Oh Canada! Summer Issue - 2014 9 This article is sponsored by Johnson & Johnson Inc. The accuracy, completeness, and usefulness of the content are the sole responsibility of the author and do not necessarily represent the official views of Johnson & Johnson Inc. Thinking About Our Thinking About Oral Rinsing: The Third Essential Component to Home Care (Part 1) By Joanna Asadoorian, RDH, PhD joanna.asadoorian@umanitoba.ca INTRODUCTION Dental hygienists know that client oral home care is critical for achieving and maintaining a healthy oral cavity. Beyond a healthy periodontium, oral health has far-reaching benefits including a positive association with systemic health. 1,2 It is clear that plaque biofilm is the major etiological factor for gingivitis, periodontitis and caries, and the primary aspect linking oral and systemic inflammation. 3,4 When biofilm matures due to suboptimal oral home care, its composition changes and includes more pathogenic bacteria. 3 These latter colonizers, sometimes referred to as red complex bacteria, contain anaerobic and erosive species that evade the immune and lymphatic systems and can kill immune cells. 3 The mature biofilm migrates subgingivally and becomes less accessible to oral hygiene efforts, thereby increasing potential for severe disease. SCIENCE Most people are well aware of the need for oral home care and perform well with toothbrushing. While most clients know they should floss, they may not fully appreciate the objective of cleaning interdentally with floss or other means. Flossing compliance remains poor with only about 10% to 30% of the population reporting doing so. 5,6 This situation is likely due to multiple factors including the cumbersome nature of the task. Dental hygienists recognize that even those who do floss do so with less than optimal technique, thereby diminishing the benefits. Because most individuals do not achieve ideal oral hygiene through mechanical means alone, scientific groups recommend augmenting routines with oral chemotherapeutics. 7 It has been demonstrated that 65% to 75% of oral surfaces remain colonized by pathogenic microorganisms after brushing and flossing. 8 While toothbrushing and interdental cleansing are indispensable, therapeutic oral rinses are recommended as the third critical component for oral care because they reach virtually everywhere in the oral cavity in about thirty seconds. 9,10 Oral rinses cause cell death, inhibit microbial reproduction, and hinder metabolism 9 and, in so doing, reduce biofilm, delay reformation, and reduce inflammation. 7 Highly rigorous trials conducted using American Dental Association (ADA) guidelines (Box 1) demonstrate the efficacy of specific rinse formulations in providing an additive benefit to mechanical cleansing. 11-13 From the literature, there are currently three antiseptic agents that have demonstrated therapeutic benefits: chlorhexidine gluconate (CHG), essential oil (EO) and cetylpyridinium chloride (CPC). Box 1. ADA guidelines for clinical trials of chemotherapeutic mouthrinses 24 ADA acceptance program for chemotherapeutic mouthrinses: 2 independent placebo-controlled studies, minimum 6 months demonstrate statistical significance in plaque and gingivitis reductions vs. control minimum of 15% gingivitis reductions in at least 1 study; average 20% across 2 studies Systematic reviews, the highest level of evidence, have evaluated the clinical relevance of these key formulations, measuring plaque and inflammation reductions compared to placebo controls over six months, and have demonstrated that CHG and EO mouthrinses provide significant reductions. Studies of CPC rinses were less conclusive as they used different formulations. 14-17 Data from an earlier study, 11 showing the adjunctive benefit of an EO rinse (Listerine ) to daily mechanical methods on plaque and gingivitis recently underwent a post-hoc site-wise analysis in which the health of each gingival site, marginal and interproximal, was evaluated at six months. The site was considered healthy if the score was 0 or 1 on the MGI scale. 18 Strikingly, even the gingival health of proximal sites dramatically improved when the EO mouthrinse augmented toothbrushing and flossing (Box 2).
10 Oh Canada! Summer Issue - 2014 This article is sponsored by Johnson & Johnson Inc. Maxillary Marginal Sites 6 months Box 2. Marginal and interproximal gingival health following toothbrushing, flossing, and therapeutic EO mouthrinse use Healthy Site (% of subjects) 100 90 80 70 60 50 40 30 20 10 0 Gingival site Brushing Alone Brushing + Floss Brush + Floss + LISTERINE Reprinted with permission of Johnson & Johnson Healthcare Products, Division of McNeil-PPC, Inc. McNeil-PPC, Inc. 2014. Post-Hoc Analysis of the Sharma et al. 2004 Study Healthy Site (% of subjects) 100 90 80 70 60 50 40 30 20 10 0 Maxillary Proximal Sites 6 months Gingival site Brushing Alone Brushing + Floss Brush + Floss + LISTERINE Reprinted with permission of Johnson & Johnson Healthcare Products, Division of McNeil-PPC, Inc. Post-Hoc Analysis of the Sharma et al. 2004 Study McNeil-PPC, Inc. 2014. INCORPORATING THERAPEUTIC RINSES INTO PRACTICE The research is compelling in demonstrating that therapeutic rinses, such as EO and CHG, are safe and beneficial in reducing both plaque and gingival inflammation over and above toothbrushing and flossing alone. In addition, comparable inflammation reductions are shown with over-the-counter EO mouthrinse and CHG prescription rinse, with the former being free of the unacceptable side effects of the latter, like dental staining. Despite the solid body of evidence, dental hygienists do not routinely recommend the incorporation of a therapeutic oral rinse to their clients. Market research estimates current use of an essential oil mouthrinse to be approximately 20% of the population. 19 More concerning is information indicating that dental hygienists recommend a therapeutic oral rinse to 3 of 10 clients in comparison to 9 of 10 who recommend flossing. 19 There is clearly a gap between the evidence and dental hygiene practice. One of the main problems afflicting health research is its failure to be integrated into practice. The broad field of knowledge translation has emerged to address this tendency, and most evidence suggests that health care providers are aware of current research but are prevented from applying it to practice by ambiguous influences. 20 This phenomenon occurs in what is sometimes referred to as the knowledge translation black box (Box 3), which is the unobservable cognitive space between knowledge acquisition and application to one s practice. 21 Much
This article is sponsored by Johnson & Johnson Inc. Oh Canada! Summer Issue - 2014 11 Box 3. translation process* translation - black box generation dissemination acquisition Deliberation and decision making application (in)action *Adapted with permission from Asadoorian J. Exploring dental hygiene clinical decision making a mixed methods study of potential organizational explanations: Phase I. Can J Dent Hyg. 2012;46(4):208. theorizing is occurring about the forces at play in the knowledge translation black box, mostly surrounding practice barriers and how to traverse them. If most dental hygienists are aware of the benefits of incorporating therapeutic oral rinse into home care routines, then one must consider the potential explanations for its failure to be more widely applied to practice. For example, dental hygienists may: not be aware of the adjunctive benefits of oral rinsing over and above toothbrushing and flossing; be concerned that clients will discontinue mechanical cleansing efforts, such as they are, if an EO oral rinse is recommended; lack the time or confidence to explain research on therapeutic oral rinses to clients; need to convince an employer and peers before making changes to practice; be worried about convincing clients to add rinsing to their routines; remain skeptical, despite the research, because of long-held biases against the efficacy and safety of therapeutic oral rinses; be generally apathetic surrounding practice changes. client care as well as ways of overcoming such barriers. Health care providers often feel defensive when hearing information contradicting their own practice behaviours because it threatens their self-concept about competency. 22 Because a cognitive dissonance is created, practitioners find ways to mentally discount conflicting information and maintain positive self-perceptions, 22 such as disbelieving the credibility of the research(er), thinking it irrelevant or simply not thinking about it all. What is important for the dental hygienist to consider is that feeling an internal dissonance is actually a sign potentially to improve one s practice rather than an indication that one is performing suboptimally. Dental hygienists can borrow from the Japanese Continuous Quality Improvement approach known as Kaizen loosely meaning good change which characterizes such moments as emotional pearls triggering reflection on practice, and making positive changes. 23 While this metacognitive perspective on practise change is complex, it offers some interesting insights into changing behaviour and improving performance for those dental hygienists who choose simply to think more about practice thinking. The next phase is to apply changes to practice, by understanding and using innovative techniques to counsel clients and encourage their positive health behaviour changes. This will be the focus of Part II of this paper to be published in the next issue of Oh Canada!. Click to view references for this article As competent dental hygienists, it is vital to be mindful of practice beliefs and biases and think about what might be preventing the implementation of current knowledge into
22 Oh Canada! Fall Issue - 2014 This article is sponsored by Johnson & Johnson Inc. The accuracy, completeness, and usefulness of the content are the sole responsibility of the author and do not necessarily represent the official views of Johnson & Johnson Inc. Thinking About Our Thinking About Oral Rinsing: The Third Essential Component to Home Care (Part 2) by Joanna Asadoorian, RDH, PhD joanna.asadoorian@umanitoba.ca In Thinking about Oral Rinsing (Part 1 of this paper), the additive benefit of therapeutic oral rinsing to mechanical cleansing for reducing plaque and gingival inflammation was outlined with particular attention to over-the-counter essential oil (EO) mouth rinse (LISTERINE ). 1 It was highlighted that dental hygienists often fail to recommend therapeutic oral rinses as a third essential component for home care routines, with only 3 of 10 clients receiving such a recommendation compared to 9 of 10 clients who receive flossing instruction. 1,2 Part 1 aimed to make dental hygienists aware of the science and to explore their thinking about implementing the evidence into practice. Now, with this clear outlook, it s time to take action! Dental hygienists, like most health care providers, are challenged by clients inability to adopt various healthy behaviours, including flossing, and stop unhealthy ones, like smoking. This paper will introduce dental hygienists to some new thinking and techniques to better facilitate their clients adoption of new healthy behaviours like therapeutic oral rinsing. Box 1. Four steps for facilitating behaviour change 6 Change based relationship Getting to the behaviour Change the behaviour Sustaining the behaviour Shared decision making Motivational interviewing Change talk Readiness assessment: Ready, not ready, ambivalent Traffic light assessment Setting SMART goals Behaviour modification Identify barriers Sustain change through self-efficacy and managing streses Educate and support Health care providers know that there is no magic bullet for changing human behaviour. However, a better approach than trying to coerce clients into complying with recommendations is to adopt health behaviour counselling techniques based in behavioural psychological theory specifically adapted for clinicians. 3-5 Patients often avoid health care providers or tune them out because of perceived judgement; dental hygienists may do better with clients by suspending judgements and recognizing that healthy behaviours are actually abnormal! Typically, unhealthy behaviour is easier, more pleasurable, and has more short-term benefits. 6 For clients who desire a healthy oral cavity, dental hygienists need to find a way to stimulate their clients inner motivation to embrace healthy behaviour and transcend the ease and pleasure of unhealthy behaviour. Helping clients to become motivated about oral rinsing is different from inspiring them. Hearing about a mother of three running a full marathon is inspiring but does little to incite sustained personal change. Conversely, motivation is intrinsic, encourages independence, and is sustainable. 6 While most practitioners realize that one cannot motivate someone else, dental hygienists are in a strong position to induce clients to talk about healthy behaviours and facilitate change. For successful facilitation, four steps have been identified: develop a change-based relationship, get to the behaviour, change the behaviour and, lastly, sustain the behaviour (Box 1). 3,6 The first step is something that many dental hygienists may believe they already have accomplished: a supportive relationship with clients. Dental hygienists have relatively long and frequent appointments with clients and enjoy a pleasant association with them. However, a friendly relationship is different from a change-based one. The latter is needed to effectively facilitate client motivation for incorporating new healthy behaviour, like rinsing with a therapeutic mouthwash, into their daily routines. 6 Health care providers aiming to help clients adopt healthier habits need to ensure that they have a neutral power relationship with clients, meaning that both clinician and client have important and active roles and will share in decision making. 6,7 This is where motivational interviewing
Oh Canada! Fall Issue - 2014 23 (MI), a widely recommended communication technique used to strengthen motivation for positive change, can be helpful. 3,8 While MI can be intimidating to use because of its complexity, dental hygienists can concentrate on its general principles, including asking open-ended questions, expressing empathy, being curious, working with ambivalence, and rolling with resistance, which together result in crucially important change talk. 3,6,8,9 When there is a change-based relationship between the dental hygienist and client, the potential exists to get to the behaviour you are targeting with your client, such as using an EO mouth rinse. Getting to the behaviour involves assessing clients health beliefs and readiness to make a change. 6 Recognize that only about 20% of clients will come to dental hygiene appointments ready to change. 6 While some clients will ask about incorporating an oral rinse, most will be ambivalent or won t be thinking about it at all, likely because they believe they are doing enough by toothbrushing. Ambivalence is normal: it means the client sees the benefits to something but also recognizes the negative aspects of changing. 6,8 For example, your client may say, I d really like to do a better job cleaning my teeth, but I m just so busy, I don t have the time. These are not excuses; they are valid perceptions about the benefit versus the cost of changing behaviour. Everyone experiences ambivalence it s no different from wanting to get up early to go to the gym but also wanting to sleep in an extra hour. To reduce gingival inflammation and improve oral health, an unquestionable opportunity exists in recommending a therapeutic oral rinse to clients. Because oral rinsing is simple to do, dental hygienists can readily show clients that the cost-side is minor. However, to clearly demonstrate the benefits, the dental hygienist needs to educate clients about the prevalence of plaque associated gingival disease so that they recognize their susceptibility and the potential consequences. Such education will likely convince the client that the cost is very much worth the benefit! Then, it is a matter of strategizing with the client about how best to tolerate the cost, such that it is, and persist through it. Box 2.Traffic light assessment 3,6 No to all or most questions Mix of yes and no answers Yes to all; little/no doubt While various methods are available to determine if a client is ready to change, 8 dental hygienists can incorporate a simple traffic light assessment (Box 2) and establish if the client is ready for, ambivalent towards or not even thinking about change. 6 The Behaviour Change Institute, an interdisciplinary group of clinician researchers who have developed behaviour change counselling strategies for nonpsychologists, suggests asking four questions for assessing readiness that may be helpful for the dental hygienist (Box 3). 3 Having assessed readiness, the dental hygienist can respond with the appropriate action: dive right into the change, expand on readiness by exploring client s health beliefs and reasons for changing versus not changing or, at least, demonstrate understanding and try to keep the conversation going.even if it needs to continue at the next appointment. 3,6 When the client is ready to make a change and try therapeutic oral rinsing, the dental hygienist can use her or his behaviour change skills to modify the behaviour. Making a change involves an explicit goal: something specific, measurable, achievable, relevant, and timely sometimes referred to as a SMART goal. 3,6 Most importantly, the dental hygienist should ensure that the goal is small and achievable and that the client s expectations for desired outcomes are realistically aligned with the behavioural goal. While adding EO mouth rinse to one s continued...
24 Oh Canada! Fall Issue - 2014 Thinking about our thinking about oral rinsing... cont d 1. Is not thoroughly cleaning your mouth/teeth a problem for you? 2. Does not thoroughly cleaning your mouth/teeth cause you any distress? 3. Are you interested in more thoroughly cleaning your mouth/teeth? 4. Are you ready to do something to more thoroughly clean your teeth/ mouth now? Box 3. Assessing client readiness 3,6 daily routine is not nearly as complex as other health behaviour changes, the principles are the same, and will still require discussion about reinforcing the behaviour and consideration of potential obstacles and how they will be circumvented. The final step, and perhaps most difficult, is to sustain behaviours, which is largely accomplished through managing emotions. 3,6 While this is a very challenging component of some health behaviour changes, like healthy eating and smoking cessation, incorporating oral rinsing is likely much less emotionally charged. However, this stage does require the clients to have the sustained confidence to take control of their behaviour and believe that they can make an impact on their oral health. The dental hygienist provides continuous education, support, and empathy. Dental hygienists, like other health care providers, have traditionally been trained to approach client behaviour change in a prescriptive manner, where the clinician is the knowledge provider and the client readily adheres to instruction. 9 People s ongoing struggle to make improvements to their health behaviours demonstrates, however, that this approach has been unsuccessful. Using the theory and techniques presented here provides the dental hygienist with a starting point for introducing an EO mouth rinse to clients oral health routine and also likely for many other important behaviour changes recommended to clients. References 1. Asadoorian J. Thinking about thinking about oral rinsing: The third essential component to home care. Oh Canada! 2014;Summer:9-11. 2. Johnson & Johnson Healthcare Products DoM-P, Inc. 2014. 3. Vallis M. Behaviour change counselling: How do I know if I m doing it well? Can J Diabetes. 2013;37:9. 4. DiMatteo MR, Haskard-Zolnierek KB and Martin LR. Improving patient adherence: a three factor model to guide practice. Health Psychology Review. 2012;6(1):71-94. 5. Michie S, Johnston M. Theories and techniques of behaviour change: Developing a cumulative science of behaviour change. Health Psychology Review. 2012;6(1):6. 6. Vallis M. Surrendering to succeed: Accepting the challenges. Presentation to the Manitoba Psychological Society, 2013. Winnipeg, Manitoba. 7. Cutica I, McVie G and Pravettoni G. Personalized medicine: The cognitive side of patients. Eur J Internal Medicine. 2014:4. 8. Ramseier CA, Suvan JE. Health behavior change in the dental practice. Ames, Iowa: Wiley-Blackwell; 2010. 177 p. 9. Bray KK, Catley D, Voelker MA, Liston R and Williams KB. Motivational interviewing in dental hygiene education: Curriculum modification and evaluation. J Dent Educ. 2013;77(12):8.