Advertorial: Making Reparative Dentistry History Brought To You By Johnson & Johnson

G. V. Black’s widely-accepted preventative ethos should now be used to its fullest potential to tackle periodontal disease

In 1896, Dr Greene Vardiman Black, an Illinois-based dentist, stated: “The day is surely coming, and perhaps within the lifetime of you young men before me, when we will be engaged in practising preventive, rather than reparative, dentistry”.¹ This turned out to be visionary; as Fox wrote in 2010: “Preventing oral disease is considered desirable and feasible and has been practised by dentists for over a century”.²

However, Fox, (2010), also went on to comment: “There appears to be no clear or consistent primary research into UK dentists’ views and attitudes relating to their understanding of prevention and its application in practice”.²

So, what does preventive dentistry mean for today’s practising clinicians in relation to periodontal disease?

Perio and Prevention
Reporting on the findings of Working Group 2 of the 11th European Workshop in Periodontology on the primary prevention of periodontitis, Chapple and colleagues, (2015), emphasised that periodontitis is a preventable disease.³

This prevention starts with the ‘almost universal recommendation’ that patients brush their teeth twice-daily for at least two minutes with a fluoride-containing toothpaste.

In addition, in patients with gingivitis, they recommended interdental cleaning once a day, with the adjunctive use of a chemical plaque control agent potentially offering further benefits to such patients.3

Current understanding of periodontal disease is that gingivitis and periodontitis are a continuum of the same inflammatory disease.⁴ However, not everyone with gingivitis will develop periodontitis.³

It would seem prudent, therefore, to adopt preventive strategies at the point of diagnosing gingivitis, in an effort to stop it progressing to periodontitis. As Chapple and colleagues, (2015), suggested: “[…] while not all patients with gingivitis will progress to periodontitis, management of gingivitis is both a primary prevention strategy for periodontitis and a secondary prevention strategy for recurrent periodontitis”.³

It has been acknowledged that lifestyle factors, stress and a genetic predisposition may all have a role to play in the development of periodontitis. However, it remains that the most significant risk factor is the accumulation of plaque biofilm.³

Exploring the concept of dysbiosis further, Meuric et al, (2017), explained: “Periodontitis is driven by disproportionate host inflammatory immune responses induced by an imbalance in the composition of oral bacteria; this instigates microbial dysbiosis, along with failed resolution of the chronic destructive inflammation”.⁵

In an effort to prevent gingivitis developing into periodontitis, therefore, professional oral health instruction should be provided in an effort to reduce plaque bacteria.

It has also been indicated that reinforcing such instruction may provide additional benefits.³

Changing Patient Behaviour
This ideology was supported by Tonetti and colleagues, (2015a), writing: “Mechanical plaque removal remains the foundation stone of successful periodontal and peri-implant therapy.

However, professional plaque removal is ineffective longer term without high standards of daily patient-delivered oral hygiene.

The latter requires a patient-centred approach to education, motivation and sustained behaviour change, as well as good knowledge of the most effective methods of plaque removal from the marginal, sub-marginal and interproximal areas of teeth and implants”.⁶

Within the clinical setting, Tonetti and colleagues, (2015b), thought that: “Oral health professionals need to identify and adopt effective techniques that help patients change oral health behaviour, but there is consensus that, in general, oral health care providers lack a structured, proven approach to facilitate behavioural changes that improve plaque control”.⁷

One route to achieving success in these endeavours may be via the Oral Hygiene TIPPS behaviour change strategy. Oral Hygiene TIPPS is based on strategies that have been demonstrated as effective at improving patient behaviour and motivation, when implemented in a primary care setting.⁸ Put succinctly, the goal of the intervention is to:

• “talk with the patient about the causes of periodontal disease and discuss any barriers to effective plaque removal”;
• “instruct the patient on the best ways to perform effective plaque removal”;
• “ask the patient to practise cleaning his/her teeth and to use the interdental cleaning aids whilst in the dental surgery”;
• “put in place a plan which specifies how the patient will incorporate oral hygiene into daily life”;
• “provide support to the patient by following up at subsequent visits”.⁸

Integral to success is gauging a patient’s level of health literacy, and the dental professional adjusting their communication style accordingly.

It has been suggested that the best way to proceed is to provide a hands-on demonstration of plaque control, and for the patient to practice in front of the clinician. As an added caveat, the patient must consent to such a process.⁸

It is also important to bear in mind that oral health instruction takes the form of an ‘empathetic and non-judgemental conversation’ and is not perceived by the patient as a lecture. In addition, motivating behaviour change is not a one-off; it should form part of the discussions each time the patient attends for an appointment.⁸

Past, Present and Future Gingival Health
In practical terms, when it comes to practising preventive – rather than reparative – dentistry in the fight against periodontal disease, Tonetti and colleagues, (2015a), considered: “Prevention requires an informed individual, a prepared oral health team, the use of appropriate screening and diagnostic approaches, and effective oral care health care aids to assist in mechanical and chemical plaque control”.⁶

Over the long term, “The key to successful prevention and treatment of periodontal diseases is life-long effective personal oral hygiene. Life-long preventive professional care may be necessary for the patient to maintain healthy gingival tissues. Regular re-enforcement of the importance of effective plaque removal and, where applicable, smoking cessation advice is also required”.⁸

References

1. Joseph R. The father of modern dentistry - Dr. Greene Vardiman Black (1836-1915). J Conserv Dent 2005; 8(2): 5-6
2. Fox C. Evidence summary: what do dentists mean by ‘prevention’ when applied to what they do in their practices? BDJ 2010; 208:359-63
3. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015; 42 (Suppl. 16): S71–S76
4. Kinane DF, Attström R. Advances in the pathogenesis of periodontitis. Group B consensus report of the fifth European Workshop in Periodontology. J Clin Periodontol 2005; 32(Suppl. 6): 130-1
5. Meuric V et al. Signature of microbial dysbiosis in periodontitis. Appl Environ Microbiol 83: e00462-17
6. Tonetti MS et al. Primary and secondary prevention of periodontal and peri-implant diseases. Introduction to, and objectives of the 11th European Workshop on Periodontology consensus conference. J Clin Periodontol 2015a; 42 (Suppl. 16): S1–S4
7. 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 2015b; 42 (Suppl. 16): S5–S11
8. Prevention and Treatment of Periodontal Diseases in Primary Care. Scottish Dental Clinical Effectiveness Programme 2014