Hygiene Tribune Middle East & Africa No. 4, 2018

Hygiene Tribune Middle East & Africa No. 4, 2018

“Up to ten times more plaque removal” / Pregnant women are hardly informed about the importance of oral health / Preservation of root cementum: A comparative evaluation of power-driven versus hand instruments / CS 5460: Dental care reinvented / Periodontal disease may be key initiator of rheumatoid arthritis / Patient motivation techniques / Interview: Oral hygiene instructions and patient motivation with and without dental hygienists

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Published in Dubai

July-August | No. 4, Vol. 8

“Up to ten times more plaque removal”

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ISSN 2567-286X

An interview with Maha Yakob, PhD, RDH, Global Director, Professional
Relations and Scientific Affairs, Philips Oral Healthcare
By Dental Tribune MEA/CAPPmea
Maha is a scientific guru for Philips
Sonicare. She started as a dental hygienist many years ago in Sweden
while also lecturing at the Karolinska
Institute. Karolinska is well known in
the industry of dentistry since it has
housed many Nobel Laureates, both
in physiology and medicine. Dental
Tribune MEA had a chance to hear
from Maha on her evidance based
approach on Sonicare, the electronic
toothbrush.
I was completely on the academic
side when Philips approached me,
and I joined them three years ago.
What I implemented in the company
was this whole evidence-based ap-

proach. Before I joined Philips, they
had all these great studies that they
had done, but they didn’t really focus
as much on getting the publications
to the professionals. We just assumed
that once people tried Sonicare, they
would love it. But then my focus
shifted and I thought, let’s publish
these papers and show our peers and
colleagues why they should recommend Sonicare based on evidence.
In that case, they are not just recommending Sonicare because they like
the product. Often, we would hear
dentists or dental hygienists say, I
know it is working because when my
patients come back they have fewer
splitting gingivae. They could all see
the clinical results, but our approach
needed to be evidence-based. Patients

loved the product, it was just that the
scientific part was missing, which is
what we see now with the Journal of
Clinical Dentistry, launched at the
International Dental Show, with five
studies that were published in this
peer-reviewed journal.

In the first study, we saw that the
Philips Sonicare Diamond Clean
power toothbrush was statistically
significantly more effective than a
manual toothbrush in reducing supragingival plaque, gingival inflammation and gingival bleeding

In this special issue, you will find five
papers. The first two are randomised
control trials looking at Sonicare
versus manual toothbrushes. Two
randomly assigned groups are compared after one group receives a
manual toothbrush and the other, a
Diamond Clean. Not surprisingly, of
course, Sonicare performed significantly better in the areas of plaque
removal and gingival health.

The second study showed that the
Philips Sonicare FlexCare Platinum
with the Premium Plaque Control
brush head significantly reduced gingival inflammation, gingival bleeding and plaque following two and six
weeks of home use, compared with
manual toothbrushing alone. This is
how we substantiated the claim, “Up
to ten times more plaque removal.”
The Sonicare toothbrush has flexible
sides, allowing it more coverage of a
larger surface area.
The objective of the third study was
to evaluate the short-term clinical
efficacy of high-frequency, high-amplitude sonic-powered toothbrushes
compared with manual toothbrushes on plaque removal and gingivitis
reduction in everyday use, through
a meta-analysis of randomised controlled trials. The combined results
of 18 studies with a total of 1,870
subjects showed that sonic-powered
toothbrushes had significantly greater plaque removal. In conclusion,
high-frequency, high-amplitude sonic-powered toothbrushes decreased
plaque and gingivitis more effectively than manual toothbrushes in
everyday use, in studies lasting up to
three months.
Of course, studies one, two and three
confirm that Sonic technology is superior to the manual toothbrush.
Study four is a head-to-head study
done by an independent research
organisation to compare the effect of
the Philips Sonicare DiamondClean
used with the Premium Plaque Control brush head to the Oral-B7000
used with the CrossAction brush
head on gingivitis and supragingival
plaque reduction. In the results, we
can see that the numbers were significantly better than with the other
technology .
The fifth study is moving away from
simply brushing your teeth to using
AirFloss in-between your teeth as
well. The addition of interproximal
cleaning to manual toothbrushing
is statistically proven to significantly
reduce gingivitis and plaque compared with manual toothbrushing
alone. Among the adjunct interproximal cleaning regimens, AirflossPro
provides a similar reduction in gingivitis and plaque to string floss.
The question now is: shall I change
to AirFloss when I floss every day? If
you floss every day and you do it the
right way, regular floss is acceptable.
But, as a dental hygienist, I can tell
you that very few of my patients floss
every day and even fewer of them
floss the right way. AirFloss was really
developed for the majority of people
who don’t floss every day, i.e. inconsistent flossers. There is a solution

1
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for them now that can help, is easy
to use, is user-friendly and disrupts
the biofilm. We wanted to make sure
that it was backed by science, which
is why we did the study. We saw that
manual toothbrush users still had
significant amounts of plaque, but
as soon as we added the string floss
or AirFloss, there was a reduction in
plaque. In fact, we found eight times
more plaque removal if something
was used in addition to the manual
toothbrush. Again, the scientific
evidence suggests that AirFloss is as
good as floss when you use it with a
manual toothbrush and strands.
This is something we have shared
with the community. We do trade
shows, events and different kinds of
summaries of the studies. In the US,
we aired a TV commercial that talks
about the studies and, of course, the
different conclusions.
Together with the FDI World Dental
Federation, we are trying to educate
and raise awareness. Partnership
with the FDI’s World Oral Health Day
is something of which we are very
proud and it is our way of spreading
the message.
For me, working for a company like
Philips feels like the perfect fit. It is
not just a technology company, but
also a health tech. Forget the lights
and everything else that people associate with Philips, it is a health tech
company that has everything from
diagnosis to home treatment to prevention, and we are really focusing
on the holistic approach so that the
FDI’s World Oral Health Day is about
increasing awareness of the oral systemic link. That’s why a partnership
with the FDI is perfect - it increases
public awareness and helps you
make the smart decision about what
you are using in daily care. Many
people are still unaware of good oral
health care, especially in this region.
They still use manual toothbrushes,
which means we still have plenty of
work, but I think we have more to do
in education.

Maha Yakob, PhD, RDH
Dr Maha is a scientific guru for Philips
Sonicare. She started as a dental hygienist many years ago in Sweden while also
lecturing at the Karolinska Institute.
Karolinska is well known in the industry
of dentistry since it has housed many
Nobel Laureates, both in physiology and
medicine.

[2] =>

hygiene tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Pregnant women are hardly informed
about the importance of oral health

By DTI
A new mother herself, pregnancy
gingivitis has become a subject close
to Dr Anja Carina Borer’s heart. She
set up a joint campaign between
Oral-B and the European Federation
of Periodontology (EFP), which promotes oral health during pregnancy
and educates health professionals
and the wider public on the issue.
Originally trained as a dentist in
Mainz in Germany, Anja now serves
as Professional and Scientific Relations Manager Europe at Procter &
Gamble in Geneva in Switzerland,
where we met with her for some
questions and answers on the subject. Fittingly, she brought along her
4-monthold daughter, who cooed
quietly in her pram throughout the
interview.

Oral-B and the EFP have
touched upon a very important and personal topic, in
that periodontal disease could
affect the developing baby.
Dr Anja Carina Borer: Yes. Gingivitis is a well-known side-effect
during pregnancy and the latest
data shows that practically every
pregnant woman suffers from it. The
number of bleeding sites is about
three times higher in pregnant women than in the average adult. Even I,
a dentist equipped with more than
enough scientifically soun Oral-B
products, experienced some gingival
bleeding for the first time in my life!
As we know, untreated gingivitis can
lead to periodontitis, the inflammatory burden of which can negatively
impact pregnancy. Although more
consistent in-depth studies are necessary, periodontitis during pregnancy has already been linked with
premature birth, low birthweight
and pre-eclampsia. This topic is im-

portant as most pregnant women
are not aware of this problem and
therefore often do not recognize the
warning signs of gum problems such
as bleeding or sensitive gums. With
our campaign, we want to inform
women and make sure they take
good care of their oral health and see
a dental professional in order to prevent possible oral health problems
and pregnancy complications.

How can periodontitis lead to
these complications?
Clinical studies suggest that bacteria
from the oral cavity —specific microorganisms associated with periodontitis—colonise the foetus and
the placenta, with blood as the most
likely vehicle of transmission. As a
consequence, the presence of periodontal bacteria in the feto-placental
unit may activate a local immune or
inflammatory response that might
negatively affect the pregnancy

Biologically, that makes
perfect sense, but how widely
accepted is this point of view?
Although clinical research on the
matter has existed for years, it is
still a fairly neglected topic. Not only
does it not receive enough attention from dental professionals, it is
also largely overseen by healthcare
professionals such as gynaecologists
and midwives. When I was pregnant, I was warned about many potential risks, ranging from flying to
eating sushi or dying my hair! I did
enough research on the aforementioned “risks” to conclude that there
is no scientific data to support these.
However, no one—my gynaecologist included—told me to go and see
a dental professional or take care of
my oral health.
To me, this really is a very personal
matter, as I fell pregnant while es-

tablishing the cooperation concerning pregnancy gingivitis with the
EFP. I find it worrying that pregnant
women are hardly ever informed
about the importance of good oral
health during pregnancy. Therefore,
I was passionate about establishing
the Oral-B/EFP cooperation and lead
the joint campaign. Our aim is to better educate dental professionals and
medical professionals in general, as
well as the wider public, on the importance of good oral health during
pregnancy.

Could you explain the changes in the bodies of pregnant
women that cause pregnancy
gingivitis?
The biggest hormonal changes in a
woman’s life take place during pregnancy. It is a period of great change
and obviously the mouth is one
of the main areas affected by such
changes, which in itself can lead to
gingivitis.
It is not for nothing that people used
to say that women gain a child and
lose a tooth. During pregnancy, there
is a 150 times increase in oestrogen
compared with the amount during
a normal menstrual cycle. This and
the increase of progesterone and
other hormones lead to an increased
vascular permeability of gingival
tissues, which promotes gingival
inflammation in the presence of
dental plaque. For women who have
already developed periodontitis, the
situation usually gets worse because
of the changed hormonal situation.

Apart from cardiovascular
disease, periodontal disease is
known complication of diabetes. What is the risk of pregnant women with diabetes

developing periodontitis?
For women who already have diabetes, the biggest challenge is to
keep their blood sugar under control. Independent from this, a small
percentage of women develop diabetes during pregnancy. Although
this type of diabetes disappears after pregnancy, these women need
treatment in order to avoid serious
complications. Both groups, however, have a higher risk of developing
periodontal disease. It is important
to note that treatment is more likely
to succeed if a person’s blood sugar
levels are under control. Vice versa,
periodontal disease also negatively
impacts diabetes. Overall, it is important that women with diabetes take
care of their oral health before and
during pregnancy.

How do you integrate all of
your findings in your Oral-B
seminars?
Oral-B’s mission is to promote oral
health and work closely with dental professionals to ensure optimal
home care. Our collaboration with
the EFP serves as a way to raise
awareness about all matters concerning oral health during pregnancy. Our educational activities
such as the Up-to-Date events are a
way to communicate this and support dental professionals in their
objective to improve oral health. We
believe a healthy mouth is part of a
healthy body and promoting good
oral health during pregnancy is one
way to help to achieve this.

How can general dental practitioners, periodontists and
dental hygienists integrate
this last thought into their
daily practice?
It is important that they under-

stand the connection between oral
and general health, be it the link between periodontitis and diabetes,
as well as cardiovascular disease, or
complications during pregnancy.
Gynaecologists, cardiologists and endocrinologists too should be aware
of this connection. That being said,
many women avoid professional
dental care during pregnancy and,
conversely, many dental professionals are insecure about treating
pregnant patients. However, female
patients of childbearing age should
be informed about the importance
of oral health during pregnancy.
This is especially important for patients who suffer from periodontitis.
These patients should be encouraged
by dental professionals to undergo
treatment before pregnancy. During
pregnancy, non-surgical periodontal
therapy has been considered safe in
the second trimester.

Finally, what would your tips
be for pregnant women?
Women who have periodontitis
must seek treatment before pregnancy, whereas women who enjoy
good oral health should go and see
a dentist or a dental hygienist in the
second trimester for a dental cleaning. Of course, they should brush
their teeth twice a day with a fluoride-containing toothpaste—even
better is an antibacterial toothpaste
containing stannous fluoride—and
clean their teeth interdentally. It is
scientifically proven that electric
brushes such as our Genius toothbrush are particularly good for reducing plaque and gingival bleeding.
Moreover, they are a practical solution for women who have less time
to brush their teeth. There is no question that all mothers with a baby
will know exactly what I am talking
about.

[3] =>

hygiene tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Preservation of root cementum:
A comparative evaluation of power-driven
versus hand instruments
By Bozbay E, Dominici F, Gokbuget
AY, Cintan S, Guida L, Aydin MS,
Mariotti A, Pilloni A., Italy

Background

Grzesik et al. suggested that cementum plays an important regulatory
role in periodontal regeneration. One
of the major goals of periodontal
treatment is the removal of pathogenic micro-organisms by scaling
and root planning. In the past the
misconception was to obtain a root
surface with smooth and hard surface characteristics that was free of
endotoxins which resulted in the removal of the subgingival plaque and
calculus deposits, and the removal
of all or most of the cementum.
Recent studies have reported that
endotoxins were not located within
cementum and removal of ‘diseased’
cementum was not necessary for a
successful periodontal treatment.
Saygin et al concluded that preservation of cementum on the root
surface was necessary for new attachment and as a source of growth factor. Hence non-aggressive removal
of cementum is essential for optimal
periodontal health and regeneration.
Ultrasonics with new shaped tips
and subgingival air polishing devices
has been developed for removal of
root accretions with minimal root
damage. Air polishing has been suggested as a treatment modality for
root debridement resulting in probing depth reductions and removal of
subgingival biofilm. No scientific evidence exists today showing the loss
of root substance or surface roughness produced by either ultrasonics
or Air polishing.

traumatically and analyzed with a
dissecting microscope
- Remaining calculus, root surface
roughness and loss of root substance
were evaluated along with scratches,
gouges, cracks, and any other changes in the cementum that was present
were noted.

Results

Remained cementum:
- Percentage of coronal cementum
remaining following subgingival in-

strumentation was 84% for U, 80%
for U + AP, 94% for AP and 65% for
HC.
- The amount of retained cementum
with AP was significantly greater
than with HC. SEM
- Smoothest root surfaces were produced by the HC followed by the AP
- Coronal and apical sections showed
that AP produced the least amount
of cementum loss and therefore the
greatest retention of residual cementum

- Root surfaces instrumented by U
or U + AP presented grooves and
scratches.
Time taken to complete root instrumentation
- Shortest time taken was using AP
and the longest time was with U + AP.
- AP required 31% less time for root
preparation in comparison to HC,
whereas U + AP needed 30% more
time

Conclusions

- Air polishing was significantly more
effective and superior in preserving
cementum.
- Hand instrumentation using curettes was most effective in removing cementum in comparison to ultrasonics or hand instruments
Editorial Note: The article was originally published in International Journal of Dental Hygiene.
08 September 2016, page 1-8

The Dental Tribune
International Subscriptions
www.dental-tribune.com

Aim

To assess the amount of cementum
remaining following in vivo root instrumentation as well as the surface
characteristics of the retained cementum

Material and Methods

- 48 caries free, single-rooted teeth
in 27 patients diagnosed with severe
chronic periodontitis with periodontal probing depth (PPD) ≥5 mm in at
least two sites per tooth with radiographical bone loss of more than two
thirds of root length and scheduled
for extraction were included in this
study
- Teeth were randomly divided into
four treatment groups: Instrumentations were performed with medium
power settings
1. Piezoelectric ultrasonic scaler - (AirFlow Master Piezon, Instrument Tip
PS; EMS SA)-U
2. Piezoelectric ultrasonic scaler - (AirFlow Master Piezon, Instrument Tip
PS; EMS SA) followed by air polishing
with the glycine powder (Air-Flow
Powder Perio, Perio-Flow Nozzles;
EMS SA) - U + AP
3. Air polishing with the glycine powder (Air-Flow Powder Perio, PerioFlow Nozzles; EMS SA) - AP;
4. Hand instruments (Gracey curettes
5/6, 11/12, 13/14 American Eagle, Missoula, MT, USA)-HC

Treatment

- One approximal root surface of
each tooth was randomly subjected
to debridement, and the other approximal surface was used as control.
- Following instrumentation, the
teeth were immediately extracted

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hygiene tribune

Dental Tribune Middle East & Africa Edition | 4/2018

CS 5460:
Dental care reinvented
By Curaden
For effective oral care, it is very important to use a toothbrush with soft
bristles. The reason for this is that
hard bristles can often damage teeth
and gums. This is a negative sideeffect which also occurs if too much
pressure is used while brushing.
Curaden’s CS toothbrushes have one
special feature in particular: they are
incredibly soft. The 5,460 CUREN®
filaments of the CS 5460 ultra soft
form an extraordinarily dense and
efficient cleaning surface. The bristles are stiffer than Nylon and remain just as stable in the mouth as
they are when dry. These properties
make it possible to manufacture
toothbrushes with many very fine
bristles. Soft on the gums and teeth,

the CUREN® filaments are extremely
tough on plaque. Anyone who has
tested the cleaning power of a CS
toothbrush will never want any other brushing experience.
An ideal toothbrush head is small
and slightly angled to make it easy
to reach those crucial areas. The bristles should be fine enough to clean
the teeth and gums softly and thoroughly. The handle should make
it possible to properly position the
toothbrush at about a 45-degree angle, always half on the gums and half
on the teeth. The gumline is just as
important as the teeth.
The CS 5460 ultra soft combines
these exact standards of design and
function. The small but efficient head
at the proper angle ensures that your

patients reach those crucial areas. An
eight-sided handle facilitates the perfect angle on the teeth and gums for
optimal cleaning. The large cleaning
surface with incredibly fine, rounded
filaments ensures soft and efficient
brushing of the teeth and gums.
The cleaning efficiency of the bristles
is tightly packed into 39 holes. Combined with the lively colours of the
CS 5460 ultra soft, it makes for one of
the most popular CURAPROX products. The toothbrush is also available with the CPS Prime interdental
brush. The CURAPROX Superduo offers the perfect choice for everyone.

Visit the website to learn more about our
products: www.curaprox.com/ch-en

Periodontal disease may be
key initiator of rheumatoid arthritis
By DTI
AMSTERDAM, Netherlands: In recent years, increasing attention has
been given to aspects of oral health
in patients with rheumatoid arthritis (RA), especially related to associations with periodontal disease. The
results of a study conducted at the
University of Leeds in the UK, and
recently presented at the Annual European Congress of Rheumatology
(EULAR 2018) in Amsterdam, demonstrated increased levels of periodontal disease and disease-causing
bacteria in individuals at risk of RA.

The study found that the prevalence
of periodontal disease was increased
in patients with RA and could be a
key initiator of RA-related autoimmunity. This is because autoimmunity in RA is characterised by an
antibody response to citrullinated
proteins in which the amino acid
arginine has been converted into
the amino acid citrulline, altering
the proteins’ structure. The oral bacterium Porphyromonas gingivalis is
the only human pathogen known to
express an enzyme that can generate
citrullinated proteins.

The study included 48 at-risk individuals (positive test for anti-citrullinated protein antibodies), 26 patients
with RA and 32 healthy controls. The
three groups were balanced regarding age, sex and smoking.
“It has been shown that RA-associated antibodies, such as anti-citrullinated protein antibodies, are present
well before any evidence of joint
disease. This suggests they originate
from a site outside of the joints,” said
study author Dr Kulveer Mankia,
clinical research fellow at the university’s Institute of Rheumatic and

Musculoskeletal Medicine. “Our
study is the first to describe clinical
periodontal disease and the relative
abundance of periodontal bacteria in
these at-risk individuals. Our results
support the hypothesis that local
inflammation at mucosal surfaces,
such as the gums in this case, may
provide the primary trigger for the
systemic autoimmunity seen in RA.”
“We welcome these data in presenting concepts that may enhance
clinical understanding of the key
initiators of rheumatoid arthritis,”
said Prof. Robert Landewé, Chair-

person of the EULAR 2018 Scientific
Programme Committee. “This is an
essential step towards the ultimate
goal of disease prevention.”
The study abstract is titled “An increased prevalence of periodontal
disease, Porphyromonas gingivalis
and Aggregatibacter actinomycetemcomitans in anti-CCP positive
individuals at-risk of inflammatory
arthritis”.

Patient motivation techniques
By DTI
When it comes to motivating patients to maintain good oral hygiene
practices, a clear plan is essential given the time constraints of most dental appointments. What this plan entails, however, depends on what the
most pressing issues to the patient
are. prevention magazine spoke with
Sandy Basheda, a dental hygienist at
the M & N Dental Practice in Bedford
in the UK, about how she structures
her oral hygiene appointments and
the importance of building relationships with patients.

Ms Basheda, how did you
first get started as a dental
hygienist at M & N Dental
Practice?

Sandy Basheda: I’ve been working at
M & N Dental Practice for three years
now. I started basically straight after
I graduated from the University of
Liverpool with a degree in dental hygiene and therapy. Prior to that, I had

a background in dental nursing, but I
wanted more of an instrumental role
with dental patients, which led me to
hygiene and therapy.

What does your average day
at work involve, and what
is the structure of your oral
hygiene appointments?
I see many patients with periodontal
problems and so conduct a lot more
hygiene right now than therapy. I
also deal with a lot of children that,
unfortunately, have dental caries
due to a poor diet, lack of oral hygiene and likely a lack of education
on how to prevent it. It’s not a good
start for children if they have to have
fillings put in or even have their
teeth pulled if it’s particularly bad—
it doesn’t give them a good first impression of the dentist.
Each oral hygiene appointment is
scheduled for half an hour and begins with a discussion about the
patient’s existing problems and

current oral hygiene routine. I then
explain to the patient what the purpose of the appointment is and what
it will entail and conduct an assessment of his or her oral health. Every
patient is very different, and it really
depends on what he or she needs addressed as to how the appointment
will proceed from there.

How can you get patients
to continue with good oral
hygiene practices after an
appointment?
I think one has to build a relationship
with them. They have to trust one
and understand what the benefits of
oral hygiene are, as they might not
be aware that they have any problems in the first place. For example,
if smokers aren’t experiencing any
bleeding in their mouths, they might
not think that there’s anything to
worry about. One needs to be able
to explain to them in a clear and understandable way why taking care
of their teeth is important not just

for their oral health but their overall
health too.

But is it possible to achieve
this all within half an hour?
Well, it’s not a lot of time, but we
can always schedule an hour-long
appointment if it is necessary. I see
many anxious patients, patients who
might not have been to the dentist in
ten to 15 years. With these patients, a
shorter appointment is often good
in the beginning, because it means
that they’re not overwhelmed and
that one can build up from there
over the ensuing sessions. By the second or third appointment, they’re a
bit more relaxed and eager for treatment.

How do you motivate your
patients to take charge of
their own oral hygiene?
I think it’s mostly about re-educating
patients on what the correct and
most effective cleaning methods are,
what products are best for them. It’s

about finding something that works
for the patient, something that will
get him or her excited about taking
care of his or her teeth and seeing
the benefits. In dentistry, it can be
difficult to engage in a cooperative
relationship with one’s patients—often, it’s a one-way conversation with
the professional giving the patient
instructions or advice on how to take
care of himor herself. I like to leave
that sort of instructional conversation to the beginning or the end of
the appointment, as this allows the
patient to think, while in the chair,
whether he or she has any questions
about anything I’ve said or what our
future appointments will entail. Being able to answer these questions in
a clear and understandable way is essential to motivating patients.
Thank you very much for the interview.

[5] =>

A soft
approach
for tough areas.
Enamel is hard. Harder than steel, even.
And it should stay that way. Enamelfriendly brushing means: pampering
your teeth and gums with tender loving
care. Like with the gentle CS 5460 ultra
soft. Mmmm, let’s do that again.

curaprox.com

[6] =>

hygiene tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Oral hygiene instructions and patient
motivation with and without dental hygienists
An interview with Dr Eric Thevissen, periodontist and pioneer of Belgian prophylaxis

By DTI

Dr Thevissen, I wanted to
talk to a dental hygienist in
Belgium. Why is that not yet
possible?
Dr Eric Thevissen: Well, the good
news is that, from June 2019 on, it
will be possible to visit and talk to a
dental hygienist in Flanders. Why
Flanders has waited such a long time
to start the education and training of
dental hygienists is politically motivated and due, in large part, to the
representative dental associations.
Belgium has a long tradition of onedentist clinics, often working without dental assistants. Since the introduction of a quite difficult admission
exam for dentistry in 1997, the discipline has attracted fewer students.
As a consequence, the number of
graduating students has dramatically decreased, while the demand for
dental care is continually increasing.
Slowly, but surely, more and more
group practices have emerged, hiring dental assistants. Back in 2006,
the first meetings were organised between universities and dental societies about the qualifications needed
to become a dental hygienist and
the tasks that could be delegated to
them. As always, there were proponents and opponents, and it took a
very long time before all stakehold-

ers agreed on the conditions and criteria needed to start dental hygienist
training in Leuven and Ghent.

Let’s talk about your study
“The provision of oral hygiene
instructions and patient motivation in a dental care system
without dental hygienists”.
Please tell us more about it.
Thirty years ago, I started working as
a periodontist in Hasselt with another colleague. Since we were the first
periodontists in this province, we
had a flying start. After a few years, I
noticed that dentists were always referring patients to our clinic with the
same complaints, such as bleeding
gingivae or bad oral hygiene. In my
opinion, treating bleeding gingivae
or giving oral hygiene instructions is
the duty of every dentist and belongs
in the sphere of primary dental care
rather than in secondary or specialist
care. Although we organised courses
where a general dental practitioner
(GDP) could learn about patient instruction and guidance, I realised
that we were considered by a large
number of GDPs to be dental hygienists rather than periodontists. The
truth was that we were both, periodontists and dental hygienists. This
annoyed me because I knew that in
neighbouring countries periodontists could spend their precious time

on the work they were trained for.
In 2004, I took the initiative to set
up a pilot study in Limburg with
65 referring dentists. We used the
Dutch Periodontal Screening Index,
a screening test for periodontal status that had been introduced in the
Netherlands a few years earlier. We
collected data from 814 patients.
The results clearly showed that the
screened age groups had, on the
whole, periodontal problems and
that there was a high need for treatment.
Around the same time, Prof. Hugo
De Bruyn joined the teaching staff
of Ghent University’s Department
of Dental Sciences. Probably thanks
to my publication, he asked me to
become one of his staff members.
Working with Prof. De Bruyn, one is
quickly involved in clinical research
and so I had the opportunity to investigate, in depth, the questions
that had bothered me ever since I
started my career. One of these questions was the kind of oral hygiene
instructions GDPs provide to their
patients.
Using questionnaire responses of
776 dental professionals gathered
for various postgraduate courses in
Flanders, we were able to determine
that, given the absence of dental
hygienists in Belgium, oral health
instructions and patient motivation
appeared to be non-compliant with
international guidelines. Though
dental professionals were concerned
with prevention, there were several
mitigating factors working against
them delivering this adequately.

The study mentioned lack
of time, remuneration and
patient interest as complicating factors for the provision of
preventative care. However,
qualification, work experience
and time are crucial for providing oral hygiene instructions
and patient motivation. Can
dental hygienists be seen as a
solution to these problems?

Dr Eric Thevissen

It is my conviction that dental hygienists are the solution to these
complicating factors. Prophylactic
care will be the main target of their
work, since dentists are primarily
trained for restorative care. Owing to
factors such as the decreasing number of graduating dental students,
the increasing number of retiring
dentists in the next ten years, an ageing population and a higher demand
for preventative care, the stress of
work increases and forces dentists
to manage their work time more
strictly. Of course, GDPs prefer restorative and other more rewarding
treatments. We all know how timeconsuming patient motivation techniques for behaviour change can be.
There is no dentist prepared to spend
that time on preventative care. Generally speaking, dentists are used to
giving a basic package of information on oral hygiene to every patient
and, depending on compliance, they
may want to spend more time on
patient guidance. Here, dental hy-

gienists can make the difference.
They will be trained to insist on the
importance of behavioural change
and will take the time to explain and
show how to perform proper home
oral care.
You have also published studies on
implants, such as on implant design.
What made you publish your study
titled “Attitude of dental hygienists,
general practitioners and periodontists towards preventive oral care: An
exploratory study”? You could have
just continued with your research on
implant systems.
Indeed, the team around Prof. De
Bruyn is very driven by and focused
on the outcome of implant therapy.
To my knowledge, the Department
of Dental Sciences at Ghent University published around 40 scientific articles in 2016, the majority of which
are related to implant therapy. The
subject of my PhD is not implantrelated, but deals with different relationships in dentistry: between the
patient and the dental professional,
and between primary and secondary dental care, that is between GDPs
and specialists.

What were the objectives and
results of this study?
This second study was a step further
than the first one. In the first study,
we looked for an explanation for the
differences in patient motivation
techniques between Flemish GDPs
and periodontists. In this second one,
we compared our rather unique Belgian system with the Dutch system,
a completely differently structured
healthcare system including dental
hygienists. We wanted to know if the
Dutch system represented the gold
standard and how we were situated
in Flanders.
The results showed that periodontists and dental hygienists shared
more common viewpoints than
GDPs and hygienists did. What was
remarkable was the fact that more
than 80 per cent of periodontists
and dental hygienists were satisfied with their efforts in informing
and motivating patients, compared
with 38 per cent of GDPs. Secondly,
whereas GDPs indicated nurture
as the factor most contributing to
the oral hygiene level of the patient,
periodontists and dental hygienists
focused on the influence of the dental practitioner and a patient-centred
approach. In our multivariate analysis, the presence of chairside assistants seemed to be of major importance.
But, as always in questionnairebased studies, the results can be biased by socially desirable answers
and by the inevitable structural differences between Belgium and the
Netherlands. One of these differences, for example, is the fact that
providing oral hygiene instructions
is not reimbursed in the Belgian dental care system, as it is not considered
an autonomous activity.

What should the role of the
dental practitioner in the
successful treatment of

periodontal disease be? What
does the patient need to do?
The role of the dental practitioner,
in particular the GDP, undoubtedly
remains to keep a panoramic oversight over everything that has to do
with the dental and oral health of the
patient. Especially considering the
introduction of dental hygienists in
the near future in Belgium, the dentist’s role as a supervising manager is
important. It is my experience that
progressive problems often remain
untreated until complications or
even complaints surface. A trigger
seems to be needed to make the idea
of treatment approachable or acceptable. Unfortunately, waiting for
this trigger often leads to the loss of
the tooth instead of its repair.
From the patients’ point of view, I am
convinced that some of them insist
on not being treated for things they
do not complain about, as they see
these treatments as unnecessary.
If I personally have to undergo an
annual medical check-up, I would
hope that all the exams needed are
performed, as this will set me at ease.
Why then does this appreciation not
apply to oral health?

What are some of the oral
hygiene instructions and
patient motivational actions
that you would recommend?
Thanks to research and clinical findings, lifestyle habits, genetics, stress,
hygiene, medication, age, nutrition
and different systemic factors have
been shown to accelerate the development of periodontal disease in
the presence of biofilm, activated
by a hyperreactive or even a hyporeactive immune system response. It
is a fact that this sort of risk analysis
has become part of the graduate curriculum, including counselling on
healthy food habits or how to quit
smoking, detecting periodontal risk
through assessment, using caries detectors, and so on.
Firstly, the patient should demonstrate his or her home care habits
using his or her own toothbrush.
We distinguish four levels of patient
information needs: the lowest level
is the patient who is almost totally
ignorant about proper home care;
the second level is the patient who
brushes his or her teeth on autopilot without paying attention to any
technique, time duration or interdental cleaning; the third level is the
patient who regularly cleans even
the interdental spaces, but unfortunately not frequently enough or
not with adequate instruments; and
finally, the fourth level is the patient
who performs extremely well and
needs none or only minor adjustments, for example tongue brushing.
In accordance with the technique
of motivational interviewing, we
build up a conversation with the
patient while giving instructions,
waiting for approval, repeating and

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Dental Tribune Middle East & Africa Edition | 4/2018

hygiene tribune

◊Page C6
counselling. One needs two or three
control sessions to check his or her
dexterity and oral cleaning performance. Plaque disclosure remains a
confronting but very effective tool
to show the results of the patient’s
cleaning habits.
Finally, the dental professional
should show enthusiasm and keep
on repeating until there are visible
improvements.

From your point of view, does
the dentist spend enough time
on the diagnosis of a disease?
Of course, dentists are dutiful people
who are concerned with their jobs.
Spending time to ensure correct diagnosis is their core business. Examining patients means exploring and
looking for mostly hidden troubles
or discomforts.
The next question is the most important one: is this problem acute
enough that it should be treated immediately, in the very near future, or
can we wait and see how it develops?
This is risk management and it is dependent on multiple factors.

Often, prevention is neglected
in dental practices in favour of
diagnosis and restorative treatment. How can dental professionals implement prophylaxis
in their daily practice, especially
primary prophylaxis?
I would say, rather, that prevention
is not neglected. Sixty-five per cent
of GDPs provide information about
oral hygiene as a standard procedure. Depending on compliance, the
GDP may decide to spend more time
on patient guidance. This requires
delicacy, as one cannot tell from a patient’s face how motivated he or she
is, nor what he or she is interested in.
This is not often asked of the patient,
so one could rather say there is not
enough time spent on communication.
I invite practitioners to do an experiment in their waiting rooms. While
the patient is waiting for his or her
appointment, he or she can be given
a short questionnaire asking him
or her to write down in a few words
his or her understanding of proper
home care and his or her personal
ritual. The patient can then be asked
if he or she would be interested to
know more about it. We use this
method in our clinic. In the waiting
room, patients have time to reflect
and one might be surprised at how
interested patients really are if one
gives them the opportunity to communicate and to prepare their questions in advance.
To be honest, I think that primary
prophylaxis is impossible to achieve

because we do not control all the
influencing factors, of which some
can be health- or patient-related. It
means that we need to try to prevent people from developing caries
or periodontal disease. This is somewhat futile, since caries and periodontal disease are the most widespread infectious diseases present
in almost every patient. Twenty-five
per cent of 5-year-old children have
bleeding gingivae, and this figure
rises to 55 per cent for 15-year-olds.
Primary prevention is like placing speed cameras on highways: it
works all the time and for everyone,
it is highly effective and inexorably
justified. Today, I heard in the news
that, thanks to these speed cameras
and other regulations, the number of
persons killed by traffic every year is
diminishing. This is primary prevention. However, I strongly believe in
secondary prevention; it is the dentist’s duty to examine and to intervene, preferably before detrimental
clinical signs occur.

How important are home care
and high-quality oral hygiene
products such as those of
CURAPROX?
It is a fact that oral hygiene devices
are not considered as pharmaceuticals and they therefore don’t have to
be thoroughly tested. If a company
designs a nice, good-looking toothbrush, it is allowed to produce it
and sell it, even if the brush does not
meet the criteria desired in an effective toothbrush.
Comparing the oral hygiene products from different companies, we
see a variety of designs and features.
This is interesting because there is no
such thing as the perfect interdental
brush. There are always compromises to make and what some patients
like, may be rejected or disapproved
of by others. We as dentists have only
an advisory, consultative role.
Nevertheless, CURAPROX makes
Swiss-quality products designed by
dental professionals, and the company is willing to listen to advice on
how to improve its products.

What is the status of dental
hygiene in Belgium? In other
words, how does the Belgian
mouth look?
When I go abroad to congresses and
meet with peers, I feel their displeasure when they hear that I come from
Belgium. The first thing I am asked is,
how can you treat periodontal disease without a dental hygienist? For
them, it is like having bars and pubs,
but no beer.
I have read some articles in which
the decayed, missing and filled teeth
and decayed, missing and filled sur-

faces scores of children were compared between different European
countries. Though Belgium was not
top of the class, it wasn’t at the bottom either. In articles from the US, it
is reported that, at 30 years of age, 25
per cent of the American population
have mild periodontitis, 60 per cent
have chronic periodontitis and 15 per
cent have aggressive periodontitis.
This is exactly the same breakdown
as in Europe. The question is not
about whether dental hygienists are
necessary; the question is, what percentage of the population do dentists reach and can afford to go to a
dental hygienist on a regular basis?
Despite all this, we seem to be able to
manage the periodontal situation in
Belgium and this was one of the reasons for the second study.

Does the addition of dental
hygienists make financial
sense or does prophylaxis
make financial sense for the
dental practice if the practice
already makes good money
with implants?
I understand your point of view that,
in the perfect world of prophylaxis,
dental implants have no place because everything should be done to
prevent implant treatment.
I remember Prof. Jan Lindhe saying
that, nowadays, too many treatable
teeth are extracted to be replaced by
dental implants. As a periodontist I
agree with Prof. Lindhe; a dental implant is an effective instrument to rehabilitate edentulous areas, but only
after all other options have been considered. But often life decides differently, and at Ghent University, I see
a lot of young people seeking dental
care because of, for example, fracture of one or more of the front teeth
owing to biking and other kinds of
accidents, sometimes under the influence of alcohol or drugs. These
students don’t want to wear removable dentures for life.
With respect to the first part of the
question, of course the addition of
dental hygienists makes financial
sense. The purpose is to relieve dentists of those tasks that can be delegated to auxiliary staff. Secondly,
dental hygienists will be trained to
communicate with patients about
their problems and questions. Delegating prophylactic care to the dental hygienist implies that more patients can be treated and followed up
on. We also must not forget patients
who live in nursing homes. Since
nurses are not allowed to provide
dental treatment, we are glad that,
in the near future, dental hygienists
will be available to give these people
the necessary preventative care.

What kind of prophylaxis does
the Belgian dentist perform in
the office? How much time do
you devote to prophylaxis?
Supposing that patients go to their
GDP on a yearly basis, supragingival
scaling and scaling of shallow pockets is standard procedure. The Dutch
Periodontal Screening Index is a perfect tool to screen patients for periodontal disease and treatment needs,
but this index is unfortunately not
yet applied widely enough, even
though it is reimbursed. If a GDP
remarks that the gingivae bleed easily or if the patient complains about
periodontal infection, then the periodontal probe is used and the patient will eventually be referred to a
periodontist.

UC Leuven-Limburg and
Artevelde University College
(in Ghent) are offering a new

professional bachelor’s degree
programme in dental hygiene.
Is that a breakthrough?
It certainly is. It is a pity that this
programme is not yet offered in the
French-speaking part of Belgium.
Let’s hope they will follow with us
as soon as possible to ensure the
levelling of our nation’s dental care.
Since Leuven and Ghent are the
only Flemish universities where the
dental graduate curriculum can be
followed, it is logical that dental hygienists will be trained at those same
universities, and that both professional groups will start to work together at chairside from trainee level
onwards.

When looking at your Dutch
neighbours, what do you
think should be replicated in
Belgium?
In the Netherlands, they have more
than 50 years of experience with
dental hygienists. This profession is
well represented and has a strong,
hardworking and lobbying society.
We in Belgium have always respected and admired the pioneering way
of organising dental care in the Netherlands. Although tough discussions
have had to be conducted, they have
always reached a consensus. Today
in the Netherlands, up to ten different levels of dental professionals
are distinguished, from specialists
to dental assistants. I don’t think we
will ever see this development in Belgium.

of our diploma as a specialist in periodontology and oral implantology.
This dream was only fulfilled in
2003. My second dream was that
dental hygienists would be legalised
to work in Belgium, and as you know,
this will also become true from 2019
onwards. So, the future is bright. I
fortunately did not mention how
long it would take before my dreams
would be fulfilled!
Looking back to ten years ago, taking digital impressions with oral
scanners was still a utopia; there
were no navigation systems available for implant therapy, and we did
not yet have these composites with
hydroxyapatite nanoparticles. Dentistry has evolved in such a rapid way
that the future is today.
However, in my opinion, the evolving trend towards cosmetic dentistry
is almost alarming. There is nothing wrong with the high demand
for aesthetic dental treatments because it has been proven that these
patients show more compliance
in cleaning their teeth, but there is
a tendency towards the belief that
appearance is more important than
function. Many patients prefer whitening their front teeth to periodontal treatment to save natural teeth.
While they argue about periodontal
therapy not being reimbursed by
the healthcare system, this point is
not raised when they seek aesthetic
dental care.

Finally, where do you see the
future of Belgian dentistry?

Another rather regrettable observation is the fact that stock-marketlisted companies invest in dental
clinics and hire dentists as employees. Of course, this is a sign of the
times. Being the manager of a group
clinic today has turned into a fulltime job that has almost nothing to
do with dentistry. Let’s hope that the
financial management of these clinics is not more important than the
patients and that the dentists working in the system still feel the same
responsibility towards their patients.

When I graduated in 1986 as a periodontist I had two dreams, the first
of which was the official recognition

Thank you very much for the interview.

The advantage of us being behind is
that we can copy the best things that
have proven to be solid and to work,
and delay the more complex or risky
things until we see how it works out
there.
I hope that dental hygienists will integrate easily into the dental workplace and that their future will be as
bright as it is in the Netherlands.

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[cover] => Hygiene Tribune Middle East & Africa No. 4, 2018

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