The perio problem

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Blessed with great oral health education and top quality dentistry, 18-to-35 year olds should have great oral health, but a recent survey revealed dentists believe that periodontal disease is rising most quickly among this group. Chris Sheedy finds out why

Dr Peter Alldritt says complacency about oral hygiene is more noticeable when it presents in younger folk.
Dr Peter Alldritt says complacency about oral hygiene is more noticeable when it presents in younger folk.

At the 35th Australian Dental Conference held in Melbourne in 2013, a survey was conducted by Wrigley with over 700 dental health practitioners. The Wrigley dental questionnaire revealed much about the beliefs, opinions and perceptions of those in the Australian dental industry but one fact stood out above the rest. Forty-six per cent of dental health professionals, the research said, think the 18-35 age group is the generation experiencing the greatest rising incidence of periodontal disease. It’s a group that has grown up with the finest dental care, clear dental messaging, advanced toothpastes and fluoridated water. Why then, does such a large percentage of the industry believe this age group is going downhill when it comes to periodontal disease?

“This finding doesn’t actually surprise me too much,” says Dr Peter Alldritt, chair of the Australian Dental Association’s Oral Health Committee. “While I’d like to see evidence-based research to discover the real facts of the matter, I think there are various causes and lifestyle issues that could potentially be resulting in more people in this age group presenting with symptoms.”

“We’re talking about a bacterial disease but the body’s response to the bacterial issue is altered by various risk factors. For example, more than 30 per cent of people only brush once a day and many never floss. If people are complacent with oral hygiene then the incidence of periodontal disease will rise. While dental experts expect to see such issues in older people, it’s more noticeable when it presents in the 18-35 age group.”

Dental hygienist and inventor of unique X-Floss, Lise Slack agrees, saying she was somewhat surprised to read the survey results but that various oral health habits and lifestyle issues could explain the rise, or at least the perception of a rise.

“Although there has been much education around dental care, there has also been heavy marketing of various products that may create a laziness in oral health habits,” Slack says. “Mouthwashes are becoming increasingly popular. You rinse it around in your mouth and it burns like crazy and this could feel as if it’s really doing something amazing like destroying bacteria. Many people are now using mouthwash instead of brushing or flossing. That’s the marketing message that they pick up. But plaque biofilm is sticky and won’t rinse off easily. Plaque deposits grow and multiply and when it matures it’s simply impossible to remove by rinsing only.”

Slack says that another explanation for the survey result could be the positive fact that dental care is opening up to more indigenous people who may not have previously received the strong oral health education that has been offered to other sectors of the population. She also says an increase in body piercings among younger people adds to the issue.

“Intra-oral and peri-oral piercings of the tongue and lips can lead to periodontitis,” Slack says. “Piercings knock against the teeth and very often damage the soft tissues and cause periodontitis. There is a very real risk with oral piercings.”

Professor Saso Ivanovski, chair of periodontology at Griffith University in Queensland says he is unsure of the veracity of the claim that periodontal disease is on the rise in the 18 to 35 age group, but is interested in the fact that the perception exists within the profession. “I’m not aware of evidence within published work to support this as a fact but there are several possible explanations as to why the perception exists,” he says.

Lise Slack says there’s a variety of possible reasons for the increase in perio disease.
Lise Slack says there’s a variety of possible reasons for the increase in perio disease.

“The most likely explanation relates to our improved ability to diagnose oral diseases. It’s a skill and a field of knowledge that is really drummed into newly trained dental health professionals. In the 18 to 35 age group there is a rising awareness of the importance of dental care so they are likely visiting their dentist more often. They’re not having complex work done, but they are likely having smaller issues caught at an earlier stage. And dental health experts are possibly seeing the actual teeth of people within the 18 to 35 age group improving thanks to water fluoridation, better education and greater access to dental care. But as periodontal disease is all about inflammation around the teeth then perhaps this stands out more as the teeth get better but the gums do not.”

So the perception among dental health experts of an increase in periodontal disease in the 18 to 35 age group, Ivanovski says, is possibly a combination of greater attendance by the age group at dental clinics, greater awareness of and ability to identify the disease by clinicians, and a more noticeable difference between the health of a patients’ teeth and the health of a patients’ gums.

Slack says the power toothbrush also has a case to answer for when it comes to oral health. When used correctly, she says, an electric toothbrush is a wonderful device. The problem comes when people don’t first learn correct brushing techniques and assume the power toothbrush will simply get the job done for them.

“Many people are relying too much on power toothbrushes but in my humble opinion it’s not necessarily the best type of toothbrush,” Slack says. “I see patients with poor oral hygiene who use power toothbrushes just as I see patients with poor oral hygiene who use manual toothbrushes. And I see just as many people with good oral hygiene who use power toothbrushes as I see people with good oral hygiene who use manual toothbrushes. People need to be taught that no matter what you use, it’s all about the technique.”

“Kids love power toothbrushes so they often don’t have the opportunity to learn good brushing technique. The power toothbrushes can vibrate, oscillate, pump, squirt, create foam and bubbles and therefore it looks and feels as if it’s cleaning effectively. But if the right technique is not taught early on then the teeth and gums will never be cleaned properly.”

Slack says she sees at her three clinics an increasing number of people who, thanks to their dedication to a more organic lifestyle, have also turned against anything that could possibly contain any form of chemical. “These folks are often against fluoride and use herbal toothpaste and essential oils,” she says. “They’re often convinced that their teeth and gums are healthier compared to other people’s. Once we have a closer look I usually find their oral hygiene is very similar to people who have less organic lifestyles.”

“Another possible issue is that people tend to react to bleeding in the gums by avoiding those areas for some time, when in fact it’s usually a sign that you need to continue to clean that area more effectively.”

Professor Saso Ivanovski says a rising awareness of dental care may account for the perceived rise in periodontal disease
Professor Saso Ivanovski says a rising awareness of dental care may account for the perceived rise in periodontal disease

In the end though, Slack says, good oral health comes down to technique and time spent cleaning the teeth. Get it right from the beginning and your teeth will treat you well. Of course this means that those in the dental health profession have a responsibility to spread an even greater knowledge of oral health practices and techniques.

Finally, the incidence of periodontal disease is not actually all about dental issues. Lifestyle issues such as diet and general health are also strongly connected to the issue of periodontal disease, our experts say. Smoking is a risk factor for instance, Dr Alldritt says. If there is an increase in smoking in a specific age and gender group then there will likely be an increase in periodontal disease. The Cancer Council of NSW says the highest rates of daily smoking among Australian men in 2010 were in the 30 to 39 and 40 to 49 age groups. For women the highest rates were in the 40 to 49 age group. But the Australian Bureau of Statistics also pointed out in 2011 that young people aged 15 to 17 were the most likely to have increased the amount they smoked in the 12-month period.

“We know diabetes is increasing and this is a risk factor with periodontal disease,” Dr Alldritt says. “Diet in Australia is changing and in general it is not for the better. More people than ever are overweight and this may also affect levels of oral health and periodontal disease. Suffering diabetes increases periodontal disease risk factors, as does a diet that is lacking in fresh fruit and vegetables. So the perceived increase in periodontal disease in the 18 to 35 age group is possibly based on fact once all of these issues are taken into consideration. Periodontal disease, as with most health issues, does not usually happen in isolation. We should be looking at oral health hand in hand with general health practitioners such as GPs. There is currently an increased momentum towards this. But the sooner it becomes reality across the board, the better we’ll be able to educate about and manage the root causes.”

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