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Inflammation: A Hygiene Perspective by Emilee Berger, RDH, BSDH

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We should all be well aware of the interrelationships between oral health, inflammation and systemic health. Inflammation is the body's response to cellular injury. The inflammatory response is actually designed to rid the body of the initial cause of inflammation. In our case, the biofilm's bacteria accumulation in the oral cavity causes the inflammation. Even in healthy individuals, the inflammatory response is not enough to rid the oral cavity of biofilm.

The bacteria in biofilm must be mechanically removed through proper oral hygiene on a regular basis. When the biofilm is left alone and accumulates, the body responds and the inflammatory process begins. Chronic inflammation anywhere in the body can be detrimental to an individual's health on multiple levels.

Every time I see a patient, whether it be for a new-patient exam or re-care appointment, I make sure to include a thorough evaluation of inflammation, including clinical signs and risk factors. Throughout my career, I have used various treatment modalities when trying to combat inflammation and have found that usually a combination approach works best—as long as there is an emphasis on patient education.

A thorough examination must include an assessment of risk factors and patient education. Patient education can't be limited to instruction on oral hygiene. We are health-care professionals and must include all aspects of the patient's health in order to individualize our education and recommendations. For example, if I have a diabetic patient with generalized inflammation exhibiting 3-4mm pockets with bleeding, I would apply a more aggressive approach than on a healthy 18-year-old patient exhibiting no known health complications. For both patients, I'm going to recommend a bacterial debridement, including air polishing, ultrasonic and hand scaling.

Yes, air polishing as in the prophy jet
Current research shows that air polishing may be more therapeutic than traditional rubber-cup polishing. It does take some getting used to, but once accomplished, I have found that it becomes a patient's preference.

I will also include a thorough explanation of periodontal diseases with individual oral-hygiene instructions. For the diabetic patient, I would emphasize the links between high blood sugar and inflammation. It is also important to provide nutritional counseling with recommendations for low-glycemic food choices. The use of a chemotherapeutic mouth rinse and the re-care interval following the debridement will always be based on the patient's anticipated tissue response. Additionally, for periodontal patients who are having difficulty getting inflammation under control, I may consider prescribing Periostat (20mg doxycycline) two times a day for three to nine months.

In the past I have worked with doctors who have recommended the use of a diode laser in addition to traditional means of bacterial debridement. Having taught a laser-certification course, I know that research does not show that the use of a laser in combination with ultrasonic and hand scaling will decrease inflammation better than using ultrasonic and hand scaling alone. That being said, I would be lying if I said I didn't see consistent results with overall less inflammation.

However, I'm not talking about a very significant difference and I didn't actually perform a controlled study. This is strictly an observation based on going from one practice that used laser treatment to one that did not.

I always include a thorough examination with risk assessment and patient education. It's hard to say exactly how much difference I saw in patients who received laser-assisted bacterial debridement versus those who did not. I will say with confidence that a majority of the patients who had laser assistance appeared to have a slight increase in the amount of decreased pocket depths and bleeding points at the first reevaluation appointment (usually eight to 12 weeks).

My theory for this isn't that the laser is better at reducing the bacterial load. Instead, I think it falls more on the patient's behavior following the laser-assisted bacterial debridement. I think that when using laser along with patient education, the patient perceives that the gingival inflammation is more serious because I "had to use the laser." This factor motivates him or her to be more diligent with personal oral hygiene in the weeks that follow that initial appointment.

My experiences with using a laser for bacterial debridement with the goals to decrease inflammation have solidified the importance of thorough patient education for all patients. Many of us need to get back to the basics and put more of an emphasis on educating our patients. As a dental hygienist, I always feel my heart break a little bit when a middle-aged patient thanks me for taking the time to educate him or her and says that no one else ever took that time.

To put it simply: The more we teach, the more they will know. The more they know, the more they will do. The more they do, the less inflammation we will see. The less inflammation we see, the healthier they are.



Emilee Berger is a registered dental hygienist with more than nine years of experience. Her experience includes clinical practice, sales and education. She works in private practice in Peoria, Arizona.


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