Demand for registered dental hygienists is likely to continue to grow, especially with an aging population that requires more involved dental care.
Periodontitis is largely preventable, but access to affordable periodontal care—especially for older adults—is woefully lacking. A 2012 study published in the Journal of Dental Research found that 47.2% of adults 30 years and older have some form of periodontal disease.1 The Centers for Disease Control and Prevention reports that periodontal disease increases with age, and 70.1% of adults 65 years and older have it.2 About one-third of adults forego dental care.3 Among elderly patients, 29.2% have dental insurance and 65.5% had a dental visit in the past 12 months.2
Nonsurgical treatment of periodontitis by a dental hygienist is time consuming if done well, and periodontal care is viewed as a “profit center” in many general practices.4 Hygienists on social media often cite inadequate time and instruments for periodontal and other procedures. Because such complaints are not seen on dentists’ blogs, it appears that hygienists are sometimes stuck with inferior equipment and insufficient time simply because they are employees who do not make these decisions. It also may indicate that some dental practices may not value clinical excellence and good outcomes the way they should.
Subgingival Biofilm and Calculus Removal
Sottosanti and Cobb, both periodontists, emphasize the complete removal of subgingival calculus to resolve inflammation but state that in recent decades clinicians and educators have diminished its significance in favor of a “’biocompatible root surface’ as a necessary requirement to eradicate the periodontal disease process.”5 They compare calculus to a porous, spongelike material, mineralized and dry, that allows periodontal pathogens to live within its framework. Further, Sottosanti and Cobb say multiple studies show a relationship between calculus and inflammation of the adjacent soft tissue wall of the periodontal pocket. The pathogens living in biofilm that also live within the calculus may over time release toxins into the periodontal pocket, causing the disease to progress.5
For dental hygienists to remove as much subgingival calculus as possible, they need time and effective instrumentation. In addition, hygienists need patient cooperation and a working knowledge of root anatomy, including furcations. There are 3 main ways calculus attaches to a root surface.
The goal of scaling and root planing is to remove subgingival calculus and biofilm, but it is a very demanding procedure for even the most accomplished clinicians.6 The cementoenamel junction (CEJ) is a common site for residual calculus.6 Following subgingival instrumentation, microbial colonization begins almost immediately, and posttreatment bacterial counts can return to pretreatment levels within a week.6 Intervals necessary for the site to return to pretreatment levels of subgingival microflora depend on disease severity, thoroughness of debridement, and supportive care including meticulous self-care and appropriate intervals of repeated removal of subgingival biofilms during periodontal maintenance.6
In a 2021 CE by Rethman, et al, the authors summarize studies comparing manual to ultrasonic instrumentation with or without surgical flaps.6 Combined use of sharp curettes and ultrasonics appears more effective than either method alone and experienced clinicians do better in removing subgingival calculus.6 Residual calculus is usually found in furcations, CEJ, interproximal root flutings, in deeper pockets, and in multirooted teeth.6 Air powder polishing using glycine or erythritol powders combined with manual and ultrasonic instrumentation seems to provide better outcomes.6 Periodontal endoscopes, when used by a skilled clinician, provide visualization of the root surface while scaling, reducing the need for traditional periodontal surgeries.7
Demand for health care professionals like registered dental hygienists (RDHs) will grow, according to the US Bureau of Labor Statistics.7 This is mainly due to an aging population that will have greater need for health care services. During the pandemic and postpandemic have seen a lot of health care services move into patients' homes. In addition to the pandemic, an aging population and renewed focus on preventive care may shift nonsurgical periodontal therapy and maintenance by RDHs into on-site primary care facilities connected to senior housing. As individuals age, chronic health care problems multiply and it is common for seniors to have anywhere from 4 to 8 such issues.7 As more senior living facilities offer primary care, consumers are demanding that senior housing deliver and manage that care, including dental services.8
Economic conditions during COVID-19 have affected the delivery of dental hygiene services. During the first wave of the pandemic, dental practices were forced to close. When they reopened, stringent infection control measures increased overhead costs and patients were reluctant to return. As patients return and as practices get busier, patients are still avoiding regular preventive recare. After a year of disrupted dental care and treatment there may be less demand for dental care, especially with inflation rearing its head. With inflation and COVID-19 come higher cost of doing business and lower profitability.9
Most RDHs in privately owned dental practice settings or dental service organizations are employees working under general or direct supervision. They are not business partners but licensed providers hired to perform a service to patients as nurses do. Running a successful dental practice means providing a high standard of care and investing in a top-notch dental hygiene department. Present and future dental hygiene departments will require meeting patients’ expectations that support their well-being. The future outlook and successful delivery of nonsurgical periodontal therapy is a critical component of care and clinical excellence will drive revenue goals. Here are some positive ways to achieve a healthy future outlook.
The future of nonsurgical periodontal therapy remains challenging, given the overall percentage of adults who cannot afford private dental care. Comprehensive periodontal treatment regimens are ideal but unattainable for many, especially older adults with limited incomes and little to no dental care under Medicare. Dental benefits for low-income Medicare recipients would help, especially as thousands of Baby Boomers are losing company-sponsored dental benefits. Oral health improvements occur when there is better access to dental care and when financial barriers are removed. Maybe someday, dental care, including periodontal care, will become essential in US policy.