Oral Hygiene Advice vs. Periodontal Instrumentation
Oral Hygiene Advice vs. Periodontal Instrumentation
Periodontal disease is the most common oral disease affecting adults. This disease is largely preventable, yet it remains the major cause of poor oral health worldwide and is the primary cause of tooth loss in older adults. Accumulation of microbial dental plaque is the primary aetiological factor for both periodontal disease and caries. Susceptibility to periodontal disease is also influenced by the host's defence mechanisms to bacterial infection and other risk factors such as calculus and smoking. Periodontal disease affects tissues surrounding and supporting the teeth and is classified into two broad categories: gingivitis and periodontitis. Gingivitis is a reversible condition characterised by inflammation and bleeding at the gingival margin. It is a pre-requisite for periodontitis and is also a risk indicator for caries progression. Periodontitis is the irreversible destruction and loss of the supporting periodontal structures (periodontal ligament, cementum and alveolar bone). The result is unsightly gingival recession, sensitivity of the exposed root surface, root caries (decay), mobility and drifting of teeth and, ultimately, tooth loss.
Effective self-care (tooth brushing and interdental aids) for plaque control and removal of risk factors such as calculus, which can only be removed by periodontal instrumentation (PI), are considered necessary to prevent and treat periodontal disease thereby maintaining periodontal health.
The 1998 UK Adult Dental Health Survey (ADHS) provides some evidence that the majority of UK adults might be at risk of developing periodontal disease: 72% of dentate adults had visible plaque, indicating tooth brushing was ineffective, and 73% had calculus on at least one tooth. Forty-three percent of adults had some moderate periodontal disease (at least one periodontal pocket with a probing depth of ≥ 4 mm < 6 mm) increasing by age from 14% aged 16–24 to 85% ≥65. Indicators of severe disease (periodontal pocket depth ≥ 6 mm) also increased with age affecting 31% of ≥65 year olds. A recent study of adults aged 20 to 55 in Scotland provided evidence that the 1998 ADHS figures underestimate the current extent of periodontal disease. Only 15% exhibited no clinical signs of disease and 63% exhibited moderate disease.
Despite evidence of an association between sustained, good oral hygiene and a low incidence of periodontal disease and caries in adults there is a lack of strong and reliable evidence to inform clinicians of the relative effectiveness (if any) of different types of Oral Hygiene Advice (OHA).
A number of relevant systematic reviews evaluating OHA have been conducted with some inconsistency in their findings. The most recent, a Cochrane review of psychological interventions to improve adherence to oral hygiene instruction in adults with periodontal disease found evidence that psychological interventions resulted in improvements in oral hygiene related behaviours and self-efficacy beliefs. However, only four low quality trials were eligible for inclusion and the authors concluded there was a need for greater methodological rigour in trials in this area. A review of studies reporting clinical health outcomes concluded that most OHA interventions provide a short-term (≤ 6 month) reduction in plaque and gingival bleeding. The authors highlighted the lack of and need for studies to assess the sustainability of these short-term benefits.
The evidence to inform clinicians of the effectiveness and optimal frequency of PI is mixed. The West Midlands Health Technology Assessment Group's systematic review of PI (including root planing) for chronic periodontal disease in specialist settings concluded that the quality of the research base, in terms of study design, quality of reporting and statistical reporting, was poor. Some positive effects (reduction in pocket depth and bleeding on probing) were found, but the marginal effect of quarterly PI over annual PI was small. No long term studies where annual PI was carried out were identified; no studies investigated patient centred outcomes; and the authors highlighted the need for further research to determine the generalisability of the findings to general dental practice. The Cochrane systematic review of PI (i.e. single-visit periodontal instrumentation without root planing) for adults found the evidence for effectiveness and optimal frequency to be weak and unreliable, providing little guidance for policy makers, dental professionals or patients. Only nine trials were eligible for inclusion, all had a high risk of bias and it was not possible to carry out a meta-analysis. Given that PI is routinely provided in general dental practice it is noteworthy that none of the eligible trials were conducted in primary care, included patient centred outcomes, economic analyses or long term effects. Evidence from a recent systematic review suggests that stability of clinical attachment for patients with a history of chronic periodontitis receiving supportive periodontal care (non-surgical and surgical) is greater, but less cost-effective, in specialist settings than in general practice settings. However, this conclusion was based on only three studies and the estimates of cost-effectiveness used data from only one study. The need for further research, including research investigating patients' willingness to pay, was highlighted.
There is therefore an urgent need to assess the relative effectiveness of OHA and PI in a robust, sufficiently powered randomised controlled trial (RCT) in primary dental care.
The aim of this study is to compare the effectiveness and cost-effectiveness of theoretically based, personalised oral hygiene advice (OHA) or periodontal instrumentation (PI) at different time intervals (no PI; 6 monthly PI or 12 monthly PI) or their combination, for improving periodontal health in dentate adults attending general dental practice.
The primary objectives are to test the effectiveness and cost effectiveness of the following dental management strategies:
a) Personalised OHA versus routine OHA;
b) 12 monthly PI versus 6 monthly PI;
c) No PI versus 6 monthly PI.
The secondary objectives include:
d) To test the effectiveness and cost-effectiveness of a combination of personalised OHA with different time intervals for PI;
e) To measure dentist/hygienist beliefs relating to giving OHA, PI and maintenance of periodontal health.
Background
Periodontal disease is the most common oral disease affecting adults. This disease is largely preventable, yet it remains the major cause of poor oral health worldwide and is the primary cause of tooth loss in older adults. Accumulation of microbial dental plaque is the primary aetiological factor for both periodontal disease and caries. Susceptibility to periodontal disease is also influenced by the host's defence mechanisms to bacterial infection and other risk factors such as calculus and smoking. Periodontal disease affects tissues surrounding and supporting the teeth and is classified into two broad categories: gingivitis and periodontitis. Gingivitis is a reversible condition characterised by inflammation and bleeding at the gingival margin. It is a pre-requisite for periodontitis and is also a risk indicator for caries progression. Periodontitis is the irreversible destruction and loss of the supporting periodontal structures (periodontal ligament, cementum and alveolar bone). The result is unsightly gingival recession, sensitivity of the exposed root surface, root caries (decay), mobility and drifting of teeth and, ultimately, tooth loss.
Effective self-care (tooth brushing and interdental aids) for plaque control and removal of risk factors such as calculus, which can only be removed by periodontal instrumentation (PI), are considered necessary to prevent and treat periodontal disease thereby maintaining periodontal health.
The 1998 UK Adult Dental Health Survey (ADHS) provides some evidence that the majority of UK adults might be at risk of developing periodontal disease: 72% of dentate adults had visible plaque, indicating tooth brushing was ineffective, and 73% had calculus on at least one tooth. Forty-three percent of adults had some moderate periodontal disease (at least one periodontal pocket with a probing depth of ≥ 4 mm < 6 mm) increasing by age from 14% aged 16–24 to 85% ≥65. Indicators of severe disease (periodontal pocket depth ≥ 6 mm) also increased with age affecting 31% of ≥65 year olds. A recent study of adults aged 20 to 55 in Scotland provided evidence that the 1998 ADHS figures underestimate the current extent of periodontal disease. Only 15% exhibited no clinical signs of disease and 63% exhibited moderate disease.
Despite evidence of an association between sustained, good oral hygiene and a low incidence of periodontal disease and caries in adults there is a lack of strong and reliable evidence to inform clinicians of the relative effectiveness (if any) of different types of Oral Hygiene Advice (OHA).
A number of relevant systematic reviews evaluating OHA have been conducted with some inconsistency in their findings. The most recent, a Cochrane review of psychological interventions to improve adherence to oral hygiene instruction in adults with periodontal disease found evidence that psychological interventions resulted in improvements in oral hygiene related behaviours and self-efficacy beliefs. However, only four low quality trials were eligible for inclusion and the authors concluded there was a need for greater methodological rigour in trials in this area. A review of studies reporting clinical health outcomes concluded that most OHA interventions provide a short-term (≤ 6 month) reduction in plaque and gingival bleeding. The authors highlighted the lack of and need for studies to assess the sustainability of these short-term benefits.
The evidence to inform clinicians of the effectiveness and optimal frequency of PI is mixed. The West Midlands Health Technology Assessment Group's systematic review of PI (including root planing) for chronic periodontal disease in specialist settings concluded that the quality of the research base, in terms of study design, quality of reporting and statistical reporting, was poor. Some positive effects (reduction in pocket depth and bleeding on probing) were found, but the marginal effect of quarterly PI over annual PI was small. No long term studies where annual PI was carried out were identified; no studies investigated patient centred outcomes; and the authors highlighted the need for further research to determine the generalisability of the findings to general dental practice. The Cochrane systematic review of PI (i.e. single-visit periodontal instrumentation without root planing) for adults found the evidence for effectiveness and optimal frequency to be weak and unreliable, providing little guidance for policy makers, dental professionals or patients. Only nine trials were eligible for inclusion, all had a high risk of bias and it was not possible to carry out a meta-analysis. Given that PI is routinely provided in general dental practice it is noteworthy that none of the eligible trials were conducted in primary care, included patient centred outcomes, economic analyses or long term effects. Evidence from a recent systematic review suggests that stability of clinical attachment for patients with a history of chronic periodontitis receiving supportive periodontal care (non-surgical and surgical) is greater, but less cost-effective, in specialist settings than in general practice settings. However, this conclusion was based on only three studies and the estimates of cost-effectiveness used data from only one study. The need for further research, including research investigating patients' willingness to pay, was highlighted.
There is therefore an urgent need to assess the relative effectiveness of OHA and PI in a robust, sufficiently powered randomised controlled trial (RCT) in primary dental care.
Trial Aim
The aim of this study is to compare the effectiveness and cost-effectiveness of theoretically based, personalised oral hygiene advice (OHA) or periodontal instrumentation (PI) at different time intervals (no PI; 6 monthly PI or 12 monthly PI) or their combination, for improving periodontal health in dentate adults attending general dental practice.
Objectives
The primary objectives are to test the effectiveness and cost effectiveness of the following dental management strategies:
a) Personalised OHA versus routine OHA;
b) 12 monthly PI versus 6 monthly PI;
c) No PI versus 6 monthly PI.
The secondary objectives include:
d) To test the effectiveness and cost-effectiveness of a combination of personalised OHA with different time intervals for PI;
e) To measure dentist/hygienist beliefs relating to giving OHA, PI and maintenance of periodontal health.
