Article
The latest Adult Dental Health Survey1 concluded that, for those patients under 45 years of age, the likelihood of retaining a considerable number of healthy teeth throughout their long life is now very high. In particular, the prospects for young adults aged 16 to 24 look better than they have ever been. For those aged over 45 years of age, the legacy of treatment due to higher levels and extent of disease earlier in their life course, and differences in patterns of dental care, have resulted in fewer teeth and fewer sound teeth, but still with a better outlook than previous generations.
The survey also acknowledged that the importance of toothbrushing twice a day is a message that appears to have been taken on board by the majority of dentate adults; 75 per cent of adults claimed to brush their teeth at least twice a day. Dental teams in primary care have contributed positively to this message, with over three-quarters of adults recalling receiving advice from them.
However, the Adult Dental Health Survey also showed that 66% of adults had visible plaque on at least one tooth, with 45% of adults having periodontal pocketing >4 mm. Whilst twice-daily toothbrushing is now a fact of life for three-quarters of the population, there is obviously still a need to improve the effectiveness of this daily procedure.
As dental teams, we need to help patients modify their existing toothbrushing methods in order to improve health outcomes.2 Since no particular toothbrushing technique has been shown to be better than another,2 I welcome the opportunity to move away from instructing patients in detail on how to brush their teeth, and at what particular angle, as we seat them in a clinical setting and get them to watch our instructions in a very different setting from what they would normally do at home. But even before we attempt to adapt our advice to their individual circumstances, do we have a true sense of how our patients brush their teeth at home? Can they actually recall what they do? And do we all brush more or less in the same way? We may have had the opportunity to observe our family members as they brush their teeth, usually children, and this may help our understanding of the challenges we face when providing tailor-made toothbrushing guidance. For example, a study found that those subjects with a more flexible day cleaned their teeth more effectively than those who had a less flexible day, and had reduced gingival bleeding.3 It is important to note toothbrushing is habitual, and established in early life. Complex manoeuvring and difficult orientation is required to optimize toothbrushing technique, and we know adopting new techniques and behaviours are difficult to sustain over longer periods of time. The authors of the Cochrane review on different powered toothbrushes mentioned that the analysis of the longer term effects (> 3 months) was particularly hampered by lack of trials, with only one trial reporting any outcome after 3 months.4
So if we agree that we need to help our patients become more effective in their daily mechanical plaque removal, with particular relevance to their periodontal health, then my plea is for us to take a fresh look at what we know, and to review what tools we can offer our patients to optimize their daily behaviour patterns. Let's start by exploring our patients' real life behaviours, and work with them on what style of communication will suit them best in their efforts individually. We may find we need to find out more about hand-to-mouth co-ordination, which enables us to brush our teeth without looking where we are placing our toothbrush. As a starting point, we have just carried out an experiment by placing a toothbrushing cubicle in a London shopping centre. Over 70 busy Saturday shoppers stopped to participate and brush their teeth as part of an investigation into daily routines, with no prompting of a link to dental care or professionals, or instructions on toothbrushing. The subjects brushed their teeth in private, with consent on filming of their behaviour, using a sink and mirror as for a bathroom setting. Post-filming, they took part in a survey about their toothbrushing regime and were asked to consider how important toothbrushing was in relation to other daily hygiene habits. The majority indicated that toothbrushing was the one thing they couldn't skip over other routine hygiene habits. The filmed footage is compelling viewing in showing how individual each subject's method was. This footage is intended as an educational resource to be made available to the profession in the near future and we hope will serve as a useful tool to fine tune our advice for individual patients. Improving effectiveness of plaque removal is the cornerstone of effective periodontal therapy and maintenance, and I believe it is time for it to evolve utilizing 21st century technology and tools along the way.
I consider it a privilege to have the opportunity to be a guest editor for this issue of Dental Update, a key journal in delivering continuing education in the UK and beyond, and welcome comments and feedback.