by LYNNE SLIM, RDH, BSDH, MSDH
Jerry, age 34, was my first patient of the day. The chair hummed as it slid into the usual supine position. Jerry's head was tilted slightly back, mouth wide open, and his hands were in the unspoken raise-hand-to-signal-pain position. As I slid the piezo tip along the gingival margin of tooth #13, Jerry's body jerked stiff, his knuckles went white while clutching the knees of his trousers, and in slow motion I watched his epiglottis flutter violently as he shrieked the only sound a human could possible utter in his horizontal position, "Ahhhhhkk!"
Jerry's eyes were suddenly wet.
"dat wadiaded hu ah toot to wa node to wa iwaw…." I removed my hand and the saliva ejector from his mouth so I could understand him better.
"What?" I repeated.
"That pointed monstrosity radiated from my tooth, through my nose, and to my eyeball."
"Oh, I'm sorry. I'm so sorry. I didn't mean to cause you any discomfort," I said as I lifted the face shield from my face.
"I suppose it's my fault," Jerry grinned. "I forgot to raise my hand, huh?"
I was relieved to see that he was making light of the incident. I never want to hurt a patient. I questioned him about the general dentin hypersensitivity, and it turned into an opportunity to educate him about the condition..
In addition, I was thrilled to be able to offer a variety of OTC toothpastes for sensitive teeth. I'm so thankful to various companies who provide toothpaste samples. I love the glitzy designs of toothpaste boxes today and all the new toothpaste formulations. My patients are thankful for the free goodies too, and you'd think they were getting a new mini I-Pad when I include a toothpaste sample in their goody bag.
Right before the Christmas holidays, I was thumbing through a Southern Living magazine and came across a stocking stuffer ad for some flashy sonic toothbrushes. They're named "Slim," and I was so briefly hoping they were named after me (but I'm very doubtful they were!). These portable brushes with mascara-style, patterned caps were adorable, and I'm sure they appeal to Millennials who are all about bling-bling. This particular company also makes toothbrush sanitizers that look like large eggcups with adorable, colorful characters.
Even though I'm not a Millennial, I have to admit that I'm a bling-bling fan too. I love Coach anything — handbags, sunglasses, shoes and I'd probably even consider purchasing a Coach-powered toothbrush if one were to appear on the market! Our American consumer-based obsession for oral care consumables is well timed and expected to continue, mostly due to increased demand from an increasing aging population as well as from the younger generations who are focused on dental esthetics.
In making recommendations to patients about self-care and some of the new glitzy devices, there's a lot to think about. Most important to the patient is that you come across as a "professional," and it's very important to set yourself apart from a trained "technician." When it comes to patient decision-making, dedication to professionalism means working constantly to improve one's skills and knowledge and providing value for money. If we are selling self-care devices to patients, we sell with principles and ethics and work hard to earn our patient's trust.
Evidence-based decision-making is new to the dental hygiene profession but unless we dedicate ourselves to its growth, we will never achieve our united professional goals. To this end, clinical practice should rest on solid research evidence where possible and this includes self-care devices.
Several questions come to mind in questioning benefits of these devices to oral health. For example, here are a few questions that have crossed my mind:
- Do these new designer toothbrushes and other devices clean efficiently?
- Do higher-end powered toothbrushes result in better therapeutic outcomes when compared to less expensive models or manual toothbrushes?
- What do we base our recommendations on regarding toothbrushes and interdental cleaning devices to maximize proximal biofilm removal and other important therapeutic outcomes?
I've answered some of these questions in previous columns and feature articles, but sometimes we don't have adequate science to guide us in clinical decision-making for many oral care devices, including the newer, flashy ones. For instance, which powered interdental cleaning devices are most effective and how do these electric devices compare to tried-and-true mechanical devices like dental floss, woodsticks, or interdental brushes?
Frandsen (1986) states that no interdental cleaning device shows greater efficacy than any other in terms of plaque/biofilm control or for establishing and maintaining gingival health.1 He further suggests that these devices should be recommended according to individual dexterity, preference, and interdental anatomy. His conclusions may still be applicable today, and I feel very strongly that the aging population needs wider interdental brushes and end-tufted toothbrushes that are designed for anatomical areas with significant clinical attachment loss.
A 2008 systematic review (a higher level of evidence compared to a single study) on interdental cleaning devices tends to favor interdental brushes over dental flossing2 in terms of plaque reduction, but there is no conclusive evidence on the effect of interdental brushes in reducing gingival inflammation and bleeding. Today's interdental brushes offer different style handles, angled or straight brush heads, and a large variety of interdental diameter brush heads that can be customized to fit your patient's needs and preferences. I love the idea of customizing interdental brush head diameter, giving the patient a sample and then directing them online to order what they need. Patients sometimes need more than one size and that's OK, too.
In looking at powered devices as alternatives to dental flossing, I would not rule out oral irrigation devices or an air/water flosser. Another 2008 systematic review on oral irrigation3 found that oral irrigation did not have a beneficial effect in removing visible plaque but resulted in improved gingival health. Oral irrigation and air/water flossers may be preferred by patients for a variety of reasons, including dexterity, even though the science is less clear on plaque removal outcomes. In addition, oral irrigation and air/water flossers can serve as delivery devices for chemical adjuncts like chlorhexidine gluconate or essential oils. Alternatives to mechanical interdental devices like oral irrigation/ air flossers should be recommended according to patient preference and hygienist guidance.
A 2010 systematic review compared the efficacy of various types of powered toothbrushes in reducing plaque and gingivitis.4 The types of powered toothbrushes included side-to-side, counter oscillation, circular, rotation oscillation, ultrasonic, and multidimensional. A total of 17 clinical trials were included in the review. After reviewing 17 trials, rotation oscillation brushes in the short term reduced plaque and gingivitis more than the side-to-side brushes. The results were statistically significant but not necessarily clinically significant, even though a previous systematic review found the rotation oscillation powered toothbrush to be superior to manual toothbrushing. The most effective powered toothbrush was not made clear in this systematic review.
The evidence to promote one particular type of powered toothbrush over another to date is weak and therefore, in terms of clinical efficacy, it may not be possible to recommend one type of powered toothbrush over another. Hygienists need to recognize that consumers (patients) rarely weigh up all the costs and benefits of choices, and they may rely on you for guidance. Sometimes it's a relief for them to depend on you for powered toothbrush recommendations so make sure you're familiar with the various features of powered toothbrushes. Like us, consumers are bombarded with a ton of information and they rarely use all the information available to them when shopping.5
Be open-minded when it comes to patient recommendations for self-care devices. Carefully assess your patient's needs and preferences and keep your eye on the research. Devices that have the highest number of appropriate research studies where results are unequivocal are your best bet. Systematic reviews are designed to assess research on a given topic/question and offer a higher level of evidence. Evidence-based resources like the Cochrane Oral Health Reviews and the Journal of Evidence-Based Dental Practice are reliable sources of information and I would study them on a periodic basis. Keep your recommendations objective and professional at all times, and remember that cheapening your patient recommendations by not keeping up with the literature is cheating your patients and profession in the long run.
Will I end up with a designer ‘Coach' toothbrush in a future Christmas stocking? Probably not because I have learned to move beyond glitz and make sure my personal oral care choices are not short on substance. RDH
1. Claydon NC. Current concepts in toothbrushing and interdental cleaning. Periodontol 2000; 2008 (48): 10-22.
2. Slot DE et al. The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review. Int J Dent Hyg 2008 Nov; 6(4): 253-264.
3. Husseini A, Slot DE, Van der Weijden GA. The efficacy of oral irrigation in addition to a toothbrush on plaque and the clinical parameters of periodontal inflammation: a systematic review. Int J Dent Hyg 2008 Nov;6(4): 304-314.
4. Deacon SA et al. Different powered toothbrushes for plaque control and gingival health. Cochrane Database Syst Rev. 2010 Dec 8; (12): CD004971.
LYNNE SLIM, RDH, BSDH, MSDH, is an awardwinning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group:
www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.
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