COVID-19 and periodontal management – with a response from Professor Iain Chapple
Imogen Fox (nee Wood) explains how to maintain our patient’s oral health during lockdown and what post-COVID-19 practice might look like.
The rumour mill is already churning out projections about what the post-COVID-19 work environment might look like. But how might these changes impact our work as hygienists? Quite rightly, we are pausing aerosol generating procedures (AGPs) to reduce the risk of further spread of disease. I believe it’s likely on return to work regulators will ask us to continue to avoid the use of AGPs. At least until we have fully cleared the virus from our communities. A recent BBC news broadcast suggested that most experts think a vaccine is likely to become available by mid-2021. This could mean that returning to what we all think of as regular practice protocol could still be some time away.
There is currently nowhere for patients to go to access periodontal care. This is deemed as non-essential, non-emergency care. In the absence of facial swelling or acute pain patients are being told to wait until the end of lockdown before they seek treatment. Dentistry is not, however, all about keeping people out of pain. Modern dentistry has a strong emphasis on prevention rather than treatment. Regular visits for examinations and support of periodontal health naturally have a beneficial impact on their oral health. But they can also have the economic benefit of saving patients hundreds, if not thousands of pounds. All by avoiding the need for expensive treatment. Furthermore, we should not overlook the effects that poor oral health can have on a person’s general health and wellbeing. With known links to cardiovascular disease, diabetes, dementia, perhaps even the growth of tumours.
Every one of us have patients under our care who are highly susceptible to periodontal disease. If, on reopening, dental practices are asked to only offer urgent care and continue to avoid the use of AGPs until a vaccine is available, especially while effective PPE is in short supply, then the role of hygienists comes into question. I consider it likely that the government will ask us to avoid seeing ‘at risk’ patients. Such as the elderly, medically compromised and pregnant; the very same patients who are the most likely to be in need of our care.
Time to adapt and grow
I fear we could see a dramatic decline in the periodontal health of patients in the coming months. This raises a number of important questions. When will hygienists be able to offer ‘non-urgent’ periodontal care to patients? Will patients hold hygienists responsible for lost teeth or failing implants when they have missed out on their regular hygienist supportive visits? Who will support hygienists if this leads to litigation? We must wait for guidance from dental governing bodies for answers to these questions. I strongly believe that when practices open, we need to begin offering patients care beyond pain relief, sooner rather than later, in a bid to prevent greater long-term damage. I remain hopeful that we will address this in the near future.
One of the greatest strengths we can show as professionals is the ability to adapt and grow. I have begun to consider how we may be able to support our patients best in the future. All whilst keeping in mind the likely changes we will experience.
Prior to the pandemic, periodontal care was becoming more and more AGP dominated. Following the current Good practitioner’s guide to periodontology, my standard appointment structure would include multiple AGPs including ultrasonic scaling and prophylaxis. Prior to the lockdown I had just started a trial using the new air polishing system, Lunos. This was for both supragingival biofilm disruption and stain removal as well as subgingival prophylaxis. This was proving to be particularly effective at maintaining patients who had orthodontic appliances or implants. Reluctantly, I may have to temporarily hang up my Lunos handpiece.
There has been a great shift away from total calculus removal with aggressive manual root planning techniques. This has been towards a focus on biofilm disruption using ultrasonic and air polishing systems. I am sure I am not alone in hoping that in the longer term we will be able to return to use of AGPs to maximise our patient care. This minimally invasive approach to periodontal care reduces patient discomfort from the sensitivity linked with root surface instrumentation. It also appears to give the same long-term results in terms of treatment outcomes (Maritato et al, 2018; Cobb, 2002; Yan et al, 2020). It is important to keep in mind that this change in outlook has taken place in an effort to make our approach more conservative. But hand instrumentation remains an effective way to remove biofilm and treat periodontal disease.
A return to hand instruments
In the aftermath of the pandemic I feel it is likely that we will need to return to hand instrumentation. At least for a period of time. If this is the case, in an effort to do this in the most effective way we must ensure we maintain all hand instruments. For example, this includes ensuring we sharpen curettes correctly. We must throw away any old ones, which have become misshapen or lost length over time. We must also ensure that we are proficient in correct instrumentation techniques. This will avoid unnecessary trauma to the tooth surface or the gingiva.
With an increase in hand instrumentation likely, we may need to consider longer appointments for hygienists. This could be difficult depending on where you work. I work in three very different environments, all of which have been dramatically effected by the current outbreak. This include working three days a week in a private practice, one day for the NHS community dental services as a dental therapist and one day in a teaching hospital. I feel very fortunate to work in a private practice where we already have one-hour hygienist sessions. But we may still need to go further than this. We may need to look into allowing time in-between patients to ensure effective cross infection control.
If you don’t have them already then it may be time to consider buying some new scalers with silicone, ergonomic handles. Good posture and the possibility of incorporating reinforced scaling techniques to reduce repetitive strain, carpal tunnel and tendonitis may further help those of us who struggle with the long-term use of hand instruments (Millar, 2007).
Oral health advice
We might also need to adapt how we give oral health advice. Effective plaque removal at home is by far the most important element of maintaining oral health. If our patients can effectively remove the biofilm at home on a regular basis they can improve their periodontal health from their own bathrooms.
I believe people benefit most when we show them the correct technique in the mirror. Then using an Oral-B Test Drive brush and observing the patient brushing their own teeth. This ensures they’ve assimilated the information. The same applies to the use of floss and interdental aids. However, when lockdown is lifted we are likely to have to minimise the time we spend in close proximity with our patients.
While we get ‘old-school’ in our hand instrumentation techniques, we may also therefore want to consider getting ‘tech savvy’ in regards to oral health delivery. There are a variety of demonstration videos already available on the internet, which we can send to our patients via email or you may wish to make your own. I have emailed my patients to share some key tips on how to maintain their oral health during the lockdown and have also given them a link to a video tutorial on my social media page (@dental.hygienist.uk).
Prevention and periodontal support is on hold, but we must continue to support our patients in every way we can. We await further advice and guidance from our governing bodies as to how dentistry is likely to evolve beyond the pandemic. I am optimistic that the importance of supportive dental care will not be overlooked for much longer, but we must aim to be flexible in our approach to delivery.
‘It is not the strongest of the species that survives, nor the most intelligent… It is the one who is most adaptable to change’ – Charles Darwin.
Professor Iain Chapple, professor and head of school and periodontology at Birmingham Dental School, response
‘I agree with many of the points raised. I don’t think we will completely eliminate the virus from our community. However, management strategies can and will develop as they did for HIV, prion disease and virulent influenza strains. The soon to be published, International Treatment Guidelines for periodontal care (EFP) provide an early insight into why and how we should designate periodontal care “essential” healthcare, due to the harms associated with no management. It provides the consensus recommendations and evidence base for delivering periodontal therapy in a step-wise manner that reduces risk.
‘The majority of care for the majority of patients can be delivered without AGPs, it may take longer, but is equally as effective as using powered aerosol generating instruments. We can do it safely, if carefully staged and planned. I also think that in time we will be able to resume AGPs, but protocols will evolve, such as having patients forehead temperature checked on arrival and routinely mouth-rinsing with povidone iodine or hydrogen peroxide, using face shields and also FFP3 or N95 masks. I would be amazed if we don’t see high pressure aspiration funnels linked to dental units drawing down any extraoral aerosol that escapes the intraoral aspirator. The aerosol fingerprint may be reduced by -ve pressure environments, and all these things put together will reduce risk.
‘Moving forward, in the absence of a vaccine, there could also be a case for saliva testing for antibodies. The dental profession always gets hit by the sequelae to new infectious diseases, but they bounce back stronger and with exemplary infection control procedures at the core of practice. I am sure as we learn more, we will become less alarmed and we will adapt.’
Cobb CM (2002) Clinical Significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planing. J Clin Periodontol 29 Suppl 2: 6-16
Maritato M, Orazi L, Laurito D, Formisano G, Serra E, Lollobrigida M, Molinari A and De Biase A (2018) Root surface alterations following manual and mechanical scaling: A comparative study Int J Dent Hyg 16(4): 553-8
Millar D (2007) Reinforced Periodontal Instrumentation and Ergonomics for the Dental Care Provider
Yan Y, Zhan Y, Wang X and Hou J (2020) Clinical evaluation of ultrasonic subgingival debridement versus ultrasonic subgingival scaling combined with manual root planing in the treatment of periodontitis: study protocol for a randomized controlled trial. Trials 21: 11