With patients coming back to dental practices after months away, Gamze Eroglu explores how the lockdown has changed the perio landscape.
Exam season was almost approaching. I had my notes all organised, a new coffee mug and was ready to spend most of my days sitting in the library.
However, this year has been a little bit different. COVID-19 has affected each one of us. Businesses forced to close, children not able to go to school, elderly loved ones left feeling alone. For me, the uncertainty of exams was frightening; all leading to a rollercoaster of emotions, a stressful experience for many.
We know that stress is a periodontal risk factor. Studies by Wimmer et al (2002) show that chronic stress, not only increases the severity of periodontal disease but also decreases the effectiveness of treatment.
In addition, passive coping strategies, such as smoking and increasing alcohol consumption, have been found to be more pronounced in individuals with more advanced disease (Wimmer et al, 2005). So, what have these unprecedented times meant for patients?
Following government guidelines, practices alongside dental schools across the UK have had no choice but to close their doors to patients, staff and students for the safety of us all. What should we expect with regard to patients’ oral hygiene habits on return?
COVID-19 and behaviour change
Each of us has had a duty to stay at home in a bid to slow the spread of coronavirus. Many have spent the time finding new hobbies. For example, embracing arts and crafts or giving Mary Berry a run for her money. Whilst others, including myself, have resorted to comfort-eating. Maybe a little more than we should (I am all about the Biscoff hype right now). It’s an easy coping mechanism to diffuse uncomfortable feelings like stress.
The physical and emotional symptoms of stress are often detected by headaches, stomach-pains and anxiety. But are we overlooking the effects it can have on our oral health? How aware are patients of the implications? A study by Vasiliou et al examined whether psychological stress contributes to poor oral health systemically, in combination with other chronic diseases (2016). The results concluded that individuals with greater perceived stress, also reported poorer oral health.
Stress can come in many forms, but we all experience it. For many, the uncertainty surrounding coronavirus has been the most difficult aspect. It made me think about the effects it might have on patients’ oral hygiene. And how patients may require closer monitoring and more vigilant maintenance when we return.
What is periodontitis?
The dental setting can be a daunting experience for some patients on a good day. Now, with extra PPE and safety precautions to keep us all safe, it can be an even more nerve-wracking visit.
Periodontitis is a multifactorial disease. It is caused by the accumulation of dental plaque. This is due to improper tooth brushing techniques and a lack of interdental cleaning. Irregular visits to the dentist, hygienist or therapist also contributes. This bacterial build-up around the surfaces of teeth, causes an inflammatory response and gingival inflammation – resulting in the gums bleeding. This is known as gingivitis and, with improved oral hygiene, can be reversed.
In some patients, if left, this progresses to the destructive disease, periodontitis, that damages the tooth-supporting tissues.
When reflecting on my time on student clinics, I was surprised to hear from some patients that they were unsure of the correct techniques required to maintain their oral health. Knowledge that we probably take for granted. As an undergraduate, we can fortunately spend significant amounts of time with patients. We can explain the course of treatment they require. And we give tailored oral hygiene instructions (OHI). This is to help them manage their periodontal condition at home.
However, we will not have quite the same luxury once we graduate. The financial considerations of running a dental practice means that appointment time in relation to the cost or price of the procedures needs considering. We should focus our time on the interventions that will deliver the most impact for the patients. With all the essential parts competing for a piece of each appointment ie taking a history, carrying out treatment and writing up notes, we really need to prioritise what we do in each appointment.
With plaque removal such an important factor, does this therefore mean that our initial appointments with our patients should prioritise oral hygiene over scaling?
The BSP supported the Back to Work document from the chief dental officer. It used the recent S3 treatment guidelines (Sanz et al, 2020) from the EFP to support its evidence base. Both make an excellent case for a phased approach to periodontal care, focusing on behavioural aspects like oral hygiene and risk factor management before moving on to a treatment phase. Some studies have shown as much as a 1.6mm pocket depth change with an oral hygiene phase alone (Hans, Al-Lami and Baelum, 2020).
Whilst patients may question this non-scaling approach, it is for us to educate our patients why we should adopt this approach for their long-term benefit. As much as we are treaters of disease, we should be champions of prevention.
With current circumstances, practices are only able to see a handful of patients per day to provide reduced treatment, alongside emergencies. This window of opportunity allows more time to primarily focus on OHI and could be rewarding in more ways than we think. There has never been a better opportunity to change the way we think and focus on patient education. Particularly with regards to disease progression, ways to control periodontal conditions at home, and the benefits it brings.
COVID-19 has changed dentistry in several ways, including how we consider aerosol exposure. During even the very first few weeks of university, the importance of PPE and hand washing to reduce our risk of exposure to infectious diseases was drilled into us and rightly so. We have seen the coronavirus outbreak put hygienists at the top of list of occupations with the highest risk to COVID-19.
Aerosols are ‘any medical and patient care procedure that results in the production of airborne particles (aerosols); relevant to COVID-19 transmission, since they may occur through both direct air-borne infection and indirect spread via contact with contaminated surfaces‘. Following GDC guidelines, we must follow the new guidance regarding AGPs to ensure safety for all. However, as practices have had to ditch the ultrasonic for hand-scalers only – what does this mean for clinicians? AGPs form a significant part of the role of a hygienist or therapist.
As dentists carry out emergency treatments, now is the time to utilise the full scope of practice for other members of the dental team. Hygienists are ‘registered dental professionals who help patients maintain their oral health. They help prevent and treat periodontal disease and promote good oral health practice’, whilst under prescription treatment from a dentist or through direct access. Therapists have the same role, in addition to being able to carry out routine restorative work. How aware are other members of the dental team of our capabilities?
A multidisciplinary team approach and understanding of the different roles within the dental team can enhance patient care. Dental school should emphasise this early on. This therefore allows the most appropriate referrals to be made while improving time management – a recipe for success.
Interdisciplinary collaboration will have an extremely positive impact for the future of dentistry. It will reduce pressure on dentists. Patients see different members of the team for different components of treatment. Introducing this approach at an educational level will also help develop trust and understanding of each other’s professional role.
As the hygiene-therapy liaison for The British Society of Periodontology and Implant Dentistry Undergraduate Group, being part of a group that champions collaborative practice has been encouraging. It has allowed a level playing field for hygiene and therapy students to work with dental students to explore each other’s professional remit and the links between oral disease and the rest of our body systems.
Welcoming patients back
Thinking about the potential behaviour changes and stresses patients may have experienced during the lockdown period has highlighted for me the extra care we may need to take when returning to see patients. We cannot underestimate the hardships faced and how it has affected us and our patients in different ways.
The unstructured days have been a dream come true for some. Whilst others are left feeling lost and unproductive. This may result in disruption to our normal sleeping patterns, a change of eating habits (increased snacking or skipping meals) and, I worry, a neglect of oral hygiene for some too. Has there maybe been one too many late nights, falling asleep on the sofa whilst binge-watching Netflix, skipping tooth brushing and flossing? Are we expecting an increase in the number of patients experiencing gingivitis or periodontitis?
We should take COVID-19 as a learning opportunity, not just for patients, but ourselves as students and clinicians too. Introducing collaboration in undergraduate programs is essential to students and clinicians of the future. It starts with the mindset of students and clinicians, followed by our patients.
Highlighting the importance of prevention; by using the time for more than treatment alone, it will allow patients to engage and understand their periodontal condition and take ownership and responsibility for their disease management and prevention. Most patients would want to know the cause and effect with any other medical treatment. It is our duty to educate and ultimately empower them to look after their oral health for life.
Hans R, Al-Lami Q and Baelum V (2020) Oral hygiene revisited. The clinical effect of a prolonged oral hygiene phase prior to periodontal therapy in periodontitis patients. A randomized clinical study. Journal or Clinical Periodontology 47(1): 36-42
Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Beglundh T, Sculean A, Tonetti M (2020) Treatment of Stage I‐III Periodontitis – The EFP S3 Level Clinical Practice Guideline Journal of Clinical Periodontology Journal of Clinical Periodontology
Vasiliou A, Shankardass K, Nisenbaum R and Quiñonez C (2016) Current stress and poor oral health. BMC Oral Health 16(1)
Wimmer G, Janda M, Wieselmann-Penkner K, Jakse N, Polansky R and Pertl C (2002) Coping With Stress: Its Influence on Periodontal Disease. Journal of Periodontology 73(11): 1343-51
Wimmer G, Köhldorfer G, Mischak I, Lorenzoni M and Kallus K (2005) Coping With Stress: Its Influence on Periodontal Therapy. Journal of Periodontology 76(1): 90-8