Translating science into action - prevention of periodontal disease at patient level

Smartphone-Based Telemonitoring for Better Oral Health With Toothbrushes: 6-Month Randomized Controlled Trial

BACKGROUND

A toothbrush device that telemonitors toothbrushing is a technologically advanced solution providing personalized feedback on toothbrushing habits and oral hygiene. These devices integrate smartphone apps to enhance oral health compliance through dental professional feedback.

OBJECTIVE

This 6-month prospective randomized controlled trial aimed to compare the clinical effectiveness, defined as improved oral hygiene measured by plaque reduction and halitosis control, of an interactive telemonitoring toothbrush (ITT), an oscillating-rotating power toothbrush (ORT), and a manual toothbrush (MT).

METHODS

Participants were recruited offline from the Department of Advanced General Dentistry at Yonsei University Dental Hospital, South Korea. A total of 150 participants were randomly assigned to 3 groups (50 participants each): (1) an ITT connected to a smartphone app providing real-time feedback and weekly dental professional reviews, (2) an ORT with smartphone-based guidance requiring participants to send weekly brushing records via screenshots, and (3) an MT with a brushing diary for review. Data collection occurred in clinical settings. Primary outcomes included plaque reduction measured using the Simple Hygiene Score (SHS), while secondary outcomes included plaque reduction measured using the Turesky modification of the Quigley-Hein plaque index (QHI), reductions in halitosis, and changes in oral microbiota. All outcomes were assessed at baseline and 1 month, 3 months, and 6 months.

RESULTS

A total of 150 participants completed the study. Over 6 months, the SHS increased in the MT group (mean 3.16, SD 4.86 to mean 5.66, SD 5.20) but significantly decreased in the ITT group (mean 3.47, SD 5.50 to mean 2.27, SD 3.82; P=.004). Similarly, QHI decreased more in the ITT group (mean 1.79, SD 0.72 to mean 0.85, SD 0.63) than in the ORT (P<.001) and MT (P<.001) groups. Regarding microbiota, there were no significant differences in high-risk periodontal microbiota or the ratio of caries-risk to anticaries microbiota between the ITT and ORT groups. However, in the MT group, the ratio of caries-risk microbiota was significantly higher at the 3-month (P<.001) and 6-month (P=.005) recalls than at baseline and at the 3-month (P=.048) and 6-month (P=.03) recalls than at the 1-month recall. Poststudy questionnaires indicated that 45 of 50 ITT participants (92%) and 37 of 50 ORT participants (76%) reported improved brushing ability. The most effective feature in the ITT group was brushing training, while participants in the ORT group cited the brushing guide as most useful (P<.001). Satisfaction scores were higher in the ORT group (mean 7.90, SD 1.21) than in the ITT group (mean 7.15, SD 1.66; P=.004). The number of brushing events decreased significantly in the ORT group (P=.02), while brushing duration increased in the MT group (P=.01).

CONCLUSIONS

ITTs enable better oral hygiene management than MTs through dental professional feedback. However, further studies are needed to optimize feedback intervals and improve long-term adherence.

TRIAL REGISTRATION

Clinical Research Information Service (CRIS), Republic of Korea, KCT0009094; https://cris.nih.go.kr/cris/search/detailSearch.do?seq=26110&search_page=L.

Periodontal health literacy in Germany-Results of a telephone survey

OBJECTIVE

Assess the periodontal health literacy of German adolescents, adults and senior residents.

BACKGROUND

The prevalence of periodontitis is high. One explanation for this may be that people lack periodontal health literacy (PHL).

METHODS

This was a cross-sectional descriptive study. Former participants of the 5th German Oral Health Study (n = 333 16-year-olds, n = 307 39-48-year-olds, n = 332 69-78-year-olds) participated in a computer-assisted telephone interview. Open-ended questions (OEQs) were used to assess the participants' current knowledge. Corresponding single- and multiple-choice questions (SCQs and MCQs) supplemented the OEQs to allow detailed analyses of the nature of the knowledge gaps.

RESULTS

Less than 10% of the participants in the three age groups could explain the term 'periodontitis' or select the correct answer in an SCQ. Responding to the OEQs, 89% of 16-year olds, 64% of 39-48-year-olds, and 59% of 69-78-year-olds, could not name any consequence of periodontitis, and 83%, 51%, and 60%, respectively, could not name any risk factors. The OEQs regarding proper oral hygiene behaviour revealed that participants lacked awareness regarding important aspects of oral hygiene (e.g., systematics) or areas to which they should pay attention to (e.g., interdental spaces and gingival margins).

CONCLUSIONS

The survey revealed PHL deficits in German adolescents, adults, and seniors and a need for community-based measures to improve PHL in all age groups. Dental teams should be aware that their patients might lack the PHL necessary for understanding and adherence to professional dental advice, and that they might even lack PHL regarding the proper use of oral hygiene devices.

"You should brush your teeth better": a randomized controlled trial comparing best-possible versus as-usual toothbrushing

BACKGROUND

Most people's tooth brushing performance is deficient, even when they are encouraged to brush to the best of their abilities. The aim of the present study was to explore the nature of this deficit by comparing best-possible vs. as-usual brushing.

METHODS

University students (N = 111) were randomly assigned to receive one of two instructions: "brush your teeth as usual" (AU-instruction) or "brush your teeth to the best of your abilities" (BP-instruction). Video analyses assessed brushing performance. The marginal plaque index (MPI) assessed after brushing was used as an indicator of brushing effectiveness. A questionnaire assessed subjectively perceived oral cleanliness (SPOC).

RESULTS

Participants in the BP group brushed their teeth longer (p = 0.008, d = 0.57) and used interdental devices more often (p < 0.001). No group differences emerged in the distribution of brushing time among surfaces, the percentage of brushing techniques used beyond horizontal scrubbing, or the appropriate use of interdental devices (all p > 0.16, all d < 0.30). Plaque persisted at the majority of the sections of the gingival margins, and the groups did not differ in this respect (p = 0.15; d = 0.22). SPOC values in the BP group were higher than those in the AU group (p = 0.006; d = 0.54). Both groups overestimated their actual oral cleanliness by approximately twofold.

CONCLUSIONS

Compared to their usual brushing effort, study participants increased their effort when asked to brush their teeth in the best possible manner. However, that increase in effort was ineffective in terms of oral cleanliness. The results indicate that people's concept of optimized brushing refers to quantitative aspects (e.g., longer duration, more interdental hygiene) rather than qualitative aspects (e.g., considering inner surfaces and gingival margins, appropriate use of dental floss).

TRIAL REGISTRATION

The study was registered in the appropriate national register ( www.drks.de ; ID: DRKS00017812; date of registration: 27/08/2019 - retrospectively registered).

Periodontal diseases and potential risk factors in Egyptian adult population-Results from a national cross-sectional study

Background

Despite the interdependence of general and periodontal health, there is paucity of national representative data on the prevalence of periodontal diseases and their associated risk factors in Egyptian population. This cross-sectional study, thus, aimed to assess the prevalence of periodontitis and tooth loss among Egyptian adults and investigate the association between potential risk factors and periodontal diseases.

Methods

A total of 5,954 adults aged ≥ 20 years were included in this study as a subsample from Egypt’s national oral health survey. Periodontitis was diagnosed with Community Periodontal Index ‘CPI’ scores ≥3 and tooth loss not due to caries was included in the analysis. Socio-demographic data and information on behavioral factors and history of diabetes were gathered in a face-to-face interview. Logistic regression was done to interpret the impact of potential predictors on the incidence of the two selected outcome variables.

Results

The overall prevalence of periodontitis was 26% and regression analysis revealed that higher odds of periodontitis existed among illiterate participants (OR = 1.74; 95% CI: 1.40–2.17), smokers (OR = 1.93; 95% CI: 1.69–2.20) and rural residents (OR = 1.16; 95% CI: 1.03–1.30). On the other hand, old age, frequency of dental attendance and history of diabetes were the main predictive factors for tooth loss.

Conclusions

Among Egyptian adults, periodontal diseases were strongly associated with a multitude of modifiable and non-modifiable risk factors and inequalities in distribution of periodontal treatment needs were determined mainly by age, gender, level of education and residency location.

Periodontal diseases: is it possible to prevent them? A populational and individual approach

Periodontal diseases are infectious inflammatory chronic diseases of a multifactorial nature. They are primarily caused by dysbiotic ecological changes in dental biofilm, which may be influenced by risk factors. The prevention of periodontal diseases may involve different strategies focused on reducing distal, intermediate, and proximal risk factors at both the population and individual levels. Effective prevention depends on interdisciplinary and common risk factor approaches. Also, patient-centered preventive models are more effective than professional-centered models in the management of periodontal diseases. Regular and periodic control of dental biofilm is an essential measure for the different levels of prevention of periodontal diseases. The effectiveness of periodontal disease prevention largely depends on positive modifications of behavior, knowledge, health literacy, patient empowerment, motivation, and compliance.

Good role models? Tooth brushing capabilities of parents: a video observation study

BACKGROUND

Research in adolescents reveals that they are not capable to remove dental plaque effectively. Inconsistent application of brushing techniques and neglect of certain areas while brushing are very common. As parents play a major role in the oral health education, the present study aimed to examine and describe the tooth brushing performance of the parents of adolescents.

METHODS

Parents of adolescents (N = 66) were asked to perform oral hygiene to the best of their capabilities in front of a video camera and dental plaque was recorded before and afterwards. Papillary bleeding was also assessed.

RESULTS

The tooth contact time (i.e. net brushing duration) averaged 155 s ± 58 s. Gingival margins showed persistent plaque at 68% ± 14% of the sections assessed. Papillary bleeding was found at 52% ± 18% of the papillae. Parents brushed inner surfaces lesser than the outer surfaces (41 s ± 24 s vs. 73 s ± 33 s) and 29% of the parents completely missed the inner surfaces of at least one sextant. On the outer surfaces parents predominantly applied circular movements (66% ± 25% of brushing time). Vertical brushing prevailed on the inner surfaces (52% ± 30%). However, horizontal scrubbing was also very common (46% ± 31%).

CONCLUSIONS

Parents' tooth brushing performance was neither effective in terms of plaque removal nor did they fully comply with tooth brushing recommendations such as considering all inner surfaces when brushing or application of other than horizontal movements to lateral surfaces. Regarding oral hygiene, parents should not only be a good role model in terms of timing, frequency and duration of tooth brushing but should also be able to demonstrate how to brush teeth completely and effectively. The current research indicates that they might lack the latter skill.

Toothbrushing Performance and Oral Cleanliness after Brushing in 12-Year-Old Children

Objectives:

Nationwide prevention programs in Germany aim to promote oral health. The group prevention program starts in kindergarten and ends when the children are about 12 y old. While in a recent study, toothbrushing behavior of 12-y-old children was analyzed, the present study’s objective was to examine the children’s ability to achieve oral cleanliness and to analyze how toothbrushing behavior and compliance with the toothbrushing recommendations taught in the group prevention programs predict oral cleanliness.

Methods:

Twelve-year-old randomly selected children (N = 174) were asked to brush their teeth to the best of their abilities, and simultaneously a video was recorded for behavioral analyses. Plaque levels were measured before and immediately after toothbrushing. In addition, dental status and gingival bleeding were assessed.

Results:

After brushing to the best of their abilities, there was plaque on 50% (±24.72%) of all measured sites at the gingival margin (Marginal Plaque Index). Regression analyses revealed approximately 22% of the variance of marginal plaque on the outer surfaces to be explained by the time brushed by circular movements (β = −0.41;P < 0.001) and the number of sextants brushed for at least 7.5 s (β = −0.171; P < 0.05). Circular movements explained most additional variance (ΔR² = 0.113; P < 0.001). With respect to inner surfaces, none of the behavioral aspects explained any variance of oral cleanliness.

Conclusion:

Despite regular group prevention measures, 12-y-old children show limited skills to clean their teeth adequately. Furthermore, none of the recommended behaviors relates to oral cleanliness after toothbrushing at inner surfaces. As a consequence, it is necessary to explore further which behavioral sequences effectively improve oral cleanliness.

Knowledge Transfer Statement:

This study illustrates that children’s compliance to toothbrushing recommendations is not necessarily related to toothbrushing effectiveness. Clinicians should therefore assess the effectivity of recommendations individually and provide individual guidance for improvement.

A public health approach for prevention of periodontal disease

Upwards of 1 in 10 adults worldwide may be affected by severe periodontitis, making the disease more prevalent than cardiovascular disease. Despite its global scope, its impact on pain, oral function, and the wellbeing of individuals, and the disproportionate burden of disease and the socioeconomic impact on communities, the perception that periodontal disease is a public health problem remains low. Although there have been substantial improvements in our understanding of the etiology of periodontal disease and how we can prevent and control it, these advances have been primarily focused on individual, patient-focused approaches. The prevention of periodontal disease depends on improving currently available individual interventions and on determining what public health interventions can be effective and sustainable under real-life conditions. Currently, public health approaches for periodontal disease prevention and control are lacking. This review traces the historical strategies for prevention of periodontal disease in an epidemiologic transition context, using a modified model developed for cardiovascular disease, and presents a possible public health approach. Improving periodontal disease prevention and control will need to take into consideration the core activities of a public health approach: assessment, policy development, and assurance.

Protective effect of hinokitiol against periodontal bone loss in ligature-induced experimental periodontitis in mice

OBJECTIVE

The overall objective of this study was to investigate the effects of hinokitiol on periodontal bone loss in a murine model of experimental periodontitis and evaluate the anti-inflammatory activity of hinokitiol in vitro.

DESIGN

Periodontitis was induced by tying a silk ligature around the maxillary second molar of mice for 8 days. Hinokitiol was injected once a day for 7 days into the palatal gingiva of the ligated molar. Periodontal bone loss was then assessed morphometrically in the maxillary second molar, and the number of tartrate-resistant acid phosphatase positive multinucleated giant cells around the molar was quantified. The bacterial load of the silk ligature was calculated by counting the number of colony-forming units, while the transcription levels of proinflammatory cytokine-related genes in the palatal gingiva were evaluated by real-time qPCR. The activity of hinokitiol against LPS-induced transcription of proinflammatory genes in RAW 264.7 macrophages was also examined.

RESULTS

Local treatment with hinokitiol significantly inhibited the alveolar bone loss and osteoclast differentiation induced by tooth ligation. In addition, hinokitiol treatment decreased the oral bacterial load of the silk ligature and downregulated the mRNA levels of inflammatory cytokine-related genes, both in vitro and in vivo.

CONCLUSION

The results indicated that hinokitiol exhibits antibacterial and anti-inflammatory activity and exerts a protective effect against periodontitis.

Factors affecting decision making at reassessment of periodontitis. Part 3: interpretation of clinical findings - local factors

This paper is the third in a four-part series outlining treatment planning at periodontal reassessment. The first article focused on the information that should be gathered at the reassessment appointment. The second article discussed systemic factors that can relate to residual periodontal probing depths. This article outlines local factors that need to be assessed when faced with residual periodontal probing depths. Treatment can involve a range of non-surgical and surgical approaches. A variety of general, practical and local site factors can affect the choice of one option over another in choosing the most predictable treatment option.

Oral cleanliness in daily users of powered vs. manual toothbrushes - a cross-sectional study

Background

Toothbrushing is a daily routine. Still, when adults are asked to manually perform oral hygiene to the best of their abilities, a considerable amount of plaque persists. Little is known about the performance of people who use a powered toothbrush. The present study thus analysed whether the capability to achieve oral cleanliness is better in people for whom powered toothbrushing is a daily routine.

Methods

University students, who either performed powered (N = 55) or manual (N = 60) toothbrushing for more than 6 months on a daily basis were asked to clean their teeth to the best of their abilities by their own device. Plaque was assessed prior to and immediately after brushing. Furthermore, gingival bleeding, recessions, periodontal pocket depths and dental status were assessed. Oral hygiene performance was video-taped and analyzed with respect to brushing duration, sites of brushing and application of interproximal cleaning devices.

Results

No differences between groups were found with respect to plaque before and after brushing, clinical parameters and overall brushing duration (all p > 0.05, all d < 0.156). After brushing, plaque persisted at approximately 40% of the sections adjacent to the gingival margin in both groups.

Conclusions

No advantage of daily powered toothbrushing as compared to daily manual toothbrushing was seen with respect to oral hygiene or clinical parameters. The capability to achieve oral cleanliness was low, irrespective of the type of toothbrush under consideration. Additional effort is thus needed to improve this capability.

Electronic supplementary material

The online version of this article (10.1186/s12903-019-0790-9) contains supplementary material, which is available to authorized users.

Toothbrushing behavior in children - an observational study of toothbrushing performance in 12 year olds

Background

Many countries offer systematic group prevention programs in kindergarten and school in order to promote children’s oral health. Little is known, however, about the actual toothbrushing abilities of children when group prevention programs end.

Methods

In Germany, all children take advantage from a nationwide group prevention program (called “Gruppenprophylaxe”) lasting from kindergarten up to sixth grade (12 years of age). Standardized recommendations are given concerning brushing systematics and brushing movements. N = 174 children at the age of 12 were thus randomly selected from two German towns and were asked to perform toothbrushing to the best of their abilities in front of a mirror which also served as a camera. Brushing behavior was analyzed by video analysis.

Results

Children brushed their teeth for an average of 200 s ± 80.48 s (mean ± SD). Still, more than 55% missed at least one sextant when brushing inner surfaces, 16% missed them all. Only 7.5% of the children brushed both inner and outer surfaces by the intended movements (vertical movements on the inner surfaces and circular movements on the outer surfaces) for at least 90% of the respective brushing time. Instead, horizontal brushing was very common on the lateral surfaces.

Conclusions

The present analysis indicates that children have low efficiency to adopt the tooth-brushing recommendations given in prevention programs. This is surprising as great endeavors are made to help children internalize the recommendations. Future research is needed to better understand which factors impede adoption of toothbrushing recommendations in children and which efforts are necessary to improve their toothbrushing abilities.

Electronic supplementary material

The online version of this article (10.1186/s12903-019-0755-z) contains supplementary material, which is available to authorized users.

Effects of Selective Versus Non-Selective COX-2 Inhibition on Experimental Periodontitis

In the present study we compared the effects of the selective COX-2 inhibitor etoricoxib with those of the classical non-selective NSAID diclofenac on the inflammatory process and alveolar bone loss in an experimental model of periodontitis in rats. Ninety male Holtzman rats (250 g) were randomly sorted into four experimental groups: Sham+CMC and Ligature+CMC (control) groups which received 0.5% carboxymethylcellulose sodium (CMC) solution; Ligature+Diclofenac and Ligature+Etoricoxib groups which received Potassium Diclofenac and Etoricoxib, respectively, suspended in 0.5% CMC (10 mg/kg/day). At 7, 14 and 21 days after placing ligatures in the cervical region of both the lower right and left first molars, the animals were euthanized. At the end of each period, the mandibles were collected for radiographic examination of alveolar bone loss. In addition, alveolar bone and periodontal ligament tissue samples were collected for COX-2 expression analysis and gingival tissues were collected for measurement of PGE2 contents. Animals with ligature-induced periodontal disease showed significant increased COX-2 gene expression at days 7, 14 and 21 (p<0.05) on alveolar bone and periodontal ligament. However, both treatments resulted in significantly reduced alveolar bone loss when compared to the untreated Ligature group (p<0.05), with no statistical difference between Etoricoxib and Diclofenac Potassium groups. This study shows that both drugs were able to reduce alveolar bone loss after periodontal disease induction.

High Plaque Levels after Thorough Toothbrushing: What Impedes Efficacy?

OBJECTIVES

Previous studies have shown high levels of dental plaque after toothbrushing and poor toothbrushing performance. There is a lack of evidence about what oral hygiene behavior predicts persistent plaque. The present cross-sectional study thus relates toothbrushing behavior to oral cleanliness after brushing and to gingivitis.

METHODS

All young adults from a central town in Germany who turned 18 y old in the year prior to the examination were invited to participate in the study. They were asked to clean their teeth to their best abilities while being filmed. Videos were analyzed regarding brushing movements (vertical, circular, horizontal, modified Bass technique) and evenness of distribution of brushing time across vestibular (labial/buccal) and palatinal (lingual/palatinal) surfaces. Dental status, gingival bleeding, and oral cleanliness after oral hygiene were assessed.

RESULTS

Ninety-eight young adults participated in the study. Gingival margins showed persistent plaque at 69.48% ± 12.31% sites (mean ± SD) after participants brushed to their best abilities. Regression analyses with the brushing movements and evenness of distribution of brushing time as predictors explained 15.2% (adjusted R² = 0.152, P = 0.001) of the variance in marginal plaque and 19.4% (adjusted R² = 0.194, P < 0.001) of the variance in bleeding. Evenness of distribution of brushing time was the most important behavioral predictor.

CONCLUSION

Even when asked to perform optimal oral hygiene, young German adults distributed their brushing time across surfaces unevenly. Compared with brushing movements, this factor turned out to be of more significance when explaining the variance of plaque and bleeding.

KNOWLEDGE TRANSFER STATEMENT

Results of this study can help clinicians and patients understand the meaning of specific behavioral aspects of toothbrushing for oral cleanliness and oral health.

Finding an upper limit of what might be achievable by patients: oral cleanliness in dental professionals after self-performed manual oral hygiene

AIMS

Though patients have been shown to have difficulties in achieving oral cleanliness after self-performed oral hygiene, scientifically and empirically justified standards for the degree of oral cleanliness they should achieve are lacking. Oral cleanliness of dental staff was therefore assessed as an indicator of what might be an upper limit of what can be expected by patients.

MATERIALS AND METHODS

In a multicentre study, N = 64 university dentists, N = 33 dental students and N = 30 dental assistants were asked to perform manual oral hygiene to the best of their abilities. The presence or absence of dental plaque adjacent to gingival margins was assessed by the marginal plaque index (MPI). As full-crown index, the Turesky modification of the Quigley and Hein Index (QHIm) was applied.

RESULTS

Only three participants showed papillary bleeding and only one a clinical pocket depth of more than 3.5 mm. After self-performed oral hygiene, no differences between groups were observed with respect to plaque nor did results differ between those who habitually used a powered toothbrush only and those who did not. Most participants (96%) achieved oral cleanliness at more than 70% of their gingival margins and QHIm levels below .63. Half of the participants showed QHIm levels below .17 and oral cleanliness at 96% of gingival margins.

CONCLUSIONS AND CLINICAL RELEVANCE

Considering that half of the dental professionals achieved oral cleanliness at 96% of gingival margins and QHIm levels below .17 after thorough oral hygiene, this might reflect an upper limit of what can be expected by patients.

Low-cost periodontal therapy

Periodontitis is a complex infectious disease that affects low-income individuals disproportionately. Periodontitis is associated with specific bacterial species and herpesviruses, and successful prevention and treatment of the disease is contingent upon effective control of these pathogens. This article presents an efficacious, highly safe, minimally invasive, practical and low-cost periodontal therapy that involves professional and patient-administered mechanical therapy and antimicrobial agents. The major components are scaling for calculus removal, periodontal pocket irrigation with potent antiseptics, and treatment with systemic antibiotics for advanced disease. Povidone-iodine and sodium hypochlorite have all the characteristics for becoming the first-choice antiseptics in the management of periodontal diseases. Both agents show excellent antibacterial and antiviral properties, are readily available throughout the world, have been safely used in periodontal therapy for decades, offer significant benefits for individuals with very limited financial resources, and are well accepted by most dental professionals and patients. Four per cent chlorhexidine applied with a toothbrush to the most posterior part to the tongue dorsum can markedly reduce or eliminate halitosis in most individuals. Systemic antibiotics are used to treat periodontopathic bacteria that are not readily reached by topical therapy, such as pathogens within gingival tissue, within furcation defects, at the base of periodontal pockets, and on the tongue, tonsils and buccal mucosae. Valuable antibiotic therapies are amoxicillin-metronidazole (250 mg of amoxicillin and 250 mg of metronidazole, three times daily for 8 days) for young and middle-aged patients, and ciprofloxacin-metronidazole (500 mg of each, twice daily for 8 days) for elderly patients and for patients in developing countries who frequently harbor enteric rods subgingivally. Scaling to remove dental calculus and the prudent use of inexpensive antimicrobial agents can significantly retard or arrest progressive periodontitis in the great majority of patients.