The Dentist talks to Benjamin Tighe about why managing gingivitis using plaque control measures is key to successful preventive care, as are personalised care plans.
As a practising dental therapist and an educator, what do you think is the key to ensuring optimal patient care in today’s society?
BT: I think optimal care comes from bespoke care. It’s that one-to-one focus, treating each patient as an individual, getting to know that patient, eventually understanding someone’s lifestyle. You need to get away from this template idea. For example, with twice-daily brushing because, although it is part of the gold standard regimen, it doesn’t fit into everyone’s lifestyle for a variety of reasons. It might eventually, but it can take time. So, our advice and the care we give must be personalised to each individual
If plaque management is the required focus, what are the barriers and how can dental professionals help their patients to achieve improved outcomes?
BT: There are a lot of potential barriers. I think it's very nuanced in the sense that you come against what people have traditionally always done. Patients will say:
- “I've always brushed my teeth this way.”
- “Why are you telling me to change this now?”
- “I've been seeing the same hygienist or the same dentist for a number of years and they've never said anything, so why are you doing this now?”
So, change, understanding why a different clinician is recommending something else, is one barrier for patients.
Then, a huge issue at the moment is the financial barrier. We can't expect all patients to be able to go out and buy the latest electric toothbrush. Even toothpaste, interdental brushes or floss still cost money that some patients won’t have. Here, it’s about being proactive, perhaps even going to the local saver or pound shop to see what is available and whether it is good enough for a cash-strapped patient.
Education is another barrier; people still don't really understand what biofilm or plaque do, or the effects on the body. That needs to be addressed so that patients can appreciate the true impact of oral health care and be motivated to make a change.
Are there any adjuncts that can help patients maintain their oral health and manage plaque?
BT: This is interesting because, before I attended the Hygienist Advisory Panel and was presented with the evidence, I would probably have said ‘no’, other than, perhaps, short-term use of chlorhexidine in some circumstances.
However, having been presented with the evidence regarding mouth rinse efficacy and then trying it for myself over a long period, I do recommend an essential oil mouth rinse for certain patients who need a little something extra beyond mechanical cleaning.
The ‘spit don’t rinse’ message has been circulating for years. However, there does seem to be some confusion surrounding it. What is the confusion, why is it not being implemented correctly in some instances, and what is the correct interpretation?
BT: When we are at university, it's drilled into us that we need to tell patients that it's ‘spit don't rinse’. The idea is that if you rinse, then you're going to get rid of all that fluoride, which was going to help strengthen your teeth.
However, that advice is based off one study that looked at kids who rinsed with water after they brushed their teeth. We're basing this whole kind of ethos and attitude around one study, which, I admit, I was guilty of doing.
It was even in earlier versions of the ‘Delivering oral health toolkit’, but now they have changed it to “spitting out after brushing rather than rinsing with water, to avoid diluting the fluoride concentration.”
The evidence actually demonstrates that the enamel uptake of fluoride from a fluoride-containing mouth rinse is as good as leaving residual toothpaste in the mouth. So, for some patients, an adjunctive fluoride hit offers benefits.
It is not unusual to come across conflicting advice when it comes to best practice. With that in mind, where should clinicians seek advice, and how can they know what to implement?
BT: It can certainly be tricky as there is new information being published all the time, but not all of it is robust. You need to identify the type of evidence and consider where it comes in the hierarchy of evidence and where it fits with Grade (grading of recommendations, assessment, development and evaluations).
Can clinicians wait for guidance to be handed down to them from leading associations and bodies within dentistry, or should they be seeking it for themselves?
BT: We are quite lucky in the UK, in that we have some very proactive associations. I’m thinking specifically of the British Society of Periodontology’s (BSP) version of the EFP S3-level Clinical Practice Guidelines, which offer UK-specific evidence-based recommendations. Had you taken the evidence directly from EFP, you would've been extremely confused. The BSP version is much more user-friendly.
That said, it's the clinician's responsibility to inform themselves, and to be able to challenge things should they need to. So, you have to lead the way with your skillset and knowledge, to ensure you are offering best practices based on the current evidence base.
You will be visiting and presenting at a number of dental events this year. What information will you share with delegates?
BT: I’ll be delving more into how the care we provide needs to be bespoke to every individual patient and addressing the ‘spit don't rinse’ issue, to make sure we’re all clear on the evidence base.
Evidence is key in everything we do, so I’m also going to run through staging and grading clinical recommendations.
I’ll also try to reduce the noise for colleagues surrounding adjunctive advice, taking it out of the social media and Google realms of confusion and back into an evidence-based reality.
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References available on request.