Abstract
Purpose Non-surgical periodontal therapy (NSPT) is considered to be fundamental in the treatment of periodontal disease. Advanced area specific instruments were designed to increase the clinician’s ability to effectively access root furcation areas during NSPT. The purpose of this study was to explore clinical dental hygienists’ familiarity, utilization, and perceived efficacy of advanced instruments in root furcation areas during NSPT.
Methods A randomized sample (n=3,500) of licensed dental hygienists in Michigan was invited to participate in a paper-based, mail survey. The 10-item instrument consisted of demographic, multiple choice, Likert scale, and open-ended questions. Descriptive and inferential statistics were used to analyze the data.
Results A total of 1,156 surveys were returned; 858 met the inclusion criteria for a response rate of 24.5%. Respondents who graduated between 2010–2020 than those who graduated between 1990-1999 were more likely to utilize advanced instruments and those who graduated in 1989 or earlier (16.0% and 19.9% respectively). Respondents familiar with advanced instruments were more likely to use them in furcation areas during NSPT than those less familiar with the instruments (95% CI [18.1, 29.6], p<0.001). Respondents who perceived advanced instruments to be effective in furcation areas were more likely to utilize them (95% CI [1.0, 8.0], p<0.05) during NSPT. Most respondents indicated that they became familiar with advanced instruments during their dental hygiene education or through continuing education courses.
Conclusion Familiarity with advanced instruments and perceived efficacy of these instruments for accessing root furcations increased the likelihood of clinical dental hygienists utilizing them during NSPT. Dental hygiene education and continuing education programs should continue to provide opportunities for students and practicing clinicians to learn NSPT instrumentation techniques utilizing advanced instruments designed for furcation access.
- non-surgical periodontal therapy
- advanced periodontal disease
- periodontal instrumentation
- advanced area specific instruments
- dental hygiene education
INTRODUCTION
Non-surgical periodontal therapy (NSPT), also referred to as periodontal debridement or scaling and root planing, is considered the “gold standard” for the treatment of periodontal disease.1-3 The goal of NSPT is to mechanically remove biofilm and calculus deposits from periodontally diseased tooth surfaces and remove factors which facilitate the formation of biofilm.4 Multiple clinical studies have demonstrated the effectiveness of NSPT in reducing microbial loads and leading to a reduction in bleeding on probing, pocket depths, and gains in clinical attachment.5-7
Nearly half of all adults in the United States (US) have some form of periodontal disease with the prevalence increasing with age.8 Advancing periodontal disease can lead to alveolar bone destruction in the furcation areas of multirooted teeth, subjecting this area to ongoing microbial colonization and further bone loss. Albanda et al. reported that approximately 13% of all periodontal cases in the US present with some type of furcation involvement.9 Prevalence and severity of furcation involvement has been shown to be site specific, with the highest frequency observed in maxillary molars.10
Furcation involvements can pose unique challenges for both the patient and the provider.11 Longitudinal clinical studies conducted over the past several decades have consistently demonstrated a poorer long-term prognosis for teeth with furcation involvement when compared to single-rooted teeth and teeth without furcation involvement.3,12 Because of their unique shape, furcations pose unique maintenance challenges. The inability by the patient and clinician to reduce biofilm accumulations in furcation areas has been shown to lead to less favorable responses to NSPT when compared to teeth without furcation involvement.13
Maxillary and mandibular furcations have anatomical configurations that pose unique challenges during NSPT.13 Effective periodontal instrumentation during NSPT requires the use of instruments that are designed to access a variety of root surfaces. Area-specific instruments, such as the standard Gracey instruments, were designed to aid the clinician in reaching subgingival periodontal pockets. However, the typical furcation measures 1mm or less and the average width of a curette blade is .75mm to 1.10 mm.14 Therefore, accessing and instrumenting furcations using a standard instrument, such as a Gracey curette, can be difficult.15 Considering the importance of effective instrumentation techniques needed for successful NSPT,2 manufacturers began to design advanced instruments with extended shanks, miniature working-ends, and micro-miniature working ends to address this challenge.16,17 In 1988 the After Five Gracey was developed, followed in 1990 by the Mini Five, and in 2008 the Micro Mini Five.18 These specially modified instruments provide better access to difficult to reach surfaces like tight, narrow periodontal pockets, and furcation areas while reducing the risk of soft tissue trauma and ultimately improving the long-term prognosis of the periodontally involved teeth.19,20
Considering the high prevalence of periodontal disease in the US, and the number of patients presenting with furcation involvement, dental hygienists are likely to encounter maxillary and mandibular furcations when performing NSPT.8,9 However, there is minimal literature on the actual usage of advanced instruments by dental hygienists during NSPT. The purpose of this study was to explore clinical dental hygienists’ familiarity, utilization, and perceived efficacy of advanced instruments in root furcation areas in the delivery of NSPT.
METHODS
This was a quantitative, cross-sectional study of licensed dental hygienists in the State of Michigan and was deemed exempt by the University of Michigan Health Sciences and Behavioral Sciences Institutional Board (HUM00180650). For the purpose of the study, advanced instruments were defined as any area specific instrument which was designed with a longer terminal shank and a shorter, thinner blade. Data was collected using a hard copy survey instrument that consisted of 10 items. Demographic questions asked participants to share their age, practice setting, and year of dental hygiene program graduation. One question asked participants to share their source of knowledge about advanced instruments. Four Likert-scale questions assessed how familiar participants were with advanced instruments, how often participants utilized advanced instruments during NSPT, percent of time they used these instruments in conjunction with an ultrasonic device, and how strongly they felt using advanced instruments produced positive long-term outcomes. One question asked participants to identify where they learned about advanced instruments. The final item asked participants to identify any barriers to utilizing advanced instruments during NSPT. Open-ended responses included the employment setting, source of knowledge, and barriers to utilization items. The University of Michigan Survey Research Center was consulted during the development of the instrument to establish content validity. The survey was pilot tested by ten registered dental hygienists and edits were made based upon reviewer feedback.
A list of the approximately 10,000 dental hygienists licensed in Michigan in 2019 was obtained from the state licensing and regulatory affairs office. A randomization scheme was used to select 3,500 licentiate addresses and the surveys were mailed in three batches. Each invitation to participate included a cover letter, the survey, and an addressed, postage-paid return envelope. All licensed dental hygienists who received the survey were asked to return it; however, only currently practicing dental hygienists’ data was included in the analysis. Data collection took place from October 2020 through February 2021.
Collected survey data was first entered into a survey program (Qualtrics, Seattle, WA, USA) then exported into a statistical software program (SPSS version 27, IBM; Armonk, NY, USA) Descriptive statistics including frequency distributions, percentages, measures of central tendency and variation were used to analyze the data. Logistic regression and Chi-square tests were utilized to analyze associations and comparisons between the different variables presented in the survey. A statistical power analysis was performed using the software program G*Power 3.1.3. Assuming 80% power, an alpha of 5%, and an effect size of 0.17 for 6 groups in a one-way ANOVA, a minimum sample of 450 respondents was needed.
RESULTS
A total of 1,156 surveys were returned; 298 surveys were from non-practicing dental hygienists and were not included in the data analysis. A total of 858 respondents met the inclusion criteria for a response rate of 24.5%. Most participants were between 41-60 years of age (51%, n=436) and were employed in a general practice setting (88%, n=784). There was only a slight difference between the frequencies in graduation years; 1989 or earlier (26.9%, n=231), 1990-1999 (24.2%, n=208), 2000-2009 (26.2%, n=225), and 2010-2020 (22.6%, n=194). Participant demographics are shown in Table I.
Respondent demographics (n=858)
Familiarity of Advanced Instruments
Table II displays the results of how familiar participants were with advanced instruments and where they gained the familiarity. Well over half (67%, n=572) stated that they were somewhat or very familiar with advanced instruments. Participants reported having learned about the instruments either through their dental hygiene educational program (37.1%, n=339), by attending a continuing education course (22.8%, n=208), conference vendor exhibit (10.5%, n=96), and by word-of-mouth (10.2%, n=93).
Familiarity and source of knowledge regarding advanced instruments. (n=858)
Utilization of Advanced Instruments
Items regarding specific utilization of advanced instruments in furcation areas during NSPT revealed that less than half of the respondents used these instruments greater than 50% of the time (37.6%, n=269). Of those who indicated that they used advanced instruments, nearly all reported using them in conjunction with other hand instruments and/or an ultrasonic scaler (90.9%, n=522) (Table III).
Frequency of use, perceived outcomes, and barriers to utilization of advanced instruments (n=858)
Expected Outcomes of Utilization of Advanced Instruments
Participants were asked to what degree they agreed with the statement, “Using advanced instruments in furcation areas alone, without other instruments or adjunctive therapies (i.e. localized antibiotic delivery systems or subgingival irrigation), help my patients achieve better long-term periodontal outcomes.” A minimal number of respondents strongly agreed with the statement (11%, n=61) and a nearly equal number strongly disagreed (7%, n=42). Open-ended comments (n=3) from respondents that neither agreed or disagreed with the long term periodontal outcomes of advanced instrument usage in furcation areas reported that the patient’s home care played a greater role in the long-term outcomes of NSPT than did the advanced instruments (Table III).
Barriers to Utilization of Advanced Instruments
Nearly one quarter of the respondents (23%, n=202) indicated that they were familiar with advanced instruments but had never used them in furcation areas during NSPT. This subset of participants was asked to provide a response as to “why” they did not utilize advanced instruments. Over half (53%, n=107), stated that the instruments were not available in their practice setting. Nearly one fifth of this subset (17.8%, n=36) reported that while they were familiar with advanced instruments, they did not feel competent to use them in furcation areas during NSPT (Table III).
Graduation Year, Familiarity, Perceived Effectiveness, and Utilization
Binary logistic regression analysis was used to explore associations between graduation year and instrument usage. Respondents who graduated in 2010-2020 were 16% more likely to utilize advanced instruments during NSPT as compared to respondents that graduated in 1989 or earlier (beta = 16.0, 95% CI [4.9, 27.2], p=.005). Likewise, respondents who graduated between 1990 and 1999 were nearly 20% more likely to use advanced instruments during NSPT as compared to respondents who graduated in 1989 or earlier (beta=19.9, 95% CI [9.2, 30.6], p=.000) (Table IV).
Logistic regression of practice setting, familiarity, efficacy of advanced instruments, and graduation year; controlling for instrument utilization
Table IV also shows the ordinary least squares regression results of the association between familiarity and utilization of advanced instruments in furcation areas during NSPT. As familiarity increased by 1 unit the likelihood of using advanced instruments for a majority of root furcations increased by 23.84 percentage points (95% CI [18.1, 29.6], p<0.001). Respondents who stated that they were very familiar with advanced instruments were about 71 adjusted percentage points more likely to use advanced instruments during NSPT in furcation areas as compared to respondents who were unfamiliar with them.
Associations between instrument utilization in root furcation areas and perceived efficacy was also examined using an ordinary least squares regression. As usage went up by one unit, the likelihood of the perceived efficacy increased by 4.4 percentage points (95% CI [.90, 7.9], p<0.05). Respondents who stated that they strongly agreed with the perceived effectiveness of advanced instruments were about 18 percentage points more likely to use these advanced instruments during NSPT in furcation areas compared to respondents who did not believe in their efficacy (Table IV). Chi-square test of independence was used to compare perceived effectiveness of advanced instruments and utilization. A participant’s perceived effectiveness was associated with greater utilization (Chi-square [4] = 25.21, p<0.001) (Table V).
Chi-square test of perceived effectiveness and utilization (n=570)
DISCUSSION
This study explored clinical dental hygienists’ familiarity, utilization, perceived efficacy, and barriers to the use of advanced instruments in root furcation areas for the provision of NSPT. Results showed that while some participants were familiar with advanced instruments, they did not utilize them on a regular basis when performing NSPT in root furcation areas. As familiarity and perceived effectiveness increased, so did the utilization of advanced instruments to access furcation areas during NSPT. While the response rate of 24.5% was lower than ideal for this analysis, response rates from paper surveys has been shown to range from 10.5% to 43.4%.21,22 In this study, lower response rates may be attributed to the fact that the surveys were distributed during the COVID-19 pandemic. Nearly 300 respondents were not eligible for the data analysis because they were not currently practicing and some indicated that they had been employed in clinical practice up until the beginning of the pandemic in 2020.
Most respondents (67%) indicated that they were familiar with advanced instruments and had learned about them through their dental hygiene educational program or by attending a continuing education course. Accredited dental hygiene programs must demonstrate that students are competent in providing dental hygiene care for all types of periodontal patients, including those with moderate to severe disease.23 In addition, accredited dental hygiene programs must demonstrated that graduates are competent in providing the dental hygiene process of care, which is patient-centered and evidence-based, to reduce oral health risks and enhance oral health outcomes.23 Dental hygiene education programs may be including advanced instruments in their curriculum during didactic and/or clinical experiences in order to provide a wider range of instrumentation skills for students to use during NSPT. However, the survey did not ask participants to identify which specific aspect (didactic or clinical) of the dental hygiene program introduced advanced instruments for NSPT.
The same argument can be made regarding learning about advanced instruments by attending a continuing education course. It is not known whether those participants received any hands-on training during the continuing education program or if it was exclusively lecture based. One interesting finding showed that a number of respondents identified conference vendor exhibits and word of mouth as frequent source of knowledge for advanced instruments. Manufacturers’ representatives can often be the initial source of information for clinicians to learn about new products including advanced instruments. Manufacturers who employ dental hygienists can bring added benefits to clinicians seeking to expand their knowledge in advanced instrumentation techniques.
Participants employed in general dentistry practices who refer their periodontal patients to a specialist for NSPT may not have had the opportunity to incorporate advanced instruments into the provision of NSPT in their practices. In this study, fewer than half of the participants indicated using advanced instruments more than 50% of the time. Possible barriers could have also been financial; clinical dental hygienists may lack the personal funds to invest in advanced instruments and may not have employers who are willing to purchase advanced instruments for their use.
The majority of participants (88%, n=784) were employed in a general dental practice setting. Dental hygienists working in general practice settings often perform a wide range of services on patients of all different ages, and do not exclusively treat patients with periodontally involved teeth. On the other hand, many general practices may wait to refer periodontal patients to a specialty office until after the initial NSPT has been completed. This may account for the unexpected finding that respondents employed in periodontal practices did not indicate using advanced instruments during NSPT as frequently as the respondents employed in other settings. It may also have been that the periodontal practice respondents saw more periodontal maintenance patients than patients undergoing initial NSPT.
This study did not ask participants to indicate whether or not their practices referred periodontal patients to a specialty office for NSPT, as this could account for the differences in having knowledge of advanced instruments and their actual implementation. This same argument may apply to the finding that the main barrier to utilizing advanced instruments was their lack of availability in the practice. However, it is typical that once NSPT is completed and the periodontal status is stable, the patient would begin an alternating recall care schedule between the general and periodontal practices. While over half (67%, n=572) of participants indicated being familiar/very familiar with advanced instruments, a majority (62%, n=448) indicated that they utilized advanced instruments less than 50% of the time in root furcation areas during NSPT. This discrepancy between familiarity and utilization was unexpected and could have been due to the use of advanced instruments in conjunction with an ultrasonic scaler or other instruments.
When providing periodontal maintenance care at a general office it would be likely that one of the dental hygienist’s responsibilities would include regular debridement of furcation areas to help maintain the site. According to Bower, 81% of maxillary and mandibular molars have a furcation entrance width of 1mm or less and traditional bladed instruments have a face width of anywhere between .75mm to 1.10mm.24 Therefore, the knowledge of advanced instruments, their usage and efficacy in treating periodontal disease due to their smaller blade width should be known by clinicians in the general practice setting in order to achieve long-term periodontal health outcomes for their patients.25
The second most frequent reason for not using advanced instruments was a lack of confidence in using them. Given the finding that the vast majority of participants were employed in general practice settings and may not have been required to perform many cases of NSPT, a lack of exposure to these patients may have contributed to their lack of confidence. Increased continuing education opportunities, including hands-on courses, might promote confidence in using advanced instruments. A little more than one quarter (28%, n=163) of the participants agreed that using advanced instruments exclusively in furcation areas, without other instruments or adjunctive therapies, helped their patients achieve better long-term oral health outcomes. However, almost the same percentage of participants either felt neutral (30%, n=172) or disagreed (24%, n=137) with the positive oral health outcomes achieved due to the use of advanced instruments. Respondents who chose to elaborate more on their responses stated that the patient’s oral hygiene behaviors at home determined the ultimate outcomes of NSPT. The importance of oral hygiene habits with positive oral health outcomes has been well established literature.
Participants who graduated from 1990-1999 or from 2010-2020 were more likely to utilize advanced instruments during NSPT as compared to participants who graduated in 1989 or earlier. These results could be due the time periods when advanced instruments were being manufactured and marketed. Miniature bladed, extended shank Gracey instruments were first introduced in 1999 followed by the micro miniature version in 2008 (Hu-Friedy; Chicago, IL, USA). These results could be due to the dental hygiene educational programs and their incorporation of advanced instruments into their curriculum as well as continuing education courses being offered to educate practicing dental hygienists. It is also noteworthy to look at the evolution of NSPT as an effective treatment option for periodontally involved teeth. Findings from studies conducted in the 1980’s reported that root planning and curettage were at least as satisfactory as other surgical techniques for the treatment of most periodontal pockets.2 These early studies on the benefits of NSPT may have triggered the development of advanced instruments designed to access root furcations.
Respondents who were familiar with advanced instruments were more likely to utilize them during NSPT in furcation areas (p<0.05). Analysis also revealed that perceived efficacy of advanced instruments was associated with greater utilization and the more effective a respondent believed that the advanced instruments were, the more likely they were going to utilize them when providing NSPT (p<0.001). Participants who were more engaged in evidence-based practice decision making may also have been more knowledgeable of the efficacy of advanced instruments and the importance of instrumentation skills on periodontal health outcomes. Along with evidence-based research and re-evaluation at every maintenance visit, one’s perceived effectiveness of advanced instruments may be related to the clinician’s personal belief system.26 It can assumed that by having more practice and experience with advanced instruments the clinician will utilize them regularly and perceive them as effective in furcation areas.
Results from an early in vitro study by Otero-Cagide et al. on the effectiveness of calculus removal from furcation areas of mandibular molars using ultrasonic scalers, suggested the effectiveness of ultrasonic scalers in the debridement of root furcations.27 Ultrasonic instrumentation has become part of routine dental hygiene care and the vast majority of participants who used advanced instruments in the current study reported using them in conjunction with ultrasonic instruments. The use of ultrasonic instrumentation in conjunction with hand scaling has been shown to support NSPT outcomes.29,30
Suggestions for future research on the use of advanced instrumentation includes exploring this topic among practicing dental hygienists in different states. Results from an expanded study could identify any regional differences and better generalize the results. A future study could focus on a similar purpose but be limited to dental hygienists who are employed in a periodontal practice setting. Both classic and more recent research studies have shown the value of advanced instruments during NSPT.6, 28-31 Additional studies focusing on the instrument purchasing practices of dental offices and clinicians may provide insights on the rationale on why advanced instruments may or may not be used when providing NSPT.
There were limitations to this study. The sample population was limited to practicing clinicians in Michigan and results cannot be generalized to all practicing dental hygienists. The response rate of 24.5% was lower than expected. Survey responses were also self-reported and the risk for biased responses was possible. The survey instrument was intentionally brief; however, it may have led to misinterpretation of the questions.
CONCLUSION
Familiarity with advanced instruments and the perceived efficacy of these instruments for accessing root furcations increased the likelihood of clinical dental hygienists utilizing them for NSPT. Dental hygiene education programs and continuing education programs should continue to provide opportunities for students and practicing clinicians to learn NSPT instrumentation techniques utilizing instruments especially designed for furcation access.
ACKNOWLEDGEMENT
The authors wish to acknowledge Lisa Holland, Director of the Survey Research Center at the University of Michigan, for her guidance developing the survey and Nolan Kavanagh for his assistance with data analysis.
Kristin Pelz, RDH, MS was the 2022 winner of the graduate ADHA/Sigma Phi Alpha Journalism award sponsored by 
Footnotes
NDHRA priority area, Professional development: Education (educational models).
DISCLOSURES
Kristin Peltz received funding from the University of Michigan Rackham Graduate Student Research Grant and from the LeGro Research Award Fund to support this research.
- Received September 26, 2022.
- Accepted March 6, 2023.
- Copyright © 2023 The American Dental Hygienists’ Association
