Dental hygiene and therapy advisory panel offers public-friendly consensus on mouthwash use

On 10 December 2021, a group of dental hygienists and therapists were brought together by Johnson & Johnson Ltd for the very first Hygienist Advisory Panel meeting, in order to build on the outcomes of the National Advisory Panel meeting conducted in October 2021.

Held on the Southbank in London, the aim of the inaugural Hygienist Advisory Panel was to discuss how Johnson & Johnson Ltd might best be able to continue its support of dental care professionals (DCPs) in their unstinting efforts to improve the oral health of its patients, as well as strengthening the company’s commitment to a supportive partnership.

As a natural progression from the National Advisory Panel event earlier in the year, and to deliver balance and perspective, it was critical to engage with this group, which, for many, represents the driving force of dental plaque management in the primary care setting.

Working on the front line, dental hygienists and therapists are key to providing education and oral health instruction to patients and supporting them through behaviour and habit change between appointments for improved outcomes.

Therefore, like their counterparts at the National Advisory Panel, the aim was to seek participants’ views in relation to supporting and maintaining oral health in patients between appointments, particularly in terms of mechanical cleaning and possible adjunctive support in the form of a chemotherapeutic mouthwash.

To support these efforts, three presentations were made on the day:

  1. Professor Iain Chapple (chairperson) – the global economic impact of periodontal disease and GRADE evidence
  2. Professor Anthony Roberts (in absentia) – a new perspective on periodontal health and disease
  3. Professor Chris Deery – the current situation in relation to dental caries.

The human and economic cost of periodontal disease

Professor Iain Chapple kick-started the event sharing information about the global burden of oral disease.

While the human cost can be considered in rather subjective terms such as problems with speech, reduced self-esteem, poorer quality of life, and a decrease in general health and wellbeing, the financial implications can be measured more objectively.

This is thanks to the work that went into the publication of The Economist’s 2021 White Paper, ‘Time to take gum disease seriously. The societal and economic impact of periodontitis’.

Data gathered for this paper, when considered overall, indicates that prevention, diagnosis, and management of periodontal disease is cost-effective, with the best return on investment arising from eliminating gingivitis. However, even diagnosing and treating 90% of periodontitis, a costly undertaking, provided a positive return on investment.

Interestingly, reducing the management of gingivitis to only 10% of cases, not only reduces healthy life years, so that the patient’s quality of life drops, but overall costs increased compared to ‘business as usual’. It is therefore more costly in economic terms to neglect gingivitis than it is to treat it.

The presentation then moved on to the importance of breaking down barriers with direct access, to help prevent the progression of periodontitis. It was pointed out that this needs to go beyond the dental practice, because so many members of the public do not access dental care on a regular basis, for a variety of reasons.

Therefore, it was suggested that interventions to promote periodontal health need to be embedded in community settings, in schools, and, perhaps, community midwife programmes, to get the message of oral health from birth firmly in the minds of growing families.

This need was then linked in with one of the aims of the day, to create simple recommendations that could be made available in relation to plaque management (detailed later on).

Summarising the current situation, Professor Chapple shared that although the dental profession is aware that periodontitis is preventable by intervening at the stage of gingivitis, there is very poor public awareness. This means that there remains an important job left to do for both the profession and public health organisations to get that preventive message disseminated effectively.

The need for a change in ethos

Professor Anthony Roberts’ presentation also acknowledged the lack of patient awareness in terms of periodontal disease, and that it raises the challenge of early intervention.

Building on this picture, due consideration was given to the spectrum for periodontal disease, in terms of gingivitis and periodontitis having been identified as a continuum of the same inflammatory disease (Kinane and Attstrom, 2005).

Bringing the issue right up to date, reflecting the need for a change in ethos to take action at stage I (ie gingivitis), information regarding the British Society of Periodontology’s (BSP) version of the EFP S3-level Clinical Practice Guidelines was shared (2021).

These guidelines offer UK-specific evidence-based recommendations for therapy in relation to periodontitis stages I-IV (of BSP implementation of the 2017 classification system) and which organises treatment into four steps.

Particular emphasis was placed on stage IV, including the need for behaviour and habit change, tailored oral health instruction and the possible value of an adjunctive mouthwash to make full use of the opportunity to prevent periodontal disease progression from gingivitis, when it is still reversible.

It was further considered important to note that guidelines such as those issued by the EFP are exactly that – and that professional knowledge is important in their application, which is why the GRADE system is so important.

Both Professor Roberts and Professor Chapple touched on this significant issue, sharing that GRADE evidence provides a recommendation framework, whereby dental professionals can assess the quality of evidence and the strength of recommendation.

Bringing this presentation to an end, it was suggested that although everyone present is aware that mechanical cleaning is the first line of defence for both periodontal disease and caries, it is not always sufficient for some people.

Therefore, perhaps further consideration is needed as to what can be done to help those falling short, even despite their best efforts with toothbrushing and interdental cleaning, and how those actions may be effectively communicated to the general public, to raise their awareness of this need.

The link between biofilm-driven diseases

Professor Chris Deery then took to the floor to explore the evidence that indicates caries and periodontal disease are both biofilm-driven. Whilst there are different bacterial species involved in the development of these two diseases, there are also common risk factors, including genetic, socio-economic, racial, cultural, disability, and gender.

Given that caries and periodontal disease are therefore inextricably entwined, you cannot address one without the other.

With this in mind, advice to be given to patients was then considered in terms of preventive care, which, of course, involves brushing the teeth twice a day with a fluoridated toothpaste. It was also stated that members of the public engage the use of several different products in their efforts to achieve a healthy mouth, including electric toothbrushes, mouthwash or dental floss and that, perhaps, clarity is needed on the use of these items.

Acknowledging that different age groups are motivated by different factors, due consideration was given to how children at various stages perceive their oral health needs. For instance, while a teenager’s motivation for brushing might be cosmetic, younger children will be more focused on ‘doom scenarios’ such as teeth falling out or becoming ‘grotty’.

The importance of mechanical cleaning as the first line of defence was then revisited, next moving on to the possibility of a benefit being gained by using a fluoridated mouthwash. The significance of when – or whether – to rinse was discussed, with evidence provided to support the fact that, where caries is the key risk, the strong recommendation is that adults spit out after brushing rather than rinsing with water, to avoid diluting the fluoride concentration.

In addition, evidence was provided to show that using an appropriately formulated fluoridated mouthwash (> 100 ppm F) to rinse after brushing will not diminish the benefits of fluoride in the toothpaste used (Duckworth et al, 2009; Duckworth et al, 2009).

In terms of periodontal disease, however, if poor gum health is the key risk, the route to follow is in the EFP S3-level Clinical Practice Guidelines. For instance, evidence-based recommendation/statement 4.13 offers the following advice: ‘In order to control gingival inflammation during supportive periodontal care, the adjunctive use of some agents has been proposed. These products can be delivered as mouth rinses’ (West et al, 2021).

The gathered evidence for this recommendation included a previously published NMA*, which ranked chlorhexidine and essential oil mouth rinses as the most efficacious agents in terms of changes in plaque control (West et al, 2021).

Wrapping this session up, the message was that, put simply, when you can control plaque levels, patients will benefit in terms of both periodontal disease and caries prevention.

The patient-friendly consensus

Following each presentation, the group discussed the issues raised as well as reviewing the evidence to consider how best to manage patients, focusing on their risk profile and ensuring that context is applied to all situations and directives. This included using the ‘spit don’t rinse’ with water message to achieve optimal outcomes, without hindering the ability to manage plaque through the use of chemotherapeutic adjuncts.

Ultimately, those present concluded that there is a need for simple recommendations to be made available in relation to plaque management, resulting in the public-friendly consensus below.

‘Healthy gums don’t bleed when brushed. Twice daily brushing along the gum line and cleaning in between the teeth is essential to support a healthy mouth. Fluoride mouthwashes clinically proven to reduce germs (plaque) offer additional benefit.’

Below the age of seven

‘Spit don’t rinse.’

Over the age of seven

‘For better gum health, after brushing spit and then rinse with a fluoride mouthwash that is clinically proven to reduce germs (plaque).’

Johnson & Johnson Ltd looks forward to continuing to work in partnership with dental professionals following the insights gained from both the earlier National Advisory Panel and this Hygienist Advisory Panel.

References

Duckworth RM, Horay C, Huntington E and Mehta V (2009) Effects of flossing and rinsing with a fluoridated mouthwash after brushing with a fluoridated toothpaste on salivary fluoride clearance. Caries Res 43(5): 387-90

Duckworth RM, Maguire A, Omid N, Steen IN, McCracken GI and Zohoori FV (2009) Effect of rinsing with mouthwashes after brushing with a fluoridated toothpaste on salivary fluoride concentration. Caries Res 43(5): 391-6

Kinane DF and Attstrom RJ (2005) Group B consensus report of the fifth European Workshop in Periodontology. Clin Periodontol 32 (Supp 6): 130-1

The British Society of Periodontology and Implant Dentistry (2021) BSP UK Clinical Practice Guidelines for the Treatment of Periodontal Diseases

The Economist Intelligence Unit Limited (2021) Time to take gum disease seriously. The societal and economic impact of periodontitis

West N, Chapple I, Claydon N, D’Aiuto F, Donos N, Ide M, Needleman I and Kebschull M (2021) BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice. J Dent 106: 103562

* NMA – network meta-analyses; a statistical technique which allows the integration of data from direct and indirect comparisons, namely treatments compared among trials through a common comparator treatment (West et al, 2021).

The dental hygienists and therapists

  • Hawa Azhar, multi-award-winning dental hygienist and therapist based in Essex
  • Laura Bailey, dental hygienist and therapist, practising in Richmond
  • Claire Berry, multi-award-winning hygienist based in Leeds
  • Faye Donald, chair of the BSDHT North East Regional Group and a multi-award-winning hygienist
  • Alison Edisbury, dental hygienist and therapist in private dental practice and chair of BSDHT North West Regional Group
  • Sarah Macdonald, award-winning orthodontic therapist in London
  • Charlotte Manahan, dental hygienist and therapist currently practising in London
  • Anna Middleton, award-winning dental hygienist in Chelsea and Knightsbridge and founder of London Hygienist
  • Amber Ojak, award-winning dental therapist based in Edinburgh
  • Anna Peterson, London-based dental hygienist and therapist
  • Maya Samuel, dental therapist practising in London
  • Benjamin Tighe, tutor dental therapist at The Eastman and a dental therapist in private practice.

Key opinion leader presenters

  • Professor Iain Chapple, director of research within the Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham
  • Professor Chris Deery, dean of the School of Clinical Dentistry, University of Sheffield
  • Professor Anthony Roberts, professor/consultant in restorative dentistry at Cork University Dental School and Hospital.

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