PATIENT MOTIVATION AND EDUCATION / "TOTAL PLAQUE CONTROL IS A KEY FACTOR IN PREVENTIVE PERIODONTICS"

INTRODUCTION

I. RATIONALE: PLAQUE BIOFILM AS THE ETIOLOGIC BASIS

1. Microbial biofilm as the known etiological factor: "Based on the knowledge that microbial plaque or biofilm is the major etiologic agent in gingival inflammation, one specific aim of phase I therapy for every patient is effective daily plaque or biofilm removal at home." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 43)
2. Reversibility of biofilm-induced changes: "Effective daily plaque biofilm control practices result in improved periodontal and gingival health. Cessation of plaque control practices for 7-21 days results in: accumulation of thick plaque on tooth surfaces; reddened gingiva that bleeds easily; shift to more virulent gram-negative flora. Changes that are completely reversed in about 7 days when plaque control practices are resumed." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50 - Clinician's Corner)
3. Epidemiological evidence for chemotherapeutic and mechanical plaque control: "Several systematic reviews have shown that chemotherapeutic and mechanical plaque control will reduce gingival inflammation. Essential oils and cetylpyridinium-chloride-containing mouthrinses may reduce gingival inflammation. Interdental brushes may reduce dental plaque, bleeding, and probing pocket depth. Power-driven toothbrushes may be more effective than manual toothbrushes for removing plaque and reducing inflammation." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 5)
4. Site-specificity of biofilm accumulation: "It is well-established that the periodontal disease typically starts interdentally. It has been demonstrated in healthy subjects that plaque biofilm formation begins on the interproximal surfaces, where the toothbrush does not reach. Masses of biofilm first develop in the molar and premolar areas, followed by the proximal surfaces of the anterior teeth and the facial surfaces of the molars and premolars. Lingual surfaces accumulate the least amount of biofilm. Patients consistently leave more plaque biofilm on the posterior teeth than the anterior teeth, with interproximal surfaces retaining the highest amounts of biofilm." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50)

II. CONCEPT OF TOTAL PLAQUE CONTROL

A. Mechanical Plaque Control

1. Fundamental elements: "Effective daily plaque biofilm control is essential to optimal periodontal health. Fundamental elements of biofilm control include toothbrushing (manual or powered) and interdental cleaning (floss, floss holders, interdental brushes, water flosser, toothpicks, and other devices). Mouthrinsing may provide supplemental biofilm control." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50)
2. Toothbrushing frequency and duration: "The general rule is to instruct patients to brush for 2 minutes twice a day. Most individuals overestimate the amount of time they brush, reporting times of 2 minutes or more. In reality, the best estimates for manual brushing range from 30 to 60 seconds. Brushing performed by dental professionals found that 2 minutes of brushing showed the best efficacy for both manual and powered toothbrushes. Resolution of experimental gingivitis required brushing once a day or every other day, but gingivitis persisted in subjects who brushed every third or fifth day. The quality of brushing may be more important than the frequency of brushing within reason." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50)
3. Powered toothbrushes and patient motivation: "Various Advantages of Powered Toothbrushes - Increases patient motivation thereby resulting in better" [plaque removal]. (Essentials of Clinical Periodontology and Periodontics, Ch. - Powered Toothbrushes)

1. Interdental cleaning: "Interdental cleaning and toothbrushing are essential mechanical means of dental plaque control. Both remove residual food [debris and biofilm]." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50)
2. Brushing force: "Research on brushing force... Studies that evaluated plaque biofilm removal to force found increased pressure corresponded to an increase in plaque biofilm removal. However, there is a point of diminishing return where excess pressure resulted in reduced efficacy. Lower force with a powered toothbrush has shown better results than a higher force." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50)

B. Chemical Plaque Control

III. PATIENT EDUCATION IN PREVENTIVE PERIODONTICS

A. Definition and Scope

B. Assessment of the Patient's Existing Biofilm Control

1. Before providing instructions, the effectiveness of the patient's existing biofilm control must be evaluated. "It is not uncommon for patients presenting with poor plaque control and the presence of disease to report brushing and flossing multiple times daily. For that reason, the effectiveness of the patient's biofilm control must be evaluated and monitored over time." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 38)
2. "If suboptimal plaque control is evident, the patient should be asked to demonstrate biofilm control (toothbrushing, flossing, etc.) in front of a mirror so that both the patient and the clinician can see their oral hygiene techniques. The patient should then be taught proper biofilm control techniques with a demonstration in their own mouth in front of a mirror." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 38)

C. Role in Phase I Therapy

D. Timing of Patient Education

IV. PATIENT MOTIVATION

A. Motivation as a Prerequisite for Plaque Control

B. Initial Therapy Focuses on Behavioral Change

C. Motivation and Treatment Compliance

D. Communication and Instruction Techniques for Motivation

1. "When delivering product instruction, first set the patient upright in the chair, so both practitioner and patient are at the same level. Hand them a mirror. Demonstrate the product and then ask the patient if they would like to try it. Ask what questions they have." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50 - e-only Patient Motivation)
2. Language matters in preserving rapport and motivation: "Making comments such as 'I guess it's better than nothing' or 'be careful, it might be messy' do not help with patient motivation." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50 - e-only)
3. "Many oral care product manufacturers have developed videos and smart phone apps with product information including demonstrations on use... Directing patients to these apps and videos give them the autonomy to learn more about the product and work on the skills needed for success in the privacy of their own home... Allowing patients to access information on their own helps them assume responsibility for their oral health and can aid in compliance." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50 - e-only)
4. "Repeated instructions regarding product use and compliance rarely result in the desired outcome. If something needs to be repeated at multiple visits, either the product, the message, or both need to be evaluated and changed." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 50 - e-only)

V. EDUCATION AND SCORING SYSTEMS (INDICES)

A. Assessment Tools as Motivational Aids

B. Disclosing Agents

C. Plaque Biofilm Control Record (O'Leary Index)

D. Bleeding Points Index as a Clinical Correlate

VI. PLAQUE CONTROL WITHIN THE OVERALL TREATMENT STRATEGY

1. Step 1 of the 2020 Clinical Practice Guideline: "The aim of the first step of therapy is to encourage behavioral changes in the patient, including improvement in biofilm control, and lifestyle and behavioral changes which may modify existing risk factors for periodontitis. Interventions during the first step in therapy include: supragingival biofilm control; improvement in oral hygiene instruction; professional mechanical plaque removal (PMPR); control of known risk factors for periodontitis; smoking cessation; glycemic control of diabetic patients." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 44)
2. Comprehensive management strategy: "The management of patients with periodontitis can therefore involve the following complementary treatment strategies: Patient education and motivation, including oral hygiene instruction; use of powered toothbrushes and connected technologies, interproximal cleaners (floss, interdental brushes), antiseptics in rinses, toothpastes with actives, and irrigation; and explanation of the rationale for any adjunctive treatments." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 55)
3. HMT is not a substitute for plaque control: "It should be emphasized to the patient that the use of HMT is not a substitute for excellent plaque control (just as it is not a substitute for excellent debridement and root surface instrumentation by the treating clinician). To achieve the best results, patients must be interested and well informed about their condition so that compliance is maximized." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 55)
4. In addition to patient motivation, oral hygiene instruction, and SRP: "In addition to patient motivation, oral hygiene instruction, and SRP to reduce the bacterial challenge, a key treatment strategy when managing periodontitis patients is risk factor modification." (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 55)
5. Maintenance phase: "The patient who enters the maintenance program may have periodontal stability for months or years. However, plaque control may deteriorate, the patient may develop or acquire new risk factors, and disease progression (i.e., further loss of attachment) may become apparent, indicating that a further course of treatment is required." The success of the maintenance phase is affected by: compliance with the maintenance regimen; compliance with oral hygiene instruction; presence of risk factors; and extent and severity of residual deep pockets. (Newman and Carranza's Clinical Periodontology and Implantology, 14th ed., Ch. 55)

CONCLUSION

• Newman and Carranza's Clinical Periodontology and Implantology, 14th Edition (Chapters 5, 8, 38, 43, 44, 50, 55)
• Carranza's Clinical Periodontology, 10th Edition (Chapter on Host Modulation Therapy)
• Clinical Periodontology and Implant Dentistry, 6th Edition (Chapter on Mechanical Plaque Control)
• Essentials of Clinical Periodontology and Periodontics (Chapters on Plaque Indices and Surgical Contraindications)