Periodontal treatment plans should focus on benefits of power brushes
by Karen Davis, RDH, BSDH, RDHMP
Dental plaque is structurally and functionally highly organized biofilm. A diseased periodontal pocket can consist of millions of bacteria depending upon its depth. Plaque biofilm has the ability to begin reorganization within days of being completely disrupted, and left undisturbed, can become the source of reinfection for gingivitis and periodontitis. Before dental professionals really understood the role of plaque biofilm in the oral environment, it would have been easy to underestimate just how important power-driven plaque control is on a daily basis for successful treatment of periodontal diseases.
Research
Even though there are numerous published studies confirming the clinical effectiveness of various types of power-driven toothbrushes compared to manual brushing1,2,3, what seems even more compelling to consider has to do with a clear understanding of just what's at stake in the supragingival environment and its potential impact on the subgingival health. Periodontitis patients have been shown to have a greater proportion of red and orange complex bacteria present in both supra and subgingival plaque, and a high threshold level of these pathogens in the subgingival environment have been thought to be associated with disease progression.4 One study recently calculated the actual amount of gram-negative anerobic bacteria and discovered that the bacterial numbers associated with disease are up to 100,000 times larger in plaque biofilm than those associated with health.5
A 2006 study published in the Journal of Periodontology revealed that as supragingival plaque increased, both gram-negative and aerobic bacteria were significantly associated with increased risk of attachment loss; therefore, a new hypothesis has been offered. Rather than just a few individual pathogens, it may be the interactions within the entire biofilm profile that determine the initiation of periodontal destruction.6 Viable aerobic and anerobic bacteria have also been found to be present within supragingival calculus living in the internal channels and lacunae.7 A 2007 study published in the Journal of Periodontology confirms that supragingival plaque control has the potential to significantly improve clinical parameters associated with gingivitis and periodontitis, and can significantly reduce pocket depths and bleeding on probing. This was tested in both smokers and nonsmokers alike.7
What does this mean? Does control of gingivitis and periodontitis rest solely on the patient's ability to perform complete plaque removal every day? Clearly not. Consideration must be given to risk factors that alter the oral environment and impact the patient's immune response. However, in light of recent studies evaluating the impact supragingival plaque biofilm can have on the prevention and/or progression of disease, clinicians should increase their appreciation of how powerful daily plaque removal really is, and something patients have full control of. Weekly professional supragingival plaque removal has been shown to provide improved clinical outcomes,8 but it is unlikely that patients (other than those committed to a clinical study) would be willing to visit the dental hygienist for weekly professional plaque removal!
Powered vs. manual brushes
While studies comparing the overall clinical benefit of powered vs. manual brushes for patients without periodontal diseases appear to be somewhat inconclusive,9 data on the value of power brushes for periodontal patients is clear. Inclusion of detailed plaque-control instructions have to be an integral part in the therapeutic treatment of gingivitis and periodontitis, and what better way to equip the patient for that than the use of power brushes?
Power-driven plaque removal has many benefits for the periodontal patient. Number one, power brushes with timers enable patients to consistently spend more time removing plaque. Brushes such as the Sonicare Flexcare+, Sonicare for Kids, and Oral-B Professional Care SmartSeries 5000 have timers built into them for patients to brush until the timed sequence is over. Secondly, studies have shown that in vitro plaque biofilm removal is possible beyond the reach of the bristles due to hydrodynamic shear forces of power brushes.10 Lastly, during the initial phase of periodontal therapy, power brushes have a superior ability to reduce supragingival plaque and reduce the level of bleeding on probing compared to manual brushes.11
If the goals of periodontal treatment for gingivitis and periodontitis are to arrest disease from progressing and establish disease remission, then clinicians must consider inclusion of power-driven plaque control into treatment plans presented to the patient. When presented as a part of the therapy itself as the patient's role in controlling the disease, it emphasizes the fact that more is required to treat infection than the therapy itself. The following case scenario reveals the power of including power-driven plaque control into a periodontal treatment plan.
Brushes such as the Sonicare Flexcare+, Sonicare for Kids, and Oral-B Professional Care SmartSeries 5000 offer oral health benefits to periodontal patients.
Case study
Heather, a high school senior, presented to the dental practice with the chief complaint of bleeding gums. Her medical history revealed that she was taking birth control pills and over-the-counter allergy medication daily. Her radiographs revealed no decay and no bone loss. Her periodontal chart revealed 1 mm to 3 mm probing measurements, and 45% of the sites bled upon probing. Disclosing solution revealed plaque biofilm present on 55% of the tooth surfaces. Light supragingival calculus was detected on the lingual surfaces of the lower anterior teeth. She was diagnosed with plaque-induced gingivitis.
When asked about her current oral hygiene habits, Heather stated that she brushed with a manual brush twice daily and did not use any tool for interproximal cleaning. When questioned about her diet, she described a diet deficient in adequate fruits and vegetables and high in simple carbohydrates.
The treatment plan presented to her included a Sonicare Flexcare+, a prophylaxis, antimicrobial toothpaste and rinse for daily use, and a multivitamin supplement to increase antioxidants levels. Also included was the recommendation to have a complete reassessment in six weeks in conjunction with another preventive prophylaxis, as well as a closely monitored interval of preventive care every three months for a minimum of one year following therapy.
During her initial prophylaxis, she was introduced to proper use of the power brush and correct use of dental floss. At her reassessment six weeks later, the bleeding sites were reduced to 2% and disclosing solution revealed plaque biofilm on only 7% of the tooth surfaces. Throughout the subsequent year, her preventive care visits revealed sustained disease remission. Consider how many patients like Heather enter the stressful college or work environment following high school with untreated gingivitis, and the potential progression into periodontitis is continually present!
Investing in power-driven plaque control
Treatment recommendations for power-driven plaque control for patients diagnosed with periodontitis should be the same as Heather's. Including power-driven plaque control directly into the treatment plan enables patients to readily see that they must make a commitment to the daily removal of plaque biofilm. Failure to do so increases the risk of reinfection. Patients who develop good plaque control habits in conjunction with their nonsurgical therapy are in a position to maintain those habits for a lifetime. Power-driven plaque control can be considered an investment almost equal to the value of periodontal therapy itself!
Brushes such as the Sonicare Flexcare+, Sonicare for Kids, and Oral-B Professional Care SmartSeries 5000 offer oral health benefits to periodontal patients.
AUTHOR
Karen Davis, RDH, BSDH, is founder of Cutting Edge Concepts, and is a practicing dental hygienist in Dallas, Texas. She is a trainer with The JP Institute and an international speaker in the dental profession. Karen serves as an independent consultant to Philips Oral Healthcare, Inc. She received her bachelor of science in dental hygiene from Midwestern State University and can be reached at [email protected].
REFERENCES
1. Moritis K, Jenkins W, Hefti A, Schmitt P, McGrady M. A randomized, parallel design study to evaluate the effects of a Sonicare and manual toothbrush on plaque and gingivitis. J Clin Dent, 2008;19(2):64-68.
2.Sicilla A, Arregui I, Gallego M, Cabezas B, Cuesta S. A systematic review of powered vs. maual toothbrushes in periodontal cause-related therapy. J Clin Periodontol. 2002; 29 Suppl 3:39-54.
3 Haffajee A, Thompson M, Torresyan G, Guerrero D, Socransky S. Efficacy of manual and powered toothbrushes. Effect on clinical parameters. J Clin Periodontol. 2001; 28:937-946.
4. Ximenez-Fyie LA, Haffajee AD, Socransky SS. Comparison of the microbiota of supra- and subgingival plaque in health and periodontitis. J Clin Periodontol. Sept. 2000; 27(9):648-657.
5. Lovegrove JM. Dental plaque revisited: bacteria associated with periodontal disease. J N Z Soc Periodontol. 2004; 87:7-21.
6. Tezal M, Scannapieco F, Wactawski-Wende J, Grossi S, Genco R. Supragingival plaque may modify the effects of subgingival bacteria on attachment loss. J Periodontol. 2006; 77(5):808-813.
7. Tan B, Mordan N, Embleton J, Pratten J, Galgut P. Study of bacterial viability within human supragingival dental calculus. J Periodontol. 2004; 75:23-29.
8. Gomes S, Piccinin F, Susin C, Oppermann R, Marcantonio R. Effect of supragingival plaque control in smokers and never-smokers: 6-month evaluation of patients with periodontitis. J Periodontol. 2007; 7:1515-1521.
9. Ximenez-Fyvie LA, Haffajee AD, Thompson M, Torresyap G, Socransky SS. The effect of repeated professional supragingival plaque removal on the composition of the supra- and subgingival microbiota. J Clin Periodontol. 2000; 27(9):637-647.
10. Bogren A, Teles R, Torresyap G, Haffajee A, Socransky S, Wennstrom J. Clinical and microbiologic changes associated with the combined use of a powered toothbrush and a triclosan/copolymer dentifrice: A 3-year prospective study. J Periodontol. 2007; 78(9):1708-1717.
11. Hope C, Petrie A, Wilson M. In vitro assessment of the plaque-removing ability of hydrodynamic shear forces produced beyond the bristles by two electric toothbrushes. J Periodontol. 2003; 74(7):1017-1022.
12. Gugerli P, Secci G, Mombelli A. Evaluation of the benefits of using a power toothbrush during the initial phase of periodontal therapy. J Periodontol. 2007; 78(4);654-660.
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