The age of plaque management – a journey of partnership



The age of plaque management – a journey of partnership 1

Gulab Singh offers insight into how he supports his patients’ efforts to control plaque biofilm, and why success is all about the journey patient and clinician take together, rather that the hygiene appointment pit-stop in isolation.

Earlier this year, a survey conducted by Johnson & Johnson, the makers of Listerine, revealed that over 95% of dental professionals have reported that they often see patients who are struggling to manage their plaque levels at home through mechanical cleaning alone (Johnson & Johnson data on file). That was on the responses of 721 oral health care professionals in April 2021.

In addition, out of the 721 dental professionals surveyed, over 80% responded that they still struggle to improve their patients’ mechanical cleaning to a level where plaque is manageable following further oral health education (Johnson & Johnson data on file).

So, whilst the standard recommendation remains to brush the teeth and clean interdentally, the overwhelming response from over 700 oral health care professionals suggests more is needed to support some patients’ plaque levels. Over and above mechanical cleaning and oral health education (Johnson & Johnson data on file; Figuero et al, 2020).

A practical perspective

For me, these figures are a reality. I work in a practice where around 60 to 70% of my patients are in the older age categories. Every day is a challenge.

I see patients struggling to maintain their oral health and keep their plaque levels down. Despite trying their best with mechanical cleaning aids.

Of course, it isn’t just an issue tied in with age. That is one example; there are other areas of potential concern in relation to oral care between appointments. Such as time constrains, dexterity, medical issues, co-ordination, and so on.

Each of these – and more – can affect a patient’s ability to maintain plaque levels and keep gum disease at bay. Even with the best will in the world.

They know very well the mantra of brushing twice a day that we all learned from childhood, but one size doesn’t fit all. Nowadays, we hygienists and therapists want our patients to clean interdentally as well. That is a challenge for patients both in terms of the dexterity needed and a change in habits.

Helping with plaque management

Plaque management is a key element of achieving and maintaining oral health, of course. So when a patient finds it difficult to maintain an effective plaque level, I try to identify the cause and rectify the problem, if possible.

I also try to adapt the brushing technique and interdental aids in certain ways that may help the patient overcome some of the difficulties they are facing.

For example, I will ask a patient to demonstrate their brushing technique. And, if it is lacking in some areas, I will show them a better way to do it. I have embraced the ‘tell, show, do’ technique in my practice. It is something that can really resonate with the patient.

We are not always successful in these endeavours. So, after we have tried to change the way a patient does things using mechanical means alone but find they are not managing to get the job done, I consider the use of a chemotherapeutic agent.

An evidence-based approach

That has not always been the case. Over time the evidence base has changed. I follow that in combination with my experiences over the years of practising.

Take interdental cleaning as one example of how things change. Decades ago, interdental cleaning was not really a ‘thing’. It was all about tooth brushing. Now, research has proven that there is a role for interdental aids, especially in the fight against gum disease.

As an oral health educator, part of our job is to share this information with patients. This way they can understand the ‘why’ behind what we are asking them to do.

It does not stop there, however; we go on a journey with our patients to support them in their efforts to change years of ingrained habits and adopt new ways of looking after their mouth.

We now know that behaviour change takes time. Every time I see a patient, we talk about how and what I can do and what they can do.

Over time, I slowly add bits to their regimen, in an effort to build a foundation for every aspect of self-care that is needed to achieve a good outcome for them.

Adding to the gold standard

Mechanical cleaning is the gold standard for plaque removal. And it does help patients once they are educated with techniques and understand why they need to do what I am asking of them.

The vast majority of patients do try their best to incorporate my recommendations to improve their oral health. However, some group of patients, despite their efforts, will always struggle.

These groups of patients need additional support and that is assessed on an individual basis. It might involve increasing the frequency of recall for supportive periodontal therapy or discussing with the patient the possibility of introducing a mouthwash as an adjunct to mechanical cleaning.

The evidence base supports the use of an adjunctive mouthwash for some patients in particular circumstances (Figuero et al, 2020).

The recently published S3-level clinical practice guideline, further justifies the plausibility of using a chemical agent, based on a combination of factors (Sanz et al, 2020).

I am very particular when it comes to recommending mouthwash. It has to be right for the individual patient, evidence-based and have a proven track record of benefits.

I want it to contain fluoride, helping to prevent decay and strengthening tooth enamel. As well as additional properties such as antimicrobial/antibacterial ingredients. Their plaque-fighting mechanism can help to prevent a host of serious dental issues such as gum disease.

Demonstrating improvement

How do you measure oral health and improvement? For me, it starts at the first appointment, before the patient has even opened their mouth for me to take a look.

I start by asking a number of questions, including:

  • Do your gums bleed?
  • Do you have any loose teeth, not the result of an accident or other mishap?
  • How often do you use dental floss or any other interdental aids?
  • How often do you snack?
  • Are you medically fit?

These questions – and more – need following up, of course. But by the time I have finished this conversation, I already have a good idea of the patient’s oral health.

As for patients needing extra help and for whom I recommend a mouthwash in addition to mechanical cleaning, when they return for review, I do often see lower plaque and bleeding scores.

Where the bleeding score and the plaque score has gone down 20%, that’s a good improvement. Sometimes you even get a 50% improvement, which is extremely pleasing for me and the patient.

It is a journey, not a pit-stop

Working towards achieving and maintaining good plaque levels is a journey we dental professionals take with our patient.

Certainly, patients need to take some responsibility regarding their oral health. But they need guidance by our advice.

Times have changed and modern dentistry is all about the evidence base. The evidence is there that a carefully selected mouthwash formulation can provide a benefit beyond mechanical oral hygiene alone in preventing plaque accumulation, and therefore helping to prevent gum disease.

It’s not for everyone, but it certainly has earned a place in the dental professional’s toolkit.

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Figuero E, Roldán S, Serrano J, Escribano M, Martín C and Preshaw PM (2020) Efficacy of adjunctive therapies in patients with gingival inflammation. A systematic review and meta-analysis. J Clin Periodontol 47(Suppl 22): 125-43

Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Berglundh T, Sculean A and Tonetti M (2020) Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. J Clin Periodontol 47(S22): 4-60