PUBLISHED IN DUBAI www.dental-tribune.me July-August | No. 4, Vol. 8 “Up to ten times more plaque removal” SUBSCRIBE NOW https://me.dental-tribune.com/e-paper/ An interview with Maha Yakob, PhD, RDH, Global Director, Professional Relations and Scientiﬁc Affairs, Philips Oral Healthcare ISSN 2767-286X 1 2017 By Dental Tribune MEA/CAPPmea Maha is a scientiﬁc guru for Philips Sonicare. She started as a dental hy- gienist many years ago in Sweden while also lecturing at the Karolinska Institute. Karolinska is well known in the industry of dentistry since it has housed many Nobel Laureates, both in physiology and medicine. Dental Tribune MEA had a chance to hear from Maha on her evidance based approach on Sonicare, the electronic toothbrush. I was completely on the academic side when Philips approached me, and I joined them three years ago. What I implemented in the company was this whole evidence-based ap- proach. Before I joined Philips, they had all these great studies that they had done, but they didn’t really focus as much on getting the publications to the professionals. We just assumed that once people tried Sonicare, they would love it. But then my focus shifted and I thought, let’s publish these papers and show our peers and colleagues why they should recom- mend Sonicare based on evidence. In that case, they are not just recom- mending Sonicare because they like the product. Often, we would hear dentists or dental hygienists say, I know it is working because when my patients come back they have fewer splitting gingivae. They could all see the clinical results, but our approach needed to be evidence-based. Patients loved the product, it was just that the scientiﬁc part was missing, which is what we see now with the Journal of Clinical Dentistry, launched at the International Dental Show, with ﬁve studies that were published in this peer-reviewed journal. In the ﬁrst study, we saw that the Philips Sonicare Diamond Clean power toothbrush was statistically signiﬁcantly more effective than a manual toothbrush in reducing su- pragingival plaque, gingival inﬂam- mation and gingival bleeding Opinion: A vision and a need for prevention Advertorial: Dentists reveal ways to proﬁ t from healthy patients Special: Understanding oral and general health In this special issue, you will ﬁnd ﬁve papers. The ﬁrst two are randomised control trials looking at Sonicare versus manual toothbrushes. Two randomly assigned groups are com- pared after one group receives a manual toothbrush and the other, a Diamond Clean. Not surprisingly, of course, Sonicare performed signiﬁ- cantly better in the areas of plaque removal and gingival health. The second study showed that the Philips Sonicare FlexCare Platinum with the Premium Plaque Control brush head signiﬁcantly reduced gin- gival inﬂammation, gingival bleed- ing and plaque following two and six weeks of home use, compared with manual toothbrushing alone. This is how we substantiated the claim, “Up to ten times more plaque removal.” The Sonicare toothbrush has ﬂexible sides, allowing it more coverage of a larger surface area. The objective of the third study was to evaluate the short-term clinical efﬁcacy of high-frequency, high-am- plitude sonic-powered toothbrushes compared with manual toothbrush- es on plaque removal and gingivitis reduction in everyday use, through a meta-analysis of randomised con- trolled trials. The combined results of 18 studies with a total of 1,870 subjects showed that sonic-powered toothbrushes had signiﬁcantly great- er plaque removal. In conclusion, high-frequency, high-amplitude son- ic-powered toothbrushes decreased plaque and gingivitis more effec- tively than manual toothbrushes in everyday use, in studies lasting up to three months. Of course, studies one, two and three conﬁrm that Sonic technology is su- perior to the manual toothbrush. Study four is a head-to-head study done by an independent research organisation to compare the effect of the Philips Sonicare DiamondClean used with the Premium Plaque Con- trol brush head to the Oral-B7000 used with the CrossAction brush head on gingivitis and supragingival plaque reduction. In the results, we can see that the numbers were sig- niﬁcantly better than with the other technology . The ﬁfth study is moving away from simply brushing your teeth to using AirFloss in-between your teeth as well. The addition of interproximal cleaning to manual toothbrushing is statistically proven to signiﬁcantly reduce gingivitis and plaque com- pared with manual toothbrushing alone. Among the adjunct interproxi- mal cleaning regimens, AirﬂossPro provides a similar reduction in gingi- vitis and plaque to string ﬂoss. The question now is: shall I change to AirFloss when I ﬂoss every day? If you ﬂoss every day and you do it the right way, regular ﬂoss is acceptable. But, as a dental hygienist, I can tell you that very few of my patients ﬂoss every day and even fewer of them ﬂoss the right way. AirFloss was really developed for the majority of people who don’t ﬂoss every day, i.e. incon- sistent ﬂossers. There is a solution for them now that can help, is easy to use, is user-friendly and disrupts the bioﬁlm. We wanted to make sure that it was backed by science, which is why we did the study. We saw that manual toothbrush users still had signiﬁcant amounts of plaque, but as soon as we added the string ﬂoss or AirFloss, there was a reduction in plaque. In fact, we found eight times more plaque removal if something was used in addition to the manual toothbrush. Again, the scientiﬁc evidence suggests that AirFloss is as good as ﬂoss when you use it with a manual toothbrush and strands. This is something we have shared with the community. We do trade shows, events and different kinds of summaries of the studies. In the US, we aired a TV commercial that talks about the studies and, of course, the different conclusions. Together with the FDI World Dental Federation, we are trying to educate and raise awareness. Partnership with the FDI’s World Oral Health Day is something of which we are very proud and it is our way of spreading the message. For me, working for a company like Philips feels like the perfect ﬁt. It is not just a technology company, but also a health tech. Forget the lights and everything else that people as- sociate with Philips, it is a health tech company that has everything from diagnosis to home treatment to pre- vention, and we are really focusing on the holistic approach so that the FDI’s World Oral Health Day is about increasing awareness of the oral sys- temic link. That’s why a partnership with the FDI is perfect - it increases public awareness and helps you make the smart decision about what you are using in daily care. Many people are still unaware of good oral health care, especially in this region. They still use manual toothbrushes, which means we still have plenty of work, but I think we have more to do in education. Maha Yakob, PhD, RDH Dr Maha is a scientiﬁc guru for Philips Sonicare. She started as a dental hygien- ist many years ago in Sweden while also lecturing at the Karolinska Institute. Karolinska is well known in the industry of dentistry since it has housed many Nobel Laureates, both in physiology and medicine.
C2 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 4/2018 Pregnant women are hardly informed about the importance of oral health By DTI A new mother herself, pregnancy gingivitis has become a subject close to Dr Anja Carina Borer’s heart. She set up a joint campaign between Oral-B and the European Federation of Periodontology (EFP), which pro- motes oral health during pregnancy and educates health professionals and the wider public on the issue. Originally trained as a dentist in Mainz in Germany, Anja now serves as Professional and Scientiﬁc Rela- tions Manager Europe at Procter & Gamble in Geneva in Switzerland, where we met with her for some questions and answers on the sub- ject. Fittingly, she brought along her 4-monthold daughter, who cooed quietly in her pram throughout the interview. Oral-B and the EFP have touched upon a very impor- tant and personal topic, in that periodontal disease could affect the developing baby. Dr Anja Carina Borer: Yes. Gin- givitis is a well-known side-effect during pregnancy and the latest data shows that practically every pregnant woman suffers from it. The number of bleeding sites is about three times higher in pregnant wom- en than in the average adult. Even I, a dentist equipped with more than enough scientiﬁcally soun Oral-B products, experienced some gingival bleeding for the ﬁrst time in my life! As we know, untreated gingivitis can lead to periodontitis, the inﬂamma- tory burden of which can negatively impact pregnancy. Although more consistent in-depth studies are nec- essary, periodontitis during preg- nancy has already been linked with premature birth, low birthweight and pre-eclampsia. This topic is im- portant as most pregnant women are not aware of this problem and therefore often do not recognize the warning signs of gum problems such as bleeding or sensitive gums. With our campaign, we want to inform women and make sure they take good care of their oral health and see a dental professional in order to pre- vent possible oral health problems and pregnancy complications. How can periodontitis lead to these complications? Clinical studies suggest that bacteria from the oral cavity —speciﬁc mi- croorganisms associated with peri- odontitis—colonise the foetus and the placenta, with blood as the most likely vehicle of transmission. As a consequence, the presence of peri- odontal bacteria in the feto-placental unit may activate a local immune or inﬂammatory response that might negatively affect the pregnancy Biologically, that makes perfect sense, but how widely accepted is this point of view? Although clinical research on the matter has existed for years, it is still a fairly neglected topic. Not only does it not receive enough atten- tion from dental professionals, it is also largely overseen by healthcare professionals such as gynaecologists and midwives. When I was preg- nant, I was warned about many po- tential risks, ranging from ﬂying to eating sushi or dying my hair! I did enough research on the aforemen- tioned “risks” to conclude that there is no scientiﬁc data to support these. However, no one—my gynaecolo- gist included—told me to go and see a dental professional or take care of my oral health. To me, this really is a very personal matter, as I fell pregnant while es- tablishing the cooperation concern- ing pregnancy gingivitis with the EFP. I ﬁnd it worrying that pregnant women are hardly ever informed about the importance of good oral health during pregnancy. Therefore, I was passionate about establishing the Oral-B/EFP cooperation and lead the joint campaign. Our aim is to bet- ter educate dental professionals and medical professionals in general, as well as the wider public, on the im- portance of good oral health during pregnancy. Could you explain the chang- es in the bodies of pregnant women that cause pregnancy gingivitis? The biggest hormonal changes in a woman’s life take place during preg- nancy. It is a period of great change and obviously the mouth is one of the main areas affected by such changes, which in itself can lead to gingivitis. It is not for nothing that people used to say that women gain a child and lose a tooth. During pregnancy, there is a 150 times increase in oestrogen compared with the amount during a normal menstrual cycle. This and the increase of progesterone and other hormones lead to an increased vascular permeability of gingival tissues, which promotes gingival inﬂammation in the presence of dental plaque. For women who have already developed periodontitis, the situation usually gets worse because of the changed hormonal situation. Apart from cardiovascular disease, periodontal disease is known complication of diabe- tes. What is the risk of preg- nant women with diabetes developing periodontitis? For women who already have dia- betes, the biggest challenge is to keep their blood sugar under con- trol. Independent from this, a small percentage of women develop dia- betes during pregnancy. Although this type of diabetes disappears af- ter pregnancy, these women need treatment in order to avoid serious complications. Both groups, how- ever, have a higher risk of developing periodontal disease. It is important to note that treatment is more likely to succeed if a person’s blood sugar levels are under control. Vice versa, periodontal disease also negatively impacts diabetes. Overall, it is impor- tant that women with diabetes take care of their oral health before and during pregnancy. How do you integrate all of your ﬁndings in your Oral-B seminars? Oral-B’s mission is to promote oral health and work closely with den- tal professionals to ensure optimal home care. Our collaboration with the EFP serves as a way to raise awareness about all matters con- cerning oral health during preg- nancy. Our educational activities such as the Up-to-Date events are a way to communicate this and sup- port dental professionals in their objective to improve oral health. We believe a healthy mouth is part of a healthy body and promoting good oral health during pregnancy is one way to help to achieve this. How can general dental prac- titioners, periodontists and dental hygienists integrate this last thought into their daily practice? It is important that they under- stand the connection between oral and general health, be it the link be- tween periodontitis and diabetes, as well as cardiovascular disease, or complications during pregnancy. Gynaecologists, cardiologists and en- docrinologists too should be aware of this connection. That being said, many women avoid professional dental care during pregnancy and, conversely, many dental profes- sionals are insecure about treating pregnant patients. However, female patients of childbearing age should be informed about the importance of oral health during pregnancy. This is especially important for pa- tients who suffer from periodontitis. These patients should be encouraged by dental professionals to undergo treatment before pregnancy. During pregnancy, non-surgical periodontal therapy has been considered safe in the second trimester. Finally, what would your tips be for pregnant women? Women who have periodontitis must seek treatment before preg- nancy, whereas women who enjoy good oral health should go and see a dentist or a dental hygienist in the second trimester for a dental clean- ing. Of course, they should brush their teeth twice a day with a ﬂuo- ride-containing toothpaste—even better is an antibacterial toothpaste containing stannous ﬂuoride—and clean their teeth interdentally. It is scientiﬁcally proven that electric brushes such as our Genius tooth- brush are particularly good for re- ducing plaque and gingival bleeding. Moreover, they are a practical solu- tion for women who have less time to brush their teeth. There is no ques- tion that all mothers with a baby will know exactly what I am talking about.
Dental Tribune Middle East & Africa Edition | 4/2018 HYGIENE TRIBUNE C3 Preservation of root cementum: A comparative evaluation of power-driven versus hand instruments By Bozbay E, Dominici F, Gokbuget AY, Cintan S, Guida L, Aydin MS, Mariotti A, Pilloni A., Italy Background Grzesik et al. suggested that cemen- tum plays an important regulatory role in periodontal regeneration. One of the major goals of periodontal treatment is the removal of patho- genic micro-organisms by scaling and root planning. In the past the misconception was to obtain a root surface with smooth and hard sur- face characteristics that was free of endotoxins which resulted in the re- moval of the subgingival plaque and calculus deposits, and the removal of all or most of the cementum. Recent studies have reported that endotoxins were not located within cementum and removal of ‘diseased’ cementum was not necessary for a successful periodontal treatment. Saygin et al concluded that preser- vation of cementum on the root surface was necessary for new attach- ment and as a source of growth fac- tor. Hence non-aggressive removal of cementum is essential for optimal periodontal health and regeneration. Ultrasonics with new shaped tips and subgingival air polishing devices has been developed for removal of root accretions with minimal root damage. Air polishing has been sug- gested as a treatment modality for root debridement resulting in prob- ing depth reductions and removal of subgingival bioﬁlm. No scientiﬁc evi- dence exists today showing the loss of root substance or surface rough- ness produced by either ultrasonics or Air polishing. Aim To assess the amount of cementum remaining following in vivo root in- strumentation as well as the surface characteristics of the retained ce- mentum Material and Methods - 48 caries free, single-rooted teeth in 27 patients diagnosed with severe chronic periodontitis with periodon- tal probing depth (PPD) ≥5 mm in at least two sites per tooth with radio- graphical bone loss of more than two thirds of root length and scheduled for extraction were included in this study - Teeth were randomly divided into four treatment groups: Instrumenta- tions were performed with medium power settings 1. Piezoelectric ultrasonic scaler - (Air- Flow Master Piezon, Instrument Tip PS; EMS SA)-U 2. Piezoelectric ultrasonic scaler - (Air- Flow Master Piezon, Instrument Tip PS; EMS SA) followed by air polishing with the glycine powder (Air-Flow Powder Perio, Perio-Flow Nozzles; EMS SA) - U + AP 3. Air polishing with the glycine pow- der (Air-Flow Powder Perio, Perio- Flow Nozzles; EMS SA) - AP; 4. Hand instruments (Gracey curettes 5/6, 11/12, 13/14 American Eagle, Mis- soula, MT, USA)-HC Treatment - One approximal root surface of each tooth was randomly subjected to debridement, and the other ap- proximal surface was used as control. - Following instrumentation, the teeth were immediately extracted traumatically and analyzed with a dissecting microscope - Remaining calculus, root surface roughness and loss of root substance were evaluated along with scratches, gouges, cracks, and any other chang- es in the cementum that was present were noted. Results Remained cementum: - Percentage of coronal cementum remaining following subgingival in- strumentation was 84% for U, 80% for U + AP, 94% for AP and 65% for HC. - The amount of retained cementum with AP was signiﬁcantly greater than with HC. SEM - Smoothest root surfaces were pro- duced by the HC followed by the AP - Coronal and apical sections showed that AP produced the least amount of cementum loss and therefore the greatest retention of residual cemen- tum - Root surfaces instrumented by U or U + AP presented grooves and scratches. Time taken to complete root instru- mentation - Shortest time taken was using AP and the longest time was with U + AP. - AP required 31% less time for root preparation in comparison to HC, whereas U + AP needed 30% more time Conclusions - Air polishing was signiﬁcantly more effective and superior in preserving cementum. - Hand instrumentation using cu- rettes was most effective in remov- ing cementum in comparison to ul- trasonics or hand instruments Editorial Note: The article was origi- nally published in International Jour- nal of Dental Hygiene. 08 September 2016, page 1-8 The Dental Tribune International Subscriptions www.dental-tribune.com I would like to subscribe to CAD/CAM ceramic implants* Clinical Masters** implants laser ortho* prevention* roots Journal of Oral Science & Rehabilitation*** EUR 44 per year (4 issues per year; incl. shipping and VAT for customers in Germany) and EUR 46 per year (4 issues per year; incl. shipping for customers outside Germany). * EUR 22 per year (2 issue per year; incl. shipping and VAT for customers in Germany) and EUR 23 per year (2 issue per year; incl. shipping for customers outside Germany). ** EUR 12 per year (1 issue per year; incl. shipping and VAT for customers in Germany) and EUR 14 per year (1 issue per year; incl. shipping for customers outside Germany). *** EUR 200 per year (4 issues per year; incl. shipping and VAT). 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C4 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 4/2018 CS 5460: Dental care reinvented By Curaden For effective oral care, it is very im- portant to use a toothbrush with soft bristles. The reason for this is that hard bristles can often damage teeth and gums. This is a negative side- effect which also occurs if too much pressure is used while brushing. Curaden’s CS toothbrushes have one special feature in particular: they are incredibly soft. The 5,460 CUREN® ﬁlaments of the CS 5460 ultra soft form an extraordinarily dense and efﬁcient cleaning surface. The bris- tles are stiffer than Nylon and re- main just as stable in the mouth as they are when dry. These properties make it possible to manufacture toothbrushes with many very ﬁne bristles. Soft on the gums and teeth, the CUREN® ﬁlaments are extremely tough on plaque. Anyone who has tested the cleaning power of a CS toothbrush will never want any oth- er brushing experience. An ideal toothbrush head is small and slightly angled to make it easy to reach those crucial areas. The bris- tles should be ﬁne enough to clean the teeth and gums softly and thor- oughly. The handle should make it possible to properly position the toothbrush at about a 45-degree an- gle, always half on the gums and half on the teeth. The gumline is just as important as the teeth. The CS 5460 ultra soft combines these exact standards of design and function. The small but efﬁcient head at the proper angle ensures that your patients reach those crucial areas. An eight-sided handle facilitates the per- fect angle on the teeth and gums for optimal cleaning. The large cleaning surface with incredibly ﬁne, rounded ﬁlaments ensures soft and efﬁcient brushing of the teeth and gums. The cleaning efﬁciency of the bristles is tightly packed into 39 holes. Com- bined with the lively colours of the CS 5460 ultra soft, it makes for one of the most popular CURAPROX prod- ucts. The toothbrush is also avail- able with the CPS Prime interdental brush. The CURAPROX Superduo of- fers the perfect choice for everyone. Visit the website to learn more about our products: www.curaprox.com/ch-en Periodontal disease may be key initiator of rheumatoid arthritis By DTI AMSTERDAM, Netherlands: In re- cent years, increasing attention has been given to aspects of oral health in patients with rheumatoid arthri- tis (RA), especially related to associa- tions with periodontal disease. The results of a study conducted at the University of Leeds in the UK, and recently presented at the Annual Eu- ropean Congress of Rheumatology (EULAR 2018) in Amsterdam, dem- onstrated increased levels of peri- odontal disease and disease-causing bacteria in individuals at risk of RA. The study found that the prevalence of periodontal disease was increased in patients with RA and could be a key initiator of RA-related autoim- munity. This is because autoim- munity in RA is characterised by an antibody response to citrullinated proteins in which the amino acid arginine has been converted into the amino acid citrulline, altering the proteins’ structure. The oral bac- terium Porphyromonas gingivalis is the only human pathogen known to express an enzyme that can generate citrullinated proteins. The study included 48 at-risk individ- uals (positive test for anti-citrullinat- ed protein antibodies), 26 patients with RA and 32 healthy controls. The three groups were balanced regard- ing age, sex and smoking. “It has been shown that RA-associ- ated antibodies, such as anti-citrulli- nated protein antibodies, are present well before any evidence of joint disease. This suggests they originate from a site outside of the joints,” said study author Dr Kulveer Mankia, clinical research fellow at the uni- versity’s Institute of Rheumatic and Musculoskeletal Medicine. “Our study is the ﬁrst to describe clinical periodontal disease and the relative abundance of periodontal bacteria in these at-risk individuals. Our results support the hypothesis that local inﬂammation at mucosal surfaces, such as the gums in this case, may provide the primary trigger for the systemic autoimmunity seen in RA.” “We welcome these data in present- ing concepts that may enhance clinical understanding of the key initiators of rheumatoid arthritis,” said Prof. Robert Landewé, Chair- person of the EULAR 2018 Scientiﬁc Programme Committee. “This is an essential step towards the ultimate goal of disease prevention.” The study abstract is titled “An in- creased prevalence of periodontal disease, Porphyromonas gingivalis and Aggregatibacter actinomyce- temcomitans in anti-CCP positive individuals at-risk of inﬂammatory arthritis”. Patient motivation techniques By DTI When it comes to motivating pa- tients to maintain good oral hygiene practices, a clear plan is essential giv- en the time constraints of most den- tal appointments. What this plan en- tails, however, depends on what the most pressing issues to the patient are. prevention magazine spoke with Sandy Basheda, a dental hygienist at the M & N Dental Practice in Bedford in the UK, about how she structures her oral hygiene appointments and the importance of building relation- ships with patients. Ms Basheda, how did you ﬁrst get started as a dental hygienist at M & N Dental Practice? Sandy Basheda: I’ve been working at M & N Dental Practice for three years now. I started basically straight after I graduated from the University of Liverpool with a degree in dental hy- giene and therapy. Prior to that, I had a background in dental nursing, but I wanted more of an instrumental role with dental patients, which led me to hygiene and therapy. What does your average day at work involve, and what is the structure of your oral hygiene appointments? I see many patients with periodontal problems and so conduct a lot more hygiene right now than therapy. I also deal with a lot of children that, unfortunately, have dental caries due to a poor diet, lack of oral hy- giene and likely a lack of education on how to prevent it. It’s not a good start for children if they have to have ﬁllings put in or even have their teeth pulled if it’s particularly bad— it doesn’t give them a good ﬁrst im- pression of the dentist. Each oral hygiene appointment is scheduled for half an hour and be- gins with a discussion about the patient’s existing problems and current oral hygiene routine. I then explain to the patient what the pur- pose of the appointment is and what it will entail and conduct an assess- ment of his or her oral health. Every patient is very different, and it really depends on what he or she needs ad- dressed as to how the appointment will proceed from there. How can you get patients to continue with good oral hygiene practices after an appointment? I think one has to build a relationship with them. They have to trust one and understand what the beneﬁts of oral hygiene are, as they might not be aware that they have any prob- lems in the ﬁrst place. For example, if smokers aren’t experiencing any bleeding in their mouths, they might not think that there’s anything to worry about. One needs to be able to explain to them in a clear and un- derstandable way why taking care of their teeth is important not just for their oral health but their overall health too. But is it possible to achieve this all within half an hour? Well, it’s not a lot of time, but we can always schedule an hour-long appointment if it is necessary. I see many anxious patients, patients who might not have been to the dentist in ten to 15 years. With these patients, a shorter appointment is often good in the beginning, because it means that they’re not overwhelmed and that one can build up from there over the ensuing sessions. By the sec- ond or third appointment, they’re a bit more relaxed and eager for treat- ment. How do you motivate your patients to take charge of their own oral hygiene? I think it’s mostly about re-educating patients on what the correct and most effective cleaning methods are, what products are best for them. It’s about ﬁnding something that works for the patient, something that will get him or her excited about taking care of his or her teeth and seeing the beneﬁts. In dentistry, it can be difﬁcult to engage in a cooperative relationship with one’s patients—of- ten, it’s a one-way conversation with the professional giving the patient instructions or advice on how to take care of himor herself. I like to leave that sort of instructional conversa- tion to the beginning or the end of the appointment, as this allows the patient to think, while in the chair, whether he or she has any questions about anything I’ve said or what our future appointments will entail. Be- ing able to answer these questions in a clear and understandable way is es- sential to motivating patients. Thank you very much for the inter- view.
A soft appdoach fod tough adeas. Enamel is hadd. Hadded than steel, even. And it should stay that way. Enamel- fdiendly bdushing means: pampeding youd teeth and gums with tended loving cade. Like with the gentle CS 5460 ultda soft. Mmmm, let’s do that again. cudapdox.com
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
Dental Tribune Middle East & Africa Edition | 4/2018 HYGIENE TRIBUNE C7 ◊Page C6 counselling. One needs two or three control sessions to check his or her dexterity and oral cleaning perfor- mance. Plaque disclosure remains a confronting but very effective tool to show the results of the patient’s cleaning habits. the dental professional Finally, should show enthusiasm and keep on repeating until there are visible improvements. From your point of view, does the dentist spend enough time on the diagnosis of a disease? Of course, dentists are dutiful people who are concerned with their jobs. Spending time to ensure correct di- agnosis is their core business. Exam- ining patients means exploring and looking for mostly hidden troubles or discomforts. The next question is the most im- portant one: is this problem acute enough that it should be treated im- mediately, in the very near future, or can we wait and see how it develops? This is risk management and it is de- pendent on multiple factors. Often, prevention is neglected in dental practices in favour of diagnosis and restorative treat- ment. How can dental profes- sionals implement prophylaxis in their daily practice, especially primary prophylaxis? I would say, rather, that prevention is not neglected. Sixty-ﬁve per cent of GDPs provide information about oral hygiene as a standard proce- dure. Depending on compliance, the GDP may decide to spend more time on patient guidance. This requires delicacy, as one cannot tell from a pa- tient’s face how motivated he or she is, nor what he or she is interested in. This is not often asked of the patient, so one could rather say there is not enough time spent on communica- tion. I invite practitioners to do an experi- ment in their waiting rooms. While the patient is waiting for his or her appointment, he or she can be given a short questionnaire asking him or her to write down in a few words his or her understanding of proper home care and his or her personal ritual. The patient can then be asked if he or she would be interested to know more about it. We use this method in our clinic. In the waiting room, patients have time to reﬂect and one might be surprised at how interested patients really are if one gives them the opportunity to com- municate and to prepare their ques- tions in advance. To be honest, I think that primary prophylaxis is impossible to achieve because we do not control all the inﬂuencing factors, of which some can be health- or patient-related. It means that we need to try to pre- vent people from developing caries or periodontal disease. This is some- what futile, since caries and peri- odontal disease are the most wide- spread infectious diseases present in almost every patient. Twenty-ﬁve per cent of 5-year-old children have bleeding gingivae, and this ﬁgure rises to 55 per cent for 15-year-olds. Primary prevention is like plac- ing speed cameras on highways: it works all the time and for everyone, it is highly effective and inexorably justiﬁed. Today, I heard in the news that, thanks to these speed cameras and other regulations, the number of persons killed by trafﬁc every year is diminishing. This is primary preven- tion. However, I strongly believe in secondary prevention; it is the den- tist’s duty to examine and to inter- vene, preferably before detrimental clinical signs occur. How important are home care and high-quality oral hygiene products such as those of CURAPROX? It is a fact that oral hygiene devices are not considered as pharmaceuti- cals and they therefore don’t have to be thoroughly tested. If a company designs a nice, good-looking tooth- brush, it is allowed to produce it and sell it, even if the brush does not meet the criteria desired in an effec- tive toothbrush. Comparing the oral hygiene prod- ucts from different companies, we see a variety of designs and features. This is interesting because there is no such thing as the perfect interdental brush. There are always compromis- es to make and what some patients like, may be rejected or disapproved of by others. We as dentists have only an advisory, consultative role. Nevertheless, CURAPROX makes Swiss-quality products designed by dental professionals, and the com- pany is willing to listen to advice on how to improve its products. What is the status of dental hygiene in Belgium? In other words, how does the Belgian mouth look? When I go abroad to congresses and meet with peers, I feel their displeas- ure when they hear that I come from Belgium. The ﬁrst thing I am asked is, how can you treat periodontal dis- ease without a dental hygienist? For them, it is like having bars and pubs, but no beer. I have read some articles in which the decayed, missing and ﬁlled teeth and decayed, missing and ﬁlled sur- faces scores of children were com- pared between different European countries. Though Belgium was not top of the class, it wasn’t at the bot- tom either. In articles from the US, it is reported that, at 30 years of age, 25 per cent of the American population have mild periodontitis, 60 per cent have chronic periodontitis and 15 per cent have aggressive periodontitis. This is exactly the same breakdown as in Europe. The question is not about whether dental hygienists are necessary; the question is, what per- centage of the population do den- tists reach and can afford to go to a dental hygienist on a regular basis? Despite all this, we seem to be able to manage the periodontal situation in Belgium and this was one of the rea- sons for the second study. Does the addition of dental hygienists make financial sense or does prophylaxis make financial sense for the dental practice if the practice already makes good money with implants? I understand your point of view that, in the perfect world of prophylaxis, dental implants have no place be- cause everything should be done to prevent implant treatment. I remember Prof. Jan Lindhe saying that, nowadays, too many treatable teeth are extracted to be replaced by dental implants. As a periodontist I agree with Prof. Lindhe; a dental im- plant is an effective instrument to re- habilitate edentulous areas, but only after all other options have been con- sidered. But often life decides differ- ently, and at Ghent University, I see a lot of young people seeking dental care because of, for example, frac- ture of one or more of the front teeth owing to biking and other kinds of accidents, sometimes under the in- ﬂuence of alcohol or drugs. These students don’t want to wear remov- able dentures for life. With respect to the ﬁrst part of the question, of course the addition of dental hygienists makes ﬁnancial sense. The purpose is to relieve den- tists of those tasks that can be del- egated to auxiliary staff. Secondly, dental hygienists will be trained to communicate with patients about their problems and questions. Del- egating prophylactic care to the den- tal hygienist implies that more pa- tients can be treated and followed up on. We also must not forget patients who live in nursing homes. Since nurses are not allowed to provide dental treatment, we are glad that, in the near future, dental hygienists will be available to give these people the necessary preventative care. What kind of prophylaxis does the Belgian dentist perform in the office? How much time do you devote to prophylaxis? Supposing that patients go to their GDP on a yearly basis, supragingival scaling and scaling of shallow pock- ets is standard procedure. The Dutch Periodontal Screening Index is a per- fect tool to screen patients for perio- dontal disease and treatment needs, but this index is unfortunately not yet applied widely enough, even though it is reimbursed. If a GDP remarks that the gingivae bleed eas- ily or if the patient complains about periodontal infection, then the peri- odontal probe is used and the pa- tient will eventually be referred to a periodontist. UC Leuven-Limburg and Artevelde University College (in Ghent) are offering a new professional bachelor’s degree programme in dental hygiene. Is that a breakthrough? It certainly is. It is a pity that this programme is not yet offered in the French-speaking part of Belgium. Let’s hope they will follow with us as soon as possible to ensure the levelling of our nation’s dental care. Since Leuven and Ghent are the only Flemish universities where the dental graduate curriculum can be followed, it is logical that dental hy- gienists will be trained at those same universities, and that both profes- sional groups will start to work to- gether at chairside from trainee level onwards. When looking at your Dutch neighbours, what do you think should be replicated in Belgium? In the Netherlands, they have more than 50 years of experience with dental hygienists. This profession is well represented and has a strong, hardworking and lobbying society. We in Belgium have always respect- ed and admired the pioneering way of organising dental care in the Neth- erlands. Although tough discussions have had to be conducted, they have always reached a consensus. Today in the Netherlands, up to ten differ- ent levels of dental professionals are distinguished, from specialists to dental assistants. I don’t think we will ever see this development in Bel- gium. The advantage of us being behind is that we can copy the best things that have proven to be solid and to work, and delay the more complex or risky things until we see how it works out there. I hope that dental hygienists will in- tegrate easily into the dental work- place and that their future will be as bright as it is in the Netherlands. Finally, where do you see the future of Belgian dentistry? When I graduated in 1986 as a peri- odontist I had two dreams, the ﬁrst of which was the ofﬁcial recognition of our diploma as a specialist in peri- odontology and oral implantology. This dream was only fulﬁlled in 2003. My second dream was that dental hygienists would be legalised to work in Belgium, and as you know, this will also become true from 2019 onwards. So, the future is bright. I fortunately did not mention how long it would take before my dreams would be fulﬁlled! Looking back to ten years ago, tak- ing digital impressions with oral scanners was still a utopia; there were no navigation systems avail- able for implant therapy, and we did not yet have these composites with hydroxyapatite nanoparticles. Den- tistry has evolved in such a rapid way that the future is today. However, in my opinion, the evolv- ing trend towards cosmetic dentistry is almost alarming. There is noth- ing wrong with the high demand for aesthetic dental treatments be- cause it has been proven that these patients show more compliance in cleaning their teeth, but there is a tendency towards the belief that appearance is more important than function. Many patients prefer whit- ening their front teeth to periodon- tal treatment to save natural teeth. While they argue about periodontal therapy not being reimbursed by the healthcare system, this point is not raised when they seek aesthetic dental care. Another rather regrettable observa- tion is the fact that stock-market- listed companies invest in dental clinics and hire dentists as employ- ees. Of course, this is a sign of the times. Being the manager of a group clinic today has turned into a full- time job that has almost nothing to do with dentistry. Let’s hope that the ﬁnancial management of these clin- ics is not more important than the patients and that the dentists work- ing in the system still feel the same responsibility towards their patients. Thank you very much for the inter- view.