Comparison of marginal bleeding using a periodontal probe or an interdental brush as indicators of gingivitis

Effectiveness of Waterpik® for oral hygiene maintenance in orthodontic fixed appliance patients: A randomised controlled trial

OBJECTIVE

To establish whether the use of a WaterPik® alongside a manual toothbrush (WaterPik® + MTB) is more effective for maintaining oral hygiene compared to the use of a manual toothbrush alone (MTB) in patients wearing fixed orthodontic appliances.

DESIGN

A single-centre, two-arm, parallel-group, single-blind, randomised controlled clinical trial with a 1:1 allocation ratio.

SETTING

Orthodontic department at York Hospital, York Teaching Hospitals NHS Foundation Trust, UK.

PARTICIPANTS

A total of 40 fit and well participants, aged 10-20 years, being treated with upper and lower fixed orthodontic appliances.

METHODS

Participants were randomly allocated, using stratified block randomisation, to the control group (MTB) or intervention group '(Waterpik® + MTB)'. Plaque, gingival and interdental bleeding indices were recorded at baseline, 8 weeks, 32 weeks and 56 weeks. A generalised linear mixed model was used to assess differences between groups.

RESULTS

An interim analysis of results was performed with 40 patients recruited and 85% of data collected. The overall mean differences between the groups were as follows: plaque index = 0.199 (P = 0.88, 95% confidence interval [CI] -0.24 to 0.27); gingival index = -0.008 (P = 0.94, 95% CI -0.22 to 0.20); and interdental bleeding index = 5.60 (P = 0.563, 95% CI -13.22 to 24.42). No statistical difference between the two groups was found for any variable. The trial was stopped at this point.

CONCLUSIONS

In terms of oral hygiene, our study did not find evidence to support the claim of benefit of using a Waterpik® in addition to a manual toothbrush for patients wearing fixed orthodontic appliances.

Periodontal pathogens of the interdental microbiota in a 3 months pregnant population with an intact periodontium

Steroid hormones and the oral microbiota of pregnant women both appear as cumulative risk factors for gingivitis. This cross-sectional study, using real-time PCR, investigated the composition and diversity of the microbiota in interdental spaces of 3 months pregnant women with intact periodontium according the 2018 EFP/AAP classification. Bacteria identified were belonged to the red (Porphyromonas gingivalis Treponema denticola, and Tanerella forsythia), orange (Fusobacterium nucleatum, Prevotella intermedia, Campylobacter rectus, and Parvimonas micra), and green (Eikenella corrodens and A. actinomycetencomitans) Socransky complexes. Approximatively 109.11 bacteria were counted per interdental space in pregnant women. Bacteria from the red complex represented 33.80% versus 62.81% for the orange group versus 3.39% for the green group of the total number spread over the 3 groups. Dietary habits and physical activity did not have a significant impact on interdental microbiota, although a decrease in the median amount of 9 periodontopathogens was observed when fruit and vegetable consumption increased. Pregnant women who brushed their teeth at least twice a day had lower counts of total bacteria and 9 periodontal pathogens than those who brushed less. In 3 months pregnant women at high risk of periodontal disease (>30% bleeding sites), the dendogram revealed 2 clusters of the 9 periodontopathogens. This provides further support for the "key pathogen" hypothesis, among which Porphyromonas gingivalis plays a key role, indicating that specific bacteria in limited quantities can influence the host immune system and convert the microbiota from symbiotic to dysbiotic to induce inflammatory disorder. As a result, this study reported that 3 months pregnant women with healthy periodontium had high levels of interdental bleeding and a dysbiotic microbiota with periodontal pathogens of the Socransky orange and red complexes. These subjects were therefore potentially at increased risk of developing periodontal disease and, consequently, an adverse pregnancy outcome. So, preventive oral prophylaxis measures, in particular individual interdental prophylaxis, should be implemented as soon as pregnancy is established.

Prevalence, Severity of Extension, and Risk Factors of Gingivitis in a 3-Month Pregnant Population: A Multicenter Cross-Sectional Study

The scope of this study was to assess the prevalence, severity of extension, and risk factors of gingivitis among pregnant women. In this cross-sectional study, 220 nulliparous women at 3 months of pregnancy were recruited in 2022 at the first obstetrical visit in Dakar, Senegal. Demographic characteristics, lifestyle habits, prenatal clinical status, and oral clinical parameters were recorded. Multivariable logistic regression modeling was used to assess relationships between gingivitis and risk factors. Eighty-eight percent of women had gingivitis, 15% were classified as moderate and 73% as severe. A total of 66.7% (95% CI [28.8-92.1]) of the sites had bleeding on interdental brushing. The odds for gingivitis decreased significantly for women consuming more than five portions of fruits and vegetables per day (OR = 0.15; 95% CI [0.03-0.66]) and increased in women who had a professional activity (OR = 6.75; 95% CI [1.27-35.87]) and high education. Concomitantly, the percentage of dental plaque (OR = 131.6; 95% CI [10.80-1619.71] and the severity of clinical attachment loss (OR = 7.70; 95% CI [3.16-18.92]) were important risk factors. Inverse associations were observed with increasing body mass index (OR = 0.76; 95% CI [0.63-0.93]). Our results underline that gingivitis cases and bleeding were particularly high among 3-month pregnant women. Literacy and adequate oral hygiene actions to modify behaviors and to achieve meticulous biofilm disorganization could make a favorable change in the gingival health outcome. Additionally, further research is necessary to precisely determine the role of biofilm-induced gingivitis and systemic-induced gingivitis in improving gingival conditions.

Interdental hygiene index - A proposal of dual-purpose tool for patient assessment and motivation

Background

Interdental areas are more prone to plaque accumulation, thereby increasing the susceptibility for periodontal diseases. Proper method of interdental hygiene assessment and motivation to use interdental aids can potentially reduce the burden of periodontal diseases.

Materials and Methods

Fifty consecutive volunteer participants who presented with gingival inflammation were recruited based on the set of inclusion criteria. Further, proposed interdental hygiene index (IDHI) and gingival index were recorded by the examiner. Patient-reported outcome measures (PROMs) were recorded on the baseline and 4-week follow-up visits. Descriptive statistics and correlation analysis were performed.

Results

The study comprised 50 participants with 22 male and 23 female participants. At baseline, the mean/standard deviation of IDHI was 1.32 ± 0.10 and 0.62 ± 0.21 on follow-up, respectively. For Gingival Index (GI) at baseline, the mean/standard deviation was 1.61 ± 0.15 and 0.70 ± 0.24 on follow-up, respectively. Correlation analysis revealed a significant correlation between IDHI and GI at baseline and follow-up. Majority of the participants scored 0 on the Visual Analogue Scale (VAS) for pain, rated "Good" for acceptability of procedure and perceived efficacy of interdental brush. Participants reported to have acquired "High level of motivation" to use an interdental brush.

Conclusion

IDHI is a simple and reliable tool to assess the interdental areas of the patient and motivate to use interdental brush for the maintenance of good oral hygiene. PROMs also revealed positive responses from participants.

Effect of Triweekly Interdental Brushing on Bleeding Reduction in Adults: A Six-Month Retrospective Study

This study assessed the effect of triweekly interdental brushing for a period of 6 months using the bleeding on full-mouth interdental brushing (BOFIB) index. All participants answered questionnaires and were instructed to clean all interdental areas using an interdental brush at least every second day. A dentist assessed the BOFIB index of 28 participants at baseline and at 3- and 6-month follow-up visits. We stratified the participants into three groups: IB-NN, those who used the interdental brush less than three times per week both before and after this program; IB-NY, those who used the interdental brush less than three times per week before the program but at least three times per week after the program; and IB-YY, those who used it at least three times per week both before and after the program. Owing to the weekly number of interdental brushings, the IB-YY and the other two groups showed a significant difference at baseline. At the 6-month follow-up, the weekly number of interdental brushings led to a significant difference between the IB-NN and the other two groups. The BOFIB index was lower among the compliant participants than among the noncompliant participants after 3 and 6 months of triweekly interdental brushing.

Intra- and Inter-Examiner Repeatability of Diagnostic Peri-implant Clinical Measurement: A Pilot Study

Despite the crucial role of examiner reliability on quality research and practice, there is still limited literature analyzing factors affecting examiner variability of peri-implant clinical measurements. The present study investigated clinical peri-implant parameters to quantify their repeatability and investigate factors that may affect their accuracy. Thirty-three implants were examined by four operators. Peri-implant probing depth (PD), recession (REC) and gingival index (GI) were measured for agreement and included for analysis. Agreement was quantified using intraclass correlation coefficients (ICC; 95% CI); mixed linear and logistic regressions were used to assess additional variables. The overall inter-examiner agreement was comparable between PD (0.80) and REC (0.78), but significantly worse for GI (0.45) (p<0.001). Similarly, the intra-examiner agreement was similar for PD (0.81) and REC (0.80), but significantly worse for GI (0.57) (p<0.05). The magnitude of PD did not influence agreement. In contrast, increasing disagreement was noted for positive REC (OR: 3.0), negative REC (OR: 4.8) and lower GI (OR: 4.4). The incidence of bleeding on probing and severity of GI increased for deeper PD (0.113 unit increase per mm). Negative and positive values of recession and lower GI were associated with increasing disagreement. Radiographic bone loss, restoration contour and implant diameter did not impact PD accuracy within this study. In conclusion, within the limitations of the study, GI measurements presented higher variability than PD and REC. PD and GI were associated with one another and increased after multiple measurements.

Plaque-induced gingivitis: Case definition and diagnostic considerations

OBJECTIVE

Clinical gingival inflammation is a well-defined site-specific condition for which several measurement systems have been proposed and validated, and epidemiological studies consistently indicate its high prevalence globally. However, it is clear that defining and grading a gingival inflammatory condition at a site level (i.e. a "gingivitis site") is completely different from defining and grading a "gingivitis case" (GC) (i.e. a patient affected by gingivitis), and that a "gingivitis site" does not necessarily mean a "GC". The purpose of the present review is to summarize the evidence on clinical, biochemical, microbiologic, genetic markers as well as symptoms associated with plaque-induced gingivitis and to propose a set of criteria to define GC.

IMPORTANCE

A universally accepted case definition for gingivitis would provide the necessary information to enable oral health professionals to assess the effectiveness of their prevention strategies and treatment regimens; help set priorities for therapeutic actions/programs by health care providers; and undertake surveillance.

FINDINGS

Based on available methods to assess gingival inflammation, GC could be simply, objectively and accurately identified and graded using bleeding on probing score (BOP%) CONCLUSIONS: A patient with intact periodontium would be diagnosed as a GC according to a BOP score ≥ 10%, further classified as localized (BOP score ≥ 10% and ≤30%) or generalized (BOP score > 30%). The proposed classification may also apply to patients with a reduced periodontium, where a GC would characterize a patient with attachment loss and BOP score ≥ 10%, but without BOP in any site probing ≥4 mm in depth.

Educational outcomes of a new curriculum on interproximal oral prophylaxis for dental students

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a preclinical oral prophylaxis education program by examining the effectiveness of the teaching module on changes to the students' attitudes towards their individual hygiene behaviors with interdental brushes (IDBs).

METHODS

As being part of a new didactic program on oral interproximal prophylaxis, all preclinical third-year students (n = 96) enrolled in the 2014/15 academic year received theoretical, preclinical, and clinical lessons on interproximal prophylaxis. The evaluation of educational outcomes was linked to observed changes in students' hygiene behaviors using interdental brushes. Knowledge, skills, attitudes, satisfaction, competence and performance were also explored. The evaluation interviews were recorded at each recall, i.e., 1 week, 1 month, 3 months and 1 year after baseline.

RESULTS

Motivation to use IDBs is clearly related to the perception of the effectiveness of the brushes and the perception of bleeding reduction. At one week, 89.6% of subjects reported using IDBs. Individual use decreased significantly from one week to one month (-26%, p = 0.006) while a non-significant upward trend occurred between one month and three months. Among students reporting usage of IDBs at 1 year (20.8%), only 2.0% used IDBs daily. Most students would recommend IDBs to other people at the beginning (69.8%). However, this share dropped to 50% at 3 months. IDB-users prescribed more than non-users.

DISCUSSION AND PUBLIC HEALTH IMPLICATIONS

The implementation of a module on interdental hygiene practices in the oral health program is strongly recommended. However, corrective measures should be considered regarding the organization and frequency of recall periods in order to improve the performance of the curriculum.

The Bleeding on Brushing Index: a novel index in preventive dentistry

BACKGROUND

The aim of this study was to evaluate the suitability of a dichotomous index, based on a special interdental brushing tool, to detect initial pathological processes in interproximal areas. Furthermore, different techniques of interdental hygiene were compared.

METHODS

Participants (n = 108) were instructed to clean their teeth using the Bass technique and were randomly assigned to three groups according to the type of interdental cleaning used: group A, use of interdental brushes; group B, no interdental hygiene (the control group); and group C, use of dental floss. Approximal Plaque Index (API), Plaque Index (PI), modified Sulcus Bleeding Index (mSBI) and the Bleeding on Brushing Index (BOB) were measured at baseline, and after 2 (t1) and 4 (t2) weeks. Statistical analysis was performed using the Wilcoxon test and the Mann-Whitney U-test.

RESULTS

One-hundred and six participants completed the study. The BOB decreased significantly in all groups (P < 0.001) with the most pronounced reduction being recorded for group A (baseline: 49.3 ± 23.0%; 4 weeks: 5.1 ± 6.9%). Also, the mSBI (P < 0.001) decreased significantly in all groups during the study. The API appeared to be less affected by the oral hygiene than other indices. The highest correlation was observed between BOB and mSBI (r = 0.785, P < 0.001).

CONCLUSION

The BOB is a valuable complement for the existing array of indices in preventive dentistry, and is able to detect potential pathological processes in interproximal spaces. Additionally, this study suggests that interdental hygiene with individually selected brushes is superior to flossing.

CLINICAL RELEVANCE

With the BOB, gingival inflammation can be demonstrated to patients, which could increase compliance.

Efficacy of interdental calibrated brushes on bleeding reduction in adults: a 3-month randomized controlled clinical trial

This study investigated the effect of interdental brushes on the reduction of interproximal bleeding in adults without periodontal disease. Forty-six adults were enrolled in a 3-month, observer-blinded, parallel-group randomized control trial. The test group used a standard manual toothbrush twice daily and an interdental brush daily. The control group used a standard manual toothbrush. At each visit, a calibrated colorimetric probe was used in all interdental spaces to determine the appropriate size of the interdental brush required, the brush of the corresponding size was introduced into the interproximal space, and the presence of bleeding was recorded. The outcome was the frequency of bleeding after application of the appropriate interdental brush. All participants were evaluated 1 wk, 1 month, and 3 months after the baseline visit. The overall preventive fraction with respect to bleeding frequency was 46% at 1 wk and 72% at 3 months. More bleeding reduction was observed in anterior sites than in posterior sites (80% vs. 69%, respectively). Participants with low baseline bleeding frequency presented with less bleeding (OR = 2.3). This study shows that daily use of calibrated interdental brushes reduces interdental bleeding. These findings may support interdental cleaning as an effective means to help individuals maintain and/or achieve optimal oral health.

Access to Interdental Brushing in Periodontal Healthy Young Adults: A Cross-Sectional Study

PURPOSE

Interdental diameter space is largely undefined in adults, which compromises the decision support for daily interdental cleaning during routine practice in individual oral prophylaxis. This study assesses the distribution of diameter access of interdental spaces in an 18- to 25-year-old adult population free of periodontal disease.

METHODS

In March-April 2015, a cross-sectional study using random sampling was performed at the University Lyon 1, France. The interproximal dental spaces of 99 individuals were examined using a colorimetric calibrated probe associated with the corresponding calibrated interdental brush (IDB).

RESULTS

Of the 2,408 out of 2,608 sites, the overall accessibility prevalence of any interdental brushing was 92.3%. In total, 80.6% of the sites required interdental brushes with smaller diameters (0.6-0.7 mm). In anterior sites, the diameter of the interdental brushes used was smaller (55.8% of IDB with 0.6 mm) than the diameter of the interdental brushes used in posterior sites (26.1% of IDB with 0.6 mm) (p < 0.01). The adjusted ORs indicate a significant association with the location of the sites (approximately doubling the risk of bleeding, i.e., OR = 1.9, in posterior sites).

CONCLUSIONS

Most interdental sites can be cleaned using interdental brushes. Even in healthy people, interdental hygiene requirements are very high. Strengthening the oral hygiene capacity by specifically using interdental brushes can have an effect on the health of the entire population. Screening of the accessibility of the interdental space should be a component of a routine examination for all patients.

Correlations between two different methods to score bleeding and the relationship with plaque in systemically healthy young adults

AIM

To evaluate the correlation between bleeding on marginal probing (BOMP) and bleeding on pocket probing (BOPP), and the correlation of both bleeding indices with plaque.

MATERIALS AND METHODS

This cross-sectional study screened 336 participants, from which 268 were eligible for examination and analysis. Bleeding and plaque indices were assessed by single examiners, at six sites per tooth.

RESULTS

The mean percentage of sites per individual with bleeding on marginal probing, bleeding on pocket probing and dental plaque were 19.9%, 51.2% and 32.2% respectively. In the quadrants where the margin was probed before the pocket, a 4.6 percentage points higher bleeding tendency with BOPP was observed (p < 0.05). At a site level, the correlation coefficients of plaque and bleeding on marginal probing and bleeding on pocket probing were 0.19 and 0.20 respectively. Both bleeding indices were also shown to be correlated (r = 0.89, fixed effect model).

CONCLUSION

The prevalence of bleeding upon probing is influenced by the scoring method that is used for the diagnosis. Probing the bottom of the pocket results in significantly more bleeding than running a probe along the margin.