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C2 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2018 “The oral environment becomes more hostile with age” By DTI Professor Hien Ngo has extensive experience in private practice, re- search and education. Over the last 30 years, he has been active as an international speaker on cariology, minimal intervention and restora- tive dentistry. At present, his focus in research revolves around the clinical management of caries, especially in elderly and medically compromised patients and the interactions be- tween glass ionomers and the oral environment. Dental Tribune Online had the opportunity to speak to him about the concept of “lifelong oral health” and the major demographic change in ASEAN countries. The term “lifelong oral health” was used by the FDI World Dental Federation in one of its policy statements. What does it mean? Previously, edentulous among older individuals was accepted as a norm. However, with recent advances in preventive and restorative dentistry, the FDI stated, “The goal of reaching old age with a full set of teeth is fea- sible if preventive measures and oral health care are accessible through- out life.” The key term here is “through- out life” because a good oral health foundation in childhood is the key determinant of oral health at a later stage in life. Lifelong Oral Health was the title of a policy statement that was adopted by the FDI General Assembly in Au- gust 2017. It identified the four pillars supporting lifelong oral health as oral health promotion, risk assess- ment, disease prevention and early diagnosis and intervention at all stages of life. These four pillars will form the framework for discussing clinical cases during the Silver Wave symposium at IDEM. There is a global phenomenon of population ageing on an un- precedented scale. What is the situation in South East Asia? Ageing is universal and there is no exception among ASEAN countries. It is expected that the percentage of the population aged over 60 will more than double in the next 30 years. By 2050, 2 out of 10 people in the region will be aged over 60. How- ever, the pace of change is much fast- er in Singapore than in neighbour- ing countries. It is predicted that by 2050, 4 out of 10 Singaporeans will be over 60 while this ratio will be 2 out of 10 in Indonesia and approxi- mately 3 out of 10 in Thailand and Vietnam. What are the consequences of this demographic change for oral health professionals? If you are working in the private sec- tor, it means that a higher portion of your clientele base will be older individuals and most of them will be dentate. As they belong to the baby boomer generation and were born between 1946 and 1964, they grew up during a period of rising living standards after economic prosperity, so their expectations are different from previous generations. The Australian Institute of Health and Welfare proposed a broad clas- sification for this group: active and capable, limited activity and capabil- ity and very limited activity and ca- pability. For the last two groups, you may need to modify your practice to allow accessibility, or there is the op- tion of referring them to specialised public institutions and specialists. For clinicians, the care pathways for elderly patients are more complex, as damage to their dentition is ac- cumulative, so its manifestation is much more severe later in life. The oral environment also becomes more hostile with age. Root caries, which are rare in younger individu- als, are common in the older pa- tients. When these conditions are coupled with either severe health or mental illness, then referral to a specialist in geriatric dentistry could be required. Gerodontology is now a recognised dental specialty; however, specialists in this field are still not common in ASEAN countries. The engagement of international bodies such as the FDI and WHO on the concept of lifelong oral health will encourage healthy discussions and policy de- velopments to ensure that preven- tive measures and oral healthcare are accessible. What is happening in this field during the IDEM conference in Singapore? Singapore recognised the impor- tance of this major demographic change and has made large invest- ments to ensure that lifelong oral health is delivered to its population. With the Silver Wave Symposium at IDEM 2018 on Saturday 14 April, there will be a full day dedicated to manag- ing the ageing population and pa- tients. Six international speakers and clinicians will be brought together to discuss the management of oral health issues, of the ageing popula- tion, and of older individuals. The day will start with discussions on the changes that were made in the pub- lic health and education institutions, then move on to clinical issues. The day will be clinically oriented and discussions will be patient focused. The symposium will be supported by The Silver Wave booklet, which will be distributed during IDEM. More information about the sympo- sium can be obtained from the con- gress programme schedule. Maurizio Tonetti: “Prevention makes excellent economic sense for the dentist” By DTI / Prof. Maurizio Tonetti Lack of compliance from patients cannot remain an excuse for giving up, says Prof. Tonetti, editor of the Journal of Clinical Periodontology and coauthor of a Perio Focus green paper on periodontal diseases. It is up to the dentist to adequately mo- tivate his patient. If the dentist and patient have shared goals, then the failure to achieve them is shared too. In your Perio Focus green paper, “Impact of the global burden of periodontal diseases on health, nutrition and wellbeing of man- kind: A call for global action”, you call for prevention, diagno- sis and treatment. Why do you recommend this threefold ap- proach to periodontal diseases? More than 750 million people suffer from severe forms of periodontitis, while another 3 billion have a milder form of it. With such a widespread prevalence of this disease, we need a multi-pronged approach to treat it, which includes: a) Prevention, to ensure that fewer people develop the disease. We suggest that we need to work on the common risk factor approach for the prevention of chronic non-com- municable diseases, as suggested by the World Health Organization (WHO), with one critical addition: we must include oral hygiene as one of the virtuous behaviours (along with not smoking, eating well, controlling weight and exercise). Prevention re- quires the implementation of appro- priate oral hygiene practices and the effective management of gingivitis, which dental professionals need to play a critical role in providing. In addition, more needs to be done by governments in this regard. b) Diagnosis, since we think that early detection and early manage- ment will lessen the economic burden of treating periodontal dis- ease. We suggest an alliance with the patient to aid early detection with self-assessment, followed by profes- sional screening and a full periodon- tal diagnosis. In addition, it is critical that dental professionals commu- nicate the message that gingival bleeding is not normal and requires attention. c) Treatment, which for dentists is the obvious step. The problem is that we know how to treat this dis- ease and we have all been trained in dental or hygiene school on how to do it, but formidable barriers are making access to the best evidence- based treatment difficult—and I am not only talking about money! A complex mix of misunderstand- ings, incorrect health messages de- rived from the advertisement of oral health products, faulty reimburse- ment systems and a historical focus on restorative dentistry are proving difficult issues to overcome. Clearly the number of periodontal disease patients is enormous and we need to rethink what we are do- ing. Fortunately, the endorsement of such a wide constituency of learned periodontist societies from around the world can be seen as a good omen. Often, prevention is neglected in dental practices in favour of diagnosis and restorative treat- ment. However, how can dental professionals equally imple- ment these three steps in their daily practise? In developed countries, and in the higher socio-economic strata of de- veloping countries, health, rather than disease, is the future of medi- cine and dentistry, since people want to be healthy and for that, preven- tion is key. The best dental practices have already shifted their business models away from traditional restor- ative treatments alone and towards a different approach. Prevention makes excellent economic sense for the dentist, but from the patient’s perspective, preventative treatment only works if it is of a very high qual- ity. What are some of your key rec- ommendations for short- and long-term preventative treat- ment? And, where does primary prevention end and secondary prevention begin? You raise an important point. The simple answer is with the diagno- sis and choice of appropriate care pathways for different individu- als. Primary prevention, or helping healthy people avoid the disease, is key. We know what to do in terms of behavioural modification and the promotion of a healthy lifestyle, oral hygiene instructions and delivery of the traditional periodontal preven- tive services (scaling and prophylax- is). This approach, however, requires diagnosis, because the dentist must first establish that the patient does not suffer from periodontitis at the time for it to work. In the conclusions of the Prevention Workshop, organised by the EFP in 2014, we underline the fact that it is inappropriate to deliver profes- sional primary preventive services to patients with undiagnosed peri- odontitis. So, each dentist needs to create different care pathways. One pathway for healthy subjects that need primary prevention, one for gingivitis patients who require treat- ment first and then primary preven- tion, and another for periodontitis subjects whose needs are totally dif- ferent, including an accurate diagno- sis, periodontal treatment planning, the completion of a cycle of effective treatment and then—only then— prevention. Secondary prevention in these cases implies a specific pro- gramme for high-risk individuals who have had the disease and who are at a risk of recurrence. How important is an early and accurate diagnosis of periodon- tal disease for maximising the effectiveness of treatment? An early and accurate diagnosis is critically important! Distinguish- ing between health, gingivitis and periodontitis with an appropriate screening test is the first step—simi- lar tests, based on the WHO Com- munity Periodontal Index, have been introduced in many countries around the world by national peri- odontal societies. Whenever a pa- tient has periodontitis, a complete examination is mandatory in order to assess the specificity of the case, establish prognosis and choose the most appropriate treatment. Treat- ment without diagnosis is like walk- ing with one eye shut—sometimes we reach the target, but only when we are lucky. Clinicians should also keep a very important issue in mind: that diagnosis is a statutory require- ment in most jurisdictions around the world. Failure to diagnose or per- form an accurate diagnosis remains the number one cause of litigation in our field. Some patients think that the dental professional alone can treat periodontal diseases. What should the role of the dental pro- fessional and the role of the pa- tient be for the successful treat- ment of periodontal diseases? Here you refer to the need to estab- lish a therapeutic alliance between an informed patient and the dental professional for the treatment of dental diseases, which includes peri- odontal diseases. The key is commu- nication. Personally, I like to present to the pa- tient the condition of his/her mouth, explain what periodontitis is, how it is treated and how its reoccurrence can be prevented. This is the time to clarify the importance of oral hy- giene and risk factor management. However, your question has a deeper implication. As dentists, we always look at the patient’s lack of compli- ance as an easy excuse for our lack of success. Allow me to elaborate: if I do not manage to adequately motivate one of my patients I ask myself (and my team) what we did wrong? It is my responsibility to help my patient understand the importance of their role and it is my duty to help them achieve our common goal of good oral health. So, the role of the patient is critical, but if they fail, I fail too. The paper – “Impact of the global burden of periodontal diseases on health, nutrition and wellbeing of mankind: A call for global action” – was written by four international experts including Maurizio Tonetti and EFP past president Søren Jepsen. More information: www.efp.org