In this exclusive interview, Alison Edisbury considers how 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.
Following the Hygienist Advisory Panel (HAP) last year, Johnson & Johnson Ltd, the makers of Listerine, followed up with four members of the group to talk more about key issues affecting dental hygienists and dental therapists
For this, Alison Edisbury, Laura Bailey, Anna Middleton, and Benjamin Tighe will be exploring important topics to shine a light on the challenges and offer support for both dental professionals and patients, including:
- The human and economic cost of periodontal disease
- Oral health – is there a need for a change in ethos?
- The association between inflammatory-driven diseases.
Here, Alison Edisbury considers how, 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.
How do you think hygienists and therapists are perceived by colleagues and the general public?
We’ve come a long way from the role of the dental hygienist being merely to provide a ‘scale and polish’. The general public are becoming much more aware of their health, including their oral health and the impact this has on their overall health.
Patients are now seeking out the care of dental hygienists and therapists via direct access and we are being utilised more in practice. It’s great to see fellow dental hygienists and therapists pushing the boundaries of the profession and using their full scope of practice.
How would you like your role to be defined/acknowledged?
My role is to help people to maintain/achieve health, specifically periodontal health. With the continually emerging evidence linking periodontal disease to general health such as uncontrolled diabetes, cardiovascular disease and Alzheimer’s disease, my role also has an impact on reducing the risk of these diseases.
The Economist White Paper, ‘Time to take gum disease seriously – The societal and economic impact of periodontitis’ (2021), highlights the need for better integration of dental and general healthcare and I believe dental hygienists and therapists could be instrumental in bridging this gap.
I would love to see dental hygienists and therapists be better utilised within the NHS system, and I would particularly like to see a ‘tier 2’ recognition for dental hygienists and therapists who have gained further qualifications such as a post-graduate diploma or master’s, for example.
We are a highly educated and skilled workforce who, despite the advances, are still hugely under-utilised in improving not only oral health of the nation, but also but also in reducing the possible risk of systemic disease as a result.
What are the primary challenges of communicating with patients about their oral health?
I often see patients with mild to moderate periodontal disease. At this stage, there usually isn’t any pain/symptoms (other than bleeding on brushing). So it can be difficult for patients to understand that there is a problem and that their behaviour needs to change to prevent disease progressing.
Most people know and follow the common oral health messages (Adult Dental Health Survey, 2009):
- 75% cleaned their teeth at least twice a day
- 76% use a toothpaste with 1350-1500 ppmF.
Despite this, the Adult Dental Health Survey (2009) found that 66% of patients had visible plaque on at least one tooth, and 68% had calculus present in at least one sextant.
Every patient is different and in the way that they brush their teeth, or the interdental aid that’s best for them, varies from person to person. Tailored oral hygiene instruction is the optimal way of improving a person’s oral health (Tonetti et al, 2015). But I find that some people can be averse to being shown how to brush more effectively, as they believe they are already doing what they need to do.
Habit is also something that is really difficult to change, and just because we give the patient the information, it doesn’t mean their oral health will automatically improve. Habit/behaviour change takes time, and we need to discuss this with our patients.
Evidence-based mouthwash use supported by Hygienist Advisory Panel consensus
When Johnson and Johnson Ltd. brought together a group of dental hygienists and therapists for the very first Hygienist Advisory Panel meeting, they shared their views in relation to plaque management.
They also explored the benefits and any limitations of mechanical cleaning, as well as possible adjunctive support in the form of a chemotherapeutic mouthwash.
Building on the outcomes of the earlier National Advisory Panel formed of key opinion leaders, the group agreed on the following consensus:
‘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 7
‘Spit don’t rinse.’Over the age of 7
‘For better gum health, after brushing spit and then rinse with a fluoride mouthwash that is clinically proven to reduce germs (plaque).’For more information, visit www.listerineprofessional.co.uk.
How do you try to overcome those challenges and motivate patients to take care of themselves between appointments?
In order for patients to change their behaviour in regard to improving oral hygiene, they need to understand the harmful consequences of disease, their own susceptibility, the condition, and how change will benefit them (Newton and Asimakopoulou, 2015).
The first point of call is education – I like to show patients as much as I can. I draw pictures, show them their radiographs and periodontal charts, as well as showing them, in their own mouth, what I’m seeing and what it all means. It’s like putting together pieces of a puzzle.
I listen to what the patient is telling me and draw on this to hit their ‘pain points’. Patients will often tell you what their concerns are. For example, they may have staining on their teeth. I link this into oral health education by showing them how improving their brushing technique and cleaning interdentally daily will not only control the biofilm but will also help to reduce the staining.
Behaviour change is facilitated by goal setting, planning and self-monitoring (Tonetti et al, 2015). This includes identifying with the patient change made.
For example, to reduce their plaque score, planning with the patient to decide when, where and how (eg every morning in the bathroom, before brushing teeth, use interdental brushes), and encouraging the patient to assess their own behaviour in relation to the goals (eg using disclosing tablets at home).
I have found this approach particularly useful as it involves working with the patient on goals that are achievable for them. This gives them the tools to improve their oral health and is a way for them to see the improvements themselves.
Have you changed your position on this at any point?
I used to think that I had to achieve perfection with my patients and that anything less would be a waste of time.
I would bombard them with education – going over toothbrushing technique, interdental cleaning, adjunctive therapy advice, diet advice, smoking cessation etc, all in one appointment. Of course, they would go away completely bewildered and then come back without much improvement; it was just too overwhelming for them.
What I’ve learnt to do now is to keep it simple – work on what the patient is already doing and build on those over subsequent appointments. A single episode of professional oral hygiene instruction leads to a small but statistically significant reduction in plaque and gingivitis, and there’s evidence to suggest that additional effects result from reinforcement of oral health instruction (Chapple et al, 2015).
What place do you think the patient-friendly consensus has in all of that?
The aim of the consensus was to reach an agreement of how we can support and maintain oral health in patients between appointments. If we can help our patients to control the biofilm, we can reduce the effects of both caries and periodontal disease.
The advice that we give to patients needs to be consistent and simple to avoid confusion, elicit behaviour change and, ultimately, improve oral health. The consensus provides a simple recommendation that is easy for patients to implement into their daily routine, supporting oral health between dental appointments.
What constitutes success for you in terms of patients’ oral health and compliance?
For me, success is some form of improvement – no matter how small. That may show itself as a decrease in plaque and/or bleeding scores or a reduction in pocket probing depths.
Even just a patient returning for subsequent appointments or asking me questions about their oral health shows me that they are engaged and, whilst it may take time to achieve optimum oral health, every step forward is a step in the right direction.
Has mouthwash use played any part in that?
Mechanical cleaning is the gold standard when it comes to biofilm management. Most patients know what they should be doing, but many struggle to achieve this. Evidence shows that most patients struggle to remove all plaque (Adult Dental Health Survey, 2009).
For some people this is made even more difficult by reduced manual dexterity, malpositioned teeth, furcation, crown and bridge work or orthodontic appliances. This is where adjunctive use of mouthwash can play a part (Serrano et al, 2015).
The recent S3-level evidence-based treatment guidelines for stage I-III periodontitis stated that mouthrinses appeared to produce statistically significant benefits in relation to plaque control, and that adjunctive chemotherapeutics delivered in mouthrinses may be more effective than brushing alone in reducing plaque levels as they will likely access more sites within the oral cavity.
Therefore, for patients who struggle to achieve optimal biofilm management through mechanical cleaning alone, adjunctive use of a mouthwash may be beneficial (Figuero et al, 2020, West N et al, 2021).
References
- Time to take gum disease seriously. The societal and economic impact of periodontitis. The Economist Intelligence Unit Limited 2021
- Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011
- Tonetti MS et al. Principles in prevention of periodontal diseases: Consensus report of group 1 of the 11th European Workshop on Periodontology on effective prevention of periodontal and peri-Implant diseases. J Clin Periodontol 2015; 42(Suppl 16): S5-11
- Newton JT, Asimakopoulou K. Managing oral hygiene as a risk factor for periodontal disease: a systematic review of psychological approaches to behavioural change for improved plaque control in periodontal management. J Clin Periodontol 2015; 42(Suppl 16): S36-46
- Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015; 42(Suppl 16): S71-76
- Serrano J et al Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: a systematic review and meta-analysis. J Clin Periodontol 2015; 42(Suppl 16): S106-138
- Figuero E et al. Efficacy of adjunctive therapies in patients with gingival inflammation. Asystematic review and meta-analysis. J Clin Periodontol 2020; 47: 125-143
- West N et al. BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice. Journal of Dentistry 2021; 106: 103562.
