Oral Health and Preventive Dentistry, 02/2007

Purpose: Diabetes is an established risk factor for periodontal disease. Management of periodontal disease is highly dependent upon effective oral hygiene. Assessment of plaque and gingivitis has been commonly used and arbitrarily set in clinical practice to evaluate patients' adherence with oral hygiene recommendations. This study aims to determine an objective cut-off criterion for assessing oral hygiene compliance utilising a combination of plaque and bleeding scores. Materials and Methods: 161 patients with diabetes, from a prospective clinical trial, provided the clinical periodontal parameters at baseline to be used to determine the oral hygiene compliance criterion in relation to a composite score of pocket depth, subgingival calculus and supragingival calculus. A sequence of different combinations of plaque and gingival bleeding scores were used. Receiver operator characteristic (ROC) curve assessment, sensitivity, specificity, and predictive values were utilised for the determination of the criterion. Results: The combination of 25% plaque scores and 15% gingival bleeding scores obtained the highest ROC value (using a probability cut-off of 0.5) of 0.868 with sensitivity 98.6%, specificity 75.0%, positive predictive value (PPV) 97.3% and negative predictive value (NPV) 85.7%. According to this criterion, amongst the cohort of subjects examined, 145 (90.1%) were categorised as non-compliant, and only 16 (9.9%) were considered compliant with oral hygiene at baseline. Conclusions: Based upon the clinical periodontal parameters of subjects from this study, a combination of 25% plaque score and 15% bleeding score appears to be a valid target for determining compliance with oral hygiene in oral health programmes. Keywords: bleeding on probing, plaque, predictive values, oral hygiene compliance, receiver operator characteristics

Purpose: The aim of this randomised single-blind, cross-over trial was to assess the effect of tongue cleansing on morning oral malodour in periodontally healthy subjects. Materials and Methods: Ten systemically healthy non-smoker subjects (6 males, 4 females), 24-38 years of age, completed two 4-day periods of oral hygiene cessation with a 7-day wash-out period. In one of these test periods, subjects were instructed to clean their tongues with a tongue scraper 2-3 times a day. Participants presented at least 20 teeth, without cavities, overhanging restorations/prostheses or periodontitis, and had no history of previous periodontal therapy or use of antibiotics in the 3 months prior to the study. Volatile sulphur compounds (VSC; Interscan Halimeter) and organoleptic scores were measured in exhaled mouth air once a day, early in the morning, by one examiner. Comparisons were performed using Wilcoxon's signed rank test and Friedman's test (α = 0.05). Results: VSC levels at baseline were 206.3 ppb (SD 139.8) and 191.4 ppb (SD 127.7) for periods of usage and non-usage of the scraper respectively (p > 0.05). VSC levels did not change significantly during the 4 days, independent of tongue cleansing (Friedman, p > 0.05). Only at day 3 did the use of the tongue scraper lead to a significantly lower level of VSC compared with controls (131.1 ppb and 199.3 ppb respectively). No significant differences in organoleptic scores were observed between groups at baseline. During the whole experimental period, there were also no significant changes in organoleptic scores when individuals used or did not use the tongue scraper. Conclusion: Tongue cleansing with a scraper was unable to prevent morning oral malodour in the absence of tooth cleaning in periodontally healthy individuals. Keywords: halitosis, oral malodour, oral hygiene, tongue

Objective: To determine the differences in oral self-care levels between 322 Romanian dental students. Materials and Methods: The design of the study was a cross-sectional survey of dental students in Romania. The examination was based upon responses to a questionnaire entitled 'Hiroshima University - Dental Behavioural Inventory' (HU-DBI) and three additional questions. Results: Statistically significant differences of the mean HU-DBI scores were observed between year 1 and 2 (level of basic science course) and year 5 and 6 (level of clinical course) and between genders (p 0.001). Statistically significant differences were notable in 10 items out of 20 between three levels of dental education (basic, preclinical and clinical levels). The most striking results were that year 5 and 6 students were less likely to use a toothbrush with hard bristles (p 0.001), and less likely to worry about the colour of their teeth (p 0.01). While 20% of year 1 and 2 students reported daily flossing, almost 46% was reported in year 5 and 6 students (p 0.001). A significant difference was also observed on flossing behaviour between genders (p 0.001). Of 205 year 1-4 students, 176 (85.9%) were correctly predicted by the models, and 177 of 193 female students (91.7%) were correctly predicted. Conclusions: There were considerable differences in dental health attitudes/behaviour between the three levels of dental education and between genders. Keywords: dental education, dental students, gender, oral health behaviour, Romania

Purpose: Previous studies have indicated that health beliefs are related to the periodontal disease status and treatment behaviour of patients. However, it is possible that treatment may affect a patient's health beliefs and thus complicate this issue. The present study therefore looked for changes in health control beliefs and oral health impacts in patients undergoing periodontal treatment in a dental school. Materials and Methods: Questionnaires assessing dental multidimensional locus of control (LOC) and oral health impact profile (OHIP) were posted to subjects due to attend for initial periodontal consultation and were returned by 127 patients who attended. Repeat questionnaires were sent to all subjects 6 months later when they had received some oral hygiene instruction, scaling and root planing, and 55 were returned. Results: Comparison of data for those subjects who completed both questionnaires showed no difference in LOC but showed a trend (p = 0.065) towards reduced OHIP (i.e. improved oral health-related quality of life). Conclusions: These subjects apparently did not alter their health control beliefs about periodontal disease as a result of treatment, but there may have been an improvement in their oral health-related quality of life. Further studies are required to confirm these possibilities. Keywords: locus of control, oral health impact profile, periodontal treatment, quality of life

Purpose: The aim of this study was to evaluate the influence of smoking on the periodontal conditions of a randomly selected population sample of 19-year-old individuals. Material and Methods: A population sample of 272 randomly selected 19-year-old individuals living in Göteborg, Sweden, was clinically examined with regard to oral hygiene, gingivitis, deepened periodontal pockets, probing attachment loss (PAL) and gingival recession. On bitewing radiographs, alveolar bone level and presence of dental calculus were assessed. The subjects were classified as 'never-smokers' or smokers based on information obtained by a questionnaire-based interview. Results: The mean plaque and gingivitis scores were for never-smokers 58% (SE 1.7) and 46% (1.4) respectively, and for smokers 60% (2.2) and 42% (2.1) respectively. Of the never-smokers and smokers respectively, 38% and 35% showed a prevalence of gingivitis of >50%. The mean number of sites with periodontal pockets >=4 mm was 12 (0.9) in never-smokers and 13 (1.4) in smokers. Of both never-smokers and smokers, 75% did not have any site with PAL >=2 mm, and only six individuals (3%), all never-smokers, showed more than three sites with a PAL of >=2 mm (facial sites). Logistic regression analyses revealed that smoking was a poor discriminator for identification of subjects with periodontal destruction (OR 0.62-1.33). Conclusions: In the present population sample of adolescents, characterised by high prevalence of plaque and gingivitis, smoking habits did not contribute to a higher prevalence or severity of periodontal destruction. Keywords: adolescents, periodontal disease, smoking

Purpose: To evaluate marginal bone loss on the individual and tooth level, with focus on the importance of the baseline marginal bone level. Materials and Methods: In 1997, 616 randomly selected individuals (mean age 42 years, range 21-63 years) underwent a full-mouth radiographic survey. In 2003, the survey was repeated for 473 of the same individuals (239 females and 234 males). The marginal bone level of each tooth was measured in mm from the cemento-enamel junction to the marginal bone. These measurements were used to calculate marginal bone loss during the 5-year period, and to analyse the average marginal bone loss for the individual, and tooth group in relation to age and to baseline marginal bone level, calculated as the average between measurements in 1997 and 2003 to circumvent regression to the mean. Results: Marginal bone loss rate was on average 0.1 mm per year. For the individual, marginal bone loss was associated with both baseline marginal bone level and age. A significant difference was shown (p 0.05) in marginal bone loss between different age groups, with a stronger association between marginal bone loss and baseline marginal bone level in the youngest age group. Moreover, marginal bone loss differed between tooth groups (p 0.001), with molars and premolars losing marginal bone more rapidly than incisors and canines and showing a stronger association with baseline marginal bone level. Conclusions: Marginal bone loss over a 5-year period is associated with age and baseline marginal bone level. Younger individuals with a reduced marginal bone level were at high risk for further bone loss. Molars and premolars exhibit more rapid marginal bone loss than incisors and canines. Keywords: alveolar bone loss, longitudinal study, radiography

Purpose: To discuss the statistical approaches that have been traditionally used to compare measures in periodontal research, highlighting its strengths and weaknesses and, finally, to suggest the use of the limits of agreement method of Altman and Bland (1983) as an alternative method to address this question. Materials and Methods: Using a sample dataset of clinical periodontal measures as a background, the different possible approaches for agreement assessment are discussed and statistical and clinical points are considered. Eight hundred and forty repeated measures, belonging to the training phase of a clinical study, were performed in five individuals presenting different severities of periodontal conditions. The use of correlation coefficient, comparison of means, linear regression technique, Kappa coefficient, intra-class correlation coefficient and means versus differences plot is demonstrated. Results: Most of the methods are applied without the appropriate care, resulting in misleading interpretations. The information that arises from some of the methods used so far is poorly informative and adds little understanding to the operational characteristics of the raters or instruments. Some of the resulting information from the correlation coefficient and kappa coefficient may even be false or not applicable for the entire range of possible values. Conclusions: The graphical approach that plots differences against means, including the 95% limits of agreement estimated by the mean difference ± 1.96 standard deviation of the differences is the most informative approach and its application should be considered for continuous clinical periodontal measures. Keywords: agreement, periodontal attachment loss, probing depth, reproducibility

Purpose: To investigate how the number of remaining teeth relates to the presence of metabolic syndrome (MetS) and markers of inflammation. Materials and Methods: A population-based prospective investigation of the vasculature in Uppsala seniors (PIVUS) study was carried out on 1016 subjects, aged 70. Results: The number of teeth was self-reported in 947 subjects and was found to be less in those with MetS using National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATP III) criteria (n = 219, mean 17.7 ± 9.0 [SD]), compared with n = 728, mean 20.7 ± 7.2 in those without MetS (p 0.0001), and in proportion to the number of criteria fulfilled (p 0.0001). The number of teeth was also inversely related to markers of inflammation (r = -0.15, p 0.0001 for leukocyte count; r = -0.10, p = 0.0023 for C-reactive protein). In a multiple regression analysis, the presence of MetS, smoking, educational level, leukocyte count and height were independent predictors of the number of teeth. Conclusions: In addition to established risk factors for tooth loss, the presence of MetS and inflammation were independent predictors of the number of teeth in an elderly population. Keywords: C-reactive protein (CRP), inflammation, metabolic syndrome, oral health, teeth

Purpose: To investigate the thresholds of restorative intervention in dental caries treatment, based upon the lesion depth seen in radiographs, among Brazilian dentists working in small cities. In addition, the threshold of restorative intervention was compared with demographic and work-related characteristics. Material and Methods: The studied population comprised dentists (n = 89) who were working in 2000 in 20 small cities of the Midwest region of the Southern Brazilian State of Santa Catarina. Four different radiographs were shown of extracted premolars fixed upon a plaster base. The criteria for the radiograph analyses were proposed by Nuttall et al (1993). Results: Of investigated dentists, 16.7% would restore a carious lesion confined to the outer half of the enamel and 33.3% would restore a carious lesion in the outer and inner half of the enamel, but without involving the enamel-dentine junction. The percentage that would restore lesions in the outer half of dentine was 91.7%. Dentists who had attended postgraduate courses in areas of interest of this study tended to adopt a more conservative treatment when compared with dentists who had not attended (p 0.01). Conclusions: There was a great variation in the thresholds of intervention based upon lesion depth seen in radiographic images among the investigated Brazilian dentists. An interventionist attitude was observed, which could result in over-treatment. It is highly recommended to educate general practitioners from the studied region in performing early diagnosis of lesions and non-invasive care in order to treat initial carious lesions with only remineralisation and monitoring. Keywords: caries depth, decision-making, radiograph, restorative decision, treatment threshold

Objective: To investigate the influence of different settings, epidemiological and clinical, and different diagnostic thresholds on caries detection in a group of 7-10-year-old children in Brazil. Materials and Methods: In total, 983 children aged 7-10 years old and enrolled in four public schools were randomly selected. Three examiners performed epidemiological examinations followed by an examination of the same children in a clinical setting. The examinations of cleaned and dried teeth in both settings were carried out using a dental mirror and ball-ended probe, under natural light in the epidemiological setting examinations and under artificial light during the clinical setting examinations. For the analysis of results, comparisons were focused on WHO (World Health Organization) diagnostic thresholds versus WHO+IL (initial lesions) diagnostic thresholds, both under epidemiological conditions, in order to demonstrate the influence of the inclusion of IL in the study; and WHO+IL in the epidemiological setting versus WHO+IL in the clinical setting, aiming to demonstrate the importance of examination setting. Outcome measures were dmfs, DMFS, ds, Ds, sealants and number of children 'free' of caries. Paired t-test and McNemar's test were used to test the difference between means and proportions for each age group. Results: Epidemiological examinations, under the WHO diagnostic threshold, showed significant differences for all outcome measures when compared with the WHO +IL threshold. Statistical differences were also detected when comparing the WHO+IL threshold under different settings. Conclusion: The choice of a diagnostic threshold (WHO or WHO+IL) and the conditions of examination (epidemiological or clinical) were important for caries detection. Keywords: dental caries, diagnosis, epidemiology

Purpose: To review in a systematic approach the effectiveness of specific fluoride treatments on the root caries activity in adults. Materials and Methods: An electronic search of the National Library of Medicine, Washington DC (Medline-PubMed), and the specialist trials register of the Cochrane Oral Health Group up to and including April 2005 was performed using specific search terms to identify randomised controlled trials, controlled clinical trials and longitudinal studies of at least 3 months duration, which investigated the effect of specific fluoride treatments with regard to root caries activity and/or incidence in healthy adults. Comparisons were made against the root caries status before the initiation of the additional fluoride application regimen and between groups in controlled studies. The papers were screened independently by two reviewers (MH and SP). Results: Out of 348 titles and abstracts, six papers fulfilled the selection criteria and were processed for data extraction. The highest level of evidence was presented in the two papers using a double-blind controlled randomised clinical trial (Wallace et al, 1993; Baysan et al, 2001). Both these studies indicate that the increased application of fluoride in the form of a high concentration dentifrice or additional mouthwash had a positive effect on the root caries incidence/severity. Conclusion: Additional fluoride appears to be a preventive and therapeutic treatment for root caries. Keywords: fluoride, root caries activity, root caries incidence, systematic review

Purpose: Odontogenic infection sources represent a predisposing risk factor for patients with cardiac valvular disease (CVD) awaiting cardiac valve replacement procedures. Study design: The incidence and quality of odontogenic infection sources (foci) were evaluated on 152 consecutive patients (study group, SG) undergoing cardiac valve replacement and were compared to 150 age-, gender- and residence-matched noncardiac patients (control group, CG). Clinical and radiographic examinations were used to evaluate the incidence of odontogenic infection sources, grouped into potential (high risk) and facultative foci (possible risk), and the presence/severity of periodontal disease (PD). Foci and PD were compared among the overall SG and the CG and also among a sophisticated subdivision of the study group, especially with respect to aortic valve (AVR) and mitral valve replacement (MVR). Results: Overall, 218 potential and 116 facultative odontogenic foci were found in 87 (58.3%) and in 79 (51.9%) patients of the SG respectively. The overall incidence of odontogenic infection sources and the incidence and severity of PD did not differ between the SG and the CG. However, in comparison with the CG (48%), the incidence of potential odontogenic infection foci was significantly higher in patients scheduled for AVR than in those scheduled to undergo MVR (70.4% vs. 25.0%, p0.01). Additionally, in patients scheduled for AVR, a significantly higher number (p0.01) of individual potential dentogenic infection foci (1.7 vs. 0.8 foci/valve) and a higher prevalence of PD (60.2%) was seen than for patients scheduled for MVR (31.8%) or for patients without CVD (1.0 foci/valve; 39.3%; p0.05). Discussion: Although the overall incidence of odontogenic infection sources did not differ between the patients with and without CVD, a sophisticated subdivison of CVD may be crucial, demonstrating that patients with AVR differ significantly from those with MVR and with the healthy CG. Cardiologists and cardiac surgeons play an important role in organising oral rehabilitation of patients scheduled for valve replacement. Keywords: cardiac valve surgery, dentogenic infection foci, focus treatment, oral rehabilitation