High-Tech Hygiene: Technologies Making a Difference in Oral Care

Ann Eshenaur Spolarich, RDH, PhD

August 2016 Issue - Expires August 31st, 2019

Inside Dentistry

Abstract

Technology has greatly influenced all phases of the dental hygiene process of care. Chairside diagnostic tools and self-monitoring devices improve early detection of lesions and previously undetected oral/systemic diseases, facilitate assessment of systemic health status, and support patient engagement in self-care. Collectively, improved patient assessment reduces risks for medical emergencies and promotes patient safety. Technological advances enable better visualization of hard and soft tissues during the assessment phase, aid decision-making with planning and delivery of appropriate oral care interventions, and facilitate evaluation of patient outcomes related to dental hygiene treatment. Additional research is needed to support the benefits of patient-centered technologies designed to affect behavioral change.

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Today’s dental hygienists use a variety of technology to assist with patient assessment and monitoring and the early detection of oral diseases. Caries detection devices and oral cancer screening tools are among the most commonly used. Chairside testing available using salivary diagnostic technologies for risk assessment include oral pH testing, rapid HIV testing, and both genetic and microbial testing for periodontal risk assessment. Hygienists are also strong adopters of automated and/or voice-activated software programs to document current periodontal pocket status and to monitor response to dental hygiene treatment.

This article will examine several burgeoning areas of technology that are being utilized in the dental hygiene process of care.

Halimeters

Once only found in the laboratory setting, halimeters are now available for use chairside to assist with assessment of halitosis. They are also favored by clinicians who practice esthetic dental hygiene. Halimeter testing allows clinicians to assess the level of halitosis and response to use of recommended products and treatment interventions targeted to address this frequent patient complaint.1

Patient Self-Monitoring

Major advances in the development of technologies have taken place that yield patient-generated data. Two popular examples include home glucose testing, using glucometers and A1C kits for patients with diabetes, and a new home testing kit to assess the international normalized ratio (INR) for patients taking warfarin. Patients conduct their own testing using automated devices to read blood samples obtained through a minor finger stick test, and relay their numeric digital test value that appears on the device via an online computerized medical monitoring service or by phoning in their results to a telehealth program. Patients benefit by receiving immediate results that can be shared with their healthcare providers, including their dental professionals. Studies support that patients who engage in self-monitoring are more likely to stay within range, which promotes compliance, reduces risks for adverse events, and improves health outcomes.2-5

Many patients are used to self-monitoring, including taking their own blood-pressure readings on a regular basis, and this behavior can be reinforced and mimicked in the dental office.6,7 Having automated blood-pressure devices in the dental office can encourage more dental professionals to engage in this same behavior by increasing the frequency of monitoring patient blood-pressure readings. This is a critical recommendation, given that recent studies suggest that only one in three patients taking antihypertensive medications are actually under control.8

Decision Support Systems

Clinical decision support systems are evidence-based clinical information systems to support decision-making at the point of care. These systems match information from individual patients with published research findings that apply to a given clinical situation. The systems provide streamlined recommendations for clinicians to use to manage patients with complex medical problems, the content of which is derived and continually updated as new evidence becomes available.

Helping support best practices, use of these databases is easy and likely preferred by busy clinicians who lack the time to keep up with reading and analyzing clinical trials and pre-appraised evidence, such as systematic reviews. The intent is that if scientific evidence is more accessible, the information to the clinician will be more useful. The more useful the information is, the more likely it will be incorporated into clinician practice behaviors.9

The best decision support systems available in dentistry are the pharmacology databases, which enable clinicians to check for drug compatibility, minimize adverse events, and avoid potential drug interactions to improve patient safety and medication management. Many of these software programs also are available via apps for smartphones and other portable electronic devices for convenient use.

Fluorescence

Technology in the laboratory has made it easier for clinicians to validate purported mechanisms of action of commercial products to support their decision-making with product recommendations for patients. Fluorescence has been used to demonstrate the ability of antimicrobial mouthrinses to penetrate biofilm and to illustrate germ kill using staining techniques for imaging using scanning electron microscopy (SEM).10 Quantitative light-induced fluorescence has been used to demonstrate the uptake of 1.5% arginine and sodium monofluorophosphate into demineralized enamel in vivo to support the anticaries efficacy of a dentifrice delivery vehicle.11

Fluorescence also is used at chairside to assist with assessment and diagnosis. Several marketed oral cancer screening devices use fluorescence or chemiluminescence for lesion visualization with the intent that use enhances early detection of both premalignant and malignant lesions. Recent systematic reviews found that, to date, there is inadequate evidence to support the use of chemiluminescence and autofluorescent imaging devices as valid and effective screening devices, given challenges with sensitivity and specificity of the measures, and risk for false-positive test results.12,13 One pilot study from the dental hygiene literature found that tactile examination and visualization using a fluorescence-based device were comparable for lesion detection in 30 patients who were either addicted to cigarettes or presented with a dual addiction.14

Collectively, studies published to date suggest that fluorescence device use should be considered as an adjunctive technology and not as a sole agent for screening purposes. Similar conclusions were reported from two dental hygiene studies, but interestingly, authors from these studies reported that use of fluorescence-based oral cancer screening devices supports patient education activities and may drive patient acceptance of the need for screening.14,15 Finally, various fluorescence-based technology tools are available to assist with caries detection and to check the integrity of margins around sealants and existing restorations.16-20

Visualization

Technological advances with instrumentation are intended to support practice by increasing access and visibility for the clinician, aiding better deposit removal and improved patient response to periodontal treatment. For example, a dental endoscope is designed to aid clinicians with visualization of root surfaces within periodontal pockets using fiber optics for illumination. One study used a split-mouth design to compare clinical outcome measures in 26 subjects who underwent two quadrants of scaling and root planing using hand and ultrasonic instrumentation in periodontal pockets with and without use of the endoscope. At 6 to 8 weeks and at 3 months post-treatment, there was less bleeding upon probing and decreased gingival index scores in quadrants treated using the endoscope. However, at 3 months, there was no difference in either probing depths or clinical attachment levels between quadrants treated with or without the endoscope, suggesting that endoscope-supported scaling and root planing was not superior to traditional scaling and root planing.21

The same study population was used to examine differences in calculus detection using an 11/12 ODU explorer alone or in conjunction with the endoscope. Use of the endoscope produced statistically significant differences in calculus detection at baseline, 6 to 8 weeks, and at 3 months (P < .005). Endoscopic use also enabled more precise calculus detection post-scaling and root planing (P < .025), suggesting that use of this technology may be most helpful during the re-evaluation phase of periodontal therapy.22

Biofilm Removal

Advances in technology have dramatically influenced recommendations for products that help patients improve their oral health by enhancing mechanical biofilm removal. These devices offer greater ease of use coupled with efficacy of the device itself. Power toothbrushes are highly efficacious in disrupting the biofilm, have greater bristle-to-tooth contact, and garner excellent patient acceptance. A systematic review confirmed that power brushes are more effective at removing supragingival plaque when compared to manual brushing.23 Power flossers, with or without water, have demonstrated safety to both oral hard and soft tissues, produce significant reductions in interproximal plaque and bleeding, and have been shown to be as effective as manual flossing.24-28

More than 40 clinical trials support the benefits of oral irrigation, which produces significant reductions in gingival bleeding.29 Oral irrigation has been shown to reduce gingivitis in patients who present with unique oral hygiene challenges, including those with interproximal restorations, crown-and-bridge work, orthodontics, and implants. Oral irrigation may produce a local host modulatory effect, as evidenced by decreased IL-1ß, a pro-inflammatory mediator, and increased IL-10, an anti-inflammatory mediator, in gingival crevicular fluid samples.30 Use of oral irrigation in patients with diabetes produced a reduction in serum inflammatory markers as well, promoting the value of its use in this at-risk population.31 Further, it is now understood that oral irrigation may disrupt up to 99% of adherent biofilm following just 3 seconds of exposure, changing the long-held belief that only planktonic bacteria were impacted by this intervention.32

Drug Delivery

Innovations in vehicles for drug delivery have influenced how oral medications are used during dental hygiene treatment. Microsphere technology with minocycline and resorbable chlorhexidine chips are used for local delivery of antimicrobial agents as adjuncts to periodontal therapy.33-36 Additionally, resorbable lozenges, discs, patches, and strips are available to manage dry mouth symptoms, protect oral lesions, and reduce halitosis.

Needle-free anesthesia enables dental hygienists to comfortably deliver treatment for patients who are needle-phobic, have high injection anxiety with related risk for syncope, and for those with complex medical histories. Intra-pocket delivery of a periodontal gel containing a eutectic mixture of lidocaine 2.5% with prilocaine 2.5% has been shown to be efficacious for pain control during scaling and root planing.37,38 However, treatment of deeper pockets is associated with increased procedural pain levels, often requiring local anesthesia. One split-mouth study compared pain perception and clinical outcomes with scaling and root planing for treatment of deep pockets among 38 subjects who were given local anesthesia on one side of the mouth and intra-pocket anesthesia on the other side. There were no differences in probing depth changes or clinical attachment levels post-treatment for either intervention, and as expected, more pain was reported with use of intra-pocket anesthesia. Interestingly, patients preferred use of intra-pocket anesthesia despite greater procedural pain perception.39

With its rapid onset and low risk for systemic toxicity, needle-free anesthesia is a viable intervention for multiple dental hygiene procedures to improve patient comfort.

Mobile Health Technologies

Finally, mobile health technologies, also known as “mHealth” interventions, have been designed with the premise that patients who are actively engaged in their own health management are more likely to take ownership of their health and will demonstrate improved self-care. These technologies include electronic appointment reminders; smartphone apps that remind patients to brush and floss; smartphone apps that sync with power toothbrushes or embedded technologies within power brushes that monitor brushing duration and technique; and interactive programs to engage patients to brush for a pre-prescribed length of time.

It is important to note that brushing more frequently and/or for a longer time does not correlate to efficacious biofilm removal. To date, there is a lack of evidence that supports the adoption of these new technologies. It is unknown how using them influences short-term and long-term changes in patient behavior and related clinical outcomes. Additional research is warranted.

Conclusions

Existing and emerging technologies have the potential to significantly impact dental hygiene practice across all phases of the process of care. Various devices have been shown to improve assessment of patient systemic and oral health status, support decision-making with product selection and treatment planning, and aid in evaluation of clinical interventions and response to treatment. Use of patient-centered educational technologies requires further investigation to determine the long-range impact on patient acceptance and adoption of recommendations and related clinical outcomes. Research is needed to document how technology can be used to support health promotion and behavioral change to improve oral health and overall wellness.

Publisher’s Note

This article reflects the content of a presentation given at the 2015 American Academy of Periodontology Spring Meeting in Chicago. Originally published in Compendium: 2016;37(7) [ePub ahead of print]. 

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Disclosure

The author had no disclosures to report

About the Author

Ann Eshenaur Spolarich, RDH, PhD
Professor and Director of Research,
Arizona School of Dentistry and Oral Health
A.T. Still University
Mesa, Arizona

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SOURCE: Inside Dentistry | August 2016

Learning Objectives:

  • Describe various new technologies dental hygienists can use to assist with patient assessment and monitoring
  • Explain how patient self- monitoring and decision support systems can improve dental patient care
  • Discuss new developments in fluorescence, visualization, biofilm removal, and drug delivery technologies