C6 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 4/2018 Oral hygiene instructions and patient motivation with and without dental hygienists An interview with Dr Eric Thevissen, periodontist and pioneer of Belgian prophylaxis By DTI Dr Thevissen, I wanted to talk to a dental hygienist in Belgium. Why is that not yet possible? Dr Eric Thevissen: Well, the good news is that, from June 2019 on, it will be possible to visit and talk to a dental hygienist in Flanders. Why Flanders has waited such a long time to start the education and training of dental hygienists is politically mo- tivated and due, in large part, to the representative dental associations. Belgium has a long tradition of one- dentist clinics, often working with- out dental assistants. Since the intro- duction of a quite difficult admission exam for dentistry in 1997, the disci- pline has attracted fewer students. As a consequence, the number of graduating students has dramatical- ly decreased, while the demand for dental care is continually increasing. Slowly, but surely, more and more group practices have emerged, hir- ing dental assistants. Back in 2006, the first meetings were organised be- tween universities and dental socie- ties about the qualifications needed to become a dental hygienist and the tasks that could be delegated to them. As always, there were propo- nents and opponents, and it took a very long time before all stakehold- ers agreed on the conditions and cri- teria needed to start dental hygienist training in Leuven and Ghent. Let’s talk about your study “The provision of oral hygiene instructions and patient moti- vation in a dental care system without dental hygienists”. Please tell us more about it. Thirty years ago, I started working as a periodontist in Hasselt with anoth- er colleague. Since we were the first periodontists in this province, we had a flying start. After a few years, I noticed that dentists were always re- ferring patients to our clinic with the same complaints, such as bleeding gingivae or bad oral hygiene. In my opinion, treating bleeding gingivae or giving oral hygiene instructions is the duty of every dentist and belongs in the sphere of primary dental care rather than in secondary or specialist care. Although we organised courses where a general dental practitioner (GDP) could learn about patient in- struction and guidance, I realised that we were considered by a large number of GDPs to be dental hygien- ists rather than periodontists. The truth was that we were both, peri- odontists and dental hygienists. This annoyed me because I knew that in neighbouring countries periodon- tists could spend their precious time Dr Eric Thevissen on the work they were trained for. In 2004, I took the initiative to set up a pilot study in Limburg with 65 referring dentists. We used the Dutch Periodontal Screening Index, a screening test for periodontal sta- tus that had been introduced in the Netherlands a few years earlier. We collected data from 814 patients. The results clearly showed that the screened age groups had, on the whole, periodontal problems and that there was a high need for treat- ment. Around the same time, Prof. Hugo De Bruyn joined the teaching staff of Ghent University’s Department of Dental Sciences. Probably thanks to my publication, he asked me to become one of his staff members. Working with Prof. De Bruyn, one is quickly involved in clinical research and so I had the opportunity to in- vestigate, in depth, the questions that had bothered me ever since I started my career. One of these ques- tions was the kind of oral hygiene instructions GDPs provide to their patients. Using questionnaire responses of 776 dental professionals gathered for various postgraduate courses in Flanders, we were able to determine that, given the absence of dental hygienists in Belgium, oral health instructions and patient motivation appeared to be non-compliant with international guidelines. Though dental professionals were concerned with prevention, there were several mitigating factors working against them delivering this adequately. The study mentioned lack of time, remuneration and patient interest as complicat- ing factors for the provision of preventative care. However, qualification, work experience and time are crucial for provid- ing oral hygiene instructions and patient motivation. Can dental hygienists be seen as a solution to these problems? It is my conviction that dental hy- gienists are the solution to these complicating factors. Prophylactic care will be the main target of their work, since dentists are primarily trained for restorative care. Owing to factors such as the decreasing num- ber of graduating dental students, the increasing number of retiring dentists in the next ten years, an age- ing population and a higher demand for preventative care, the stress of work increases and forces dentists to manage their work time more strictly. Of course, GDPs prefer re- storative and other more rewarding treatments. We all know how time- consuming patient motivation tech- niques for behaviour change can be. There is no dentist prepared to spend that time on preventative care. Gen- erally speaking, dentists are used to giving a basic package of informa- tion on oral hygiene to every patient and, depending on compliance, they may want to spend more time on patient guidance. Here, dental hy- gienists can make the difference. They will be trained to insist on the importance of behavioural change and will take the time to explain and show how to perform proper home oral care. You have also published studies on implants, such as on implant design. What made you publish your study titled “Attitude of dental hygienists, general practitioners and periodon- tists towards preventive oral care: An exploratory study”? You could have just continued with your research on implant systems. Indeed, the team around Prof. De Bruyn is very driven by and focused on the outcome of implant therapy. To my knowledge, the Department of Dental Sciences at Ghent Universi- ty published around 40 scientific ar- ticles in 2016, the majority of which are related to implant therapy. The subject of my PhD is not implant- related, but deals with different rela- tionships in dentistry: between the patient and the dental professional, and between primary and second- ary dental care, that is between GDPs and specialists. What were the objectives and results of this study? This second study was a step further than the first one. In the first study, we looked for an explanation for the differences in patient motivation techniques between Flemish GDPs and periodontists. In this second one, we compared our rather unique Bel- gian system with the Dutch system, a completely differently structured healthcare system including dental hygienists. We wanted to know if the Dutch system represented the gold standard and how we were situated in Flanders. The results showed that periodon- tists and dental hygienists shared more common viewpoints than GDPs and hygienists did. What was remarkable was the fact that more than 80 per cent of periodontists and dental hygienists were satis- fied with their efforts in informing and motivating patients, compared with 38 per cent of GDPs. Secondly, whereas GDPs indicated nurture as the factor most contributing to the oral hygiene level of the patient, periodontists and dental hygienists focused on the influence of the den- tal practitioner and a patient-centred approach. In our multivariate analy- sis, the presence of chairside assis- tants seemed to be of major impor- tance. But, as always in questionnaire- based studies, the results can be bi- ased by socially desirable answers and by the inevitable structural dif- ferences between Belgium and the Netherlands. One of these differ- ences, for example, is the fact that providing oral hygiene instructions is not reimbursed in the Belgian den- tal care system, as it is not considered an autonomous activity. What should the role of the dental practitioner in the successful treatment of periodontal disease be? What does the patient need to do? The role of the dental practitioner, in particular the GDP, undoubtedly remains to keep a panoramic over- sight over everything that has to do with the dental and oral health of the patient. Especially considering the introduction of dental hygienists in the near future in Belgium, the den- tist’s role as a supervising manager is important. It is my experience that progressive problems often remain untreated until complications or even complaints surface. A trigger seems to be needed to make the idea of treatment approachable or ac- ceptable. Unfortunately, waiting for this trigger often leads to the loss of the tooth instead of its repair. From the patients’ point of view, I am convinced that some of them insist on not being treated for things they do not complain about, as they see these treatments as unnecessary. If I personally have to undergo an annual medical check-up, I would hope that all the exams needed are performed, as this will set me at ease. Why then does this appreciation not apply to oral health? What are some of the oral hygiene instructions and patient motivational actions that you would recommend? Thanks to research and clinical find- ings, lifestyle habits, genetics, stress, hygiene, medication, age, nutrition and different systemic factors have been shown to accelerate the devel- opment of periodontal disease in the presence of biofilm, activated by a hyperreactive or even a hypo- reactive immune system response. It is a fact that this sort of risk analysis has become part of the graduate cur- riculum, including counselling on healthy food habits or how to quit smoking, detecting periodontal risk through assessment, using caries de- tectors, and so on. Firstly, the patient should demon- strate his or her home care habits using his or her own toothbrush. We distinguish four levels of patient information needs: the lowest level is the patient who is almost totally ignorant about proper home care; the second level is the patient who brushes his or her teeth on autopi- lot without paying attention to any technique, time duration or inter- dental cleaning; the third level is the patient who regularly cleans even the interdental spaces, but unfor- tunately not frequently enough or not with adequate instruments; and finally, the fourth level is the patient who performs extremely well and needs none or only minor adjust- ments, for example tongue brush- ing. In accordance with the technique of motivational interviewing, we build up a conversation with the patient while giving instructions, waiting for approval, repeating and ÿPage C7