Standards for Clinical Dental Hygiene Practice

Biofilm Control at the Gingival Frontier: 3-Step Oral Hygiene

Oral health is fundamental to overall health and well-being.1 However, despite the availability of readily accessible preventive mea-sures, oral disease remains a signif-icant global economic, psychologi-cal and social burden.2 Estimated to affect 3.9 billion people worldwide, untreated oral disease represents considerable discomfort, disability and expenditure, ranking as the fourth most expensive disease to treat in industrialized countries.2,3

Chronic gingivitis, to some degree, affects over 90 percent of the population.4 Left untreated, it can progress to more serious conditions, such as periodontitis. The National Health and Nutrition Examination Survey reports that from 2009 to 2012, 46 percent of American adults over 30 years of age have periodontitis, representa-tive of 64.7 million people.5 Further, severe periodontitis affects 8.9 percent of the adult population over 30 years of age,5 a major cause of tooth loss and the sixth most preva-lent condition in the Global Burden of Disease Study (GBD) 2010.3

As oral biofilm is a leading cause of gingivitis, biofilm control is fundamental to maintaining oral health.6 However, the high inci-dence of oral disease worldwide would suggest that mechanical methods alone—and their inher-ent challenges of compliance and technique dependency—are insuf-ficient for achieving and maintain-ing oral health.6 These challenges are why dental hygienists play

such a key role in encouraging their patients to maintain a consis-tent and effective brush, floss and mouthrinse regimen.

Although brushing and other mechanical methods of interdental cleaning remove plaque from the tooth surface, the tooth surface represents only 25 percent of the oral surface exposed to bacteria.7 Other areas of the mouth can act as reservoirs for bacteria that can then re-colonize on teeth following dental prophylaxis or treatment.8 The adjunctive use of an anti-mi-crobial, effective mouthrinse has the potential to benefit the oral health of the public. It is a requirement of the Standards under Definition of

Dental Hygiene Practice for dental hygienists to provide patient educa-tion on biofilm plaque control and home care protocol by incorporating techniques and products that will become part of an individualized self-care oral hygiene program.

Numerous systematic reviews and meta-analyses have reported that mouthrinses can provide a ben-efit beyond mechanical oral hygiene alone in preventing plaque accumu-lation.6,8-10 Systematic reviews and meta-analyses are vital components

to making evidence-based treat-ment recommendations in medicine and dentistry.

A recent landmark meta-analysis led by Marcelo W.B. Araujo, DDS, MS, PhD, published in The Journal of the American Dental Association

The American Dental Hygienists’ Association’s Standards for Clinical Dental Hygiene Practice emphasize the necessity for dental hygienists to use cutting-edge scientific evidence in the implementation of a preventive oral hygiene regimen for our patients, such as a brush, floss and mouthrinse routine. The Standards require that dental hygienists recommend only those products that are supported by clinical trials and scientific evidence. Dental hygienists should recommend a complete brush, floss and mouthrinse regimen for all patients’ self-care routine based on the dental hygiene process of care as outlined in the Standards.

Dental hygienists play a key role in encouraging their

patients to maintain a consistent and

effective brush, floss and mouthrinse

regimen.

0No Plaque

1Small Pieces

2Thin Band

3Medium

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4Large Band

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in August 2015, evaluated stud-ies with a focus on applicability to clinical practice. The meta-anal-ysis reviewed randomized, ob-server-blind, placebo-controlled, published as well as unpublished clinical studies assessing the effect of an essential oil-containing mouthrinse (MMEO) versus me-chanical method (MM) in subjects with mild-to-moderate biofilm. The magnitude of the data pooled in this study is noteworthy—29 clinical studies spanning three de-cades and three different countries, all of at least six months’ duration, and over 5000 patients.11

The meta-analysis evaluated a number of outcomes, includ-ing percentage of “plaque-free sites” (characterized by little to no plaque, as defined by a Plaque In-dex [PI] score ≤1), and percentage of “healthy sites” (considered gen-erally healthy by dental hygienists, as defined by a Modified Gingival Index [MGI] score of ≤1).

Specifically, at six months, MMEO subjects were five times more likely to have healthy sites

compared to MM subjects, and greater than seven times more likely to have dental sites without visible plaque: plaque index (PI) less than or equal to 1.

This meta-analysis represents a paradigm shift in evaluating oral health. In most clinical studies for plaque and gingivitis, indices such as the PI and MGI are utilized. While these are validated indices and widely accepted for clinical studies, they are not typically employed in clinical practice. In this meta-analysis, the outcomes that were evaluated are easily translatable to clinical practice, such as “healthy sites.” By using site-specific (tooth and location) data beyond whole-mouth biofilm reductions to interpret clinical data, the meta-analysis proposes a benefit-based approach to clini-cal research and practice.11

Dental hygienists should as-sess each patient individually to determine what combination of mechanical and chemotherapeutic interventions is best for improv-ing and maintaining oral health, as supported by the Standards. Clinical evidence maintains that

the adjunctive use of an essential oil containing mouthrinse with effective, professionally instructed brush and floss regimen creates a three-step oral hygiene plan that may help prevent the occurrence of oral diseases.

Adherence to the Standards of Clinical Dental Hygiene Practice helps dental hygienists assess and plan an oral health regimen to im-prove patients’ gingival health as well as decrease the level of bio-film accumulation. Daily preven-tive home oral care may be most effective when it combines brush-ing and flossing with mouthrinse, as indicated by the meta-analysis that demonstrates that implemen-tation provides almost eight times greater odds for “plaque-free” sites and five times greater odds for healthy gingival sites. Famil-iarity with and implementation of research supporting such combi-nation therapy is Standards-com-pliant practice for dental hygien-ists educating patients on an appropriate at-home oral care routine which includes clinically supported products and a brush, floss and mouthrinse regimen. •

Biofilm Control continued

World Health Organization. Oral health. Fact sheet No 318. April 2012. http:// www.who.int/mediacentre/factsheets/fs318/en/. Accessed April 17, 2015.

Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bull World Health Organ. 2005;83(9):661-669.

Marcenes W, Kassebaum NJ, Bernabe E, et al. Global burden of oral conditions in 1990-2010: a systematic analysis. J Dent Res. 2013;92(7):592-597.

Coventry J, Griffiths G, Scully C, Tonetti M. Periodontal disease. Brit Med J. 2000;321(7252):36-39.Eke PI, Dye BA, Wei L, Slade GD, et al. Update on Prevalence of Periodontitis in Adults in the United States: NHANES 2009 to 2012. J Perio. 2015; 86(5): 611-622.Gunsolley JC. Clinical efficacy of antimicrobial mouthrinses. J Dent. 2010;38(suppl 1):S6-S10. Kerr WJS, Kelly J, Geddes DAM. The areas of various surfaces in the human mouth from nine

years to adulthood. J Dent Res. 1991;70(12):1528-1530. Boyle P, Koechlin A, Autier P. Mouthwash use and the prevention of plaque, gingivitis and caries. Oral Dis. 2014;20(suppl 1):1-68.Gunsolley JC. A meta-analysis of six-month studies of antiplaque and antigingivitis agents. J Am Dent Assoc. 2006;137(12):1649-1657. Swango PA. Regular use of antimicrobial mouthrinses can effectively augment the benefits of oral prophylaxis and oral

hygiene instructions at 6-month recall intervals in reducing the occurrence of dental plaque and gingivitis. J Evid Base Dent Pract. 2012;12(12):87-89. Araujo M, Charles C, Weinstein R, et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. J Am Dent Assoc. Manuscript ID: 539-14.RI.U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General (Executive Summary). Rockville, MD:

U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2005;33(2):81-92. Glick M, da Silva OM, Seeberger GK, et al. FDI Vision 2020: shaping the future of oral health. Int Dent J. 2012;62(6):278-291.

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2.3%

15.8%19.4%

2.3%

30.2%

46.1%

0%

5%

10%

15%

20%

25%

30%

35%

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45%

50%

MONTH 0 MONTH 3 MONTH 6

Perc

ent H

ealth

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7.1%8.5%

2.6%

26.9%

40.5%

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15%

20%

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35%

40%

45%

MONTH 0 MONTH 3 MONTH 6

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Mechanical OnlyMechanical + Essential Oil Mouthwash

Mechanical OnlyMechanical + Essential Oil Mouthwash

Total Percent of Sites with No Visible Plaque (out of 295,000 tooth sites)

Total Percent of Healthy Gum Sites (out of 225,000 tooth sites)

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