- An accurate assessment of the periodontal status of the patient must include accurate parallel x-rays that are either vertical bitewings or x-rays that clearly show the crestal bone. You must be able to produce earlier x-rays so bony crests can be compared.
- A thorough assessment of the effectiveness of plaque control. Never assume your patients are doing it correctly. Hand them a brush, WaterPik tip, floss or whatever technique is being evaluated and watch them use it. Just learn from what they are doing which will indicate how to reinstruct them.
- Accurate measurement of pocket depth compared with previous readings.
- Observation of bleeding upon probing.
- Observations regarding inflammation; ease of probability as well as color and sponginess of the tissue.
Patient must fully understand that in susceptible patients, plaque forms within 12 hours. The objective of oral hygiene is to remove all of the plaque every 12 hours.
Reviewing the patient's efforts in plaque removal if not currently effective. The patient should demonstrate to the clinician what they are doing so it can be observed before it is reinstructed. Once the patient demonstrates their technique, the clinician will redemonstrate an appropriate technique and rationale for the procedures recommended whether it be toothbrushing or water irrigation if those are the chosen modalities.
Once those teeth demonstrating active inflammatory changes and/or increases in pocket depth are identified, aggressive scaling and root planing is performed on those individual teeth. This represents the sine qua non of periodontal maintenance.
The scaling of these teeth should be done first prior to any other form of prophylaxis on teeth that do not have active pathology. Patients should be informed they you are going to focus on particular teeth that show changes so the patient will understand why you are spending so much time on so few teeth. However, if there are multiple teeth that require intervention, a second visit or re-evaluation may be necessary.
When the teeth in question have been effectively scaled which may take in some patients most of the visit, the remaining teeth can be prophied or debrided.
The 100-stroke-solution is something I have observed in treating patients who have had recurrent periodontitis and where previous maintenance has not been effective. I want to identify these teeth as generally having flat surfaces and
lower molars. Flat surfaces can also include the palatal aspects of bicuspids and molars; often areas that are missed. Furcation involvements are often difficult to practice the solution on since access to these areas is challenging.
The 100-stroke-solution is based upon the principle that it is generally difficult if not impossible to perceive all the calculus that remains on a root. Using a perioscope, we observe in patients that we've treated over a long period of time but have recurrence, that there is still calculus remaining. The 100-stroke-solution per surface gives the clinician a greater possibility of removing any calculus which is not perceived. By repeating and overlapping the strokes, there is a much lower possibility that calculus has been left.
The use of a sharp curette is absolutely necessary and often sharpening is necessary during the procedure.
If there is pathology, there is calculus on the root and most of the time you will not feel it therefore you will overinstrument the root to ensure that you have removed debris.
In addition to this regimen in some patients this procedure is followed by 100 strokes of the Cavitron over the same area just to make sure that small spicules of calculus do not remain.
During clinical observations in my practice over the years, this approach has been frequently accompanied by a clinically significant improvement and reduction in periodontitis.
It takes discipline to change what we do in our approach to treating periodontal patients. The time spent with polishing, ultrasonics which often dominate a visit, must be minimized so teeth that have active periodontal disease are the primary focus.
One must always consider outcome-based treatment.
You must educate your patients regarding what you are trying to accomplish. They will be appreciative of the fact that you preventing any further loss of bone which is essentially the goal of periodontal maintenance.
As always, I appreciate your feedback.
Victor M. Sternberg, D.M.D.
Dental Office of:
Victor M. Sternberg, D.M.D., PC
Westchester Center of Periodontal and Implant Excellence
141 North State Road
Briarcliff Manor, NY 10510