E2 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2021 Plaque control measures and thrust for preventive dentistry—dentists’ attitude By Dr Hadal C. Kishore, India Periodontitis is pandemic in nature and distributed all over the world. The disease’s prevalence and burden on oral health in India is no differ- ent, and periodontitis shows no dis- crimination between race, sex, caste or creed. Many studies quote an incidence rate of greater than 30% among the global adult population. The numbers are staggering: more than 300 million people in India have periodontitis. If we consider gingivitis, the numbers are even more mind-boggling. Periodontitis remains the single largest reason for loss of teeth currently. Although many risk factors and predisposing factors are attributed to the aetiol- ogy of periodontitis, dental plaque is the predominant reason and the most easily modifiable risk factor to prevent periodontal disease. Many studies state that low dentist- to-patient ratios and lack of aware- ness among patients are some of the plausible causes of the high inci- dence of periodontitis in the Indian population. However, hardly any studies exist that inform us about dentists’ awareness and their views on plaque control measures avail- able and the professional recom- mendations that they endorse to their patients in the ever-changing world of plaque control. We thought that it would thus be of relevance to seek valuable insight on this issue through an online questionnaire- based survey. The questionnaire was devised in a multiple-choice format, and the link to the survey was shared with Indian dentists through various social media channels. It all starts interdentally More than 300 respondents com- pleted the survey, among whom there was a balanced mix of 52% males and 48% females. The age of the respondents ranged from 23 to 65 years, and the majority were in the age group of 29 to 50 years. Re- garding professional experience, the respondents included dentists who were just starting out their careers and seasoned practitioners with over 25 to 30 years of experience. The study sample ranged from general dentists to post-graduate students. The majority of the survey respond- ents (54%) had a master’s degree in dentistry. It is almost universally accepted that periodontitis is initiated mostly in the interdental areas, and these re- gions are the most vulnerable to the accumulation of plaque. Hence, the survey questions were designed in such a manner that sufficient weight was accorded to matters pertaining to interdental areas and the plaque control measures employed to keep these areas healthy. An overwhelming 96% of the den- tists stated that they prescribed in- terdental cleaning aids on a routine basis to most patients, which we be- lieve is a very healthy indication. As to which is the most recommended interdental cleaning aid, most of the respondents fell into two categories: 55% of them preferred interdental brushes and 40% dental floss. Only 2.65% recommended oral irrigators. We deduced that India being a cost- sensitive market, the higher expense for the patient of procuring an irri- gator deterred most of the dentists from recommending irrigators. Practice what you preach The survey probed this matter fur- ther, asking whether the dentists themselves used an interdental cleaning aid on a regular basis; nearly half of them confessed that they did not use such aids, while an- other 35% of the dentists responded that they used them occasionally. These figures point to an apparent contradiction: it would appear that dentists are not practising what they are preaching. This left us wondering whether all the professional advice that dentists provide is limited to patients alone and whether dentists lack conviction in prescribing inter- dental cleaning aids. There were various reasons given by the respondents for not using inter- dental cleaning aids themselves. The most predominant being that they could manage to clean their inter- dental areas with regular brushing alone, followed by the reason that they had tight contacts between their teeth and thus the use of inter- dental aids was not warranted. Other main reasons given were that they were lazy to use the aids and that it was time-consuming to clean inter- dental areas. The questionnaire investigated this compliance issue in patients too with a question on the main chal- lenges associated with the use of in- terdental cleaning aids in patients. Most of the dentists (54%) opined that a lack of awareness was the ma- jor issue, followed by a lack of moti- vation in patients and the technique sensitivity in using the aids. Some re- spondents said that patients found it too time-consuming, and ten per cent said that cost factor was an issue for patients. Mouthrinses are employed rou- tinely as a chemical plaque control measure as adjunct to mechanical plaque control. Mouthrinses are a popular choice among both den- tists and patients, as these are easily available, cost-effective, and not very technique-sensitive or time-con- suming to use. The survey question- naire elicited the dentists’ opinions regarding the efficacy of anti-plaque mouth- rinses in disrupting plaque in the interdental areas. Forty per cent of respondents believed that such mouthrinses could effectively disrupt plaque even in interdental ar- eas, and an equal number of respond- ents felt this not to be true, while 20% were uncertain in this regard. Another interesting insight that we obtained through the questionnaire survey was that 60% of the dentists had never used a single-tufted brush, yet 57% opined that single-tufted brushes can benefit all patients. Some of the dentists felt that their use is limited, being beneficial only in orthodontic patients, in cases of crowding or in implant patients. This highlights lacunae in our education system: the majority of the dentists, some of them having more than 25 years’ experience, had not used something as basic as a single-tufted brush even once. Dental implants have been the fast- est-growing treatment modality for quite some time now. We wanted to ascertain what measures are employed by dentists to maintain implants and keep them plaque- free. Of concern was that 20% of the dentists did not prescribe any special form of care. Oral irrigators were the most prescribed tool, more than 30%of the respondents recom- mending these. Implant floss/tape, interdental brushes and single-tuft- ed brushes were prescribed by fewer than 20 per cent of the dentists. Only two respondents said that they rec- ommended the Hydrosonic sonic brush (CURAPROX). The choice of oral irrigators as the most preferred for maintaining implants assumes importance in light of hardly any of the dentists recommending these to their patients on a routine basis. This supports our earlier affordability reasoning; patients who can afford high-value treatments such as im- plants can also afford irrigators. Toothbrushes are the most hum- ble of tools, but are the workhorses when it comes to plaque control. When asked about their choice of bristle hardness of toothbrushes, 62%of the respondents recommend- ed soft bristles and 12.5% ultra soft. Nearly 25% of the dentists preferred medium-hardness bristles. We wanted to test the awareness of dentists on the functioning of sonic toothbrushes. In response to the question on this, nearly 40% said that they knew how a sonic tooth- brush functions, whereas the other 60% of respondents either did not know or had only a vague idea. through Better prevention hands-on instruction We believe that, with rising aware- ness on oral health among the pa- tients, preventive programmes will receive thrust henceforth. Thus, we explored the dentists’ views in this regard. An overwhelming 97% of the respondents agreed that a great deal more emphasis has to be given to plaque control measures in their practices, and 91% of the dentists agreed that adopting preventive dental care routines in their clinics could benefit their practices. The ma- jority of the respondents (76%) regu- larly set aside clinic time to educate their patients regarding prevention; however, most dedicated only two to five minutes to educating patients, which we feel is grossly inadequate. In conclusion, we would like to make the following observations. A great deal more emphasis has to be given to training dental students on the practical aspects of plaque control measures during their dental edu- y a b a x P / n a i i l e m h o h S h p e s o J © cation in India. They have to be ex- posed to the plaque control tools available in the market, and their pros and cons have to be debated upon. In pursuit of incorporating ad- vanced treatment modalities in their practices, it appears that dentists are neglecting something as basic as plaque control, which forms the cornerstone of the preservation of natural teeth. Editorial note: This article was originally published in prevention-international magazine for oral health, Issue 2/2020. About the author Dr Hadal Chandrasekhara Kishore He has over a decade’s experience as a consultant periodontist and is from Bangalore in India. He holds a BDS and MDS in Periodontics from Krishnade- varaya College of Dental Sciences and Hospital in Bangalore. Dr Hadal places great emphasis on patient education alongside treatment, in order to create a motivated and educated patient, as he believes this is beneficial to the patient, the dentist and society at large. He is a postgraduate guide and associate profes- sor at Krishnadevaraya College of Den- tal Sciences and Hospital and is a much sought-after speaker in dental circles. He has over 15 international and national publications to his name. The first iTOP lecturer from India, Dr Hadal completed the iTOP Teacher seminar in Prague in the Czech Republic and is head of education at Curaden India.