Discussion Topics
Patient Education / Patient Motivation
Which is the most effective teaching technique for patient education in plaque control?
Is the effectiveness of a plaque control program based on frequency, length or other parameters of the visit?
What is your preferred method in teaching plaque control and why?
What parameters affect patient compliance when with regards to plaque control?
1. Soderholm G, et al: Teaching plaque control. I. A five-visit versus a two-visit program. J Clin. Periodontol. 9:203-213, 1982.
2. Axelsson P, Nystro¨m B, Lindhe J: The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. J Clin Periodontol 31: 749–757, 2004
3. Stewart JE, Wolfe GR: The retention of newly-acquired brushing and flossing skills. J. Clin. Periodontol. 16:331-332, 1989.
4. Hausen H. Oral health promotion reduces plaque and gingival bleeding in the short term Evidence-Based Dentistry 6: 31, 2005.
5. Emler BF, et al: The value of repetition and reenforcement in improving oral hygiene performance. J. Periodontol. 51:228-234, 1980.
6. Rayant GA, Sheiham A: An analysis of factors affecting compliance with tooth cleaning recommendations. J. Clin. Periodontol. 7:289, 1980.
7. Macgregor ID, Balding JW: Self-esteem as a predictor of toothbrushing behaviour in young adolescents..J Clin Periodontol. J Clin Periodontol. 1995 Aug;22(8):603-8.
8. Nowjack-Raymer R, Ainamo J, Suomi JD, Kingman A, Driscoll WS, Brown LJ.: Improved periodontal status through self-assessment. A 2-year longitudinal study in teenagers. 1991 May;18(5):312-6.
9. Abegg C, Marcenes W, Croucher R, Sheiham A.: The relationship between tooth cleaning behaviour and flexibility of working time schedule. J Clin Periodontol. 1999 Jul;26(7):448-52.
10. Tan A, Wade A : The role of visual feedback by a disclosing agent in plaque control. J. Clin. Periodontol. 7:140, 1980.
11. Wood S, Metcalf D, Devine D, Robinson C. Erythrosine is a potential photosensitizer for the photodynamic therapy of Oral plaque biofilms. J Antimicrob Chemother. 57;4:680-4, 2006
Toothbrushing
Which works best: Manual or electric toothbrushes?
Which technique do you recommend to your patients and why?
13. Wilson S, Levine D, Dequincey G & Killoy WJ: Effects of two toothbrushes on plaque, gingivitis, gingival abrasion, and recession: a 1-year longitudinal study. Compend Contin Educ Dent. 14 (Suppl 16): S569-S579, 1993
14. Tritten C, Armitage G: Comparison of a sonic and a manual toothbrush for efficacy in supra-gingival plaque removal and reduction of gingivitis. J Clin Periodontol. 23:641-648, 1996.
15. Bergenholtz A, Gustafsson LB, Segerlund N, Hagberg C, Ostby N.: Role of brushing technique and toothbrush design in plaque removal. Scand J Dent Res. 1984 Aug;92(4):344-51.
Effects of Oral Hygiene
How often should our patients brush? Why?
Compare different toothbrushing techniques and toothbrush types.
REVIEWS
26. Robinson PG, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, Glenny AM, Shaw WC. Manual versus powered toothbrushing for oral health. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD002281.
27. Van der Weijden, Campbell, Dörfer, González-Cabezas,and Slot Safety of Oscillating-Rotating Powered Brushes Compared to Manual Toothbrushes: A Systematic Review Journal of Periodontology 2011, Vol. 82, No. 1, Pages 5-24
28. Needleman, Suvan, Moles and Pimlott. A systematic review of professional mechanical plaque removal for prevention of periodontal diseases (pages 229–282) J Clin Periodontol, vol 32, supplement 6 pg 229
Patient Education / Patient Motivation
Which is the most effective teaching technique for patient education in plaque control?
Is the effectiveness of a plaque control program based on frequency, length or other parameters of the visit?
What is your preferred method in teaching plaque control and why?
What parameters affect patient compliance when with regards to plaque control?
Soderholm 1982 part I: ARTICLE
P: To compare the effects of oral hygiene instructions given during 5 visits to oral hygiene instructions given during 2 visits.
M&M: 69 pts were recruited. Pts were divided into 3 groups: 5-visit OHI, 2-visit OHI, and the control. The following values were measured: Plaque Index (PI), Probing Depth (PD), Bleeding on Probing (BOP), the number of teeth, and age. Every group received prophylaxis by dental hygienist after baseline examination. Oral hygiene instructions were given in either (5)-30 minute appointments or (2)-60 minute appointments during 14 days. Pts were observed at 2, 6, 12 weeks and then at 3 month recalls for 48 months.
R: Plaque scores of 5- and 2- visit oral hygiene instruction groups decreased from 65% to 15-20% (NSD between the two groups). NSSD in BOP between 5- and 2-visit OHI. They both were SS better than control. In the control group a decrease in PI was observed at 2 weeks and then increased at 6 weeks. NSSD in periodontal pocket scores (% of surfaces having PDs > 5 mm) in all 3 groups. Long-term observations showed that PI remained at the 10-15% range with NSD between the 2 OHI groups.
BL: The 5- and 2- visit oral hygiene instruction groups were equally effective in achieving good plaque control.
Axelsson 2004 ARTICLE
Purpose: To monitor the incidence of tooth loss, caries and attachment loss during 30-years in a well plaque controlled group and to compare 51-65 year olds in 1972 and 2002 regarding their oral health status.
M&M: 375 pts in test group and 180 individuals in control group were recruited. Test group maintained in preventive program that included presentation in self diagnosis, OHI, prophylactic sessions with fluoride, every 2 months first 2 years, once every 3 months for 3-6 yrs. After 6 years control stratified into 3 risk sub-groups risk1 (R1 60% of subjects maintenance every 12 months), risk 2 (R2 30%, maintenance every 6 months), risk 3 (R3 10%, maintenance every 3 months) according to estimated risk for additional disease. Variables recorded: Plaque, Caries, BOP, PPD, PAL, CPITN. All baseline variables were performed after 3, 6, 15 and 30 years by a dentist (PA) and a dental hygienist (BN) working together
Participants in the test group were divided in 3 groups according to their age group 1: 20-35, group 2: 36-50, group 3: 51-65.
Results: Tooth loss for entire 30-year period.
Plaque: 50-60% of all surfaces contained plaque in all three groups in 1972. In 2002, less than 20% in all 3 groups.
Carries: In all three groups only one or no new dental caries lesion during 30 years.
CPITN scores: 1972, 27% of all sites were in need of varying amounts of periodontal therapy, in 2002 only 1%.
PAL: 2-4% of sites in all three groups exhibited PAL loss of ≥ 2 mm. The amount of attachment loss was more frequent in the mandible (5-6%) than in the maxilla (2-3%).
BL: Self performed plaque control and professional mechanical tooth cleaning combined with needs-related scaling and root planning are effective means of controlling periodontitis, gingivitis and dental caries.
Stewart 1989: ARTICLE
P: Assess the retention of newly acquired brushing/flossing skills over time as a cause of loss of plaque removal behavior.
M&M: 33 patients were given two 30 minute sessions of oral hygiene instructions, teaching the Bass method of brushing and proper use of dental floss. Plaque index and brushing and flossing skills were measured initially, at 3 weeks and 1 year post-intervention. Brushing and flossing were measured by a modified oral hygiene achievement index using 6 areas for brushing and 12 for flossing.
R: Mean scores increased from 20% to 60% for brushing and 7% to 60% for flossing. There was an initial SS decrease in plaque levels but returned to pre-intervention levels at 1 year, while brushing and flossing scores remained essentially the same.
BL: Patients were able to maintain their brushing and flossing skills for 1 year. The return of plaque to pre-intervention levels was not due to loss of brushing and flossing skills.
Hausen, 2005 ARTICLE
P: Summary of Watt & Marinho’s article titled “Does oral health promotion reduces plaque and gingival bleeding in the short term”
D:
Study selection:
Systematic reviews and RCTs assessing reductions in dental plaque levels and/or gingival bleeding and comparing health education/health promotion interventions that did not involve clinical professional input or the use of pharmacological interventions such as antiplaque agents were included.
Result:
26 potential studies were identified, 5 reviews and 13 control trials were discussed. The majority of studies achieved short-term reductions in plaque and gingival bleeding. Two meta-analyses indicate a reduction in plaque levels of 32- 37%. Positive effects on plaque and/or bleeding were seen in eight studies with no difference in five studies, of which only two employed a control group. None of the studies produced a negative effect, and there was no clear indication that any particular type or style of educational approach was more effective than the others.
Conclusion:
Reductions in plaque and gingival bleeding were seen in the short-term in the majority of studies reviewed. However, the clinical and public health significance of these changes is questionable, and future studies should use longer follow-up periods to assess whether short-term beneficial results are sustained.
Comment: It is possible to achieve short-term reductions in plaque and gingival bleeding by means of health education interventions. It is unclear how well the beneficial changes are sustained in the long-run. However, it is possible that a favorable change in health behavior can have good long-term results. Also, as experts we have an ethical imperative to tell patients about how they might control their health better. The term oral health promotion used in the title of the review should be changed to health education since health education is only one out of five areas of health promotion.
Emler 1980 ARTICLE
P: To assess the value of repetition and reinforcement in a dental health education program for school children.
M+M: 61 children (11-13 years of age) were divided into 3 groups.
Group I (Control): 7th graders; received no oral hygiene lectures or instructions until the conclusion of the experiment.
Group 2 (Non-reinforced): 6th graders; received one lecture and individual toothbrushing instructions on first visit to school, but no repetition or reinforcement.
Group 3 (Reinforced): 6th graders; received the same program as Group 2 on the initial visit and also received two additional visits for repetition and reinforcement of the lectures and instructions, plus a final summary lecture.
For all groups, six visits were conducted at intervals of 0, 1.5, 3, 8, 20, and 52 weeks following a double-blind experimental format. Patient hygiene performance (PHP) scores were obtained on all subjects at each of the six visits. The lecture given was 30 minutes, consisted of: dental health importance, proper brushing technique and included instructions on how to use disclosing tablets and horizontal scrub brush technique.
R: Repetition and reinforcement components of this dental health education program were of significant value in improving the oral hygiene performance of the school children over a period of 1 year. There was an overall regression in plaque scores towards the baseline values among all groups between the 2nd to the 6th visit. Most noticeable was the regression in the control group. There was a carry-over effect past the end of the 3 week program for the reinforced group, which continued to the end of the study. The improvements in oral hygiene were observed in the reinforced group from baseline to 1 year. These appear to be at clinically meaningful levels, especially for females. There were no significant differences between the control and non-reinforced groups on visits 2 through 6.
BL: Repetition and reinforcement components of this dental health education program were of significant value in improving the oral hygiene. Single-visit programs lacking repetition and reinforcement fail to show any long-term positive results.
Rayant 1980 ARTICLE
P: To test whether subjects knew they had periodontal disease, thought the disease was serious, knew how to prevent the disease and were complying with their previously prescribed OH regimen.
M&M: 161 periodontal recall pts. (20-40 yo, 107 m, 54 f) from dental hygiene clinic completed a questionnaire to assess 1) attitudes and beliefs 2) knowledge of disease and 3) reported behavior. GI and PI were recorded on Ramfjord teeth. Pts chosen for the study were those who had called to make an appointment for a recall visit without being reminded by the clinical staff (the school has no recall system).
R/BL: Highly motivated pts are concerned with the susceptibility, seriousness, and benefits of tx for periodontal dz, but this alone is not necessarily followed by a change in behavior as shown by gingival health status. Other factors are important for pts to clean their teeth effectively. Bleeding gums seemed to be their cue to seek care (75%).
Macgregor 1991 No ARTICLE
Purpose: To examine the relation between self-esteem and reported tooth-brushing frequency and motivation for mouth care in young adolescents.
Materials and methods: 4075 14-year-olds from 75 secondary schools (52.3%males and 47.7% females) in UK completed a health-behavior questionnaire. The questionnaire consisted of 103 questions concerning tooth-brushing frequency, motivation for mouth care and self-esteem. Also, information was requested about national newspapers in the home from which the social (readership group) for each child was assessed. Only answered questions were included in the analysis.
Results: Students were divided into 3 readership groups: upper 17.1%, middle 26.1% and lower 56.8%. There was a significant association between social readership group and self-esteem in males and females. In both sexes, there was a general trend towards higher proportions of students in the upper and middle social readership groups with increasing self-esteem. Males had significantly higher scores of self-esteem than females. Also, there was a significant association between self-esteem and tooth-brushing frequency in both males and females. Brushing frequency increased as self-esteem increased. Proportionally more females (67%) than males (57%) gave cleanliness or cosmetic effect as the principal reason for mouth care. In both males and females, as self-esteem increased the proportions of those brushing to make the teeth feel clean increased.
Conclusion: Tooth-brushing frequency was positively related to an adolescent’s self-esteem. The main reason for tooth care in both males and females was to make teeth feel clean. As self-esteem increased more students brushed for this reason.
Nowjack-Raymer 1995 No ARTICLE
Purpose: To clinically compare in a field trial the effect on periodontal health of two self assessment strategies over a two-year period. One approach was focused on the self-assessment and elimination of bleeding (group I) and the second on the self-assessment and elimination of plaque(group II) .
Materials and methods:
§ 493 14 and 15 year olds were randomly assigned to a group.
§ Each subject was given a manual describing one of the self assessment processes.
§ Dental hygienists provided standardized classroom based instruction, and two weeks later, individualized counseling.
§ Examinations were done at baseline at 6, 12, 18, and 24 months for BOP, plaque, calculus, and PD; and at baseline and at 24 months for recession and decayed, missing, and filled surfaces (DMFS).
§ After 12 months, all subjects had oral prophylaxis and additional individual training session.
Results:
No statistical significant differences between groups for any clinical parameter at the final examination.
TThe mean number of sites with BOP decreased from baseline to 24 months with a 59% decrease for group I and 55% decreased for group II.
BL: This study shows us that school based programs can be effective at improving the long term periodontal health status in 14 and 15 year olds.
Abegg 1999 No ARTICLE
P: To try to correlate flexibility of working time schedule with the pattern (frequency of tooth cleaning), structure (range of items used), and performance (relative effectiveness of cleaning).
M&M: 471 individuals 25-44 yrs of age were interviewed and examined (plaque and bleeding). To eliminate confounding associations by sex, socio-economic status, marital status, and age, the following groups were formed: high socio-economic status + high flexibility of working time schedule, high socio-economic status + low flexibility, low S-E status + high flexibility, and low S-E status + low flexibility. Interviews took an average of 30 minutes. Pts that brushed more than twice a day were grouped in the high group (the rest in the low group). Pts were also asked the range of OH aids they used (floss, mouthwash, toothpaste, woodstick, toothbrush).
R: There was a highly statistically significant relationship between flexibility and pattern (Odds 2.2), structure (Odds 2.8), and performance (Odds 2.0). Socio-economic status was associated with these categories as well. Multiple regression analysis was performed to rule out the associations confounded by age, sex, S-E status and marital status.
BL: People with flexible work schedules have better OH.
Tan and Wade, 1980 ARTICLE
P: To investigate the effect of supplementing oral hygiene education with home use of a disclosing agent and to observe any changes in plaque control after discontinuing its use.
M&M: Crossover designs. 38 subjects
FIRST VISIT: 0 weeks; Initial plaque score taken; Patients instructed to use Bass brushing technique twice a day. GROUP 1: 20 patients, received toothbrush only; GROUP II: 18 patients, received toothbrush and 2-week supply of disclosing tablets and mouth mirror (used at evening time). Scale and polish to reduce plaque score to 0.
SECOND VISIT: 2 weeks Plaque scores recorded again; GROUP I: received toothbrush, disclosing tablets, & mouth mirror while GROUP II received toothbrush only. Scale and polish to reduce plaque score to 0.
FINAL VISIT: 4 weeks - plaque scores recorded for all subjects.
R: NSSD in the improvement in plaque control between the two groups. Plaque scores decreased for both groups during the 3 visits. Plaque scores were higher on the Lingual surfaces & in the posterior teeth of both groups. Delivering OHI to pts resulted in a SS improvement in plaque control.
D: Disadvantages of disclosing agents: lack of visibility in certain areas; problem of manual dexterity for the cleaning of inaccessible areas.
BL: The use of disclosing agents to supplement oral home care does not result in a SS improvement in plaque control. Repeated OH education seems to be the most critical factor.
Wood 2006 ARTICLE
Purpose: To evaluate the clinical plaque disclosing agent erythrosine as a photosensitizer in the photodynamic killing of the oral bacterium Streptococcus mutans grown in a biofilm
M & M: S. mutans biofilms of 200 um thickness were grown in a constant-depth film fermenter for either 48 or 288 hours, biofilm pans were then placed in foil-covered vials containing 10 mL of erythrosine, Methylene blue or photofrin in Ringer solution for 15 min at room temperature. Killing measured in logarithms cfu (colony forming units)
Results: Confocal laser scanning microscopy revealed that erythrosine localizes primarily in the biomass of the biofilm. Erythrosine without irradiation had little effect. Photodynamic therapy (PDT) using erythrosine reduced bacteria between 2.2–0.2 log10 (for 48 h biofilms) and 3.0–0.3 log10 cfu (for 288 h biofilms). Photodynamic therapy using Methylene blue resulted in log10 reductions in cfu of between 1.5–0.1 (for 48 h biofilms) and 2.6–0.2 (for 288 h biofilms). Finally, photofrin-mediated photodynamic therapy showed reductions of 0.5–0.2 to 1.1–0.1 log10 cfu reductions observed.
BL: Erythrosine has been shown more effective than two established photosensitizers (methylene blue and photofrin).
Toothbrushing
Which works best: Manual or electric toothbrushes?
Which technique do you recommend to your patients and why?
Stillman, 1932 No ARTICLE
P: An opinion article in which the author proposes treating periodontal disease by scaling, occlusal adjustment, and stimulation of the gingival tissues (tooth brushing).
Disc: Both in office and home care are important to maintain periodontal health. Scaling was designed to remove substances from the root surfaces and that its act will always be a necessity. Surgery is necessary if inadequate access to clean the root surfaces with nonsurgical approach. Adjusting occlusion is a prerequisite for treatment of periodontal disease. During chewing, increased circulation occurs in the gingiva. This is the effect desired by the toothbrush. The brush is not intended to clean the teeth, that is just a natural incidental effect of this technique.
Technique: a new toothbrush is rinsed in solution of tap water with salt and baking soda. Brush is placed with bristles resting partly on gingiva and partly on the cervical portion of teeth, at an oblique angle. Sufficient pressure applied, bristles bend slightly, until blanching of gingiva. Brush is lifted to allow "rapid inrush of blood". Bristles may rotate and bend in any direction but always remain as placed. Only occlusal surfaces (of bicuspids and molars) may be "scrubbed". Everywhere else friction is harmful. Bleeding (which may occur) will remove stagnant blood (which will be replaced by new supply). Brushing the entire mouth should be done no less than 4 times in a treatment and should be performed twice/day.
BL: Tooth brushing should not be used with the sole purpose of cleaning the teeth, but also should aim to stimulate the gingiva, as they are simulated by chewing, to promote healing.
Wilson et al 1993 No ARTICLE
P: To monitor the effectiveness of the Interplak (counter-rotational) toothbrush compared to a manual (Butler Gum) toothbrush for plaque removal, reduction of gingivitis and occurrence of gingival abrasion and recession over 12-month period.
M&M: 32 patients with at least 50% plaque (O'Leary) and 0.75 score for bleeding (Barnett-Muhleman Index). A single-blind randomized two-group design, with 16 using the manual and 16 using the electric brush. Patients examined at baseline (PD, gingival recession, bleeding index, plaque score, gingival abrasion).Upon completion of the baseline data collection, each patient was instructed on the use of his/her assigned toothbrush. Visual demonstrations and written instructions were used. The control group was taught the modified Bass brushing technique. Patients were asked to refrain from using other OH devices and cleaning aids, including dentifrices, other than the one provided. The patients returned at day 7, and at 1,2,6,9, and 12 months. Patients were asked to brush within 1 hour prior to each visit. First investigator measured all parameters used. Second investigator evaluated and brushing skills and gave individualized instructions for improvement. Patients were again asked to brush unsupervised for 3min. Abrasion indices and plaque scores were repeated.
R: 29 patients completed the study, with no significant differences in pocket depths, gingival abrasion, and recession. SSD reduction in gingival bleeding was seen in both groups, although not significant between the groups. For plaque scores, both groups showed improvement although the Interplak scores remained significantly lower than the initial visit through month 9 of the study. The Butler plaque scores remained low through the second month. These scores increased and returned to baseline for months 6, 9, and 12. For the interproximal areas, the Interplak group demonstrated significantly lower plaque scores throughout the study. After OHI were given, patients were asked to brush for 3 min and plaque scores were taken again. There was significantly greater amount of plaque reduction in the Interplak group.
BL: The first long term study showing that Interplak is an efficient plaque remover with adequate supervision. Both toothbrushes were effective in preventing recurrence of gingivitis over a 12-month period.
Tritten and Armitage, 1996 ARTICLE
P: To compare the ability of the Sonicare toothbrush and a manual toothbrush to remove supragingival plaque and reduce gingival inflammation in patients with gingivitis, and to determine the incidence of gingival abrasion associated with use of either device.
M+M: 56 subjects (22-59 yrs) with a GI of at least 1.5 and no PD > 5mm on the six Ramfjord teeth. Patients were divided into 2 groups: manual and sonic and given OHI. Manual group- instructed the modified Bass technique, for sonic- instructed to brush by a slow horizontal back and forth movement. All subjects instructed to brush 2x/day with the same toothpaste. Subjects asked not to use other OH aids (dental floss, rinses, etc) for the first 4 weeks of the study. Provided with an electric timer and asked to brush for full 2 mins, 30 sec/quad. One examiner, who was blinded to the brush assignments of each group,performed all the clinical measurements. Patients were instructed not to brush for 12-14 hours prior to appointments to assess overnight plaque formation, and then patients brushed with their assigned brush for 2 mins after teeth were stained w/ erythrosine and the blinded examiner left the room. Pre-brushing PI and after brushing PI was taken at each exam, and had GI, BT (bleeding tendency), BOP, GCF, AST: aspartate aminotransferase (from frozen GCF sample) recorded at baseline, 1, 2, 4, and 12 weeks. PD and CAL were recorded at baseline, 4 and 12 weeks. All measurements were taken on Ramfjord teeth.
R: Both groups saw significant reduction in PI at the pre-brushing observation. Post-brushing PI reduction was significantly better in the Sonicare group, especially in IP and posterior sites when compared to manual group. 5 patients in the manual group and 1 in the Sonicare group had asymptomatic superficial gingival abrasions. All other parameters (clinical or laboratory) at all other time periods did not show a SSD. The manual and sonic brushes both resulted in SS reductions in GI, BT, and BOP. NSSD between the manual or sonic brushes in the volume of GCF or its content of AST.
BL: Both manual and Sonicare toothbrush seems to be effective at maintaining OH. The Sonicare toothbrush does not seem to cause significant gingival abrasion, but does appear to be statistically superior over manual toothbrush at plaque removal, especially in hard-to-reach areas such as IP and in posterior areas.
CR: Study partially funded by Optiva corp. (makers of Sonicare toothbrush). Not sure how “blind” the examiner really was in this study.
Bergenholtz 1984 No ARTICLE
P: To compare intra-individually the plaque removing ability of straight to V shaped tooth brush either used by the participant themselves or used by dental assistants , performing the brushing with 4 different techniques . The second aim was to compare the cleaning ability interproximally.
M&M: 24 adults aged 20-49 yrs. All received OHI. Half of pts had IPX loss of tissue with open, but healthy IPX area whereas other half had no perio breakdown. In part I, pts were asked to brush with their own brushing technique and length over two periods (No interdental cleaning), use one brush for the 1st (2 weeks) and other brush for the 2nd period (2 weeks). Plaque score registered after each period. Both brushes were soft.
In part II, participants were professionally brushed with 4 brushing techniques (Bass, Roll, Circular Scrub, Horizontal Scrub) randomly assigned to the 4 quads (1 quad/1 technique) . Cleaning was performed once a day for two-5 day periods, during which time participant refrained from brushing and IPX cleaning. Plaque score was then taken.
R: NSSD between the 2 brushes tested in the unsupervised brushing. IPX plaque removal was better with the V shaped toothbrush with professional cleaning. No diff in B or L plaque removal when professionally cleaned between brushes.. The V-shaped brush removed plaque better IPX than the straight brush (regardless of brushing technique), but plaque still remained. The Bass technique was superior compared with the other methods tested on the distolingual and mesiolingual surfaces. All pts developed gingivitis interdentally after each of the the 2 week periods in part I. IPX area with tissue breakdown and loss of interdental papilla accumulated more plaque than those with no perio breakdown.
BL: Plaque removal b/t pts differed, but there was no difference b/t brushes for the unsupervised part. When professionally used, the V shaped removed more IP plaque, but no difference in B or L sites. Interproximal areas cannot be completely cleaned with brushing alone.
Effects of Oral Hygiene
How often should our patients brush? Why?
Compare different toothbrushing techniques and toothbrush types.
Lang 1973 ARTICLE
Purpose: To investigate the rate and pattern of plaque development, to study the effect of gingival health upon plaque formation and determine how frequently effective oral hygiene procedures must be performed to maintain gingival health.
Materials and methods: 32 dental students with clean teeth and healthy gingiva participated in the study. The students were randomly assigned into four groups: Group 1: removed plaque every 12 hours, Group 2: removed plaque every 48 hours, Group 3: did so every 72 hours, Group 4: did so every 96 hours. The OH was performed using Charters technique, dental floss and interdental woodsticks for interdental cleansing. Using disclosing system, a dental hygienist ensured that no plaque remained following the performance of oral hygiene. PI and GI were assessed weekly for a period of 6 weeks, immediately before the scheduled cleansing.
Results: Group 1 obtained the least plaque. In Group 2 the amount of plaque tended to increase during the first 3 weeks. After that time it leveled off and decreased during 5th and 6th week. Groups 3 and 4 formed similar amounts of plaque. Large differences were observed between the amounts of plaque formed in 12 hours. Some individuals developed minimal amounts of visible plaque, while others consistently displayed visible plaque. Differences between the amounts of plaque formed by the individuals within the other groups were not as obvious. In Group 1 plaque was rarely detected on the facial surfaces of any teeth except for the second molars, on the oral surfaces only the molars displayed plaque on a regular basis. In Group 2, some plaque was detected on nearly all surfaces. In Group 4, almost all surfaces except those of the maxillary incisors displayed visible plaque. In Groups 2, 3 and 4 the interproximal surfaces almost consistently were covered with visible plaque. Only Groups 3 and 4 developed gingivitis during the experimental period. Plaque formation began in the interproximal areas of the premolars and molars, then on the interproximal surfaces of the anteriors and on facial surfaces of the premolars and molars. The oral surfaces accumulated at least plaque. Gingival inflammation generally started in the interproximal surfaces of the premolars and molars and in the facial gingiva of the premolars and canines (although usually plaque free-maybe due to narrow width of KG). The performance of effective OH procedures every 48 hours maintains gingival health.
Conclusion: Minor differences in the amount of plaque between Groups 2, 3 and 4 revealed that factors other than the amount of plaque determine its pathogenicity ( it takes more than 48 hours for plaque to become gram negative, chemical changes as plaque matures, longer exposure of the gingival tissues to plaque results in greater irritation if these structures). The rate of plaque accumulation increased before the appearance of clinically detectable gingivitis and leveled off as gingivitis developed. It was apparent that alterations on gingival exudation and other clinical changes of the tissues affected the rate of plaque accumulation. Plaque occurred first in the interproximal surfaces of molars and premolars. Complete removal of plaque once every second day is more valuable than numerous inadequate OH procedures each day.
Kelner 1974 ARTICLE
Purpose: To determine if complete plaque removal every three days is enough to maintain health.
Materials and Methods:.
§ 10 male dentally oriented (dental students and faculty) males, 23-33 years old- had little to no clinical gingival inflammation, no radiographic bone loss and sulci less than 3mm.
§ All subjects received SRP and were given specific OHI.
§ The subjects were randomly divided into 2 groups. Group 1: performed oral hygiene once a day for 30 days and Group 2: performed oral hygiene once every 3 days for 30 days.
§ Patients used disclosing solution, then performed both brushing and flossing. All subjects were scored and photographed on days 0, 9, 15, and 30. The plaque index, gingival index, and exudate were measured at each evaluation. Exudate scores with strips and GI used to measure gingivitis.
Results:
§ Exudates and GI values showed a state of clinical health in all individuals at day 0.
§ Plaque index both groups plaque scores increased between each measure but no statistical significant difference.
§ Gingival index of Group 1 at 0 days was .24, and at 30 days was .49 - no stat signficance. Group 2 at 0 days was .27 and at 30 days was .62 - stastically significant.
§ Exudate mean flow for Group 1 at 0 days was 3.04 and at 30 days was 4.58 – no statistical significance; Group 2 at 0 days was 3.48 and at 30 days was 9.86 statistically significant.
§ The first changes in GI and exudates scores of group 2 occurred on the day 15. The signficant increase of both GI and exudates scores between days 0 and 30 in group 2 may be attributed to cumulatively deleterious effect of plaque removal every third day. A three day plaque begins to show a complex bacterial flora which has been associated with gingivitis.
BL: Plaque removal every 72 hours is not compatible with gingival health while plaque removal every 24 hours will maintain a pre-existing health periodontium in that state.
Waerhaug 1981 ARTICLE
P: To discover to what extent subgingival plaque formation may be prevented by toothbrushing and, what impact it has on the adjacent soft tissue in monkeys.
M&M: 32 molars were studied in 4 monkeys. At baseline, the presence of gingivitis and PD were recorded. Following the measurements, all supra and subgingival plaque was removed. For one year, the right side of the mouth remained unbrushed, meanwhile the left side was brushed using the Bass method 3 times a week. The animals were sacrificed and histology was performed. No distinction was made between plaque and calculus because hematoxylin and eosin staining does not distinguish one from the other.
R: At baseline, there were different degrees of marginal gingivitis and PD were 1.5-2.0 mm. On brushed teeth, subgingival plaque was never found, except approaching the contact areas. A very thin layer of supra-gingival plaque was regularly present, and a mild to moderate cellular infiltration prevailed in the gingival margin. On the unbrushed teeth, subgingival plaque was continuous with supragingival plaque and a moderate to severe cellular infiltration was found in the gingiva adjacent to the plaque
BL: Brushing 3 times a week with the Bass method prevents formation of subgingival plaque in monkeys, except near contact areas (other methods of plaque removal are required).
Cr: authors do not state what they consider mild, moderate or severe cellular infiltration (or what types of cells).
Tabita, 1981
P: To evaluate if subgingival plaque formation is dependent on the presence of supragingival plaque, the effects of supragingival plaque on subgingival plaque formation and the direct relationship between them.
M&M: 12 patients with PD of 4-6 mm; each one had 3 quads SRP and polished. Following initial treatment, each quad was assigned to one of the following modality of plaque control: one quad received daily professional supragingival plaque removal (PP); 2nd quad was maintained by patient who received OHI (Bass/flossing) (HC), no plaque control was performed on the 3rd quad (NHC). With respect to the initially untreated 4th quad, patients were divided into 3 equal groups and each group performed one of the treatment modalities. GI scored at baseline and at 14 days (end of treatment). Supra and subgingival plaque were collected from each tooth and weighed. Mean dry weights for each quadrant were recorded.
R: NSSD in mean plaque weight difference in the first 2 groups (PP and HC). A statistically significant difference in plaque weight was found between the first 2 groups and the groups not receiving plaque removal. Comparing the supragingival plaque weight with the final GI, a significant correlation existed in the quads maintained by the patient. When comparing the subgingival plaque weights to the final GI a significant correlation existed in the quads treated by daily professional prophylaxis.
BL: Plaque control therapy must include the removal of all subgingival plaque and the elimination of periodontal pockets. The control of supragingival plaque reduces but does not completely eliminate the reformation of subgingival plaque, and although the gingival inflammation is reduced, the gingival score does not reach zero. Only in the abscense of plaque control is there a positive correlation between the amount of supra- and subgingival plaque present. Only by making a tooth surface accessible to cleaning can it be possible for the patient to maintain a plaque free dentition.
Beltrami 1987
Purpose: To evaluate the effect of supragingival plaque control on the composition of the subgingival microflora.
M&M: 8 patients with moderate to severe periodontits were chosen for the study. Sites with periodontal destruction (GI > 2, PD > 6.5 mm, vertical bone loss) received professional plaque control 3X/week for 3 weeks. Contra-lateral side received no prophy & served as control. Pts maintained OH during the observation period. Clinical exam & bacterial sampling were performed every week utilizing, Plaque Index (PLI), GI, PBI, and PD & dark field microscopy.
Results:
| PLI | GI | PBI | PD | Spirochetes | |
| TEST | 0.4 | 2.1 | 2.8 | 6.7 | 57% |
| CONTROL | 2.0 | 2.1 | 3.3 | 6.6 | 60% |
PlI for experimental sites showed a marked reduction compared to control sites.
No variations were observed in GI or PD in test or control sites.
The composition of subgingival plaque in both groups showed no significant variations during the study period.
BL: Elimination of supragingival plaque over a 3 week period did not improve the clinical status or subgingival flora. Supragingival plaque control has no appreciable benefit on the subgingival environment.
Westfelt 1998
P: To study the effect of meticulous supra-gingival plaque control on the sub-gingival microbiota, and the rate of progression of attachment loss in patients w/ advanced perio disease.
M&M: 12 patients w/ advanced perio disease were subjected to a base line exam including OH status, BOP, PD, CAL and sub-gingival microbiota from each quadrant (with PPD >5mm). Measurements repeated after 12, 24 and 36 months using split mouth design. 2 quads in each patient were "test"(supra-gingival scaling only) w/ remaining 2 quads as controls (supra-and sub-gingival SRP). OHI and plaque control repeated every 2 wks during initial 3 months, then every 3 months for 3 yrs. Sites w/ attachment loss of >2mm in the test quadrants on reexamination were treated sub-gingivally.
R: Repeated OHI and supra-gingival plaque removal procedures resulted in low plaque scores for both test and controls. BOP and PD’s >4mm were significantly higher in the test quadrants than controls. At 3yrs, the controls showed significant more reduced PD’s (>2mm) than the test quads (39.7% vs 15.3%). Test sites w/ >2mm attachment loss was 4x greater than controls .A more pronounced reduction for Pg only in controls.
BL: Supra-gingival plaque control alone fails to prevent further periodontal destruction in patients with advanced perio disease.
Al-Yahfoufi et al 1995
P: To study the effect of full mouth supra-g prophylaxis and OHI in subjects with minimal periodontal disease but high prevalence of putative periodontal pathogens.
M&M: 10 subjects (7M/3F) from Arabic countries (22-48 years old) who had previously not been exposed to any dental care other than extractions and fillings were selected. Less than 5% of pockets were >5mm and mean PD<3.5mm. DNA probe analysis of sub-g samples (from deeper sites). PD, BOP, PI and AL were also measured. Supra-g prophylaxis (removal of calculus and soft tissue deposits) was performed and OHI (Bass technique + dental floss + tooth pick/floss/interdental brush) was given. At 7 days the patients were recalled, supra-g cleaning and polishing was provided. After 1 month, sub-g microbiota samples were taken in the same sites and clinical parameters recorded.
R:
The % of pockets deeper than 3 mm was reduced from 13% to 3%, BOP was reduced from 68% to 20%
BL: This study demonstrated a considerable clinical and microbiological effect of supra-g plaque control in subjects with high prevalence of periodontal pathogens but minimal periodontal disease.
Davies 1988 No ARTICLE
P: To identify an accurate, unbiased method of measuring plaque levels and then to apply the method using popular brands of toothbrush under nearly normal conditions in order to detect differences in plaque levels brought about by specific variations in toothbrush handle design.
M+M: 27 patients with anterior and premolar teeth were selected. Tooth brushes tested: Oral B 32(short, straight handle), Wisdom Mouth Master Major (long, straight handle), Sensodyne Search 4 (long, contoured handle), and Reach compact head medium (long, contoured handle, with head crancked at 12 degrees to handle). All patients received professional tooth cleaning and all plaque was removed. Patients were then asked to brush with their normal toothbrush and routine for two weeks. At the 2 week visit, plaque was recorded 16 hours after normal, unsupervised brushing and after supervised brushing for one minute. Teeth disclosed after both supervised and unsupervised brushing and photographs were taken to record plaque each time. Plaque was recorded using Quigley and Hein plaque index as modified by Bastian. Patients were then re-cleaned and administered a test brush and asked to follow normal routine for two weeks. Process was repeated until all brushes had been used
R: After normal, unsupervised brushing NSSD in plaque levels result from variation of toothbrush design. Under timed supervised brushing, all test brushes performed better than patient’s own brush. Long handle brushes SS better than short handle. Contoured handle brushes SS better than plain handled brushes. NSSD was noted between crank handle and straight handle brushes.
BL: SS incease in plaque removal was noted with contoured and long handled brushes. Crank handle brushes also increased performance although results were not SS.
Daly 1996 No ARTICLE
P: To investigate the effect of progressive toothbrush wear on plaque control.
M: At baseline (wk 0), 20 dental students (2nd year) were given a new toothbrush, which they used for 9 weeks. Each subject received written and verbal instructions to use the same toothbrush (Sensodyne Search 3.5) and same toothpaste. No instruction given for frequency/duration of brushing. No interdental devices were used. Subjects returned at 3,6,9 weeks and at each visit plaque was disclosed and scored (facial and lingual surfaces of 1st M, 1st PM, Lateral Incisor each quadrant), then professional cleaning done to return pt’s plaque score to 0. Brushing surface of each toothbrush was photographed (standardized) at each visit.
R: At baseline, the mean plaque score was 43%. Wear increased form 0% surface area to 100% surface area (both at 9 wks). Despite progressive toothbrush wear, the amount of plaque that accumulated in each successive 3 wk period decreased. Decrease in plaque scores between wks 3 and 6 and between 3 and 9 were found to be highly significant. Toothbrush wear varied widely amongst the subjects. When plaque scores were evaluated for the 10 subjects with highest wear (mean 40% inc surface area) and 10 with lowest wear (mean 6% increase), no significant differences were found between the 2 groups.
BL: Wear status of toothbrush may not be critical in ensuring optimal plaque control up to 9 wks.
Cr: Could use non-dental subjects, evaluate over a longer period of time, and use a variety of toothbrushes.
Day 1998 no ARTICLE
Purpose: To determine if Sonicare was superior in plaque removal compared to a manual toothbrush for special needs – needs patients when oral hygiene was provided by a caregiver.
Materials and methods: 40 subjects a Nursing and Residential Center in Seattle, 40-90 years of age, at least 16 teeth, oral preventive care provided by a caregiver and be able to be examined without sedation. Residents needing antibiotic prophylaxis were excluded. Caregivers were trained, and two groups were created. In the first one Sonicare was used and in the second one manual toothbrush with the Modified Bass technique, twice a day.
Pre-brushing plaque scores on Ramfjord teeth were taken on baseline and then at 2,4 and 6 weeks and Silness and Loe plaque index was calculates.
Results: 3 pts were withdrawn from the Sonicare group. 89.5 years mean age in the manual toothbrush group and 82.2 yrs in the sonicare.
Conclusion: Sonicare is superior to manual toothbrush in removing the supragingival plaque in nursing home residents when oral care is provided on a regular basis by the caregiver.
REVIEWS
Robinson 2009 ARTICLE
Systemic Review (Updated their 2005 analysis)
Purpose: To compare manual and powered toothbrushes in everyday use, by people of any age, in relation to the removal of plaque, inflammation of the gingiva, removal of staining and calculus, dependability and cost, and adverse effects.
Materials and methods:
§ Cochrane Oral Health Group, Cochrane Central, EMBASE, Medline, and CINAHL were searched.
§ Trials were selected for the following criteria: random design, general public with uncompromised manual dexterity, unsupervised manual and powered toothbrushing for at least 4 weeks.
§ Primary outcomes were the change in plaque and gingivitis for that period. This search included 42 trials with a combined total of 3,967 participants.
Results:
§ Brushes with a rotation oscillation action removed plaque and reduced gingivitis more effectively than manual brushes in the short term and reduced gingivitis scores in studies over 3 months.
§ The difference in the Quigley Hein plaque index was 11% better for rotation oscillation brushing, and there was a 6% reduction in the Loe and Sillness gingival index for the rotational oscillation method.
§ At the groups over 3 months, there was a 17% reduction in bleeding on probing index.
BL: Powered toothbrushes with a rotation oscillation action reduce plaque (short term) and gingivitis (long term) more than manual toothbrushes.
Van der Wejiden 2011 ARTICLE
P: To publish a comprehensive review of all clinical and laboratory investigations solely comparing the safety of oscillating-rotating power toothbrushes to manual toothbrushes.
M&M: A search was conducted on PubMed, Cochrane and EMBASE through the end of May 2010. Letters, case reports and narrative reviews were not included. Criteria for inclusion encompassed human RCT or CCT, humans free from systemic disorders, oscillating-rotating power toothbrushes utilized, manual toothbrush as a control, and a hard or soft tissue safety assessment as a primary or secondary outcome measure. Orthodontic brackets and restorative materials were excluded in the in vitro studies.
R: A total of 35 articles met the inclusion criteria, 31 of them being in vivo. A commercial sponsor funded 19 of these studies. There was no significant difference between groups in gingival recession. As for gingival abrasions, the within-group differences for the baseline and end of treatment of studies consistently showed post-treatment increases in the mean number of gingival abrasions: overall, these changes ranged from 0.2 to 4.3 in the power-brush groups and from 0.5-5.6 in the manual brush groups (according to the authors there were no significant changes in test or control groups). With respect to the safety of four of the studies in vitro, only one had an author that stated that loss of tooth structure in erosive acid-softened enamel might be relatively greater with power brushes (did not account for brushing force though). One study found that less force is used with a power toothbrush versus a manual toothbrush.
BL: There is no clinically significant difference with regard to the safety of power toothbrushes in comparison to manual toothbrushes.
Needleman 2005
P: To investigate the effect of professional mechanical plaque removal (PMPR) on the prevention of periodontal diseases.
M&M: Electronic and hand search was done for randomized controlled trials, controlled clinical trials and cohort studies from 1950 to October 2004. Screening and data abstraction were conducted independently and in duplicate.
Comparisons: PMPR vs. no PMPR and different methods of PMPR
Interventions: Supragingival plaque control with hand instruments (scalers, curettes) or powered instruments (US, rotating devices, air polish). Subgingival plaque removal using hand or powered instruments, if the intention was to debride minimally into the gingival sulcus. Studies with adjunctive use of antiseptics or other antiplaque chemical agents, and studies where the only professional intervention was deliberate subgingival debridement were excluded. Comparison interventions included no treatment, different modes of supragingival plaque removal, or patient performed oral hygiene alone.
Outcome measures: Primary: Tooth loss, changes CAL, GI, BOP. Secondary: Changes in PI, PD, GR.
Patient-centered outcomes: Quality of life, Effects on wellness and function and aesthetics, Patient experience of the treatment, pain. discomfort (e.g. taste alteration,sensation, function disruption). Preferences.
Post-operative adverse events: root sensitivity, tooth surface damage, tissue trauma
R: This review identified 39 articles that fulfilled the inclusion criteria
Outcomes:
There is some evidence that PMPR+OHI provides more favorable clinical outcomes than no treatment. A reduction in PI and BOP or inflammation was common to both RCTs and CCTs, however, evidence for improvements in PD and maintenance or gain in AL was only found in CCTs. Overall, the evidence is weak in strength due to methodological issues and inconsistencies in outcomes.
The evidence for a benefit from PMPR+OHI vs. OHI alone is less clear. In RCTs, PMPR+OHI appeared superior to OHI alone for measures of plaque and bleeding. In a CCT, no evidence of a difference was found between these interventions.
PMPR+OHI with SRP+OHI in the non-surgical management of chronic periodontitis, SRP+OHI produced greater clinical improvements than PMPR+OHI. Regarding systemic health effects, PMPR+OHI appeared to reduce the incidence of fever, death and aspiration pneumonia. However, with losses to follow-up of more than 50%, the validity of these observations is unclear and the results may have been confounded by the general health status of the subjects.
PMPR alone (without OHI) had some evidence of a benefit over no treatment in terms of plaque and inflammation, but NSSD vs. OHI alone or when the status of OHI was unclear.
PMPR+SRP vs. SRP alone in a nonrandomized study, and in the absence of oral hygiene instruction, no evidence of a difference between interventions was seen. The follow up was 10 weeks making conclusions regarding probing changes difficult to interpret. Another short-term study (2weeks) indicated a greater reduction in gingival inflammation resulting from SRP+PMPR+OHI vs. SRP, but no evidence of a difference between PMPR+SRP+OHI and SRP+OHI, suggesting that OHI may have a stronger effect than PMPR alone in controlling gingival inflammation.
The added value of PMPR in SPT for periodontitis is unclear since the two studies investigating the comparison of PMPR versus no treatment as RCTs produced conflicting findings. One study, which emphasized OHI, demonstrated a substantial difference favoring repeated PMPR while the other study, which did not provide further OHI, showed no evidence of a difference. The subjects in both studies had received OHI as part of their initial periodontal therapy and follow-up appeared to be adequate to detect changes in outcomes. When this comparison was examined in a CCT, PMPR offered an advantage over no PMPR for all clinical outcomes during the supportive phase of therapy. The difference in tooth loss was small and not tested for statistical significance.
Different methods of PMPR: clinical efficacy was similar comparing prophy cup vs. air polishing. Bleeding and trauma were greater for air polishing immediately post-treatment, but differences were not evident after a few days. NSSD for the incidence of bacteremia, which occurred with both treatments. Comparing Scaling+prophy cup vs. scaling alone, there was evidence favoring the combined approach both for clinical outcomes and patient preferences, with NSSD between Gracey curettes and US scalers.
Comparison of different PMPR frequencies. Overall, the evidence suggested that increased frequency was associated with better clinical outcomes. Comparing fixed vs. variable PMPR frequency, there was no evidence of a difference in clinical outcomes whether the comparison was to 6 monthly PMPR in non-periodontitis subjects or 3 monthly PMPR in periodontitis patients.
BL:
- Limited evidence suggests that in adults, PMPR, particularly if combined with OHI, may be more effective than no treatment in surrogate measures of periodontal disease prevention, including the reduction of plaque, gingival bleeding/inflammation and PD and the maintenance of ALs.
- It is unclear whether professionally or patient-performed plaque control (or a combination) is important to primary or secondary prevention of periodontal diseases. Conflicting evidence exists as to the value of PMPR in secondary/tertiary prevention of periodontitis.
- There is no evidence of a difference between the effect of rubber cup polishing and air polishing in efficacy outcomes although bleeding and trauma will be transiently greater with air polishing. Bacteremia can be caused by both, and there is no evidence of a difference between them in this respect. One study suggests greater clinical benefits if scaling is combined with rubber cup prophy, and these patients preferred the combined treatment.
- More frequent PMPR is associated with higher levels of periodontal health, although the optimal frequency is undetermined. The strength of evidence for these conclusions ranges from weak to moderate due to factors including risk of bias, inconsistent results, lack of appropriate analytical statistics and small sample size.
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