Observations about preventative dentistry

(Written by Chris Turner – edited by Cary Cray-Webb)

We’ve recently been working with Chris Turner, Managing Director at Spacemark Dental. Spacemark Dental is the developer of advanced periodontal treatment and prevention systems. We asked Chris to give us some thoughts on the prevention and treatment of Periodontal Disease and edited them into an article for our website.

The Spacemark Dental chart is now available with your Pearl Dental system to give you the world’s most comprehensive and thorough software support for Periodontal examination, charting and treatment here in the UK.

If you would like more information on this integration, please get in touch by emailing info@pearldentalsoftware.com or calling 0116 275 9995.

Effectiveness and Efficiency

As dental professionals we work with the above Cochrane principles:

• Effectiveness does the treatment work
• Efficiency which is more relevant to clinical practice, and asks how well we carry out a given procedure.

We know that when patients control their plaque well they can bring, with professional help, their periodontal disease under control.
I believe we should apply the Cochrane principles to patients and their plaque control and ask the following questions:

1. Have we observed how patients brush their teeth and corrected any errors?
2. Do they have the correct size and shape of toothbrush and is it fit for purpose?
3. Which place do patients miss when they brush?
4. If we have prescribed inter-space brushes are they cleaning interproximally?
5. Have they followed our advice when we follow up?

In summary, how can we help our patients be more efficient in their daily plaque control and gain not only dental but other health benefits in relation to heart disease, diabetes, rheumatoid arthritis and possibly Alzheimer’s?

Interspace Brushes

Can someone please explain to me why the usual prescription of interspace brushes is just two sizes; one large and one small diameter. This cannot be effective:

1. A too-small brush will not remove all the plaque and create a false sense of security.
2. Leaving patients to decide for themselves which of the two sizes to use where could be regarded as a failure in the duty of care.

For my own patients, I found that everyone had a unique pattern of interproximal bone loss and the number of brush diameters required varied from 2 to 7.

Following a patient complaint about which brush to use where I developed the Spacemark Dental computerised charting system for the most commonly prescribed ‘TePe brushes’. Here, you check each space manually for the correct diameter, click on the space then the colour brush you have chosen and the programme inserts that on the chart, and so on around the mouth. You save the chart to prove your prevention advice. Then for it to be patient-usable click on change the view. The programme flips the chart through 180 degrees. Print this or let your patient take a photograph. Each chart will cost you less than £1.00 to produce.

Plaque control techniques

When teaching patients how to control their plaque, I always found that the most useful first step was to ask them to bring their present toothbrush to the next appointment and not to buy a new one. Many had the bristles turned over and therefore not effective and were surprised to be told that the average life expectancy of a toothbrush head is about 6 weeks.

Brushing technique

The next stage was to ask them to demonstrate their brushing method. ‘I start here and then go there’. It was immediately obvious that there was no plan, that areas would always be missed, and that the starting point was to teach an organised approach to clean each quadrant, in turn, both labially/buccally and palatally/lingually and follow up at the next appointment to see what had been learned.

If your patients are not using electric brushes, decide which brushing method you will teach. Explain that time is required for plaque control both in the morning and especially thoroughly last thing at night.

If your patient agrees, disclosing tablets, on a one-off basis, will show where plaque has been retained and are a useful teaching aid. If you have a clinical camera take a picture. If not detail where the stained areas are.

Correct what faults you can. There is much more to effective plaque control than you might think.

Note – Your Protection Society will thank you for this evidence if ever your patient complains that you have not diagnosed or treated their periodontal disease.

Use your data

Since the mid-1990’s it has been an NHS requirement that a basic periodontal examination is carried out at each examination visit. What do you do with this information?

For example, my cousin’s wife who has type II diabetes and an HbA1C score of over 8.5 is at risk of developing irregular or atypical periodontal disease. She hears the numbers called out, but is neither told what they are or what they mean and has no means of knowing if she is getting worse, is stable, or getting better. This is no way to practice prevention in my opinion.

I found that sharing the BPE score with patients was a useful teaching and motivational aid. ‘You need to concentrate more here and spend a little extra time.’ You have to explain what the numbers mean, otherwise patients might think that a score of two is twice as bad as a score of one. The numbers refer to different clinical entities. Perhaps the inventors of the method, Ainamo and Ainamo, should have used letters instead?

There is another important aspect that your Pearl Dental Imaging system provides. Pearl holds a record of a patient’s BPE score over multiple examinations. Never look at just the last numbers, but also compare with the previous ones to identify trends in what is happening to your patient. Again print off and share the information with your patient. It is not a secret as the Access to Medical Records Acts confirm.

Why does periodontal disease start interproximally?

If you watch patients using manual toothbrushes then the most common method of brushing is backwards and forwards, a method that will always leave plaque in these sites. Over time, the body’s hypersensitivity reaction will cause inflammation and gradual bone loss in less susceptible patients, or more rapid bone loss in the more susceptible.

Why do some areas of the mouth exhibit more periodontal disease than others?

For a right-handed patient, you will find that maxillary left molars are cleaned less well than right molars, that maxillary right lateral incisors have more bone loss than left ones, and that mandibular right lingual surfaces are often less well cleaned than the left. The reverse is true for left-handed patients.

Surprisingly, the answer lies in the limitations allowed by the anatomy of the wrist, i.e., the angle that the brush is held in relation to a parasagittal plane in the case of maxillary molars, and the inability to carry out rotational movements for the other two sites. The answer –  teach your patients to use the opposite hand.

Better still, changing to electric brushes may eliminate some of the above, but do check.

More claims against dentists in the UK than the USA!

Your Protection Society will be able to confirm that:

1. In the UK there are more claims against dentists per head of the population than in the USA.
2. The largest number relates to the failure to diagnose and treat periodontal disease.

This raises the thorny question about prevention in your practice, and more importantly how you might be able to prove that you have adopted a preventive approach to the care that you provide. I suggest that there is an answer to this question by recording as follows:

1. You have checked the size and state of your patient’s toothbrush and given corrective advice if necessary.
2. You have checked your patient’s toothbrushing methods and given corrective advice, and followed this up at each subsequent visit to ensure that old habits have not returned.
3. You have used the last two BPE scores as a teaching aid to show any trends in changing status and given your patient a printout of their records with an explanation of what the numbers mean.
4. If there is a score of 3 or more in any sextant you have a full periodontal charting with follow up and this is also given to your patient.
5. Advising patients to use just two sizes of interspace brush is neither effective nor efficient. Prepare a Spacemark Dental chart which will be unique for each one. Update the chart if your patient says they can now use a larger size brush in any space.
6. Be prepared to sell interdental brushes to your patients at a less price than online or chemists, and record who buys which size and when as a means of checking on usage.

This may sound time-consuming, but it should save you hours of time if ever there is a complaint.

You can find more information about these tips – go to: turnersdentaltips.com.

About the author

After qualification Chris worked in general dental practice before entering higher training at both UCH and Newcastle Dental Hospital during which time he gained his Fellowship in Dentistry from the Royal College of Surgeons of England.

At age 34 he was appointed as a Consultant in Restorative Dentistry in Sheffield, then aged 35 he became Head of the new Department of Dental Services with the remit to be the first head of, and develop the Dental Practice Unit in 1980. The Unit continues to flourish and train dental students.

Chris later worked as Director of Dental Services for Salisbury Health Authority before establishing a private restorative dental practice in Cirencester. He has had nearly 100 papers published and is now retired.
Chris has created several inventions, including colour coded pocket probes and the Spacemark Dental system of charting correct sizes of interdental bottle brushes for patients.

For more information go to: www.spacemark-d.com