My Favorite Things

Toothpicks..Stimudents, slim Stimudents(new product for small interproximals)  and Soft Picks by Butler
Manual toothbrushes...Jordan V soft(used to be Viadent TB), Lactona S-19 extra soft(great gumline brush), Colgate Slim Soft....great gumline brush!!!
End Tuft Brush...great for hard to get places esp. posterior lingual interproximals
Titan Sonic Cleaner(Blissonic)...so much better than a Cavitron.
Compressed air...I do all my gross scaling with the Titan..can't live without it!
Digital x-rays...very helpful with oral hygiene instruction
Floss...for decay prevention
Instrument...Gracey 17-18 curette great design

The Monkey on Your Back/Why you Want Out of Hygiene

 You were accepted to dental hygiene school because you had good grades, good work ethic and excelled in most things you tried...right!  I believe my experience is typical of most hygiene students. Spring quarter of my senior year I finished my prophy and got the clinic instructor to check my patient and I would be done. She checked my patient and told me I had missed some calculus on the mesial of 14.  I could not feel the calculus I missed so just scaled the whole mesial surface and had her check again.  The calculus was still there!  Again, I tried to find the calculus with my explorer...couldn't find it...scaled the mesial surface again....got my instructor again....yes it was gone!  I graduated that spring knowing I should do a perfect prophy every time...I had never done a perfect prophy....I didn't know how to find all the calculus...I now had one hour to do a prophy not the three hours I had in school....the dentist doing the exam was the instructor.  I believe many young hygienists  leave the profession within a couple years for this reason.  I had been practicing 10 years when I got a part-time job as a clinic instructor at a dental hygiene school. I was finding missed calculus when I did the exams....WHEN HAD I LEARNED TO FIND CALCULUS!  The last ten years when I was checking if I missed anything, I had learned to find calculus.  That's the year the monkey came off my back and I have since found profound pleasure in my work.  Every prophy you do is better then the one before.. every day you get better and better!  I'm 66 years old now and will work in my beloved and fascinating profession til I 'stick the fork in the wall'.

My First Epiphany

  Refer back to my blog 7/26 about oral hygiene education.  A middle aged woman came to me gum infection so bad that her gums were purple.  She was worried and the dentist in New York City had told her she had a Vit C deficiency.  I told I thought it was gum infection  and if she would brush her teeth in the rolling stroke and use floss her gums would get better.  There was improvement but not enough.  I was very discouraged and remember thinking that oral hygiene instruction was probably a waste of my time and I would just clean teeth.  BUT I had been taught that oral hygiene instruction was 50% of my job.  I talked to my sister who was in dental hygiene school at the time and she mentioned the new way to brush called the Bass Technique..... soft brush....45 degree angle to gumline. I also started asking new patients with healthy gums what they did for their oral hygiene....I still do this today.  I kept hearing toothpicks almost 100% of the time.  The New York lady came back for her 3 mo recall . and I had her start using Stimudents  and a Lactona S-19 along the gumline.......her gums became perfect.  I love oral hygiene instruction today.  We live in an anti-tooth
picking culture...floss is the socially acceptable  way to deal with interproximal  oral hygiene.  Shortly after I learned about toothpicks from my patients. I had an opportunity to talk to Don Rolfs DDS periodontist and researcher.  I asked him what he thought of Stimudents...he said "I don't know if I want to blow up the company or buy it...I get my patients to start using the Stimudents and within 6 months they can reduce 4,5,or 6 mm pockets back to 3 mm....anything deeper I have to do surgery"
  I have been a strong advocate of toothpicking since.  I could take a 1000 new patients and walk around the interproximal gingival sulcus and guess right 100% of the time.
-if generalized bleeding....they use nothing between their teeth
-if sporadic bleeding...some interproximals  bleed some don't...they are flossers                                       -if there is no bleeding...they are toothpickers

I like toothpicks that are flexible and conform to the shape of the interproximal space...Stimudents(J&J), Soft Picks(Butler). I wish J&J would made a toothpick out of Balsa wood so it would always be soft and flexible...Stimudents are made out of pine and there are hard and soft toothpicks in each package.  I tell my patients to throw the hard one away or use them for kindling.

Teamwork vs the Prima Donna

  I never ask an assistant to do something for me that I can do myself!  Being a dental assistant for 12 years before I became a dental hygienist taught me....the hardest working people in a dental office is the multi-tasked dental assistant. If I have a cancellation or extra time I try to help the assistant out..because there will be a time I have to ask them for help and I want a lot of karma in my bank!  Dental hygienists who are considered and disliked as PRIMA DONNAS fail to understand this concept.

Oral hygiene circa 1967 U of W Dental Hygiene

  Brush your gums with the rolling stroke using a medium hard toothbrush. I told my father, who flossed every day he should floss less often.....a couple times a week but no more!

  They did stress that oral hygiene instruction was an important part of our job.

A Little History

 Arlo Baker RDH U of W I believe was the first dental hygienists in north Central Washington. In 1957 she talked my father and his partner in Chelan to hire her.  They agreed to half a day each once a week.  That was the same year I started being a dental assistant in the summer for the next twelve years until I graduated from college.  I loved watching Arlo work....I believe she was trying to discourage me because she would call me in to see the worst cases.  It didn't discourage me..to this day, the worse the case the better I like it.  Twelve years later I started working for my father in Chelan and two dentists in Seattle....I was busy.   My husband was in dental school, we lived Seattle.  Every two months I would come to Chelan and work two straight weeks.

First Time I See the Patient

  On the first appointment I have to decide how I will continue treatment.  The questions I answer are:
1. How much calculus?
2.How old is the calculus?
3.Where is the gum infection..buccal, lingual, interproximal?
4. How fearful is the patient?
5.How much do they have to learn with their oral hygiene?

  They will be put into one of three categories.
1. Less than 12 mos since last cleaning acceptable oral hygiene...adult prophy, oral hygiene 101
2.More than a year since last cleaning but not too long and poor oral hygiene..... two appointments two weeks apart.... gross debridement, oral hygiene 101...two weeks later adult prophy, review oral hygiene 101.
3.Lots of old calculus,poor oral hygiene, fearful, worse than the first two categories...
  *First appt...gross debridement with Titan sonic cleaner of all teeth(getting outer layer of softer calculus off..refer to "Calculus and it's characteristics"), oral hygiene 101, give proper tools to do the job ie tooth brush, tooth picks, approximate perio readings for insurance etc.
  *Second appt two weeks later...gross debridement with Titan of all teeth(getting outer layer of softened calculus off), review oral hygiene, paying attention to technique, do they have any questions, be sure to compliment on any progress they have made.
  *Third appt two weeks later....finish gross debridement with Titan and hopefully start root planing, review oral hygiene problems and compliment patient on progress.
  *Forth appt.... start or finish root planing, perio reading again because first ones approximated, review and compliment on oral hygiene progress.

The advantage  of this process is: You don't get carpal tunnel from trying to get old tenacious calculus off on the first visit...You don't have to anesthetize the patient because you go as far as they can tolerate and stop....the next visit they will be more healed and will be able to continue farther and calculus has softened....They have homework to do and they aren't so sore that they can't practice what you are preaching......They will come back in 4 or 6 mos for recall because you treated them with respect and didn't hurt them....The appt. can be shorter because it doesn't take two hours to gross debride.....The patient describes  the procedure like scratching an itch.

I put two weeks between the appointments because if they are missing places with their oral hygiene technique it will start to show up....sooner the healing will be a result of what you did. The other  reason...I want enough time for the newly exposed calculus to soften.

I write in charts SRP UL, SRP LL, SRP UR, SRP LR...I have accomplished the same thing.  The insurance company wants me to go from A to Z in each quadrant in four appointments. I go from A to H in the first appt G  to M in the second appt N to S in the next appt and T to Z in the last appt.  The end result with both is the same.  Except it was easier on you and the patient.

Sonic Cleaner to remove Calculus

  I mentioned below that the older calculus is the harder and more tenacious. I use a Titan sonic cleaner, it's very good at removing old calculus.  The Cavitron is only effective on young...6 mo. old calculus.

Calculus and it's characteristics

 Calculus builds up in layers  and hardens with age.  Old calculus is very tenacious.  The amount of calculus the depends on oral hygiene habits ie how well is the plaque removed daily and the pH of the saliva.  Calcium enters the mouth via the saliva, it is in solution....when it enters the atmosphere of the mouth it will stay in solution if the patients saliva is acidic and the more basic the saliva the more the calcium will crystallize.  The calcium crystals need the plaque matrix or rough tooth surface to attach.  Patients pH fluctuates between basic and acidic.  They have no control of this fluctuation.  I have cleaned the same patients teeth for 17 years every six mouths...every couple years there is change...more calculus less calculus.  Since I believe oral hygiene stays the same or gets better...the time they are forming more calculus is their" basic stage" and I tell them to be patient it will pass in a couple years. Calculus formation tells you where the patient habitually misses....like posterior interproximal, gumline mandibular anterior, distal posterior 2nd molars etc.
  VERY IMPORTANT TIDBIT OF INFORMATION: When you remove the newer layer of calculus...leaving older calculus exposed....it softens.  Two weeks later what you couldn't remove  two weeks prior will now come off.  This affects how I do my SRPs.

Turning the Light on in the Room- Oral Hygiene 101

  I use analogies  to teach anatomy and physiology of the mouth.
  Anatomy...your gums fit your teeth like turtleneck collars..picture every tooth sitting there with a turtleneck on! When we measure your gums we are measuring the depth of the turtleneck collar.  The teeth touch each other like wine glasses with a small contact point.
  Physiology...our mouth is like a forest it has plants(yeast and fungus) and animals(bacteria).  Gum disease is caused by one type of bacteria that lives in our mouth.  We need to disable the bad bacteria without harming the beneficial bacteria.  The bad bacteria are anaerobic...you and I are aerobic...we need oxygen to function...the bad bacteria need the absence of oxygen to function.  So they find a hiding place where hopefully you won't disturb them(inside the turtleneck collar, between the teeth and the back of the tongue).  It takes about 24 hours to create an oxygen free bubble around themselves..they start converting sugar to acid.  The acid dissolves  our teeth causing decay and eats away at our gums causing gum infection, loss of gum attachment  and bone loss.
  So when the hygienist points out bleeding gums....she is pointing out where the  bad bacteria are not being disturbed.

Formula for Perfect Oral Hygiene

  I have perfect oral hygiene because 1. I'm motivated and 2. I'm educated(I know the anatomy and physiology of the mouth).   Every patient that sits in your chair is motivated or they wouldn't have made the appointment.  If they aren't educated that is the hygienists fault, that is our responsibility.  Oral hygiene is like cleaning a dark mysterious room.....we hand the patient some tools(floss, toothbrushes), send them into the dark room and when they are done we flip the light on and tell them what they missed with a tsk tsk try harder next time!  The hygienist needs to turn the light on in the room.  If the patient knows anatomy and physiology of the mouth and they are motivated they will have perfect oral hygiene.

How to Treat the Patients

  After I graduated and before I started my first job my first employer my father  Fred Pomeroy DDS had a heart to heart talk with me.  He told me it was very important not to hurt the patient physically or mentally.  I was to look at the big picture.  If I was gentle in the cleaning process they would not fear coming back in six months.  If  I didn't belittle or send them on a guilt trip about their oral hygiene  they would happy to come back.  What I had to remember that every patient I see is motivated or they would not have made the appointment.

My Credentials

  I graduated from the University of Washington with a Bachelor of Science degree in Dental Hygiene class of '67.   I have worked full time in private practice the last forty five years. In 1977 I was a part time clinic instructor for the hygiene program at Clark County Community College in Las Vegas, Nevada.