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Individual Periodontitis Aftercare: A User Report

Tigon+ user report by Eva Lädrach
First published in Quintessenz Team-Journal 49 (2019) No. 9

Introduction

Despite improvements in oral health and better awareness of the importance of good oral hygiene, ten per cent of the global population – around 743 million people – still suffers from severe periodontitis [1]. Even after 30 years, periodontitis and caries are two diseases that I still encounter on a daily basis at work. Older people in particular often suffer from periodontitis [2]. If caught in good time, the world’s sixth most common disease [1] can be treated successfully.

Regular dental hygiene aimed at stabilising the periodontal situation is particularly important in patients with periodontal disease. However, as such patients often present with deep periodontal pockets, exposed tooth necks and BOP (bleeding on probing), and the teeth are particularly sensitive, professional teeth cleaning often proves very painful. Special instruments such as the Tigon+ allow efficient treatment which is also gentle and comparatively agreeable at the same time. This is reflected positively in recall attendance, which helps maintain the stability of the periodontal situation and allows retention of the natural dentition for as long as possible.

My role as a dental hygienist in the Periodontology Clinic at the University of Berne, Switzerland, predominantly involves treatment of patients with periodontal disease. The patients are either referred to us from a general practice following diagnosis of a periodontal condition or come to us of their own accord after noticing increased tooth mobility, gingival bleeding, pain or inflammation. Following initial treatment by the dentist, the patients then attend recall appointments with me and are monitored and treated by me and the entire dental team over the course of many years. Monitoring them for the rest of their lives and providing appropriate aftercare means I am faced with new challenges every day.

Case Study

The following case report concerns a male patient born in 1967 with chronic, already very advanced periodontitis with furcation involvement. The initial diagnostic findings revealed periodontal pockets measuring 6-8 mm across the dentition. The patient visited us in the clinic for the first time in 2011. Prior to treatment in our clinic, he had not seen a dentist for ten years. The patient reported smoking around half a pack of cigarettes a day. At the start of the treatment, a number of teeth were extracted that were not worth preserving. A hygiene phase was conducted for the first time in 2012. Following subsequent re-evaluation, flap surgery (modified Widman flap) was performed in all four quadrants. As a result of the active periodontal therapy, massive, 3-4 mm deep recessions with exposed tooth necks appeared throughout and the patient displayed very sensitive reactions. In addition, root caries was diagnosed at a number of points. The patient has now been attending recall appointments with me regularly since 2014.

Gentle removal of plaque and biofilm makes it possible to maintain the periodontal situation unchanged

Periodontal therapy comprises a number of different steps. Following the patient examination and evaluation of the indicated findings, the patient is briefed and the decision taken about the treatment and treatment goals. The patient’s motivation to perform oral hygiene measures at home is decisive. If the findings require it, the patient’s dentist is also involved. The patient’s wishes are also decisive for the type of treatment, but the primary goal is always preservation of the dentition and masticatory function.

Following the diagnosis, briefing and discussion, hard and soft deposits are removed carefully and gently. This is done by means of supragingival and, if necessary, subgingival scaling in the active, deep pockets using electronic and hand instruments. The combination of electronic and hand instruments allows optimal and complete biofilm and plaque management. The treatment is concluded with final polishing with a polishing compound for removal of the biofilm and any persistent stains. In my opinion, this is both a decisive and intrinsic part of the treatment and an agreeable treatment step for the patient. The pleasant feeling in the mouth motivates most patients to keep up the oral hygiene measures at home following their recall appointment, to maintain the stability of the periodontal situation and to prevent the appearance of carious lesions.

As patients with periodontal disease often present with exposed tooth necks, it is essential to remove hard and soft deposits as gently as possible. My patients can expect professional treatment that is both painless and also complete and in no way superficial. High-quality devices and instruments help to satisfy these requirements.

In this case, the Tigon+ allows extensive and atraumatic removal of the biofilm and flushing of the pockets while still being relatively comfortable for the patient. Prior to 2016, the treatment in the recall appointment involved deep scaling using electronic and hand instruments (Gracey curettes), which was painful for the patient. In addition, hand instruments cannot reach the bottom of the pockets. As such, the treatment in the recall appointments was always a great challenge for the patient and treatment provider alike. This patient was treated with the Tigon+ for the first time in August 2016 and reported considerably less pain during treatment. Cleaning and flushing the pockets, which is atraumatic for the hard and soft tissues but still effective with the water heated to around body temperature and the frequency of the Tigon+, which is perceived as pleasant, represent a considerable added value for the patient. The gentle and more relaxed treatment has a positive effect on the BOP and the active pockets are reduced.

International literature confirms BOP as a clinical indicator for the progression and stability of periodontal disease [3]. It has been shown that an increase in the number of BOP points is linked to recession of the periodontium and an elevated risk of a periodontal collapse [4, 5, 6], whereas an absence of BOP is an indicator of periodontal stability [7, 8]. The pocket depth, which is directly related to the bleeding on probing [4], is connected to the periodontal stability.

The periodontal chart in Figure 1 shows the periodontal improvement since treatment with the Tigon+ was initiated.

Figure 1: The BOP ratio has decreased considerably since August 2016. Whereas 18% of all measurements displayed bleeding on probing at the start of the treatment on 22.08.2016, the figure is just 5% almost two years later. Photo: © Zahnmedizinische Kliniken Bern / Klinik für Parodontologie
Figure 2: The example of a 52-year-old female patient shows how the narrow, straight tip 1P, which is universally suitable for the instrumentation of natural teeth, can be used to gently remove biofilm and gently rinse pockets.

More comfortable treatment contributes to better recall compliance

The excellent accessibility thanks to the long, slender 1P tip and possibility of adjusting the power setting makes it possible to clean the biofilm out of the deep pockets and flush them carefully (see fig. 2, tip 1P on natural teeth of a 52-year-old female patient). A control algorithm for the Tigon+ tip’s oscillating system specific to W&H allows the frequency to be adjusted to reflect the external conditions. The frequency of the oscillations is adjusted continuously depending on the pressure, water supply and other factors, which allows much finer determination of the frequency. The patient says that the frequency adaptation and the heated water are particularly agreeable and gentle.

In addition, the Tigon+ also permits treatment without anaesthesia, as the pain is bearable for the patient and there is no need to use hand instruments.

The sensitivity of the tooth necks has decreased over the course of the treatments and the root caries has been brought under control through the regular use of a toothpaste containing 5,000 ppm of fluoride. The caries prophylactic effect of the application of toothpastes and varnishes containing fluoride has been confirmed by numerous studies [9, 10, 11]. The patient uses a sonic toothbrush and interdental brushes at home.

The clear communication with the patient means that he is now thoroughly aware of the critical periodontal situation. The less painful treatment with Tigon+ also motivates the patient to attend regular recall appointments. Regular recall appointments at short intervals mean almost no hard deposits are able to form and consequently only soft deposits need to be removed. Thanks to the Tigon+ and to the patient’s delight, it has proven possible to maintain the periodontal situation at the same level and preserve adequate masticatory function. The Tigon+ is also suitable for the long-term treatment of patients with advanced periodontitis.

Even though we are aware of the periodontically delicate situation, it is still possible to postpone the loss of the patient’s teeth and thus hopefully satisfy his wishes to retain his own dentition for the years to come. That is a very satisfactory and particularly pleasing result for me too.


Eva Lädrach
Eva Lädrach

Eva Lädrach began her training as a dental hygienist at the School of Dental Hygiene in Berne, Switzerland, in 1984, the first year the new qualification was offered. She has enjoyed her profession as a dental hygienist ever since, and has worked in various private practices over the years. In the course of her professional career, Eva Lädrach has trained prophylaxis assistants and dental hygienists as an adult educator and has been an active voice for the interests of dental hygienists in the professional association. Her ultimate goal always has been and remains the well-being of the patients. She has been working as a dental hygienist at the Periodontology Clinic headed by Prof. Anton Sculean at the School of Dental Medicine in Berne for nine years.

References

  1. http://www.efp.org/publications/projects/perioandcaries/recommendations/Guideline03_Researchers.pdf
  2. https://www.bzaek.de/fileadmin/PDFs/dms/Zusammenfassung_DMS_V.pdf
  3. Joss A, Adler R, Lang NP. Bleeding on probing. A parameter for monitoring periodontal conditions ibn clinical practice. J Clin Periodontol 1994:21(6):402-8.
  4. Lang NP, Joss A, Orsanic T, Gusberti FA, Siegrist BE. Bleeding on probing fort he progression of periodontal disease. J Clin Periodontol 1986:13(6):590-6.
  5. Haffajee AD, Socransky SS, Lindh J, Kent RL, Okamoto H, Yoneyama T. Clinical risk indicators for periodontal attachment loss. J Clin Periodontol 1991:18(2):117-25.
  6. Gonzalez S, Cohen CL, Galván M, Alonaizan FA, Rich SK, Slots J. Gingival bleeding on probing: relationship to change in periodontal pocket depth and effect of sodium hypochlorite oral rinse. J Periodontal Res 2015:50(3):397-402.
  7. Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on probing. An indicator of periodontal stability. J Clin Periodontol 1900:17(19):714-21.
  8. Swedish Council on Health Technology Assessment. Chronic Periodontitis – Prevention, Diagnosis and Treatment: A Systematic Review [Internet]. Stockholm: Swedish Council on Health Technology Assessment (SBU) 2004. SBU Yellow Report No.169. SBU Systematic Review Summaries.
  9. Rugg-Gunn A, Bánóczy J. Fluoride toothpastes and fluoride mouthrinses for home use. Acta Med Acad 2013; 42(2):168-78.
  10. Clark DC: A review on fluoride varnishes: an alternative topical fluoride treatment. Community Dent Oral Epidemiol 10;1982;117–23.
  11. De Bruyn H, Arends J. Fluoride varnishes-a review. J Biol Bucc 15;1987; 71–82.