Dental Tribune Asia Pacific
According to Dr Kishore, dental students should learn through practical training how to instruct patients on managing plaque formation using the correct preventative tools. (Image: Hadal Chandrasekhara Kishore)

Plaque control measures and thrust for preventive dentistry—dentists’ attitude

By Kishore Chandrasekhara Hadal
July 10, 2020

Periodontitis is pandemic in nature and distributed all over the world. The disease’s prevalence and burden on oral health in India is no different, and periodontitis shows no discrimination between race, sex, caste or creed. Many studies quote an incidence rate of greater than 30% among the global adult population. The numbers are staggering: more than 300 million people in India have periodontitis. If we consider gingivitis, the numbers are even more mind-boggling. Periodontitis remains the single largest reason for loss of teeth currently. Although many risk factors and predisposing factors are attributed to the aetiology of periodontitis, dental plaque is the predominant reason and the most easily modifiable risk factor to prevent periodontal disease.

Many studies state that low dentist-to-patient ratios and lack of awareness among patients are some of the plausible causes of the high incidence of periodontitis in the Indian population. However, hardly any studies exist that inform us about dentists’ awareness and their views on plaque control measures available and the professional recommendations that they endorse to their patients in the ever-changing world of plaque control. We thought that it would thus be of relevance to seek valuable insight on this issue through an online questionnaire-based survey. The questionnaire was devised in a multiple-choice format, and the link to the survey was shared with Indian dentists through various social media channels.

It all starts interdentally

More than 300 respondents completed the survey, among whom there was a balanced mix of 52% males and 48% females. The age of the respondents ranged from 23 to 65 years, and the majority were in the age group of 29–50 years. Regarding professional experience, the respondents included dentists who were just starting out their careers and seasoned practitioners with over 25–30 years’ experience. The study sample ranged from general dentists to postgraduate students. The majority of the survey respondents (54%) had a master’s degree in dentistry.

It is almost universally accepted that periodontitis is initiated mostly in the interdental areas, and these regions are the most vulnerable to accumulation of plaque. Hence, the survey questions were designed in such a manner that sufficient weight was accorded to matters pertaining to interdental areas and the plaque control measures employed to keep these areas healthy.

An overwhelming 96% of the dentists stated that they prescribed interdental cleaning aids on a routine basis to most patients, which we believe is a very healthy indication. As to which is the most recommended interdental cleaning aid, most of the respondents fell into two categories: 55% of them preferred interdental brushes and 40% dental floss. Only 2.65% recommended oral irrigators. We deduced that India being a cost-sensitive market, the higher expense for the patient of procuring an irrigator deterred most of the dentists from recommending irrigators.

Practice what you preach

The survey probed this matter further, asking whether the dentists themselves used an interdental cleaning aid on a regular basis; nearly half of them confessed that they did not use such aids, while another 35% of the dentists responded that they used them occasionally. These figures point to an apparent contradiction: it would appear that dentists are not practising what they are preaching. This left us wondering whether all the professional advice that dentists provide is limited to patients alone and whether dentists lack conviction in prescribing interdental cleaning aids.

There were various reasons given by the respondents for not using interdental cleaning aids themselves. The most predominant being that they could manage to clean their interdental areas with regular brushing alone, followed by the reason that they had tight contacts between their teeth and thus the use of interdental aids was not warranted. Other main reasons given were that they were lazy to use the aids and that it was time-consuming to clean interdental areas.

The questionnaire investigated this compliance issue in patients too with a question on the main challenges associated with the use of interdental cleaning aids in patients. Most of the dentists (54%) opined that a lack of awareness was the major issue, followed by a lack of motivation in patients and the technique sensitivity in using the aids. Some respondents said that patients found it too time-consuming, and 10% said that cost factor was an issue for patients.

“Training patients on the use of interdental cleaning aids is the responsibility of the dentist, and can be addressed with proper training during dental education”

Mouthrinses are employed routinely as a chemical plaque control measure as adjunct to mechanical plaque control. Mouthrinses are a popular choice among both dentists and patients, as these are easily available, cost-effective, and not very technique-sensitive or time-consuming to use. The survey questionnaire elicited the dentists’ opinions regarding the efficacy of anti-plaque mouthrinses in disrupting plaque in the interdental areas. Forty per cent of respondents believed that such mouthrinses could effectively disrupt plaque even in interdental areas, and an equal number of respondents felt this not to be true, while 20% were uncertain in this regard.

Another interesting insight that we obtained through the questionnaire survey was that 60% of the dentists had never used a single-tufted brush, yet 57% opined that single-tufted brushes can benefit all patients. Some of the dentists felt that their use is limited, being beneficial only in orthodontic patients, in cases of crowding or in implant patients. This highlights lacunae in our education system: the majority of the dentists, some of them having more than 25 years’ experience, had not used something as basic as a single-tufted brush even once.

Dental implants have been the fastest-growing treatment modality for quite some time now. We wanted to ascertain what measures are employed by dentists to maintain implants and keep them plaque-free. Of concern was that 20% of the dentists did not prescribe any special form of care. Oral irrigators were the most prescribed tool, more than 30% of the respondents recommending these. Implant floss/tape, interdental brushes and single-tufted brushes were prescribed by fewer than 20% of the dentists. Only two respondents said that they recommended the Hydrosonic sonic brush (CURAPROX). The choice of oral irrigators as the most preferred for maintaining implants assumes importance in light of hardly any of the dentists recommending these to their patients on a routine basis. This supports our earlier affordability reasoning; patients who can afford high-value treatments such as implants can also afford irrigators.

Toothbrushes are the most humble of tools, but are the workhorses when it comes to plaque control. When asked about their choice of bristle hardness of toothbrushes, 62% of the respondents recommended soft bristles and 12.5% ultra soft. Nearly 25% of the dentists preferred medium-hardness bristles.

We wanted to test the awareness of dentists on the functioning of sonic toothbrushes. In response to the question on this, nearly 40% said that they knew how a sonic toothbrush functions, whereas the other 60% of respondents either did not know or had only a vague idea.

Better prevention through hands-on instruction

We believe that, with rising awareness on oral health among the patients, preventive programmes will receive thrust henceforth. Thus, we explored the dentists’ views in this regard. An overwhelming 97% of the respondents agreed that a great deal more emphasis has to be given to plaque control measures in their practices, and 91% of the dentists agreed that adopting preventive dental care routines in their clinics could benefit their practices. The majority of the respondents (76%) regularly set aside clinic time to educate their patients regarding prevention; however, most dedicated only 2–5 minutes to educating patients, which we feel is grossly inadequate.

In conclusion, we would like to make the following observations. A great deal more emphasis has to be given to training dental students on the practical aspects of plaque control measures during their dental education in India. They have to be exposed to the plaque control tools available in the market, and their pros and cons have to be debated upon. In pursuit of incorporating advanced treatment modalities in their practices, it appears that dentists are neglecting something as basic as plaque control, which forms the cornerstone of the preservation of natural teeth.

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