Plaque Removal; Individualized Patient Education

 

1: Plaque Removal; Individualized Patient Education

Case 1Plaque Removal; Individualized Patient Education

CASE STORY

The patient is Mrs. A., a 58‐year‐old Caucasian female with a history of periodontal disease, and who has been under periodontal maintenance for the past six years. At her dental hygiene appointment, the patient provided the following information summarizing the purpose of her visit: “I am concerned because recently my gums are sore on my lower jaw. Every time I brush there, it bleeds, and I think my breath has been bad lately. I used to be better at cleaning under my bridges but getting floss under those areas has become too difficult lately, my hands are not as good as they used to be. Plus, I have been traveling so I am overdue for my cleaning appointments.”

PROBLEM‐BASED LEARNING GOALS AND OBJECTIVES

• Customize oral hygiene instruction for plaque removal
• Identify specific patient needs and advise for appropriate oral self‐care for implants, crowns, and bridges
• Techniques for behavioral modifications

Medical History

Mrs. A has a history of mild hypertension that is under dietary control. Drug allergies include sulfa and tetracycline. Due to menopause, the patient has been experiencing symptoms of xerostomia and insomnia. She has been taking a low dose 0.25 mg of Alprazolam to help with sleep when needed.

Dental History

Mrs. A has had the following dental treatments on her existing dentition: extractions, amalgam and composite resin restorations, endodontic therapy, implant placement, crowns, and in‐office teeth whitening. She received nonsurgical periodontal therapy six years ago with recommended periodontal maintenance appointments every three months, which she continued until approximately 14 months ago. She is pleased with her smile and is interested in keeping her natural teeth as long as possible. She has not had any dental treatments in over 14 months due to her professional and personal schedule (see Figure 7.1.1).

Figure 7.1.1: Odontogram of Mrs. A’s current oral restoration status. Green color indicated “Existing Other,” restorations completed by patients previous Doctor of Dental Surgery (DDS), blue color indicated existing restorations completed with current DDS. W indicated “watches.”

Review of Systems

• Vital signs
  • Blood pressure: 128/85 mmHg
  • Pulse: 72 beats/min
  • Respiration: 16 breaths/min

Social History

Mrs. A is married and is excited to be a new grandma. She is also planning to retire this year from her stressful job as the CFO of a large finance firm. Her friends and family are a big part of her life. She enjoys golf, working out, and traveling. Mrs. A consumes alcohol on a social basis of approximately two to four drinks per week. She admits to taking more Alprazolam during the workweek to help with the stress of her job. She does not smoke or have a history of recreational drugs use.

Extraoral/Intraoral Examination

Details shown in Figure 7.1.2.

Figure 7.1.2: Oral photo using cheek retractors. Note uneven anterior wear from bruxism, #9 thinning enamel near the cervical third of tooth. Gingival color and texture are visible in the photo.

Extraoral Findings

Mrs. A’s face is moderately symmetrical, and there were no palpable nodes. The muscles of mastication and facial expressions were asymptomatic. Mandibular range of motion was within normal limits, and the temporomandibular joints were asymptomatic.

Intraoral Findings

Soft tissue examination of the lips, tongue, oral mucosa, and pharyngeal tissues was within normal limits. Salivary glands were not swollen, and salivary ducts flowed freely. No swelling or irritation to the tonsillar area was apparent. Present were moderate inflammation and bleeding upon probing with a range of 4–6 mm pocket depth in the posterior aspects, and Class II embrasure spaces in the posterior region. Examination of the hard tissues confirmed light dental calculus and moderate dental biofilm subgingivally. Moderate dental biofilm was detected supragingivally around the gingival margins of the posterior lingual aspects. Clinical gingival characteristics included: gingiva color was uniformly pale pink, anterior consistency was firm while posterior consistency was soft, spongy, and dented slightly with the probe. Attrition of the anterior teeth was apparent.

Radiographic Examination

Updated vertical bitewings revealed vertical bone loss (see Figure 7.1.3).

Figure 7.1.3: Full mouth series radiographs, updated vertical bitewings to reveal bone loss.

Periodontal Charting

Confirmed Periodontitis, Stage III (Severe Periodontitis with potential for additional tooth loss) generalized, Grade A (slow rate of progression) with gingival inflammation and bleeding upon probing localized to sextant one, four, and six (see Figure 7.1.4).

Figure 7.1.4: Periodontal charting indicated chronic periodontitis.

Dental Hygiene Diagnosis

Problems	Related to Risks and Etiology
Periodontitis	Recurring periodontal pockets/dental neglect
Peri‐implantitis	Dental biofilm invading implant site
Generalized alveolar bone loss	Chronic periodontal disease/dental neglect
Bleeding upon probing	Pathogenic microorganisms found in biofilm
Anterior abrasion	Parafunctional bruxism

Dental Hygiene Treatment Plan

Dental Hygiene Planned Interventions
Clinical	Education/Counseling	Oral Hygiene Instruction
Selective nonsurgical periodontal therapy with local infiltration anesthesia to selected quadrants and tooth numbers. LRQ: #28, 29, 30 and LLQ: #20,18Removal of dental calculus and soft plaque deposits on all tooth and root surfaces. Implant scalers (plastic or titanium) used to scale and debride implant sites.Chemotherapeutics delivered to #18M, 18D, 31M, 30M.Fabrication of occlusal appliance (night guard) to help with bruxism.Periodontal re‐evaluation four to eight weeks.Periodontal maintenance appointments every three months.	Educate and motivate about:The importance of regular dental visits including three‐month periodontal maintenance appointments with chemotherapeutic agents if needed to reduce the risk of recurrence of periodontal pockets and advancement of alveolar bone loss.The importance of daily mechanical removal of biofilm around implants and bridges to maintain the longevity of restorations and maintain periodontal health.Hands‐on demonstration using plaque removal aids that are appropriate to help heal the periodontium and manage self‐care maintenance.Compliance and hygiene maintenance for occlusal guard	Patient education of oral self‐care hygiene instructions included reinforcing brushing techniques to Bass Sulcular for posterior lingual aspects along with interproximal brushes for interdental care and a water irrigator for implants, crowns, and bridges.Recommended the use of a floss threader or tufted floss when traveling or when the patient does not have access to her water irrigator to cleanse under abutments and around implants properly.Recommended antimicrobial cleaning tablets for maintenance of occlusal appliance. The patient should be bringing the occlusal guard appliance in at all recare appointments to evaluate and professionally clean the appliance in the ultrasonic bath.

Discussion

There are myriad options to consider when selecting appropriate oral hygiene aids for patient self‐care programs. The availability of self‐care aids can be overwhelming; therefore it may be useful to limit the number of suggestions and choose an aid, (or aids) that can address multiple conditions. The hygienist should include with their recommendations: why the selected aids are necessary, how to use them correctly, the times and frequency with which they should be used, benefit factors, and expected outcomes. Individualized patient education can be motivational and increase the chances of the patient being responsive to the suggested behavioral modifications as part of their self‐care regimen. Patient education should also include a discussion of the risks factors involved if neglecting to follow the individualized self‐care program. Keep in mind that creating changes in behavior is neither quick nor easy. Research shows that the formation of a new habit can take considerable time and that the patient has to develop intrinsic motivation before new oral hygiene behaviors are likely to become a habit. The road to habit formation starts with unawareness and moves through six steps to finally the habit. Esther M. Wilkins, RDH, DMD describes the six steps of habit formation as follows:

1. Unawareness – many patients have little concept of the new information about dental and periodontal infections and how they are prevented or controlled.
2. Awareness – patient may have a food knowledge of the scientific facts, but they do not apply the facts to personal action.
3. Self‐interest – realization of the application of facts/knowledge to the well‐being of the individual is an initial motivation.
4. Involvement – with awareness and application to self, the response to action is forthcoming when attitude is influenced.
5. Action – testing new knowledge and beginning of change in behavior may lead to an increased awareness that a real health goal is possible to attain.
6. Habit – self‐satisfaction in the comfort and value of sound teeth and healthy periodontal tissues helps to make certain practices become part of a daily routine. Ultimate motivation is finally reached.

In the situation with Mrs. A, she starts with the second stage of habit formation – awareness. She has prior dental knowledge of her periodontal history. Therefore, the best way to help her form a new self‐care habit is to educate her about her current specific stage of oral health. It is helpful to show Mrs. A her most current periodontal charting record, radiographs, and intraoral photos of the areas that need attention. The information presented to Mrs. A is a comprehensive way to describe her individual needs by explaining the concerns regarding her current oral state, and the reasons why new recommendations for a customized plaque removal regime, are taking place. It is important to be clear with instructions, use demonstrations, and to take the time to answer all questions. Mrs. A will be more aware of her oral condition thereby creating self‐interest that will hopefully encourage involvement in new oral self‐care habits.

Mrs. A’s next dental hygiene periodontal maintenance appointment is an excellent time to revisit the past individualized patient education recommendations, and also it is a good opportunity to continue to motivate and or modify techniques with her self‐care regime. Creating proper oral hygiene habits take constant motivation and continuous education plus support from the entire dental team.

The goal for Mrs. A. is to prevent the progression and recurrence of periodontal disease and peri‐implantitis. Patients who have nonsurgical periodontal treatment, and/or restorative treatment including implants and bridges need thorough and customized oral hygiene instructions to keep the tissue, and dental restorations maintained to achieve optimum oral health.

Periodontitis is reactive to plaque‐induced factors. Therefore, plaque accumulation will lead to inflammation that can result in negative outcomes such as alveolar bone loss. This is why daily removal of biofilm is critical for Mrs. A. Data indicates that plaque control is a major contributor when improving gingival health by reducing inflammation (Chapple et al. 2015; Wilkins 2013). The removal of dental plaque by the forces of mechanical interdental cleaning will remove the primary etiological factor for periodontal or gingival diseases (Johnson et al. 2015). Toothbrushing with an acceptable dentifrice is the standard recommended self‐care practice for cleaning the lingual, facial, and occlusal surfaces of all the teeth (Darby and Walsh 2015), but toothbrushing alone does not reach the interproximal surfaces effectively. Dental floss or other interproximal self‐care aids are a helpful tool for plaque removal within the interproximal space and col area. However, the patient’s dexterity and the likelihood of compliance is a consideration when recommending specific aids.

Assessments for Mrs. A include vitals, extraoral and intraoral exams, FMX (full mouth x‐rays), periodontal charting, plaque index, calculus detection, following up today’s reports of bleeding upon probing around the upper right implant bridge, the lower left three‐unit bridge, and the lower right molars with Class II embrasure spaces around porcelain fused to metal crowns. Mrs. A’s assessment results are an immediate concern to the dental hygienist to avoid peri‐implantitis and the advancement of periodontitis.

Individualized patient education was created for Mrs. A to help restore her to gingival health and prevent further periodontal destruction. Mrs. A was instructed with regards to the following:

• Toothbrushing twice a day for at least two minutes

  Toothbrushing was recommended for the patient twice per day, morning and night after meals, for a duration of two minutes (minimum) using the Bass Sulcular method. Clinical evidence shows that brushing with a mechanical toothbrush can be more efficient than using a manual toothbrush (Lyle 2015; Yaacob et al. 2014), so with that in mind, and considering the moderate loss of dexterity she reported, Mrs. A was encouraged to use a mechanical brush. She was instructed focus on the lingual surfaces because she has higher rates of plaque and inflammation in these areas. To address Mrs. A’s complaint of malodor, she was instructed to brush her tongue each time she brushes her teeth to reduce the bacteria that inhabit the dorsal surface (Darby and Walsh 2015).

• Interdental brushes for daily interproximal cleaning

  Interdental brushes were recommended for the patient over dental floss because they will be easier for her to use with her appliances, and evidence suggests that interdental brushes are the most efficient method for interproximal plaque control (Chapple et al. 2015; Lyle 2015). Interdental brushes come in a variety of sizes for a range of embrasure spaces, including type II and III and recently even small or slim sizes are available for tight interproximal spaces. It is important to demonstrate the use of interdental brushes: if used incorrectly there is a chance that the patient can cause harm to the papilla or dental restoration. Interdental brushes for cleaning around implants should have a coated wire to avoid scratching the titanium or implant material (Johnson et al. 2015). Mrs. A was instructed how to determine the appropriate size and shape of interdental brush for her embrasure spaces, implants, bridges, and crowns. The dental hygienist demonstrated how to insert the brush into the embrasure space at a 90° angle while moving the brush in and out from facial to lingual. The wire should not bend when inserting into the embrasure space; this will be an indicator that the brush size is too big. Insertion should be easy, yet the brush bristles should be slightly larger than embrasure space to be able to reach both interproximal tooth surfaces.

• Water irrigation at least once per day

  Daily water irrigation can help reduce the levels of biofilm and inflammation. A water irrigator is helpful to remove plaque and food debris around and implants and under pontic teeth. Irrigation is beneficial to implants, crowns, and bridges due to the hydrokinetic activity, which produces a pulsating stream of fluid subgingivally where toothbrushes and interdental aids cannot reach (Darby and Walsh 2015; Jahn 2010; Johnson et al. 2015). The water stream of the irrigator can reach deeper than any other self‐care aid. Multiple studies have shown that adding a dental water irrigator to self‐care regimes can help reduce periodontal pathogens, bleeding, pocket depth, and inflammatory mediators (Jahn 2010; Lyle 2015). Oral irrigators should be used with caution because incorrect use around implants can cause damage to the junctional epithelium (Johnson et al. 2015). Mrs. A was instructed to use a low setting and to hold the irrigator tip horizontally while the nozzle tip is directed toward the interproximal area along the implant to avoid excessive water pressure and to help flush the aspects under the pontic teeth. Chlorhexidine gluconate or phenol compounds can be added to the water irrigators’ reservoir to aid in the reduction of bacteria (Ernst et al. 2004; Jahn 2010; Johnson et al. 2015).

• Floss threader or tufted/braided floss

  Mrs. A has a two unit implant bridge on the upper right quadrant (URQ) tooth #3–4, a three unit implant bridge in the upper left quadrant (ULQ) tooth #’s 13–15, and a three unit bridge in the lower left quadrant (LLQ) tooth #’s 18–20. Dental tape or tufted/braided dental floss can clean around the abutments and crown margins. Some tufted or braided floss comes with a rigid needle attached to the floss acting as a floss threader to help with insertion into the abutment interproximal space. Gently guide the floss facial to lingual to cleanse interproximal space and then swept under pontic to the next interproximal space to remove and disturb biofilm accumulation. The tufted or braided floss can be wrapped around the implant to help clean the sulcular areas (Darby and Walsh 2015; Wilkins 2013).

  Include follow‐up discussions with Mrs. A. regarding her self‐care regime at every dental or dental hygiene appointment. Other self‐care aid options can help Mrs. A. achieve optimum oral health if these above aids do not produce expected outcomes, and/or cause a lack of compliance (see Table 7.1.1).

Table 7.1.1: Self‐care aid options and their use.

Self‐care device	Description	Indication
Rubber tip stimulator	Rubber tapered cone tip on the top of a metal or plastic handle	Use light pressure to massage gingival margin and sulcus areas. Best for type II and III embrasures
Wooden wedge	Triangular toothpick	Use light pressure to remove plaque and food debris from type II or III embrasure (mild in and out motions)
End‐tuft brush	Small brush head with a few tufted bristles on a handle.	Mimics vibration movements of Bass toothbrushing method for posterior areas and around dental restorations
Floss holder	Reusable plastic handles with floss attachments on the end in a Y or C shape.	Thread floss attachments and hold handle to cleanse interproximal spaces. Suitable for users with limited dexterity.

Take‐Home Hints

1. Interviewing the patient during recare appointments is critical to determine if the suggested self‐care aids are being used or helpful, or if modifications are needed.
2. Document what specific oral hygiene self‐care recommendations are for each patient with proper education, demonstration, and include the risks and benefits in a legal record.
3. It is important when discussing recommendations to have samples devices or literature to help educate the patient on the purpose of the aid. They can then take the literature or sample to the store to purchase the new product.
4. Demonstrations are critical for increasing patient compliance. The patient has a better chance recalling the instruction when they were able to observe what they were taught by the dental hygienist.
5. Many individuals are noncompliant with traditional flossing techniques they do not know when traditional floss is required and its limitations (Segelnick 2004).
6. It is important to stay updated with which oral self‐care aids consumers have access to, know which device is adequate for each condition, and recommend modifications if needed.