HOW TO PROFIT FROM...cosmetic dentistry —Merging aesthetics and hygiene

As aesthetic and adhesive dentistry expands and advances, the hygienist's role continues to change.

by Kristine Hodsdon, RDH, BS

As aesthetic and adhesive dentistry expands and advances, the hygienist's role continues to change. The dental hygienist is an integral player in the education, marketing, and continuing care of optimal esthetic and restorative treatments. But, before hygienists can be of complete value to clients, the dental hygiene profession needs to conduct a self-examination, challenging traditional hygiene paradigms. Comprehensive esthetic and restorative dentistry is the ideal evolution for hygiene's "top guns" to provide widespread services in progressive cosmetic, restorative, and periodontal practices.

Dental hygienists still have many misconceptions about the disciplines of cosmetic and esthetic dentistry. I often hear concerns from hygienists such as "I am not sure if I want to work in a cosmetically oriented environment," or "No one has explained esthetic procedures to me!"

How care is delivered within the envelope of cosmetic dentistry means many things to many practices. Doctors have different goals and visions for providing comprehensive restorative and aesthetic care, clinical excellence, five-star service, etc. Since dental hygiene is actually a "practice within a practice," it is vital that the hygienist and the doctor share not only values and goals, but a tangible understanding of how a vision translates into daily clinical practice.

This integrated vision is the blueprint for the practice that they wish to build. If the doctor is using one "set of plans" and the hygienist is using another, neither will have created what they want. Both will feel unappreciated and, possibly, even burned out.

Successful esthetic practices have broken down the traditional barriers — the restorative department is about only teeth and the hygiene department is about only soft tissue. Instead, these practices evolve into: It's about the whole person. It's about their wants and needs. It's about their emotional motivators and personalities. It's about how their oral health relates to their overall systemic and emotional well-being. It's about the teeth, the bone, the soft tissue, the muscles, and the joints. It's about their health, function, and beauty in relation to each other.

Each hygienist has to ask the following questions:

  • Do I shared a vision with the doctor and team?
  • What knowledge will I have to gain to support the shared vision?
  • What services am I currently providing that would merge with comprehensive restorative and esthetic care?
  • What services may need to be reconsidered in order to support the shared vision?
  • What is my ideal smile?
  • How do I feel about having optimal esthetic and restorative dentistry in my mouth?
  • What procedures am I unsure about and why?
  • What restorative and esthetic procedures can I support 100 percent and why?

Furthermore, hygienists should not close their minds and believe that cosmetic dentistry is of no use for specialists — periodontists' offices, for example. If your office is sharing clients for periodontal maintenance appointments with a periodontist's practice, we need to make sure that our clients have coordinated care plans with their interdisciplinary network of offices. This will guarantee that the preventive management protocols complement each other. The client receives the same home-care message from all locations, and no one is unintentionally damaging or neglecting the needs of the restorative work.

Hygiene's rules of smile order

One clinical change hygienists must undertake is the commitment to a comprehensive assessment of clients prior to diagnosis and treatment. A hygienist's prediagnostic system usually includes the standard steps, such as a complete and regularly updated medical/dental history, blood pressure, extraoral/intraoral exam, periodontal exam, charting of existing restorations and caries, oral hygiene status, and necessary radiographs. But more contemporary data may include the following:

Smile design. The hygienist establishes a basis for restorative and esthetic treatment planning, such as esthetic concerns and oral health goals.

Functional considerations. The hygienist gathers information and clinically notes signs and symptoms that could affect preventive and restorative care, such as occlusal discrepancies, muscles of mastication, and TMD joints.

Hygiene clinical delivery. The hygienist tracks the recare schedule, as well as the appropriate armamentarium and modalities.

Restorative possibilities. The hygienist communicates areas of concern, treatment options, and the benefits and risks

Home service products. The hygienist records information on home care habits, including the what, when, and how.

While implementing a consistent prediagnostic system for data collection, the hygienist also can determine and record clients' perceptions of their dental condition and needed treatment, as well as their appreciation and understanding of the dentistry. But I caution, the data is only valuable if the hygienist remembers that there is an appropriate order to successful case enrollment.

To illustrate my point, the following is a copy of an email discussion I recently had with a doctor. In this particular scenario, he feels that his hygienist has gone "out of order." He begins, "On several occasions, I have heard conversations conducted by our hygienist with 'nice patients with ugly teeth.' The hygienist is deep into her making a pitch for porcelain veneers. She is educating the patient with smile design photos, displaying her own veneered teeth, explaining golden proportion concepts, etc."

After listening to as much as I can stand, I am compelled to enter the hygiene room and cordially greet the patient, squelch the hygienist's monologue on veneers, and inquire about whether the patient expressed an interest in tooth whitening. To my chagrin, I find out that a discussion of tooth whitening has not even been broached yet, and the patient is reluctant to do even simple tooth whitening, let alone do a multiple veneer case."

There is no point in selling water to a fish. If patients want to chew better, they're probably not going to be excited if a hygienist begins educating them on the advantages of whitening. But if they are concerned about bad breath, and you document generalized 4 mm periodontal pockets, the hygienist can start talking about how these pockets harbor "stinky germs" that cause bad breath. Clinicians know these germs as volatile sulfur compounds that, if left untreated, can contribute to an inflammatory response and early periodontal breakdown. By beginning with information that focuses on the client's need, malodor, the motivation is ignited that leads to a discussion about the periodontal work that needs to be scheduled.

Hygienists possess an unwavering pledge to educate clients. They know dentistry has the technology and services that can have a tremendous impact on our clients' health and smiles. But let's not replace the traditional "judgmental, long-winded flossing speeches" with the same one-way dialogues about esthetics and restorative dentistry. During inquiries, the following list of skills and goals may help the hygienist "keep in order":

  • Establish trust and rapport with our clients.
  • What is the mood and self-esteem of the client?
  • What are clients' concerns and perceptions (if anything) about their teeth and oral health? What do they want or desire? Are they concerned about the color of their teeth? Are they crooked? Are they bleeding? Is there bad breath? What about time, money etc.?
  • Educate them about what they might not know about dental and dental hygiene options and treatments.
  • Talk about smile design.
  • Discuss the importance of restoring the dentition.
  • Assist clients in making decisions and maintaining their oral health.
  • Prescribe a plan in partnership with the dentist.
  • Present the treatment plan.
  • Initiate the arrangements, such as financial considerations or a series of necessary appointments.

Hygiene clinical delivery
Proper post-care management can assist in preserving the "dazzle of the smile," as well as prolong the longevity of the treatment. An analysis of newer treatments, however, may suggest that how hygienists customarily practice in relation to the new techniques and materials can be harmful.

Before selecting appropriate hygiene instrumentation and home service products, clinicians must first clarify:

  • The nature and extension of the aesthetic treatments
  • Oral health status
  • The client's commitment to self-care routines and/or varying oral behaviors.

Examples of hygiene technologies and armamentarium may include: magnification devices, cosmetic polishing agents, cups, brushes, strips, discs, debriding instruments, neutral sodium fluoride agents/fluoride varnishes, laser technology, chairside workstation, interior video camera, digital still camera, digital imaging, and/or hi-tech educational support material.

The post-treatment evaluation by the hygienist may reveal, for example, stain accumulation. When establishing a protocol for polishing, the hygienist should avoid aggressive polishing with conventional prophy paste. It has been demonstrated that polishing resin materials with prophy paste may cause the surfaces to roughen, scratch, and/or dull.

Coarse prophy paste also may cause premature plucking of glass or silica filler particles from the resin matrix of composites, leaving a porous surface. This may cause excessive wear, staining, or breakdown of the restoration. The composite then becomes susceptible to increased accumulation of plaque and endotoxins that can (depending on the location of the margins) irritate the tissue. The restoration's integrity may be jeopardized and the surrounding soft tissue may be compromised due to the possible increase of bacterial endotoxins. This is accompanied by a heightened difficulty in cleaning (roughened margin).

If the restorations exhibit accumulation or are stain free, selectively polish with a material-specific polishing system or a low-abrasive, over-the-counter toothpaste.

In the area of debridement, ultrasonic scalers, sonic scalers, and air abrasive units also have the ability to damage the surface or margin of adhesive materials. They are contraindicated for direct use. As an adjunct to metal (hand) instruments, a hygienist may consider the newer plastic instruments.

Generally, neutral sodium fluoride agents are recommended for use with esthetic materials. These agents include both professional and self-application options, including brush-on gels, home rinses, etc. The use of acidulated phosphate and stannous fluoride should be considered carefully. Stannous fluoride has demonstrated discoloration capabilities, and acidulated phosphatefluoride may affect the filler particles in composite resin materials. Remember to evaluate clients for a sodium-fluoride tray application at each esthetic hygiene care session.

There are dentists and dental hygienists who are the catalysts for change. If we acknowledge that awareness and self-education enable us to expand professionally and personally, then esthetic and restorative dentistry is a gateway to redefining the traditional hygiene system and providing comprehensive care.

When discussing optimal esthetic and restorative dentistry, first understand, as clinicians, the reasons for comprehensive care. Take the time to make sure your practice is not giving off mixed messages. By asking our clients questions and actively listening, we can begin to discover the services they seek.

When consistently collecting data from many apparently disparate areas, we can also begin to see what they are interested in and then we can develop more harmonious conversations surrounding our clients' goals.

Assisting clients in maintaining their new dentistry may mean a re-evaluation of our clinical systems, instruments, materials, and hygiene techniques. Ultimate practice success involves a combined effort of the oral health team and the client. This integration can be used on a continuum for building solutions.

Author's note: The author would like to acknowledge Jeffery Dornbush, DDS, of Marblehead, Mass., for providing insights and challenging thoughts. References available upon request.


Home Service Education
Hygiene sessions scheduled before the restorative phase, during the provisional stage, and post-operatively should stress the client's self-care regimens and home care products.

  • The client must be proficient in maintaining healthy gingival tissue. Emphasis is placed on the importance of daily plaque elimination, as well as a commitment to oral health management schedules.
  • Improper brushing techniques (such as scrubbing, excessive speed or pressure, and use of an inappropriate toothbrush) may damage or wear down tooth-colored restorations and irritate gingival margins. Recent clinical studies show that powered toothbrushes demonstrate significant improvement in efficacy over manual tooth brushing, as well as avoiding increased gingival abrasion. With this background in mind, it is suitable to recommend a powered toothbrush.
  • Powered toothbrushes can conveniently eliminate any challenges encountered with improper brushing techniques and/or dexterity, while ultimately ensuring health through effective plaque and stain removal.
  • In light of inconclusive, published data about which toothpastes can abrade the surface of esthetic restorations and if the data merits any clinical relevance, a low-abrasive tooth polish should be recommended for self-care.
  • Instructions to clients should include a demonstration of interproximal plaque/bacteria removal.
  • Some published studies address the effect of alcohol on tooth-colored restorations, concluding that alcohol may affect the longevity of a restoration by softening the composite matrix. This can result in a possibility for increased staining and early breakdown. Patients are encouraged to dilute alcohol-containing rinses or switch to alcohol-free alternatives.
  • Conversations should support daily tongue deplaquing, using sugar-free, fresh-breath related products, as well as tobacco cessation. How these steps can affect the total body and health of the periodontium can also be discussed.
  • Bruxism, fingernail biting, chewing on pens, etc., can damage or dislodge restorations as well as natural teeth. An evaluation for a nightguard may be appropriate.

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