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T H E B R I T I S H S O C I E T Y O F D E N T A L H Y G I E N E A N D T H E R A P Y

DENTAL HEALTHA n n u a l C l i n i c a l J o u r n a l o f

NO. 4 2015

www.bsdht.org.uk

Denture hygiene: a guide to the

delivery of improved denture hygiene

for our patients

A literature review on the associated link

between periodontal disease and adverse

pregnancy outcomes and its impact on

dental treatment for the pregnant patient

Consent, the law and

professional regulation

The efficacy of using sustained release

chlorhexidine chip as an adjunct to the

treatment of periodontal disease

Is there a need for training in current

cleft lip and palate care?

Are waterpipe smokers aware that

there are health risks associated with

waterpipe smoking?

UK dental hygienists – the road to direct

access: the results of a literature review

ANNUAL CLINICAL JOURNAL OF DENTAL HEALTH2

© Annual Clinical Journal of Dental Health – The British Society of Dental Hygiene and Therapy 2015. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise without the prior permission of Dental Health.

Views and opinions expressed in Dental Health are not necessarily those of the Editor or The British Society of Dental Hygiene and Therapy.

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Printed on Regency Satin by: Crossprint Ltd, Newport Business Park, Barry Way, Newport, Isle of Wight PO30 5GY.

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EDITORHeather L Lewis, 19 Cwrt-y-Vil RoadPenarth, Cardiff CF64 3HN

Tel: +44 7824 555921 Email: [email protected]

BSDHT NATIONAL ENQUIRY LINETel: 01452 886365Fax: 01452 886468Email: [email protected]

ADVERTISING SALESEmail: [email protected]

CLASSIFIEDS & JOBLINETel: 01452 886365Email: [email protected]

PUBLICATIONS COMMITTEESue AdamsAlastair LomaxAlison LowePatricia Macpherson Emma Pacey Pippa Stewart Elaine Tilling Helen Westley

EDITORIAL BOARDUnited KingdomIan DunnAndrew GouldAmit PatelMatt PerkinsSheila ScottInternational Fiona Collins

3No. 4 2015

CONTENTS

Editor’s Comments page 4

Guest Editorial page 5

Denture hygiene: a guide to the delivery of page 6 improved denture hygiene for our patients Mylonas P, Afzal Z, Attrill DC, Walmsley AD

A literature review on the associated link between periodontal page 11 disease and adverse pregnancy outcomes and its impact on dental treatment for the pregnant patient Emma Fisher

Consent, the law and professional regulation page 14 Hayley Lawrence

The efficacy of using sustained release chlorhexidine chip page 19 as an adjunct to the treatment of periodontal disease Danielle Houston

Is there a need for training in current cleft lip and palate care? page 24 Rhiannon F Jones

Are waterpipe smokers aware that there are health risks page 28 associated with waterpipe smoking? Miriam Khan

UK dental hygienists – the road to direct access: page 35 the results of a literature review Michael G Wheeler

Abstracts page 40

CPD page 48

www.bsdht.org.ukBRITISH SOCIETY OF DENTAL HYGIENE AND THERAPY

Promoting health, preventing disease, providing skills

A n n u a l C l i n i c a l J o u r n a l o f


In my past editorials I have stressed the importance of DHTs becoming involved in research and I am delighted to have observed an increase in the number of posters submitted for the annual Oral Health Conference this year - 13 in total, including 3 from students - you can read the abstracts on pages 40-47. In addition, a number of our colleagues have given verbal and poster presentations at the FGDP(UK)/FDS Primary Care Research Day and meetings of the British Society for Oral and Dental Research. It would appear therefore that our specialty is becoming research active. This may in part be due to some of our peers presenting papers which illustrate their experience of the process and how they managed to become involved. This is described further by Susan Bissett in her Guest Editorial of this edition.

There is an increasing emphasis within the profession for us to undertake research that has a benefit for our patients, individuals, communities and populations. This can involve evaluation of novel clinical interventions or the application of scientific findings from previous laboratory studies, so called translational research. However, we still lag behind Canada, USA and the Scandinavian countries in sharing the findings of our research. Many of you will have undertaken research projects but I wonder how many of you subsequently submitted them to your professional journal? How many students’ dissertations are never read beyond the final exam? How many MSc or PhD thesis are languishing in cupboards gathering dust? There must be so much latent information which we are not accessing or utilising. I am sure that all of these report outcomes which could benefit us as clinicians and inform our everyday practice; they should be shared, not lost. It is vital that we disseminate the outcomes of our research.

Outcome is especially important because of the large amount of time, effort and money that is often involved in undertaking research. Major funding charities, in particular the Medical Research Council (MRC), channel millions of pounds into research and are now expecting that the outcome of this investment is freely available to all - not just those who subscribe to scientific journals. This process is known as ‘open access’ and is an important step in publishing for the whole of our profession.

In the UK, the Research Excellence Framework (REF) is a process which oversees the quality of academic activity. Traditionally, this exercise has been based on the assessment of published papers – each academic being expected to publish four quality papers in a five year period. However, the REF 2014 included an evaluation of the outcome of the submitted research. This means that individuals are now required to submit impact cases that summarise the benefits of the research on the health of the population. Put simply, this means that money spent on research must have a beneficial outcome for the nation. This is directly relevant to DHTs because we should be undertaking translational research – from laboratory to clinic – with our outcomes being clinically relevant.

Furthermore, to ensure that the findings of this clinically relevant research are available to all, researchers wishing to be included in the next REF in 2020 will only be able to submit papers that are available on an open access basis. Definitely something to consider!

Heather LewisEditor

Editor’s CommentsWelcome to the 2015 edition of the Annual Clinical Journal. As in previous years, the journal will again provide you with a selection of reports that describe a wide spectrum of the research undertaken by our dental hygienist and dental hygienist-therapist colleagues (DHTs). All the papers present findings that are of direct clinical relevance. Topics this year include: denture hygiene; periodontal disease and adverse pregnancy outcomes; consent, the law and professional regulation; adjunctive use of sustained release chlorhexidine chip; cleft lip and palate care; waterpipe smoking and the historical road to direct access.

EDITOR’S COMMENTS

5No. 4 2015

GUEST EDITORIAL

My first experience of research was when I was employed to work on a study assessing the effect of periodontal treatment on inflammatory biomarkers in people with diabetes. At the end of my first week, I can remember feeling so invigorated. Five years on, and numerous studies later, I still feel as enthusiastic, still wishing there were more hours in the day!

In 2011, I became Team Lead of a purpose-built Dental Clinical Research Facility in Newcastle Dental Hospital (http://www.ncl.ac.uk/business/facilities/research/dcrf.htm) and earlier this year I applied for, and was awarded, an NIHR Doctoral Research Fellowship to do a PhD. This will enable me to build on the research that I carried out in my Masters in Clinical Research, which looked at the awareness of medical healthcare professionals of the links between diabetes and periodontitis.1

How can you get involved in research?

You may be able to take a course on research methodology and governance. For example, Newcastle University runs a modular clinical research training programme that delivers high calibre, inter-disciplinary integrated training in research methodology focusing on the translation of research findings into therapy. It is possible to study this programme by attending teaching days on campus or through e-learning. You can exit after 1 year with a Postgraduate Certificate, or after 2 years with a Postgraduate Diploma, or after 3 years with a Masters in Clinical Research.2

Choose journals and papers which are of interest to you

Research papers can be difficult to read due to technical language and dry subject matter. Choose papers that are written about topics that fascinate you, as this makes them easier and more enjoyable to read. I am interested in interventional studies, qualitative methodologies,

behaviour change and social cognitive theories. These are the areas which I like to explore, you may be different. Look at what is out there; there are many more open access journals than there used to be.

Consider peer review instead of reading in isolation

If you find reading papers on your own difficult, then why don’t you get together with friends or colleagues? This could be a good way of getting your non-verifiable CPD. You could read a paper independently and then discuss it as a group and review/critique it. Or you could each chose a different paper and present it to the group in turn.

Design and implement service evaluation or audits in your own area

It is within your scope of practice to carry out service evaluation projects. These do not require ethical approval and are not bound by complicated research governance. How about involving your patients in service evaluation and publishing it on the practice website or on a notice board in the waiting room? You could place a ‘post box’ in the waiting room and invite your patients to comment on a specific topic, for example, why having professional teeth cleaning is important to them? Or, what motivates them to look after their teeth?

Finally, I hope you enjoy the research published in this journal and that it inspires you to think about how you can get more out of research, whether you want to develop your own journal club, carry out a patient engagement exercise, or actually develop a research question, design the methodology, apply for approvals, collect the data and analyse the results. Research is interesting and exciting - good luck!

Susan M Bissett RDH, MClinResNIHR Doctoral Research Fellow, Newcastle University.

Editor’s Comments Guest Editorial It is an honour to be invited to write this Guest Editorial for the Annual Clinical Journal 2015.

Research is something that I feel passionate about, but it hasn’t always been as strong a feature in my life as it is now. Maybe that is a reflection of my age, as I have been qualified for almost 20 years. These days, not only is evidence-based practice, attending courses and reading journals integral to our CPD and professional registration, but dental hygienists and therapists are also invited to personally get involved in research.

References1. Bissett SM, Stone KM, Rapley T, Preshaw PM. An exploratory qualitative interview study about collaboration between medicine and dentistry in relation to diabetes management. BMJ Open 2013;3.

2. PG Certificate/Diploma/Master of Clinical Research, Newcastle University Graduate School, Faculty of Medical Sciences, Framlington Place, Newcastle upon Tyne. NE2 4HH. Tel: (0191) 208 5199. Email: [email protected] (http://www.ncl.ac.uk/biomedicine/study/postgraduate/taught/pgclinres/)


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Denture hygiene: a guide to the delivery of improved denture hygiene for our patients

Mylonas P1, Afzal Z2, Attrill DC1, Walmsley AD1

Key words: Denture hygiene; denture cleaners; cleaning dentures

Introduction

The aim of this paper is to provide a review based on an audit conducted in general dental practice and provide details on current methods of denture hygiene management.

According to the Office for National Statistics the population of the UK is ageing and is expected to rise, and by 2035 it is projected that those who are aged 65 and older will account for 23% of the total UK population.1 The most recent Adult Dental Health Survey conducted in 2009 has shown that nearly a fifth (19%) of adults wore dentures of some description, and the proportion of those wearing dentures was found to increase with age.2 As a result of these findings it comes as no surprise that we could also expect the projected number of denture wearers to increase with time.

Oral hygiene assessment and management are rarely carried out for denture hygiene, as there is currently a lack of standardisation in both the techniques for denture hygiene assessment and denture hygiene management. Several different methods for assessing denture hygiene

have been suggested in the current literature, but no one has been widely accepted and as such there is currently no standardised method of assessing and/or managing denture hygiene.3-7

The oral cavity is full of microorganisms which contribute to a complex biofilm according to the local micro-environment; for example there are differences in the species of bacteria found in a diseased gingival crevice compared to the palatal mucosa. The reason for this variation is due to the many different surfaces and areas available for microorganisms to accumulate and multiply.8-10

A denture acts as an extra surface on which microorganisms will colonise. The denture is also porous, and consists of surfaces which are rarely bathed in saliva. Plaque and calculus can accumulate and develop on them in a similar manner to the natural dentition, and as a result, problems can arise from poor denture hygiene, such as periodontal disease, dental decay, halitosis, and denture stomatitis.4,8 Studies have shown that many denture wearers have inadequate denture hygiene and continue to wear their dentures at night, despite the fact that this is linked with compromised oral health compared with those who remove their dentures at night.4,11-14 Poor denture hygiene has been linked to an

Aim: The study was conducted in order evaluate current methods for denture hygiene maintenance and test the DCI Index. Currently there is no widely accepted method for scoring denture hygiene, so our own index was developed for use by both general dental practitioners and dental hygienists.

Methods: A method for evaluating denture hygiene was developed, known as the Denture Cleanliness Index (DCI). This utilised a plaque disclosing dye applied to the fit surface of the denture, and a DCI score given according to staining present. DCI scoring consists of a number from 0-4, with 0 showing no plaque stained (best score) and 4 indicating

extensive plaque and calculus presence (worst score). Denture hygiene instructions (DHI) were given according to DCI score given, and patients were reviewed at 1-month with a further analysis of their denture hygiene.

Results: Concomitant use of mechanical and chemical methods are key to effective denture hygiene, and the DCI scoring system allows for quick evaluation of patients’ denture hygiene

Conclusion: A new scoring system for denture hygiene has the potential to be used by both dentists and dental hygienists.

A B S T R A C T

7No. 4 2015

DENTURE HYGIENE

Fig 1. Summary of current chemical cleaning agents. [15-20]

CHEMICAL METHOD OF ACTION

Alkali Hypochlorite

Alkali hypochlorite denture cleaners act in much the same way as sodium hypochlorite irrigant does when used in endodontic procedures; they act to disrupt the cell membrane of microorganisms and dissolve the mucins that collect on the denture, however they can bleach the denture. [15,17]

Alkali PeroxideAlkali peroxide are the most commonly used denture cleaners and act by producing bubbles, in a similar process to ultrasonic cleaners, which helps to remove and disrupt microorganisms from the denture surface by the process of cavitation [15,18].

AcidsAcid based cleaners act by dissolving calculus that might have formed on dentures, and also disrupt the cell membrane of microorganisms. However they also can degrade metals and are therefore unsuitable for use with metal-framework dentures [15].

EnzymesEnzyme based cleaners use various different enzymes such as lipases and amylases, designed to degrade fats, glycoproteins and other structures that then help destroy microorganisms present [15].

Oral Rinses

Oral rinses include any dental mouthwash products available for patients such as 0.2% chlorhexidine gluconate or 0.05% salicylate solution (a derivative of salicyclic acid), these are used as a soak like the above products and have a good range of antibacterial properties; however, the chlorhexidine solutions do tend to stain dentures with prolonged use [15].

increased likelihood of periodontal disease and caries of abutment teeth in partially dentate patients.3 The condition, whilst not painful, contributes to unforeseen problems in the mouth and general wellbeing of patients.

Good denture hygiene is important to the wellbeing of patients and reduces the likelihood of denture related diseases; this can be achieved through patient education and motivation.

Methods of denture plaque control

The key to good denture hygiene, just as with oral hygiene, is good plaque control. There are a number of methods available for denture hygiene which can be split into mechanical methods and chemical methods, both ideally used concomitantly.

Mechanical methods can be further subdivided into:

• Manual

• Ultrasonic

Mechanical methods by definition are those methods used to remove plaque and biofilm from the denture using a mechanical force.

Manual methods

These most commonly utilise some type of brush, be it a toothbrush or specific denture brush, together with either water alone, household soap, a denture cream or toothpaste. The purpose behind mechanical cleaning of dentures is to reduce and disrupt the biofilm which has accumulated on the dentures. However, a brush can scratch the denture which could in turn increase the surface area for plaque formation. The degree of scratching depends to a large extent on the bristle

hardness; the stiffer the bristles the more abrasive the brush will be on the denture.15,16

Ultrasonic cleaning of dentures, involves the use an ultrasonic device which produces ultrasonic sound waves (between 20 – 120 kilohertz) that in turn create bubbles (microscopic cavities) that implode on denture surfaces. The implosion of bubbles on the dentures creates localised areas of disruption that loosen and remove debris from the denture surface; this process is known as cavitation. It functions in a manner very similar to ultrasonic scalers when used to remove calculus and plaque from teeth. Dentures are soaked in an ultrasonic cleaner solution which facilitates the chemical cleaning of the denture. The use of ultrasonic cleaners by patients is uncommon due to the expense of commercially produced cleaners currently available.15

Chemical methods

These can be categorised according to their chemical composition and method of action:

1. Alkali based

• Hypochlorite

• Peroxide

2. Acid based

3. Enzyme based

4. Oral rinses

Chemical cleaners are designed for use by immersing the denture entirely within a bath containing a particular cleaner. They all have a different mode of action and they all rely on a chemical reaction to remove the denture plaque and biofilm (Fig.1). 15-20


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The role of the dental health professional

To assess patient compliance with regards to oral hygiene, we can utilise a number of different methods including, the Basic Periodontal Examination (BPE) as an initial screening tool, plaque and bleeding scores, and detailed pocket charts.3 However, the issue still remains as to how to check for patient compliance with denture hygiene instruction; a number of different ways of quantifying denture hygiene have been proposed but none have gained general acceptance.5-7

Denture hygiene audit

An audit was conducted to assess the quality of record keeping, and the denture hygiene of patients in general dental practice, utilising a denture hygiene index known as the Denture Cleanliness Index (DCI), which was developed specifically for the purposes of the audit.

Methods

Thirty acrylic denture wearing patients were chosen for the audit, which included those wearing both complete and partial dentures, and were independently examined by one of two clinicians. For the first cycle of the audit, a baseline record of patients’ denture hygiene was made using the DCI index with patients given DCI scores. They were then given specific denture hygiene instructions based upon the DCI scores

they were designated. The patients were then reviewed after one month with DCI scores being repeated and evaluated to check for any changes in scores compared with the baseline scores from the first cycle. An audit standard of 90% of patients having a DCI score of 2 or less was selected.

The Denture Cleanliness Index used in the audit was as follows:

Each denture was gently washed under cold water to remove loose debris; a liquid plaque disclosing dye was then applied onto the entire denture fit surface, and left for 30 seconds. The denture was then gently washed under cold water to remove excess dye. The fit surface was then inspected visually and scored according to the DCI system, the system is numerical and semi-quantitatively grades severity of denture hygiene through the presence of staining.

The scores range from 0 (the best) up to 4 (the worst) and are designated according to the Denture Cleanliness Index criteria (Fig.2).

The asterisk notation was used purely for the purposes of indicating which dentures required/did not require physical alterations to them.

The Denture Hygiene Instructions were given to patients according to their DCI scores (Fig.3):

0 Clean denture. No plaque is visibly seen, no staining, no plaque detectable.

1 Denture is visibly clean. Little staining (<25% fit surface stained)

2 Denture has visible plaque and/or debris. Moderate staining of fit surface (25-50% fit surface stained)

3 Denture has visible plaque and/or debris. Severe staining of fit surface (>50% stained)

4 Denture has visible calculus deposits, on any surface.

*Visible defects in denture, in addition to any of the above score.(Defects defined as those which are potentially plaque retentive, those which require repair or remake of denture)

DCI Score Intervention

0 No intervention required, reinforce current denture hygiene

1 Denture hygiene reinforcement

2 Denture hygiene reinforcement, patient information leaflet

3 Denture hygiene reinforcement, patient information leaflet and denture hygiene kit

4 Intervention by clinician to clean dentures, denture hygiene reinforcement, Patient information leaflet and denture hygiene kit

* Consider denture reline or remake (depending on severity of defect)

Fig 2. DCI Index criteria

Fig 3. Intervention modalities based on DCI score given

9No. 4 2015

DENTURE HYGIENE

The denture hygiene care kit (GlaxoSmithKlein Brentford, Middlesex) that was given to patients contained a medium bristled denture brush, a container to soak dentures in, a free sample of alkali peroxide cleaning tablets and instructions on their use.

Results

Of the thirty acrylic denture wearers included in the audit, 9 wore complete dentures and 21 wore partial dentures, either upper, lower or a combination of both. After the first cycle, 24 patient notes (80%) had no indication of denture hygiene recorded for the dentures currently worn, whilst 25 patients (84%) had denture hygiene scores of 3 or greater. Recommendations for improvement in current practice were then implemented, these included: a new denture hygiene leaflet available to patients, extra training for dental nurses to give denture hygiene instruction, and standardisation of denture hygiene instructions given by the entire dental team.

There was a vast improvement in the DCI scores in the second cycle, 100% patient notes had evidence of denture hygiene instruction recorded, and 90% of patients had denture cleanliness scores of 2 or less at the one month review; a summary and comparison of results between cycles can be seen in Figure 4.

Discussion

This audit demonstrated a change in practice which resulted in a short term improvement in denture hygiene. However, follow up work looking at the impact this would have on patients’ general health and wellbeing over a longer time period would be necessary.

The first cycle highlighted the poor levels of denture hygiene of patients within a primary care setting. Exact reasons why this was the case could not be ascertained, however it may be multifactorial in nature: lack of patient education, no evidence of denture hygiene instructions

being given to the patients, and lack of standardisation in giving said instructions.

Higher DCI scores were seen in patients wearing partial dentures, which is in agreement with a study conducted by Taiwo and Arigbede which looked at the standard of denture hygiene in a cohort of elderly patients in Nigeria.5

The quantity of denture biolfim is linked to the presence of lesions within the oral cavity which range from periodontal disease of abutment teeth, to denture-related stomatitis, and as a result, the key to good denture hygiene is the successful removal of this biofilm.21-23

Mechanical methods still remain one of the most popular and easiest ways of cleaning dentures, utilising a toothbrush or specific denture brush, together with soap and water, or other denture pastes. However care must be taken to reduce the amount of damage to dentures that can occur from using hard bristled brushes or abrasive denture pastes.15,21

Cruz et al 2011 found that ultrasonic cleaners were effective in the removal of denture biofilm even when only saline was utilised as the conducting fluid. They highlighted that together with the use of a chemical cleaner, its cleaning potential is significantly increased. This potentially could be a method used by those patients who have issues with their manual dexterity where they may have difficulty in using mechanical methods to clean their denture.21

Chemical methods of denture removal have been shown to be effective against a wide range of pathogens found within the denture biofilm. Sodium hypochlorite based cleaners, in an in vitro study by Lee et al (2009), are capable of killing methicillin-resisitant Staphylococcus aureus (MRSA). This could be very beneficial to those patients that are hospitalised or institutionalised, where MRSA infections are major issue.24

Figure 4. Bar chart comparing 1st and 2nd audit cycle results for denture cleanliness scores obtained.1st Cycle represented by Blue and 2nd Cycle represented by Red.

Num

ber

of P

atie

nts

Denture Cleanliness Score0 1 2 3 4


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It is important to highlight that dentures must be cleaned extra orally to ensure effective cleaning occurs, and reduces the risks of issues from denture cleansers that may have adverse affects on the oral mucosa.

Studies conducted on the effectiveness of current denture cleaning methods state that whilst chemical and mechanical methods are both equally effective in reducing biofilm, a greater reduction is seen when they are used in combination.21-23

The DCI index worked well as a proof of concept of a standardised way of assessing patients’ denture hygiene and subsequent compliance, although work will still need to be done to evaluate its clinical effectiveness and relevance. The concept of scoring denture hygiene has already been proposed by a number of authors but to limited success, and few have gained wide acceptance.5-7

Further research will need to be conducted to refine the parameters of the scoring system and assess whether there is a correlation between the DCI score designated and oral hygiene status.

Conclusion

This audit showed that the DCI system was effective in aiding patient education and motivation in denture hygiene.

The provision of both oral hygiene and denture hygiene instructions should be carried out on a regular basis to help patients maintain good oral health.

References1. Population Ageing in the United Kingdom, its Constituent

Countries and the European Union. Office for National Statistics; 2012 [cited 5 August 2013]. Available from URL: http://www.ons.gov.uk/ons/dcp171776_258607.pdf

2. Steele J, Treasure E, Fuller L, Morgan M. Complexity and maintenance – a report from the Adult Dental Health Survey 2009. The Health and Social Care Information Centre, 2011.

3. Walmsley AD, Walsh TF, Burke FJT et al. Restorative Dentistry, second edition. United Kingdom: Churchill Livingston (2007).

4. Gendreau L, Loewy ZG. Epidemiology and etiology of denture stomatitis. J Prosthodont. 2011;20(4):251–60.

5. Taiwo JO and Arigbede AO. Denture Hygiene of the elderly denture wearers in South East local government area in Ibadan, Nigeria. J Biol Agricult Healthcare. 2012;2(6):22-26.

6. Wefers KP. Der “Denture Hygiene Index” (DHI). Dental Forum 1999; 9(1): 13-14. Online [PDF] Available from URL: http://www.dental.uni-greifswald.de/fpk/pdf/prothesenhygiene.pdf [cited 21st November 2013] (Article in German).

7. Schubert R, Schubert. The prosthesis hygiene index--a method for documentation and health education. Stomat DDR. 1979;29(1):29-31. (Article in German)

8. Coulthwaite L, Verran J. Potential pathogenic aspects of denture plaque. Brit J Biomed Sci. 2007;64(4):180-89.

9. Emami E, Taraf H, de Grandmont P et al. The association of denture stomatitis and partial removable dental prostheses: a systematic review. Int J Prosthodont. 2012;25(2):113-9.

10. Preshaw PM, Walls AW, Jakubovics NS et al. Association of

removable partial denture use with oral and systemic health. J Dent. 2011;39(11):711-9.

11. Peltola P, Vehkalahti MM, Wuolijoki-Saaristo K. Oral health and treatment needs of the long-term hospitalised elderly. Gerodontology 2004;21(2):93-9.

12. Marchini L, Tamashiro E, Nascimento DF et al. Self-reported denture hygiene of a sample of edentulous attendees at a university dental clinic and the relationship to the condition of the oral tissues. Gerodontology 2004;21(4):226-8.

13. Dikbas I, Koksai T, Calikkocaoglu S. Investigation of the cleanliness of dentures in a university hospital. Int J Prosthodont. 2006;19(3):294-8.

14. Khasawneh S, al-Wahadni A. Control of denture plaque and mucosal inflammation in denture wearers. J Ir Dent Assoc. 2002;48(4):132-8.

15. Chittaranjan B, Taruna M, Sudhir N, Bharath VM. Material and Methods for cleaning the Dentures. Indian Journal of Dental Advancements 2011;1:423-26.

16. Sorgini DB, Silva-Lovato CH, de Souza RF et al. Abrasiveness of conventional and specific denture-cleansing dentifrices. Braz Dent J. 2012;23(2):154-9.

17. Rossato MB, Unfer B, May LG, Braun KO. Analysis of the effectiveness of different hygiene procedures used in dental prostheses. Oral Health Prev Dent. 2011;9(3):221-7.

18. Uludamar A, Ozkan YK, Kadir T, Ceyhan I. In vivo efficacy of alkaline peroxide tablets and mouthwashes on Candida albicans in patients with denture stomatitis. J Appl Oral Sci. 2010;18(3):291-6.

19. Ramsay DS. Patient compliance with oral health regimens: a behavioural self-regulation analysis with implications for technology. Int Dent J. 2000;50:304-11.

20. Strauss SM, Stafanou LB. Interdental cleaning among persons with diabetes: relationships with individual characteristics. Int J Dent Hyg. 2013 [online publication] [cited 5 August 2013] available from URL: http://onlinelibrary.wiley.com/doi/10.1111/idh.12037/full

21. Cruz PC, Andrade IM, Peracini A et al. The effectiveness of chemical denture cleansers and ultrasonic device in biofilm removal from complete dentures. J Appl Oral Sci. 2011;19(6):668-73.

22. Fernandes RA, Lovato-Silva CH, Paranhos HF, Ito IY. Efficacy of three denture brushes on biofilm removal from complete dentures. J Appl Oral Sci. 2007;15(1):39-43.

23. Salles AE, Macedo LD, Fernandes RA et al. Comparative analysis of biofilm levels in complete upper and lower dentures after brushing associated with denture paste and neutral soap. Gerodontology 2007;24(4):217-23.

24. Lee D, Howlett J, Pratten J et al. Susceptibility of MRSA biofilms to denture-cleansing agents. FEMS Microbiol Lett. 2009;291(2):241-6.

A U T H O R A F F I L I AT I O N S : 1Prosthodontics Department, Birmingham Dental School

2Foundation Trainer, City Hospital Scheme, General Dental Practice

ADDRESS FOR CORRESPONDENCE : [email protected]

11No. 4 2015

PERIODONTAL DISEASE

A literature review on the associated link between periodontal disease and adverse pregnancy outcomes and its impact on dental treatment for the pregnant patient

Emma Fisher

Key words: Adverse; pregnancy; periodontal

Introduction

From the early 21st century, several studies have demonstrated a link between periodontal disease and systemic disease, in particular, diabetes mellitus and cardiovascular disease. The theoretical link exists due to periodontal disease creating an inflammatory response, affecting the whole body system which in turn leads to the onset of these systemic conditions. From the mid 1990’s there has also been a growing body of evidence associating periodontal disease with adverse pregnancy outcomes (APOs). APOs include preterm birth (PTB), preterm low birth weight (PLBW), low birth weight (LBW), growth restriction, pre-eclampsia, still birth and miscarriage. Preterm birth is defined as before 37 completed weeks of gestation.¹

It is estimated that there are 15 million worldwide preterm births every year, with around 1 million babies dying and many left with disabilities.²

The biological plausibility is similar to the aforementioned onset of systemic disease; however there have been two proposed pathways. The Direct Pathway involves periodontal bacteria and/or their components moving to the foetal-placental interface where they are said to trigger or initiate an inflammatory response or infection. The Indirect Pathway involves the production of inflammatory mediators in the gingival tissues due to periodontal pathogens. These inflammatory mediators enter the circulation and reach either the foetal-placental interface or the liver where a systemic inflammatory response occurs.³

The purpose of this literature review is to facilitate discussion of the evidence linking periodontal disease to APOs and highlight any implications this may have for a pregnant dental patient.

Literature review

Inflammatory markers

Patients suffering from periodontal disease show increased levels of proinflammatory cytokines, prostaglandins and matrix

Aim: To review the literature that explores the link between periodontal disease and adverse pregnancy outcomes (APOs). APOs include preterm birth, preterm low birth weight, growth restriction, pre-eclampsia, still birth and miscarriage.

Method: A comprehensive literature search of PubMed, MEDLINE, CINAHL databases and the Cochrane Library using the key-phrases, ‘periodontal disease’ and ‘adverse pregnancy outcome’ allowed selection of the most relevant studies and papers. The included studies were printed in English and dated from 1931 to 2014.

Results: While a number of systematic reviews and meta-analyses have demonstrated a link, there is a high degree of variability in the

studies. A number of studies fail to report on important confounding factors such as child bearing age, race and ethnicity, smoking status and previous history of APOs.

Conclusion: There is no evidence of a causal link between periodontal disease and APOs. The confounding factors may account for a link. Further studies of robust design are required to fully determine whether periodontal disease is a factor for APOs. However it is still significant to note the importance of good oral hygiene practices. Treatment of the pregnant patient is safe and wherever possible oral health should be maintained or re-introduced to reduce periodontal disease and inflammation.

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metalloproteinases (MMPs). Proinflammatory cytokines (IL-1, IL-6, IL-8 and TNFa) are involved in the initiation and progression of periodontal disease. In pregnancy they are found to initiate the cervical ripening process and stimulate MMP production. Elevated levels of TNFa can induce labour, pre-eclampsia and miscarriage.4 In patients with periodontal disease, TNFa is involved in the regulation of immunity. Prostaglandins, such as PGE2, are seen in high levels in periodontal disease. Prostaglandins affect osteoclastic activity, resulting in destruction of alveolar bone. However, elevated levels of PGE2 in pregnancy are responsible for the softening of the cervix and promotion of uterine contractions during labour. MMPs influence connective tissue destruction in periodontal disease and are seen in elevated levels. Naturally toward the end of a full term pregnancy, MMP levels begin to rise. This process leads to the lysis of the foetal-maternal membrane or cervical ripening in preparation for parturition. The commonality of these cell mediators compounds further the theoretical link between periodontal disease and APOs. Galloway 5 reported on the potential link in 1931, stressing that the pregnant woman should be screened for focal infections regularly. His rationale for this stemmed from earlier studies, one as early as 1916, which proved that focal infection was an aetiological factor of miscarriage. He further explained the drainage process which occurs with focal infections and its progression into the circulatory system.

Confounding factors

More recently several studies have looked into the potential link. Corbella et al 6 conducted a systematic review and meta-analysis of case controlled studies which observed periodontal disease as a risk factor for APOs. A total of 17 studies were included in the review, totalling 10,148 subjects. The meta-analysis suggested a link between APOs and periodontal disease. However, Corbella et al 6 highlighted a number of important confounding factors which were not taken into consideration, controlled or reported in the included studies. One important point to note is that many studies identified periodontal disease with differing definitions, thereby proving difficult to draw upon conclusions when the data was combined. The important confounding factors noted by Corbella et al 6 include age, previous preterm birth, history of abortion, smoking, alcohol and drug abuse. Another important confounding factor, although not reported in this systematic review, is whether the pregnant women were suffering from Bacterial Vaginosis (BV). BV is a condition known to increase the risk of premature birth and miscarriage.7 It is therefore important to allow for these confounding factors when looking into the relationship between

periodontal disease and APOs.

Xiong et al 8 also conducted a systematic review observing periodontal disease and APOs. 25 studies were selected; of these, 18 suggested that periodontal disease was associated with APOs whereas 7 studies found no link. Amongst the studies suggesting a link, several reported that the risk of APOs increased with the severity of periodontal disease. Again, the review had its reservations regarding the accuracy of the results. Xiong et al 8 commented that there were variations in the definitions used for periodontal disease and also variations in the definitions used for the various APOs. The researchers also noted a number of confounding effects such as low socio-economic status, history of previous APOs, maternal disorders including diabetes and hypertension and infections e.g. BV. The sample size of a number of the included studies was less than 100 therefore limiting the reliability of the data collected.

Recent developments

In 2013, the European Federation of Periodontology (EFP) and the American Academy of Periodontology (AAP) published a joint report detailing the findings of a working group who researched the evidence on periodontal disease and APOs.9 The group, led by Sanz, were tasked with:

a) Reviewing the current evidence for a role of periodontal disease in APOs;

b) Reviewing the epidemiological evidence for an association between periodontal disease and APOs;

c) Identify the current known potential mechanisms that may explain the observed association and review the evidence;

d) Review and interpret the evidence from periodontal intervention trials, summarising the overall interpretation of the combined evidence from epidemiological, mechanisms and intervention studies and identify the key issues for future research;

e) Provide general recommendations for general oral health professionals and the medical profession.

Sanz et al9 noted that the definitions of periodontal disease used in the studies may not be appropriate. The majority of the definitions did not capture patients who were suffering from gingival inflammation without clinical attachment loss (CAL) and pocketing. They also noted that in cases of low evidence/extent of periodontal disease, where mean values were recorded for probing depths and CAL, this may not truly reflect the periodontal status of the patient. Many studies also used a time saving approach when collecting data, thereby only detailing partial mouth recordings. Using this method is likely to underestimate the full extent

13No. 4 2015

PERIODONTAL DISEASE

and prevalence of periodontal disease in individuals. The report highlighted a number of potential errors with epidemiological studies. Many studies have not recorded bleeding after probing. In addition, a number of studies appear to have only assessed and recorded the measurements at one point therefore not taking into account the potential changes occurring during the progression of pregnancy.

Microbial connections

A number of periodontal bacterial species have also been associated with APOs, these being Fusobacterium nucleatum,10 Campylobacter rectus,11 Porphyromonas gingivalis12 and Bergeyella Sp13. These bacterial strains have been identified in intrauterine infections which appear to have originated from the oral cavity.

Impact for the pregnant dental patient

Sanz et al9 investigated whether periodontal treatment improved the incidence of APOs. They highlighted that treatment of periodontal disease in pregnant women is safe but evidence suggests that treatment does not reduce the incidence of APOs, although there has been some positive associations in certain population groups. Sanz et al reported more generally on aspects of periodontal and oral care of the pregnant woman, suggesting that ‘oral health should be maintained or re-established in pregnant women with the aim of eliminating the clinical signs of periodontal inflammation and control of the biofilm’. Sanz et al noted that the current available evidence does not allow the identification of specific subgroups who would benefit from treatment leading to improved pregnancy outcomes.

With this evidence in mind, it would be useful for dental professionals to explain to pregnant patients that there are a small number of studies linking periodontal disease and APOs, however some studies report no link. It is important to emphasise that dental treatment including preventive, diagnostic and therapeutic procedures are safe during pregnancy, however general obstetric guidelines recommend that procedures be avoided during the first trimester due to possible stress to the foetus.9 Further treatment would involve establishing their current oral health status and performing a comprehensive periodontal assessment involving recording pocket depths, CAL and bleeding on probing. Tailored oral health and general health advice would be beneficial to the pregnant woman and her family. It would be useful to explain that some changes may occur to her oral health during pregnancy e.g. increased vascularity, possibility of higher incidence of bleeding and gingival enlargement.9

Conclusion

Adverse pregnancy outcomes are of multifactorial origin

and may be provoked by many risk factors including child bearing age, low socio-economic status, race, smoking and stress. There is no evidence of a causal link between periodontal disease and APOs. A number of studies fail to report on important confounding factors and do not take these into consideration when discussing their results. Other limitations include self-reported data, periodontal health and population differences and data collection complications such as missed data due to busy wards and time constraints.

References1. World Health Organisation. (2012). Preterm Birth. Available:

www.who.int/mediacentre/factsheets/fs363/en/. [Accessed 22nd August 2014]

2. Blencowe H, Cousens S, Oestergaard MZ et al. National, regional and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet 2012;379(9832):2162-72.

3. Bobetsis YA, Barros SP, Offenbacher S. Exploring the relationship between periodontal disease and pregnancy complications. J Am Dent Assoc. 2006;137(Suppl.)7S-13S.

4. Romero R, Gotsch F, Pineles B, Kusanovic JP. Inflammation in pregnancy: Its roles in reproductive physiology, obstetrical complications and fetal injury. Nutr Rev.. 2007;65(12 Pt 2):S194-202.

5. Galloway CE. Focal Infection. Am J Surg. 1931;14(3):643-45.

6. Corbella S, Taschieri S, Francetti L et al. Periodontal disease as a risk factor for adverse pregnancy outcomes: a systematic review and meta-analysis of case control studies. Odontology 2012;100(2):232-40.

7. Oakeshott P, Hay P, Hay S et al. Association between bacterial vaginosis or chlamydial infection and miscarriage before 16 weeks gestation: prospective community based cohort study. BMJ 2002;325:1334-38.

8. Xiong X, Buekens P, Fraser WD et al. Periodontal disease and adverse pregnancy outcomes: a systematic review. BJOG 2006;113(2):135-43.

9. Sanz M, Kornman K, and on behalf of working group 3 of the joint EFP/AAP workshop. Periodontitis and adverse pregnancy outcomes: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol 2013;40(Suppl.14):S164-S169.

10. Han YW, Redline RW, Li M et al. Fusobacterium nucleatum induces premature and term stillbirths in pregnant mice: Implications of oral bacteria in preterm birth. Infection and Immunity 2004;72(4):2272-79.

11. Novak MJ, Novak KF, Hodges JS et al. Periodontal bacterial profiles in pregnant women: response to treatment and associations with birth outcomes in the obstetrics and periodontal therapy (OPT) study. J Periodontol 2008;79(10):1870-9.

12. Hasegawa-Nakamura K, Tateishi F, Nakamura T et al. The possible mechanism of preterm birth associated with periodontopathic Porphyromonas gingivalis. J Perio Res 2011;46(4):497-504.

13. Han, YW., Ikegami, A., Bissada, NF., Herbst, M., Redline, RW., Ashmead, GG. (2006) Transmission of an uncultivated Bergeyella strain from the oral cavity to amniotic fluid in a case of preterm birth. J Clin Microbiol 2006;44(4):1475-83.

A U T H O R A F F I L I AT I O N S :

Head of Academic Unit Dental Hygiene and Dental Therapy School of Clinical Dentistry University of Sheffield Sheffield S10 2TA



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Consent, the law and professional regulationHayley Lawrence

Key words: Consent; autonomy; paternalism; ethics; decision making

Introduction

There is a history of professional autonomy in healthcare which is based on a premise of claims of superior knowledge and objective scientific truth.1 However, this ‘doctor knows best’ philosophy has been replaced with a partnership model of decision making and good communication. The principle of a partnership model of decision making advocates both the patient and doctor sharing knowledge to ensure that the patient makes the best decision for themselves.2 It is not the doctor, but rather the patient, who ultimately makes the decision.

What is consent?

According to D’Cruz, consent is the voluntary and continuing permission of the patient to receive particular treatments and must be given by a patient who has capacity to consent to the intervention in question.3 Respect for a patient’s autonomy pervades a health professional’s daily clinical practice. The Department of Health (DOH) in its guidance document, Reference Guide to Consent to Examination and Treatment states:

It is a general legal and ethical principle that valid consent must be obtained before starting treatment or physical investigation or providing personal care, for a person.4

There are three important elements to valid consent:

1. The person who gives consent must be competent;

2. They should receive enough information to make a decision;

3. They should not be influenced by coercion or manipulation.5

One important principle in the consent process is the need for it to be given voluntarily and freely. An individual has the right to accept or refuse treatment and this should be without pressure or the exertion of undue influence.4 There may be circumstances where an individual of sound mind makes a decision that a dental professional believes is unreasonable, or not in the patient’s best interest, but ultimately it is the patient’s right to make that decision.3

The dental professional should respect the patient’s right to self-determination and autonomy, and the evidence suggests that when patients are offered options they are more likely to consider that they were involved in the decision making process.6

In order to gain valid consent the individual needs to understand the nature and the purpose of the procedure.4 It is incumbent on the clinician to give full and detailed information about the intervention, risks, benefits and the possible implications of the refusal of treatment. This information cannot be generic and needs to be tailored specifically for each patient.5

The third fundamental principle of valid consent is that the individual has to have the capacity to consent and this is determined through an assessment. The dental professional needs to establish whether the patient

Obtaining valid consent is crucial to daily professional practice and is a legal as well as an ethical requirement. The principles of consent are set out in various guidance documents and are well established in case law. Paternalism, historically rooted in the principle of ‘doctor knows best’, is no

longer an acceptable model of medical decision making and all health care professionals have a moral obligation to recognise an individual’s right to choose and take appropriate action to facilitate this.

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VALID CONSENT

can understand the information that is given, whether the information is retained, whether the patient believes it and can weigh that information and balance the risk against the advantages, and make informed decisions.3

The Law

Tort can be defined as a civil wrong which gives rise to an action of damages and is independent of contract. Tort law includes a body of rights, obligations, and remedies that is applied by courts in civil proceedings to provide relief for persons who have suffered harm from the wrongful acts of others. The patient’s rights are protected and there is a duty to obtain the patient’s consent prior to commencing treatment. This protection is under the tort of battery.2 However, the duty to provide the patient with enough information during the consent process is dealt with under a dental professional’s normal duty of care.

A claim of battery is very rare because the patient would need to establish that they did not consent to the treatment they received. There is the implication in such a case that the patient did not receive any information about the procedure. Such a complete failure to provide the patient with any information is quite rare. Consequently, the courts are reluctant to make a finding under the tort of battery and disputes are dealt with under the tort of negligence.2

If a dental professional gains the patient’s valid consent they can be absolved from the liability in battery for unlawful touching. Trespass to a person can be the tort of battery but it can also be criminal assault.

Sufficient information

One could argue that a ‘reasonable doctor’ approach to how much information the patient should receive is paternalistic and under these circumstances the patient is not making an autonomous choice. Dental professionals should consider what a ‘reasonable patient’ wishes to hear.3 In dentistry, we have moved away from the ‘reasonable dentist’ to consider the ‘reasonable patient’.7 While the ‘reasonable doctor ’test is considered to be paternalistic, the informed choice is patient-centered and respects autonomy and personal values.5

In addition to giving patients the information they need, the dental professional also must give them sufficient time to consider it. This will ensure that the GDC guidelines Standards for the Dental Team are complied with. The guidance states:

You must provide patients with sufficient information and give them a reasonable amount of time to consider that information in order to make a decision.8

Professional guidelines

There are several professional guidelines available including: from the DOH, Reference Guide to Consent or Treatment and Seeking Consent: Working with Children; and from the GDC, Standards for the Dental Team and Principles of Patient Consent. As a part of practice visits the Care Quality Commission reviews dental records and has produced a supporting document on consent.

In section 3 of the GDC Standards for the Dental Team is a section entitled ‘Obtain Valid Consent’. It states that the patient expects to be asked for their consent to treatment before it starts and that: You should find out what your patients want to know as well as what you think they need to know. Things that the patient may want to know include:

• The likely prognosis

• Your recommended option

• The cost of the proposed treatment

The guidelines also state that consent should be obtained for each patient’s needs, which reinforces the individualization of the process.8

One could argue that the requirements of these guidelines go beyond the requirements of the law but following these professional guidelines will reduce the likelihood of a successful litigious claim against you. Professional guidance produced by the regulatory authority sets high standards for information disclosure that forms the basis of valid consent.5 There is a considerable difference between Tort law and the requirements of the GDC. Tort law places minimal requirements on dental professionals while guidance from the GDC and DOH tend to be detailed, expansive and places more onerous duties on professionals.2

The process of consent

The consent process reinforces the importance of good communication and a patient-centered approach to dental care. A dental professional can violate the law by not giving the patient enough information in order for them to make an informed decision.7 One challenge facing the clinician is deciding when is the best time to give the patient the information; one could be criticised for trying to achieve this when treatment is already underway and you are working in the patient’s mouth.9 The patient needs to be able to communicate with the clinician so this would be more practical before starting a procedure.

There is evidence from medical negligence claims to suggest that the basic principles of consent are not always clearly defined and therefore not clearly understood by many professionals.1 There are challenges associated with gaining informed consent and these include:


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• The health professional’s relevant knowledge;

• The amount of information that the patient should be given in a specific situation;

• Whether the patient understands the information given;

• Judging the patient’s level of understanding.

Dental professionals need to be skilled and competent to carry out the procedure for which they seek consent. The court has the discretion to consider clinical negligence as they are of the view that a patient cannot consent to negligent treatment so dental professionals need to provide a proper standard of care.1

According to the GDC Standards for the Dental Team patients should be informed of the risk and benefits of the proposed procedure.8 However, one audit demonstrated that while dentists were aware of this they did not realise that patients also need to be informed of the risks and benefits of alternative procedures. This has been established by case law in Birch v University College London Hospital [2008]. The court ruled that the patient did not give fully informed consent because she was not advised of the risks and benefits associated with the different procedures.10

Additionally, the audit found that while patients were given the option of no treatment, it was not clear to the dentist that the consequences of no treatment should be explained.11 The GDC guidelines clearly state that patients should be informed of what might happen if the proposed treatment is not carried out.

Ongoing consent

Consent is not a one off event and remains an ongoing process. It gives the dental professional the opportunity to communicate the details of the treatment, offer any options and address the patient’s concerns, and if subsequently new information comes to light then the patient needs to be informed.11 Similarly, if the patient’s treatment plan changes they need to be informed and the full implications and costs explained: dental professionals have a duty to communicate with patients throughout the treatment, and not only at the start.

Consent forms may be used but obtaining a signed form does not mean that informed consent has been obtained.12 Lengthy and complex consent forms are likely to inhibit rather than promote good communication between the dental professional and the patient.2 Interestingly, Tahir et al found that 40% of the parents who signed a consent form did not fully understand what consent was required, despite being informed. Consequently, the patients signed the consent form which was invalid.12 Additionally,

consent forms give the perception that consent is a one off event rather than a process which takes place over time.2 Consent forms do have a purpose but they should only be considered as a part of the consent process.13

In the event of a litigious claim, one practical problem commonly faced by dental professionals is establishing what information was disclosed to the patient. With the passage of time neither the clinician nor the patient is likely to recall accurately what was discussed. Standards for the Dental Team state:

You should document the discussions you have with patients in the process of gaining consent. Although a signature on a form is important in verifying that a patient has given consent, it is the discussions that take place with the patient that determine whether the consent is valid.8

Withdrawal of consent

As a part of the patient’s right to self-determination they can withdraw their consent at any time and terminate the procedure, even if the clinical procedure is already underway. If a patient indicates that they would like to withdraw consent, then treatment must be terminated. Should the clinician continue with treatment despite the patient verbally withdrawing their consent the courts would view this as unlawful.5

Children

The Children Act 1989 sets out the rights and responsibilities that parents have for their children and this includes consent to medical treatment.14 The Act clearly states who has parental responsibility when the parents are married, divorced or are step parents. Furthermore, it provides guidance on the treatment of children in the care of the local authority and those who are adopted. One common challenge faced by dental professionals is when an adult, who is not the parent, accompanies a child to the dental practice, for example the extended family, child minders or friends. According to Dental Protection these adults may have the child’s best interest in mind but they are unable to give consent for treatment.15 If a dental professional was to provide treatment under these circumstances the parent could subsequently allege assault or battery. Dental professionals need to be familiar with the law so that the correct decision can be made regarding parental responsibility. Such an adult, despite having the child’s best interest at heart, can only consent to treatment if they have been authorised so to do by the parent. However, this needs to be confirmed by the parent and the dental professional needs to establish the parent’s wishes. The Department of Health has produced guidance and in their document, Seeking Consent: Working with Children, highlight the need to involve children in the decision

17No. 4 2015

VALID CONSENT

making process, irrespective of the fact that they do not give consent. The child may have an opinion and if it is an older child negotiation may be required before a final decision is made.16

Capacity

Adults are presumed to be competent under common law. The Mental Capacity Act 2005 (MCA) sets out the legal framework which governs decision making for adults who lack capacity to make decisions themselves.17 The principle of MCA balances the individual’s right to make decisions and protecting them from harm.18 These include:

• The presumption that an individual has capacity;

• Providing support to assist in decision making;

• The individual’s right to make unwise decisions;

• The requirement to act in the patient’s interest;

• To consider the least restrictive intervention.

The clinician needs to assess an individual’s capacity with a two staged test. There should be no assumption that a patient is incompetent without a proper assessment. There may be challenges when treating a borderline patient in deciding whether or not a patient who appears to be refusing treatment is in fact making no decision at all or is making a valid refusal.19

Assessing competence is not assessing understanding, but rather the capacity to understand. This will vary according to the risks and benefits of the proposed treatment.18 The MCA code of conduct gives examples of patients whose decision making skills may be impaired but consideration may need to be given to:

1. The elderly

2. Chronically ill and other vulnerable groups

3. Individuals with learning disabilities

4. Individuals suffering from depression

There are other conditions that may temporarily affect capacity, for example: medication, drugs or alcohol and anaesthetic or sedation.

Changes to professional practice

Prior to Direct Access, which came into effect on 1st May 2013, the dentist would examine the patient, discuss the proposed treatment, highlight any associated risks as well as benefits and then formulate a treatment plan. Under current legislation a dental hygienist is now able to treat a patient without the written prescription of the dentist, which obviously brings with it increased responsibility for all acts and omissions.

However, it could be argued that the new standards guidance from our professional regulator, the GDC, is contentious and is likely to impact on all dental hygienists, not only those who provide Direct Access. It states:

You must make sure you have valid consent before starting any treatment or investigation. This applies whether you are the first member of your team to see the patient or whether you are involved after other team members have already seen them. Do not assume that someone else has obtained the patient’s consent.

This suggests that the dental hygienist needs to gain consent even if the dentist has written a treatment plan detailing the treatment to be provided. While these discussions between the hygienist and patient take place, in reality, they are not as detailed as those set out under consent in Standards for the Dental Team. It would appear that the patient needs to be consented twice, first by the dentist in order to formulate a treatment plan and refer to the hygienist for treatment, and secondly to the hygienist before providing treatment. For example, the dentist may discuss the options of: providing treatment on the NHS; privately; a referral to a specialist; an initial course of treatment by the hygienist; or the necessity of the treatment before a treatment plan can be finalised.

Based on the guidance all dental hygienists need to ensure they obtain informed consent before starting treatment, irrespective of whether they are practising Direct Access. The GDC would be in a position to raise an allegation that treatment was provided without informed consent if these guidelines were not followed. From a fitness to practise perspective the GDC would take such an allegation seriously and in its Indicative Outcomes Guidance states that this could lead to a referral to a Practice Committee for further investigation. Fortunately, any deficiencies in professional practice can be remediated through appropriate education and continuing professional development (CPD).

Conclusion

Obtaining valid consent is an integral part of daily professional practice. Dental professionals need to adopt a patient-centered approach which respects the patient’s right to self-determination and autonomy. Good communication skills will reduce complaints and improve the clinician-patient relationship. The consent process calls for dialogue, the sharing of information and understanding between both the dental professional and the patient.


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References

1. Cannavina CD, Cannavina G, Walsh TF. Effects of evidence-based treatment and consent on professional autonomy. Br Dent J. 2000;188(6):302-6.

2. Jackson E. (ed) (2013) Medical law: text cases and material. 3rd edn. Oxford: Oxford University Press.

3. D’Cruz L. Risk management in clinical practice. Part 2. Getting to ‘yes’ - the matter of consent. Br Dent J. 2010;209(2):69-72.

4. Department of Health (2009). Reference guide to consent for examination and treatment. 2nd ed. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_1036 53__1_.pdf (Accessed: 1 December 2013)

5. Samantha J and Samantha A. (2011) Medical law. Hampshire: Palgrave Macmillan.

6. King J. Consent: the patients’ view – a summary of findings from a study of patients’ perceptions of their consent to dental care. Br Dent J. 2001;191(1):36-40.

7. Brands WG. The standard for the duty to inform patients about risk: from the responsible dentist to the responsible patient. Br Dent J. 2006;201(4):207-10.

8. General Dental Council Standards for the Dental Team. Available at: http://www.gdcuk.org/Newsandpublications/Publications/Publications/Standards%20for%20the%20Dental%20Team.pdf (Accessed: 17 November 2013)

9. General Dental Council Indicative Outcomes Guidance. Available at:http://www.gdc-uk.org/Aboutus/Thecouncil/committeedocs/Investigating%20Committee%20- %20Indicative%20Outcomes%20Guidance%20(January%202013).pdf

10. Shaw D. Continuous consent and dignity in dentistry. Br Dent J. 2007; 203(10):569-571

11. Birch v University College London Hospital NHS Foundation Trust [2008] EWHC 2237 (QB)

12. Chate RAC. An audit of the level of knowledge and understanding of informed consent amongst consultant orthodontist in England, Wales and Northern Ireland. Br Dent J. 2008;205(12):665-73.

13. Mohamed Tahir MA, Mason C, Hind V. Informed consent: optimism versus reality. Br Dent J. 2002;193(4):221-4.

14. Ernst S, Elliot T, Patel A et al. Consent to orthodontic treatment--is it working? Br Dent J. 2007;202(10):E25; discussion 616-7. Epub 2007 Apr 13

15. Great Britain. Children Act 1989. Available at: http://www.legislation.gov.uk/ukpga/1989/41/introduction (Accessed: 1 December 2013).

16. Dental Protection. If a patient is under 16, who can consent to treatment? Available at: http://www.dentalprotection.org/uk/askdpl/consentforpatientunder16 (Accessed: 1 December 2013).

17. Great Britain. Seeking Consent: Working with Children. Available at: http://www.dhsspsni.gov.uk/consent-guidepart2.pdf (Accessed: 1 December 2013).

18. Great Britain. Mental Capacity Act (2005). Available at: http://www.legislation.gov.uk/ukpga/2005/9/contents (Accessed: 1 December 2013).

19. Dougall A, Fisk J. Access to special care dentistry, part 3. Consent and capacity. Br Dent J. 2008;205(2):71-81.

20. Bridgman AM, Wilson MA. The treatment of adult patients with mental disability. Part 1: Consent and duty Br Dent J. 2000;189(2):66-8.


This paper was written as a submission for the PgCert in Dental Law and Ethics at the University of Bedfordshire.


19No. 4 2015

CHLORHEXIDINE CHIP

The efficacy of using sustained release chlorhexidine chip as an adjunct to the treatment of periodontal diseaseDanielle Houston

Key words: Chlorhexidine; literature review; periochip; periodontitis

Introduction

Periodontal disease is a localised inflammatory response caused by the infection of a periodontal pocket arising from plaque accumulation. If this pocket continues to harbour the bacteria associated with the disease, then the potential for a further destructive phase exists.1 When a periodontal pocket is unresponsive to routine measures of treatment, the clinician faces the difficult challenge of selecting an adjunctive treatment, or referring the patient directly for a surgical intervention from a specialist.

Plaque inhibition by chlorhexidine has been documented as long ago as the 1970s.2 There is a broad range of susceptibility to chlorhexidine among both gram-positive and gram negative strains of bacteria. The ability of the drug to absorb and bind to soft and hard tissue is known as substantivity. Chlorhexidine is retained on the oral surfaces by reversible electrostatic binding to glycoproteins. It is these properties which make chlorhexidine a first choice of treatment against plaque inhibition.3

Chlorhexidine gluconate is usually prescribed in the form of a mouthwash which is in a 0.2% solution but is also available in a gel

formulation of 1%.4 The local delivery of this antimicrobial, in the form of a chip, gives site specific and therapeutic levels of the drug at the site of infection for prolonged periods of time.5 However, in one small study, measured on 19 volunteers over a 10 day period, it was concluded that any chlorhexidine absorbed into the circulatory system is negligible, with no detectable chlorhexidine in the blood plasma or urine of any of the test subjects.6

A barrier to the administration of such medicaments is the introduction of the antimicrobial into a periodontal pocket. Irrigation of the liquid into the periodontal pocket will not suffice as successful drug therapy depends on establishing and maintaining effective concentrations of the antimicrobial agent at the site of infection.7 Chlorhexidine is cationic in nature and does bind to the anionic surfaces of the epithelium of periodontal pockets, however Goodson and co workers calculated the turnover rate of gingival fluid to be 40 times per hour and suggested that this accounts for the rapid clearance and short duration of action observed with irrigation. This was also supported by the American Academy of Periodontology who supported the claim and concluded that the greatest short coming of irrigation was the quick elimination of the sub-gingivally placed drugs.8

There has been an emergence of a range of controlled-delivery devices

Aim: To determine the influence of a sustained release chlorhexidine chip in positively impacting on periodontal disease.

Methods: A review of the available literature from 1990-2013 was undertaken using the following search engines: Pubmed; Science Direct; The Knowledge Network; Google Scholar; Medline; Wiley Online Library; Sage Publishing; and the Dental Update Website. The American Academy of Periodontology kindly allowed the author free access to the literature. Only papers written in the English language and

free of charge were considered. A total of 15 papers, where a sustained release Chlorhexidine chip (SRCC) had been used as an adjunct to periodontal therapy, were selected for review.

Results: The studies carried out do not give conclusive evidence to ascertain clinical benefit. The review highlighted a level of bias due to the conflicting interests of the researchers.

Conclusions: The influence of chlorhexidine chip on the periodontium is modest.

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to introduce antimicrobials directly to periodontal pockets.9 For the purposes of this literature review the researcher will focus on the efficacy of using a sustained release chlorhexidine chip in the treatment of periodontal pockets - known commercially as PeriochipTM.

Periochip is the controlled release sub-gingival delivery of chlorhexidine in the form of an orange/brown rectangular chip which is rounded at one end for ease of insertion. It measures 5mm x 4mm x 0.3mm and weighs about 7.4mg. It contains 2.5mg of chlorhexidine. Initially the product had to be stored in a refrigerator but further advancements have seen biodegradable chips which can be kept at room temperature. Both products have been reviewed in this paper.

Method

A literature search was undertaken of relevant papers relating to the use of all types of chlorhexidine used in the treatment of periodontal disease using the following search engines: Pubmed, Science Direct, the Knowledge Network, Google Scholar, Medline,Wiley Online Library, Sage Publishing and the Dental Update Website. The American Academy of Periodontology kindly allowed the researcher free access to the literature. Key search words used were: cholrhexidine; periodontal disease; gel; solution; chip; irrigation; monotherapy.

More than 50 papers which discussed gel, solution and periochip were considered in the initial search. This was subsequently narrowed to those papers which discussed periochip alone. This was because the author’s background search revealed that gingival crevicular fluid turnover is rapid in diseased pockets and only a chlorhexidine device, which remains within a periodontal pocket, can deliver the medicament adequately.

A total of 15 papers were reviewed where a sustained release chlorhexidine chip (SRCC) had been used as an adjunct to periodontal therapy. A total of 14 of the papers selected were randomised controlled trials and one was a controlled trial. Papers were published between 1991 and 2013 and originated from 8 different countries. Only studies where patients had already undergone a full course of hygiene phase treatment were included.

Results

A total of 13 papers concluded that SRCC has beneficial effects as an adjunct to treatment. Carvalho et al. and Grisi et al. failed to observe any adjunctive effect to the use of SRCC beyond scaling and root planning (SRP). 10,11 Rodrigues et al. found that SRP plus SRP/SRCC were equally effective treatments and that SRCC was more effective in deeper pockets.12

Each study tended to focus on different methods of assessing periodontal improvement. Thus the researcher had to focus on a single parameter which was consistently measured; pocket probing depth (PPD). The results of this analysis are collated in Figure 1.

The researcher found that when analysing this information it was not necessarily apparent what the results of each study were. In studies by Stabholz et al, Soskolne et al., Jeffcoat et al., Azmak et al., Paolantonio

BASELINE END OF TREATMENT

Paper Length of study

ControlPPD (mm)

RCCPPD (mm)

ControlPPD (mm)

SRCCPPD (mm)

Total gainFrom SRCC

Total gain from SRP

Heasman et al. (2001) 6 months 6.47 6.64 6.02 5.86 0.78 0.45

Kasaj et al. (2007) 6 months 6.3 6.2 5.6 4 2.2 0.70

Machtel et al. (2011) 8 weeks N/A 7.17 N/A 5.09 2.08 N/A

Puri et al. (2013) 3 months N/A 5.07 N/A 3.13 1.94 2.8

Grisi et al. (2002) 9 months 5.2 5.2 2.4 2.2 3 2.8

Avinash et al. (2011) 6 months 5.6 5.6 4.4 3.3 2.3 1.2

Kaner et al.(2007) 6 months N/A 3.7 N/A 2.45 1.25 N/A

Azmak et al. (2002)

6 months6.83 7 * * * *

Stabholz et al. (1991) 2 years 6.8 7.35 * * * *

Soskolne et al. (1997) 6 months 6.01 5.99 * * * *

Carvalho et al. (2007) 9 months 5.6 5.9 4.5 4.7 1.2 1.1

Paolantonio et al. (2008)

1 year 10months

* * * * * *

Jeffcoat et al. (2000) 9 months * * * * * *

Rodrigues et al. (2007) 6 months 6.1 6.2 3.9 3.4 2.8 2.2

Gonzales et al. (2011) 9 months * * * * * *

Figure 1: The PPD of studies reviewed, before and after treatmentsN/A – This study used another means of comparison to show the efficacy of SRCC* The results in these studies were deemed incomprehensible by the researcher.

21No. 4 2015

CHLORHEXIDINE CHIP

et al. and Gonzales et al. results were displayed on a graph. When analysing the results in such small parameters, graphs can be particularly misleading and do not contain enough detail to ensure clear interpretation of the results.13-18

Three studies, Stabholz et al., Azmak et al. and Kaner et al., displayed the results of baseline indices. 13,16,19 These were easily interpreted but the test results were not. It would be preferable if the results were displayed in the same format to allow for simple comparison.

Only results in the studies by Kasaj et al. and Avinash et al. would be appreciable to the everyday clinician working in general practice, as most probing devices used to measure attachment gains are in millimetres. 20-21 The participants in each of these studies had no periodontal therapy for three and six months respectively. Interestingly the results produced by Avinash suggested no further reinsertion of SRCC had been undertaken. This study was not randomised and the patients included were divided into groups dependent on the type of treatment they received. No attempt was made to prevent the Placebo or Hawthorne effect in this study. A total of 30 participants were included; 10 underwent SRP; 10 underwent SRP and CHX irrigation; and 10 underwent SRP and SSCC. These numbers are very low and there is no mention of any male to female ratio of the study participants. Ultimately, all the study numbers were low. The average sample size of all papers reviewed was 39. The number of patients enrolled in a study has a large bearing on the ability of the study to reliably detect the size of the effect of the study intervention.

Additionally only two studies lasted longer than 9 months, both of which had results which were not clear to the researcher and one of these studies exhibited bias, which was not mentioned in the paper. This area of literature needs clarifying as clinical gains may not be noticeable until later on in the wound healing process.

Of all the papers analysed, the study by Kasaj and co workers was the only one which analysed results with a new treatment device.20 This was also one of the studies to find noteworthy tests results. The Vector ultrasonic scaling machine was used, which claims to move parallel to the root surface, and this treatment intervention could attribute to the higher gains in attachment found in this study.

The studies undertaken by Stabholtz et al., Soskolne et al., Jeffcoat et al. Azmak et al. Gonzale et al., Kaner et al., Avinish et al. and Puri et al. included smokers.13-16,18-19,21-22 This is a known risk factor for periodontal disease and will have an impact on the study results. 9

Grisi et al., Stabholz et al., Soskolne et al., Gonzales et al. Kaner et al., Kasaj et al. and Machtel et al. all reported to have reinserted the chip at one point or another during the study. 11,13-14,18-20,23 This means that the targeted sites were exposed to longer periods of the drug at the site of infection and the author would suggest that this is an area that would benefit from further research.

The site specificity and predilection in periodontitis and gingivitis probably relates to the retention of plaque in specific areas.24 Figure 2 depicts the periodontal status of the cohort sampled for each study included in this review. The design and nature of the SRCC allowed ease of use across a variation of different stages of the disease process. It allows for insertion in difficult to maintain areas, which is one of the main advantages of its use. The varying periodontal status across these studies should be assessed as independent variables. It may be that SRCC works better on patients with different stages/subtypes of the disease.

Bias was evident in 6 of the studies reviewed: Stabholz et al., Soskolne et al., Jeffcoat et al., Gonzales et al., Kasaj et al. and Machtel et al.13-15,18,20,23 Kasaj et al. and Gonzales et al. were supported by DexcelPharma to complete their study. Stabholz et al., Soskolne

Paper Depiction of periodontal status

Heasman et al. (2001)

Moderate to severe periodontitis. Minimum for 1 pocket >5mm

Kasaj et al. (2007)

Chronic periodontitis. At least 4 pockets >5mm

Machtel et al. (2011)

Chronic periodontitis. At least with 2 teeth with periodontal pockets of 5-9mm

Puri et al. (2013)

Chronic periodontitis. 2 bilateral periodontal pockets of 5-7mm

Grisi et al. (2002)

Chronic periodontitis. At least 4 sites with pockets >5mm

Avinash et al. (2011)

Moderate or advanced periodontitis. At least one site with a pocket of >5mm

Kaner et al.(2007)

Generalised aggressive periodontitis. 20 teeth showed pockets of at least 6mm

Azmak et al. (2002)

Moderate to severe chronic periodontitis. At least 4 sites showing >4mm loss of attachment.

Stabholz et al. (1991) Multiple deep periodontal pockets

Soskolne et al. (1997)

Moderate periodontitis. At least one pocket with of 5-8mm in depth

Carvalho et al. (2007)

Two sites, in non-molar teeth with pocket depths of >5mm

Paolantonio et al. (2008) Two sites >5mm

Jeffcoat et al. (2000)

Adult periodontitis. 4 sites with pockets 5-8mm

Rodrigues et al. (2007)

Chronic periodontitis. At least 1 site with pockets 5-8mm on a single rooted tooth.

Gonzales et al. (2011)

Chronic periodontitis. With more than 12 teeth exhibiting pockets >5mm

Figure 2 : The periodontal status of study cohorts


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et al. and Machtel et al. all work for DexcelPharma directly. Jeffcoat et al. were supported by PerioProducts, who distribute the product Periochip. DexcelPharma is a multinational pharmaceutical company. Most of these papers did mention the support from such companies although others did not.

Discussion

A total of 5 of the studies reviewed failed to include bleeding on probing indices (BOP), which can be an indicator of active disease: Grisi et al., Rodrigues et al., Jeffcoat et al., Azmak et al., Puri, et al.11-12, 15-16, 22 However, previous research has found that only 30% of those sites that continued to bleed actually demonstrated further loss of attachment therefore the researcher concluded that this was not a major flaw.9

It has been noted that following periodontal therapy healing may continue for up to 6 months, and it is advisable to delay probing until a period 6-12 weeks has elapsed. This will allow the optimum opportunity for regeneration of the periodontal fibres and/or reformation of the long junctional epithelium. Premature probing disrupts this process and could theoretically result in a reduction of the attachment gain.26 Over half the studies reviewed probed prior to the accepted wound healing time.10,12,14-16,18,20,22-23,25

The researcher concluded that using the brand name Periochip did not mean bias as Carvalho et al., Avinash et al., Puri, et al. and Heasman et al. all used this terminology and were not found to have conflicting interests.10,21-22,25

The studies by Rodrigues et al., Soskolne et al., Jeffcoat et al., Azmak et al., Paolantonio et al., Kaner et al. and Heasman all reported time spent scaling and root planing.12,14-17,19,25 This is crucial when trying to replicate a study; no other study gave clear indication of time spent debriding the root surface. This is important to ensure that study participants were assessed as having the same level of calculus deposits as their counterparts. The researcher would suggest that ensuring that test sites were free from calculus formation should have been declared by the authors.

All studies reviewed referred to the mechanical removal of biofilms as scaling and root-planing (SRP). Based on the assumption that bacterial endotoxins were cementum-bound the goal of root planing remains to remove cementum and therefore only focuses on the root surfaces. The terms scaling and root planning, actually constitute outdated over treatment. Debridement therapy deals with bacterial infection, rather than the narrow focus of root surface smoothness.

Today, complete cementum removal (root planing) to eliminate endotoxins is considered over treatment. Debridement takes into account more than just root surfaces and the focus of debridement therapy is to control bacterial infection as opposed to removing the deposits from root surfaces. Debridement is accomplished without the aggressive removal of cementum. Cementum removal leaves open dentinal tubules which allow pathogens to travel between the periodontal pocket and the pulp. Applying this new knowledge to the studies being reviewed with a focus on debridement as opposed to scaling and root planning suggests a gap in the available literature.

It has been shown that Sodium Laurel Sulphate containing medicaments deactivate chlorhexidine: the chlorhexidine molecule reacts with the anionic surfactants present in the toothpaste formulation, thus reducing the activity of the agent. Therefore chlorhexidine should not be used before, or immediately after using toothpaste.3 There was no mention of this in any of the studies. No patients were told not to use such products and this could have caused the low levels of attachment gained over the studies.

All papers reviewed at some point refer to the study by Soskolne et al. It would appear that this particular study set the precedent for the use of SRCC yet it is flawed in many ways.14 There is no mention of bias despite the fact that some authors are consultants for DexcelPharma. There was no intra-centre calibration when recording clinical criteria, which is important due to the very small parameters measured in this study. On inspection of graphs used to display results, increments used lead the analyser to believe that results are somewhat measurable but upon further inspection it is noticed that clinical measurement of these results would actually be the same for the test and control groups.

Conclusion

When evaluating the clinical intervention of introducing SRCC into the periodontal pocket the researcher concludes that the benefit resulting from this use appears to be modest. This is in line with the recommendations from the British Society of Periodontology (2012).

It has been shown that the adjunctive use of the chlorhexidine chip resulted in a limited additional reduction of both probing depths and loss of alveolar bone. These results are in line with the conclusions of this current review of literature.27

Periodontal disease is a multi-factorial disease. Although certain types of bacteria are known to affect its progress, it is not just specific bacteria which cause the loss of

23No. 4 2015

CHLORHEXIDINE CHIP

attachment. Susceptibility to these diseases is highly variable and depends on the host’s response to periodontal pathogens. Also the characteristics of this disease are also influenced by acquired and genetic factors.28 In a review of the antimicrobial therapies available it has been found that the combined mechanical and chemotherapeutic therapies of the dental professional and the patient will give the best results.29

When applying the use of SRCC in general practice it was found after some brief research that prices for the treatment of SRCC range from £20-£70 per site. Coupled with the cost of attending a dental care professional for the provision of this treatment SRCC seems expensive for the actual clinical outcome gained.

The SRCC can only be inserted at pockets with >5mm PD. An adjunctive treatment which could work at any level of attachment loss would be more beneficial. In contrast researchers have reported that SRCC may be more effective in the treatment of deeper periodontal pockets.30,12

The author is in agreement with the conclusions of Matesanz et al.30 that there is a need for further clinical trials with strict methodological criteria for following a more precise assessment of the efficacy of local antimicrobials in the treatment of chronic periodontal disease.

References

1. Jain N, Jain GK, Javed S et al. Recent approaches for the treatment of periodontitis. Drug Discov Today. 2008;13(21-22):932-42.

2. Loe H, Schiott CR. The effect of mouth rinses and topical application of chlorhexidine on the development of dental plaque and gingivitis in man. J Periodontal Res. 1970;5(2):79-83.

3. Gupta R, Chandavarkar V, Galgali SR, Mishra M. Chlorhexidine: A medicine for all the oral diseases. Global J Med Pub Health. 2012;1(2):43-8.

4. NICE (2013) Chlorhexidine Gluconate (online}, Available from <http://www.evidence.nhs.uk/formulary/bnf/current/12-ear-nose-and-oropharynx/123-drugs-acting-on-the-oropharynx/1234-mouthwashes-gargles-and-dentifrices/chlorhexidine-gluconate>{03/12/2013}.

5. Kothari S, Gnanaranjan G, Kothiyal P. Periodontal chip: an adjunct to conventional surgical treatment. Int J Drug Res Technol. 2012;2(6):411-21.

6. Soskolne W, Chajek T, Flashner M et al. An in vivo study of the chlorhexidine release profile of PeriochipTM in the gingival crevicular fluid, plasma and urine. J Clin Periodontol. 1998;25(12):1017-21.

7. Goodson JM. Pharmacokinetic principles controlling efficacy of oral therapy. J Dent Res. 1989;68:1625–32.

8. Greenstein G. Research, Science and Therapy Committee of the American Academy of Periodontology. Position Paper: The role of supra- and subgingival irrigation in the treatment of periodontal disease. J Periodontol. 2005;76(11):2015-27.

9. Heasman P, Preshaw M and Robertson P. Successful Periodontal Therapy: A Non-Surgical Approach. London:Quintessence (2004).

10. Carvalho J, Novak JM, Mota LF. Evaluation of the effect of subgingival placement of chlorhexidine chips as an adjunct to scaling and root planing. J Periodontol. 2007; 78(6):997-1001.

11. Grisi DC, Salvador SL, Figueiredo LC et al. Effect of controlled-release chlorhexidine chip on clinical and microbiological parameters of periodontal syndrome. J Clin Periodontol. 2002; 29(10):875-81.

12. Rodrigues I, Machion L, Casati MZ et al. Clinical evaluation of the use of locally delivered chlorhexidine in periodontal maintenance therapy. J Periodontol. 2007;78(4):624-8.

13. Stabholz A, Soskolne WA, Friedman M, Sela MN. The use of sustained release delivery of chlorhexidine for the maintenance of periodontal pockets: 2-year clinical trial. J Periodontol. 1991;62(7):429-33.

14. Soskolne WA, Heasman PA, Stabholz A et al. Sustained local delivery of chlorhexidine in the treatment of periodontitis: a mulitcenter study. J Periodontol. 1997;68(1):32-8.

15. Jeffcoat MK, Palcanis KG, Weatherford TW et al. The use of a biodegradable chlorhexidine chip in the treatment of adult periodontitis: clinical and radiographic findings. J Periodontol. 2000;71(2):256-62.

16. Azmak N, Atilla G, Luoto H, Sorsa T. The effect of subgingival controlled-release delivery of chlorhexidine chip on clinical parameters and matrix etalloprotienase-8

levels in ginigival crevicular fluid. J Periodontol. 2002;73(6): 608-15.

17. Paolantonio M, D’Angelo M, Grassi RF et al. Clinical and microbiologic effects of subgingival controlled-release delivery of chlorhexidine chip in the treatment of periodontitis: a muliticenter study. J Periodontol. 2008;79(2):271-82.

18. Gonzales JR, HarnackL, Schmitt-Corsitto G et al. A novel approach to the use of subgingival controlled-release chlorhexidine delivery in chronic periodontitis: a randomized clinical trial. J Periodontol. 2011; 82(8):1131-9.

19. Kaner D, Bernimoulin JP, Hopfenmüller W et al. Controlled-delivery chlorhexidine chip versus amoxicillin/metronidazole as adjunctive antimicrobial therapy for generalised aggressive periodontitis: a randomised control trial. J Clin Periodontol. 2007; 34(10):880-91.

20. Kasaj A, Chiriachide A, Willershausen B. The adjunctive use of a controlled-release chlorhexidine chip following treatment with a new ultrasonic device in supportive periodontal therapy: a prospective, controlled clinical study. Int J Dent Hyg. 2007;59(4):225-31.

21. Avinash JL, Shama Rao HN, Sucheta A et al. Comparative evaluation of efficacy of controlled release local drug delivery system and local irrigation of chlorhexidine gluconate following scaling and root planning- clinical study. Int J Contemp Dent. 2011;2(6):71-7.

22. Puri K, Dodwad V, Bhat K, Puri N. Effect of controlled release Periochip on clinical and microbiological parameters on patients with chronic periodontal disease. J Indian Soc Periodontol. 2013;17(5):605-11.

23. Machtel EE, Hirsh I, Falah M et al. Multiple applications of flurbiprofen and chlorhexidine chips in patients with chronic periodontitis: a randomised, double blind, parallel, 2-arms clinical trial. J Clin Periodontol. 2011;38(11):1037-43.

24. Kinane DF. Causation and pathogenesis of periodontal disease. Periodontol 2000. 2001;25:8-20.

25. Heasman PA, Heasman L, Stacey F, McCracken GI. Local delivery of chlorhexidine gluconate (PeriochipTM) in periodontal maintenance patients. J Clin Periodontol. 2001;28(1):90-5.

26. Noble Sl, Kellett M and Chapple IL. Decision-Making for the Periodontal Team. London:Quintessence (2003).

27. Quirynen M, Teughels W, De Soete M, van Steenberghe D. Topical antiseptics and antibiotics in the initial therapy of chronic adult periodontitis: microbiological aspects. Periodontol 2000. 2002;28:72-90.

28. Lang NP and Lindhe P. Clinical Periodontology and Implant Dentistry. Oxford:Blackwell Munksgaard (2008).

29. Slots J, Jorgensen MG. Effective, safe, practical and affordable antimicrobial therapy: where are we going, and are we there yet? Periodontol 2000. 2002;28: 298-312.

30. Matesanz P, García-Gargallo M, Figuero E, et al. A systematic review on the effects of local antimicrobials as adjuncts to subgingival debridement, compared with subgingival debridement alone, in the treatment of chronic periodontitis. J Clin Periodontol. 2013;40(3):227-41.


This work was undertaken as a student at the University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness IV2 3JH.

The author currently practises as a Dental Hygienist Therapist Vocational Trainee at Woodside Dental Practice, Glasgow.



Is there a need for training in current cleft lip and palate care?Rhiannon F Jones

Key words: Cleft lip and palate; dental hygienist; dental therapist; knowledge; training; post-graduate

Introduction

The author began working in a Cleft Lip and Palate Unit as a Dental Hygienist in 2008. It was an entirely new role within the current team based at Frenchay Hospital, Bristol. It involved working closely with the consultant orthodontist, consultant paediatric dentist and oro-maxillo facial surgeon. Many patients reported negative experiences during general dental care, resulting in many avoiding further visits. The experiences ranged from misdiagnosed conditions to upsetting comments. In general the problem seemed to be a lack of confidence in attending for treatment with a clinician who appeared to know little about their condition. Dentistry requires a high level of trust between the clinician and the patient. It is perhaps

therefore understandable, when listening to some people’s experiences, that many cleft patients do not attend general dental practices. Although specialist care is provided by cleft teams across the country, routine dental care should be provided in primary care settings. With the latest figures showing an incidence of approximately one in every 645 live births in England, Wales and Northern Ireland presenting with some form of clefting2 we should expect to see more patients with a repaired cleft. Should it be the case that specialist centres are treating routine dental problems when they could easily be dealt with in the primary care setting? The financial considerations aside, these patients deserve a ‘normal’ life and should be able to access care within their communities.

Aim: To determine the level of under-graduate training received by a group of dental hygienists and therapists in the care of cleft lip and palate patients.

Method: Delegates attending two regional British Society of Dental Hygiene and Therapy (BSDHT) scientific meetings were asked to complete a questionnaire prior to a one hour presentation on cleft care. The questionnaire asked five questions and additional comments were encouraged. The questionnaires were collected prior to the presentation to avoid late answers. 129 delegates responded (n=129) 81% dental hygienists, 8% dental nurses and 8% dental hygiene-therapists. There were two dental surgeons and two dental hygiene students also involved.

Results: Only 31% of respondents had received some training in the care of cleft lip and palate patients. Of the 33% of delegates that said that they did know where to refer, only 25% were correct in their answers. Many delegates based their decisions on knowledge that would be

considered outdated, particularly considering the changes brought about as the result of the Clinical Standards Advisory Group (CSAG) report in 1998.1 Of the 42 respondents that stated that they had received some training, 30% commented that it was “very minimal”. Written comment from delegate: “We definitely need to know referral pathways and have a greater understanding of the management of children and adults”.

Conclusions: It would seem that there is a lack of undergraduate training in cleft care. There is a distinct lack of knowledge regarding treatments and referral procedures. Cleft patients could benefit from a greater awareness of current practice amongst the general dental community. At present, only specialist care is carried out within the Cleft Units. A training programme that could be used by all dental training establishments could be an effective way of reaching the new generation of dental professionals and included in continuing professional development programmes for post-graduates.

A B S T R A C T

WWW.BSDHT.ORG.UK

25No. 4 2015

Method

The CSAG (Clinical Standards Advisory Group) Report 1998 was commissioned to study the care of patients born with a cleft lip and/or palate. The research identified poor patient outcomes and the fact that the 57 centres worked as a dispersed model of care for their patients. The research team presented a critical recommendation: the centralisation of cleft palate services in the UK. The author of this paper graduated in 1999 (pre-CSAG implementation) and had received both clinical experience and lectures on cleft care as part of her undergraduate training. There have been a number of changes since that time and therefore it is useful to consider the training other dental professionals received during their journey to qualification and whether or not it is still clinically relevant. This study aimed to evaluate the need for post-graduate training in order to ensure the general dental community was as up-to date as possible.

A one hour presentation to two BSDHT Regional Group Scientific Meetings was delivered to delegates in Cardiff and Oxford, with a combined audience of 129 (n=129). Prior to the presentation delegates were requested to complete an anonymous questionnaire asking about their current level of knowledge regarding cleft care. The presentation then included: a brief history of cleft care in the United Kingdom; an explanation as to why the service had changed; an overview of current practice; and the referral pathways for adult patients. A 10 minute video clip was played where children with repaired cleft lips and/or palates explained what they thought the

difference was between ‘us’ and ‘them’.

Questionnaire

Delegates were requested to answer the following five questions:

1. What is your profession?

2. In which decade did you qualify?

3. Did you receive any training in cleft lip and palate care as a trainee or undergraduate?

4. What form was the training? (lecture, clinical experience etc…)

5. Would you know where to refer a patient or receive information for cleft care?

The delegates comprised mostly dental hygienists (81%); dental nurses (8%); and dental hygiene/therapists (8%). There were a further four questionnaires completed by dental surgeons and student dental hygienists. The majority of respondents qualified between 1980 and 2000 (77%) with only 3% qualifying since 2010. This is an interesting result as the designated Cleft Centres set up as a result of the CSAG Report published in 1998 were not established until 2006. This shows that even where training was available only graduates post-2006 were likely to have been given up-to-date information.

Of the 129 delegates asked if they had received training as an undergraduate, 54% replied ‘no’, 31% replied ‘yes’ and 15% were unsure. Of the 42 respondents that claimed to have received some training, 30% commented that it was “very little”. (Fig. 1)

Figure 1: Did you recieve training as a trainee or undergraduate?

Yes 31%

No 54%

Little or unsure 15%

CLEFT CARE


WWW.BSDHT.ORG.UK

Figure 2: In what form was the training?n=42 (more than one answer was allowed)

Not Answered

Lecture

Clinical

Lecture and Clinical

Reading Material

Figure 3: Would you know where to refer a patient or recieve information on Cleft Care? n=126

Yes

No

Unsure

27No. 4 2015

CLEFT CARE

The delegates were able to write more specific details and comments regarding their training. It was interesting to note that a few dental hygienists who had received their qualification outside of the UK had more exposure to cleft care.

Questions were also asked regarding the training that they had received. The delegates were allowed to answer more than one option and some had left this blank even though they stated that they had received some training. The results showed that the majority of training received was in the form of a lecture. This may have been a specific lecture on cleft care or possibly as an element of their embryology module. For many people, remembering the exact nature would be difficult. Only 21% of the respondents who received training gained clinical experience. (Fig. 2)

The question that I was most interested to see the results of was ‘Would you know where to refer a patient or receive information on cleft care?’ A total of 33% of respondents thought that they knew where to refer. Of those who stated the place that they believed to be the correct referral centre, only 25% were correct. (Fig. 3)

Conclusions

The results of this small study highlights the fact that many dental care professionals did not receive training on cleft lip and/or palate care during their undergraduate training, and those who did are likely to have outdated knowledge due to the changes

implemented following CSAG in 2006. Now, fifteen years on, the survey of outcomes is about to be repeated by CSAG in five-year old children with cleft lip and palate across each of the 11 centres. Early signs following the restructure have been positive. Preliminary evidence has shown that outcomes for patients have significantly improved. Patients may be more encouraged to receive dental care in the general dental setting if there was more knowledge amongst the team regarding current treatment and care.

A second study would involve a redesign of the questionnaire to provide more accurate analysis.

Recommendations

The development of a programme for use in all dental training schools that could be delivered by the current tutors would ensure that all new dental professionals are aware of current treatment and referral pathways. It would also be helpful to include cleft care in post-graduate programmes and which would be available to dental professionals in their continuing professional development.

References1. Sandy J, Williams A, Mildinhall S et al. The Clinical Standards

Advisory Group (CSAG) Cleft Lip and Palate Study. J Orthod. 1998;25(1):21-30.

2. CRANE Database www.crane-database.org.uk . Annual Report on Cleft Lip and/or Palate 2014 (pp65).


University Hospitals Bristol South West Cleft Team Bristol Dental Hospital Lower Maudlin Street, Bristol. BS1 2LY



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Are waterpipe smokers aware that there are health risks associated with waterpipe smoking?Miriam Khan

Key words: Waterpipe; shisha; smoking; tobacco; health risks; cessation

Introduction

Waterpipe smoking originated in India in the 15th century. Since then the habit has pervaded many different cultures and is identified variously as narghile, shisha, hookah, huqqa and hubble bubble.1 Historically, a Persian physician was the first to experiment using water to cool and purify the smoke of his pipe, in an attempt to help the empire tackle their drug problems.2

Waterpipe smoking is a method of smoking tobacco, normally flavoured and referred to as molasses.3 The smoking process is based on the mechanism of indirect heat and water filtration (Figure 1).4

The smoke from a waterpipe is slightly different to smoke generated from a cigarette; with a cigarette the smoke is produced by directly burning the tobacco, whereas here it has a layer of foil, generating smoke with an “essence” and flavour of the tobacco.2

Health effects of waterpipe smoking

Waterpipe smoking has not been studied as intensively as cigarette

smoking. However, preliminary research on patterns of smoking, the chemistry of the smoke that is inhaled and adverse health effects supports the idea that waterpipe smoking is associated with many of the same risks as cigarette smoking. Furthermore it may involve some unique health risks.5

The current evidence base supports the following conclusions:

• Using a waterpipe to smoke tobacco is not a safe alternative to cigarette smoking.6

• Commonly used sources that are applied to burn the tobacco, such as wood cinders or charcoal, are likely to increase the health risks. When these fuels are combusted they produce their own toxicants, including high levels of carbon monoxide, metals and cancer causing chemicals.7,8

• Even after it has been passed through water, the smoke produced by a waterpipe contains high levels of toxic compounds, including carbon monoxide, heavy metals and cancer causing chemicals.9,10

• A typical hour long waterpipe smoking session involves inhaling 100 to 200 times the volume of smoke inhaled with a single cigarette.11

Aim: To investigate whether those students at the University of Portsmouth, who are waterpipe smokers, are aware of the health risks associated with the practice of waterpipe smoking.

Methods: A literature review was performed to compile information relating to waterpipe smoking. Primary research was obtained through an anonymous electronic questionnaire sent to 200 students at the University of Portsmouth.

Results: 48% of respondents consider themselves to be waterpipe smokers, 12% of waterpipe smokers do not associate any health risks at all with this practice and 47% consider it safer than smoking cigarettes.

Conclusion: This study raises concern regarding the misconceptions attached to waterpipe smoking due to little awareness of its adverse health effects. Increased knowledge and resources will enable all dental care professionals and students to deliver smoking cessation advice specifically related to waterpipe smoking, for patients who require or request it.

A B S T R A C T

29No. 4 2015

WATERPIPE SMOKING

• The smoke produced by waterpipes is a mixture of tobacco smoke in addition to smoke from the fuel, therefore poses a serious risk for passive non-smokers.9

• To date, there is no proof that any device or accessory can make waterpipe smoking safer.5

• Sharing a waterpipe mouthpiece poses a serious risk of transmission of communicable diseases, including tuberculosis and hepatitis.6

• Waterpipe smokers may be subject to similar health risks as those incurred by cigarette smoking, including cancer, heart and respiratory diseases.12

Attitudes towards waterpipe smoking

As the prevalence of waterpipe tobacco smoking increases globally9 it becomes more important to understand the reasons for use and the attitudes of waterpipe smokers. A waterpipe smoking habit seems to be readily adopted due to unsupported assumptions of relative safety compared to cigarettes.13 Many of these misconceptions stem from the design of the waterpipe itself, where it is suggested that smoke should first pass through a small receptacle of water so that it is rendered harmless.5

Nakkash et al 14 conducted a study in Lebanon, where the main reasons identified for smoking a waterpipe were: availability, affordability, innovation, influence of media, lack of a policy framework and the sensory characteristics evoked from waterpipe smoking. A similar study was carried out in the UK (Birmingham) and Canada (Toronto) amongst university students. Results showed that waterpipe smokers had not thought deeply about the health risks and reasoned that if no warnings about waterpipe smoking were apparent (unlike cigarette smoking) then it was probably safe.15

Waterpipe tobacco is often sweetened and flavoured to add taste and smell to the smoke, making it very appealing. This may explain why some, particularly young people who otherwise would not use tobacco, begin to use the waterpipe.9 Waterpipe tobacco products and accessories in Lebanon (the majority of which are also imported for use in the UK), demonstrate the lack of appropriate health warning labels, the presence of misleading qualitative descriptors and fundamental misreporting of tar and nicotine levels.14 These implicit claims encourage commercial marketing, a factor in contributing to the spread and popularity of waterpipe smoking and a lack of awareness of its health effects.5

Fig. 1: Diagram illustrating the main components of a waterpipe and the process of waterpipe smoking.Picture source: Mohamud, A. (2014). Through the smoke – the rise of shisha. Retrieved from http://www.ignitenews.ca/through-the-smoke-the-rise-of-shisha


Aims of research

The primary aim of this research was to investigate through an anonymous online questionnaire whether those students at the University of Portsmouth who are waterpipe smokers are aware that there are health risks associated with waterpipe smoking. Secondary objectives included investigating whether students, who are waterpipe smokers, consider waterpipe smoking safer than smoking cigarettes and if so, why.

Methodology

Secondary data was gathered using various web search engines including Google Scholar, PubMed and the British Medical Journal. Initially the words ‘waterpipe smoking’, ‘prevalence’, ‘health effects’ and ‘attitudes’ were combined and used to search each database for reliable papers. Only a specific few papers and studies were eventually chosen to critically analyse, as these were varied and individually interesting, whilst remaining relevant to the aims of this study.

The selected literature was filtered using inclusion and exclusion parameters (Figure 2).

Primary data was gathered by carrying out data collection using an anonymous questionnaire distributed via a Google Drive link to students at the University of Portsmouth. The sample size was restricted by the Student Voice Group at the hosting organisation, therefore, the sample selection was limited to 200. Within

the dental academy this was sent to all 160 students (65 hygiene therapy students, 15 dental nursing students, 80 dental students) by the administrative team, however the researcher asked a random 40 of these students to each pass the link onto an additional unknown individual elsewhere from the university to participate, totalling 200. A randomised pilot of 10% was conducted before submitting the final questionnaire. Questions were a mixture of multiple choice, tick boxes and short text answers.

A participant information sheet was included to obtain consent and make participants aware of their right to withdraw until the questionnaire has been submitted. As questionnaires were completed and submitted, the results were automatically collected on the researcher’s Google Drive account. The results were collected and stored securely with a protected password.

Results were analysed using Google Drive, which automatically collated results from all participants into spreadsheet tables for each question. Graphs were created to allow for visual representation of results.

Please note: on the results table for question 9 and the bar graph for question 14, participants could pick more than one answer, however the percentages for each answer is still out of the total number of participants.

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INCLUSION CRITERIA

• Recent studies (2008 – present) • Advisory notes – WHO tobacco framework• Studies examining prevalence and spread of waterpipe smoking• Studies examining attitudes and health beliefs of waterpipe smoking• Studies done within the UK• Studies done in a university setting, or limited to a particular age category of university students • Global studies of relevance that are written in English• Literature that was free to access

EXCLUSION CRITERIA

• Studies prior to 2008• Scientific studies about the health effects of waterpipe smoking• Studies not written in English• Global studies not of relevance • Literature that cost to access (a note was made of these for possible future studies)

Fig. 2: Table defining the exclusion and inclusion parameters used to filter any secondary data collected.

31No. 4 2015

Key results

Email reminders were sent out to all participants, twice. This was the best way of following up any non-responders through this anonymous questionnaire. Reminders had to be limited to only two as the researcher did not want to continuously bother those who had already participated.

However the 53.5% response rate (107 of 200) from the questionnaire was considered adequate to gather enough data to analyse for this research project.

A total of 48% of 107 people who responded were waterpipe smokers, with 78.5% of a full Arab, Asian (Pakistani, Indian or Bangladeshi) or African background. The student population within Portsmouth was the targeted population and, as expected, the majority of the waterpipe smokers (80%) were between the ages of 18 and 24 years, with a further 14% in the 25 to 29 age bracket. The majority of respondents smoked for enjoyment or relaxation, but two individuals reported that they were addicted (more than one reason could be chosen). Tobacco (molasses) was more popular than the herbal (tobacco free) substance: some smokers used both. All 51 participants stated they prefer to smoke the waterpipe in a social environment, with only two participants also choosing to smoke individually.

Just over 10% of the respondents did not consider there to be any health risks with waterpipe smoking. In total, 53% rightly identified that smoking a waterpipe is not safer than smoking cigarettes, however a significant 47% deemed waterpipe smoking safer than smoking

cigarettes. Overall, a higher percentage of waterpipe smokers thought that the correct facts, associated with health risks, were true. However between 20% and 29% believed the common misconceptions to be true.

An open question was designed to collect comments from the participants who thought that waterpipe smoking was safer than cigarette smoking. Here is what some of them had to say about why they thought this to be true:

“The water in the base of the waterpipe acts as a filter in the smoking process, reducing or removing any toxicity. The waterpipe is also smoked differently, the smoke is not deeply inhaled into the lungs, unlike cigarettes”

“There is less public awareness about the health effects of waterpipe smoking, so it must be safer than cigarettes, which are heavily advertised as being harmful.”

“Waterpipe tobacco has less harmful chemical substances than cigarette tobacco, and I smoke herbal flavour which is tobacco free.”

“It is not as addictive. I can go months without smoking a waterpipe however people can get addicted to smoking cigarettes”

Discussion of the key results

Overall there are worrying misconceptions that waterpipe smoking is safer than cigarette smoking. The fact that some people do not consider there to be any adverse health effects associated with waterpipe smoking at all, is disturbing. The participants surveyed were undergraduate or postgraduate university students, therefore considered to be educated. Nevertheless a small percentage believed there to be no ill effects

WATERPIPE SMOKING

Q1. Do you smoke a waterpipe? Q3. What is your ethic origin/background?

No 52%Arab 2% White British 19.5% Pakistani 41%

Bandladeshi 2%

Yes 48% Mixed 2% African 10%

Number of Smokers

Indian 23.5%


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associated with smoking tobacco in a waterpipe. This is of huge concern, especially as research shows that globally 4.9 million deaths each year are attributed to tobacco use, and this annual toil may increase to 10 million within the next 20 – 30 years.9 The results of this study reveal that these students have formed the views that waterpipe smoking is less harmful than other forms of smoking, mainly in the absence of public health information. Although cigarette smoking is seen as a major compounding risk factor along with regular waterpipe use15 in this study most waterpipe smokers did not smoke cigarettes. This may be because the majority of the participants use the waterpipe for enjoyment and social purposes, rather than as an addictive habit.

Limitations of the study

Due to the large population of students within Portsmouth, the restricted sample size chosen did not give an accurate reflection of the whole university. Only students were included in this study as they were easier to access by the researcher, therefore the age range and occupational diversity of participants was limited. In addition to this, the study only included active and non waterpipe smokers, excluding those people who did not consider themselves to be waterpipe smokers but may have just tried waterpipe smoking, or ex waterpipe smokers.

The process of 40 random participants sourcing another individual to complete the questionnaire may have skewed the results for question 1 (do you smoke a waterpipe?), as the questionnaire could have been passed onto people who were known to be waterpipe smokers in an attempt to aid this research. Unintentional selection bias means that this is not an accurate proportionate display of waterpipe smokers at the university, however to an extent it still supports research stating waterpipe

smoking is becoming a common part of student culture.15

This study portrays positive findings in participants identifying the correct health effects of waterpipe smoking, however the method used to collate results did not allow for analysis of individual answers. The number of participants that identified a correct answer but may have also selected “true” for a misconception about waterpipe smoking, could not be accounted for. Therefore, measuring the extent of misconception amongst smokers regarding health effects of waterpipe smoking was limited.

Recommendations

There is little research addressing tobacco smoking using a waterpipe in comparison to cigarette smoking, especially given that there are many millions of current waterpipe smokers and that waterpipe use is spreading across the globe.5 This lack of research links to the current lack of public health information, which seems to be viewed by some students as an indication of safety in relation to waterpipe smoking. Further research in areas such as treatment methods to help waterpipe users quit, would benefit health professionals when managing cessation for patients who use a waterpipe. The restricted sample size means that this research only provides a small glimpse of attitudes towards waterpipe smoking at one university, and cannot be generalised for the entire student population. Further research on various aspects of waterpipe smoking, its prevalence, risks and health effects, needs to be carried out on a larger scale. This includes within cities and provinces, nationally and globally.

The cessation training programme delivered at universities should integrate waterpipe smoking into the teaching plan. This would provide students with the skills to deliver specific smoking cessation to those patients

QUESTION 9 WHY DO YOU LIKE TO SMOKE THE WATERPIPE? (MORE THAN 1 ANSWER CAN BE SELECTED)

Enjoyment or relaxation 44 (86%)

Addiction 2 (4%)

Peer pressure 5 (10%)

Other

5 (10%)Out of this:3 people said “to be social”1 person said “nothing else to do”1 person said “for the novelty”

TOTAL ANSWERS 56 (51 PARTICIPANTS)

33No. 4 2015

WATERPIPE SMOKING

who require or request it. In addition to the training, resources such as leaflets that provide information should be readily available if needed on clinic, or included in the smoking cessation packs. It may be that cessation rates for waterpipe smokers may be more successful, due to the decreased dependency of waterpipe smoking in comparison to cigarette smoking. Delivering cessation advice is especially relevant in areas where both the student and local population are ethnically diverse.

Heath warnings on waterpipe tobacco and accessories can help make the health professionals, regulators, and the public more aware of how dangerous this growing

trend is, and also address some of the misconceptions associated with waterpipe smoking. The Government needs to enforce stricter and more controlled regulations for waterpipe smoking and waterpipe tobacco, so it is subjected to the same regulations as cigarettes and other tobacco products. These efforts and others combined may contribute to reducing the epidemic of waterpipe smoking and the associated diseases.

Second hand smoke from a waterpipe is relatively safe and does not pose a health risk - False (20%)

Intoxicants released from charcoal can cause cancer - True (69%)

Sharing a waterpipe can increase the risk of hepatitis - True (57%)

Volume of toxic smoke in haled from a 1 hour waterpipe smoking session is more than that from smoking a packet of 20 cigarettes - True (59%)

After the smoke has been filtered through water, it contains low levels of toxic compounds - False (27%)

Certain devices/accessories can make waterpipe smoking safer - False (29%)

Q14. Which of the following statements do you think are TRUE? (more than 1 can be selected)

Number of Smokers

Q10. Do you consider there are any health risks associated with waterpipe smoking?

Q12. Do you consider waterpipe smoking safer than cigarette smoking?

No 6 (12%) No 27 (53%)

Yes 45 (88%) Yes 24 (47%)


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References

1. Nakkash R, Khalil J. Health warning labelling practices on narghile (shisha, hookah) waterpipe tobacco products and related accessories. Tob Control. 2010;19(3):235-39.

2. Hubpages. (2011). Shishapedia – All about shisha. Retrieved March 23rd, 2014 from http://naeemebrahimjee.hubpages.com/hub/Shishapedia-All-about-shisha

3. BHF – British Heart Foundation. (n.d.). Shisha smoking. Retrieved March 23rd, 2014 from http://www.bhf.org.uk/heart-health/prevention/smoking/shisha.aspx

4. The Colours of India. (n.d.). Hookah History. Retrieved March 23rd, 2014 from http://www.thecolorsofindia.com/hookah/hookah-history.html

5. WHO Study Group on Tobacco Product Regulation. (2005). Advisory note: waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators.

6. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: an emerging health risk behavior. Pediatrics 2005;116(1):e113-e119.

7. Shihadeh A. Investigation of mainstream smoke aerosol of the argileh water pipe. Food Chem Toxicol. 2003;41(1):143-52.

8. Shihadeh A, Saleh R. Polycyclic aromatic hydrocarbons, carbon monoxide,“tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food Chem Toxicol. 2005;43(5):655-61.

9. Maziak W, Ward KD, Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control. 2004;13(4):327-33.

10. Sajid KM, Akhter M, Malik GQ. Carbon monoxide fractions in cigarette and hookah (hubblebubble) smoke. J Pakistan Med Assoc. 1993;43:179- 82.

11. Shihadeh A, Azar S, Antonios C, Haddad A. Towards a topographical model of narghile water-pipe café smoking: a pilot study in a high socioeconomic status neighborhood of Beirut, Lebanon. Pharmacol Biochem Behav. 2004;79(1):75-82.

12. Al-Kubati M, Al-Kubati AS, Al’Absi M, Fišer B. The short-term effect of water-pipe smoking on the baroreflex control of heart rate in normotensives. Autonomic Neurosci. 2006;126:146-49.

13. Shafagoj YA, Mohammed FI, Hadidi KA. Levels of maximum end-expiratory carbon monoxide and certain cardiovascular parameters following hubble-bubble smoking. Saudi Med J. 2002;23(8):953-58.

14. Nakkash RT, Khalil J, Afifi RA. The rise in narghile (shisha, hookah) waterpipe tobacco smoking: A qualitative study of perceptions of smokers and non smokers. BMC Public Health 2011;11(1):315.

15. Roskin J, Aveyard P. Canadian and English students’ beliefs about waterpipe smoking: a qualitative study. BMC Public Health 2009;9(1):10.


Dental Public Health Student, The University of Manchester


35No. 4 2015

DIRECT ACCESS

UK Dental Hygienists – the road to direct access: the results of a literature reviewMichael G Wheeler

Key words: Dental hygienist; direct access; collaborative practice; scope of practice; permitted duties

Introduction

The term direct access in relation to dental hygienists is best defined as:

a dental hygienist can initiate treatment based on his or her assessment of a patient’s needs, without the specific authorisation of a dentist, treat the patient without the presence of a dentist and can maintain a provider / patient relationship

(American Dental Hygienists Association)2

In 2003 the Office of Fair Trading (OFT) sought to seek a change in legislation through the General Dental Council (GDC). Their aim was to offer patients the choice of seeing a dental hygienist without first undergoing an examination and subsequent referral by a dentist. This provoked strong opposition by various dentists’ groups on the grounds of patient safety. To date, the OFT has found no credible evidence that would prevent providing patients with a choice of treatment through direct access. This paper charts the history of the many legislative changes in permitted duties that finally, ten years later, made direct access possible on the 1st May 2013.

Aim: To review the literature which discusses the historical development of the dental hygienist profession in the United Kingdom highlighting the progressive changes in the range of duties leading up to the General Dental Council’s (GDC) decision to make legislative changes on the 28th March 2013, when the Council voted to remove the restriction on patients to be seen by a dentist first, with effect from 1st May 2013.1

Methods: The information related to direct access by dental hygienists is limited therefore a comprehensive literature review was undertaken, as opposed to a systematic or meta-analysis review. Searches were conducted of PubMed database, National Health Service Register and Evidence, Cochrane library, EMBASE and a detailed review undertaken of the British Dental Journal (BDJ), and the International Journal of Dental Hygiene using key words: scope of practice; direct access; roles and responsibilities; community dental practice; clinical duties; unsupervised practice; collaborative practice; independent practice. Sixty nine articles with direct relevance to this paper were selected for review.

Results: The early duties of the dental hygienist are based around removing calculus and polishing the tooth surface, coupled with carrying out basic tooth brushing instruction. This scope of practice was based on the science of dental disease as it stood just over 100 years ago when the dental hygienist profession began to develop. As the science of oral disease has developed, so too has the permitted duties of the dental hygienist and the additional roles they undertake, including holistic health advice, especially around smoking cessation and diet.

Conclusion: The term direct access has been widely misunderstood by members of the dental team. Many have interpreted it as working in isolation or in independent practice away from the traditional dental practice setting. In reality, the changes in the scope of practice of dental hygienists have resulted in providing choice to patients in the options available to them in accessing dental care. Dental hygienists can now choose how they practice, either in an independent way, away from the traditional dental team setting, or taking a collaborative approach, enhancing the services provided by a dental practice.

A B S T R A C T


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Methodology

A detailed search of PubMed database, National Health Service Register and Evidence, Cochrane library, EMBASE the British Dental Journal, and the International Journal of Dental Hygiene was undertaken using key words: scope of practice; direct access; roles and responsibilities; community dental practice; clinical duties; unsupervised practice; collaborative practice; independent practice.

A total of 245 papers were identified. However, on reviewing these 180 were excluded since they related to clinical practice as opposed to any detail related to permitted duties, or having any bearing on direct access.

A total of 69 papers were selected for review along with the content of eight books, identified in the British Dental Association (BDA) library and University of Bristol Medical library. Forty two papers originate from the United Kingdom, ten from the United States of America, five from Canada, four from mainland Europe and two from Australia. Six papers were from the International Journal of Dental Hygiene published by the International Federation of Dental Hygienists (IFDH). Research themes identified related to the global history and development of the dental hygienist profession, direct access in the United States of America, and Europe.

Results

In reviewing the relevant papers a bias was identified3 on two sides: papers in publications aimed at dental hygienists tend to favour direct access and an increase in the scope of practice. One exception to this, is a quantitative survey by Jaecks4 published in the American based Journal of Dental Hygiene, which makes it clear that the findings ‘support a call for greater interdisciplinary collaboration’, rather than promoting direct access.

Papers in journals aimed at dentists are in the main focused on how dental hygienists play an important role in the dental team but should always work to the direction of a dentist. Although there are exceptions to this, for example in the United Kingdom (UK) Hellyer 5 agrees that ‘Dental Hygienists have a clear role to play in the care of the elderly patient ...there is a need for dental hygienists in particular to be trained specifically in the needs of older patients’. He suggests that ‘there is a strong case for the development of a specialism within this dental care professional remit’, clearly promoting the role of dental hygienists. Also in the UK Evans et al 6 reporting on a study related to the potential delegation of clinical care in general dental practice, makes it clear that a ‘considerable proportion of work in general practice could be delegated to dental hygienists and therapists’. There were no papers that highlighted any clinical problems as a result of a dental hygienist providing treatment without a referral from a dentist.

The road to direct access in UK historically

In 1942, Mr. William Kelsey-Fry, Civilian Consultant to the Royal Air Force (RAF) in a report to the Director of Dental Services suggested that dental hygienists should be employed to help alleviate the problems of acute necrotizing gingivitis in the neglected mouths of young men who had little knowledge of basic oral hygiene procedures.7

The Nuffield Foundation8 report published in 1993 highlighted that University College Hospital in London had piloted a scheme in 1928 of formal training for dental ancillaries. It was later abandoned largely due to pressure from within the dental profession and an amendment to the Dental Act 1921, which defined the work that could be carried out by a dental ancillary limiting it to scaling and polishing tooth surfaces. Bowdler Henry in 19449 confirmed the importance of dental hygienists; he was part of the 1928 experiment which was designed to produce dental hygienists to treat patients only in civil (charitable) practices. For many years he employed a female dental surgeon solely to treat gum disease, and credited the RAF for taking forward this cost effective step.

A trial scheme suggested by Kelsey-Fry for the training of dental hygienists was initiated at the RAF Medical and Dental Training Establishment in 1943. Specially selected dental clerk orderlies (dental nurses) completed sixteen weeks training which enabled them to scale and polish teeth and, most importantly, trained them in educating patients to prevent dental disease. Tremendous interest was shown by the dental profession to their introduction to the RAF dental team.10 As the initial training was governed by the RAF, students qualified with the title dental hygienist as a trade indicator. No formal qualification was awarded by an educational or dental board. It was not until 1961 that RAF dental hygienists undertook final examinations that permitted them to register with the GDC, in common with those who had trained at civilian establishments. Although not defined in the literature review it is the author’s understanding, having trained as a dental hygienist in the RAF, that the move enabled dental hygienists to contribute to the National Health Service (NHS) on leaving the service, rather than undertake a further examination to ensure that there was no delay in the utilisation of their skills.

Interest and pressure by eminent dentists in the field of dental health led the Government to sponsor a trial training scheme at the Eastman Dental Hospital in London between 1949 and 1954. Although in line with the recommendations made in the Dentists Act 1921 their employment was still restricted to the public sector, and not privately owned practices, even though they would provide treatment on behalf of the NHS.

Hansard 11 states that the Labour Government of the day was so concerned about the recruitment of dentists to the school dental service they advocated the employment of dental hygienists to ensure school children had better access to dental care, working as part of a team under the direction of a dentist. Although it was felt by some that this was a dilution of the care provided and the employment of the dental hygienist would only be a temporary measure.

As a professional man I agree that it is always doubtful to dilute a profession in any way, but if we limit this dilution to the treatment of school children, under the supervision all the time of qualified dental surgeons, it will not do very much harm. We therefore have to look at the question of dental hygienists in the school dental service very seriously as a help to solving our temporary problem.

John Baird Member of Parliament for Wolverhampton North East 12

During 1952 a new Dental Bill was introduced with recommendations to regulate the work of ancillaries in dentistry, but was abandoned after its first hearing in the House of Commons.12 The objections were due to the potential introduction of dental auxiliaries based on the New Zealand

37No. 4 2015

dental nurse model, who like the dental dressers of the 1920’s carried out simple restorative treatment on children,13 rather than direct opposition to dental hygienists.8 Continued debate took place between the Ministry of Health, the Dental Board and dentists, both for and against the expansion of the use of dental hygienists. The House of Commons passed a resolution approving draft Ancillary Dental Workers Regulations to be made by the GDC under the Dentists Act.8

For many Members of Parliament the regulations still did not go far enough: although they welcomed the expansion of the employment of dental hygienists into general dental practice, it was still felt that their role should include simple fillings. This resulted in the establishment of the New Cross Dental School which exclusively trained dental auxiliaries (now dental therapists) for the school dental services. Their remit was to provide preventative and restorative care to children and nursing mothers working to the direction of a registered dentist. 14

The Dentists Act 1957 was successfully passed and through it the Ancillary Dental Workers Regulations 1957 was introduced. A dentist had to be present on the premises when the dental hygienist was working. Dental hygienists working in the community dental service and the armed forces were not subjected to this ruling.15

Expansion of clinical duties

The permitted duties of the dental hygienist remained unchanged until 1974 when carrying out fissure sealants and using fluoride gels was added to their list of clinical competencies.16 In 1991 the Privy Council acting on recommendations made by the GDC amended the Dental Auxiliaries Regulations 1986 to incorporate amongst their other duties:

Dental hygienists once having received formal training would be permitted to undertake the scaling of teeth by administering local infiltration analgesia on a patient as long as there was a registered dentist present on the premises

Statutory Instrument17

One other duty introduced at this time was that the dental hygienist may replace a lost filling with temporary cement if it was removed when they were carrying out treatment. While these additions to the permitted duties were warmly welcomed by dental hygienists18 a BDJ editorial leader entitled ‘The Hygienists Dilemma’ outlined the conflict in a practice that may occur because of the change in law relating to the administration of local anesthetic. In particular around who should meet the costs of the extra syringes and cartridges.19 This conflicted with the editorial leader by Seward20 who supported the expanded duties for dental hygienists that were being discussed at the time, especially permitting them to work without the supervision of a dentist so they may undertake domiciliary care for the disadvantaged - once again in line with the original foundations of the role of the dental hygienist.

A dentist on the premises

The biggest single change to the working practices of dental hygienists came about when the Dental Act 1984 (Dental Auxiliaries) Amendment order 1991 was enabled. This repealed the previous Dental and Dentist Act in outlining that “dental auxiliaries whether or not NHS (meaning directly employed NHS staff) may now work to the direction of a registered

dentist rather than the direct supervision. In essence this removed the restriction that a registered dentist must be on the premises if the dental hygienist is providing treatment. The BDA opposed this move stating that there was a fear that oral health care shops would set up where dental hygienists would treat patients on demand without the referral from a dentist. However although the powerful BDA representative body opposed the move, its rank and file members were supportive of this change defined within the act. A number of letters to the BDJ including one letter from a past president of the BDA stated:

with sadness (he) finds it hard to believe that at the end of the twentieth century the profession dedicated to providing care has turned its back on a most effective way of improving care

Miller Yardley21

He was referring to the fact that dental hygienists can now provide care in homes for the elderly on a regular basis, as this group is often forgotten about. Leatherman22 one of the foresighted dentists to introduce dental hygienists in 1943, argued that while he supported the relaxation of direct supervision it was essential that the training of dental hygienists is changed to fully reflect this change. No indication in the literature is given as to what the likely changes in the curriculum would be. One letter in the BDJ during the consultation period stated:

(he) could not understand why a community dental service dental hygienist could work effectively on their own but a dental hygienist working in general dental practice could not, when they receive the same training

Miller -Yardley21

Fearn23 echoes Miller -Yardley’s view about the ‘red herring’ of community dental service dental hygienists working without supervision, but argues that, ‘patients deserve the most experienced operators and sees no reasons for a change or an expansion in dental hygienist duties or their numbers’.

There is no evidence in the literature to show that dental hygienists started to provide domicilliary care either in individuals’ homes or in centres for the elderly outside of the community dental service. The biggest single change was that many dental practices now had the flexibility to provide dental hygienist services. Although not defined in the literature, anecdotally many dental practitioners did not work a fixed five day week often reducing their working week by a day to compensate for working a Saturday morning. For small practices this left a dental surgery free that a dental hygienist could utilise.

In 1995 the GDC announced that all programmes for dental hygienists from 1st May 1996 would be of two academic years in length, as opposed to the one calendar year that most schools followed.24

Further expansion of clinical duties

If a dental hygienist carried out treatment under local anesthetic then a registered dentist must be on the premises. In 2002 this was changed and a registered dentist was no longer required to be on the premises. This was part of a series of changes introduced by the GDC as part of the recommendations of the Dental Auxiliaries Review Group (1998).25 Additional duties agreed by the GDC were:

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• replacing crowns with temporary cement in an emergency

• removing excess cement using instruments which may include rotary instruments

• taking impressions

• treat patients who are under conscious sedation provided the dentist remains in the room throughout treatment

• administer inferior dental nerve block anesthesia under the direct supervision of a registered dentist (the dentist must be on the premises)

Lewis26

In 2006 two very important regulations were laid before parliament that would have a major impact on the role and responsibilities of dental hygienists and therapists. Hitherto the permitted duties of the dental hygienist and dental therapist, along with all matters related to their registration, including minor changes such as setting the annual retention fee paid to the GDC, was controlled by the Privy Council which in the past has led to lengthy delays in permitted duties changing. The GDC (Professions Complementary to Dentistry) (dental hygienists and dental therapists) regulations Order of the Council 2006 Number 1667 passed responsibility from the Privy Council to the GDC as set out below:

At present, only two types of dental auxiliaries – dental hygienists and dental therapists are regulated by the General Dental Council. They work under the direction of dentists on lists of permitted duties which restrict their discretion in a mechanistic way which may not be necessary for the protection of patients. This is not fully compatible with Government policies to allow the redesign of care around patients’ needs by allocating different roles to staff, and to encourage staff to build up skills so that they can work at a higher level. Under the new system of regulation, dental hygienists and dental therapists will no longer be subject to the restrictions which have previously been applied to them.

Para 7.2 Explanatory Memorandum to the above Act

Running alongside the above Act was the General Dental Council (Professions Complementary to Dentistry) (Business of Dentistry) Rules Order of Council 2006 Number 1670. This set out that:

The class of registered dental care professionals prescribed for the purposes of section 41(1) (b) of the Dentists Act 1984 (restriction of individuals who may carry on the business of dentistry) are those persons registered in the dental care professional register under the titles which apply to the professions pursued by

a. clinical dental technicians

b. dental hygienists

c. dental nurses

d. dental technicians

e. dental therapists and

f. orthodontic therapists

Para 2 Statutory Instrument 2006 1670 Health Care and Associated Professions (2006)27

Ross 28 reports that this was a great step forward but highlights the disappointment of many dental hygienists that a referral following a dental examination from a registered dentist is still required before a patient may be treated. Evans and Blinkhorn29 stated that 64% of dental hygienists did not receive a treatment plan (detailed prescription), this information formed part of a much wider national survey of working of practices in the United Kingdom at the time.

Hay30 states that dental hygienists have embraced this change in the law that now permits dental hygienists and other dental team members not only to own a dental practice but also to employ dentists.

During 2007 the GDC started a major review of the permitted duties of all members of the dental team. Collins31 argues that the GDC are moving away from the term ‘permitted duties’ and are utilising the term ‘scope of practice’ as a way of describing what competencies may be undertaken by individual dental team members.

In April 2009 the GDC published the document ‘Scope of Practice’ which removed the following restrictions related to clinical practice:

• a registered dentist was no longer required to be on the premises if administering inferior dental block analgesia (or carrying out any permitted duties)

• placement of temporary restorations may be undertaken for any lost restoration not just those displaced during treatment also temporary crowns may also be requested if required by a patient

• if trained to carry out inhalation sedation the dentist does not have to stay in the room

In addition, it re-clarified that if a registered dentist refers a patient for treatment then that referral may last up to three years.32 This was a way of providing patients with choice about when they access care provided by dental hygienists. These legislative changes were finally beginning to make direct access for dental hygienists in the UK a reality.

Conclusions

The major theme that emerged from the papers reviewed is that the vast majority of dentists wish to retain the right to be gate keepers of dental care. However, this should be balanced against the view that there are also many dentists who value the role of dental hygienists in delivering periodontal and preventive treatments. The professionalism of dental hygienists is not in question. Secondly, as the number of dentists increase and the patient dentist ratio diminishes, it seems that some dentists are concerned that they are going to lose income if they delegate clinical work to dental hygienists.

I am writing with a petition of signatures from myself and my fellow young dentists of the South Yorkshire deanery. While we recognise the utilisation of dental care professionals, we are concerned that the introduction of direct access would not be in the interest of patients.

Holden33

Holden argues that dental hygienists (and therapists) are simply not trained to the same standard as dentists. Furthermore, he states that dental hygienists carrying out examinations would confuse the public, who do

39No. 4 2015

not understand the role of dental hygienists. There is of course no clear evidence to support this - the term dental hygienist has become widely recognised in the UK.34

It should also be noted that there are no clear drivers for direct access contained within the literature. The evidence is not clear that patients want this choice, although there is strong support for dental hygienists to be able to work as part of public health programmes to improve oral health and wellbeing for school children, especially in disadvantaged areas, and to provide unrestricted care to the elderly. The BDA show some support for this in their Dental Futures booklet ‘Forward to Twenty Twenty.35 The Centre for Workforce Intelligence (CfWI) commissioned by Health Education England stress the benefits of the increased use of all dental care professionals in delivering primary dental care.36

Of course, the above letter from the young dentists in South Yorkshire does outline a problem that has yet to be resolved. While the UK can be proud of its record of dental team working37 dental students still appear to lack training in the true role of dental care professionals and how a collaborative approach to dental practice, utilising all members of the dental team, will have benefits for all patients - including the oral and general health of the population, as set out by Fones over 100 years ago.

References

1. Dental Protection Limited. Team Wise 2013; 14: 4-7.

2. American Dental Hygienist Association. Direct Access States’ Position Paper 2011.

3. Sim J, Wright C. Research in Health Care: Concepts, Designs and Methods. Cheltenham: Stanley Thorne Publishers. (2000)

4. Jaecks KMS. Current perceptions of the role of dental hygienists in interdisciplinary collaboration. J Dent Hygiene 2009; 83(2): 84-91.

5. Hellyer PH. The older dental patient - who cares. Brit Den J. 2011;211:109–11.

6. Evans C, Chestnutt IG, Chadwick BL. The potential for delegation of clinical care in general dental practice. Brit Dent J. 2007: 203(12):695–9.

7. Hulme F. Fifty Years of The Royal Air Force Dental Branch. Ministry of Defence (Air) 1981: 38

8. The Nuffield Foundation. Education and Training of Personnel Auxiliary to Dentistry. The Nuffield Foundation. (1993)

9. Henry BC. Dental Hygienists. Br Med J .1944; 1(4351):733.

10. Thomas GL. Focus on Hygienists. Brit Dent J. 1983;155:28-9.

11. Hansard Volume 475 Education (School Dental Service Debate) (113) 1950: 106.

12. Hansard Volume 499 Parliamentary Address 1952: 161.

13. Gelbier S. 125 years of developments in dentistry 1880 – 2005. Part 5: Dental education, training and qualifications. Brit Dent J. 2005;199:685–89.

14. Rowbotham JS, Godson JH, Williams SA et al. Dental Therapy in the United Kingdom: Part One. Developments in therapists training and role. Brit Dent J. 2009;207(8):355– 9.

15. Young B, Lloyd S. Dental Health is Thirty. Dental Health 1992; 31(4):10.

16. Khan R. The History of the British Dental Association. UK: British Dental Hygienist Association..(1999)

17. Statutory Instrument. Amendment to the Dental Auxiliaries Regulations 1986. London: Her Majesties Stationary Office: 1991;1795:1.

18. Gibbons DE, Corrigan M, Newton JT. A national survey of dental hygienists: working patterns and job satisfaction. Brit Dent J 2001;190(4):207-10.

19. Grace M. The Hygienists’ Dilemma. Brit Dent J. 1992;173:187.

20. Seward, M. General Dental Council Decides Future Role of Dental Hygienists. Brit Dent J. 1990;169(1):1.

21. Miller-Yardley R. The Great Debate. Brit Dent J. 1989;166:150.

22. Leatherman GH. The Great Debate. Brit Dent J. 1989;166:196.

23. Fearn A. The Great Debate. Brit Dent J. 1989;166 :318.

24. Clitter C. Update on the training of dental hygienists. Dental Health 1995;44(1):18.

25. General Dental Council. Report of Dental Auxiliaries Review Group (DARG). (1998)

26. Lewis H. General Dental Council Update. Dental Health 2002;41(6):12.

27. Statutory Instrument 1670 General Dental Council (Professions Complementary to Dentistry) (Business of Dentistry). London: Her Majesties Stationary Office : 2006.

28. Ross M. From the President. Dental Health 2006;45(6):22-3.

29. Evans CL, Blinkhorn AS. A national survey of dental hygienists. Brit Dent J. 1982;153(8):309-10.

30. Hay R. Partners in Progress. Dental Health 2008;47(6):24-6.

31. Collins J. Dental Care Professionals Who Can do What. Vital 2008;Summer:46- 8.

32. General Dental Council: Scope of Practice 2009.

33. Holden ACL. No To Direct Access. Brit Dent J. 2012;212: 355.

34. Office of Fair Trading. The Private Dentistry Market in the United Kingdom (2003).

35. British Dental Association. Dental Futures Forward to Twenty Twenty (2007).

36. Centre for Workforce Intelligence. Strategic Review of the Future Dental Workforce 2013:14 -15.

37. Wheeler MG. Developing the dental team. Brit Dent J. 2010;209:26

DIRECT ACCESS


Bramcote Dental Practice, Castle Carey. Training and development lead, Health Education Kent, Surrey and Sussex Older Persons Initiative. Dental tutor Health education South West.



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Objectives: To assess the extent that Irish dental hygienists (DHs) use their skills. To assess the confidence levels, barriers and access to CPD related to these skills. To assess what skills Irish DHs would like added to their scope of practice and what their likely work practice would be should they be given the option to practice independently.

Method: An online survey was designed, piloted and amended based on feedback and ultimately sent to all dental hygienists whose names were on the database of the Irish Dental Hygienist Association in 2013 and 2014.

Results: The response rate was 52%. 37% use infiltration LA several times a day, 19% never/hardly ever use this skill. 13% use Block LA several times a day and 40% never/hardly ever use this skill. 62% never/hardly ever take dental radiographs, 73% never/hardly ever place temporary dressings, and 82% never/hardly ever recement crowns temporarily. 81% were confident or very confident using infiltration LA, while 45% were confident or very confident using block LA. 68% said they had no difficulties or barriers in relation to carrying out their skills. 51% said they had no difficulties accessing courses.

There was a wide range of skills dental hygienists would like to see added to their scope of practice which were in line with skills carried out by dental hygienists in other countries. When asked “If Direct Access was to be introduced how do you see your work practice changing?” 48% responded that they would work in a practice with a dentist with both referrals and Direct Access. 16.5% were not sure.

Conclusion: Dental hygienists in Ireland do not use their full range of skills on a regular basis. They are keen to expand their scope of practice in line with other countries.

CURRENT AND FUTURE WORK PRACTICES OF IRISH DENTAL HYGIENISTS

Authors: Catherine Waldron, Bairbre Pigott-Glynn

Dublin Dental University Hospital, Trinity College, Dublin.Email: [email protected]

Objectives: Based on a book chapter in the Best Ideas 2013*: ‘A clean mouth, a pure soil: the mouth says it all’, this study examined to what extent oral self-care was predicted differently for males and females by fear of social rejection as a result of one’s poor oral health, including having ugly teeth and a bad breath.

Method: In a representative sample of the Dutch population, 18 years and older, an online questionnaire was completed by 1677 respondents. Besides a few demographics, questions about aversion to physical partner characteristics (including ugly teeth and a bad breath), and the intention to perform described oral self-care**, as well as a 4-item scale (a=0.65) fear of social rejection were included.

Results: Fear of social rejection and aversion of ugly teeth and bad breath in a partner predicted the willingness to engage in oral hygiene behaviour. In all respects, males took less care of their own teeth than females did, and females indicated more likely than males to reject a potential partner on the basis of his or her bad breath.

Conclusion: These findings are illustrative; provide more insight in the way males and females experience social aspects of oral health. In addition, the findings suggest that one way to motivate males to perform better oral self-care is by emphasizing the negative effects a poor oral health may have on the impression they make on females. There is a need for further experimental research to refine oral health promotion for males and females in the desired direction.

* Buunk, A.P. & Buunk-Werkhoven, Y.A.B. ‘Een zuivere mond, een zuivere grond: de mond spreekt boekdelen.’ [A clean mouth, a pure soil: the mouth says it all]. In: Jos Baijens, (Ed.), Het beste idee van 2013 (The best ideas of 2013), Uitgeverij De Wereld, 2013, p. 184.

** Buunk-Werkhoven, Y.A.B. & Dijkstra, A. Gender Variations in Determinants of Oral Hygiene Behavior: A Secondary Analysis based on the Theory of Planned Behavior. In: Vincent L. Rush, (ED.), Planned Behavior: Theory, Applications and Perspectives, Nova Science Publisher, Inc. 2014, p 37-54.

GENDER DIFFERENCES IN FEAR OF SOCIAL REJECTION AND ORAL SELF-CARE

Authors: Yvonne A.B. Buunk-Werkhoven1, Abraham P. Buunk2,3

1 SPOH ARTS – International Oral Health Psychology – Amsterdam, The Netherlands. 2 Royal Netherlands Academy of Arts and Sciences – Evolutionary Social Psychology – Amsterdam, The Netherlands. 3 Faculty of Social and Behavioral Sciences, University of Curaçao – Dr. Moises Da Costa Gomez – CuraçaoEmail: [email protected]

BSDHT Oral Health Conference & Exhibition 21st & 22nd November 2014, LiverpoolABSTRACTS SUBMITTED FOR POSTER DEMONSTRATION

41No. 4 2015

ABSTRACTS SUBMITTED FOR POSTER DEMONSTRATION

ABSTRACTS

Objectives: To explore the experiences of final year BSc (Hons) Oral Health Sciences students in a new programme and to determine if dental outreach teaching is good preparation for practice.

Method: Semi-structured interviews were undertaken at the end of semesters one and two. Both rating scale and open-ended questions were used and the data was manually analysed using open coding, three main themes emerged from the data.

Results: The themes that emerged from the data were: development of personal skills, outreach arrangements and preparation for practice. The positive aspects related to the students’ experiences with patient groups, team working and outreach placements mimicking ‘real life’ working environment. For some, the fourth year of the programme felt similar to that of vocational training year. The development of key skills such as communication, independence, confidence and time management were evident from the data. With any pilot scheme feedback reflection is required and suggested improvements included factors relating to surgery space, instruments choice, nursing support, repetitive observational sessions and lack of patient referrals in some centres.

Conclusion: Students highly rated the outreach teaching environment in which they gained useful experiences and developed skills which have prepared them for practice.

Authors: Joanne MacLeod

Lecturer in Oral Health Sciences, School of Clinical Sciences, University of EdinburghEmail: [email protected]

DENTAL OUTREACH TEACHING: GOOD PREPARATION FOR PRACTICE? A STUDY INTO THE EXPERIENCES OF FINAL YEAR STUDENTS IN A NEW PROGRAMME: BSC (HONS) ORAL HEALTH SCIENCES

Objectives: Most common oral diseases can be prevented by simple and inexpensive methods: daily oral self-care. Even when preventive interventions implemented at schools, workplaces and by the dentist / oral hygienist are provided, people don’t perform this behaviour adequately. This pilot study aimed to evaluate a relatively new implementation of monitored oral hygiene activities in the HORECA (Hotel, Restaurant en Catering).

Method: In a period of 5 days a pilot study was conducted in 3 restaurants in Amsterdam. Single wrapped and / or table packs of toothpicks were presented passively or actively to the customers. The passive approach involved existing cocktail picks being exchanged for single wrapped toothpicks and provided in the bathroom, entrance and table. At the cash desk, toothpicks were provided by customers asking the waiter directly or by helping themselves. The active approach involved including toothpicks when the customer received the bill. At the end of every day, or period, depending of the sort of approach, the number of toothpicks taken by the customers was counted.

Results: In the first restaurant (toothpicks were offered by active and passive approach over several days) in one day 203 single wrapped toothpicks were taken actively. The next day 92 toothpicks were taken actively from the table pack. From a passive approach, 160 toothpicks were taken. In the second and third restaurant (toothpicks were only offered by a passive approach), in 5 days 370 toothpicks and in 4 days 150 toothpicks were taken, respectively.

Conclusion: It seems that people are more engaging in ‘Pick a T’ – behaviour if the toothpicks are readily available. HORECA is a welcome additional location to provide toothpicks in order to promote oral self care among the public.

PICK A T - A PILOT PUBLIC CAMPAIGN TO PROMOTE THE USE OF TOOTH PICKS IN RESTAURANTS AND BARS

Authors: Nora Löb,1 and Yvonne A.B. Buunk-Werkhoven2

1All About Behaviour, Amsterdam, The Netherlands. 2SPOH ARTS – International Oral Health Psychology – Amsterdam, The NetherlandsEmail: [email protected]


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BSDHT Oral Health Conference & Exhibition 21st & 22nd November 2014, Liverpool

Objectives: To present a new approach in the management of patient denture hygiene within a secondary care setting and build upon work which has been conducted within a primary care setting. Describe an audit conducted at the Birmingham Dental Hospital to evaluate patient denture hygiene and quality of record keeping, as well as introduce a method for quantifying denture cleanliness.

Methods: The Denture Cleanliness Index (DCI) was utilised to assess quality of denture hygiene (best score 0, worst score 4). Baseline DCI scores and a retrospective analysis of the quality of record keeping with respect to denture hygiene instruction was undertaken (n=60). Preventative strategies were introduced, and patients reviewed after 1-month.

Results: Improvements in denture hygiene were noted between baseline and review, 11.7% (n=7) had DCI ≤2 at baseline compared with 93.8% (n=45) at 1-month review. A vast improvement in quality of record keeping was noted, with 63% (n=38) of patients having evidence of DHI being recorded within their notes at baseline, improving to 100% at recall.

Discussions: New clinical guidelines for denture hygiene instructions have been devised and introduced to the Prosthetics Department, as well as a new patient information leaflet. The DCI scoring system worked well as a method for clinically evaluating patient compliance, and aided patient education with denture hygiene instruction delivery.

The authors recommend, in order to help patients maintain optimum oral health, oral hygiene and denture hygiene instructions should be delivered concomitantly.

DENTURE HYGIENE: EVALUATING QUALITY AND MANAGEMENT AT THE BIRMINGHAM DENTAL HOSPITAL

Authors: Mylonas P1, Attrill DC1 and Walmsley AD1

1Prosthodontics Department, Birmingham Dental School

Email: [email protected]

Aim: To improve adherence with guidance on caries prevention as given in Delivering Better Oral Health (DBOH) by dental hygiene and therapy students. In order to achieve this aim the objectives were:

• to derive criteria and standards from from Delivering Better Oral Health;

• to measure current activity in meeting standards for these criteria;

• to give feedback, make recommendations and re-audit

Method: Case note review of 52 consecutive patient notes from student clinics was undertaken. Inclusion criteria were patients with a current treatment plan including restoration of teeth and an assessment since January 2013. A second review was carried out 1 year later for 39 patients.

Results: The audit revealed low levels of adherence in both preventive advice and prescription of preventive therapies for all adults. Following implementation of recommendations the re-audit demonstrated improvements in the giving and recording of preventive advice. For high risk patients increases in the prescription of high fluoride toothpaste and advice on fluoride mouthwash and diet were seen. Fewer patients received prescriptions of fluoride mouthwash and application of fluoride varnish.

Conclusion: Increased levels of adherence to DBOH guidelines resulted from recommendations from the initial audit, however the adherence continued to fall short of expectations. Further recommendations are made towards making improvements in the future.

IMPLEMENTATION OF DELIVERING BETTER ORAL HEALTH FOR THE PREVENTION OF CARIES IN ADULTS: AUDIT OF DENTAL HYGIENE AND THERAPY CLINICS

Author: E Fisher, J Weeks

Dental Hygiene and Dental Therapy Programme, School of Clinical Dentistry, Claremont Crescent, Sheffield S10 2TAEmail: [email protected] [email protected]

43No. 3 December 2013


ABSTRACTS

Objectives: To investigate whether students at the University of Portsmouth who are waterpipe smokers, are aware that there are health risks associated with waterpipe smoking.

Method: A literature review was performed to compile information relating to waterpipe smoking. Primary research was obtained through an anonymous electronic questionnaire sent to a limited 200 students at the University of Portsmouth.

Results: 51 out of 107 responses consider themselves to be waterpipe smokers, with 86% of the 51 smoking the waterpipe for enjoyment and relaxation and 100% stating they prefer to smoke the waterpipe in a social environment. 12% of waterpipe smokers do not associate any health risks at all with waterpipe smoking and 47% consider it safer than smoking cigarettes.

Common misconceptions are considered to be true by some participants, these include; second hand smoke from a waterpipe is relatively safe and does not pose a health risk, after the smoke has been filtered through water it contains low levels of toxic compounds and certain devices/accessories can make waterpipe smoking safer.

Conclusion: This study raises a concern regarding the level of misconceptions attached to waterpipe smoking due to little awareness of its actual health effects. The research is limited as it only provides a glimpse of attitudes towards waterpipe smoking at the University of Portsmouth and cannot be generalised for the entire student population.

However, increased knowledge and resources will enable health care professionals to deliver smoking cessation specifically related to waterpipe smoking, for patients who require or request it.

ARE WATERPIPE SMOKERS AWARE THAT THERE ARE HEALTH RISKS ASSOCIATED WITH WATERPIPE SMOKING?

Author: Miriam Khan

Student Dental Public Health, The University of Manchester


Introduction: There is tentative evidence that psychological approaches to behaviour management can improve oral hygiene related behaviours. Psychologists have identified oral hygiene behaviour as an interesting target for behaviour change given its near universality and the central role of behaviour in maintaining oral health. There are several possible targets for interventions, distinguishing between situations where individuals lack the motivation to change their oral hygiene behaviour (lack of motivation), and those who are motivated but require support in planning and maintaining behaviour change (lack of volition).

Improvement in a patient’s oral hygiene is often accomplished through the cooperative interaction between the patient and the dental professional ( patient centre approach). Also individual self-care is important in attaining proper oral hygiene and methods that encourage adherence to recommendations given by dental hygienist or dentist are needed.

Method: An individually tailored oral health psychological programme (ITOHPP) based on cognitive behavioural intervention on oral health in adults was trialled on 25 experimental group patients and comparisons were made with 25 control group patients using a Standard Oral Health Programme (SOHP).

Results: An ITOHPP approach significantly change the patient’s behaviour to adherence and compliance in maintaining good oral hygiene, resulting in reduced plaque scores and gingival bleeding for patients in the experimental group.

Discussion: It is important, therefore, for the dental healthcare professional to ascertain the patient’s view of their condition and to correct any misconceptions which may be hampering their motivation. Verbal persuasion is an important component for tailoring a programme to a particular patient and encouraging successful changes.

Conclusions: This study showed evidence that psychological approaches to behaviour management can improve oral hygiene related behaviours. The limitation of the study was the short duration of the trial: the effect of the behavioural change was only assessed during a period of 3-4 months. Ideally, a period of 12 months is required to further investigate the effectiveness of an ITOHPP approach in improving long term oral hygiene behaviours.

PSYCHOLOGICAL INTERVENTIONS TO IMPROVE ADHERENCE TO ORAL HYGIENE INSTRUCTIONS IN ADULTS

Authors: Taraneh Taheri

Dental Hygienist, Devonshire Place Dental Practice





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Aim: To demonstrate how BSc Dental Therapy and Hygiene students will integrate with dental students and become more rounded clinicians because of the opportunities to engage with their local communities as part of their interprofessional engagement projects.

Method: Amongst many other community based projects, the Community Engagement Team deliver the Interprofessional Engagement Modules as part of the BDS curriculum. Currently in year 1 and 2 of the BDS programme, students in small study groups undertake supervised community engagement projects within 4 different sectors; Early Years; Older People; Statutory Provision; Community and Voluntary Sector.

Discussion: Using the tried and tested format from the BDS programme, skills will be transferred from the BDS curriculum to the BSc programme. The BSc students will be integrated with the dental students in the early years of their course including the joint Interprofessional Engagement Modules. Positive feedback has been obtained from host organisations involved in the Interprofessional Engagement Projects with BDS students. A partnership is formed and maintained between undergraduates, PDS and host organisations, who have expressed that they are proud to play a role in the development of the clinicians of the future. The ethos of the module, along with the learning outcomes, is to leave a legacy to continue to improve the oral health of the region. Although we are unable to quantify the role community engagement plays in student satisfaction, PDS has climbed from 7th to 2nd out of 15 in the UK Dental School National Student Survey 2014. The Community Engagement Team and their projects have been highly valued through an Impact Evaluation.

These are mapped to the General Dental Council’s Preparing for practice Dental team learning outcome for registration document: 59 out of 144 for BDS; 45 out of 117 for BSc.

Conclusion: These modules provide students with important insight through civic engagement, and in doing so brings a sense of realism to important oral health challenges and the wider responsibilities of being a dental professional which cannot easily be taught in the classroom. This provides unparalleled contextual learning and experience.

ENGAGEMENT FOR BETTER ORAL HEALTH; DEVELOPING CLINICIANS OF THE FUTURE

Author: Sarah Hill1, Ruth Potterton2

1Lecturer in Community Based Dentistry. 2Lecturer in Community Based Dentistry. Plymouth University Peninsula Schools of Medicine & Dentistry

Email: [email protected] [email protected]

Aim: To propose a clear accessible set of internal periodontal management policies, one of which offers guidance on Non-Surgical Periodontal Therapy (NSPT) that highlights the optimal interval period between appointments.

Method: A two fold approach: a literature search to establish the rational/the optimal interval period, compared to a retrospective clinical evaluation; a comparison between current practice within an educational institution training dental hygiene and therapy students to evidence drawn from the literature review.

Results: Interval periods and treatment divisions for non- surgical periodontal therapy are diverse within educational settings and are not optimal.

Conclusion: There are obstructing obstacles distinctive to dental hygiene and therapy students working environments in comparison to general dental practice, and for avoidance require additional planning and better communications with patient administration.

DO OPTIMAL INTERVAL PERIODS FOR NON-SURGICAL PERIODONTAL THERAPY EXIST? A RETROSPECTIVE CLINICAL EVALUATION

Author: Danny Hoskins

University of Portsmouth Dental Academy



ABSTRACTS


Objectives: Comparing the oral health of a population over a substantial period and understanding how socio-economic changes influenced oral health will assist in the future planning of dental treatment. This study will compare the rate of oral pathologies including caries, enamel hypoplasia, calculus and periodontitis, found within the medieval and post-medieval populations of London, using archaeological data provided by the Centre of Human Bioarchaeology at the Museum of London.

Method: The percentage rates of each condition were collected from 7 medieval and 8 post-medieval cemetery sites. An overall average percentage for each condition, for both medieval and post-medieval London, was calculated. The differences between the two averages, for each condition, were compared using Student’s T-test (p<0.025).

Results: Results indicated a significantly higher caries rate in the post-medieval skeleton sample (69.03%) than found in the medieval sample (50.35%) (p=0.025). Although medieval hypoplasia, calculus and periodontitis rates were not significantly different when compared to the post-medieval percentages, rates for these conditions remained high throughout both periods.

Conclusions: The high rates of these pathologies are thought to be a result of inadequate oral hygiene and dental knowledge, due to financial restrictions and the exclusivity of education for high-status individuals. Social factors such as overcrowding and pollution led to increased levels of disease and a lack of effective healthcare meant the rates of oral conditions remained high. Increased availability of cariogenic foods during post-medieval London subsequently led to an increase in caries. These results illustrate the impact of socio-economic conditions on oral health and allows for future healthcare issues, resulting from socio-economic change, to be pre-empted, potentially preventing any detrimental effects to the oral health of current and future populations.

STUDENT SUBMISSIONMEDIEVAL MOUTHS – A COMPARISON OF ORAL HEALTH IN MEDIEVAL AND POST-MEDIEVAL SKELETONS IN LONDON

Authors: Cara A Green

Dental Hygiene & Therapy Student at King’s College Hospital, London



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Objectives: To establish whether there is a causal relationship between breastfeeding and early childhood caries (ECC).

Method: A questionnaire with 10 questions regarding breastfeeding habits, diet and oral hygiene was given to the parents of children aged between the ages of 2-5. The study involved a sample size of 41children.

Results: The results suggest that there is no causal link between breastfeeding and early childhood caries as 4% of the children in this study, of whom all had been breastfed, were not reported to have any decay in their primary dentition. Twenty four percent of the children had been exclusively breastfed for the first 6 months of life and of those children only one was reported to have decay. The results suggest that oral hygiene has a greater role in the ECC story as 95% of the children were reported to have had their teeth brushed ‘when the first tooth appeared’ despite 48% of parents reporting that they introduced sugar to the child’s diet before the age of 1 year and 46% of the children not having seen a dentist by the time they were 2 years old.

Conclusions: Breast milk is widely renowned for being the ultimate nutrition for infants. Consequently, and in the absence of evidence that proves otherwise, it is paramount that the mother is not discouraged from breastfeeding but is given support and guidance on how to best care for the child’s teeth during the breastfeeding years.

STUDENT SUBMISSIONNATURE’S ELIXIR OR JUST ANOTHER SUBSTRATE? INVESTIGATING THE ROLE OF BREAST MILK IN EARLY CHILDHOOD CARIES

Authors: Ruvimbo D Chamunorwa

King’s College Hospital, London



ABSTRACTS


Objectives: Ludwig’s angina is a rare but potentially life-threatening infection that can have a catastrophic outcome if it is not diagnosed immediately. The rapidly spreading soft tissue infection affects the submandibular and the sublingual spaces, first described by Wilhelm Fredrick Von Ludwig in 1836. This condition is notorious for its aggressive nature, rapid development to airway compromise and a high mortality when not treated quickly. In the pre- antibiotic era Ludwig’s angina was frequently fatal, however modern dental care, antibiotics and surgical treatment have significantly lowered mortality and the infection is now rare. The objective is to review and analyse existing literature in regards to the manifestation, clinical characteristics, and application for diagnosis and treatment modalities of Ludwig’s angina, followed by a recent case presentation of Ludwig’s angina.

Method: This is a retrospective study which will review and analyse existing literature.

Results: Due to the rapid evolution of this disease if not correctly identified it will lead to death. Odontogenic infection is the most common aetiological factor of Ludwig’s angina: approximately 80% of patients will present, or offer a history of, recent dental treatment or dental pain. What begins as a mild infection soon develops into a bilateral induration of the upper part of the neck.

Conclusions: It is important to identify a correct and early diagnosis based on clinical presentation and a thorough patient assessment. Airway compromise and the spread of infection is the most problematic complication, so maintenance of a secure airway is vital, along with drug mediation and primary surgical intervention, to provide superior control of the infection.

STUDENT SUBMISSIONTHE STRANGULATING EFFECTS OF LUDWIG’S ANGINA

Authors: Rahana Begum, Dr Hughes

King’s College Hospital, London



SELECT ONE CORRECT ANSWER IN EACH QUESTION:

EACH PAPER IS WORTH 30 MINUTES VERIFIABLE CPD

TO TAKE YOUR CPD LOG ONTO THE WEBSITE WWW.BSDHT.ORG.UK

1. What proportion of the population wore removable dentures according to the Adult Dental Health Survey 2009?

A. 17% B. 18% C. 19% D. 20%

2. What is the most common method of denture plaque control used by patients?

A. Soap, water, and denture brush B. Acid-based solutions C. Peroxide/effervescent tablets D. Hypochlorite based solutions

3. Denture plaque is most likely to accumulate on which surface of the denture?

A. Fitting B. Occlusal C. Polished D. None of the above

4. Which chemical denture cleaning solution is most commonly used by patients?

A. Alkali Hypochlorite B. Alkali Peroxide C. Enzyme-based D. None of the above

5. What main factor will determine how abrasive a brush will be on an acrylic denture?

A. Bristle length B. Bristle stiffness C. Bristle angulation D. None of the above

6. Ultrasonic cleaning devices loosen and remove debris by a process known as...?

A. Diffusion B. Implosion C. Vibration D. Cavitation

CPD QUESTIONS FOR PAPER 1: DENTURE HYGIENE: A GUIDE TO THE DELIVERY OF BETTER DENTURE HYGIENE TO OUR PATIENTS PP6-10

Self Assessment for CPD

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CPD


1. Which of the following best describes the principal of ‘doctor knows best’?

A. Maternalism B. Officialism C. Paternalism D. Egoism

2. Patients’ rights are protected by law. The duty to obtain the patient’s consent prior to the commencement of treatment is held under which of the following?

A. The tort of negligence B. The tort of battery C. The tort of trespass D. The tort of consent

3. Which of the following is true? Consent should be obtained...?

A. At the start of the treatment B. At the patient’s first visit to your practice C. As an ongoing dialogue D. By the reception staff

4. Consider the following: A patient of sound mind makes a decision that you as the clinician believe to be unreasonable, and not in that patient’s best interests. Which of the following statements is true?

A. The dental professional has the right to override the patient’s decision B. It is the patient’s right to make that decision C. The dental professional should change the patient’s mind regarding their decision D. The dental professional should refuse to treat the patient

5. Which of the following is recommended by The Department of Health in their guidance ‘Seeking Consent: Working with Children’?

A. Not involving children in the decision making process B. Only discussing treatment options with the parent of the child C. Involving children in the decision making process D. Letting the child give consent to treatment

6. Based on the guidance from the GDC in its Standards document, dental hygienists, irrespective of whether or not they are working under direct access must...?

A. Make sure that the prescribing dentist has obtained consent B. Rely on the prescribing dentist to obtain consent C. Assume that consent has been obtained D. Obtain informed consent themselves

1. What are the main systemic diseases associated with periodontal disease?

A. Diabetes mellitus and cardiovascular disease B. Diabetes mellitus and hypertension C. Diabetes mellitus and bacterial vaginosis D. Cardiovascular disease and hypertension

2. What is defined as pre-term birth?

A. Before 32 completed weeks of gestation B. Before 37 completed weeks of gestation C. After 37 completed weeks of gestation D. Following 40 weeks of gestation

3. It is estimated that there are 15 million worldwide preterm births every year, with around 1 million babies dying and many left with disabilities. There is now a growing body of evidence that suggests a link between periodontal disease and adverse pregnancy outcomes (APO’s). What two proposed pathways have been implicated in its onset?

A. The biological plausibility pathways B. Inflammatory response and inflammatory mediator pathways C. Foetal and placental interface pathways D. Direct and indirect pathways

4. Certain pro-inflammatory cytokines are involved in the initiation and progression of periodontal disease, but what is their role during pregnancy?

A. They initiate the cervical ripening process and stimulate MMP production B. Induction of labour, pre-eclampsia and miscarriage C. Regulation of immunity D. Destruction of alveolar bone

5. Why do general obstetric guidelines recommend that dental procedures are avoided during the first trimester?

A. In order to avoid potential stress to the foetus B. In order to avoid possible stress to the patient C. In order to avoid a systemic inflammatory response D. In order to prevent inflammatory mediators entering the circulation and reaching the foetal-placental interface

6. Of what possible oral health changes should we advise our patients?

A. Increased vascularity and the possibility of a higher incidence of bleeding and gingival enlargement B. Increased periodontal pocket depths C. Focal infection as this is an aetiological factor of miscarriage D. Clinical attachment loss and gingival bleeding

CPD QUESTIONS FOR PAPER 3: CONSENT, THE LAW AND PROFESSIONAL REGULATION PP14-18

CPD QUESTIONS FOR PAPER 2: A LITERATURE REVIEW ON THE ASSOCIATED LINK BETWEEN PERIODONTAL DISEASE AND ADVERSE PREGNANCY OUTCOMES AND ITS IMPACT ON DENTAL TREATMENT FOR THE PREGNANT PATIENT PP11-13


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1. How is Chlorhexidine Gluconate usually administered in dentistry?

A. Tablets B. Spray C. Capsules D. Mouthwash

2. Chlorhexidine is retained in the oral surfaces by reversible electrostatic binding. To what does it bind?

A. Glycoprotein B. Glycolipid C. Polypeptide D. Monosaccharide

3. What is thought to be the turnover rate for gingival crevicular fluid?

A. 40 times per hour B. 40 times per day C. 100 times per hour D. 100 times per day

4. How many milligrams of Chlorhexidine does Periochip contain?

A. 2.5mg B. 5.2mg C. 6.5mg D. 25mg

5. Which single parameter did the researcher focus on when comparing the papers selected?

A. Pocket probing depth B. Free gingival margin C. The presence of delayed bleeding D. Furcation involvement

6. What pictorial method of displaying the results found did the author consider misleading?

A. Pictures B. Graphs C. Tables D. Photographs

1. How many questions were there in the questionnaire?

A. 2 B. 5 C. 7 D. 10

2. How many babies are born with some degree of clefting?

A. One in three hundred B. One in five hundred C. One in seven hundred D. One in one thousand

3. What percentage of the delegates who completed the questionnaire had not received training on cleft lip and palate as an undergraduate?

A. 24% B. 34% C. 44% D. 54%

4. How many of the respondents to the questionnaire thought they knew where to refer a patient or where to receive information on cleft lip and palate?

A. 13% B. 23% C. 33% D. 43%

5. The majority of undergraduate training received on cleft lip and palate was in the form of what?

A. Clinical experience B. Reading material C. Lecture D. Lecture and clinical

6. As a result of the CSAG recommendations in 1998 designated Cleft Centres were not established until?

A. 1999 B. 2001 C. 2003 D. 2006

CPD QUESTIONS FOR PAPER 4: THE EFFICACY OF USING SUSTAINED RELEASE CHLORHEXIDINE CHIP (SRCC) AS AN ADJUNCT TO THE TREATMENT OF PERIODONTAL DISEASE PP19-23

CPD QUESTIONS FOR PAPER 5: IS THERE A NEED FOR TRAINING IN CURRENT CLEFT LIP AND PALATE CARE? PP24-27



1. Which of the following gases is present in relatively high levels within smoke from a waterpipe?

A. Carbon dioxide B. Carbon monoxide C. Nitrous oxide D. Methane

2. How many times larger is the volume of smoke inhaled during an hour of waterpipe smoking compared to smoking a single cigarette

A. 5-10 times B. 10-50 times C. 50-100 times D. 100-200 times

3. What percentage of the study population did not think that there was any health risk associated with waterpipe smoking?

A. 6% B. 9% C. 12% D. 15%

4. Approximately what proportion of the study population thought that waterpipe smoking was safer than smoking a cigarette?

A. Quarter B. Third C. Half D. Two thirds

5. What was the main reason that individuals smoked the waterpipe?

A. Enjoyment / relaxation B. Peer pressure C. Addiction D. To be social

6. Which of the following was NOT a recommendation of the authors?

A. Provide leaflets to be included in smoking cessation packs B. Place health warnings on waterpipes C. Make waterpipe smoking illegal D. Introduce waterpipe cessation programmes at university

1. In which year were fissure sealants and the use of fluoride gel added to the dental hygienist’s list of clinical duties?

A. 1974 B. 1978 C. 1986 D. 1991

2. In April 2009 the GDC published the document ‘Scope of Practice’ which re-clarified that...?

A. A registered dentist must be on the premises when a hygienist is carrying out any permitted duties B. If trained to carry out inhalation sedation the dentist must stay in the room C. If a registered dentist refers a patient for treatment then that referral may last for three years D. Placement of temporary dressings may be undertaken for any restoration lost during treatment

3. Which organisation sought to seek a change in legislation through the GDC in 2003?

A. The BDA B. The BSDHT C. The OFT D. The BDHF

4. How many of the papers included in the review originated in the UK?

A. 6 B. 26 C. 42 D. 48

5. What was the major theme that emerged from the papers reviewed?

A. The vast majority of dentists wish to retain the right to be gate keepers of dental care B. Young dentists of the South Yorkshire Deanery were unconcerned about the introduction of Direct Access C. There is no concern amongst dentists regarding possible loss of income D. The professionalism of dental hygienists is in question

6. How many papers included in the literature review highlighted the possibility of clinical problems as a result of dental hygienists providing treatment without a referral from a dentist?

A. None B. Two C. Five D. Six

CPD QUESTIONS FOR PAPER 6: ARE WATERPIPE SMOKERS AWARE THAT THERE ARE HEALTH RISKS ASSOCIATED WITH WATERPIPE SMOKING? PP28-34

CPD QUESTIONS FOR PAPER 7: UK DENTAL HYGIENISTS – THE ROAD TO DIRECT ACCESS: THE RESULTS OF A LITERATURE REVIEW PP35-39

CPD

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