, Y. Natalie Jeong1, Robert J. Rudy1 and Daniel K. Coleman1
Department of Periodontology, Tufts University School of Dental Medicine, Boston, MA, USA
Eliminating the accumulation of dental biofilm on the teeth is the most effective means of preventing and controlling infective periodontal, dental, and implant diseases. The immune system mediates inflammation; however, as it is difficult for patients to regulate or control their immunologic responses, the primary objective of the patient then becomes to focus on daily reducing the quantity of bacterial plaque on their teeth in order to successfully prevent and control their periodontal diseases and help prevent dental caries. Keeping in mind quorum sensing discussed previously in Chap. 1, the goal of the patient’s plaque removal is to reduce the quantity of microorganisms, thus affecting the virulence and the concentration of the toxins. The clinician’s role as the patient’s assistant and coach is to periodically see them for maintenance hygiene therapy and inform them if and where plaque is accumulating. Seeing plaque and inflammation, the clinician will then coach them in removal techniques and then eliminate any calculus and stain that the patient is unable to remove. Additionally, if there are rough roots or calculus subgingivally, root planing is done for patients who have or have had periodontitis. As plaque accumulates daily, it is the primary responsibility of each patient to accomplish the major part of the disease prevention/control for themselves. To the patients, this concept needs to be considered as analogous to handwashing or taking a bath or a shower, hygiene concepts commonly accepted and performed. Taking the analogy a step further, the patient needs to understand that the mouth is different from most skin surfaces of the body, being warm, wet, and replete with bacteria, which makes it a perfect incubator for rapid growth of microorganisms. Also the tooth surfaces are an excellent habitat for colonization of bacteria being a non-shedding surface.
The removal of the microbial biofilm from the teeth is a displacement process and is not done by abrasion. The adherence of the bacterial biofilm to the teeth is through an acquired dental pellicle made up of salivary glycoproteins. This is also a sticky amorphous attachment similar to the biofilm secreted by the bacteria. Its removal does not require abrasion, although there are abrasives in toothpaste, which assist in removing stain from the tooth surface. The concept that two objects cannot occupy the same place at the same time and that the object of the greater mass will displace the object of the lesser mass is the mechanics for the removal of biofilm, which is the displacement mentioned above and not an abrasive process. Thus, the removal of dental plaque does not require scrubbing; however, it requires a device such as a toothbrush bristle and dental floss with a mass greater than the plaque to dislodge it from the tooth surface. Once freed from the tooth surface, it is eliminated from the area by the bulk fluids by rinsing, or through mastication. It is helpful to keep in mind that the sticky biofilm is a composite of secretions from a community of bacterial cells, and once removed, it will not reattach and a new climax community has to colonize a tooth surface by adhering to the salivary pellicle that reforms soon after its removal.
Why do the bacteria preferentially colonize the tooth surfaces? This question is asked frequently and demands an explanation. The answer that is most easily understood by patients is that although bacteria can and do colonize on the skin cells, gums, cheek, tongue, etc., the soft tissues are constantly shedding their surface (epithelial) cells, and thus, the critical mass does not collect, whereas the mineralized tooth surface is a stable unchanging habitat. Thus, it is the confluence of bacteria on the teeth, both supra- and subgingivally, that requires the displacement of the bacterial plaque/biofilm.
Most individuals when first given a toothbrush will use it like they would any brush device by utilizing a scrub motion. (Techniques of brushing will be covered in Chap. 3.) Thus, for most people, the concept of tooth cleaning is an abrasive, scraping action. This same perception is prevalent among many patients when they have professional hygiene therapy. The common belief is that patients go to the dentist or hygienist to have the deposits “scraped” off of their teeth. Some even do not feel that it is necessary to have consistent hygiene appointments as they do a good job of “scrubbing” the deposits themselves. It is not commonly understood by patients that they are unable to visualize or perceive plaque remaining on the teeth after they have cleaned. The concept that the clinician is a teacher enabling the patient to learn where plaque remains and to assist with the “correct” plaque removal techniques is not generally held by the public. Instead they look at the professional hygiene appointment as if they were taking their car to the carwash to have a machine or a person remove the accumulated road grime. Additionally, the concept of displacement of plaque, without abrasive scraping, is also not commonly understood by patients regardless of their background and education. They focus on the professional removal of calculus, which does require a scraping/abrasive action, which cannot be done by the patient with a toothbrush. It is the clinician’s responsibility to instill in their patients the understanding of the differences in plaque and calculus removal professionally and what the patients must do for themselves daily.
Controlling the biofilm, and hence the diseases that are caused by its presence, periodontal diseases and dental caries, cannot be entirely done by professional dental therapists as the accumulation of a dental pellicle reoccurs within minutes of its being removed, and the adherence and maturation of the microbial biofilm can then occur within 24–72 h. As a professional dental hygiene visit every few days is impractical, the onus is on each individual to be thorough and complete with their biofilm/plaque removal. For a child or otherwise dependent individual, the parent or caretaker must assume this responsibility.
The maturation of dental biofilm, which can produce dental diseases, varies among individuals. This is due to several factors such as frequency and thoroughness of mechanical plaque removal (brushing, flossing, etc.), diet, mouth breathing along with host resistance factors: genetics, body chemistry, nutrition, and systemic diseases. Studies show that dental biofilm, which is capable of producing caries must be attached to a tooth surface in order for the acid by-products to create a pH of 5.5 or below on that surface. Enamel demineralizes at a pH of ~5.5 and dentin demineralizes at a pH of ~6.7. The process of demineralization then can exceed the process of remineralization resulting in caries (tooth structure loss). The two primary bacteria responsible for producing caries are Streptococcus mutans and Lactobacilli, both of which thrive in an acidic pH. It takes varying amounts of time to develop dental caries; however, the penetration of dental caries through the enamel might take up to 6 months or longer. Biofilm that can produce clinically obvious gingivitis requires from 5 to 21 days, and likely gingival inflammation would be seen microscopically several days sooner. Thus, as it is difficult to clinically see the initial breakdown of a tooth by acid attack, the visualization of gingival inflammation by seeing erythema or gingival bleeding is an early warning sign prior to tooth breakdown. This affords the clinician the opportunity to advise the patient that besides having gum infection, they also could be developing tooth decay.
The control of dental diseases by the patient requires three factors:
The patient must be motivated to perform daily biofilm removal and be in concordance with its concepts and benefits.
The patient must have the knowledge and ability to perform effective techniques of biofilm control.
The patient must have access to the tooth or dental implant surfaces containing biofilm in order to perform the plaque removal techniques.
It is the clinician’s and the patient’s responsibility to achieve the above goals in order for them to maintain dental health.
2.2 Motivation of the Dental Patient to Remove Biofilm (Dental Plaque)
In order for an individual to be self-motivated to perform an act from which they will derive benefits and prevent disease, they must truly understand and believe in that action. “ The real key to patient compliance is to care enough about the patient to work with them to find a solution that they can do and think it was their idea” (Leslie Andrews, MBA, RDH). Substituting the word “concordance” (Jill Rethman, RDH) for the word compliance helps to strengthen the sentence. Concordance, which means agreement, comes from the root word meaning heart (cor), which implies that the person in agreement is doing the action because it has become part of their innate beliefs. Simply stated our job is to motivate a patient to be concordant with daily plaque removal and not just being compliant, doing it because someone told them to do it. There are many ways that patients can be motivated to be concordant, and it is not within the scope of this handbook to discuss all of them. Suffice it to say, one of the most effective tools for motivation are analogies relating to things about which the patient is familiar. In order to do this, it is critically important to know your patient and understand their medical, dental and social histories along with their occupation, family, hobbies, background, etc. Each of these histories tells us something about our patient to which we can refer when using an analogy. Even knowing their name could tell us something of their ethnic background, which can give us insight into their thinking. Knowing a patient’s occupation can be most useful in making a point. For example, when talking with an attorney about their being thorough in their plaque removal, an analogy can be drawn to the thoroughness of “discovery” that attorney must do in learning about their client and their client’s problem, which will also help in understanding the opposing views. If a thorough “discovery” is not done, the attorney and the client are likely to lose the case. If thorough hygiene therapy (biofilm removal) is not done by the patient, the patient likely will continue to have the disease. Similar analogies can be drawn to carpenters, musicians, artists, etc., regarding being thorough and meticulous and paying attention to detail. In addition, knowing the age, gender, socioeconomic status, and dental/medical histories of a patient will help us style our analogies to be specific to that individual. For example, to draw an analogy between leaving plaque on the teeth and developing periodontal disease is similar to removing most but not all of a splinter from one’s finger. If a splinter is incompletely removed, the wound will not heal. Similarly if plaque removal is not thorough, and the patient is susceptible to periodontal inflammation, the infection will remain. Much like a splinter, the destruction of the periodontium around a biofilm-coated tooth is nature’s way of eliminating a foreign object (the biofilm-coated tooth). If a splinter is not removed, likely it will come out due to the destruction of the tissue surrounding it. Asking a patient the frequency of their brushing and flossing their teeth helps in our discovery; however, equally or more important is to understand the techniques that they are using by observing the patient brush and floss. It is as important to know the frequency of the patient doing their brushing and flossing as to know how effective they are with their techniques in removing the biofilm. Leaving plaque just in one area might lead to periodontal disease or caries in that area depending on susceptibility. As patients develop a habit with their techniques of plaque removal, usually the same techniques are employed repeatedly and thus the same area(s) would be cleaned or perhaps missed.
Most patients state that they brush their teeth twice a day, and some say that they clean every time that they eat. The latter comment gives a clue that the patient relates food to dental disease. In many cases, patients are aware that germs grow in the mouth; however, they do not often relate the germs (biofilm) to their dental diseases, because they cannot perceive it. Many patients believe it is the food that they eat that causes cavities and gum infection, or some think that what they eat provides nutrition for the germs. Phrases like “Candy causes cavities” and “Brush after meals” play into this thinking, and most people have heard them repeated often throughout their lives. Often patients will state that they do not understand why they have dental disease as they do not eat candy. Also for a majority of the public, a lack of tooth decay is the gold standard of dental health, which stems from a previous toothpaste advertisement “Look Ma, no cavities!” It is generally not “Look, no bleeding gums!” that is considered as dental health. The lack of bleeding gums, which usually signifies gingival/periodontal health, is not considered important criteria by most individuals. In fact, many believe that bleeding gums are expected. To dispel the notion that bacteria entirely grows on the nutrients from the food that they eat, remind the patient that after brushing their teeth before bed, when they arise after several hours of sleep, the “mossy” feeling on their teeth and the stale breath is due to the growth of germs in the absence of their consuming food.
Thus, it is often necessary to advise the patient of the two major oral diseases: dental caries and periodontal disease. Both of these diseases result from living germs that attach to the sticky film on teeth (biofilm/plaque) and from exposure to the toxins (waste products) that these germs release and that these toxins will either destroy the tooth (caries) or cause an infection in the gums, which can destroy the bone holding the teeth. It is also important to inform patients that the bacteria that cause periodontal diseases have commonly not been associated with food intake, whereas bacteria that cause caries come primarily from dietary intake of sugars. Thus, reducing sugar intake should also be addressed with patients at high risk for dental caries, as sugars are fermented by the caries-causing (cariogenic) bacteria and converted to acidic wastes that lowers pH and demineralizes tooth structure. It is the clinician’s responsibility to advise the patient that all dental plaque needs to be removed from the teeth thoroughly and frequently (at least daily), depending on the patient’s susceptibility and dietary habits, in order to reduce or prevent the presence of tooth decay and gum infections. Focusing on the mechanical removal (displacement) of dental biofilm (plaque) will reduce the patient’s risk of dental caries as well as periodontal diseases. One cannot discern whether the plaque emanates from caries-producing microorganisms or periodontal disease pathogens.
The process of tooth cleaning has been recorded since chew sticks were found in Babylonia over 5500 years ago, and the brushing of teeth is well understood today by the general public for removing food, reducing mouth odor, and for maintaining healthy teeth. The first bristle toothbrush, which resembled today’s toothbrush, was discovered in China in the sixth century. Although brushing is important to dislodge the germs on three sides of the teeth, facial, lingual, and occlusal, it does not dislodge dental biofilm interproximally. This concept is not generally apparent to the public. When a patient is asked how often they use dental floss, it is commonly stated that they “try” to floss every day, or “I know that I should floss more,” or “Never.” The number of days per week that patients floss is often significantly fewer than with toothbrushing. The reason for this is that patients are not often raised with the concept of interproximal plaque removal. Most parents say to their child, “It’s time to brush your teeth.” This begins very early in life and easily becomes a habit like taking a bath or a shower. Most parents do not say, “It’s time to brush and floss your teeth.” There are two possible reasons for this. First, flossing requires good hand-eye coordination and is usually not easily done by a young child until the age of eight or older. It is recommended that the parent or guardian flosses a child’s teeth until they have the proper hand-eye coordination to do it for themselves and for clinicians and parents to work with the children to help develop that coordination. Second, it is quite likely that the parent does not floss regularly or not at all. Thus, since flossing or cleaning interproximally is generally not considered as important as brushing, the problem of infrequent interproximal cleaning is perpetuated. Education of the patient can take place by allowing the patient to express their own ideas and views. For example, the clinician may ask the patient if they can feel the toothbrush bristles completely cleaning in between the teeth. Usually the answer is “No”. This will allow the patient to verbalize an answer, which supports Leslie Andrews’ statement regarding working with the patient in a manner that the patient thinks it is their idea, which helps to produce concordance.
Complete plaque removal is of key importance, and the clinician can explain that if only the “front,” “backs,” and “tops” (facial, lingual, and occlusal) surfaces of the teeth are cleaned with the toothbrush bristles; however, in between, the teeth has plaque because floss is not used; it is like washing only half of one’s face. This analogy underscores that a toothbrush is ineffective in removing plaque in between the teeth. This is especially true for subgingival interproximal plaque removal.