Let's Talk Oral Health
Let's Talk Oral Health is an expert podcast designed specifically for oral health professionals. This first season brings together experts from around the globe to discuss the latest trends in preventing periodontal and peri-implant diseases. LTOH is your go-to source for dental research topics, practical insights, and interviews featuring top professionals in the field.
Let's Talk Oral Health
Interdental Cleaning and Mechanical Plaque Control
Prof. Filippo Graziani reveals the latest techniques and tools for effective plaque management. Learn how to empower your patients to maintain optimal oral health through consistent home care.
This is let's Talk Oral Health, the expert podcast for oral health professionals brought to you by Sunstar.
Speaker 2:Welcome back to our let's Talk Oral Health expert series for the fourth episode of this year. In previous episodes we have been exploring a 360-degree strategy to support prevention of periodontal and peri-implant diseases, talking about behavioral change, general health and the oral microbiome. So today we'll conclude the series by discussing arguably the strongest preventative approach mechanical plaque removal. And to do so we have a very special guest in our studio. So without further ado, let's get started. So today we are joined by a friend of the show, professor Filippo Graziani. Hello, filippo, welcome, thank you. Filippo is a full professor of periodontology at the university of Pisa, italy, where he coordinated the subunit in periodontology, halitosis and periodontal medicine. He's also a visiting professor in periodontology at the Eastman Dental Institute University College of London and an honorary professor at the faculty of Dentistry in Hong Kong. So again, welcome, filippo. It's good to see you. How are you doing?
Speaker 3:Well, I'm very well, and thank you for having me here. I'm very happy to be here.
Speaker 2:We are also very pleased and very honored. So today we're going to talk about mechanical plaque control and I think, as a start, it's very important that we know what we are talking about when we're talking about plaque. So when we talk about plaque development, plaque accumulation, could you maybe give us some insight into the properties of plaque? What is actually happening on a biological level? Where does it accumulate? Are there some risky areas in the oral cavity that we need to pay special attention to? Could you maybe enlighten us on that topic?
Speaker 3:Well, yes, of course I mean plaque. It's a biofilm, as you might know and I'm sure all the people that are watching this show actually are very well aware and biofilm are a puzzling and very complex structure. First of all, they are structures that are really made to survive. It's a clever organization that allows bacteria to survive and to strive and be successful. But we do need biofilms. We are surrounded by biofilms, we have them in our gastrointestinal areas and in fact we call them intestinal flora, and it's a place where actually bugs are welcome.
Speaker 3:Apparently, if you look at commercials, for example, for yogurts, you'll see that they are very well known, but we never say oral flora. We have a sort of a bias, a tendency, we as professionals of the oral cavity, to think that any bacterial combination is detrimental per se. But in fact we need bacteria, we need bacteria to live, we need bacteria to think, we need bacteria to taste. They cover many aspects. The problem in fact doesn't come with plaque. The problem comes when there is a dysbiosis of plaque. It comes when there is some shift in the population in the internal composition of plaque towards some specific bacteria. Usually we are talking about strictly anaerobic, gram-negative bacteria that actually are strictly linked with the inflammation of the tissues. But bacteria per se and plaque per se is not necessarily negative things.
Speaker 3:In fact, as I said, we need bacteria. Just think about how bad is the word sterile. Sterile is really a tremendous word. We are really made to be contaminated, not just by bacteria but ideas and people. So in a way, our oral cavity allows more accumulation because of course, it's a secluded area with different tension of oxygen, different light, different temperature and especially different humidity. So this allows bacteria to grow even faster than compared, for example, other areas such as the skin.
Speaker 3:But, as you mentioned, the risky areas, it is very clear that there are some unfracks, there are some overhangs that would tend to accumulate even more and, classically I would say, the interdental areas and, for example, restorations or areas where you have crowding. These are areas where plaque tend to grow even more. So what is happening? I'm pleased to stop me if you need, because otherwise I will keep talking for hours. That's why we're here. But really what is happening is that when you do have some sort of accumulation and some bacteria tends to develop even more, tissues would react with inflammation and when there is inflammation in a very peculiar way, that will influence bacterial population as well. It's a vicious circle because the more inflamed you are, the more some specific type of bacteria will grow and the more they will grow, the more inflammation will determine. And, to give you an idea, this is very different from where we started in the 60s and the 70s the idea of bacteria as a sort of a primal link of the disease the only cause.
Speaker 3:So the disease was infective. So we had lots of fight towards plaque, a lot of fight, a lot of research on antimicrobials, for example. But that was very clear you need to have bags to have inflammation. But now it is really not that clear. I mean, they're more talking to each other. I'll make an example A few years ago we released a trial that was based on nutrigenics sorry, nutraceutics so the adjunctive effect, for example, of kiwi fruit on people with periodontitis.
Speaker 3:It's an infamous study, because all the friends in the research tease me for that, but it's a different story. But what we learned? That in the first two months in which we didn't do any treatment whatsoever, we just simply gave two kiwis per day to the patient, we saw that there was a reduction of inflammation. That was expected because kiwi has so much vitamin C, so there was something expected. But even plaque decreased significantly. That means that even without doing anything to the plaque, plaque decreased Mechanically. Yes, indeed, Plaque decreased because there was less inflammation. So there is a continuous talk between inflammation and plaque accumulation.
Speaker 2:And is there? I mean everybody develops a certain amount of inflammation when they're exposed to plaque. I mean it's normal, as you mentioned, an interaction between the host immune response and the plaque. Is there an explanation why some patients go into this vicious cycle of inflammatory processes, exaggerating each other over and over again, while other patients maybe remain stable once they have developed gingivitis, but they don't progress into periodontitis? Is there maybe a reason for that? Is it Well, inflammation is a good thing.
Speaker 3:We need to start to think. For sure, inflammation is a good thing. We need to start to think Inflammation is a good thing, it's something that we need. In fact, the bacterial accumulation would determine inflammation to anyone. This is what we know classically, but it is true. Then, of course, inflammation would manifest itself differently according to the type of population, but inflammation will be present for anyone, at least histologically, so to speak.
Speaker 3:The issue why, despite, we all have plaque accumulation? Because, apart a very minority periodontists and dental hygienists out there the majority of the people well, not even them and I can tell you, because I measured plaque level even to colleagues all my life but let's say, apart a minority of population, the majority of the people will actually have very high level of plaque Exactly. Yet the disease is widespread, but usually it doesn't really affect more than the 50% of the population on the adult level, let's say, between 30 and 40, 50 years old of age. So how come that everybody has the enemy but only one out of two loses attachment and loses bone? The issue is related, in fact, to inflammation per se.
Speaker 3:It is linked to the susceptibility of getting more inflamed. Basically, there are people for some specific reason, and if you want, we can even discuss who tend to inflammate more, to create more inflammation. Now, because the gum tissues are strictly packed, there are really layers and layers of collagen fibers and it's a lasagna of collagen fibers and the only way inflammation can find the space is to destroy itself with some specific mechanism the collagen and the lasagna, so to speak. So the people that would tend to inflamed more will have to reduce the amount of collagen and the amount of gingiva in order to create a space for the inflammatory infiltrate. So what is it that leads some people to develop this hyper-responsive, this redundant inflammation? Well, this susceptibility is actually due to many aspects.
Speaker 3:I clinically this is my clinical view of course I don't have anything, no one has really scientific data on this, but I believe that there is never a single cause for an innate sensitivity.
Speaker 3:It's really a mix of many different possible effects.
Speaker 3:But usually there is surely a genetic component that is very strong, for example in the cases of the young population, and some specific type of disease with some specific patterns, for example. But it is not just about genetics, and we should not even make confusion between genetics and familiarity. The disease has some sort of familiar cluster which might not be due confusion between genetics and familiarity. The disease has some sort of familial cluster which might not be due only to genetics, because when we live in family together, we drink from the same glasses, we eat from the same fork and so forth, so we live in the same bacterial context. But I think that is also linked very much to smoking, most importantly, but also all the metabolic status of the subject, and I'm not just referring to the glycemic level of the patient, but also the cholesterol level or the overall inflammatory status of the patient. And then one of the very important cause of course, let alone some systemic diseases, but one of the most important cause is the stress. Stress has a tremendous impact on the oral cavity.
Speaker 2:This is super fascinating and, for those who are watching, we also have separate episodes on, for example, the microbiome, the effect of the biofilm. We will also have an episode on the systemic health and how you can leverage systemic health to reduce the risk for periodontitis and help to prevent periodontitis. So if you're more interested to go in-depth into those risk factors and topics, feel free to go to our YouTube channel and watch out those videos in the same playlist. But it's super insightful to see these massive effects of plaque, but especially the interaction with the host and the host immune system. That's really the key you mentioned about how systemic health, systemic diseases, how lifestyle, can influence your susceptibility to periodontitis. It's also maybe interesting to mention that there's also the other way around, so the plaque, the bacteria in your mouth, can also have systemic consequences. Could you maybe share a bit insight into that direction of the relationship?
Speaker 3:Sure, and you know. I just want to say that this story, the funny bit that we are the only one surprised about this. You know we keep saying within our field and you know what, but the oral cavity also affects systemic issues. But the oral cavity is systemic, the body is just one and if you talk to any doctors with a capital D, but even to patients would never even hesitate to think about that. That's a good point. We did a study that was many years ago 10 years ago when I was 12. And we simply asked our patient do you think that what you have in your mouth will actually affect the body? And the 89% said that for sure that there was a link. Back then there was also another study that did ask the same questions to dentists and not even the 60% of the dentists thought that the oral cavity would influence the body. So that means that the patient had a more holistic perception of health, more than the dentist themselves, because we are very tremendous specialists. We just work on a tiny bit of our body and sometimes we might tend to forget. But making this preamble very short, I mean the point is that the inflammation and the bacterial combination that we have in the mouth would affect the body in an important level.
Speaker 3:Just to make it clear at the moment periodontitis is associated with 57 systemic diseases, which does not mean that periodontitis causes any of those, but it doesn't mean, not even the opposite. It might be that some, there might be some causal link, but we still don't know. But surely there is an association and the association is resting on some specific aspects. The reason why, for example, by having predontitis, you might be prone to have atherosclerotic disease or diabetes, is really linked to some specific mechanism. First of all, even if bacteria do not normally infect the tissues I mean, periodontitis is not an infective disease. They don't infect the gum but there is some passage of bacteria and these bacteria actually would go in the bloodstream. We know this from many evidence, from the biopsy, from carotid atherosomal plaque up to some other studies on bacteremia that bacteria would enter in the bloodstream. And we also know that if you are healthy from a gingival standpoint, or if you have gingivitis, when you go to the dentist and you get, for example, a dental clinic, you surely have some passage of bacteria in the blood, which doesn't matter.
Speaker 3:We have so many mechanisms. If you remember the book of pathology, which is as tall as this, at least in my generation, we still used to have books. But we are really a war machine. I mean our human are really a war machine. I mean our human body has so many mechanisms. So every time that you shave, if you have menstruation, if you have fevers, there are continuous passages of bacteria in the blood. And it is not a problem. We fight it and we win it. The problem comes when you have too many bacterias, and that is of course it's an infective cytosemia, or when, for example, these bacteria are chronically elevated in the bloodstream. And, for example, we know that if you are affected by periodontitis, one out of five times that you are chewing your bacteria are going in the bloodstream. That implies that perhaps somebody with a severe periodontitis you know stage three or stage four it may happen that it has a sort of a daily passage of bacteria in the bloodstream.
Speaker 3:That might actually create some important alteration, which is, in a way, not just the presence of bacteria, some periopathogens, so to speak, like Porphyromonas gingivalis. Porphyromonas gingivalis is really a belligerent animal. It is really a bacteria that has so many clever capabilities in terms of to create issues and troubles everywhere. That is incredible. It can infect single cells and get it out when inflammation goes down. I mean, it is really potent and has some important effect on myocardial cell as well as endothelial cells. But I think what is important is the fact that all this bacterial release would determine also some local inflammation which we believe creates a sort of a resonance mechanism of the old systemic inflammation.
Speaker 3:For example, if I have my local gingiva that is inflamed, that would determine lots of production of interleukin-6. This interleukin-6 would spill over, would go in the bloodstream and would reach the liver and at the liver level there would be a production, for example just to quote one which is very famous in research of C-reactive protein. Crp is an opsonin. Maybe you might remember that opsonin are these molecules that would bind, for example, to bacteria or some pathological agents so that the antibodies can actually recognize it and attack. So C-reactive protein is enhanced through inflammation and in periodontitis. People with periodontitis tend to have higher level of C-reactive protein compared to people identical without periodontitis. Why this is a problem? It is a problem because when you are chronically inflamed, even at the lower level, that is actually associated with a higher tendency to develop an enormous amount of different type of systemic diseases.
Speaker 3:In fact, an elevation of systemic inflammation is clearly an indicator of future cardiovascular risk events, and this is particularly true when you search for C-reactive protein at the high sensitive level not the big one, but the one that you can find with the test that is extremely sensitive. In that case, you can clearly stratify people according to the risk for cardiovascular diseases. What happens when you have periodontitis is that you would tend to have higher level of this CARP. That would put you already in a category of an enhanced risk, for example, of cardiovascular diseases. So what is happening, to sum up, is that when you have a local inflammation, our body is so intelligent that it would back it up with a systemic inflammation, but this systemic inflammation would not solve itself and, per se, can link to other diseases.
Speaker 2:So the presence of, for example, periodontitis can actually enhance the risk of developing it, and taking away the local inflammation can also help contribute to alleviating the body from systemic inflammation Massively. Yes, I think that's very interesting. You mentioned the association with cardio At Sunstar. We also did a recent study on the effects of now we're talking about professional, maybe professional cleaning, right, so really under the supervision of periodontists, reducing the inflammation. However, we also did some recent research on home care, three times per day interdental cleaning. What is the effect on systemic health when you look at blood sugar levels, comparing the two groups One group who did it three times per day, the other group who did not perform in the clean three times per day and you really saw difference in in glucose levels fluctuating over the day, with the group cleaning, incidentally more frequent, showing better HbA1c value, so better blood glucose control. I mean that's fully supports your story of yeah.
Speaker 3:Yeah, that doesn't come as a surprise. In fact we published just recently a paper on JCP Andromedic Clinical Predontology a few months ago in which we analyzed people with gingivitis and that was the first time that we were looking at systemic effects of gingivitis and you could clearly see that even in gingivitis patient we had to take a very large sample. We're talking about 140 patients, otherwise you would not notice. But removing local inflammation, even when it is not associated with periodontitis, determine a reduction of systemic inflammation. So every time that you touch a local inflammation the body will respond because everything is linked In periodontitis, because the amount of inflammation is so huge, the effects are so important that actually would also determine effect on, for example, glycemic control.
Speaker 3:Classically we know that treating periodontitis would actually improve trachea and hemoglobin to an extent that it's the same extent of, for example, a second hypoglycemic drug. But also we have indirect evidence that improvement of oral hygiene control would actually benefit for your cardiovascular health. So there is no discussion that within the frame of holistically treat somebody with a chronicity, oral health should be endorsed.
Speaker 2:Yeah, I mean we don't need more rationale for mechanical plaque control. I mean we now see the. It's really about removing the inflammation on a local level and you even have systemic effects, even on top of what you achieve locally in the mouth. So I think that's, yeah, putting perfectly in context why we need mechanical plaque control. Going to the actual mechanical plaque removal, of course, the obvious one is toothbrushing. It's a habit we've adopted already 2000 years or maybe even longer ago. We have some recent developments, going from manual tooth brushing to power tooth brushing, to smart tooth brushing. How do you see those developments? Have they helped you with guiding your patients for better plaque control? Do you see massive differences in efficacy of plaque removal? What is your opinion on the development?
Speaker 3:I do I do, I do. I believe that the advent of electric toothbrush, especially the newer generation, changed dramatically plaque control, because it made it easier, even for somebody with not such a good hand dexterity, manual dexterity to have a good plaque control, provided, though, that the professional teaches the patient how to use it. If we keep selling things to the mass market in the mall and people doesn't even have an idea how to use it, perhaps that will not change, so there should be a professional behind. I think this is crucial. Hora hygiene instruction and motivation, which are two different aspects, should actually always start with the professional working. Now, what is important about toothbrushing is that I believe that for oral hygiene in general, the important is that are the moments in which we realize that we need a drastic change.
Speaker 3:I'll try to make myself clearer the fact that we've been using something for 2,000 years doesn't mean that it's the best thing that we can use. In fact, I think the way electric brush work and the one that I like the most sometimes are the ones that are not necessarily designed as a classical toothbrush. It's the moment that you change a mental frame and that really allows you to go a step beyond. So you were mentioning about the importance of tooth brushing and in my mind I kept having and maybe for you, maybe it's part of what you really want to hear, but for me what is really important is what you do interdentally, more than the way you brush. If I would have a patient that is rushing, I would have no hesitation. I would say brush in between teeth, then you brush way you brush. If I would have a patient that is rushing, I would have no hesitation, I would say brush in between teeth, then you brush when you can, but the people don't do it because a bias of 2,000 years, yes, and I mean internet of cleaning.
Speaker 2:For sure. It's for us also one of the most important topics. Obviously, however, you also see it's not a common practice everywhere, so it still needs explanation, still needs motivation on why it is important. So maybe that's the next topic we can touch upon is why do we need it? Again, maybe looking back also at the susceptible niches in the oral cavity, why is the interdental space so important to clean? It's only a very small part of the oral cavity itself. What are your?
Speaker 3:views on this. Yes, Martin, I think. Well, first of all, it's not that small. If you think that in a molar area this interdental area can be long 13 millimeters, it's not that small. It's actually a huge area. And that is a plaque that is rarely removed, not by food, not by talking, not by kissing. There is no mechanical action that can remove, most of the time, plaque interdentally. So plaque accumulation over there has some specific characteristics. We know that it's more acid, but most importantly, we know and I like the fact that every time that we make these interviews I always quote one paper that to me it's the base.
Speaker 2:I already know what you're going to say.
Speaker 3:Because it's the base really of dental hygiene, which is 1982. 1982, per Axelsson and Jan Linde published this wonderful study that basically, to cut the long story short, clearly indicates that if you work very well the patient works very well in between teeth. There will not be inflammation in the gums, no new cavities in the long run, in six years, whereas if you just clean somebody and these people brush as they can, these things will deteriorate, even when they brush very well on a buccal, palatal occlusal, which means that you can be very good with the normal toothbrush, but if you don't brush in between, the maintenance of oral dental health is impossible. So that really it's a dogma for me. If you want to maintain health in the cavity, you need to clean in between teeth full stop when we talk about internet, the cleaning.
Speaker 2:Obviously we have a plenty of tools that can help us do that. Of course, one of the oldest development was floss string, floss interdental brushes, rubber interdental cleaners. You did some some research on this as well, to compare the the effectivity of all those tools, both in healthy subjects and in periodontitis patients. What were your principal findings on the efficacy of those tools? Were they comparable? Were they very different?
Speaker 3:Well, pretty much I mean oral floss. Of course it's historically important. To me it's just an historical importance and I like another study from the group, from Friedrich von der Weiden, from the ACTA that you might be aware of I guess I'm talking about a study of 2008, but it clearly indicates that really, floss was not providing, on a scientific level, an additional effect.
Speaker 3:So many people might say that this is due to the fact that it's difficult to use, which is true. Difficult to the point that even the study that has been designed on dental hygiene students do not show an additional effect of floss. So even the people that should know how to use things are not capable to show an additional effect and, as a pre-dontist, I have no for me. Interdental brushes are the instruments, not floss. When I compared various instruments, I did two trials, one that got out in 2017, another one more recent. Because what is important when you are evaluating and making trials on interdental cleaning, you need to really differentiate people that have open embrasure let's say, they have no papilla or attachment loss in the papilla versus people that have a papilla that is completely integrated, because this changes the type of actions that you may have. Clearly, it was very clear that floss would not add anything to tooth brushing in both cases.
Speaker 3:So flossing that I used this morning I flossed and in the study that I quoted before of Axis and Linde, the majority of the patients did floss, which means that high-quality flossing is effective. It does something? Yeah, absolutely. The problem is that how many efforts you have to make as a professional to bring somebody to be able to do high-quality flossing. So it may work for me, but I've been working on gums for the last 20 years. I know the anatomy and I have good dexterity, but I'm not sure that if I see one patient once or twice I can pass this knowledge. So floss was not effective at all, even with four sessions of origin, instruction and reinforcement, whereas toothbrushes interdental toothbrushes in both systems I'm talking both in people that were healthy, in people with periodontitis would show an enhancement of plaque removal.
Speaker 3:So, there was less plaque at the end after a month, with people using interdental brushes in both samples more than with floss or just a control. What was interesting was the interdental peaks. I think these two are the only two trials that are present on interdental peaks. Perhaps there are more and that I'm showing to the camera that I'm my ignorance but at the moment I don't even remember. But it might be my fault and I want to be sure. I tend to be self-centric in quoting papers.
Speaker 2:There may be a few.
Speaker 3:I'm sure there must be some An interesting one, but what is interesting is the fact that in these two studies the interdental peaks proved to be as effective as interdental brushes. What was interesting is a tendency this is not statistically significant, but a tendency that was seen in people with intact periodontium, and it was the fact that it wasn't just a concept of plaque control, but there was even a slightly more tendency of inflammation reduction, which I think might be due to the fact that the peaks may really act as a sort of a massage and this massage effect.
Speaker 3:I remember something that my grandfather used to quote to patients, that the gums should be massaged and I kept reading it or people saying this, but I never saw numbers relating to this Because the anatomy of the peak is really pressing significantly on the papilla. I think that could be the explanation for the bleeding.
Speaker 2:Interesting, interesting, and you already touched upon it a little bit when comparing different internet cleaning tools. It's not just about their efficacy, it's also about the patient using them properly. Floss is extremely difficult to do properly and therefore it's also very unlikely that patients will do it on a daily basis. What are your views on driving compliance by choosing the appropriate interdental cleaning tool? Do you maybe have tips for hygienists and other oral care professionals who are watching how to leverage the user-friendliness of certain interdental cleaning tools to drive compliance and build rituals and habit formation?
Speaker 3:Yes, I mean, I have to tell you that I'm a clinical trialist, I'm not a behavioral trialist, which?
Speaker 3:means that I don't have my own data on showing that there is a system that is more capable to determine motivation, on showing that there is a system that is more capable to determine motivation. So this is based on 20 years of continuous practice to gingival diseases. But I'm a pure periodontist. I'm in my clinic just to periodontitis treatment and we do run other clinics, so the amount of patients that I've been treated is quite significant and it is very clear. Motivation starts with the report that we have with our patient and interdental brushes and I think that's the first step. That should be clear is the first thing that is taught to the patient, the first thing that is shown to the patient In the first session. We don't even quote a toothbrush, we just make it simple, just to make it clear.
Speaker 3:The intervention for changing oral hygiene habits should be short and effective, because life is beautiful. People should not be forced to listen to some random dentist or dental hygienist talking about bugs in the oral cavity. I mean, out there there is war, but there is also love, so people should be out of dental practices and leave and not to hear story about dental plaque. So two minutes and those two minutes you need to be effective. It's passing a skill. You don't need to make a conference, and the skill to be passed is something that the patient needs to be able to do it itself, himself or themselves in the moment, that is, in the practice. To empower someone, you need to make sure that when I teach you something, you can do it. So when you get home you know how to do it. And that works for everything in terms of human behavior. All the sports that you are capable of doing and I'm sure you're a massive sport person you're good because you're being taught how to do things in a way that appeared extremely easy. Otherwise, if something would have been appearing complex, you would have stopped doing it. So that is the same story with oral hygiene.
Speaker 3:So the first time we go for interdental cleaning, we show and then the patient has to do it. Once the patient is capable of doing it, that's it, it's finished. Then next time I want to have a toothbrush with these people and then check in toothbrush only if there is good plaque control in between teeth, because remember, accents on the linden. So the first thing is that, which means that we always say to the patient first and foremost, you brush in between, then you use your toothbrush. This morning, for example, I would like to say that I woke up at 4 to do yoga. That is not the case. I just woke up very late, but the first thing that I do, I brushed in between. I actually used floss, but it's okay, I'm a professor of podontology, I mean I can do it. And then I changed, I did all my things and then eventually I use a toothbrush.
Speaker 3:It's also important sometimes to differentiate, otherwise the session can be too long for the patient. Many patients, for example, would use interdental brushes while watching TV on the sofa and then brushing in the toilet. Yes, but this is important. I would always go for first. You brush in between right then if you have time, you do toothbrush.
Speaker 2:Super, yeah, interesting. We also have an entire episode on behavioral change and how to drive behavioral change, so if you again want to watch that back, it's in our playlist. Let's talk oral health, so go and have a watch and if you like it, of course, hit the like button and subscribe for more interesting videos on that topic. Yeah, super. We've talked about the importance of plaque, mechanical plaque control. We are reaching the end of our session, so I would like to ask you if our audience who are watching would need to remember one single thing from the conversation that we had today and apply it in our daily practice. What would that be?
Speaker 3:That the highest change they can create in a patients to make sure that the patient brush correctly in between teeth. Okay wonderful that will impact their cavity, their eye cavity, but we also have some evidence even on diabetic status and perhaps the entire systemic health.
Speaker 2:Wonderful, I think that's a very nice take-home message, and I think with that we we reached the end of our conversation, so I would uh, yeah, like to thank you for your valuable insights. It was a very pleasant conversation, as always, with you. That's uh, that was already uh sure when we started this today, so, um, again, I want to thank you, thank you.
Speaker 1:Thank you, martijn, thank you goodbye thank you for tuning in to today's episode of the let's talk oral health podcast. Don't forget to subscribe on spotify Apple Podcasts to catch all our new episodes.