolves.”⁹ The dissolution of the pre-calculus is achieved by chelating the calcium.

EDTA disodium is another well-known chelator that has been extensively studied since its development by Ferdinand Munz in Germany in the early 1930s. EDTA is commonly used as a chelator added to many food items as a preservative. In high concentrations (18% to 25%), it is useful in removing smear layers during root canal preparation. 

Given the safety and efficacy of chelators, research has explored ways to implement chelation in methods of plaque control that are even more targeted and effective than conventional uses of chelation. One major development has involved using chelators to strengthen the natural negative electronic charge of the tooth surface to repel unhealthy calcium, thereby achieving the dual aims of making unwanted calcium in the plaque fluid (calcium in the wrong place at the wrong time) easy to remove from the tooth environment without getting rid of the calcium necessary for oral health. 

Tooth surfaces are negatively charged, and so are bacteria; therefore, they should repel each other. However, salivary calcium coats the negative charges on the tooth surface and bacteria, allowing them to get very close (within 10 nm). At this point, van der Waal’s forces (attractive electrostatic forces at small distances) take over, allowing the bacteria to deposit on the tooth surfaces, initiating biofilm formation.¹⁰ A unique formulation of EDTA strengthens the negative electronic forces of the tooth, allowing the teeth to repel harmful plaque. This special formulation quickly penetrates through the plaque down to the tooth surface. There, it changes the surface charge back to negative by neutralizing the positively charged calcium ions. This new, stronger negative charge on the tooth surface environment simply allows the plaque and the tooth surface to repel each other. This requires neither an abrasive nor killing the bacteria (Figure 3). 

This specialized formulation of 2.6% EDTA, which is currently available in LIVFRESH Dental Gel (Livionex), not only repels the bacteria but also remains on the tooth surface—a characteristic known as substantivity—and slows down the rate of future bacterial attachment to that tooth surface, reducing the rate of plaque buildup. In addition, the increased negative charge of the tooth surface weakens the attachment of plaque to the tooth surface, making it easier to remove the next time the tooth is brushed. Brushing at night with this formulation of 2.6% EDTA has been shown to significantly lower plaque buildup overnight.¹¹ This “smart technology” mechanism effectively controls plaque and tartar buildup without the need for abrasives, soaps, and bactericidal chemicals (Figures 4 and 5).

As Table 2 shows, the per-brush chelating capacity of LIVFRESH Dental Gel is extraordinarily targeted and is less than 10% of the chelating capacity of the 13% SHMP used in Crest Pro-Health. 

The amount of toothpaste used in a single brushing of Colgate Total or Crest Pro-Health would chelate 6 or 13 times the amount of calcium, respectively, that would be chelated by the same amount of LIVFRESH Dental Gel used in a single brushing, even as LIVFRESH has shown remarkable efficacy in the removal of plaque. In multiple controlled studies, the use of the uniquely formulated 2.6% EDTA has consistently resulted in lower plaque, gum inflammation, and bleeding compared to other toothpastes.^15-17 Most recently, a double-blind study published in the Journal of Periodontology confirmed that, without prophylaxis, 2.6% EDTA showed statistically and clinically significant reductions in pocket depths and gum inflammation and bleeding compared to a leading stannous fluoride-containing anti-gingivitis toothpaste in early/moderate (stage 1 and stage 2) periodontitis patients.¹⁸

CONCLUSION

The selectively focused use of chelators has the potential to effectively control dysbiotic oral diseases by increasing the negative charge of teeth to repel plaque naturally. At the same time, this novel approach is respectful and supportive of healthy oral flora. Repurposing a safe, popular tartar-control agent to repel plaque offers an exciting future for more effective home care that does not rely on abrasives and antimicrobials.

REFERENCES 

1. Koenig P, Faller R. Fundamentals of dentifrice: oral health benefits in a tube. Updated June 28, 2020. Available at: https://www.dentalcare.com/en-us/professional-education/ce-courses/ce410

2. American Dental Association (ADA) Division of Science. For the patient. Keeping your gums healthy. J Am Dent Assoc. 2015;146(4):A46. doi:10.1016/j.adaj.2015.01.021

3. Jin Y, Yip HK. Supragingival calculus: formation and control. Crit Rev Oral Biol Med. 2002;13(5):426-41. doi:10.1177/154411130201300506

4. Damle SG. Genetic determination through dental calculus: Promise and hope! Contemp Clin Dent. 2016;7(2):129-30. doi:10.4103/0976-237X.183065

5. Vranić E, Lacević A, Mehmedagić A, et al. Formulation ingredients for toothpastes and mouthwashes. Bosn J Basic Med Sci. 2004;4(4):51-8. doi:10.17305/bjbms.2004.3362

6. Levine RS. Pyrophosphates in toothpaste: a retrospective and reappraisal. Br Dent J. 2020;229(10):687-689. doi:10.1038/s41415-020-2346-4

7. Davidsohn AS, Milwidsky B. Synthetic detergents. 7th ed. Longman Scientific & Technical; 1987.

8. Schiff T, Saletta L, Baker RA, et al. Anticalculus efficacy and safety of a stabilized stannous fluoride/sodium hexametaphosphate dentifrice. Compend Contin Educ Dent. 2005;26(9 Suppl 1):29-34. 

9. Ashland Corporation. Gantrez S polymers for tartar control in toothpastes and mouth rinses. Bulletin VC-814. 

10. Hermansson M. The DLVO theory in microbial adhesion. Colloids and Surfaces B: Biointerfaces. 1999;14(1–4):105-119.

11. Anbarani AG, Wink C, Ho J, et al. Dental plaque removal and re-accumulation: a clinical randomized pilot study evaluating a gel dentifrice containing 2.6% edathamil. J Clin Dent. 2018;29(2):40-44. 

12. Kozak, KM, White DJ. Poster 2086: Dentifrice effects toward chemical stain prevention: An in vitro comparison. 2000. Poster 2086; Presented at 78th General Session and Exhibition of International Association for Dental Research (IADR). 

13. Schiff T, Saletta L, Baker RA, et al. Anticalculus efficacy and safety of a stabilized stannous fluoride/sodium hexametaphosphate dentifrice. Compend Contin Educ Dent. 2005;26(9 Suppl 1):29-34.

14. Ashland Corporation. Gantrez TM-95 polymer building performance for non-phosphate dishwashing products. Ashland Product Sheet, PC 7822.

15. Dadkhah M, Chung NE, Ajdaharian J, et al. Effects of a novel dental gel on plaque and gingivitis: a comparative study. Dentistry (Sunnyvale). 2014;4(6):239. doi:10.4172/2161-1122.1000239

16. Ajdaharian J, Dadkhah M, Sabokpey S, et al. Multimodality imaging of the effects of a novel dentifrice on oral biofilm. Lasers Surg Med. 2014;46(7):546-52. doi:10.1002/lsm.22265

17. Nayudu A, Lam T, Ho J, et al. Plaque removal and gingival health after use of a novel dental gel: a clinical study. Dentistry (Sunnyvale). 2016;6(10):396. doi:10.4172/2161-1122.1000396

18. Kaur M, Geurs NC, Cobb CM, et al. Evaluating efficacy of a novel dentifrice in reducing probing depths in stage I and II periodontitis maintenance patients: a randomized, double-blind, positive controlled clinical trial. J Periodontol. 2021;92(9):1286-1294. doi:10.1002/JPER.20-0721

ABOUT THE AUTHORS

Dr. Jacobsen has a PhD in Comparative Pharmacology and Toxicology, and he directed the Oral Medicine Clinic at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco for 25 years. He is a Diplomate of the American Board of Oral Medicine and a past chairman and vice-chairman of the ADA Council on Scientific Affairs. He has been named as one of Dentistry Today’s Leaders in Continuing Education for several years. He also received the 1999 Gordon J. Christensen Lecturer Recognition Award. He writes the Dental Drug Booklet, a succinct handout and reference on commonly prescribed dental medications. Dr. Jacobsen lectures extensively on dental pharmacology as well as over-the-counter dental drugs and products. He also presents on the topic of the dental management of medically complex patients. He can be reached at pgjacobs@pacbell.net.

Dr. Nový is the chief dental officer of the Alliance Dental Center, Massachusetts Public Employees Fund, and holds faculty appointments at the Harvard School of Dental Medicine and Western University. He served on the ADA Council of Scientific Affairs from 2011 to 2014 and as president of the National CAMBRA Coalition. In 2016, he was appointed the consumer representative to the US Food and Drug Administration Dental Products Panel. He is the recipient of the Dugoni Award, the Weclew Award, and the 2021 ADA Evidence-Based Dentistry Practice Award. He can be reached at drbriannovy@gmail.com.

Disclosure: Drs. Jacobsen and Nový are members of the Livionex Scientific Advisory Board. 

HYGIENE
The practice of dentistry by all members of the clinical team involves static posture, precise and repetitive motions, long work hours, and suboptimal ergonomics.^1,2 The prevalence of musculoskeletal disorders (MSDs) among dentists and dental hygienists can range from 64% to 93%, with prolonged static postures (PSPs) and repetitive movements being listed as major risk factors.^3-5 More troubling were the results of a study in the United Kingdom that found that MSDs were the most frequent cause of premature retirement among dentists.⁶ The World Health Organization defines work-related MSDs as “disorders or injuries affecting muscles, tendons, joints, ligaments, and bones mainly caused by mechanical overload of the respective biological structures. Potential overload of tissues results from high intensity forces or torques acting on and inside the body.”⁷ The types of MSDs in dentistry broadly fall into 3 categories: neck and shoulder disorders, hand and wrist disorders, and back disorders.²

Focusing specifically on hand and wrist disorders, dentists and dental hygienists suffer from more hand, wrist, and arm pain than the general population.^8-10 Carpal tunnel syndrome (CTS) is the most common MSD within the hand and wrist disorder category and is caused by compression of the median nerve, causing symptoms to include numbness, tingling, or pain in the thumb, index finger, middle finger, and half of the ring finger. There are many suspected causes of CTS, and besides a history of trauma to the wrist, contributing factors can include an overactive pituitary gland, an underactive thyroid gland, and rheumatoid arthritis.¹⁰ Females are 3 times more likely to develop CTS, with diabetic and obese individuals also being at increased risk.¹¹ General work-related risk factors for CTS include mechanical stress to the hand and wrist, forceful exertion, repetitive motions, and PSP.7 In dentistry, activities such as forceful gripping of small instruments, flexing the wrist forward, vibration, and repetitive motions for long periods of time have been implicated in the development of CTS symptoms.^8,11

Figure 1. The use of big-handled instruments (pictured: PremierAir Probex Explorer [Premier Dental Products]) and proper finger rests can help reduce muscle workload and pinch force.

Figure 2. A variety of dental hygiene instruments demonstrates the trend away from small-diameter handles toward larger-diameter, textured handles. From top to bottom, the instruments are the Premier scaler H6/H7 (Premier Dental Products), PremierAir scaler H6/H7 (Premier Dental Products), American Eagle EagleLite Resin Scaler H5-33 (American Eagle Instruments), American Eagle EagleLite Stainless H6-7 (American Eagle Instruments), Hu-Friedy DE Scaler H6/H7 (Hu-Friedy), Hu-Friedy DE scaler ResinEight H6/H7 (Hu-Friedy), Hu-Friedy Nevi Posterior EverEdge (Hu-Friedy), PDT R144 Queen of Hearts (PDT), and Nordent DuraLite ColorRings CESCN135 (Nordent Manufacturing).

An early study by the ADA found that 9.2% of dentists had been diagnosed with a repetitive motion disorder, causing 19% to require surgery and 40% to work reduced hours.¹² Another study found that 71% of dentists experienced CTS symptoms, although only 7% were diagnosed with CTS.¹³ This finding was also reported by Hamann et al,8 who found the symptoms of CTS were more prevalent among dentists than in the general population. The authors noted several strategies for reducing CTS symptoms: a night-time wrist splint, pacing of work activity (including breaks to prevent extended wrist flexion), larger-handled instruments, fitted gloves, and improved wrist posture to reduce stress on the median nerve.⁸ Additional strategies noted by another author include using sharp hand instruments to decrease needed force, adequate finger rests, using textured grips to reduce pinch strength, reducing cord pullback or tubing torque, and frequent stretch breaks10 (Figures 1 and 2). Currently, the ADA has a webpage devoted to “Reducing Hand Pain” and lists examples of motions that may aggravate hand pain and tips for lessening the demands of the hand.¹⁴

Dental Hygienists at Increased Risk
Although the entire clinical dental team is at risk for MSDs, dental hygienists have been shown to be disproportionally affected compared to dentists.9 This is especially concerning because an effective dental hygiene program is the lifeblood of a general practice. Hygiene procedures are not only vital to the overall health of patients, but recall appointments often serve as the first line of defense for prevention of oral disease.

Studies by Rucker and Sunell^15,16 found that 67% of dentists and 86% of dental hygienists reported MSD pain within the previous year. Again, focusing on hand and wrist pain, the same study¹5 reported a higher prevalence of hand pain in hygienists compared to dentists: 75% vs 38%, respectively. Several studies have reported the prevalence of CTS in dental hygienists, with rates of 6.4% to 11%, 23%, and 50% being reported.^17-20 In a review article by Johnson and Kanji,²¹ the specific risk factors for dental hygienists were listed as repetitive movements, awkward and static postures, pinch-grasp, forceful exertions, vibration, poor ergonomics, and insufficient breaks.

Figure 3. An otherwise healthy patient with a severe extrinsic stain. In this case, either rubber cup polishing or air polishing is appropriate.	Figure 4. Following stain removal, the clinical appearance is much improved. Note the absence of trauma to the marginal gingiva.
Figure 5. A patient with a severe stain who, because of restorations and an exposed root surface, is not appropriate for air polishing. Conventional rubber cup polishing is recommended.	Figure 6. After the rubber cup polishing and complete stain removal.

The use of ultrasonic hygiene instruments has been reported as a means to decrease pinch force and reduce procedure time.²² However, the vibration of ultrasonic instruments may still be a risk factor of MSD and CTS.^10,17,21,23 Because effective hygiene treatment usually involves both hand and ultrasonic instruments, it is recommended that a combination of both techniques be used. In doing so, the duration of either technique is decreased, which can help to vary hand positioning, reduce muscle workload, and provide intermittent rest to hand muscles—specifically those involved with pinch force.¹⁰

A Fresh Perspective on an Old Idea?
Despite an appropriate perio/prophy ratio and hygiene:service mix, adult and child prophylaxes are commonly performed procedures.²⁴ Using the techniques described to prevent MSDs and improve hand and wrist health offer the ability to help hygienists practice more comfortably, but is it possible to provide the same level of care while decreasing the amount of time hand muscles are in use? Alternating hand instrumentation with ultrasonic instrumentation is a first step, but an additional approach could be re-evaluating the routine nature of coronal polishing as a part of the prophylaxis procedure.

Since the late 1970s, the notion that every tooth during every routine prophylaxis should be polished has been replaced by the “selective polishing theory” that asserts that polishing should only be performed on teeth with extrinsic stains.^25,26 An article by Pence et al²⁷ reported an insignificant loss of enamel during the coronal polishing procedure, while a recent report highlights the idea that improper coronal polishing can cause significant damage to gingival tissues, exposed dentin and cementum, enamel, and especially restorations.²⁸

Despite the theory of selective polishing, full-mouth polishing is routinely performed as a component of a dental prophylaxis. As a result of this reality, the term “selective polishing” has been updated to “essential selective polishing” to reinforce that if coronal polishing is to be routinely performed, then dental hygienists should select the most appropriate polishing or cleaning agents according to the patient’s individual needs.^29,30

Figure 7. Several examples of cordless prophy handpieces in their charging bases (left: iStar Cordless Prophylaxis Handpiece [DentalEZ] and Pivot Disposable Prophy Angle [Preventech], center: AeroPro Cordless Prophy Handpiece System and 2pro Disposable Prophy Angle [Premier Dental Products], right: NUPRO Freedom Cordless Prophy System and NUPRO Freedom Slim Disposable Prophy Angle [Dentsply Sirona]).

Figure 8. Several examples of cordless prophy handpieces (left: iStar Cordless Prophylaxis Handpiece [DentalEZ], center: AeroPro Cordless Prophy Handpiece System [Premier Dental Products], right: NUPRO Freedom Cordless Prophy System [Dentsply Sirona]).

So, why has coronal polishing become a seemingly routine part of the patient’s prophylaxis appointment? Explanations may range from patient expectations to the oral healthcare provider’s desires to satisfy patients and provide the best care possible. The best case scenario is to reserve the coronal polishing procedure for the clinical situations that warrant it (eg, the removal of extrinsic stains, plaque, and biofilm), use the correct prophylaxis paste grit or cleaning agent, and avoid situations where it may be contraindicated (eg, acute periodontal infections, aesthetic restorations, tooth sensitivity, amelogenesis imperfecta, enamel demineralization, enamel hypocalcification, enamel hypoplasia, exposed cementum, and the absence of extrinsic stains)^25,29 (Figures 3 and 4). By minimizing the vibration, cord pullback and drag, pinch force, and muscle fatigue associated with the use of traditional prophylaxis handpieces, hygienists can reduce muscle workload.³¹

It is worth mentioning that air polishing is another option for the removal of extrinsic stains and can be an important part of the hygiene armamentarium. The device typically comprises a handpiece similar to an ultrasonic insert that is connected via a hose to the unit and powder chamber. Compared to polishing with a rubber cup, the advantages of using air polishing include more efficient stain removal in less time, and with diminished dentin hypersensitivity and less operator fatigue.^32,33 The contraindications to air polishing include certain medical conditions (eg, restricted sodium diets and respiratory, renal, or metabolic disease), use on root surfaces, use on composites or porcelains, and use around ceramic or metal orthodontic brackets^25,32,34 (Figures 5 and 6). A significant hazard to air polishing is the increased risk of aerosols, which can be mitigated with universal precautions, use of high-volume evacuation, and antimicrobial rinses.³⁵ Advances in the latest powders used in air polishing may diminish some of these contraindications in the future (eg, the use of glycine or the use of reduced air pressure).

Figure 9. A hygienist uses the AeroPro Cordless Prophy Handpiece for coronal polishing. Ergonomic factors of the prophy handpiece (eg, thick diameter, tactile grip, weight, and balance) combined with an extraoral finger rest can help to reduce muscle workload and fatigue.	Figure 10. A hygienist uses the AeroPro Cordless Prophy Handpiece for coronal polishing of the mandibular right teeth. Because there is no cord pullback with cordless prophy handpieces, polishing procedures can be performed more quickly and comfortably for the patient and provider.

An Innovation in Prophy Handpieces
Technology has helped provide solutions for dental hygienists, specifically in larger-handled instruments and ultrasonic inserts with more effective tips for better control and precision (Figure 2). However, prophy handpieces have historically been air driven via tubing and may be heavy and unergonomic (eg, a slow-speed motor combined with a straight nose cone). Even dedicated prophy handpieces (eg, NUPRO RDH [Dentsply Sirona] and Ultrapro Tx Air [Ultradent Products]) may cause cord drag despite lighter weight and improved ergonomics.

In 2011, Dentsply Sirona introduced the first cordless prophy handpiece, originally named the Midwest RDH Freedom Cordless Prophy System (Dentsply Sirona) and more recently renamed to the NUPRO Freedom Cordless Prophy System (Dentsply Sirona). The original system included a motor component, metal sheath, charging base, and Bluetooth foot pedal, whereas the newer version can be used with or without a foot pedal.36 Both use proprietary disposable prophy angles.

In 2015, DentalEZ introduced the iStar Cordless Prophylaxis Handpiece, which is compatible with any prophy angle. The iStar is push-button operated; has variable speeds from 500 to 2,500 rpm; and is non-sterilizable, with infection prevention mediated by disposable sleeves. On the other hand, the NUPRO handpiece has variable speeds of up to 3,000 rpm and uses sterilizable sheaths with disposable barriers for infection prevention (Figures 7 and 8).

In 2019, Premier Dental Products introduced the AeroPro Cordless Prophy Handpiece System (Figures 7 and 8). It is compatible with any disposable prophy angle and is designed to allow the angle to be easily rotated 360° for improved intraoral access. As per the manufacturer, AeroPro is “ergonomic and lightweight with a well-balanced design, featuring a textured grip to help reduce pinch strength and hand fatigue” (Figures 9 and 10). It is controlled using a single button and features ChargeSMART technology for rapid charging and all-day battery life, and infection prevention is available via autoclavable sheaths and disposable barriers. It has 3 speeds of 500, 1,500, and 2,800 rpm.

A study by McCombs and Russell³¹ compared the muscle loads required during simulated tooth polishing using a corded vs a cordless handpiece. Electromyography (EMG) was used to measure the activity of 4 muscles involved in high pinch force. The results showed a reduced EMG for 3 out of the 4 muscles tested when the cordless handpiece was used, but the intensity of muscle workload between the corded and cordless handpieces was not statistically different. The biggest difference was an average 30-second reduction in polishing time with the cordless handpiece, which over the course of a workday would reduce duration of muscle workload, an important factor in preventing MSDs. The dental hygienists mostly preferred the cordless handpiece over the corded handpieces used in the study, and, when queried, they listed a lack of cord, weight and balance, and low noise as the main reasons for the preference.

CLOSING COMMENTS
Because of the nature of clinical dentistry—static posture, precise and repetitive motions, long work hours, and suboptimal ergonomics—all members of the clinical team are at risk for MSDs. Dental hygienists especially may be at an increased risk for MSDs compared to dentists and must practice preventive strategies to maintain hand and musculoskeletal health. Appreciating that an effective dental hygiene program is an integral component of a successful dental practice and comprehensive patient care, hygienists should seek clinical equipment that can reduce muscle workload and its duration.

Cordless prophy handpieces offer a meaningful innovation over their corded predecessors and should be considered a worthwhile upgrade for the safe and ergonomic delivery of hygiene care.

References

1. Zaerian M. Musculoskeletal disorders and the impacts on the dental professional. Oral Health. February 1, 2009. https://www.oralhealthgroup.com/features/musculoskeletal-disorders-and-the-impacts-on-the-dental-professional/. Accessed February 12, 2019.
2. Chopra A. Musculoskeletal disorders in dentistry—a review. JSM Dentistry. 2014;2:1032-1035.
3. Hayes M, Cockrell D, Smith DR. A systematic review of musculoskeletal disorders among dental professionals. Int J Dent Hyg. 2009;7:159-165.
4. Padhye NM, Padhye AM, Gupta HS. Effect of pre-procedural chair-side finger stretches on pinch strength amongst dental cohort—a biomechanical study. J Clin Diagn Res. 2017;11:ZC82-ZC85.
5. McCombs GB, Russell DM. Reducing muscle workload. Dimens Dent Hyg. April 8, 2016. https://dimensionsofdentalhygiene.com/article/reducing-muscle-workload/. Accessed February 12, 2019.
6. Burke FJ, Main JR, Freeman R. The practice of dentistry: an assessment of reasons for premature retirement. Br Dent J. 1997;182:250-254.
7. World Health Organization. Preventing musculoskeletal disorders in the workplace. 2003. https://apps.who.int/iris/bitstream/handle/10665/42651/924159053X.pdf?sequence=1. Accessed February 12, 2019.
8. Hamann C, Werner RA, Franzblau A, et al. Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists. J Am Dent Assoc. 2001;132:163-170.
9. Hayes MJ, Smith DR, Cockrell D. An international review of musculoskeletal disorders in the dental hygiene profession. Int Dent J. 2010;60:343-352.
10. Valachi B. Getting the upper hand on pain: preventing hand and wrist pain syndromes on dental professionals. https://www.dentalacademyofce.com/courses/1878/pdf/handandwristpain.pdf.pdf. Accessed February 12, 2019.
11. National Institute of Neurological Disorders and Stroke. Carpal tunnel syndrome fact sheet. July 13, 2018. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Carpal-Tunnel-Syndrome-Fact-Sheet. Accessed February 12, 2019.
12. American Dental Association (ADA) Survey Center. Survey of current issues in dentistry: repetitive motion injuries. Chicago, IL: American Dental Association; 1997:2-8.
13. Rice VJ, Nindl B, Pentikis JS. Dental workers, musculoskeletal cumulative trauma, and carpal tunnel syndrome: Who is at risk? A pilot study. Int J Occup Saf Ergon. 1996;2:218-233.
14. ADA Center for Professional Success. Reducing hand pain. https://success.ada.org/en/wellness/reducing-hand-pain. Accessed February 12, 2019.
15. Rucker LM, Sunell S. Musculoskeletal health status in B.C. dentists and dental hygienists: evaluating the preventive impact of surgical ergonomics training and surgical magnification [final report]. Vancouver, British Columbia, Canada: Workers’ Compensation Board of British Columbia; November 2000.
16. Rucker LM, Sunell S. Ergonomic risk factors associated with clinical dentistry. J Calif Dent Assoc. 2002;30:139-146.
17. Sanders MA, Turcotte CM. Strategies to reduce work-related musculoskeletal disorders in dental hygienists: two case studies. J Hand Ther. 2002;15:363-374.
18. Morse TF, Michalak-Turcotte C, Atwood-Sanders M, et al. A pilot study of hand and arm musculoskeletal disorders in dental hygiene students. J Dent Hyg. 2003;77:173-179.
19. Anton D, Rosecrance J, Merlino L, et al. Prevalence of musculoskeletal symptoms and carpal tunnel syndrome among dental hygienists. Am J Ind Med. 2002;42:248-257.
20. Lalumandier JA, McPhee SD, Riddle S, et al. Carpal tunnel syndrome: effect on Army dental personnel. Mil Med. 2000;165:372-378.
21. Johnson CR, Kanji Z. The impact of occupation-related musculoskeletal disorders on dental hygienists. Canadian Journal of Dental Hygiene. 2016;50:72-79.
22. Dong H, Barr A, Loomer P, et al. The effects of finger rest positions on hand muscle load and pinch force in simulated dental hygiene work. J Dent Educ. 2005;69:453-460.
23. Akesson I, Lundborg G, Horstmann V, et al. Neuropathy in female dental personnel exposed to high frequency vibrations. Occup Environ Med. 1995;52:116-123.
24. Miller K. Five characteristics of a profitable dental hygiene department. April 6, 2017. http://www.speareducation.com/spear-review/2014/08/five-characteristics-profitable-dental-hygiene-department-part-ii. Accessed February 12, 2019.
25. Sawai MA, Bhardwaj A, Jafri Z, et al. Tooth polishing: the current status. J Indian Soc Periodontol. 2015;19:375-380.
26. Barnes CM. The science of polishing. Dimens Dent Hyg. November 1, 2009. http://www.dimensionsofdentalhygiene.com/2009/11_November/Features/The_Science_of_Polishing.aspx. Accessed February 12, 2019.
27. Pence SD, Chambers DA, van Tets IG, et al. Repetitive coronal polishing yields minimal enamel loss. J Dent Hyg. 2011;85:348-357.
28. Christensen GJ. Prophy pastes: helpful and harmful. Clinicians Report. 2018;11:1-8.
29. Barnes C. Shining a new light on selective polishing. Dimens Dent Hyg. 2012;10:42-44.
30. Barnes CM. Polishing. In: Wilkins EM, ed. Clinical Practice of the Dental Hygienist. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
31. McCombs G, Russell DM. Comparison of corded and cordless handpieces on forearm muscle activity, procedure time and ease of use during simulated tooth polishing. J Dent Hyg. 2014;88:386-393.
32. Graumann SJ, Sensat ML, Stoltenberg JL. Air polishing: a review of current literature. J Dent Hyg. 2013;87:173-180.
33. Barnes CM. Air polishing: a mainstay for dental hygiene. https://www.dentalacademyofce.com/courses/2423/PDF/1305cei_Barnes_RDH_final.pdf. Accessed February 12, 2019.
34. Johnson K. Air polishing has changed—so why hasn’t the dental hygiene curriculum? Dentistry IQ. August 16, 2016. https://www.dentistryiq.com/articles/2016/08/air-polishing-has-changed-so-why-hasn-t-the-dental-hygiene-curriculum.html. Accessed February 12, 2019.
35. Gutmann ME. Air polishing: a comprehensive review of the literature. J Dent Hyg. 1998;72:47-56.
36. Dryer M. Coronal polishing: the evolution of handpieces offers a new spin on dental hygiene services. RDH. June 1, 2017. https://www.rdhmag.com/articles/print/volume-37/issue-6/contents/coronal-polishing.html. Accessed February 12, 2019.

Dr. Goodchild is an associate clinical professor in the Department of Diagnostic Sciences at the Creighton University School of Dentistry in Omaha; an adjunct assistant professor in the Department of Diagnostic Sciences at the Rutgers School of Dental Medicine in Newark, NJ; and in private practice in Havertown, Pa. He can be reached at jgoodchild@premusa.com.

Disclosure: Dr. Goodchild is the director of clinical affairs for the Premier Dental Products Company in Plymouth Meeting, Pa.

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Dental offices have an ethical obligation to provide the best care for their patients. All too often, dental practices cling to old beliefs such as, “Our hygiene department is a loss leader.” Experienced hygienists with excellent communication skills can easily transform a “loss leader” hygiene department, producing $600 to $800 daily, into a profitable department, achieving $1,800 to $2,500 in daily production. This can be accomplished by embracing a comprehensive, patient-focused approach to both periodontal therapy and restorative/aesthetic treatment options. Hygienists that are patient-focused spend about 50% of their time providing services with insurance codes (CDT 2009 to 2010, American Dental Association) in the D4000 to D4999 range. In addition to periodontal services, a comprehensive hygienist will offer oral cancer screenings, discuss occlusal guard therapy, sealants, tooth whitening, orthodontic alignment, and more. To achieve this level of success, having a comprehensive practice philosophy, along with the right team members to implement it, is a must.

ONLY “SUPERSTARS” NEED APPLY 

In Part 1 of this article series, we discussed the use of personality profiles in the selection of the right hygienist for your practice. There are numerous other essentials to perform during the hiring process (ie, the one-on-one interview, advertising, etc) For the sake of brevity, let us once again emphasize the use of the personality profile to avoid hiring the wrong person. You should always strive to employ only “SUPERSTARS” on your team. Let’s now look at some other helpful suggestions for the successful selection process.
You should have a working interview where the dental hygienist candidate does a prophylaxis for a team member, the doctor, and/or scheduled patient. It is imperative that the new hygienist get to know the other team members as quickly as possible. This can be accomplished with a lunch outing with the office team. (We suggest that the doctor stays out of this meeting.) This provides an excellent opportunity for interaction between team members and the potential employee outside the dental environment.
An important part of the selection process is to always check references. Check with the candidate’s past employer to try to determine if there was a willingness to merge their personal standard of care with that of the doctor. Hygienists will come and go, but leadership and the philosophy of care should remain the same or improve, regardless of the hygienist you employ. One final word of advice, do not hire someone you do not like. Furthermore, never hire someone out of desperation. Stick to your guns and hold out for the dental hygienist that will meet your expectations, meet the needs of your patients, and support your practice goals.

CLARIFY EXPECTATIONS

Once the dental hygienist has been hired, the next step is for the doctor to clarify any and all expectations. Stephen Covey, in his book The Seven Habits of Highly Effective People, states that, “The cause of almost all relationship difficulties is rooted in conflicting or ambiguous expectations around roles and goal… Unclear expectations in the area of goals also undermine communication and trust… Make expectations clear and explicit in the beginning.”
This takes a real investment of time and effort upfront, but it saves great amounts of time and effort down the road. Discord, after the “honeymoon period,” is almost always traced back to unclear expectations and assumptions. It is a good idea to prioritize the expectations according to the practice philosophy. Without proper preliminary communication of your clinical and management expectations, you may find yourself surprised and disappointed after hiring what seemed like the right hygienist.

WIN-WIN COMPENSATION 

Compensation for the dental hygienist can come in “many flavors.” An effective way to insure profitability is to enable the dental hygienist to take “ownership” concerning their production and compensation. Doctors get paid based on production and ideally the dental hygienist should also be paid in the same way. Compensation should depend on the services provided. Providing comprehensive care and maintaining a profitable dental hygiene department creates a winning scenario for im-proved patient health, as well as satisfied and productive dental hygienists.
Let’s take a look at some of the ways the doctor and the hygienist can experience a win-win as far as compensation is concerned. Our first premise is, “empowerment fosters comprehensiveness.” The doctor is a professional and so is the dental hygienist. When doctors empower their dental hygienists to use clinical judgment to provide densensitizing treatments, update necessary radiographs, enroll patients into necessary nonsurgical treatment, etc, it fosters a culture of being more comprehensive in their services. Consider paying a dental hygienist an average of 30% of what she/he produces based upon any comprehensive services provided. Another way to compensate a hygienist would be: the dentist and dental hygienist could agree on a guaranteed hourly (or daily salary) and any overage on the guaranteed salary, the dental hygienist would receive 30% of it.

DENTAL TECHNOLOGICAL ADVANCES 

Of all the technological advances available today, probably none have impacted the dental hygiene appointment more significantly than the intraoral camera and its use as a patient educational tool. Achieving case acceptance in the treatment room is much more easily accomplished when the patient sees what the clinician sees. However, a mistake that many practices make is in having only one camera available for the entire office. Dental hygienists should have an intraoral camera in their treatment rooms and should use it on every patient. In fact, beginning the dental hygiene appointment with a live “tour of the mouth” is a very effective way to get the patient involved. An example of one company that manufactures a “user-friendly” intraoral camera is SOTA Precision Optics. Their camera features a lightweight fingertip focus and capture button.
We are often asked, “Which power-driven technology produces the best clinical results? Magnostrictive or piezoelectric?” There is good news here in that both are clinically effective in calculus removal. However, in clinical studies, neither technology has been consistently shown to out-perform the other so it simply becomes a matter of preference by the clinician. One difference is that piezoelectric thin tips can be used on higher power settings to more easily remove tenacious deposits compared to magnetostrictive thin tips. One example of a state-of-the-art piezoelectric unit that has multiple
tip choices is the Piezon Master 400 (Electro Medical Systems [EMS]). It has a unique feature in its ability to automatically detect the tenaciousness of the deposit at the tip, and to compensate by adding or subtracting power. This unit also comes with a self-contained irrigation reservoir for water or medicament usage.

COMPREHENSIVE PERIODONTAL EXAM

Without someone to physically assist with data collection, or the use of technology to gather the data unassisted, many dental hygienists do not record adequate periodontal information at each patient visit. If no current periodontal data is recorded, routine prophylaxis patients can receive cleanings even in the presence of undiagnosed periodontal disease! Sometimes treatment is begun without proper diagnostic testing and determining the prognosis. This violates the standard of care that should be provided for patients.
The No. 1 priority in implementing a comprehensive periodontal program would be to perform full-mouth comprehensive periodontal charting (6 readings on each tooth) at least once per year. This should also include noting and recording any findings such as bleeding/exudate, recession, furcation involvements, degree of mobility, clinical attachment levels/loss, and muco-gingival involvement. When armed with this information, practices can diagnose and manage periodontal patients properly.
Fortunately, we have technology available that can expedite tedious data collection. It can also allow the dental hygienist to collect/record periodontal data unassisted and to produce a very easy-to-understand periodontal chart that will enhance patient education. The following is a descriptive list of just some of the data collection equipment and vision-enhancing equipment that is currently available:
PerioPal (PerioPal LLP; periopal.com), a voice-activated technology, allows the dental hygienist to collect periodontal data using a “verbal script.” This “verbal script” consists of commands, abbreviations, and short cuts to record data efficiently while the patient listens. It can be used in any order that the clinician chooses—in a single pass for pocket measurements, bleeding, recession, etc.
Florida Probe (Florida Probe Corporation; floridaprobe.com) is a data collection system that utilizes a controlled-force handpiece delivering a standard 15 grams of pressure to provide patient comfort and to record each measurement to 0.2 mm accuracy. This distinctive feature helps to standardize data collection between different clinicians. The patient participates by listening to the computer voice calling out their own pocket measurements, bleeding, recession, etc, while the dental hygienist collects data unassisted. The Florida Probe System provides easy-to-understand periodontal charts, patient education brochures, and a periodontal risk assessment tool.
The Dental Remote Access Terminal, or Dental R.A.T. (dentalrat.com), is another technology that allows unassisted periodontal data collection. The foot-operated mouse enables the clinician to input periodontal probe readings through individual buttons that (when pressed once) record 1-, 2-, 3-, and 4-mm pockets; or (when held down) record 5-, 6-, 7-, and 8-mm pockets. The foot mouse can also be utilized to open dental x-rays, utilize the intraoral camera, and check the schedule. The Dental R.A.T integrates with current dental software and includes a headset for patient audio feedback during probe recordings.
DIAGNOdent (KaVo) screens for dental caries and can be used by the dental hygienist. This technology utilizes a handpiece with laser florescence to shine on tooth surfaces to differentiate between healthy and diseased tooth structure. When caries are detected, a digital and audible indicator is activated so that the clinician and the patient can participate in the screening process together. This technology is clinically effective in detecting dental caries that are not yet visibly detectable with regular caries examination or radiographs.

Orascoptic (orascoptic.com) and Sheervision (sheervision.com) are companies that make a variety of magnification and portable illumination systems for the dentist and dental hygienist. Utilization of magnification and illumination for the dental hygienist has become “nonnegotiable” for many dental hygienists in this technologically advanced world. Both from the vantage point of increased visualization and improved ergonomic positioning which can prevent severe back pain, enhanced visualization systems are considered indispensable. See Table 2 to learn the important factors that you should take into account when purchasing one of these products.

SUMMARY

In this 2-part article, we have addressed the correct methods to use in selecting the right hygienist and the importance of creating a purposeful vision for your dental hygiene department. We have touched on the role of having the doctor discuss practice expectations, and the qualities and traits a dental hygienist should possess. Finally we have briefly reviewed some ideas regarding hygienist compensation as well as the integration of the new technologies to help you build a successful, productive, and profitable dental hygiene department.
Many of today’s practice owners have invested hundreds of thousands of dollars in updated facilities and state-of-the-art technology. They have invested in management and leadership courses, developed their business acumen, and have worked to insure that their clinical assistants’ skills stay sharp. However, when it comes to dental hygiene, too many practices still operate a 1980s-style “prophylaxis mindset palace.” The time has come for more dentists to embrace up-to-date dental hygiene practice standards.

Dr. Doherty is a certified financial planner, national lecturer, and CEO of Doctor’s Financial Network. For more information on his future upcoming “Financial and Management Boot Camps for Dentists,” or to receive a free newsletter Doherty’s Bottom Line, please contact him at (772) 225-3021 or hughdohertydds@comcast.net.

Dr. Doherty did not report any disclosures.

Ms. Davis earned her bachelor of science in Dental Hygiene degree from Midwestern State University. She is the owner and founder of Cutting Edge Concepts, and she lectures internationally. She is also a senior consultant of The JP Institute. She can be reached at (972) 669-1555 or karen@karendavis.net, or visit her Web site at karendavis.net.

Disclosure: Ms. Davis is affilated with The JP Institute, OraPharma, Philips, and PreVisor.

Ms. Miller is a senior consultant and partner of The JP Consultants Institute, and is also a director and featured instructor of the JP Institutes’ postgraduate curriculum certification program in Carlsbad, California. She can be reached at (800) 846-4944 or visit the Web site at jpconsutlants.com.

Disclosure: Ms. Miller is an employee of JP Institute and is paid per diem when she provides office training for dentists, workshops, seminars, etc. She lectures occasionally for OraPharma, and is currently providing Webinars for Philips Oral Health Care, receiving honorariums on a project basis from both companies.

What does it take to create a clinically successful, productive, and profitable hygiene system within a dental practice? Over the past years, research and technology in periodontics has created exciting changes in the responsibilities of hygienists and the scope of technology available for practicing dental hygienists. With these changes there is also an opportunity to achieve ideal preventive care for our patients. However, the idealism needed to achieve clinical excellence must be merged with sound business strategies. Simply stated, clinical excellence must be merged with a profitable hygiene department. With the increased costs to run a quality practice with excellent service, receiving a deserved and healthy profit from your practice is more essential today than ever before. Throughout this 2-part article, we will discuss the milestones, goals, and roadblocks that you need to look at in order to make the hygiene department productive and profitable.

CREATING A VISION

A successful dental hygiene system is the backbone of a general practice. It is a vital component to any dental practice that allows patients to attain the highest level of dental health. It provides the doctor (and the entire dental team) the opportunity to treatment plan patients based on their restorative and aesthetic wants and needs. A successful hygiene department requires a philosophy that includes the mouth-body connection and helps patients maintain and “keep their teeth for a lifetime.”
A successful dental hygiene department has many components. The key performance indicators must be monitored and the team must be kept on track and motivated through effective leadership. Protocols must be in place, to guide dental hygienists
who are dedicated and motivated, to provide each and every patient treatment that meets or exceeds current standard of care. Most doctors agree on this point, but the systems and protocols necessary to create a thriving dental hygiene department, are often missing or only partially developed.
To get started building (or reworking) your dental hygiene department, the doctor and team must develop their own vision of what the ideal hygiene department should look like. This vision should include the purpose of the dental hygiene department and what the dental hygiene team hopes to accomplish for the patients, the practice, and themselves. Purpose is what truly leads people. A clearly defined purpose established with guidelines gives the team (specifically the dental hygienist and doctor) the opportunity to discipline themselves, and to operate on principle not desire. To establish a purposeful vision for the hygiene department, one must consider developing and following these essential issues, ie, practice goals, outcomes of the patient’s periodontal treatment, American Association of Periodontology guidelines for the treatment of periodontal disease, maintenance of disease remission, when to refer to the periodontist, use of adjunctive therapies, and fully understanding oral-systemic relationships.

TEAM APPROACH TO CARE IS CRUCIAL

One of the main reasons for low production in a hygiene department is that there isn’t a team approach to the preventive/periodontal philosophy of the practice. Everyone must be on the same page. For the team approach to be meaningful, each team member have a clear understanding of their individual role as related to supporting and maintaining proper patient oral health. Unfortunately, it is not uncommon to find practice administrators and front desk staff members who do not fully know and understand what periodontal treatment/services are available to their patients through the practice. (This sometimes applies to clinical team members as well.) It is our belief that the patient is first and foremost to be served with optimum clinical quality. In serving the patient to the best of our abilities, we also serve the practice and the team at its highest level as well. In order for patients to increase their perceived value of management of periodontal disease by the practice, it is imperative that the entire team is always involved.
The entire team must be ready to deliver the necessary information to educate the patient on how to keep their teeth for a lifetime. To accomplish this they must understand the practice preventive philosophy and what proper dental health means. It is important to understand that we not only focus on what is “above the gums,” but also what is “below the gums.” With this concept in mind, we need to educate the patient concerning the importance of treating and maintaining good oral health.
Management of a successful hygiene department cannot be done haphazardly and requires leadership, education, and team dedication to the process. The returns on the investment of time and effort required will be a well-cared-for, educated, and motivated patient who “owns” their dental health. Our experience also indicates that the ultimate reward is found when your dental hygienist cannot imagine a career any more satisfying!

HIRING THE RIGHT HYGIENIST

Hiring a hygienist is one of the most feared aspects of staffing by most doctors. With the current dental hygiene compensation packages, making the right choices is imperative to sustain the growth of your practice. If the hiring process is carried out correctly, it will also positively affect your profit margin. For every practice, and each individual dentist, there is a somewhat different vision regarding the “ideal” hygienist.
The doctor must determine the particular personal and professional qualities that would work best and fit the culture and framework of his or her practice. Our experience dictates that one of the best ways to determine the traits of a potential new hire is to have them participate in a personality profile study (see Web sites at discprofile.com and therainmakergroupinc.com). There are numerous advantages to using the personality profile to hire the right candidate. You will improve hiring success up to 75%, better matching individuals to jobs in which they will excel. Most importantly, it will improve employee retention, improve communication, and definitely will help you in identifying each team member’s potential strengths and weaknesses.
It is vital that you select the right person to work within your hygiene system for the following reasons: the cost of hiring the wrong person, which could be extremely expensive; what is not known about a future employee could and will hurt you; and the cost of turnover for 1 team member can range from 3 to 4 times the employee’s annual compensation. Here is a list of the important qualities and personality traits, which we perceive would be desirable and essential for a professional dental hygienist. The best of the best traits are: warm, friendly, productive, committed, loyal, pays attention to detail, follows up instantly without having to be told, conscientious, follows protocols, trustworthy, knowledgeable, motivated, able to lead, and loving what they do.

DEVELOPING A PROFITABLE HYGIENE SYSTEM

It is imperative that you consider the following issues, and that you not focus only on the bottom line. Today’s dental consumer is interested in health and beautiful smiles more than ever before. With media attention on body and smile transformations, the marketplace in dentistry has never been better for treating patients within the hygiene department, enhancing and preserving smiles! If you develop and maintain a continued focus on optimum care, always standing up for what is best for your patients, it is our belief that you will profit. Current research compels us to diagnose and treat the early stages of periodontal disease very seriously with nonsurgical treatment. In spite of these realities, most dental hygiene departments operate with a “business as usual” approach, utilizing minimal or even antiquated technology while profitability levels remain stagnant or even decline. Let’s examine 3 components of a highly profitable hygiene department and see what makes them successfully different.

The successful dental hygiene system recognizes the need for consistently providing more comprehensive services such as: scaling and root planning (including the utilization of locally applied antimicrobials such as ARESTIN [OraPharma]); applying desensitizing agents (such as AcquaSeal Benz [Acquamed Technologies) or varnishes (such as Omni Vanish [3M ESPE]) especially to adult patients; updating full series and panoramic x-rays instead of just bite-wings (when indicated); helping to provide whitening treatments in office; and providing oral cancer screenings. These are just some examples of services that can easily raise production to $180 to $200 PPH or more, increasing the percentage of hygiene production to total practice production to around 35%. The end result can be healthier patients and a healthier business! The chart shows an example of what a comprehensive day might look like for a hygienist seeing 8 adult patients per day utilizing sample fee structures.

PREBLOCKING

Preblocking the hygiene schedule in advance for necessary nonsurgical procedures helps to ensure profitability. In the movie Field of Dreams, the premise “if you build it they will come,” proved to be true. Preparing or building your schedule for patients needing nonsurgical therapy gives hygienists the freedom to enroll patients into the early stages of periodontal disease right away once a diagnosis has been confirmed, rather than instructing the patient to simply “work on their flossing.” If hygienists know that the schedule is booked solid for several months, it is difficult for them to create urgency for the patient to return for scaling and root planning appointments. On the other hand, when a schedule is preblocked in advance, knowing a patient could begin treatment within a week or 2, increases the likelihood that optimal treatment options will be presented.
Depending on the practice, 1 to 3 appointments should be preblocked per day, per hygienist; specifically reserved for nonsurgical treatments given the high incidence of periodontal disease among our adult patients. Most software programs used in dental practices enable preblocking to be done through a template. If not, one can do so manually. Once reserved, the preblocked appointment should be held until 2 days prior. If it is not filled with a scaling and root planing appointment 2 days out, then administrators can begin to call patients identified on a “priority list” and offer the opening to anyone.

NO-SHOWS AND CANCELLATIONS

Profitability increases as deliberate steps are taken to reduce average open time from missed appointments to 5% or less. Missed appointments through no-shows and short-notice cancellations have the ability to completely eliminate profitability. Practices managing open time to maintain it around 5% of the hygiene schedule do so through team effort and with a plan. Benjamin Franklin said, “Drive thy business or it will drive thee.” In other words, control the schedule, or it will control you. One can calculate open time percentages by dividing the number of unfilled time units by the number of time units available, per day.
When a patient cancels an appointment with short notice for any other reason other than an emergency or illness, they should NOT be offered the next available opening simply to fill another hole in the schedule. Offer the patient who is canceling an appointment, an appointment in 6 weeks or more. Then, let them know that you will place them on a priority list and do everything you can to work them in at a time closer to their interval. You can always call them back later that day, or the next week to offer them an open appointment. Most patients, knowing the alternative is many weeks away, are inclined to accept the new appointment time and to keep it, realizing the alternative is another 6 weeks out.
Rather than confirming hygiene appointments the day before, which leave administrators scrambling to fill openings due to cancellations, calls or email confirmations should be made 1 week to 48 hours prior to the appointment. Patients should be given written appointment guidelines requesting 2-business days notice to change reserved appointments. Many patients call at 4:00 pm to cancel a 9:00 am appointment the next day, which means an administrator may or may not reach another patient to fill that appointment time.
Providing more comprehensive hygiene services, preblocking the schedule for nonsurgical treatment, and taking steps to reduce open time can take your hygiene department to higher levels of profitability. Capturing your patient’s desire to improve health and to enhance smiles by utilizing state-of-the-art technology to improve hygiene care can be a return on investment that you cannot afford to miss!

CONCLUSION

In summary, we have addressed the necessity of how to create the vision of a successful dental hygiene department, and that success is best realized when you have used a team approach. In order to have this happen, you must take the time to select the right person for the team. These issues are vital components to consider when developing and improving production and profitability for the hygiene system. It is a well-established fact that profitability in any hygiene department is directly proportional to the billable services provided. In addition, without proper scheduling, elimination of cancellations and no-shows, profits will drop. Next month in Part 2 of this article, we will discuss how to hire the right hygienist, clarify the expectations for both the hygienist and doctor, create a win-win hygiene compensation plan, and how to successfully introduce and integrate new technology into the hygiene system. All of these components will help you build a successful dental hygiene department.

Dr. Doherty is a certified financial planner, national lecturer, and CEO of Doctor’s Financial Network. For more information on his future upcoming Financial and Management Boot Camps for Dentists, or to received a free newsletter “Doherty’s Bottom Line,” please contact him at (772) 225-3021 or e-mail hughdohertydds@comcast.net.

Dr. Doherty did not report any disclosures.

Ms. Davis earned her bachelor of science in Dental Hygiene degree from Midwestern State University. She is the owner and founder of Cutting Edge Concepts, and she lectures internationally. She is also a senior consultant of The JP Institute. She can be reached at (972) 669-1555 or Karen@karendavis.net, or visit her Web site karendavis.net.

Ms. Davis did not report any disclosures.

Ms. Miller is a senior consultant and partner of The JP Consultants Institute, and is also a director and featured instructor of the JP Institutes’ postgraduate curriculum certification program in Carlsbad, California. She can be reached at (800) 846-4944 or visit the Web site jpconsutlants.com.

Disclosure: Ms. Miller is an employee of JP Institute and is paid per diem when she provides office training for dentists, workshops, seminars, etc. She lectures occasionally for OraPharma, and is currently providing Webinars for Philips Oral Health Care, receiving honorariums on a project basis from both companies.

The United States now has the largest and fastest-growing population of older adults in its history. According to the Centers for Disease Control (CDC)1, the number of older Americans, aged 65 or older, will double during the next 25 years due to 2 factors: longer life spans and aging baby boomers. By 2030, one in 5 Americans will fit within the older adult classification.1
In the geriatric population, chronic diseases often take precedence over dental problems. Research shows that older Am-ericans are at greater risk for oral health problems than any other population, due to lowered resistance to disease, existing medical conditions, difficulty in accessing dental services, and increased dependence on others for care.2

VARIATIONS IN SELF-SUSTAINABILITY

Illustration by Nathan Zak

The geriatric population is a diverse group that ranges in self-sustainability from independent living to complete reliance on others for assistance with activities of daily living. Older adults’ quality of life is determined by a combination of factors, in-cluding self-sustainability, medications, physical and mental health, financial limitations, and oral health. These factors play a vital role in assessing our patients’ needs during inoffice dental visits as well as in designing their at-home preventive care. Keep these contributing factors in mind when offering maintenance tips, suggesting at-home care products, and setting future appointments.

A LINK TO SYSTEMIC HEALTH

The exploding geriatric population, coupled with recent discoveries surrounding links between oral health and systemic health, make it increasingly important for the dental community to be prepared to treat geriatric patients in the dental office or where they live. Ongoing research suggests that periodontal bacteria entering the bloodstream may be linked to conditions such as respiratory disease, diabetes, heart disease, increased risk of stroke, and osteoporosis. Studies further suggest that periodontal bacteria can pose a threat to people whose health is already compromised by these conditions.3 In light of this growing body of research, comprehensive dental care becomes increasingly important to help improve our geriatric patients’ quality of life and outlook.

ENCOURAGING SENIOR VISITS AND PREVENTIVE CARE

A natural part of aging can be dramatically diminished pain perception, which can easily mask the need for professional dental care.4 Additionally, many individuals accept oral problems and tooth loss as inevitable results of aging, making dental visits unimportant to them.5 These patients may not understand that regular dental appointments become increasingly important as they age or that professional care can positively impact their quality of life and attitude. Given this, the entire dental team needs to encourage older patients to maintain daily oral hygiene as well as regular dental visits.
This can also hold true for elderly individuals with dentures who believe their prostheses to be a final “cure” for their tooth loss and see no need to return to the dentist for regular check-ups. While it is true that more elderly people are keeping their teeth than ever before, the number of people wearing full or partial dentures is on the rise as well. The Centers for Disease Control6 reports that in 1991, 33.6 million people needed one or 2 complete dentures and this number is predicted to reach 44 million by 2020.
With patients who wear complete or partial dentures it is just as important to stress proper care and maintenance procedures as it is to encourage follow-up appointments. One report showed that only 19% of denture wearers remember their dental professionals’ instructions regarding regular checkups.7 In particular, it is advisable to stress oral re-evaluations for denture patients when considering bisphosphonate therapy.8 By remembering to emphasize these details to your elderly patients and explain why it is important they follow your advice, you can help make check-ups routine and not just a painful emergency.

STRATEGIES FOR SUCCESS

Dental care for seniors has always posed unique challenges. It requires understanding and sensitivity to the medical, psychological, social, and financial status of elderly patients. When providing care to aging patients with physical and sensory limitations, the entire dental team needs to ensure that patients feel welcomed and comfortable. Start by reviewing office signage and lighting. Include in your reception room magazines that encompass geriatric oral health. Be sure that written information such as health history forms, business cards, brochures, appointment cards, and postcards are available in large-print.9 The National Institute on Aging offers an excellent and comprehensive guide called “Making Your Printed Health Materials Senior Friendly,” which can be downloaded by visiting nia.nih.
gov/HealthInformation/Publications/srfriendly.htm. Extra reminders of appointments may also be appreciated; take care to leave clear, understandable messages on answering devices.
Arrange furniture to accommodate wheelchairs and walkers, and to reduce or eliminate barriers. Be sure to offer supportive armchairs (that are not too deep or too low) in easy-to-access areas of the reception room.9 Similarly, it may be helpful to raise the upright dental chair from its lowest position when elderly patients are entering and exiting. For wheelchair transfers, always position the seat of the dental chair at the same height as the patient’s wheelchair. Pay particular attention to obstacles frequently faced by seniors and make every effort to understand and adapt to their special needs, even if it means scheduling extra time.

BEFORE THE EXAM

Dental providers will find more success when they communicate clearly, respectfully, and reassuringly with elderly patients. Speak slowly and directly to the patient.10 Do this understanding that it is worth the extra time it may take for them to respond. Longer appointments may need to be considered in order to accommodate the pace and special needs of geriatric patients.
Knowledge of the patient’s medical and dental history aids the practitioner in planning and providing safe, personalized, appropriate, and comfortable treatment. An accurate health history is more than a legal necessity. For medically compromised patients, it can mean the difference between life and death. As people age, their healthy therapeutic window narrows, and even slight alterations in the medical condition can cause significant changes. Awareness of systemic changes can also direct attention to subtle manifestations in the oral cavity. Reviewing histories at each appointment provides not only essential updates, but impresses upon the patient that what happens in the mouth affects the rest of the body, and vice versa.
Given the variations in self-sustainability of geriatric patients, it may be necessary to ask the caregiver or representative from the long-term care facility to bring or fax a list of current medications. Always inquire whether the individual has any swallowing difficulties (dysphagia or aphagia) that may require adjustments in patient positioning, water usage, suctioning, or rinsing in order to avoid aspiration problems during treatment. Swallowing and expectoration limitations also indicate special consideration when recommending therapeutic rinses and fluoride gels. Remineralizing agents (MI Paste [GC America]), which are safe to swallow and simple to apply, can be an appropriate alternative to daily fluoride use.

ENCOURAGING CAREGIVER INVOLVEMENT

Geriatric patients may have difficulty performing routine oral hygiene procedures due to physical limitations and/or memory problems, making the instruction and coordination of home care particularly important. Because of the possibility of actively declining skills, every dental hygiene visit should include an assessment of the patient’s manual dexterity. As reliance on others grows, include the caregiver in homecare instructions. Make specific suggestions as to how the caregiver can supplement the patient’s abilities and daily efforts. Demonstrate the use of power brushes and interdental aids and, most importantly, have the caregiver don gloves and participate. Dental professionals need to make sure patient and caregiver completely understand the oral care they will be practicing at home.
Emphasize that homecare combined with regularly scheduled preventive and restorative care are important components of the patient’s overall health and quality of life. The following guidelines may be shared with patient and caregiver:
First, brush teeth and gumline with toothbrush dipped in a mouthwash designed for Dry Mouth. Not using toothpaste facilitates better visibility for the caregiver, as well as the opportunity for the patient to explore with the tongue for lingering plaque. Fluoride toothpaste may be applied once all plaque is removed.
Second, apply lip balm and oral moisturizing gels during oral care and throughout the day as often as comfort demands.
Third, apply appropriate remineralizing agents daily to control xerostomia-induced caries.
Fourth, denture wearers need to be aware that some regular toothpaste contains abrasives that may dull and scratch dentures, promoting bacteria build-up. Dentures should be brushed daily with a denture-specific, non-abrasive cleanser, such as Fresh Cleanse antibacterical foaming cleanser (GlaxoSmithKline). These microclean tough stains and kill odor-causing bacteria. Also, acrylic surfaces naturally have microscopic pores that have been shown in studies to harbor bacteria. Soaking dentures in some commercial cleansers, such as Polident (GlaxoSmithKline), can kill 99% of bacteria, effectively disinfecting prostheses.11

ORAL CARE AND NURSING HOME PATIENTS

As the elderly population grows, so does the number of adults who move into nursing homes and require assistance with their activities of daily living. While providing adequate oral hygiene in community care facilities is an achievable goal, in reality most facilities overlook this duty.5
According to a study by the Academy of General Dentistry,2 nursing home residents have increased risk for dental problems compared to seniors who live independently. Approximately 5% of Americans over the age of 65 (currently about 1.75 million people) are residents of long-term care facilities where they may have problems accessing adequate dental care.12 The problem of neglect and high levels of unmet needs among elderly residents of nursing homes has been widely documented. A survey of 1,063 residents in 31 nursing homes found that the greatest single need among dentate elderly was for routine oral hygiene.13

Dental health often declines precipitously as elderly patients become unable to perform their own daily hygiene and arrange professional dental visits. Therefore, until onsite dental clinics and effective daily oral hygiene programs are established in long-term care facilities, dental professionals need to encourage caregivers to play an assertive role in meeting the dental needs of residents. (Table).

CONCLUSION

Geriatric healthcare is complex. The medical team’s goals include maximizing each person’s function, health, independence, and quality of life. Ideally, every geriatric team should include a dentist and/or dental hygienist to promote optimal quality of life through proper oral care.5 Poor dental health does not have to be an inevitable consequence for America’s aging population. By keeping abreast of the complex issues that impact geriatric dental care and offering treatment that takes into consideration the physical, mental, and social status of older adults, dental healthcare providers can enhance their older patients’ health, thus enabling them to enjoy healthier, longer lives with improved comfort, outlook, and quality of life.

References

Ms. Van Sant has been providing onsite dental hygiene services in long-term care facilities throughout South Carolina’s upstate region since 2002. She received her BS in Dental Hygiene from the Medical College of Georgia in 1975, and is a member of ADHA and the Special Care Dentistry Association. Her experience includes working as a public health dental hygienist, clinical periodontal therapist, and community oral health educator. She can be reached via e-mail at residental@charter.net or visit residental.net.

Great hygienists are always looking for ways to help their patients understand, believe, and accept their recommended treatment plans. They spend the time required to develop a strong, trusting relationship with their patients. By the end of a hygiene appointment, they have received or retrieved an enormous amount of information that can help the doctor quickly assess, diagnose, and recommend appropriate treatment at the examination.
There are at least 2 compelling reasons to improve the hygiene handoff to the doctor during or at the conclusion of hygiene appointments. First, if the verbal handoff is really good, you will see a greater percentage of patients accepting more recommended periodontal, restorative, and cosmetic treatment. Second, you are likely to be on time more often, which is good for patients, the practice, and, of course, you.

Photograph by Brian Green

THE VERBAL HANDOFF

To think differently about the hygiene handoff, we must understand a few core communication principles. First, while you are talking, the patient as the listener has 2 conversations going on inside his or her head simultaneously. Patients are listening to what you are saying, and they are listening to their own internal conversation, which is analyzing what you have just said. For example, they may be listening to your explanation of their probing measurements and why this confirms the need to proceed with a periodontal therapy program, while at the very same time they are listening to their internal concerns about cost, time, and whether it makes sense to them. And to complicate matters further, the entire time they are probably looking straight at you with interested looks and nodding heads, implying understanding and acceptance. Often, that could not be further from the truth!
Nothing can be done about this very human condition, but we can understand it and anticipate, if not mitigate, the consequences. If you believe that patients toggle between these 2 conversations in their minds, then you will also know that for as long as they are listening to one conversation, they have completely missed part of the other—hence your frustration when you know you have told patients something and they say that they never heard it. (You’re sure to recognize this phenomenon happening often with children and spouses as well).
What does this have to do with the information handoff to your doctor? It solidifies the need to relay your information verbally in front of the patient to the doctor as often as possible. Your patient cannot hear it too many times—the more the better if you are striving for clear communication and greater compliance.

THE CONSTRUCT OF A GREAT HANDOFF

The second principle required is that you cannot relay information in a handoff that you never received in the first place. So to construct a great handoff, you have to work backward and start with the end in mind. For example, if you and your doctor decide that you would like to report on 5 areas at the hygiene exam—ie, changes in health or medications, current periodontal condition and treatment recommendations, oral cancer screening results, restorative concerns (the patient’s and your own), and aesthetic concerns—then you will have to structure your appointment protocol to allow for the assessment of all 5 areas. For instance, you may decide that in the initial patient interview at the beginning of the appointment, you will review the medical history, ask about restorative concerns, and always ask about any cosmetic concerns as well. Then you will perform an oral cancer screening and an appropriate periodontal assessment. You may also commit to an intraoral camera tour of the mouth to assess any restorative concerns so that pictures of any suspicious areas can be ready for the doctor’s exam. At the conclusion of such an appointment protocol, you would have all the information necessary to conduct your predetermined verbal handoff upon the doctor’s entry into the room.
This handoff can be very brief, but still complete. I recommend allowing the doctor a couple of minutes to connect personally with the patient. The information handoff works best when the doctor commits to giving a verbal cue to the hygienist that he or she is ready to hear it. Otherwise, if the hygienist has done his or her job in ascertaining the data and the doctor bypasses the handoff by jumping in to ask the patient questions, 3 things are virtually guaranteed to happen: the hygienist will not continue to ask questions the doctor will only ask again; patients will not be overly impressed with your communication, teamwork, and trust; and patients will not get the chance to clearly hear the information for a second time confirmed by the verbal handoff.
A great doctor cue could sound something like this: “I’m glad you’ve had a great summer, Jane. Now, Sara, I know the two of you have spent the last hour gathering some great information. Bring me up to speed on Jane’s current situation.” It can be any words that communicate the doctor is finished building personal rapport and now would like to hear the handoff preceding the examination. This cue is a small, but very critical piece.
The clinical handoff would then continue, perhaps sounding something like this: “Dr. Smith, Jane is doing very well overall. Her health is good, with no changes to her medications or health status (Health). The health of her gum tissue and bone levels has improved in some areas and worsened in others. The 4-mm pockets on the anteriors are now measuring at 3 mm with no bleeding, which is good news. However, I’m concerned about the lower molar area, where there are some fours along with bleeding on probing. These areas have proven difficult for Jane to floss, so I have recommended some additional homecare tools and also that we see Jane in 4 months instead of 6 months to keep a closer eye on the progression of the disease in those areas (Perio). As far as her jaw joint, she is experiencing some clicking occasionally in her left joint as well as frequent head and neck aches. I also noticed some advanced wear on some of her teeth, and we discussed the possibility of a nightguard to protect her bite and relieve some of her symptoms. Of course, we wanted to check with you to see if you concurred with that course of treatment, and if you do, she is very interested (TMJ). Jane’s current restorations appear healthy to me (Restorative), however she doesn’t care for the look of the composite fillings on her upper 2 front teeth. They have darkened, and she is interested in changing those. We discussed several options, including veneers, and she’s very interested and wanted to discuss that further with you at this time (Cosmetics).”
The point here is that whether your findings are positive or negative, there is always a report. It should include a report to the dentist of the findings in all the areas that you have decided upon in advance so that he or she hears they were checked and discussed. Remember to include all areas, every time, positive or negative. When it becomes the routine, patients love the thoroughness of this handoff and always feel well cared for.

HANDLING AESTHETIC ISSUES IN A HANDOFF

One note about the cosmetic or aesthetic piece of this handoff format: I find in observation of hygienists, they often do an outstanding job of relaying health and perio issues to the doctor. Many also do a great job with regard to restorative findings. However, aesthetic issues are often only articulated when the patient has initiated the conversation. I have queried many hygienists about this and found it very enlightening that, by and large, they worry it will be perceived as pushy or too “hard-sell” to ask patients about cosmetic concerns at every visit. I agree that if the opening conversation with a patient is more focused on selling something than really listening to the patient’s concerns, experiences, and desires, then you will always be perceived as a salesperson instead of a health-care provider. What we are after here is a comprehensive check-in at the checkup to ascertain (initially from the patient’s perspective and later in the appointment from yours) where things stand in all 5 areas. You would never stop asking about changes in patients’ health just because the last 4 times you saw them they were healthy. The same should be true for all other areas of the hand-off, including cosmetics.
Here’s a great example: I have been seeing my hygienist for many years. We have developed a deep trust relationship and friendship. In the last few years, I had received orthodontic treatment using Invisalign (Align Technology) and had noticed some darkening of my teeth over the course of my treatment. I had every intention on my next hygiene visit to ask if I could use my last Invisalign tray (currently serving as my retainer) as a whitening tray to whiten my teeth. As always, when I arrived, my hygienist and I got caught up on the life events that had transpired since my last visit as well as with a review of my health and an inquiry about any problems I might be experiencing. As usual, it was a great visit: no cavities, no failing restorations, no perio.
After my appointment, as I pulled out of the parking lot, I realized that I never asked about the whitening. Oh well. I’ll ask next time…in 6 months! What if my hygienist, as part of her initial interview, had simply added the last question to her usual ones? “Have there been any changes in your health or medications since we saw you last? Experiencing any problems with your teeth? How about cosmetically? Are you still as satisfied with the look of your teeth as you were the last time that I saw you?” No doubt my memory would have been jogged and I would have left with either some whitening gel or with impressions for new whitening trays. I would not have left thinking she was pushy. As a matter of fact, it would have been quite the opposite. I would have thought that she was being incredibly thorough. The power of this question rests in your true intentions and ease in asking it. Patients will follow your lead.
Additionally, I’m not a big believer in strict communication scripts because I find hygienists, and all team members for that matter, do better and are more consistent in the long run when they are part of an effort to create a communication structure rather than a word-for-word script. This allows for each of us to be genuinely and authentically ourselves in our interactions with patients, while still challenging us to become high-level communicators. I think it is much better to create a checklist of the points you always want covered in your handoff and ultimately to commit that list to memory.

Conclusion

I would like to finish with a synopsis of my recommendations for improving your clinical handoffs:
It is important to sit down with your doctor and teammates and create a list of the areas you’d like reviewed at every exam. Then, be sure to work backward to create a hygiene protocol that ensures the gathering of that information in your initial interview and throughout the appointment. Until it becomes rote, create a cheat-sheet that you can reference with all the areas of your handoff. (If you’d like a free example of a hygiene handoff cheat-sheet, e-mail Info@KatherineEitel.com with “hygiene cheat-sheet” in the subject line). Decide with your doctor what words they would feel comfortable saying for the handoff cue. Finally, sit back and watch your stress levels go down and your treatment acceptance skyrocket!

Ms. Eitel is the creator of The Lioness Principle and founder of Lioness Learning, a revolutionary training company helping dental and discretionary healthcare professionals access and harness intuitive leadership, instinctive greatness, and phenomenal, nonscripted communication skills. The Lion Camp Leadership Experience at the Wild Animal Park in San Diego, Calif, is a premier team retreat for healthcare teams nationwide. For more information, call (800) 595-7060 or visit KatherineEitel.com. (For a free copy of statistical ranges successful hygiene departments strive for, e-mail info@katherineeitel.com with “hygiene stats” in the subject line.) Ms. Eitel is an international speaker, author, and communications and leadership coach in the dental and discretionary healthcare fields. She is president of the Academy of Dental Management Consultants (2007 to 2008), a member of the National Speaker’s Association, and a board member of the Speaking Consulting Network. She can be reached at info@katherineeitel.com.

In 2004, the American Cancer Society estimated that 1,368,030 new cases of cancer were diagnosed with 563,700 deaths.1 In 2007 new cancer diagnoses accounted for 1,444,920, with deaths totaling 559,650.2 What this means for you as a clinician, and for your practice, is an increase in the number of patients with a cancer diagnosis and more of your patients being treated for cancer. It is entirely possible that you, a family member, or a friend will come face-to-face with this disease with all its implications.
What does this mean for you, your staff, and your patients? Are you remembering to screen every patient for oral cancer at each appointment? Are you fully prepared to evaluate someone prior to chemotherapy or radiation treatment? Can you actively support a patient who is undergoing therapy for months at a time?

Illustration by Nathan Zak

CANCER IN DAILY LIFE

I am a cancer survivor. While many things in life create change in our routines, cancer seems to turn our world upside down. What was once the exception becomes the norm, and what was once routine becomes the exception. The dictionary defines routine as a regular course or procedure, a chore that we do regularly. In the world of dentistry, it means going to the dentist every 6 months from early childhood, brushing our teeth twice a day or maybe after every meal. Routines often start early in our lives, and we are not even consciously aware that we are following them. For young people today, flossing is taught from an early age. For those of us who are a bit more mature, flossing is hard to incorporate into our routine because we were not taught it was important until we were older.
What happens when something like cancer comes along that not only interrupts our routine, but also leaps into our lives, suddenly, through no control of our own, and demands a new routine? The result is mental chaos! Have you ever tried to listen to a different radio station on your way to work? Or has the roll of paper towels been reversed by someone who does not know the sheets are supposed to come off the top of the roll? It seems to upset our psyche.
One day several years ago, a day that many fear, I was diagnosed with a fairly aggressive form of breast cancer and put on an intensive chemotherapy regimen. I was sick, depressed, bald, and scared, and suddenly all my routines changed. Overnight, illness, once the exception, became the rule. Normal routines became the exception. My world was upside down, and my mind and my life were in chaos.

CANCER AND THE DENTAL CHECKUP

Before starting my chemotherapy regimen, I was instructed to go to my dentist—not at 6-month intervals, but at 1- or 2-month intervals. Now, I am not crazy about going to the dentist. As a matter of fact, it was a toss up for me as to which was worse: chemotherapy or a trip to the dentist. I grew up in the era when having a cavity filled was nearly comparable to tying one end of a string around your tooth and the other on a doorknob. As an adult, I learned that the dentist was usually painless, and that the dentist was my friend. I discovered that the dentist played nice music in the office, and the spit bowl had become a thing of the past. However, that did not stop me from flashing back emotionally to childhood and feeling the same dread. So, faced with having to go every 1 or 2 months to create a new dental routine, I thought the doctors had to be kidding!
Why did I need to do this? Mouth sores, a much increased chance of decay, and the need for a special mouthwash are just 3 of many good reasons why I was told to change my routine. It was hard to do. It should not have been: I wanted to take care of the cancer, I wanted to take care of my body, and I wanted to take care of my teeth. But when you feel your life is hanging by a thread, the old routines just feel comfortable. They are like an old pair of slippers. And yet I was told my routines had to change by someone who had no idea what this was doing to my peace of mind.

DENTISTS AND THEIR CANCER PATIENTS

This story has 2 sides: the patient’s side and the clinician’s side. The dental clinicians want their patients to move through this journey with little trouble, so they give more instructions than ever before. This happens at a time when the patient is already receiving hundreds of instructions from doctors, oncologists, and nutritionists. And yet, at the same time, prevention and management of oral complications of cancer and cancer therapy will improve oral function and quality of life.
While patients are warned about possible complications, they really have little or no idea just how extensive the complications can be. Mucositis (an acute oral mucosa reaction), lose of taste, lack of saliva, very thick saliva, an increase in caries, candidiasis, osteonecrosis, and soft-tissue necrosis are some of the most common complications.3
At the very least, most patients will develop mucositis. If it is acute, chemotherapy may have to be suspended for a week. The lack of desire to eat often results in weight loss and weakness. Patients who have not shown any degree of caries activity for years may develop dental decay and varying degrees of disintegration. This condition appears to be due to the lack of saliva as well as to changes in its chemical composition and viscosity due to the radiation therapy. Oral yeast infections of the mouth, by the ever-present Candida albicans fungus, are commonly seen in irradiated patients.
When a patient is on chemotherapy, the most appropriate time to schedule dental treatment is after the patient’s blood counts have recovered, usually just prior to the next scheduled chemotherapy treatments. If oral surgery is required, it should be scheduled to allow 7 to 10 days of healing before the patient’s next treatment.4
While dentists know that the complications of having and treating cancer can be very serious and can have implications for years to come, cancer patients only know that they want to live. As far as the patient is concerned, the primary risk is not dental; it is feeling lousy from the cancer treatment and surviving the cancer itself. The patient is not focused on the risk from possible side effects. The impact on the teeth and mouth are incidental and does not seem as relevant to the patient as it does to the dentist.
How does this balance with the need for the dentist to become an important part of the overall cancer treatment program? I think the most important thing is to try to keep it simple for the patient. Basically, the patient needs to understand he or she is facing risks, yet too much information will just cause emotional overload and possibly rebellion.

ORAL HYGIENE PROGRAM FOR THE CANCER PATIENT

An oral hygiene program must be individualized for each patient and modified throughout therapy according to the patient’s medical status. While it appears obvious that everyone knows how to brush their teeth, those on a cancer treatment program need to be taught very gentle, yet thorough brushing techniques. They should be cautioned about eating crunchy or sharp foods that may damage delicate oral tissues. Tooth-picks should not be used. They should be taught that alcohol-based mouthwashes and full-strength peroxide solutions (and gels) should not be used due to their drying and irritating effects.4 That’s about it. Remember to keep it simple!
The most important element for the patient is not physical, and it is not the dental treatment. The most important element for the patient is emotional. The dentist needs to be more like a parent taking care of a child: just go ahead and do it. The patient does not really need to know why everything is being done.
First and foremost, the dental clinician needs to recognize that he or she is only one in a long chain of command. During this time, patients are overwhelmed emotionally and physically. After a while, more instructions just roll off their back. It is best to give a written regimen for the few steps for dental care along with a simple explanation like, “We just need to make sure there are no unwanted side effects.”

CHEMOTHERAPY AND DENTAL CARE

I wanted to live. I wanted to beat my cancer. I wanted to keep my teeth and not develop mouth sores. So I tried to adapt. However, I was not sure my dentist understood that while this seems routine and textbook for him, it was just one of hundreds of things that turned upside down for me. It is not as if my life was the same day to day and the only interjection was additional trips to the dentist. Everything in my life changed simultaneously.
After each chemotherapy treatment, I could only crawl into my bed and wait for the anti-nausea medicine to kick-in. Many times, it did not work and I found myself sick several times a day. Food was simply not part of my life for 5 days after a treatment. Brushing my teeth twice a day? How could I, when the taste of anything caused instant nausea? For 5 days after treatment, I was in such a dazed state that I hardly knew day from night. Brushing my teeth? Sorry! It just wasn’t going to happen that day—but hopefully tomorrow—and I promised myself I would brush twice as hard. Did it matter? Did the dentist understand what he was asking of me? If I did not eat at all, would my teeth still decay? Probably, but I must admit it was hard to care at the moment. A nagging thought would then go through my head: if I don’t survive, will people come to my funeral and say, “My, too bad she ended up toothless.” My self-esteem could not bear the thought! So, I struggled to the bathroom and brushed. Perhaps I did not always do it perfectly, but at least the attempt was made. If on my next visit to the dentist, I was warned about not brushing well enough, so be it. I felt I had more important things to worry about.
My new routine became chemo one day, bed and oblivion for 4 days, new anti-nausea medicine for 5 days, operate at 50% the next week, then 75% the following week, and finally back for more chemo at week 4. The dentist had to fit in there somewhere. The only time I could eat and really care about my hygiene was week 3, so that is where the dentist had to fit in.
Usually at my “regular” dental checkup, which occurred every month instead of every 6 months, I would get scolded for not taking proper care of my teeth. I was either not flossing enough or I was not brushing properly. I knew they had to do it, and I knew that they were concerned about my overall health and me. And I cared, I really cared, but along with everything else that turned upside down, this new routine was hard to digest.
Did the dentist understand? As you read this, do you understand this world I was living in? I would like to think that you do. I believe that they did, and I am confident that they were concerned. I am confident my welfare was truly in their hearts. They were warm and friendly when I visited, and I believe it was genuine. I also know they knew things that I do not know. I want to compare it to an innocent child who has no idea that touching the hot stove will cause a burn. We as adults know what can happen, but the child has no idea. My dentist and physicians knew what could happen. I, as the innocent patient, did not know. So I was not worried. I let them worry for me. That was their job, not mine.
Fortunately I made it through my 6 months of chemo with little or no long-term dental effects. My life went back to normal once again. My routine went back to normal, and I now actually miss those regular dental visits. Six months between visits seems like a long time to those who have become my friends, to those who supported me through my ordeal. I no longer dread the visit to the dentist, and I look forward to seeing my caring dental professionals.

CONCLUSION

I did not really want to know all that could have gone wrong. I just needed to know that someone else was watching out for me, that someone was going to step in and prevent me from touching the hot stove, and that all I needed to do was show up on time and my dentist would do the rest. They cared. I know that they cared and that was enough. Hmmm, maybe turning my world upside down and upsetting my routine was not so bad after all.

References

Ms. Massie lives in Spokane, Wash, and is an award-winning speaker who draws from her years as an international business executive and her journey through 2 near-fatal illnesses. As a teenager, a rare, life-threatening illness left her paralyzed and confined to a wheelchair for more than 2 years; then she spent 5 years learning to walk again. At the height of her business career, she was diagnosed with an aggressive form of breast cancer, which left her with a renewed sense of living her soul purpose. She is the author of the book I’ll Be Here Tomorrow – Transforming Tragedy Into Triumph, and her mission is to bring peace and joy to the lives of patients, families, and caretakers who are affected by cancer or serious illness. She can be reached at Lynne@turningpointsuccess.com.