Evaluation of an oral physiotherapy center in the reduction of bacterial plaque and periodontal disease

Methods for Evaluating the Effectiveness of Home Oral Hygiene Measures-A Narrative Review of Dental Biofilm Indices

Dental plaque is a biofilm structured in an extracellular matrix of polymers of host and microbial origin; the microorganisms can coexist in harmony with the host, thus guarantying oral health. Environmental modifications can lead to dysbiosis and onset of oral diseases; in fact, plaque is the etiological agent both of periodontal disease and dental decay. The use of an effective oral hygiene index should be considered as a relevant goal for the clinicians and the researchers, and consequently, numerous plaque indices have been proposed during the years. The present literature review aims primarily to obtain a complete summary of these scores to assess plaque deposits. It is useful because the clinician/researcher will select the right scoring method for the specific situation only if he knows the available options and if he is aware of both their strengths and weaknesses. This review applies a basic classification of plaque indices that distinguishes the ones that use non-quantitative methods from the ones that use quantitative methods. Non-quantitative methods are more subjective because they are based on the ability of the clinician to point out the presence or the entity of deposits, while quantitative methods introduce objectifiable means to measure plaque deposits.

The efficacy of powered toothbrushes: A systematic review and network meta-analysis

Aim

This systematic review and network meta‐analysis synthesizes the available clinical evidence concerning efficacy with respect to plaque scores following a brushing action with oscillating‐rotating (OR) or high‐frequency sonic (HFS) powered toothbrushes (PTB) compared with a manual toothbrush (MTB) as control.

Material and methods

Databases were searched up to 1 August 2021, for clinical trials that evaluated the efficacy of a PTB with OR or HFS technology compared with an MTB on plaque removal after a single‐brushing action and conducted with healthy adult patients. Meta‐analysis (MA) and a network meta‐analysis (NMA) were performed.

Results

Twenty‐eight eligible publications, including 56 relevant comparisons, were retrieved. The overall NMA results for the mean post‐brushing score showed a statistically significant difference for the comparison between an OR PTB and an MTB (SMD = −0.43; 95% CI [−0.696;−0.171]). The change in plaque score data showed a significant effect of a PTB over an MTB and OR over HFS. Based on ranking, the OR PTB was highest, followed by the HFS PTB and the MTB.

Conclusion

Within the limitations of the present study design, based on the outcome following a single‐brushing action, it can be concluded that for dental plaque removal, there is a high certainty for a small effect of a PTB over an MTB. This supports the recommendation to use a powered toothbrush for daily plaque removal. There is moderate certainty for a very small benefit for the use of a powered toothbrush with an OR over an HFS mode of action.

How effective is a powered toothbrush as compared to a manual toothbrush? A systematic review and meta-analysis of single brushing exercises

Objectives

In adult participants, what is, following a single brushing exercise, the efficacy of a powered toothbrush (PTB) as compared to a manual toothbrush (MTB) on plaque removal?

Methods

MEDLINE‐PubMed and Cochrane‐CENTRAL were searched from inception to February 2019. The inclusion criteria were (randomized) controlled clinical trials conducted in human subjects ≥18 years of age, in good general health and without periodontitis, orthodontic treatment, implants and/or removable prosthesis. Papers evaluating a PTB compared with a MTB in a single brushing exercise were included. When plaque scores were assessed according to the Quigley‐Hein plaque index (Q&HPI) or the Rustogi modified Navy plaque index (RMNPI). From the eligible studies, data were extracted. A meta‐analysis and subanalysis for brands and mode of action being oscillating‐rotating (OR) and side‐to‐side (SS) were performed when feasible.

Results

Independent screening of 3450 unique papers resulted in 17 eligible publications presenting 36 comparisons. In total, 28 comparisons assessed toothbrushing efficacy according to the Q&HPI and eight comparisons used the RMNPI. Results showed a significant effect in favour of the PTB. The difference of Means (DiffM) was −0.14 (P < 0.001; 95%CI [−0.19; −0.09]) for the Q&HPI and −0.10 (P < 0.001; 95%CI [−0.14; −0.06]) for the RMNPI, respectively. The subanalysis on the OR mode of action showed a DiffM −0.16 (P < 0.001; 95%CI [−0.22, −0.10]) for the Q&HPI. For the SS mode of action using RMNPI, the DiffM showed −0.10 (P < 0.001; 95%CI [−0.15; −0.05]). The subanalysis for brands showed for the P&G OR PTB using the Q&HPI a DiffM of −0.15 (P < 0.001; 95%CI [−0.22; −0.08]) and the Colgate SS for RMNPI showed a DiffM of −0.15 (P < 0.001; 95%CI [−0.18; −0.12]).

Conclusion

There is moderate certainty that the PTB was more effective than the MTB with respect to plaque removal following a single brushing exercise independent of the plaque index scale that was used.

Efficacy of homecare regimens for mechanical plaque removal in managing gingivitis a meta review

FOCUSED QUESTION

Based on evidence as presented in systematic reviews what is the efficacy and safety of available homecare toothbrush regimens for mechanical plaque removal on plaque and gingivitis in adults?

MATERIAL & METHODS

Three Internet sources were used (up to and including August 2014) to search for appropriate papers that satisfied the study purpose. Plaque scores and gingivitis scores were considered to be the primary parameter of interest. Safety was considered an important facet in relation to efficacy. Data and conclusions as presented in the selected papers were extracted. The potential risk of bias was estimated and the emerging evidence was graded.

RESULTS

Independent screening of 176 unique reviews resulted in 10 published and eligible systematic reviews. They were categorized into one review evaluating the effect of an oral hygiene instruction with a toothbrush on plaque and gingivitis scores, five evaluating the efficacy of manual and power toothbrushes and three reviews evaluating toothbrush safety and one evaluating toothbrush contamination.

CONCLUSION

Tooth brushing is effective in reducing levels of dental plaque. With respect to gingivitis power toothbrushes have a benefit over manual toothbrushes. The greatest body of evidence was available for oscillating-rotating brushes. Tooth brushing generally can be considered safe for the teeth and their investing tissues.

Clinical validation of robot simulation of toothbrushing--comparative plaque removal efficacy

BACKGROUND

Clinical validation of laboratory toothbrushing tests has important advantages. It was, therefore, the aim to demonstrate correlation of tooth cleaning efficiency of a new robot brushing simulation technique with clinical plaque removal.

METHODS

Clinical programme: 27 subjects received dental cleaning prior to 3-day-plaque-regrowth-interval. Plaque was stained, photographically documented and scored using planimetrical index. Subjects brushed teeth 33-47 with three techniques (horizontal, rotating, vertical), each for 20s buccally and for 20s orally in 3 consecutive intervals. The force was calibrated, the brushing technique was video supported. Two different brushes were randomly assigned to the subject. Robot programme: Clinical brushing programmes were transfered to a 6-axis-robot. Artificial teeth 33-47 were covered with plaque-simulating substrate. All brushing techniques were repeated 7 times, results were scored according to clinical planimetry. All data underwent statistical analysis by t-test, U-test and multivariate analysis.

RESULTS

The individual clinical cleaning patterns are well reproduced by the robot programmes. Differences in plaque removal are statistically significant for the two brushes, reproduced in clinical and robot data. Multivariate analysis confirms the higher cleaning efficiency for anterior teeth and for the buccal sites.

CONCLUSIONS

The robot tooth brushing simulation programme showed good correlation with clinically standardized tooth brushing.This new robot brushing simulation programme can be used for rapid, reproducible laboratory testing of tooth cleaning.

The effect of sugar-free chewing gum on plaque and clinical parameters of gingival inflammation: a systematic review

OBJECTIVE

The aim of this study was to systematically review the current literature on the clinical effects of sugar-free chewing gum on plaque indices and parameters of gingival inflammation.

MATERIAL AND METHODS

The MEDLINE-PubMed, Cochrane-CENTRAL and EMBASE databases were searched up to 20 April 2012 to identify any appropriate studies. Plaque indices and parameters of gingival inflammation were selected as outcome variables.

RESULTS

An independent screening of the 594 unique titles and abstracts identified six non-brushing and four brushing studies that met the eligibility criteria. In the non-brushing studies, the use of chewing gum did not significantly affect the parameters of interest. In the descriptive analysis of the brushing studies, four of five comparisons showed a statistically significant effect in favour of the sugar-free chewing gum with respect to plaque scores. The meta-analysis for the Quigley & Hein (J Am Dent Assoc 1962; 65: 26) plaque index scores in the brushing studies also showed a significant difference (DiffM -0.24, 95% CI [-0.41; -0.08]). For bleeding tendency, the descriptive analysis showed that one of the two comparisons identified a significant difference in favour of chewing gum. The meta-analysis, however, did not substantiate this difference.

CONCLUSION

Within the limitations of this systematic review, it may be concluded that the use of sugar-free chewing gum as an adjunct to toothbrushing provides a small but significant reduction in plaque scores. Chewing sugar-free gum showed no significant effect on gingivitis scores. In the absence of brushing, no effect on plaque and gingivitis scores could be established.

Plaque levels of patients with fixed orthodontic appliances measured by digital plaque image analysis

INTRODUCTION

A digital plaque image analysis system was developed to objectively assess dental plaque formation and coverage in patients treated with fixed orthodontic appliances.

METHODS

The technique was used to assess plaque levels of 52 patients undergoing treatment with fixed appliances in the Department of Orthodontics at Johannes Gutenberg University in Mainz, Germany.

RESULTS

Plaque levels ranged from 5.1% to 85.3% of the analyzed tooth areas. About 37% of the patients had plaque levels over 50% of the dentition, but only 10% exhibited plaque levels below 15% of tooth coverage. The mean plaque coverage was 41.9% ± 18.8%. Plaque was mostly present along the gum line and around the orthodontic brackets and wires.

CONCLUSIONS

The digital plaque image analysis system might provide a convenient quantitative technique to assess oral hygiene in orthodontic patients with multi-bracket appliances. Plaque coverage in orthodontic patients is extremely high and is 2 to 3 times higher than levels observed in high plaque-forming adults without appliances participating in clinical studies of the digital plaque image analysis system. Improved hygiene, chemotherapeutic regimens, and compliance are necessary in these patients.

Application of the Gingival Contour Plaque Index: Six-Month Plaque and Gingivitis Study

The Gingival Contour Plaque Index (GCPI) is a recently introduced and validated method of measuring plaque accumulation in dogs. It focuses on plaque accumulated along the gingival margin. Plaque accumulation in this area leads to gingival inflammation and, potentially, periodontitis. A 6-month plaque and gingivitis study was conducted to demonstrate the clinical research application of the GCPI, and to ensure that documented quantification of plaque-reducing efficacy could be related to a reduction in gingivitis. Advantages of the GCPI method are the ability to quantify plaque accumulation in an awake dog with fewer research personnel and more efficient time usage.

Quantification of dental plaque in the research environment

OBJECTIVES

To review the established and novel methods of plaque quantification employed in dental research, including a discussion of their merits and to present a new method of planimetrically measuring plaque using light induced fluorescence.

METHOD

Quantitative light-fluorescence (QLF) images were acquired from the buccal surfaces of an individual who had refrained from oral hygiene both with and without traditional plaque disclosure. Digital photographs were also taken. Images were analysed using a novel method and a percentage plaque index produced.

RESULTS

Traditional plaque indices are problematic due to their integral nature and their failure to detect small, but potentially clinically relevant changes in plaque area. The use of a fluorescent technique demonstrated good reliability although there was no correlation between red fluorescent plaque and total disclosed plaque suggesting that the auto-fluorescing plaque is not a good measure of total plaque volume.

CONCLUSIONS

The use of planimetric techniques can increase the power of plaque studies, potentially reducing the number of subjects and time required to separate therapies or products. Fluorescent methods of quantification have potential as they enable clear separation of the plaque covered and non-covered tooth surfaces.

Quantification of dental plaque on lingual tooth surfaces using image analysis: reliability and validation

AIM

The aim of this study was to increase the versatility and further validate the method reported by Smith et al. (2001) by testing the reliability of plaque measurement against two well-known dental plaque quantification methodologies using image analysis in a clinical trial.

METHOD

The teeth of 40 subjects were disclosed before digital images of the labial and lingual surfaces of their upper and lower incisors were acquired. The amount of plaque present was quantified using a modification of the method described by Smith et al. (2001). The method was modified for obtaining images of the lingual surfaces by incorporating the use of orthodontic occlusal mirrors and 5-mm pieces of moistened blue articulating paper used to enable calibration. Plaque measurements were made from 320 upper and lower anterior teeth from the 40 subjects by two operators. Fliess' coefficient of reliability was used to assess intra- and inter-operator reliability and the independent sample t test was used to assess statistical significance between test and control groups after checking the data for normality. For validation, measurements were recorded using the Turesky et al. (1970) (modification of the Quigley & Hein (1962) plaque index and the Addy et al. (1983) plaque area index. The results were compared with the image analysis method using Pearson's correlation coefficient.

RESULTS

The results for reliability were within Fliess' range of "excellent" for both intra-operator repeatability and inter-operator reproducibility. Pearson's correlation coefficients showed highly significant values indicating the close similarity between all three methods.

CONCLUSIONS

This method for the measurement of dental plaque on lingual surfaces of anterior teeth proved reliable. The combined results from the labial and lingual surfaces of anterior teeth using image analysis produced trial conclusions comparable with the alternate plaque quantification methods used, with less clinician time and further producing a permanent database of images for future use.

Interexaminer reproducibility of ordinal and interval-scaled plaque indices

BACKGROUND

Although many plaque scoring indices have been proposed for clinical or research purposes, only few of them are commonly used in the dental literature. Owing to the ordinal nature of these established indices, only nonparametric tests can be performed, while statistical analysts usually prefer parametric methodologies. Furthermore, these indices do not discriminate between the proximal and the broad surfaces of the teeth.

AIMS

The aim of this study was to assess the interexaminer reproducibility for one established ordinal plaque index and two recently proposed interval-scaled indices.

METHOD

Six subjects received a professional tooth cleaning and stopped all oral hygiene measures during 48-62 h. Accumulated plaque was disclosed and separately scored on all teeth except third molars by two examiners using the visual plaque index (VPI), the axial plaque extension index (APEI) and the proximal plaque extension index (PPEI). In total, 168 teeth (48 molars, 48 premolars, 24 canines and 48 incisors) were scored.

RESULTS

Statistically significant differences were found between the means of buccal VPI (p<0.05, Wilcoxon test), mesiobuccal, mesiolingual and distolingual APEI, and distobuccal, mesiolingual and distolingual PPEI (p<0.05, t-test). Spearman correlation values between the duplicate VPI measurements were 0.84 for buccal and 0.64 for lingual VPI, while Pearson correlation values varied between 0.51 and 0.83 for APEI and between 0.48 and 0.74 for PPEI. For VPI, 71% of the buccal (kappa=0.60) and 74% of the lingual (kappa=0.53) scores were identical. For APEI and PPEI scores, a linear regression was found with slopes ranging between 0.50 and 0.80. Mean measurement errors were 7.7% for buccal and 0.4% for lingual VPI, and ranged between 0.9% and 46.1% for APEI and PPEI.

CONCLUSION

The interexaminer reproducibility of all three indices showed fair to good agreement. Buccal VPI and buccal APEI in particular showed good agreement.

A new method of plaque scoring: a laboratory comparison with other plaque indices

AIM

The aim of this study was to propose a simple, clear and as sensitive as possible numerical plaque index for the use in clinical oral hygiene trials known as the New Method of Plaque Scoring (NMPS), and to evaluate this index for simplicity, clarity and examiner agreement in comparison with the Distal Mesial Plaque Index, Proximal Marginal Index and a modification to the modified Navy plaque Index.

MATERIAL AND METHODS

The scoring system proposed for the NMPS is based on a numerical range from 0 to 10 representing the total stained plaque on the facial or lingual tooth surfaces with the greatest weight of scores placed at the gingival and proximal regions of the surface. For scoring purposes, a horizontal boundary is imagined on the smooth facial or lingual tooth surfaces between the gingival third (A) and coronal two/thirds, the latter being subdivided vertically into thirds, mesial (B), middle (D) and distal (C). Depending on the extent of plaque coverage, whole number scores 0-3 are assigned to A, B, C and 0 or 1 for D. Ten examiners scored four selected tooth surfaces on an acrylic model according to the NMPS and the three comparative indices. The time required for each examiner to score according to each index was recorded. The scores obtained from this trial were analyzed for examiner agreement and correlation between the four indices.

RESULTS

The time required for scoring according to the NMPS was found to be significantly less than the three comparative indices. The variability between examiners was found to be least for the NMPS compared to the three comparative indices. A strong correlation was found between all pairs of indices.

CONCLUSION

The proposed new method of plaque scoring seems to be simpler, clearer and more reproducible than the three comparative indices. However, clinical testing is warranted.

The quantification of dental plaque using an image analysis system: reliability and validation

AIM

Established clinical indices used to measure dental plaque have limitations. The aim of this study was to develop and evaluate a new method of quantitative plaque measurement, with increased sensitivity and reproducibility, using a purpose designed image analysis system.

METHOD

After plaque disclosure, the patient was positioned in a cephalometric head holder mounted in a custom-built frame with standard lighting and camera position. A 32-bit Digital Camera grabbed the image of the patient's teeth, which was analysed using Adobe Photoshop (V5.02, Adobe Systems Ltd, Europe) and Image Pro Plus software (V4.0, Media Cybernetics, USA). Measurements were made on 120 incisors in 15 patients and reproducibility was assessed using Fliess' Coefficient of Reliability. Sensitivity was assessed by comparison of results of treatment effects from a clinical trial involving 30 patients. Analysis of covariance was used to compare the image analysis system with the Turesky modification of the Quigley and Hein plaque index and the Addy plaque area index.

RESULTS

The results were within the 'Excellent Reliability' category, for inter-operator reproducibility and intra-operator repeatability.

CONCLUSIONS

This new system provided accurate quantitative measurements of dental plaque and labial tooth surfaces and was shown to have increased sensitivity when compared with the Turesky modification of the Quigley and Hein plaque index and the Addy plaque area index. The stored images can be re-measured for reliability and comparability between studies.

Intra-examiner reproducibility of 4 dental plaque indices

BACKGROUND, AIMS

The aim of the present study was to assess the intra-examiner reproducibility for 2 established ordinal plaque indices and 2 newly proposed interval plaque indices.

METHOD

15 subjects received a professional tooth cleaning and interrupted all oral hygiene measures for 48 to 62 hours. Plaque accumulation was scored 2x for all canines, premolars and 1st and 2nd molars in the 1st and 3rd quadrants with the visual plaque index (VPI), the modified navy plaque index (mNPI), the axial plaque extension index (APEI) and the proximal plaque extension index (PPEI). 147 teeth (57 molars, 60 premolars, 30 canines) were scored.

RESULTS

No statistically significant differences were found for duplicate measurements with all indices, except for buccal and lingual VPI (p < 0.05. Wilcoxon test) and for buccal APEI (p < 0.01, t-test). High correlations existed between all duplicate measurements with r-values ranging from 0.76 to 0.94. For the VPI, 78% of buccal (kappa = 0.70) and 89% of lingual (kappa = 0.75) scores were identical, whereas this was the case for 88% of buccal (kappa = 0.81) and for 73% of lingual (kappa = 0.62) mNPI scores. For APEI and PPEI scores a linear regression was found with slopes ranging between 0.76 and 1.00. For these indices, the mean measurement error ranged between 0.4 and 9.1%. Results were comparable for VPI, mNPI and PPEI, whereas APEI appeared slightly less reproducible.

CONCLUSION

In conclusion, a high intra-examiner reproducibility was found for all plaque indices tested, both the ordinal and the interval indices.

A plaque index for occlusal surfaces and fissures. Measurement of repeatability and plaque removal

Plaque indices have largely been developed for buccal and lingual tooth surfaces. There has been minimal interest in plaque accumulation on occlusal surfaces despite the predilection for caries at these sites. A numerical plaque index (0-5) is described based on the presence and distribution of plaque in the fissures and over the occlusal surfaces of permanent molar and premolar teeth. The repeatability of a single examiner in scoring the index was performed using 4 groups of 10 subjects. Each group of volunteers suspended tooth cleaning for 48 h and the index scored after disclosing plaque deposits. The index was rescored 60-90 min later. Plaque area was also determined by drawing the outline of plaque onto grids. Except for one condition of repeatability for one group, the 4 conditions of repeatability in scoring the index were met for all 4 groups of subjects. The sensitivity of the index and area recordings to detect plaque removed by brushing was then evaluated. A group of 10 subjects had plaque scored by index and area after suspending toothcleaning for 48 h. Subjects were then randomly allocated to brush or not brush their teeth and plaque rescored. The experiment was then repeated and brushing or not brushing crossed over. Highly significant differences between brushing and no brushing plaque indices and areas were determined. In conclusion, the occlusal fissure plaque index was easy to apply, repeatable and sufficiently sensitive to detect plaque removed by brushing. The index could find use as an additional measure of oral hygiene, in clinical trials on plaque control and possibly epidemiological studies relating to caries.

An accurate, time-efficient method to assess plaque accumulation

The authors compared the accuracy and time efficiency of a simplified index called the Plaque Assessment Scoring System, or PASS, and the O'Leary Plaque Control Record. Using both indexes, they examined 35 participants. They found a strong correlation between the results achieved with each method. They also noted that the mean time required to complete the PASS examination was considerably less than that needed to record the O'Leary index, 1.47 vs. 7.07 minutes, respectively.

Comparative single-use plaque removal by toothbrushes of different designs

Overall literature reviews have concluded that no one design of the manual toothbrush is superior for plaque removal. More recently, a toothbrush with filaments angled away from the head was shown to be more effective in several single-use studies than conventional designs. The aim of this study was to compare plaque removal by this new toothbrush and 3 other toothbrushes which had more conventional filament arrangements. 36 volunteers participated in this single-blind, randomised, 4-cell, crossover single use toothbrushing study. On day 1 of each period, volunteers brushed with a standard toothbrush and toothpaste for 60 s and then suspended oral hygiene for 48 h. On day 3, volunteers were scored for plaque by area and then brushed with the allocated test toothbrush with toothpaste for 60 s and plaque area was rescored. A washout of 4 days was allowed between test periods. The plaque areas were used to record the binary scores of the Rustogi et al. modification of the modified Navy plaque index but away from the clinic employing the Claydon and Addy procedural method for the index. Plaque removal scored by area and site were not significantly different between the brushes. This study is at variance with previous similar investigations which suggested that the new design of toothbrush head was superior for plaque removal. It is concluded again that there are no data which demonstrate unequivocally that any one manual toothbrush design is superior to any other for plaque removal.

The use of planimetry to record and score the modified Navy index and other area-based plaque indices. A comparative toothbrush study

Many plaque-scoring methods are based on a subjective assessment of the amount of tooth surface covered by plaque or the presence or absence of plaque at specific sites. The 2x modified Navy plaque index is an example of the latter and requires chairside decisions from 9 zones of all buccal and lingual tooth surfaces, i.e., up to 576 for a complete dentition. The present study describes a procedural modification to the index, whereby plaque is recorded using an established planimetric plaque area method. Scoring is then performed using an overlay away from the clinic. To test the method, plaque-area measurements were made during a 30-subject, crossover study to compare plaque removal following single toothbrushings with 3 different types of manual toothbrush. Consistent with many such studies, no significant differences in plaque removal were noted between the brushes. The method was found quick and simple at the chairside, provided a permanent record of plaque distribution and could be analysed by clinical or nonclinical personnel under ideal conditions. The same method could be employed for other plaque indices based on area or site subjective decisions.

The effectiveness of a disposable tooth cleansing device on plaque

A disposable polyester foam sponge on a stick, impregnated with a non-foaming dentifrice, has been widely dispensed to hospitalized and nursing home patients for intraoral cleansing and refreshing. Since no information was found relative to tooth cleansing capabilities, we have evaluated its effectiveness in the removal of accumulated plaque and also in prevention of plaque accumulation. Removal of 72 hours of accumulated plaque was assessed in a cross-over design study comparing the device with a commercially-available toothbrush by two different groups of 13 and 29 adult, healthy subjects who used each instrument for 1 and 3 minutes respectively. No significant differences were found between mean scores assessed by Turesky's modification of the Quigley-Hein plaque index by either group using either instrument at either time period (P > 0.05). Prevention of plaque accumulation was assessed in a third group of 25 subjects who used each instrument an average of 3 times a day for 1 week in a cross-over study. While the toothbrush was found significantly more effective in retarding the accumulation of plaque from a plaque-free baseline on both facial and lingual surfaces (P < 0.02), the tooth cleansing device still retained plaque-preventive capabilities by maintaining plaque formation below 2 mm at the cervical margin of the tooth. Results of this study indicate the tooth cleansing device may be a viable alternative to conventional toothbrushes.

The effect of a triclosan-containing dentifrice on established plaque and gingivitis

The aim of the present clinical trial was to study the effect on existing plaque and gingivitis of an oral hygiene regimen which utilized a dentifrice which contained triclosan. 120 subjects were recruited for the trial. They were examined for plaque and gingivitis using the criteria of (i) the Turesky modification of the Quigley & Hein plaque index and (ii) the Löe & Silness gingival index. Plaque and gingivitis were assessed in all parts of the dentition and at 6 location points around each tooth. Following a baseline examination, the subjects were stratified in 2 balanced groups based on age, plaque and gingivitis scores. The subjects were randomly assigned to the following treatment: 1 test group used a dentifrice containing triclosan/copolymer/fluoride and 1 control group used a traditional fluoride containing dentifrice. The participants were given the assigned dentifrice and a soft-bristled toothbrush for home use. They were instructed to brush their teeth in the morning and in the evening for one minute each time. They were reexamined 6 weeks, 3 and 6 months after the baseline examination. The findings from the re-examinations revealed that an oral hygiene regimen which utilized a dentifrice which contained triclosan/copolymer significantly reduced pre-existing plaque and gingivitis above what was accomplished by a traditional fluoride containing dentifrice. The improvement of the gingival conditions occurred in all parts of the dentition and at all tooth surfaces and units. In addition, the present data support the hypothesis that triclosan may induce alterations in the quality of existing plaque.

Computerized planimetric method for clinical plaque measurement

A computerized planimetric method for plaque area measurement has been developed. Using a computerized image analysis system (CIAS), the plaque area and tooth area on color slides were digitized and the number of pixels automatically counted. The proposed Plaque Percent Index (P% Index) expresses plaque area as a percentage of tooth area. The reproducibility of this method was tested and the influence of photographic technique on the P% Index was determined. The association of the Turesky modified Quigley-Hein plaque index (Q-H Index) and the P% Index was assessed. The present method was highly reproducible for the P% Index with an intraexaminer variation of 0.28% and intraexaminer correlation coefficient of 0.99. The results show that highly reproducible P% Index values with an error of less than 3.0% were obtained when the photographs were taken under the following conditions. For the buccal surfaces of anterior teeth, the slides were photographed within a 20-degree range in the horizontal plane and a 30-degree range in the vertical plane; and for the lingual/palatal surfaces of anterior teeth and the buccal or lingual/palatal surfaces of posterior teeth, the slides were photographed with an image of the whole tooth surfaces in the photographic mirrors. The comparison of the Q-H Index and the P% Index revealed that for each score of the Q-H Index the corresponding values of P% Index were wide with a significant crossover value, although a strongly positive correlation was found between the Q-H Index and the P% Index (r = 0.92, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative effectiveness of flossing and brushing in reducing interproximal bleeding

This study assesses the comparative effectiveness of three types of dental floss and toothbrushing in reducing interproximal bleeding sites, measured by stimulation with wooden interdental cleaners using the interdental bleeding index assessment method. The 119 adult subjects with gingival inflammation were randomly assigned to one of four groups at the beginning of a supervised 2 week clinical trial. The toothbrushing only group achieved a 35% reduction in bleeding sites and the three flossing groups all demonstrated dramatic reductions of about 67%. The three varieties of dental flosses were about equally effective in reducing interproximal bleeding and doubly effective as toothbrushing alone. Compared to probing, the interdental bleeding index method is considered a simplified method of assessing interproximal gingival inflammation.

Clinical index systems used to assess the efficacy of mouthrinses on plaque and gingivitis

The American Dental Association's Council on Dental Therapeutics has adopted Guidelines for acceptance of chemotherapeutic products for the control of supragingival dental plaque and gingivitis. The most widely used plaque indices are the plaque index (PI) and the Turesky index. Gingivitis has usually been assessed by the Löe and Silness method, although the modified gingival index of Lobene and a bleeding index reported by Caton and Polson have also been used. To date, 2 products have been accepted by the Council as being effective in helping control supragingival plaque and gingivitis. These products were evaluated using clinical indices described in this review. The indices were selected from the many in the literature as being valid, reliable, and easily learned. Suggestions are made for criteria to be used in comparability studies.

The result of periodontal treatment in relationship to various background factors

The aim of the present study was to investigate whether various background factors of patients play a role for the result of periodontal treatment and whether their attitudes towards prevention change during treatment. The study was carried out as a retrospective analysis using data obtained during periodontal treatment of 143 patients. The result of the treatment was assessed by the recording of presence or absence of gingival bleeding by probing prior to treatment and after 3, 6 and 12 months. The background factors were assessed by letting the patients answer a questionnaire about their dental history, tooth cleaning habits and knowledge about their own dental health situation. Moreover, they responded to statements regarding their attitudes to and general knowledge about prevention of dental diseases. 89 of the patients were asked again 3 months later to respond to these statements. After treatment, 3 groups were formed on the basis of the 12-month gingival score: a successful treatment group (S) comprising 79 patients with a gingival bleeding score of 20% or less, a non-successful treatment group (N) comprising 49 patients with more than 20% tooth surfaces showing bleeding and a drop-out group (D) of 15 patients who did not appear for the 12-month examination. No statistically significant difference was found in the various background factors of patients with a successful or a non-successful treatment result. However, dropping out showed a significant relationship to unfavorable dental beliefs and young age (P less than 0.005). Following treatment, the patients responded more favorably to statements about oral hygiene as a preventive means.

Current status of indices of plaque

Microbial plaque has been described by the Council on Dental Therapeutics of the American Dental Association in their recently drafted Guidelines for acceptance of products for the management of dental plaque and gingivitis. The choice of an index system to be used in plaque trials should be made in terms of the objective of the trial, the size of the population, the period of the study, and the type and extent of change anticipated. The indices currently in use estimate the quantity of plaque in terms of tooth area covered or the thickness of material in the area measured. The Silness and Loe and the modified Turesky methods have been suggested as acceptable indices for the estimation of cleansing ability.

Oral cleanliness and gingival health following oral hygiene instruction by self-educational programs

The aim of the present study was to determine the motivational effect of using a periodontal self-examination manual prior to a self-instructional manual in oral hygiene and to examine whether instruction provided at a later time than the scaling procedure improves the effect of the instruction. 74 patients with periodontal disease were divided into 3 groups: (1) A group of 23 patients who performed a self-examination of their periodontal condition prior to self-instruction in oral hygiene; (2) a control group of 27 patients who used only the self-instructional oral hygiene manual; and (3) a group of 24 patients who were not given the self-instructional oral hygiene manual before 6 weeks after the baseline examination. All these patients had their teeth scaled at the start of the study and after 3 and 7 months. The effect of the various modes of instruction was evaluated by assessments of plaque and gingival bleeding scores. These parameters were determined at the baseline and after 2 and 6 weeks and 3 and 7 months. The results demonstrated a significant improvement in plaque and gingival bleeding scores following the use of the self-instructional manual in oral hygiene. The use of the periodontal self-examination manual or a delay of the instruction had no additional effect on oral cleanliness. The level of oral hygiene and gingival health achieved at 3 months was maintained in all 3 groups for an additional period of 4 months. After that time, they were divided into 2 other groups depending on whether or not their plaque score was less than 20%. A total of 26 in the group who had a plaque score higher than 20% demonstrated a plaque score of than 20% after having performed the tooth brushing test. 10 of the remaining patients, who still had a plaque score of more than 20% after the tooth brushing test, received additional instruction in oral hygiene which subsequently resulted in improved oral cleanliness after 6 months.

Evaluation of various feedback mechanisms in relation to compliance by adult patients with oral home care instructions

The purpose of the present study was to examine the effect on oral hygiene and gingival health of plaque scoring and the performance of a 'tooth brushing test" at each visit during initial periodontal treatment. A total of 63 adult periodontal patients (22-67 years of age) was allocated to 4 matched groups: Brushing test group (B), open scoring group (O), minimal feedback group (M) and control group (C). The oral hygiene instruction for groups B, O and M was provided by handing out a self-educational manual on oral home care, while the patients of control group (C) received a short brochure describing the Bass brushing technique and the use of toothpicks. Feedback on the improvement of oral hygiene performance was delivered to groups B and O by scoring of plaque and gingival bleeding by probing while this feedback was avoided in the 2 other groups (M, C). The patients of group B performed a tooth brushing test at each of 3 visits. After 3 months the plaque scores of groups B (27%) and O (22%) had improved more than those of the 2 other groups (35%). However, the improvement in gingival bleeding scores was similar in all 4 groups (from 55% initially to 17% at 3 months). At later examinations only minor differences in plaque and gingival bleeding scores were recorded between the various groups. The findings show that, irrespective of the mode of instruction, a considerable improvement occurs and that this improvement is not related to open scoring of plaque or the tooth brushing test.

Oral hygiene instruction of adults by means of a self-instructional manual

The need for improved oral cleanliness in adults presents a large scale resource requirement for professional manpower if oral hygiene instruction is to be accomplished conventionally on an individual basis at the chairside. Therefore a self-instructional manual in oral hygiene measures, to be used by the patients at home, has been designed. The effect on oral hygiene of periodontal patients following instruction by means of this manual has been compared with the effect of one instruction carried out by a dental hygienist as well as with the effect of minimal instruction by the aid of a short brochure. Thirty-seven patients (25--64 years of age) were allocated to three groups matched with regard to baseline scores of dento-gingival plaque, age and sex. Presence of disclosed dento-gingival plaque (Plak-lite) and gingival bleeding on probing were recorded at the start, 1, 2 and 6 weeks, 3 and 6 months. Toothbrushing performance of the patients was evaluated at each visit by a "brushing test". The treatment of all the patients consisted of scaling and polishing of the teeth at the start and after 3 months as well as the patients being supplied with the necessary oral hygiene aids including a lighted mouth mirror, a toothbrush, toothpicks and disclosing tablets. The baseline mean plaque and bleeding scores of 64 and 40% decreased during the first 6 weeks to a level of 20 and 14%. This improvement was maintained during the 6-month study period. Among the three groups no significant differences were observed in oral hygiene and gingival health. The results indicate that an oral hygiene instructional mode relatively independent of professional manpower may be equally effective as one single personal instruction. Furthermore the results suggest that factors other than the instruction per se are important for obtaining improvements in oral home care.

Oral Hygiene Skill Achievement Index I

The oral hygiene Skill Achievement Index (S.A.I.) is a general method for the direct, quantitative evaluation of oral hygiene skill. The S.A.I. evaluates a person's ability to manipulate a toothbrush and floss in a given fashion. It is applicable to any brushing or flossing procedure. The Index was developed to fulfill all the postulated requirements of a perfect measuring instrument. The key feature of the Index is the evaluation of the position and the motion of the cleaning device on each tooth surface. Consequently, the Index provides a format for the instruction and evaluation of oral hygiene skill. Furthermore, if used in conjunction with other dental indices, it enables one evaluate hygiene procedures and devices in a controlled fashion.

The role of visual feedback by a disclosing agent in plaque control

The common prescription of disclosing agents for home use assumes a relationship between visual feedback from stained plaque and subsequent oral hygiene behaviour. A study of double crossover design showed that there was no significant difference in the improvement in plaque control between the group which received only individual oral hygiene education and another group which had the same oral hygiene education supplemented by the home use of a disclosing agent for 2 weeks. On receiving oral hygiene reinforcement and discontinuing use of the disclosing agent, there was a further significant improvement in plaque control after another 2 weeks. This again suggests that visual feedback from the disclosing agent did not play a critical role in patient motivation. It appears that oral hygiene education is still fundamental to the whole concept of prevention. The prescription of a disclosing agent for home use should not be considered mandatory. Thorough and repeated oral hygiene education seems to be the most important feature in patient motivation.

Design of studies to evaluate plaque control agents

The importance of plaque in the etiology of periodontal diseases is reviewed. A survey is also presented of the various indices for scoring plaque in clinical trials. Variations in the clinical design, type of population studied, and difficulty in scoring gingival plaque are reviewed. A survey is presented of some recent published studies of plaque-inhibiting agents.

A clinical study of healing in humans following the excisional new attachment procedure

The excisional new attachment procedure was used to treat 75 suprabony pockets on 32 teeth in 9 patients. One-year postoperative measurements demonstrated an overall mean pocket reduction from 4.7 mm to 2.0 mm, of which 2.1 mm (77%) was new attachment and 0.6 mm was recession. Average amount of new attachment and percentage of new attachment were greatest on the midlingual surfaces of the teeth treated in this study. The results of this study showed the excisional new attachment procedure to be a simple, effective, and predictable procedure for achieving pocket elimination by means of a clinical new attachment of the gingival tissues in suprabony pockets.