Dr Saskia Salvestro, practicing dentist in Wagga Wagga and academic at Charles Stuart University, explores the importance of instructing patients to make the right choices for their oral health routines.

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Oral hygiene instruction: floss or interdental brushes (IDBs)? Manual or powered toothbrushing (PTB)? As busy dental practitioners, we need to have a better appreciation and understanding of evidence behind patient-directed biofilm control and what we recommend for our patients. This helps to avoid the repetitive and dull oral hygiene instruction carousel our patients are tired of hearing, and the time that we – as time-precious practitioners – can’t ethically charge for, but rely on for optimal treatment outcomes.

One thing I’ve learned over the past decade in the dental profession – both as an oral health therapist and a dentist – is that patients genuinely like to know what’s happening in their mouth, and if given the chance, to help themselves improve.

With modern dentistry continuously evolving, and more complex treatments becoming readily available and affordable (such as dental implants and orthodontia), it’s not only our job as practitioners to be abreast of the latest research, but additionally to take into consideration the influence of patient-involved, individualised oral-hygiene maintenance programs, as part of the treatment itself.

I always highlight to periodontitis patients that their treatment outcome is dependent on the 80/20 rule, both of which involve biofilm removal in a similar environment: the 80% involves the patient carrying out personalised oral hygiene as prescribed in their home environment. The other 20% is the dental team’s responsibility clinically for non-surgical or surgical periodontal therapy. It’s important to emphasise and communicate with patients the fact that no treatment, no matter the complexity or cost, will survive long-term, without a healthy periodontium (Samet & Jotkowitz, 2009¹).

The concept of oral hygiene instruction can be as simple or as complex as a practitioner creates. The central value behind oral hygiene instruction is often overlooked: ensuring prevention of gingivitis, periodontitis, and dental caries. Not to mention the bidirectional relationship between dental and systemic health. We are responsible for involving our patients in their disease control – if patient involvement is dismissed, the likelihood of their risk of disease progression increases.

Understanding the target: health or disease?

Latest evidence in supragingival biofilm control categorises patients into ‘health’ or ‘disease’. The benefit of this is our ability to further individualise and modify oral hygiene instruction, and further involve our patients in their homecare. Prioritising quality oral hygiene instruction far outweighs quantity when it comes to results.

When looking at biofilm control research, it’s important to understand whether that research is recommending specific techniques for a patient who is periodontally healthy, or a patient who has gingivitis or periodontitis.

For example, when recommending flossing to a patient, most research consensus explains “flossing is only beneficial in gingival health” vs research that explains “flossing is not beneficial compared to interdental brushing (IDB) [in gingivitis patients]”. There are two different consensuses here, and if not understood correctly, one could find that IDB far surpasses flossing in terms of biofilm removal and that flossing is a ‘waste of time’, when in fact, a healthy patient who is looking to maintain their oral hygiene can use floss to remove interdental plaque, so long as it maintains their oral hygiene.

On the other hand, a patient with gingivitis or periodontitis would be more successful controlling plaque deposits with an IDB, as the evidence points to IDBs as superior for plaque removal vs floss in gingivitis and periodontitis patients.

We are acquiring quality information that can be used in a brief discussion, compared to tiresome and impractical ‘cookie-cutter’ oral hygiene approaches. Following up on this new advice at a subsequent appointment –and asking patients how they are doing with their new routine – can enhance the relationship and make patients more open to further modifications.

What to recommend: floss or interdental brushes (IDBs)?

The evidence has spoken – flossing is not recommended in sites of disease, as most studies prove it is less effective at plaque removal than IDBs in diseased sites. IDBs are the most effective method for interdental plaque removal for diseased sites. If an IDB cannot be used for a specific reason, floss is then recommended (Salzer et al, 2015²).

A systematic review on patients with periodontitis by Sambunjak et al in 2011³ found unreliable evidence on the effectiveness of flossing in addition to toothbrushing for disease reduction on periodontitis patients after one and three months. The same evidence suggests that there are no studies reporting the effectiveness of flossing plus toothbrushing for preventing dental caries.

In 2022, further systematic reviews found rubber interdental picks were more efficient than tooth brushing alone in reducing plaque and gingival inflammation, measured in a periodontitis-affected population (Gennai et al, 2022)⁴. This was supposedly due to the interdental papilla loss during this stage of periodontitis, and the subsequent biofilm accumulation in these difficult-to-reach areas. When involving the patients in these studies, rubber coated IDBs were preferred, due to the higher user safety and patient preference (Van Der Weijden et al, 2022⁵, Gennai et al, 2022⁴). It is common sense: if they prefer it, they are more likely to do it.

What to recommend: manual (MTB) or powered (PTB) toothbrushes?

The next big question many of our patients ask is whether a PTB is more effective than an MTB. In a systematic review and meta-analysis by Thomassen et al, 2021⁶, there was high certainty that use of a PTB over an MTB was more effective at plaque removal, and a moderate certainty in the benefit of an oscillating-rotating (OR) PTB over high-frequency sonic (HFS) powered toothbrush.

OR toothbrushes had a statistical benefit over an MTB in reducing plaque levels in patients with gingivitis (Van Der Weijden and Slot, 2015⁷, Chapple et al, 2015⁸). Note here that this study specifically discusses findings within diseased sites. There is still a need for more research into the effectiveness of these modalities on healthy patients without gingivitis or periodontitis.

A note on toothpaste additives and chemotherapeutic agents

Sodium-fluoride toothpaste has a weak inhibitory effect on plaque regrowth (Valkenburg et al, 2019⁸) – but we need the fluoride. Moderate evidence is available that brushing with an active-ingredient toothpaste, such as stannous fluoride or triclosan, has added clinical effect in plaque inhibition capabilities, more than the effect of a regular sodium fluoride toothpaste.

However, it is now known that triclosan is toxic and shouldn’t be used. The consensus is that the risk outweighs the minor benefit these active ingredients have in our toothpaste (besides fluoride of course), and that, again, mechanical plaque removal is our best bet at eradicating gingival inflammation.

Chemotherapeutics and additives should always be used as an adjunct measure to mechanical plaque removal. Chlorhexidine’s potent effect on oral flora (including the beneficial flora) has sparked new studies to investigate the potential of probiotic specific strains that target and weaken periodontal bacteria, such as P. gingivalis. Zinc oxide, zinc lactate 0.2%, and slow-release oxygen therapy that target anaerobes are also worth reading about.(Valkenburg et al, 2019⁹).

Getting the patient on board

In gingivitis, interdental cleaning with IDBs should be professionally taught to patients (Sanz, M, Herrera, D, Kebschull, M, et al, 2020¹⁰). Having the patient involved in their dental hygiene routine is required for optimal oral (and systemic) health outcomes. It’s important to understand that when delivering oral hygiene to our patients, we are dealing with differing personalities that need alternate approaches and discussions. As dental practitioners, utilising emotional intelligence can come in handy and can often result in a better relationship between the practitioner and the patient.

Our patients need to understand that we are not here to tell them what to do, but to help them improve what they already do. Patients also need to accept their role and responsibility in improving their oral health outcomes.

In summary

Saskia works both in private practice and as an academic at Charles Sturt University. She believes oral hygiene instruction is the most valuable conversation a clinician can have with their patients, so long as it’s taught properly, and primarily involves the patient in the process.

References

¹ Samet N, Jotkowitz A. Classification and prognosis evaluation of individual teeth--a comprehensive approach. Quintessence Int. 2009 May;40(5):377-87. PMID: 19582242.

² Sälzer S, Slot DE, Van der Weijden FA, et al. Efficacy of inter-dental mechanical plaque control in managing gingivitis - a meta-review. Journal of Clinical Periodontology 2015;42. doi:10.1111/jcpe.12363

³ Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, Worthington HV. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD008829. doi: 10.1002/14651858.CD008829.pub2. Update in: Cochrane Database Syst Rev. 2019 Apr 23;4:CD008829. PMID: 22161438.

⁵ Weijden F, Slot DE, Sluijs E, et al. The efficacy of a rubber bristles interdental cleaner on parameters of Oral Soft Tissue health‐a systematic review‐. International Journal of Dental Hygiene 2021;20:26–39. doi:10.1111/idh.12492

⁴ Gennai S, Nisi M, Perić M, et al. Interdental plaque reduction after the use of different devices in patients with periodontitis and interdental recession: A randomized clinical trial. International Journal of Dental Hygiene 2022;20:308–17. doi:10.1111/idh.12578

⁶ Thomassen TM, Van der Weijden FG, Slot DE. The efficacy of powered toothbrushes: A systematic review and Network meta‐analysis. International Journal of Dental Hygiene 2021;20:3–17. doi:10.1111/idh.12563

⁷ Van der Weijden FA, Slot DE. Efficacy of homecare regimens for mechanical plaque removal in managing gingivitis a Meta Review. Journal of Clinical Periodontology 2015;42. doi:10.1111/jcpe.12359

⁸ Chapple IL, Van der Weijden F, Doerfer C, et al. Primary prevention of periodontitis: Managing gingivitis. Journal of Clinical Periodontology 2015;42. doi:10.1111/jcpe.12366

⁹ Valkenburg C, Else Slot D, Van der Weijden G (Fridus). What is the effect of active ingredients in dentifrice on inhibiting the regrowth of overnight plaque? A systematic review. International Journal of Dental Hygiene 2019;18:128–41. doi:10.1111/idh.12423

¹⁰ Sanz, M, Herrera, D, Kebschull, M, et al; On behalf of the EFP Workshop Participants and Methodological Consultants. Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020; 47: 4– 60. https://doi.org/10.1111/jcpe.13290