Effective Strategies for Plaque Removal: Insights from Professor Filippo Graziani
November 5, 2024
In an episode of our Let’s Talk Oral Health podcast for professionals, we talked with Professor Filippo Graziani, an expert in periodontology from the University of Pisa, to discuss plaque removal and its role in preventing periodontal and peri-implant diseases.
The discussion centered around the biological significance of bacterial plaque accumulation, its impact on oral and systemic health, and why controlling it is essential for maintaining a healthy oral cavity. We also delved into the most effective mechanical methods for removing plaque and ensuring patient compliance with oral hygiene routines. Listen to her insights in our podcast or continue reading here.
Understanding bacterial plaque accumulation and its role in oral health
Professor Graziani begins by explaining that dental plaque is a naturally occurring bacterial biofilm – similar to for example in the gut – and that we actually need these biofilms to function and survive.
However, when the balance of bacteria within the biofilm is disrupted, also known as dysbiosis, it can lead to inflammation, especially when there is a shift to an abundance of anaerobic, gram-negative bacteria. Professor Graziani emphasizes that bacterial plaque is particularly problematic in hard-to-reach sites like the interdental area, where regular brushing may not be effective.
This bacterial plaque accumulation in the oral cavity leads to a chronic inflammatory response that can result in gum disease and even bone loss if left unchecked. This may lead to a vicious circle, in which the inflammatory environment favors the growth of more pathogenic bacteria, as they thrive in this type of environment.
Susceptibility to periodontitis: more than just the bugs
Professor Graziani stresses the importance of plaque removal, particularly in spaces between teeth, to prevent these conditions. However, he also points out that the last few decades have seen a paradigm shift. In the past, bacteria were seen as the only cause of periodontal diseases, and treatment or prevention was focused on eradicating them as much as possible.
Nowadays however, it is believed that it is way more complex than that, and it’s the interaction between the bacteria and the host immune system that causes disease development and progression. This also explains that – while everyone develops some level of inflammation (i.e. gingivitis) when exposed to bacteria – only a portion of patients progresses to periodontitis.
These individuals are more susceptible to developing more inflammation, and this may have several reasons. Professor Graziani explains that for example, there may be a genetic component, lifestyle can play a role, patients may suffer from metabolic diseases such as diabetes, and there’s an important role for stress. Tackling these issues has become an important part of periodontal disease prevention and treatment, alongside plaque control.
Dental plaque and its impact on systemic health
In addition to its local impact on the oral cavity, Professor Graziani emphasizes that bacterial plaque accumulation can have far-reaching systemic consequences. He explains that chronic inflammation in the gums allows bacteria and inflammatory mediators to enter the bloodstream, causing systemic inflammation. This in turn can lead to or exacerbate systemic conditions such as cardiovascular disease and diabetes.
Graziani points to growing research demonstrating that likewise, alleviating local inflammation can in turn improve systemic inflammation. As an example, he discusses the effect of periodontal therapy on HbA1c, a marker for glycemic control in diabetics, and mentions indirect evidence that demonstrated how good oral hygiene can contribute to cardiovascular health.
The basics of mechanical plaque removal
Moving to the topic of mechanical plaque removal, Professor Graziani discusses various tools and techniques for controlling bacterial plaque. The most common method – toothbrushing – has evolved significantly over the centuries, from manual brushes to electric and now smart, connected toothbrushes.
Professor Graziani believes that modern electric toothbrushes have revolutionized oral care by making effective plaque removal more accessible, even for people with limited manual dexterity. However, he underscores the importance of professional guidance: patients must be taught how to use these tools correctly.
While toothbrushing is essential, Professor Graziani shifts the focus to an even more critical area: cleaning the interdental space. According to him, cleaning between teeth is paramount. In fact, he argues that if a patient is short on time, it’s more important to clean the interdental space than to brush the other surfaces of the teeth. These areas are prone to plaque accumulation because they are not touched by natural mechanical action, such as chewing.
Why the interdental space is crucial for plaque removal
The interdental space is often underestimated in terms of its importance to oral health. Professor Graziani points out that in areas like the molars, these spaces can be as large as 13 millimeters – a significant portion of the oral cavity. Plaque that forms here tends not only to accumulate easier, but also to be more acidic and more difficult to remove, making it a breeding ground for harmful bacteria.
Professor Graziani references a landmark 1981 study by Axelsson and Lindhe that clearly demonstrated the importance of cleaning between teeth. In patients who practiced proper interdental cleaning, there was no gum inflammation or new cavities over six years, compared to patients who only brushed the visible surfaces of their teeth. This underscores that plaque removal between teeth is essential to long-term oral health, even if you already brush your teeth very well with a toothbrush.
The most effective tools for cleaning the interdental space
When it comes to choosing tools for cleaning the interdental space, Professor Graziani shares insights from his research comparing the efficacy of various methods. Traditional floss, while historically significant, is no longer considered the best option by many dental professionals.
Professor Graziani cites a study (Berchier et al., 2008) that found no additional benefit from flossing, even when dental students performed the task. This suggests that floss is difficult to use correctly and may not be the most effective method for most people.
Instead, interdental brushes are Professor Graziani’s preferred tool for cleaning between teeth. His research, including two trials published in 2018 and 2022, showed that interdental brushes were significantly more effective at removing plaque and reducing inflammation than floss. This was true in both healthy individuals and those with periodontal disease.
Professor Graziani also highlights the potential of rubber interdental picks, which were shown in his studies to be just as effective as interdental brushes in his studies. Interestingly, rubber interdental picks may even provide an added benefit by massaging the gums, which is believed to reduce inflammation.
Ensuring patient compliance with plaque removal techniques
A key challenge in oral health is ensuring patient compliance with recommended plaque removal routines. Professor Graziani acknowledges that even the best tools won’t be effective if patients don’t use them correctly or consistently.
He emphasizes that motivation begins with the relationship between the healthcare provider and the patient. The first step in building compliance is passing a skill by teaching patients how to use interdental brushes properly. He advises against overwhelming patients with too much information in the first session.
Instead, he recommends starting with a simple, effective demonstration on cleaning between teeth, ensuring the patient can perform the task themselves, before even thinking of moving on to toothbrushing. He encourages patients to prioritize interdental cleaning over traditional brushing if time is limited, given its greater impact on preventing gum disease and inflammation.
The importance of consistent plaque removal for long-term health
In the final moments of the discussion, Professor Graziani provides a clear takeaway: the most impactful change patients can make for their oral and systemic health is to ensure they clean between their teeth properly. This simple habit, performed with the right tools like interdental brushes or rubber interdental picks, can prevent a wide range of oral health issues and improve overall well-being.
Expand your knowledge on a 360º approach to periodontal and peri-implant disease prevention by listening to the other episodes in the Let’s Talk Oral Health podcast for experts. Don’t miss our discussions on the oral microbiome, behavioral change in patients,and the oral -systemic link.