Professors Nicola West and Tim Newton spoke to Johnson & Johnson about how dental professionals can build on the support they already provide to their patients, to try to achieve improved plaque control.
Where are we in in terms of oral health levels, both in the UK and globally?
Nicola: The keystone paper on this is by Marcenes et al (2013), which provides data on the global burden of oral conditions between 1990 and 2010. It tells us that 3.9 billion people are affected by oral conditions worldwide. And that severe periodontitis was the sixth most prevalent condition, affecting 11% of the population.
In England, Wales and Northern Ireland, according to the most recent Adult Dental Health Survey (2009), 66% of dentate adults had visible plaque. Only 17% had very healthy periodontal tissues and no periodontal disease.
How does the future look for dental patients in the UK?
Nicola: We’re living longer and healthier lives, and we care more about our appearance.
I think most people would like a lovely smile. For those reasons, I think people are more aware of periodontitis and seek treatment.
For the majority of the population, gum disease is totally preventable (Chapple, 2014). So we need to make an impact, and ideally prevent or stabilise this disease.
A lot of the change that is needed is about raising patient awareness. For example, people need to know that as soon as they find they have bleeding gums, they need to see their dentist. Bleeding gums are not normal or healthy.
Tim: I think another big factor for patients is a concern about impact of our behaviour on the wider environment.
That’s going to have big implications for healthcare. Especially in terms of thinking about how we provide resources to look after ourselves, as well as thinking about the bigger picture.
So, when I go to see the dentist or the periodontist or the hygienist, what’s the environmental impact of intensive treatments, and might that better be avoided by small steps I can take at home?
We’re thinking about many factors that drive our behaviour. So our health, the environment, wellbeing, quality of life and so on.
I think it’s a much more complex picture, which is very exciting.
Why is it that mechanical cleaning is not always sufficient to control plaque in some people?
Nicola: According to van der Weijden and Slot (2015), under half of the plaque is removed if you ask someone to clean their teeth. If you ask them to clean again, it tends not to be not much better.
We are creatures of habit and clean in the same way each time.
Tim: Although evidence can always tell us what will work on average or in general, it’s about how you tailor that evidence for the person in front of you. That’s particularly true for behaviour change.
What we tend to think about is principles that are very effective in helping to change someone’s behaviour. But when it comes to the individual, you have to think about where they are, what they might be able to achieve, what they can fit in, and how you take those principles and tie them to that individual case.
Nicola: I agree. It’s important to recognise that different people have different susceptibilities. And to know how to take those into consideration when creating a plan if individual patients are going to be successfully managed.
At what point is intervention needed to prevent the progression of periodontal disease?
Nicola: For me, it’s at BPE 1. That is when I would like dentists to instigate oral hygiene advice and, if possible, send their patients to the dental hygienist.
Educating patients about prevention is key at this point, rather than not intervening until later at BPE 3 or 4. This is often when dental professionals think it’s time to take action.
Tim: I think part of that plan should be how to change the patient’s behaviour. This is going to be a very gradual process of change, until new habits are formed.
We need to be thinking more, having made the behaviour change, on how you turn this into a habit and how you maintain it.
Self-monitoring is also important in this transition to habit. Start off by seeing how well patients are doing something, how often they are doing it, how successful they are in making any change, and whether they keep it going.
If you can fully understand your patient’s values and goals, then you can work with them to achieve shared, valued goals. Goals that fit in with the framework of looking after their gums, teeth and mouth.
Can you offer an example of how that might work?
Tim: So, we’re all developing new habits all the time. And mobile phones are a great example of that. It’s a habit we’ve developed very, very rapidly, because it gives us something that we value very directly.
But the key to habit formation is repetition and cues. So it’s the fact that you do it every day.
And that goes back to what I was saying about trying to get people to self-monitor. If you self-monitor, you’re reminding yourself to do it every day and seeing how well you do.
The other thing is having clues or cues that tell us that it’s time to do something.
So, for example, tooth brushing is often the first thing you do when you get up. If we can tie the behaviour we want into a cue, it just reminds us to do it.
There’s a lovely study that I often quote about putting your running shoes by the front door makes you run more, because you see your shoes (Lally and Gardner, 2013).
Leaving your mouthwash out in the bathroom or having your mouthwash in the bag that you always take to work will remind you that you have to use it.
Where does the current evidence base lead you in terms of plaque control?
Nicola: The evidence continues to show that the bedrock of periodontal treatment is daily tooth brushing by the individual.
For certain patients, when critical threshold for plaque accumulation to trigger gingivitis is low, the patient may benefit from adjunctive agents for primary prevention of periodontal disease, the literature would then suggest using an adjunctive mouthrinse.
We know, reviewing the literature, for example Serrano et al (2015) and Figuero et al (2020), that adjunctive mouthrinses are beneficial.
The research suggests that to reduce plaque, essential oils have efficacy. As does chlorhexidine (see boxed text for specific benefits).
Johnson & Johnson Ltd has two products in its Listerine range to help support patients’ gum health; Listerine Total Care and Advanced Defence Gum Treatment.
It has been demonstrated that as an adjunct to mechanical cleaning, Listerine Total Care, an essential oil mouthwash, manages plaque levels, to help prevent gingivitis (Boyle,.
Listerine Total Care may therefore support the efforts of a patient requiring early intervention. By virtue of its essential oil formulation consisting of eucalyptol, thymol, menthol and methyl salicylate. All of which are proven to:
- Penetrate the plaque biofilm (Pan et al, 2000)
- Manage the bacterial load of the mouth (Minah et al, 1989)
- Reduce maturation of remaining biofilm colonies (Johnson and Johnson data on file).
Listerine Advanced Defence Gum Treatment is a twice-daily mouthwash clinically proven to treat gingivitis as an adjunct to mechanical cleaning (Gallob et al, 2015).
It is formulated with unique LAE (ethyl lauroyl arginate) technology. This forms a physical coating on the pellicle to prevent bacteria attaching, and so interrupts biofilm formation. When used after brushing, it helps to treat gingivitis as demonstrated by the reduction of bleeding by 50.9% (p<0.001) in just four weeks (Gallob et al, 2015).
With Listerine Advanced Defence Gum Treatment is clinically proven to interrupt the plaque colonisation process (Johnson and Johnson data on file). This may offer a viable option in terms of supporting patients’ gum health.
Through our range of mouthwashes, Johnson and Johnson Ltd help dental teams work in partnership with patients, with specific products designed to improve home care routine outcomes significantly, which help to support the prevention or management of periodontal disease when used in conjunction with mechanical cleaning.
For more information visit www.listerineprofessional.co.uk.
Boyle P,Mouthwash use and the prevention of plaque, gingivitis and caries. Head & Neck Oral Diseases 20(1): 1-76
Chapple IL (2014) Time to take perio seriously. BMJ 348: g2645
Figuero E, Roldán S, Serrano J, Escribano M, Martín C and Preshaw P (2019) Efficacy of adjunctive therapies in patients with gingival inflammation. A systematic review and meta-analysis. Journal of Clinical Periodontology
Gallob JT, Lynch M, Charles C, Ricci‐Nittel D, Mordas C, Gambogi R, Revankar R, Mutti B and Labella R (2015) A randomized trial of ethyl lauroyl arginate-containing mouthrinse in the control of gingivitis. J Clin Periodontol 42: 740-7
Lally P and Gardner B (2013) Promoting habit formation. Health Psychology Review 7(supp 1): S137-58
Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A and Murray CJL (2013) Global burden of oral conditions in 1990-2010: a systematic analysis. Journal of Dental Research 92(7): 592-7
Pan P,MB (2000) Determination of the in situ bactericidal activity of an essential oil mouthrinse using a vital stain method. J Clin Periodontol 27: 256-61
Van der Weijden FA and Slot D (2015) Efficacy of homecare regimens for mechanical plaque removal in managing gingivitis: a meta review. J Clin Periodontol 42 (Suppl. 16): S77-91