D2 ◊Page D1 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 3/2020 demonstration, the toothpaste is not used. The patient needs to understand that physical effort and adapted instruments are central to toothbrushing. The demonstration employs proximal cleaning devices, mainly interdental brushes. For paediatric patients, parents are involved in the demonstration. For adult patients, the demonstration is performed without the presence of anyone accompanying the patient, to avoid any interference. The following phrases or sentences need to be employed during motiva- tion: • “plaque”, a term now used in toothpaste advertisements; • “bacteria” or “microbes”; • “it is normal to have bacteria (or microbes) in the mouth”; • “everyone’s mouth has dental plaque, including the practitioner’s”; • “a toothbrush and an interdental brush are like a broom”; • “to take the plaque off the tooth surfaces”; • “to optimise the technique of brushing”; • “to get healthy gums”; and • “to keep teeth lifelong”. Fig. 1: The Socransky infectious model20 revisited by Axelsson.1 Plaque control and the position of orthodontic braces relative to the gingival margin act directly on the environmental factor in the sulcus. PMN = polymorphonuclear leucocyte. consequences—The Clinical motivation “scenario” Xun Kuang said, “Tell me and I for- get, teach me and I may remember, involve me and I learn.” This maxim, laid down more than 2,500 years ago, can help us to understand the strategy of the motivation scenario. The patient must understand, and for this, he or she must see and be involved. Some words need to be totally banned from our communication with patients because they can be misinterpreted or considered as value judgements, such as “hygiene”, “good”, “bad”, “clean” and “dirty”. Fi- nally, we should speak in a positive manner to encourage and motivate our patients, because they alone can create the conditions for improved plaque control (Figs. 3a & b). Fig. 2: Information retention according to the Industrial Audiovisual Association (now the Communications Media Management Association).11 Figs. 3a & b: Fifty-five-year-old male patient with chronic periodontitis. (a) Initial clinical situation. (b) Clinical situation at re-evaluation, four months after motivation, plaque control technique explanation, scaling and root planing. Some bleeding on probing was still present. on longer periods. This means that a regular orthodontic and periodontal maintenance needs to be done, at every orthodontic session, every six to eight weeks, to reinforce and promote good oral hygiene. The objective of this phase, common to all periodontal treatment and thus to any orthodontic treatment, is to develop all non-coercitive means to radically change the behaviour of the patient regarding the oral cavity and dental plaque. To motivate means to move, to create conditions that lead to action. In order to reach these objectives, the patient must understand what justifies these changes. Passive elements of communication, such as flyers, huge plastic jaws and a toothbrush for elephants, and vid- eos playing in the waiting room, may be possible reinforcement elements, but at no time will cause changes in patient behaviour, because they are impersonal. The patient cannot identify with what he or she is seeing and standardised speech has very lit- tle impact. Rozencweig states that information retention is boosted to 90% if the person receiving the information hears it, sees it, receives explanations and is involved in a demonstration at the same time (Fig. 2).11 It is also im- portant for the patient to immedi- ately repeat what he or she has seen because this can help to achieve this high rate of retention of the informa- tion, including how to perform the plaque control technique. Benqué states that “allowing our patients to see and to be aware about the exist- ence of the biofilm is an act of abso- lutely major motivation”.12 He asks of the reader whether he or she has disclosing solution in his or her oral hygiene arsenal, and if the answer is no, he (ironically) invites the reader to close his book.12 in Three tools are essential for patient comprehension: disclosing solution, a toothbrush and a large round mirror. The demonstration is done systematically the patient’s mouth with disclosing solution and a large mirror with a handle to help the patient see his or her teeth directly. A simple brushing technique that aims to remove plaque from all the surfaces is used. In the absence of orthodontic attachments, the roll technique is the simplest, moving vertically from the gingivae to the teeth. In the presence of fixed orthodontic appliances, be horizontal. However, at the end of the orthodontic treatment and after the removal of the fixed orthodontic appliances, a new motivation scenario will be presented with a return to the roll technique. For brushing will At this time, personalised letters, easy to achieve on computer, can be sent to the patient, summarising the origin of periodontal disease, clinical signs reported by the patient and those that were observed by the practitioner. A flyer describing the brushing technique, even with schemas, can be given to the patient, listing the instruments used for the demonstration and the brand/name of a recommended toothpaste. These documents are written to sup- port the information that the patient has received during the appoint- ment, allowing him or her to review the information at home. OK! But what do I recommend? Toothbrushes, oral irrigators, interdental devices, etc.? The pinnacle of improvisation is evident in the recommendation of the instruments (manual or elec- tric toothbrushes, oral irrigators, etc.) and the products (toothpaste, mouthwash, etc.). The practitioner’s recommendations tend to be guided by either medical representatives from companies or the practitioner’s unsubstantiated personal opinion. “I prescribe only this electric tooth- brush. I feel that it works well on my patients.” Unfortunately, such anec- dotic feeling does not appear in the pyramid of evidence-based dentist- ry. It is again systematic reviews or meta-analyses that can help us in our choice because they are independent of any commercial pressure. Electric toothbrush Two recent systematic reviews13,14 arrived at the same conclusion. They found that the use of electric compared with toothbrushes manual toothbrushes causes a modest reduction in the plaque index (amount of plaque) and the (inflammation). index gingival electric Among the toothbrushes, is higher for those with oscillating- rotating movement. Finally, these two reviews indicate that there is no evidence showing superior efficacy of ultrasonic brushes. A meta- the efficiency various analysis examining the effectiveness of electric toothbrushes among orthodontic patients15 found a lack of sufficient evidence suggesting particular efficacy. The authors state that, among the five studies included, none had a duration of longer than 60 days. Irrigators If an irrigator is effective, disclos- ing solution placed in the device’s water tank should leave no stain on the surfaces of crowns. A systematic review concerning the effect of irri- gator use on plaque scores and gin- gival inflammation, based on seven articles selected from 914 publica- tions, found no reduction in visible plaque.16 Thus, while an irrigator can help to remove food stuck in fixed orthodontic appliances, it removes plaque only partially. A recent study on the use of a special orthodontic device showed a significant reduc- tion in plaque scores and gingival inflammation.17 However, at four weeks, there was no statistically sig- nificant difference in proximal re- gions, more difficult to reach with a toothbrush. Dental floss Tooth cleaning is not complete with- out the use of interdental devices. The presence of a fixed orthodontic appliance is an obstacle to the effec- tive use of dental floss. However, a systematic review, of 11 publications selected from 1,353 articles, on the ef- fectiveness of flossing in addition to toothbrushing reported that many of the studies showed no benefit on the plaque index and the clinical pa- rameters of gingival inflammation.18 The authors concluded that the practitioner should check whether the patient is able to achieve a high technical level of cleaning (dexter- ity), but the routine use of floss is not supported by scientific evidence. Interdental brushes A systematic review, of nine arti- cles selected from 334 publications, concluded that interdental brushes remove more plaque than does brushing alone and that a statisti- cally significant decrease is obtained on the plaque index, on the bleed- ing index and in proximal pocket depth.19 The plaque index is even lower than that obtained with floss. Finally, the interdental brush is not hindered by the presence of a fixed orthodontic appliance. Conclusion All progress requires change, but not all changes constitute systematic progress. Evidence-based dentistry can be helpful in our everyday prac- tice, particularly in choosing for the patient, good devices for performing oral hygiene, during an orthodontic treatment. Editorial note: A list of reference can be obtained from the publisher. This article was first published in or- tho-international magazine of ortho- dontics, Volume 4, issue 2, 2019 About the author Dr Jean-Marc Dersot is past president of the Société Française de Parodontologie et d’Implantologie Orale [the French Society of Periodontics and Oral Implantology] and previously taught as assistant professor in the Fac- ulty of Dental Surgery at Paris Descartes University in France. He has a practice lim- ited to periodontics and implant surgery in Paris.