Hanoverian prevention concept to improve (self-responsible) home-based oral hygiene
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PRACTICE MINIREVIEW 65
Hanoverian prevention concept
to improve (self-responsible)
home-based oral hygiene
Caries and periodontitis are biofilm larly root and crown margin caries) ment should be expected to increase
associated diseases with multifactori- and inflammatory periodontal dis- in the future.
al causes. In addition to regular visits ease. Nowadays, successful preven- Meanwhile, ample evidence from
to the dentist and dietary control, the tion concepts combined with ad- epidemiological, clinical and experi-
efficient removal of oral biofilm plays vances in the field of restorative den- mental studies has suggested that
a major role in the prevention of tistry have made it possible to pre- periodontal infections are not only
these diseases. The removal of bio- serve natural teeth for much longer influenced by systemic factors, but
film should not only be the concern or even until the end of life [26]. that they themselves can also exert
of the dental professional, but rather Hence, there is a clear trend towards systemic effects [24]. Oral health,
that of the patient who should rou- “tooth preservation in old age” (sig- which can be defined as the unre-
tinely employ home-based oral hy- nificant reduction in tooth loss) [23]. stricted functionality and symptom
giene measures [10]. Therefore, self- However, the longer that teeth are free from inflammation and discom-
responsible, home-based oral hygiene preserved, the more they are exposed fort, is an important component of
is an important pillar for maintaining to the risk of periodontitis or caries. general health together with a
oral health. The causes of increased susceptibility healthy diet and it has a close link to
The awareness with regard to oral to root or crown margin caries in the quality of life [8, 36]. The saying
health of the German population has older people is multifactorial (e.g. in- “health begins in the mouth” is in-
increased significantly in recent creased proportion of exposed root deed true when a well functioning
years. In the Fifth German Oral surfaces or crown margins, extensive and well maintained masticatory sys-
Health Study (DMS V), depending on prosthetic restorations, insufficient tem is present. The effectiveness of a
the age group, between 70–85 % of removal of plaque, reduced sali- good home-based oral hygiene com-
the survey respondents were con- vation [caused by medication], bined with regular prophylactic visits
vinced that they could contribute previous periodontal therapies) [1, 7, to the dental professional for the pre-
“very much” or “much” to maintain- 20, 29]. vention of caries and periodontitis
ing or improving their oral health In relation to periodontal health, has been proven in studies [2, 6]. The
[23]. Thus, patients are certainly DMS V shows that 75.4 % of younger sole removal of biofilm by qualified
aware of the fact that plaque/biofilm seniors (65 to 74-year-olds) suffer dental personnel in the context of
removal as part of self-responsible, from moderately severe (one in two; professional tooth cleaning is not suf-
home-based oral hygiene is of great 50.8 %) or severe periodontitis (one ficient for the prevention of caries
importance in the prevention of car- in four; 24.6 %) and that 80.6 % of and periodontitis. Rather, it should
ies and periodontitis. Especially in older seniors (75 to 100-year-olds) be regarded as an individual prophy-
the age group of young seniors (65 suffer from moderately severe (one in lactic component in a more compre-
to 74-year-olds), a significantly in- two; 50.5 %) or severe periodontitis hensive prophylaxis concept [38]. In
creased awareness of their own oral (one in three; 30.1 %), thus suggest- addition to needs-based plaque re-
health was observed in DMS V [23]. ing that periodontitis is still wide- moval, a thorough prophylaxis con-
However, DMS V also shows that a spread [23]. Given that periodontitis cept should also focus on teaching
relatively large number of patients increases with age, the demographic practical skills for optimal home-
are still affected by caries (particu- trend implies that the need for treat- based oral hygiene, as well as, foster
Translation from German: Christian Miron
Citation: Günay H, Meyer-Wübbold K: Hanoverian prevention concept to improve (self-responsible) home-based oral hygiene. Dtsch Zahnärztl Z Int 2020; 2: 65–72
DOI.org/10.3238/dzz-int.2020.0065–0072
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2020; 2 (3)
66 PRACTICE MINIREVIEW
Figure 1 Hanoverian prevention concept to improve self-responsible, home-based dental and oral hygiene
health-promoting and health-pre- Components of the Hanove- ment and establish the current level
serving behavior patterns through rian prevention concept of oral hygiene, oral (tooth, implant,
education, instruction and moti- AF-iIMI (anamnesis, findings, indi- periodontal, peri-implant and muco-
vation [30]. vidual information, motivation and sa) findings and quantitative
At the Clinic for Conservative instruction) is the main component plaque indices for the smooth and
Dentistry, Periodontology and Preven- of the prophylaxis concept. However, proximal surfaces of teeth are col-
tive Dentistry in Hannover, we have it should not only be understood as lected. The degree of gingival in-
developed a practicable prophylaxis pure oral hygiene training. flammation is checked using the
concept which consists of different index “Bleeding on Probing” (BoP)
interlinking and overlapping com- A and the need for periodontal treat-
ponents: “anamnesis and findings – In the beginning, a general, specific ment is determined using the “Peri-
individual information, motivation and prevention anamnesis (in- odontal Screening Index” (PSI). The
and instruction (AF-iIMI)”, “the cluding dietary anamnesis) is re- bleeding and plaque indices are suit-
CIOTIPlus tooth brushing system corded. On the one hand, this able for quantifying and monitoring
and technique”, “self-control of allows conclusions to be drawn the current oral hygiene status of the
oral hygiene” and “compliance regarding compliance (health aware- patient. For better visualization,
assessment” (Fig. 1). The effective- ness and behavior, individual sig- plaque staining agents are applied to
ness of each individual component nificance of oral hygiene, moti- make plaque visible for the patient,
has already been investigated and vation for change), while on the while keeping in mind to differen-
confirmed in several studies and pilot other hand, it also provides clues as tiate between “old” and “new”
projects [13–18, 25]. The combination to whether interdisciplinary coop- plaque. The results of a plaque
and integration of each component eration is needed as part of oral index, where only a yes or no deci-
into an overall concept should lead to health care promotion interdisci- sion is made with regard to the pres-
an improvement in self-responsible, plinary (OHCP-i) (e.g. cooperation ence of plaque, is often less suitable
home-based oral hygiene and oral with diabetologists, general physi- for motivating the patient than an
hygiene self-control, specially in risk cians, family physicians). index that assesses plaque quanti-
groups, hence ensuring sustainable tatively (e.g. Quigley-Hein-Index –
dental, oral and general health. Each F QHI). Hardly any patient is able to
components of the Hanoverian pre- After this, in order to evaluate the achieve complete plaque free within
vention concept are presented below. risk, determine the need for treat- the framework of home-based oral
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2020; 2 (3)
PRACTICE MINIREVIEW 67
Figure 2 Using a magnifying mirror, problem areas are revealed Figure 3 Education regarding AF-iIMI of the same patient
to an 89-year-old female patient based on the AF-iIMI framework
hygiene. The value of a plaque index iI mine the extent to which the patient
with a simple qualitative yes or no Based on the anamnesis and findings, can be motivated and is willing to co-
decision may change only margin- each patient receives individua- operate. Depending on the patient,
ally in the course of follow-up lized needs-oriented education and different models (e.g. the preventive
examinations, despite a significantly information regarding, for exam- intervention or transtheoretical mod-
reduced amount of plaque. There- ple, caries (root surfaces and crown els) can be used for support. Based on
fore, this type of index does not margins), gingivitis, periodontitis and the categorization of the patient, in-
track changes in plaque levels thor- peri-implantitis, as well as advice on dividualized motivation then follows,
oughly enough and could result in possibilites of risk minimization, pre- which should include the principles
patient demotivation. Similar to the vention, treatment and maintenance of “motivational interviewing” (MI)
QHI, which assesses the extent of therapy (recall). Supplementary die- for active participation. In order to
plaque on smooth surfaces, we have tary recommendations for (dental) make this session strictly individua-
suggested an index to assess the ex- health should also include advice on lized for the patient, the motivational
tent of plaque in approximal areas foods that promote and inhibit in- interview should make use of aids in
(mAPI) [15]. Under optimal lighting flammation. Moreover, the function the form of denture models of the pa-
conditions and with the help of of mastication and the necessity of tient, X-rays, photographs and the
magnifying mirrors, the patient is intensive chewing needs to be ex- documented findings of the plaque
shown “problem or weak areas” in plained (Fig. 3). When periodontal and inflammation indices which
the mouth (Fig. 2). Individual den- treatment is required, it is essential present the patient’s own case. If the
ture models or intraoral images of that the patient understands the need for treatment was identified at
the patient’s mouth can also be meaning and purpose of “partner the time of diagnosis, it is vital that
helpful here. The presentation of the treatment”. In this step, the relevance the patient is first given a “whole
patient’s specific case using, for of being “self-responsible” and active mouth therapy concept” before follow-
example, X-rays, photos (not only participation for his/her dental and ing any further instructions on oral
current, but also previous ones, if oral health should also be clarified. hygiene measures; this is done in
available) as part of a “case presenta- Furthermore, the effect of regular and order to minimize iatrogenic irri-
tion” individualizes the possibly effective home-based dental and oral tation factors and establish hygiene
existing problem and should act to hygiene on oral health should also be ability. It is imperative to avoid stan-
sensitize the patient with regard to explained while not forgetting to em- dardized, ordinary, and boring rou-
his/her dental and oral hygiene and phasize the importance of employing tine explanations when familiarizing
self-responsibility. For patients with a systematic approach (e.g. the patients with the AF-iIMI approach!
removable dentures, a demonstra- CIOTIPlus system or technique). The patient must have the feeling of
tion is necessary to point out any receiving personalized individually
existing plaque on the denture, as M care! It is recommended not to resort
denture hygiene is also a component An important prerequisite for sub- to any repetition of well-known slo-
of dental and oral hygiene. sequent motivation is to first deter- gans (e.g. “Don‘t forget to brush your
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2020; 2 (3)
68 PRACTICE MINIREVIEW
teeth twice daily after meals!”) in pre-
ventive care, as only individualized
health counseling can shape health-
conscious behavior [19]. In order to
ensure consistent professional think-
ing using the same language, the
dental professional and the office
staff must discuss the office’s prophy-
laxis concept as a team and update it
regularly with new findings (very im-
portant: joint continuous internal
and external training). Motivational
Interviewing (MI) is another evi-
dence-based method for positively
influencing patient behavior in den-
tistry [37]. Based on the “preventive
intervention model” according to
Weinstein et al. (1989), the patient‘s
perception of risk (“recognizing hav-
ing a problem”) and willingness to
cooperate (willingness to work on the
problem) are the basic prerequisites
for successful prophylaxis [35]. The Figure 4a Observation of a 71-year-old patient through a venetian mirror in a special
reasons for failure in the area of moti- oral hygiene place while she performs oral hygiene in the context of AF-iIMI
vation and instruction usually have
3 different causes: lack of knowledge,
lack of skills or lack of motivation. A
thorough behavioral analysis before
starting motivation and instruction
should therefore establish whether
the problems are connected to
knowledge, skill or motivation. Ac-
cordingly, in several small steps,
either knowledge can be imparted
(for problems on the knowledge
level), skills can be trained (for prob-
lems on the skill level) or work can
be done on problems with moti-
vation [11]. In any case, the patient
must be aware of their own responsi-
bility. In order to successfully moti-
vate a patient, his/her willingness to
cooperate should be assessed in ad-
vance. Although originating from
health psychology, a classification
using the “transtheoretical model”
can also be of help in dentistry [9].
I
As part of instructions, the patient
should first demonstrate how he/she Figure 4b Observation-oriented oral hygiene instruction using a model for the same
performs home-based oral hygiene patient at a special oral hygiene place within the context of AF-iIMI
with his/her personal oral hygiene
tools brought from home. Before-
hand, the plaque should be made vis-
ible to the patient with a plaque patient. It is advisable to perform this light source, opportunity to sit). The
staining agent. Instructions must be step together with the patient in patient is asked to demonstrate his/
observation-oriented (Fig. 4a and b) special oral hygiene places with her daily dental and oral hygiene
and dependent on individual abilities “bathroom-like equipment” (mirror, routine with own oral hygiene tools
as well as the intraoral status of the washbasin, magnifying mirror with a brought from home. Firstly, it should
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PRACTICE MINIREVIEW 69
be evaluated if the tools already cleaning the dentures should also be tooth hard tissue [22]. The aim of
being used by the patient allow for shown and explained. “CIOTIPlus” system is to achieve both
sufficient oral hygiene or whether Many dental professionals recom- a more effective plaque reduction (re-
small changes in the application of mend the “modified bass technique” moval of supragingival [visible] and
these tools could lead to hygiene im- for mechanical plaque removal using achievable subgingival [non-visible]
provement. Depending on the indi- a toothbrush [5]. However, this tech- plaque from the tooth surface) and
vidual abilities and motivation of the nique is difficult to learn. There is no improved fluoride availability to the
patient, various other oral hygiene evidence in literature indicating that tooth surface. In addition, the peri-
tools can be recommended and train- this technique is superior to, for odontium is also stimulated by me-
ing with them should occur on site example, the “horizontal scrubbing chanical stimuli (plus function),
with the patient. Oral hygiene rec- technique” for plaque removal [12, which is intended to promote blood
ommendations for older people, in 27, 34]. It is generally agreed that it is flow to the epithelium and subepi-
particular, should be formulated as probably more important to follow a thelial connective tissue and to
simple as possible and tailored to brushing system than to follow a spe- strengthen the periodontal tissue. The
their individual abilities and moti- cific technique when using both effectiveness of CIOTIPlus has already
vation, while simultaneously paying hand and electric toothbrushes [12]. been proven in several studies [13, 15,
particular attention to possible age- The regular use of a certain system is 17, 25]. In older patients that had
related functional limitations such as intended to prevent teeth or tooth undergone periodontal therapy, the
a decline in motor, sensory or mental surfaces from being overlooked dur- use of the CIOTIPlus system not only
abilities [36]. In order to objectively ing home-based oral hygiene [28]. For increased the removal of plaque on
verify the motor, sensory and mental this reason, we recommend, explain smooth and proximal surfaces [13,
abilities of a patient, various “short and demonstrate the “CIOTIPlus” sys- 15, 17, 25], but combined with effi-
tests” can be used (e.g. the money tem and technique to the patient as cient regular supportive periodontitis
counting test and the neck grip left/ part of the instructions [16]. Accord- therapy, it even minimized the
right, and if necessary, the fist/finger- ing to this system, the patient first formation of new root surface and
tip test) [31]. The results of the vari- brushes the chewing, followed by the crown margin caries and stabilized or
ous tests can then be used to decide inside and outside surfaces, with a improved the periodontal conditions
which oral hygiene tools (hand and toothbrush. Afterwards, the tongue [15]. Yet, in order to identify “prob-
electric toothbrushes [oscillating/ and interdental spaces are cleaned lem sites” in the area of plaque con-
rotating or sonic]) can be used for with interdental hygiene tools. Subse- trol, and thus successfully prevent
home-based oral hygiene. Often, quent to this cleaning procedure, the caries and periodontal disease, indi-
“modifications” of oral hygiene tools patient re-applies the same pea-sized vidualized and observation-oriented
can be useful. For example, if patients amount of fluoride-containing tooth- dental and oral hygiene advice, in-
are no longer able to grip or guide a paste evenly across all tooth surfaces formation and instruction (AF-iIMI),
manual toothbrush properly, an indi- and uses the toothbrush to systemati- as well as regular re-instruction and
vidualized “gripping aid” for the cally brush the tooth surfaces and re-motivation are absolutely essential
toothbrush handle may help them. gums using circular or rotating move- for every patient. Following the oral
Changing to an electric toothbrush, ments (“plus”). In order to clearly hygiene training, a professional tooth
which has a more compact and easier demonstrate the advantage of the sys- cleaning is performed.
to grip handle, and which also tem’s “plus” step to the patient, it is
requires no movements from the useful to make the plaque visible SC
wrist joint, may also be beneficial. In again before and after the “plus” step. In order to achieve the best possible
case of decreased eyesight we recom- The plaque is made visible to the pa- results in self-responsible, home-based
mend wearing reading glasses during tient a total of 3 times: before the oral hygiene, a patient should be able
oral hygiene and using a magnifying instruction, after performing the to evaluate and control the cleaning
mirror with an integrated light “CIOTI” system and after the “plus” process and cleaning result alone.
source. An opportunity for seating step. In this manner, the patient can
gives the patient the chance to take see and be convinced that a further Self-control of the cleaning
sufficient time for oral hygiene. reduction of plaque can be achieved process (daily):
For patients with removable den- by the “plus” step. This system does It appears that many patients have
tures, advice regarding the impor- not literally denote “double” brush- difficulties with the regular imple-
tance of regular and effective denture ing, as the entire cleaning process is mentation of a specific daily dental
hygiene for oral health should not be not repeated in the same way [16]. and oral hygiene system. Numerous
overlooked. The plaque (biofilm) on By applying the fluoride-containing possibilities exist for patients to per-
removable dentures represents a toothpaste once more, the tooth sur- form the self-control of the cleaning
source of microorganisms. Therefore, faces are mechanically cleaned again process or system. In the digital age,
careful cleaning and, if necessary, dis- on the one hand, while on the other computer programs or apps may
infection of the dentures is as impor- hand, additional fluoride adminis- offer the possibility to support pa-
tant as brushing natural teeth and tration occurs. Fluoride appears to be tients in their daily dental and oral
implants. The tools and procedure for more effective on clean, plaque-free care [21]. However, the fact that
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70 PRACTICE MINIREVIEW
Figure 5a 72-year-old patient, condition Figure 5b The same patient, status Figure 5c The same patient, status
before the start of AF-iIMI before the start of AF-iIMI, plaque made 3 weeks after AF-iIMI, plaque made
visible with a plaque-staining agent (t0) visible with a plaque-staining agent (t2)
(QHI: 2.4; mAPI: 4.0) (QHI: 1.1; mAPI: 1.8)
veloped an initial “oral hygiene
protocol” in which the patient can
document the system he/she has
used on a daily basis. We evaluated
the use of these protocols in a study
and it could be shown that such
Figure 5d The same patient, status Figure 5e The same patient, status protocols are well suited for the self-
6 months after AF-iIMI, plaque made 3 weeks after Fig. 5d, plaque made monitoring of the cleaning process
visible with a plaque staining agent (t3a) visible with a plaque-staining agent (t3b) for a short period of time and that
(QHI: 2.2; mAPI: 3.5) (QHI: 0.6; mAPI: 1.6)
they do indeed improve oral hygiene
[15]. However, such simple protocols
are frequently not very attractive for
patients in the long run. Thus, we
have additionally developed an aba-
cus (“CIOTIPlus-Abacus”). With this
tool, it is very easy for the patient to
document the “CIOTIPlus” brushing
system and technique on a daily
basis in a playful way, which also in-
(Fig. 1–5: H. Günay & K. Meyer-Wübbold)
creases the motivation to use this
tool for documentation and self-con-
trol. At the same time, this tool
allows the patient to test his/her cog-
nitive and motor skills. Unfor-
tunately, the success of the tool was
not evaluated over a longer time
period and this is why we developed
an app/computer program. The use
Figure 5f Smooth and proximal surface plaque index values of the 72-year-old patient of the CIOTIPlus-App and the CIOTI-
at different times Plus-Abacus were tested in a pilot
study; it was shown that dental and
oral hygiene could be significantly
improved by self-controlling the
computer programs or apps are not older age, such as visual or hearing cleaning process with an app or aba-
suitable for everybody should be impairments, limitations in fine cus in senior citizens [18].
considered. Particularly, many older motor skills and cognitive limi-
people use newer technical devices tations, can also be a hurdle [31, 32]. Self-monitoring of the cleaning
less than younger ones. The reasons In a survey, 41 % from 1000 people result (once weekly):
for this are manifold. First, older over the age of 65 stated that they Many patients find it difficult to ob-
people barely have any contact with found it difficult to operate modern jectively evaluate their own cleaning
new technologies because they did technical devices [31, 32]. In order result. A pure visual check, even with
not grow up with them and thus lack that these patients also have the magnifying aids and optimal lighting
an understanding of how modern possibility to self-control their oral conditions or a “tongue feel test” to
technology works [31, 32]. Moreover, hygiene at home, our working group identify any plaque-affected areas
physical challenges occurring in “oral health care promotion” has de- that may still be present is insuffi-
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2020; 2 (3)PRACTICE MINIREVIEW 71
cient and cannot reveal hidden of all, the necessary home conditions Conclusion
“problem or weak areas” (e.g. inter- should be discussed (optimization of The improvement of home-based
dental spaces, the inside surfaces of the site for home-based oral hygiene oral hygiene for risk groups is a chal-
the teeth and the areas around the by means a telescope magnifying mir- lenge both for the dental profes-
gum line) particularly well. We there- ror with a light source and possible sionals and teams as well as for the
fore recommend that patients use seating). patient. The presented concept can
plaque staining agents (e.g. staining help to contribute to sustainable den-
[chewing] tablets or rinsing solution) C tal, oral and general health in these
at least once weekly during their All good intentions fade with time. groups.
home dental and oral hygiene in In this respect, success in terms of
order to visualize plaque. Plaque patient cooperation is rather
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