We are back with a brand-new series of educational webinars for oral care professionals! Join us on our journey, where each month, we connect with two experts from different dental specialties. Putting ourselves in their shoes, we will explore home based oral care from their perspective: what special demands do their patients have in this regard, which specific challenges are they facing, and what tactics and strategies have they developed over the years to overcome those challenges? On April 4, we kicked off the series with an episode dedicated to periodontology. Two renowned international experts in periodontology, Prof. Dr. Dagmar Else Slot and Prof. Dr. Filippo Graziani, shed their light on the topic.
What are the most crucial phases of periodontal treatment that can be managed by the patient?
Prof. Graziani starts by saying that periodontal treatment cannot exist without the direct involvement and collaboration of the patient: ”The patient has to be motivated to the point that he or she is triggered to adopt behavioural changes, which is the first step of periodontal treatment”. And this is true for surgical and non-surgical treatment, but also for the final treatment phase: supportive periodontal treatment: “If the patient cannot keep plaque under control, there is no way that we can produce periodontal treatment to an effective level”. However, he also puts it into another perspective: “Any patient is capable of everything, it’s just the professionals that need to find a way to make sure that the patient will change. And that is the challenge of our work: making sure that we not just convey some messages, but also stimulate change in the patient that we have in front of us”. Prof. Slot adds: “From the dental hygiene perspective, there is also a need to state that self-care is very important for people who will get dental implants – before and after they got the implants – because the collaboration we see between dental hygienists and periodontists is quite good already but with implantology there is room for improvement. And that also applies to a restorative dentistry”. Prof. Graziani fully agrees: “We know for sure that one of the determinants of implant success is actually the level of plaque and inflammation. Patients who previously had periodontitis, and are now undergoing implant treatment, without having supportive treatment throughout years, are more likely to lose bone around their implants, or even to lose their implants completely. And that’s backed up by pretty strong evidence of up to 10 years”. Prof. Slot concludes: “it always starts with a good collaboration between the patient, the dentist/periodontist/implantologist and the dental hygienist in my perspective”.
Oral hygiene is not only important during and after periodontal treatment; it also plays a big role in prevention. Prof. Graziani: “Prevention of periodontitis is in fact the treatment of gingivitis. Every time you treat gingivitis, or maintain somebody healthy, you are actually preventing periodontitis. And therefore, it’s so crucial to focus on the healthy patients, or at least the patients that are not affected by periodontitis, because that is really the first battle to be won”. Prof. Slot agrees and envisions a more integrative approach during for example school life: “With the current trend of living healthy, we see that students at high school learn how to make healthy choices, and I think it’s also time that we start to teach them how to brush. So, in the light of prevention, having oral hygiene as an integrated part in your education would be very helpful. Prof. Graziani adds: “As professionals, we’ve been taught how to address the treatment or the cure of a disease, which is very different from the model of preventing something. Maintaining wellness really is the new frontline of medicine, keeping people healthy instead of trying to solve the disease. And that’s something that doesn’t belong to the DNA of a doctor, we haven’t been taught this. So, this is a tremendous shift of mentality”.
Is toothbrushing alone already enough, or is it crucial to clean interdentally?
Prof. Slot starts: “Already ten years ago, we did a systematic review where we evaluated the effect of a single brushing exercise with a manual toothbrush. We found around 40 studies, including approximately 10,000 people in total, and showed that only 42% of plaque is removed during a single brushing exercise with a manual toothbrush. We did the same with a power toothbrush, for which we found that only 46% of plaque was removed”. With those percentages in mind, there certainly is room for improvement: “I think by definition, a toothbrush is not enough when you have periodontitis, as a toothbrush cannot enter the interdental area. You need something to clean interdentally”. Prof. Graziani complements by reverting to the findings of one of the keystone publications that shaped his professional life, Axelsson & Lindhe (1981): “Basically, people that had not been formally instructed for oral hygiene and were followed throughout time (for 6 years) kept accumulating plaque only interdentally. Because if I tell to brush more, everyone – even without training – brushes better occlusally, buccally, and lingually. However, interdental plaque stayed up to 100 percent. After six years, the people in this group would develop more and more inflammation, even buccally and lingually! Which means that if you don’t brush in between teeth, the inflammation will also go where the plaque is not even present. That means that the determinant of inflammation is what happens in the papillary area, what is happening interdentally. In the test group, where the plaque incidentally was kept under control, no inflammation and no caries developed”. This landmark study points out the paramount importance of interdental cleaning. Prof. Graziani concludes: “The first thing that we do is teaching patients to clean interdentally, as for me it’s the key essential point of maintaining a disease-free dentition throughout time”.
What do we know about the cleaning efficacy of different interdental cleaning devices?
Being one of the leading international experts on this topic, Prof. Slot starts by taking us through a series of systematic reviews on different oral care devices she and her colleagues published in 2008, such as manual and powered toothbrushes, floss, woodsticks, interdental brushes, and oral irrigators, and more recently in 2022, rubber bristles interdental cleaners. Among those, they found for example that “floss was not so effective on plaque removal, nor on bleeding and gingival index”, that “woodsticks have an effect on reducing the bleeding tendency”, and that “interdental brushes have an effect on plaque reduction and probing pocket depth”. More recently, they published a meta-review on different interdental cleaning devices, while colleagues in the US – Kotsakis et al. and Liang et al. – published two network meta-analyses. Prof. Slot on the findings: “They found out in the network meta-analysis that the interdental brushes and the oral irrigator rank high for both bleeding tendency and plaque removal”.
Prof. Graziani performed clinical studies on interdental cleaning himself, one with subjects without periodontitis and one with periodontitis affected patients with attachment loss. He talks us through his main findings: “In both studies, flossing wasn’t really capable of providing an added benefit to the manual toothbrush, which is consistent with a great deal of Prof. Slot’s literature”. On interdental brushes, the findings were more positive: “Interdental brushes were clearly superior in both studies, which was something we expected. What we didn’t expect to see though was that interdental rubber picks were as effective as interdental brushes in periodontitis affected patients. What was also very interesting to see was that in subjects without periodontitis, they were equally effective in terms of plaque control to the interdental brushes, but they were more effective in terms of reduction of inflammation”. Because both devices removed an equal amount of plaque, there had to be another explanation for this finding: “The rubber picks could have a sort of a massaging effect on the papilla. Apparently, this kind of frictional effect or squeeze effect probably has some sort of effect on the blood vessels level, on the inflammatory level, to the point that there is less inflammation with the same amount of plaque production”.
What do we know about patient preference, compliance and motivation as it relates to home based oral care and more specifically, oral care devices?
In terms of interdental brushing, Prof. Slot explains that data from Korea indicated that while 87% of the population brushes at least once per day, 63% do not use any interdental cleaning device. This indicates there’s much room for improvement, and a retrospective study she performed with her research group does show that oral care professionals can make a difference. They evaluated patients during non-surgical periodontal therapy for oral hygiene behaviour, and observed that after treatment, use of a powered toothbrush increased by 26%, the number of patients brushing at least 3 minutes increased by 33%, and the use of woodsticks and interdental brushes increased by 15% and 40%, respectively. Prof. Slot explains those findings: “What we see is that based on our instructions, oral hygiene self-care is improved. If people get information from us during active periodontal treatment, at least they changed their habit. That’s very helpful for us, because now we know that, if we give advice, it’s taken”.
However, recommendations from oral care professionals are not the only aspect that influences compliance and motivation. Prof. Graziani on the effect of ease-of-use of different interdental cleaning devices on compliance: “Crucial aspect in research for any device is not just the amount of plaque that the tool removes, but also to understand how many sessions you need per patient for that tool to be effective”. While this may explain the lack of effectiveness of floss in trials, as it’s difficult to master and you need many instruction sessions, it could also explain the superiority of interdental brushes and picks. Prof. Graziani: “Surely interdental brushes or picks are easier because it’s easy to transmit, it’s easier for the patient to check the effectiveness, and most important it is also very democratic. You’ll find yourself easily applying these tools between “a six” and “a five”, and not just between the central incisors, whereas when you teach floss, we tend to show how to use it in the interdental papilla of the central incisors. Which doesn’t need to be intensely brushed because the disease is back in the posterior areas”.
Prof. Slot continues the discussion about patient preference: “One of our latest systematic reviews was on the rubber picks as adjunct to tooth brushing, comparing them to floss and interdental brushes. We saw hardly any difference between the rubber picks compared to floss or interdental brushes. We could also evaluate the participants’ preferences, and in all four studies that compared patient preference of rubber picks to interdental brushes, the participants preferred the rubber picks”. As for the reasons why patients preferred the rubber picks over floss and interdental brushes, this mostly had to do with ease-of-use and willingness to continue using in the future. On a personal note, Prof. Slot adds: “Personally, I think when it comes to gingivitis patients for example, the rubber picks are a bit easier to use, because they bend not as easily as the small interdental brushes”.
Let’s Talk Oral Health! is a series focused on discussing home based oral care with professionals across the globe. Watch out for the upcoming sessions here.