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
Expert Q&A: Mastering Mechanical Plaque Control
Prof. Filippo Graziani returns to address key questions from dental professionals following a discussion on interdental cleaning and mechanical plaque removal.
This is let's Talk Oral Health the expert podcast for oral health professionals brought to you by Sunstar.
Speaker 2:Hello everyone, welcome back to our let's Talk Oral Health expert series. For this Q&A session that follows the episode on mechanical plaque control, we are reconnecting again with Professor Graziani to answer the questions you had about this episode. Welcome back, filippo, it's great to see you again. How are you doing? Not bad yourself Very well. I'm very pleased to have you again back on the show Because we had a very interesting conversation back when you were with us in the studio, and our viewers have sent us some questions. We will try our best to answer them all, although some of them were quite similar, so we try to bundle those questions. But yeah, without further ado, here is the first question. You talked about the massaging effect of the rubber interdental pigs and that this may stimulate blood flow and benefit gingival health. At least it's hypothesized. Is there also a risk that this massaging effect or the continuous compression of the papilla, that this can damage or hurt the papilla and maybe increase the size of the interdental space, or do you think the papilla is resilient enough?
Speaker 1:Well, whenever you use friction of an instrument, so something that actually works, by creating some abrasion or some moment in fact of friction, there is always a risk of a possible trauma. However, trauma rarely goes unnoticed. I mean, it's unlikely that you would get trauma and the patient would not report some sort of soreness or something like that. So when you see changes in the papilla, asymptomatic changes in the papilla throughout time, it is more due to the effect of inflammation resolution than actual trauma. Trauma per se creates desepitalization and when you have desepitalization you get soreness.
Speaker 1:In that case the clinician should intervene by stopping the usage of interdental cleaning, perhaps using some antiseptics and even maybe some wound healing enhancer, even some hyaluronic acids, and then, lastly, would revert to the use of interdental brushes, perhaps changing either the technique or the caliper.
Speaker 1:I'm saying this because most of the time, trauma is not due to the caliper but the incorrect movement of the interdental, for example, brush, which is usually used horizontal instead of going from slightly downwards, because you have to realize that the papilla are not placed like this, but they are tilted and oriented in this situation. That may happen with the brush, theoretically, may happen even with the peaks which every instrument can actually damage. But please don't get confused what is damage and what is just simple gingival resolution, which would eventually transfer in anatomical changes of the pig? Thank you. However, going back directly to the topic of the rubber pig, let me expand a bit more. Sure, this effect, this messaging effect, is that we hypothesized in due to the paper, I think in 2019, that we published on the topic, because there was a tendency, but not statistically significant.
Speaker 1:but was a tendency when comparing interdental brush with interdental peaks of seeing less bleeding in the interdental peaks, despite the level of plaque reduction was the same, so that actually was hypothesized as a massaging effect.
Speaker 2:Exactly, yeah, yeah, yeah, we all indeed already mentioned that also in the episode, so if you're interested in learning more about that, of course you can go and watch it back. Thank you for that interesting uh answer, and I think that's a actually a nice bridge into the second question that we had, again about this massaging effect, which reads do you think pics have a higher massaging effect compared to, for example, internal brushes and, if so, why?
Speaker 1:well, uh, as I said, massage effect. This massaging effect was hypothesized due to the paper that we made on predominantly healthy patients. That was a trend between brushes and peaks, ensuring that the peaks would actually reduce more gingival inflammation interdentally. But it's just a trend, it's not statistically significant and that was not noticed in predominantly affected patients. So of course we are speculating. I'm speculating here and I think the reason is due to the structure really of the rubber bristles, because the rubber area, the rubber cone per se, would actually exert pressure on the papilla and that would squeeze a little bit more the papilla compared to the Brussels. Of course it's just an hypothesis, there's nothing that I could prove it, but this is what I'm proposing.
Speaker 2:Yeah, that makes sense. That is more a mechanical action of the sturdiness of the structure of the pig compared to the more softer bristle type of contact the internet brush makes with the papilla. I think that the hypothesis could hold. Yeah, on to the next question. In some countries professionals still recommend wood sticks a lot for internet cleaning. I know, for example, this is true for the Netherlands. Yes, what is your opinion on wood sticks for interdental cleaning as compared to, for example, rubber interdental picks or interdental brushes?
Speaker 1:So, as per the wood stick, I mean, wood sticks in my country are usually limited in terms of usage to osterias and trattorias and restaurants. So if you go to the Osteria d'Ammario and you eat a wonderful steak, you might need a wood stick afterwards. The Osteria da Amario and you eat a wonderful steak, you might need a wood stick afterwards, but clearly it will not remove your interdental plaque more some chunks of steak or pasta. Having said that, the literature shows some effects of interdental wood stick as a cleaning aid. Clearly, however, the effect is located mainly on the buccal part of the interdental papilla, Whereas often, as we know, it's actually the palatal side which might need more support. So because the action is similar, I would not hesitate to go to interdental brush.
Speaker 2:Okay, okay, that's clear, thank you. Thank you, we stick to the topic of interdental tools because the next question is about applying chemical agents. There's a question what is your opinion on applying chemical agents like antiseptics on interdental brushes? So really combining an interdental brush with by dipping it into an antiseptic, for example?
Speaker 1:Do you know if this is effective? Is there any literature on this? As far as I remember, there is no literature that indicates that applying a chemicals on the toothbrush makes it more effective than just the mechanical action I would. I mean, if someone wants to use it, I would not see any issue against, although it might be that too much antiseptics can actually make the mechanical action, the mechanical friction, perhaps even less effective. Uh, but, but. But in general, I wouldn't see any problem if people would add some toothpaste or or uh or you, just, you know, pouch a little bit, rinse a little bit the peaks or the brush in the mouth, rinse or antiseptics and then use it interdentally. But I don't have data. I mean, it's actually a rather interesting topic, but I don't have data that would provide clearly a benefit.
Speaker 2:Yeah, okay, so it's more kitchen logic rather than evidence-based recommendations. Thank you, okay, thank you for that answer. So far we've been talking about interdental cleaning mainly. Let's move now on to toothbrushing, because this question is about toothbrushing techniques. Which toothbrushing technique do you recommend for prevention of periodontal diseases and pre-implant diseases, or?
Speaker 1:does it matter as long as the patient brushes. Well, I'm not aware that there is a specific technique that is superior to the other in terms of prevention of periodontitis and gingivitis, and it is not the case that I'm happy as long as the patient brush, because the issue is not that the patient would brush, but we want the patients to brush effectively and efficiently, and that's a different story. I normally nowadays actually since 2003, so now it's more than 20 years we've been working with any possible patients with prednisone, that is, with electric toothbrush. So I escaped, in a way, and moved away from the different techniques and focus more on efficiency or something very simple, because electric toothbrush is actually simpler to be used by patients. So that's why, for me, it's an essential tool in terms of prevention.
Speaker 2:So you would rather focus on making it as easy as possible for a patient to help him brush better rather than focusing on a specific technique like, for example, the modified base technique that is recommended by several institutions or guidelines.
Speaker 1:It's very generic of course, the modified bus technique, which is usually being modified, modified, modified thousands of times by any clinician and becomes a technique that everybody's inventing by themselves a little bit, but it's actually a very complex technique. So the problem with manual techniques is that they are operator-sensitive, so it depends on the patient, the dexterity and the time that the clinician can spend with the patient. So I would not hesitate. I would try to be effective and efficient.
Speaker 2:Yeah, that makes sense. Thanks a lot for that answer. That makes sense. We have a question on motivation from some of our viewers. They ask or they experience that some of their patients are not easy to motivate to start cleaning. Incidentally, in such a case, which product do you recommend starting with as an entry point to interdental cleaning?
Speaker 1:Clearly not flossing, because flossing is too technically sensitive. First of all, I would work on the motivation aspects, making sure to empower the patient with the knowledge that interdental cleaning is the most important thing that can patient do on their own oral health. So I would stress the fact that interdental cleaning should actually precede the brushing, like it's the being really the keystone of oral health and cleaning. But then I would choose perhaps a brush that fits just one size, that fits the majority of the papilla, not all of them. It might be unlikely that you get all of them, but I will try to make sure the patient just goes out with one simple product, with one technique. Tell them to work in the area that you've seen together and if there are some areas where the brush or pick or whatever the internet and he cannot go through, it doesn't matter for the time being. Just clean where you can so the patient has just one product, one simple product, and then reassess the patient in a few weeks time.
Speaker 2:That actually would allow the patient to start to get some confidence with the tool, with the techniques and at the same time not to be overloaded with tips and products and something that actually could in fact create a barrier in terms of motivation yeah, I think maybe one of the reasons this question was asked is that some patients may experience some resistance again against the metal wire of an internet brush when they start performing internet cleaning for the first time as an alternative, and this is probably particularly true for people with an intact papilla and healthy periodontium who just want to start cleaning incidentally for prevention's sake. What do you think in that case about a brush versus a pick, for example? What is then sort of the best starting point for incidental cleaning?
Speaker 1:well, once again, I have no data comparing this and of course this is something that is very intangible, but it goes very much to the patient preferences and everybody is always very different in the market. When you don't think about patient but you think about consumers, of course everybody has his own preference. But clearly, you know, I understand your point and and if patients have some sensitivity with, with the metal structure of the bristles and of course there are no alternatives the rubber picks could actually be a good tool as a starting point. In fact, when I mentioned before that it's important to give at the beginning, when people is not highly motivated or has some difficulty in motivation, just one tool or has some difficulty in motivation, just one tool. In that case, usually rubber picks are a very viable alternative because in fact they just come with just one size when one buys a box, so it's just a matter to see whether they fit correctly or not in the patient's mouth.
Speaker 2:Yeah, okay, thank you. On to the penultimate question. So far, we've mainly talked about mechanical plaque control, also in the episode that already aired a while ago. However, what is your opinion on the use of antiseptics for plaque control?
Speaker 1:Well, antiseptics are a wonderful add to mechanical plaque control. You can't do anything without mechanical plaque control. You can't do anything without mechanical plaque control. But sure, antiseptics can give you something more. Now it's always very tricky to understand which are really the indication for antiseptics.
Speaker 1:Now, toothpaste it is often an antiseptics and it's widely accepted. Nobody would brush their teeth without toothpaste, let's face it. So we're not here to try to understand whether to add or not a toothpaste, because that would be there by default. The question is whether to add perhaps a mouth rinse or some specific tools to empower more, to potentiate the effect in terms of plaque control or any other effect that could be relevant, such as inflammation, breath control and so forth. But clearly there are some local and general factors that would actually suggest me to consider the usage, for example, of an antiseptic such as a mouth rinse, for example.
Speaker 1:In terms of generalized situation, I would say if the patient is, for example, very old and frail, or patients that can actually might have lost or reduced dexterity, in that case antiseptics are very efficient. When I can see a clear discrepancy between plaque and inflammation, then I would perhaps always give a bit more and try to enhance as much as I can. And then, of course, local factors are mainly related to inadequate plaque control in some areas, you know, to crowding overhangs or some anatomical features that wouldn't allow the patients to be efficient with the classical techniques. So instead of making perhaps a too complicated and tailored origin extraction, we can add a little bit, and we can add a mouth in that case.
Speaker 2:So it's always dependent on the indication of the patient. I think that makes a lot of sense.
Speaker 1:Yeah, absolutely on the indication of the patient. I think that makes a lot of sense. Yeah, absolutely, I'm really not at all in favor of the fact that the patient should go as sort of a representative of the mass market to go in a mall and buy themselves products. Everything should actually be seen by a professional beforehand.
Speaker 2:Absolutely, yes, no, absolutely, that makes sense. Yes, okay, thank you. We have one final question lined up, and that is at what age would you recommend starting with internal cleaning?
Speaker 1:that's an interesting question. I'm saying it's an interesting question because, as everybody knows, I hardly treat people that are below the age of 20 because I just treat people with prudentitis. But but I would um well, I, if I would look at the gum size of it, perhaps I would say 18 years old of age, because the incidence of uh periodontitis before 18 is really anecdotal. Of course there are some cases, clearly with some medical issues, some syndromes or even some pubertal cases, but overall we're talking about a minimal in terms of a population really neglectable amount of incidence. But at the same time you have people, especially in the teenager, that are clearly cardiophilic or at least they have a tendency to develop caries. So I would say that whenever you can achieve some compliance from the patient, you should consider it. So you might find maybe some girl, a 13, that is capable of doing maybe a gentle floss or something which you might want to consider, whereas you might find somebody that before 18 doesn't even think about it.
Speaker 2:So it's very much related to the patient, but overall I would say teenager roots slash onwards yeah, yeah, that makes sense also from the point of view that when you already start adopting internet cleaning as a habit or as a ritual already early in your life, it's probably more likely to be maintained during the course of your life, whereas when you start, for example, when you're already in your 30s or 40s or 50s, it's probably harder to start a new ritual. So maybe from that perspective it also makes sense to start early, even maybe if there is no indication yet for uh yeah I would like to hear the opinion of a pediatric dentist.
Speaker 1:Yeah, for me, 17 years old, it's a pediatric patient. I'm not really capable to provide no, okay, that's, that's fine.
Speaker 2:Maybe, uh, it's a nice topic for a follow-up conversation we have in the future, um, in any case, um, that were all the questions that we had for today. So thank you so much, filipo, for entering them all. I think it offered a lot of additional insight on top of the conversation that we already had in our studio previously. So, filipo, thank you again for your availability and for sharing your expertise. Thank you, and thank you also to our audience for tuning in and see you all next time thank you for tuning in to today's episode of the let's.
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