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In 1347, 12 galleys docked at a Sicilian port after a long journey through the Black Sea. In medieval times, ships routinely left port and traveled to faraway lands to trade not just goods, but theologies, philosophies, technologies and culture.
Family members waiting for their loved ones at the port in Messina were met with a devastating reality … half the men on board were dead and those who were alive were dying. Delirious and weak, covered with black boils that oozed pus and blood, the surviving crew had fever, chills, vomiting, diarrhea and terrible aches and pains. Authorities ordered the “Death Ships” out of the harbor, quickly recognizing the malady as the Great Pestilence which was decimating populations along the trade routes of the Near and Far East. In Europe, it became known as the Black Death and would kill more than one half of Europe’s population (an estimated 25 million people).
At the time, many believed that the Black Death was a kind of divine punishment, retribution from God who was angered by the hedonistic practices of His children. Eventually modern science identified the culprit as a bacillus called Yersinia pestis, a particularly virulent little bug (one nasty side effect is the development of gangrene in the extremities, which is where the term “Black Death” originated) whose spread was hastened by the vile, unsanitary conditions of medieval Europe where rats (and the fleas infesting them) lived in close proximity to humans. People did not wash regularly, drank filthy water, and buried the dead in mass graves. Once hygiene improved, incidence of the Plague decreased and eventually subsided.
Hygiene: the conditions or practices conducive to maintaining health and preventing disease, especially through cleanliness. It is the province of dental hygienists; the foundation of our profession and the theology of a visionary, Dr. Fones, who understood that mouth cleanliness would ensure not just oral health, but general systemic health. His idea to create a new oral healthcare provider who would focus on disseminating information and practices which would remove the disease-causing bacteria and their byproducts, was met with equal parts harsh criticism and ridicule by turn of the century dentists. One hundred years later, oral health professionals across the world are well aware of the pathogenesis of oral disease (i.e., periodontal disease and dental caries).
In May 2015, the Journal of Clinical Periodontology published a consensus report titled, “Principles in prevention of periodontal diseases: Consensus report of group 1 of the 11th European Workshop on Periodontology on effective prevention of periodontal and peri-implant diseases.” It outlines the most current and effective practices in the prevention of periodontal disease. Prevention can be primary and it “refers to preventing the inflammatory process from destroying the periodontal attachment” and “consists of treating gingivitis through the disruption/removal of the bacterial biofilm” and secondary which is “preventing recurrence of gingival inflammation.” In examining all the literature (in fact, the consensus report is a systematic review), the authors’ first recommendation:
Repeated and individually tailored OHI
is the key element in achieving gingival health
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This information is not new but merely a repetition of what has been taught in every single dental hygiene program across the country.
Why, then, do dental hygienists use their time, skill, talent and energies on the utilization of technology/gadgetry as opposed to the teaching of basic oral hygiene techniques and dietary instruction?
Most recently, a dental hygienist authored an article regarding her frustration at the burnished calculus dental hygienists are leaving behind. After all, “thorough removal of calculus is the cornerstone to excellent periodontal therapy.” In order to reach this No-calculus Nirvana, any good dental hygienist must invest in a perioscope and be quick about it as “our ‘dirty little secret’ has ever more serious consequences than we may fully understand or even think about. We are taught to perform blind root planing, which is an impossible task with no definitive end point.”
Removing the calculus, she contends, would ensure that “biofilms [have] nowhere to flourish and multiply.”
In fact, there is a definitive endpoint. Referred to as the therapeutic endpoint, it is “the restoration of gingival health, a reduction in pocket depth, and a gain in or maintenance of a stable clinical attachment level.”
Evaluation of the therapeutic endpoint is done at the four-to-six-week interval after nonsurgical periodontal therapy (i.e. scaling/root planing). Additionally, biofilms begin to form minutes after even the most thorough periodontal debridement and their maturation is wholly dependent on the patient’s ability to maintain cleanliness via plaque removal techniques.
I am aware of the value of perioscopy and do not admonish its users. I am unaware, however, of any good data which advocates its use in the prevention of periodontal disease and the inflammatory process. At best, we can say that removing calculus inhibits the production of biofilm but even that statement can be refuted. If a healthy client brushes his calculus diligently thereby preventing the maturation of biofilm, then no inflammatory response would ensue. No inflammatory response equals no periodontal disease.
Eradicating periodontal disease would require a return of focus to the most basic of all oral health practices: effective, regular removal of plaque biofilm by an individual. Proponents of modern technology may choose to promote lasers, perioscopy, scaling instruments created from metals which resist dulling, digital radiography, prophy jets, ultrasonic scaling devices and any other “gadget,” but none of these, nor the expertise of the clinician, can substitute for the effectiveness of the daily removal of plaque biofilm.
It’s not “jazzy” or exciting and it doesn’t pay much, but using the plethora of good, scientific research which supports disease prevention via proper nutrition and hygiene, dental hygienists can promote vis medicatrix naturae (the body’s natural ability to heal itself) and improve overall health outcomes, not just reduce the incidence of burnished calculus.
In the end, what we are really interested in is helping our patients maintain health. Good oral hygiene is just as important now as it was in medieval times.
About the author
Sasha de la Playa is a registered dental hygienist who works in private practices across New York City. Having graduated from hygiene school in 1995, she considers herself a veteran of the profession and has grown weary of the misinformation and partial truths being shared regarding the practice of dental hygiene. She fully supports the work of the National Center for Dental Hygiene Research & Practice, which seeks to encourage the "translation of research evidence so that it is meaningful and useful in dental hygiene education and practice." Guided by the ADHA Code of Ethics, inspired to speak by the current lack of leadership, supported by decades of experience and armed with a keen intellect, she hopes to bring light and a fresh voice to the world of dental journalism.