Aligning patient need with product benefits.
The answer is that a variety of both prescription and over-the-counter mouth rinses can boost the effectiveness of brushing and flossing. It's simply a matter of aligning patient need with the proper product.
For the dental hygienist, the first step is to use a thorough oral health assessment. For Teri Gutierrez, RDH, this process begins with a health history review with new patients and a once-a-year update with return patients to learn of health changes and medication additions to the patient's life.
While many patients associate mouth rinses with breath issues, Gutierrez discusses breath issues as a side effect of health problems so as to not make the patient self-conscious. "We want our patients to feel comfortable about their oral health," she explained. "I want them to understand the domino effect that goes on with not only a bad breath situation, but periodontal disease and inflamed gums. Patients are more compliant when they understand what is happening with their body. An educated patient is the best kind."
Tammy L. Filipiak, RDH, BS, stressed the importance of risk assessment when recommending any product to patients.
When you commit to a philosophy of risk assessment, Filipiak said, "you identify risk areas with your patients. [The dental hygienist] becomes less skewed ... by knowing what the patient has done in the past, what their dental benefit plan might cover, what you think they could or could not afford. You talk to patients about exposed root surfaces, or gingival conditions. You give the patients the facts and let them decide. A risk-assessment process makes it easier for clinicians." Filipiak lets patient need dictate what type of mouth rinse she recommends.
It is a similar situation for Celeste Baranowski, RDH. In addition, she promotes "anything that will have the patient using the recommended home-care product."
Peter Gangi, RDH, BSEd, looks for products that are proven effective and taste good. "Patients will be more compliant to use that," he commented.
Choices for the Operatory
Filipiak believes in pre-procedural rinsing to reduce bacteria for a variety of procedures from extractions to ultrasonic. "It makes a huge impact on the amount of bacteria we're putting out in the air and in the mouth," she said. For Gangi, Listerine is the pre-procedural rinse of choice, and the practice in which Gutierrez works uses Tooth & Gum Tonic from the Dental Herb Co., unless the patient has trouble with the taste.
"Some patients find the taste objectionable. We note that on their chart and if that is the case, then we use BreathRx," Gutierrez commented. For pre-procedural rinses, irrigation and occasionally homecare, Baranowski used Perio Rx and/or Peridex chlorhexidine rinse.
Gutierrez uses chlorhexidine for subgingival irrigation. "If a patient has active rampant periodontal disease, we will prescribe some chlorhexidine for them to use while they are going through their non-surgical therapy. We actually just started using CloSYS," she said, adding that the product is similar to BreathRx in that it works on the volatile sulfur compounds that cause bad breath. Filipiak commented that she uses subgingival antimicrobial therapies such as Arestin, and may also use mouthrinses as needed in her care planning.
Filipiak notes that there are many products available for patients today and will recommend BreathRx for patients sensitive to alcohol, and sometimes a stannous fluoride rinse for patients as another option when indicated.
"It has somewhat of an antimicrobial effect, so it can be used with the patient with periodontal issues as well," Filipiak stated.
The greatest challenge is getting the patient engaged in home-care therapies. To gauge if a patient is actually using prescription products, Filipiak asks patients at their next appointment how they are doing with the home therapy and if they need a refill. If the patient says they still have plenty of product at home, then she knows that the patient probably has not been using it on a daily prescribed basis.
"I get the patient more engaged when I can hold their hand and lead them down the path!" Filipiak said. For a patient who is reluctant to spend the extra money on a prescription product in favor of one that is over-the-counter, she shares the parts per million of fluoride found in each. The patient might be surprised at the cost and improved oral health benefits of using a stronger formula that requires more of an investment.
"Sometimes we have to downshift if we have a patient who doesn't want to make the investment in a prescription product, and then we might go to that over-the-counter rinse," she admitted. "We are always going to give them the best recommendation first, and also follow-up at future visits to revisit the benefits of the better therapy. For some patients, it takes more time and education; we cannot give up on them."
For a patient with high caries risk, Filipiak may also discuss the benefits of a chlorhexidine rinse. "It has an impact on bacteria. Most commonly, we would combine that with other caries management therapy such as home fluoride use or MI Paste or something else to reduce the caries risk," she said. Chlorhexidine rinses also aid patients with gingivitis and denture stomatitis. In the practice in which Filipiak works, products such as chlorhexidine and fluorides are dispensed on site, and are part of a comprehensive caries risk assessment/remineralilzation protocol. "Our hygienists work in partnership with our doctors to determine the best therapies and care plan for each individual patient," she said. "We feel that it increases patient compliance because it's one less thing they have to go out and pick up. Part of [compliance] is about convenience."
Gutierrez shared a similar philosophy. Any product she recommends must be readily available. "We don't like patients to have to go 'off the hill'" she said, referring to trips outside of her small mountain community perched at 7,000 feet in the Southern California mountains. "If they can't get it, they can't use it," she commented. Gutierrez recommends both BreathRx rinse and toothpaste, and frequently offers samples to patients in the office.
Baranowski, who also liked to recommend BreathRx and Listerine home care products, added TheraSol antimicrobial rinse to her list. For at-home caries control and sensitivity prevention, she included Fluorigard and ACT fluoride rinses. Gangi recommended similar fluoride products, as well as Listerine, for at-home use.
"For patients who have a history of decalcified enamel, you hope for a remineralization through the use of fluoride rinses," continued Gangi, who sometimes varies from his usual product lineup with a non-alcohol product such as Crest ProHealth rinse. "For patients who have orthodontics, you want them to have plenty of fluoride rinse."
For cancer patients, Baranowski recommends Oasis and Biotene as a home-care product "because it is alcohol-free and has enzymes that boost antibacterial action."
What Baranowski hoped to accomplish with each mouth rinse recommendation was "to educate patients [about] proper use and how this product, along with other oral health care, can benefit their health."
Gangi similarly wanted his patients to achieve a greater awareness of their own oral health. "If they go home and pay more attention to their teeth--what they look like, how they feel, how their mouth feels after using these products--they tend to be more enthusiastic," Gangi reported.
For patients with dexterity issues, such as elderly patients and children, fluoride mouth rinses offer additional bacteria-removing benefits, said Gangi, but the rinse works only for those who are clearing the way by brushing and flossing.
"The problem with kids is they need to have better oral health home care for the fluoride to work. If their teeth are covered in plaque and food debris, it will be hard for the fluoride to reach the tooth surface," Gangi commented. He takes time with child patients and their caregivers during visits to make certain they know the proper procedures for using mouth rinses at home.
Gutierrez sees benefits with each prophy appointment, "especially those returning at a three-month recall [who] have gone through some nonsurgical therapy." Her skills with laser therapy, paired with a prescribed chlorhexidine rinse aid the situation as well by providing deep bacterial control without harming the tissue. Gutierrez also has noticed that periodontal patients and those with stomach issues really benefit from adding mouth rinses to their at-home therapy.
With each return visit, Filipiak hopes to see decreased caries risk, fewer areas of decay, decreased risk for periodontal disease and improved compliance.
"If you are able to celebrate successes with patients, they become more receptive to other recommendations. They begin to see improvements in their oral health and they become more of a partner in their oral care," concluded Filipiak, who pointed out that aesthetic services become more appealing to patients whose oral health problems are being resolved.
Educating for Improved End-Results
Home care "has to be more than the one-second brush down," Gangi said. He spends time educating patients during initial visits and takes additional time during recall visits to check patients' progress.
"Their best brushing should be done at night when they spend the next seven or eight hours lying in bed. Whatever they leave on their teeth is going to do damage," Gangi concludes.
With prescription products such as chlorhexidine, the patient probably gets more instruction in the office and has the packaging to which they can refer later. With over-the-counter products, however, only so much instruction is heeded by the patient.
"We can verbally give them the recommendation, but what we know about communication is that only so much of it sticks," said Filipiak. Time perception is a frequent challenge in oral health care. Most mouth rinses require 30-60 seconds of usage. Patients tend to underestimate that time requirement.
To combat the time-perception challenge, Gutierrez has patients literally watch a clock with a second hand that is available in her operatory while doing the preprocedural rinse. "If I am recommending a home rinse, I show them how long 30 seconds can be. If I use the clock, they understand that they need to keep track of the time at home. Then I do get increased compliance," Gutierrez shared. She finds that part of the problem is the taste of high-alcohol-content products, which tend to burn the mouth, causing the patient to not rinse for the prescribed amount of time.
In addition to stressing the length of the 30-second rinse, Gutierrez also uses the preprocedural rinse time to explain the reason for and the information about the tie between chronic inflammatory gum disease with systemic issues.
"[Patients] are all very interested in that and seem to be more compliant when they know that their whole body is suffering," she reported. "We reinforce the fact that it is the actual brushing and flossing that mechanically remove the biofilm from their teeth and that rinsing [alone] will not do the trick. It might get the surface layer but it will not get all the way down to the layer that actually adheres to their teeth and tissues."
Gangi carefully notes the return-visit results of patients to whom he has recommended a mouth rinse. "Some patients get a little too carried away," said Gangi, who checks patients for blanched tissues or sloughing in areas of the mouth. He finds that those patients will admit they are using half a disposable paper cup of mouth rinse instead of the recommended amount.
"I show them with a mirror what is happening and stress that they need to comply with what we are telling them. Too much of a good thing can be bad," said Gangi, who recommends that patients make rinses part of a thorough night-time cleaning process. For patients who use products such as Act in the morning, he advised them to wait an hour before eating or drinking anything.
Filipiak recommended written home-care instructions to send with the patient. "Creating a template as we have in our group, where we can check the things recommended and make notes, helps the patient to have a take-away reminder of the things discussed.
"There is a thought that [a product] is safe because it can be purchased over the counter," she said. "Patients expect us to give them that overview." With the prescription product, she can show the patients the measure mark on the cap of the product, tell them the recommended time of use and the length of time the entire container of the product should last if used as instructed.
"Today, more than ever, there are far more over-the-counter choices," Filipiak continued. Dental hygienists should take a tour of the oral health products aisle at the local pharmacy, pick up consumer magazines and watch popular television shows to see the commercials bombarding their patients.
"It can be overwhelming. You need to make a commitment to remaining current," said Filipiak, adding that the emphasis on overall health and prevention has created more products than ever.
"Dentistry is changing at lightning-fast speed," Filipiak concluded. "Patients have an abundance of research at their fingertips. We need to know what they know--and more. Patients depend on our professional recommendations."
Celeste Baranowski, RDH, is the immediate past president (2008) and current legislative chair for the Connecticut Dental Hygienists' Association, Inc. She practices one day a week in private practice and holds a fulltime position in a city health department, in which five hygienists serve 25 public, private and parochial schools, as well as 32 nursery/preschool programs. The team also serves the three city high schools. The department has six clinical dental hygiene treatment rooms in six different school buildings around the city, and these facilities serve city children ages 3 to 18 years.
Tammy L. Filipiak RDH, BS, is a practicing dental hygienist with more than 21 years of experience in clinical and educational settings. She currently is the director of dental hygiene for Midwest Dental, a group with offices in Wisconsin, Illinois, Iowa and Minnesota. She was a 2003 winner of the Butler/RDH Healthy Gums Healthy Life Award of Distinction, and a recipient of the Wisconsin Dental Hygienists' Association Outstanding Service Award. Filipiak is an active member of the American Dental Hygienists' Association and has served on a number of councils and committees, and as a member of the task force that developed Standards for Clinical Dental Hygiene Practice. In addition to her dental hygiene education, Filipiak has a bachelor's degree in business and is currently working on a master's degree in organizational leadership and quality. To contact her, email email@example.com.
Peter Gangi, RDH, BSEd, a 1988 graduate of The University of Vermont, has been a clinical dental hygienist for 20 years. Gangi is currently an adjunct clinical faculty instructor for Middlesex Community College in Lowell, Mass., and works in Methuen, Mass., with his brother in a family dental practice. He also has been a member of ADHA for 20 years and a past president of the Massachusetts Dental Hygienist's Association.
Teri Gutierrez, RDH, graduated from the Foothill College Dental Hygiene program in 1990 and has practiced in a general practice setting for 18 years. Prior to becoming a dental hygienist in 1990, she was a registered dental assistant for 13 years, giving her a total of 31 years in the dental profession. She started with lasers in 1993 with a Standard Proficiency on the 1064 nm Nd: YAG laser, received her Advanced Proficiency in 1995 on the Nd:YAG laser and her Standard Proficiency on the 810 nm Diode laser in 2000. Gutierrez received her UCSF/Academy of Laser Dentistry (ALD) Certified Laser Educator status in 2000. Gutierrez is a past hygienist representative to the board of directors of the ALD, a past chair of the hygienists' committee, functions as an examiner for the ALD, is a yearly speaker at the organization's annual conference, and has published many articles on lasers. Gutierrez provides in-office, chairside, hands-on training and Standard Proficiency certification for dental hygienists through her business Soft Tissue Laser Training. She is a member of ADHA, CDHA, SCVDHA and ALD. Gutierrez is the clinical education coordinator for OroScience Inc, a laser company from Palo Alto, Calif.
Susan Elliott-Smith is a freelance writer in Chicago, Ill.
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|Date:||May 1, 2008|
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