Establishment of a new marginal plaque index with high sensitivity for changes in oral hygiene

The clinical and microbiological efficacy of a zinc-citrate/hydroxyapatite/potassium-citrate containing toothpaste: a double-blind randomized controlled clinical trial

OBJECTIVES

To evaluate the antibacterial efficacy of two fluoride-containing (1450 ppm F) toothpastes with or without zinc-citrate (ZCT), hydroxyapatite (HAP) and potassium-citrate (KCit); to assess and compare their clinical effects in terms of tooth sensitivity, plaque accumulation and gingivitis, as well as patients' satisfaction.

MATERIALS AND METHODS

Healthy, adult patients were selected and randomly assigned to two groups (n = 50): Experimental: ZCT-, HAP-, KCit- and fluoride-containing toothpaste; Control: fluoride-containing toothpaste. Salivary counts of Streptococcus mutans (S. mutans), plaque and gingival index, as well as clinically diagnosed sensitivity were recorded at baseline, and after 4 weeks. A custom-made questionnaire was used to assess patients' self-reported sensitivity (baseline and after 4 weeks) and overall satisfaction with the tested toothpastes. Data were statistically analyzed (α = 0.05).

RESULTS

After 4 weeks, a statistically significant salivary reduction of S. mutans was observed in both groups (p = 0.001). Furthermore, the percentage of S. mutans decrease was significantly higher in Experimental group (p = 0.014). There were no statistically significant differences between the groups in terms of plaque and gingival index (p > 0.05). After 4 weeks, the self-reported tooth sensitivity was lower in Experimental group (p < 0.001).

CONCLUSIONS

Both toothpastes showed good antimicrobial effect after 4 weeks; however, the toothpaste containing ZCT, HAP, KCit and fluoride was found to be more effective in reducing the salivary counts of S. mutans than the product containing fluoride alone.

CLINICAL RELEVANCE

Toothpaste containing ZCT, HAP, KCit and fluoride can be recommended for patients at risk for developing caries and may also be beneficial for individuals experiencing dental sensitivity.

Making plaque assessment easier - a validation study of simplified versions of the Marginal Plaque Index

BACKGROUND

The assessment of plaque indices may be time-consuming and error-prone. Simplification of these indices may increase their utility without compromising their validity. The aim of this study was to evaluate the validity of two simplified versions of the Marginal Plaque Index (MPI).

METHODS

Two simplified versions of the MPI as well as the Plaque Control Record (PCR) were derived from full-scale MPI assessments in two studies with four age groups (N = 42 10-year-olds; N = 24 15 year-olds; N = 53 university students (18y-33y); N = 66 parents (32y-57y). Correlations with the Turesky modification of the Quigley-Hein Index (TQHI) and the Papillary Bleeding Index (PBI) were calculated.

RESULTS

The indices derived from the MPI showed high convergence with each other (all r ≥ 0.94) and with the TQHI (r ≥ 0.80). The concurrent validity of the MPI with the PBI was equal to that of the TQHI in all age groups. The simplified versions of the MPI and the PCR show a lower convergent validity with the PBI than the MPI within parents (p < 0.05). In the other age groups, their convergent validity was equal to that of the MPI.

DISCUSSION

Simplification of the MPI does not affect its convergent validity with other plaque indices but may reduce its concurrent validity with the PBI in middle-aged adults.

Manual toothbrushing techniques for plaque removal and the prevention of gingivitis-A systematic review with network meta-analysis

BACKGROUND

The meaning of the toothbrushing technique for the effectivity of toothbrushing in terms of plaque removal and parameters of gingivitis is unknown. This systematic review and network meta-analysis (NMA) aimed to synthesize evidence from randomized controlled trials (RCTs).

METHODS

We searched MEDLINE (PubMed), the Cochrane Central Register of Controlled Trials, and the Web of Science for RCTs that compared any self-applied manual toothbrushing technique to any other technique or control and assessed plaque after toothbrushing and gingivitis. Where intervention effects were recorded repeatedly, the last post-intervention assessment was treated as the primary outcome date (POD), and the assessment closest to the intervention as the secondary outcome date (SOD). Age restrictions were not imposed. Participants with fixed orthodontic appliances were excluded. The evidence was evaluated using the Confidence in Network Meta-Analyses (CINeMA) approach, which is based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Thirteen publications, including 15 studies, were identified. Ten studies assessing the Fones, Bass, and Scrub techniques provided data eligible for the NMA. The confidence rating of the evidence varied from very low to high in the case of plaque, and from very low to low in the case of gingivitis. Regarding PODs, Fones probably reduces plaque slightly compared with no training; the evidence is very uncertain that Fones may have little to no effect on gingivitis. Bass may result in little to no difference in plaque; the evidence that Bass may result in a slight increase in gingivitis is very uncertain. The evidence is very uncertain that Scrub may result in little to no difference in plaque at the SOD (no POD-data available) and that it may result in a slight increase in gingivitis.

CONCLUSION

There is limited evidence regarding the effects of toothbrushing techniques on plaque after brushing or gingivitis.

It is the habit not the handle that affects tooth brushing - a randomised counterbalanced cross over study with young and healthy adults

OBJECTIVE

To assess the effect of the toothbrush handle on video-observed toothbrushing behaviour and toothbrushing effectiveness.

METHODS

This is a randomized counterbalanced cross-over study. N = 50 university students and employees brushed their teeth at two occasions, one week apart, using either a commercial ergonomically designed manual toothbrush (MT) or Brushalyze V1 (BV1), a manual toothbrush with a thick cylindrical handle without any specific ergonomic features. Brushing behaviour was video-analysed. Plaque was assessed at the second occasion immediately after brushing. Participants also rated their self-perceived oral cleanliness and directly compared the two brushes regarding their handling and compared them to the brushed they used at home.

RESULTS

The study participants found the BV1 significantly more cumbersome than the M1 or their brush at home. (p < 0.05). However, correlation analyses revealed a strong consistency of brushing behavior with the two brushes (0.71 < r < 0.91). Means differed only slightly (all d < 0.36). These differences became statistically significant only for the brushing time at inner surfaces (d = 0.31 p = 0.03) and horizontal movements at inner surfaces (d = 0.35, p = 0.02). Plaque levels at the gingival margins did not differ while slightly more plaque persisted at the more coronal aspects of the crown after brushing with BV1 (d = 0.592; p 0.042).

DISCUSSION

The results of the study indicate that the brushing handle does not play a major role in brushing behavior or brushing effectiveness.

Effectiveness of novel oral hygiene instruction avoiding inattentional blindness using an application for unique plaque control record calculation: A randomized clinical trial

OBJECTIVE

This study was performed to estimate the effectiveness of novel oral hygiene instruction (OHI) focusing on areas with deep periodontal pockets for reduction of periodontal inflammation.

BACKGROUND DATA DISCUSSING THE PRESENT STATUS OF THE FIELD

Because stained areas on the plaque chart do not always correspond to the areas with deep periodontal pockets, conventional OHI based on O'Leary's plaque control record (PCR) often provides guidance inconsistent with the target area.

METHODS

This randomized clinical trial involved two groups: (1) OHI based on the PCR limited in deep pocket sites (novel OHI group) and (2) OHI based on O'Leary's PCR (conventional OHI group). The unique PCR (aggressive target for PCR [agPCR]; only counting the plaque-stained areas with PD at ≥4 mm sites) for the novel OHI was calculate by dedicated expression program. The probing depth (PD), bleeding on probing (BOP), and periodontal inflamed surface area (PISA) were obtained at the baseline and 5 to 6 months later.

RESULTS

The approximation curve with PISA before and after instruction indicated that the PISA converged to a lower value after instruction in the novel OHI group. The approximation curve with the improvement rate of the PISA and agPCR showed a positive correlation in the novel OHI group but no correlation in the conventional OHI group.

CONCLUSION

Control of inflammation was more effective in the novel OHI group. These results suggest that this novel OHI technique using our developed application could be used as a strategy to improve the effectiveness of brushing instruction.

Comparison of modified bass, rolling, and current toothbrushing techniques for the efficacy of plaque control - A randomized trial

OBJECTS

This study aimed to compare the effectiveness of the modified Bass technique (MBT), the Rolling technique and the current brushing technique(CBT) for plaque removal and to assess the acceptability of the first two brushing techniques.

METHODS

180 participants were randomly assigned to PowerPoint-based training with a demonstration of either the MBT plus basic toothbrushing, the Rolling technique plus basic toothbrushing, or the basics of tooth brushing alone (CBT group). The participants were asked to brush their teeth based on what they had learned. The Turesky modification of the plaque index of Quigley & Hein (TQHI) and marginal plaque index (MPI) were assessed at the baseline examination and after 1, 2, and 4 weeks. Brushing sequence, brushing technique, and brushing duration were measured immediately after training and at each subsequent interview.

RESULTS

After instruction (0 weeks), all groups showed a significant decrease in TQHI and MPI (p<0.001), followed by a gradual increase. There was no difference in the overall effect of plaque removal between the groups(p>0.05). MBT had a better effect on cervical plaque removal than the Rolling technique after 4 weeks (p<0.05). More participants in the Rolling group were able to fully master the brushing technique during the whole four weeks.

CONCLUSIONS

There was no difference in the overall plaque removal effect among the three groups. The MBT was most effective in removing plaque at the cervical margin but more difficult to master.

CLINICAL SIGNIFICANCE STATEMENT

This study was conducted to compare the teaching and plaque removal effects of two brushing techniques and to understand which method is better for plaque removal as well as adoption. This study provides a reference and basis for future clinical work and oral hygiene education.

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.

"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).

Insight Into the Laboratory Diagnosis of Periimplantitis Using Reactive Oxygen Metabolite Levels - A Biochemical Study

Aim The study aims to substantiate the quantitative role of the predominant periodontopathogen (Porphyromonas gingivalis) associated with peri-implantitis and evaluate the reactive oxygen metabolite levels in peri-implantitis patients. Methodology A total of 40 participants were taken from the department of periodontology, Thai Moogambigai Dental College and Hospital, Chennai, and divided into groups I (control) and II (test). Group I included 20 participants with healthy peri-implant tissue, and group II included 20 participants with infected peri-implant tissues. The predominant periodontopathogen was detected by using a quantitative real-time polymerase chain reaction. Samples (gingival crevicular fluid (GCF), saliva, and plasma) were collected, and a biochemical assay was conducted for reactive oxygen metabolites (ROM) analysis in healthy implants (control group) and peri-implantitis conditions (test group). ROM levels of the patients were statistically analyzed. Results The qualitative and quantitative profiles of Porphyromonas gingivalis (P. gingivalis) associated with Peri-implantitis were analyzed, and the levels of ROM in periimplantitis patients were assessed. The study results substantiate the quantitative picture of Porphyromonas gingivalis in the detection of periimplantitis. The saliva and GCF samples showed significant differences in ROM levels between the test and control groups. Conclusion This is one of the few studies to detect the predominant bacterial pathogen associated with peri-implantitis and assess the ROM levels in periimplantitis patients. The study gives a correlation between the periopathogens and ROM levels, thereby facilitating the attainment of the best possible treatment options.

Patients' awareness regarding the quality of their oral hygiene: development and validation of a new measurement instrument

BACKGROUND

The present research aimed to develop and validate a standardised survey instrument for the assessment of patients' awareness of the quality of their oral hygiene performance.

METHODS

A digital questionnaire was developed that assesses both patients' naïve self-perceptions of oral cleanliness (SPOCn) after tooth brushing and patients' perceptions after being informed how oral cleanliness may be captured in dentistry (SPOCd). Three studies (N = 56 adults, N = 66 adolescents and one of their parents, N = 24 university students) assessed the instrument's feasibility (patient reports), reliability (internal consistency), validity (correlation with other constructs; sensitivity to manipulation of actual tooth brushing), and the correlation with actual oral cleanliness after tooth brushing.

RESULTS

All study groups accepted the questionnaire well; average answering times were less than 5 min. Cronbach's α exceeds 0.90; correlational analyses support the discriminant validity regarding oral hygiene related self-efficacy expectations and stages of change; manipulation of oral hygiene behaviour results in the expected changes of SPOC scores. Patients' SPOC correlate only moderately with actual oral cleanliness. The comparison between SPOCd scores and actual oral cleanliness indicate that they considerably overestimate their oral hygiene performance.

CONCLUSIONS

The SPOC questionnaire is an easy-to-use, well-accepted, reliable and valid instrument for the assessment of patients' awareness of the quality of their oral hygiene for research and clinical purposes. The results of the questionnaire may help to reveal unrealistic self-perceptions of patients regarding their oral hygiene. It can raise their awareness of the need to improve their skills and/or efforts in this regard. Trial registration The third study was an interventional study and was registered in the appropriate national register ( www.drks.de ; ID: DRKS00018781; date of registration: 12/09/2019).

Comparison of different plaque indices with regard to sensitivity and specificity for the quantification of plaque during orthodontic therapy

To compare four plaque indices used in orthodontics. An objective, quantitative plaque index and three subjective conventional plaque indices were analyzed. The study included n = 50 photographs of n = 50 subjects with a multibracket appliance (MB) in the maxilla and mandible. Photographs were taken using Digital Plaque Imaging Analysis (DPIA) and the Percentage Plaque Index (PPI) was calculated. The conventional plaque indices, a modified version of the Turesky-modification of the Quigley & Hein Index (TQH index), Attin index, and modified bonded bracket index (mBB index) were collected from n = 14 evaluators using the DPIA photographs. The evaluators had different levels of orthodontic experience: n = 4 evaluators had little orthodontic experience, n = 5 evaluators had moderate orthodontic experience, and n = 5 evaluators had a lot of orthodontic experience. Plaque accumulation was assessed differently with the plaque indices. Thus, the plaque indices are not interchangeable. We recommend DPIA as an objective, quantitative and sensitive method for plaque determination in scientific studies. The simple statistical evaluation offers a great advantage over conventional plaque indices.

What characterizes effective tooth brushing of daily users of powered versus manual toothbrushes?

Background

Recent data show comparable deficits in oral cleanliness after tooth brushing in habitual users of powered toothbrushes (PT) and manual toothbrushes (MT). The present analysis explores the origin of these deficits by relating aspects of the observed tooth brushing behaviour to plaque after tooth brushing.

Methods

Users of rotating-oscillating PT (N = 48) and of MT (N = 52) brushed their teeth the best they could while being filmed. Video analyses assessed brushing time, number of sextants brushed sufficiently long (7.5 s per surface; NSBSL), brushing of outer surfaces with closed jaws, and brushing movements. Correlation analyses examined the relationship between these parameters and plaque after brushing (Marginal Plaque Index (MPI); Turesky modification of Quigley Hein Index (TQHI)) and gingivitis (Papillary Bleeding Index (PBI)).

Results

In PT users, correlations between behaviour and MPI-scores were significant for the NSBSL (outer surfaces: rho = − 0.249; inner surfaces: rho = − 0.510) and brushing duration (outer surfaces: rho = − 0.399; inner surfaces: rho = − 0.509). In MT users, vertical movements on the outer surfaces were positively related to MPI (rho = 0.299). In contrast, circular movements correlated negatively with MPI in those who brushed all outer sextants sufficiently long (n = 47: rho = − 0.294). In both groups, PBI-scores on the inner surfaces were negatively correlated to NSBSL and brushing duration (rho = − 0.327 − rho = − 0.246).

Conclusion

NSBSL and brushing duration appear to play an important role for brushing effectiveness and gingival health in PT and MT users. Whether PT users apply brushing movements or not apparently does not affect the result. In MT users, circular movements seem to be more efficient than vertical movements on the outer surfaces.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02045-0.

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.

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.

Effectiveness of brushing teeth in patients with reduced oral hygiene by laypeople: a randomized, controlled study

Background

To evaluate the success of plaque reduction after external toothbrushing by instructed laypeople versus dental professionals using either a manual or powered toothbrush. Longitudinal, randomized, parallel-group intervention study in periodontitis patients with reduced oral hygiene quality undergoing anti-infective therapy. Patients were randomly and equally assigned to one of four groups: laypeople using a manual or powered toothbrush or dental professionals using a manual or powered toothbrush. Plaque reduction (Quigley–Hein-Index (QHI), Marginal Plaque Index (MPI)), gingivitis (papilla bleeding index), and cleaning time (seconds) were investigated.

Results

Thirty-nine patients participated in the study. Neither the choice of toothbrush (p = 0.399) nor the use of a dental professional (p = 0.790) had a significant influence on plaque levels achieved. However, multivariate modeling indicated statistically significant differences in the external cleaning time between brushing groups, with longer time required by laypeople (p = 0.002) and longer use of the powered toothbrush (p = 0.024).

Conclusion

When the ability to carry out personal oral hygiene is reduced, external brushing by dental professionals or instructed laypeople who meet previously defined criteria such as sufficient personal oral hygiene at home could help to fill the emerging dental care gap. A combination of oral hygiene approaches adapted to the individual needs of the patients in need of external help is necessary for optimum oral hygiene.

Trial registration: German Clinical Trials register (https://www.germanctr.de; number DRKS00018779; date of registration 04/11/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01590-4.

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.

GoPerio - impact of a personalized video and an automated two-way text-messaging system in oral hygiene motivation: study protocol for a randomized controlled trial

Background

Oral hygiene is of paramount importance for the preservation of oral health, and for patients affected by periodontal disease establishing an effective oral hygiene routine is the first step of therapy. Several clinical frameworks have been developed to foster behavior change, such as motivational interviewing. However, two obstacles can be identified. First, patients tend to forget the advice they were given during the consultation. Second, it is hard to maintain motivation in the long term, thus leading to relapse. An innovative eHealth solution was designed with the aim to tackle both obstacles and supplement the current clinical standard of care. The primary objective is to compare the full mouth plaque scores of study groups (eHealth plus standard of care versus standard of care only) at 8 weeks of follow up. The main secondary objective is to compare the full mouth bleeding score at 8 weeks of follow up.

Methods/design

The “GoPerio” study is a multicenter, randomized, controlled trial assessing the impact of a novel eHealth concept for oral hygiene motivation (personalized video of oral hygiene routine available for the patient via a cloud server plus interactive text messages) in addition to the current standard of care (motivational interviewing plus tooth scaling and polishing). The minimum sample size required is 86 patients. Participants will be randomized (allocation ratio 1:1): test group (eHealth plus standard of care) versus control group (standard of care only). The primary outcome is oral hygiene as measured by the full mouth (six sites per tooth) plaque control record (PCR) index. The main secondary outcome is gingival inflammation as measured by the full mouth (six sites per tooth) bleeding on probing (BOP) index. Both the primary and the main secondary outcomes are evaluated by blinded and calibrated examiners at 8 weeks of follow up. The other secondary outcomes are patient satisfaction and patient behavior change and motivation.

Discussion

The study will investigate the value of an innovative eHealth approach to strengthen patient motivation for oral hygiene. If proven effective, such an approach would supplement the current clinical standard of care, resulting in improved clinical outcomes with negligible impact on productivity in a dental practice.

Trial registration

ClinicalTrials.gov, NCT03109808. Registered on 12 April 2017.

Sponsor: Hospices Civils de Lyon. BP 2251, 3 quai des Célestins, 69,229 Lyon cedex 02.

Protocol version: 1.0 as of 21 September 2016.

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.

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.

One-to-one oral hygiene advice provided in a dental setting for oral health

BACKGROUND

Effective oral hygiene measures carried out on a regular basis are vital to maintain good oral health. One-to-one oral hygiene advice (OHA) within the dental setting is often provided as a means to motivate individuals and to help achieve improved levels of oral health. However, it is unclear if one-to-one OHA in a dental setting is effective in improving oral health and what method(s) might be most effective and efficient.

OBJECTIVES

To assess the effects of one-to-one OHA, provided by a member of the dental team within the dental setting, on patients' oral health, hygiene, behaviour, and attitudes compared to no advice or advice in a different format.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 10 November 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 10) in the Cochrane Library (searched 10 November 2017); MEDLINE Ovid (1946 to 10 November 2017); and Embase Ovid (1980 to 10 November 2017). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were also searched for ongoing trials (10 November 2017). No restrictions were placed on the language or date of publication when searching the electronic databases. Reference lists of relevant articles and previously published systematic reviews were handsearched. The authors of eligible trials were contacted, where feasible, to identify any unpublished work.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of one-to-one OHA delivered by a dental care professional in a dental care setting with a minimum of 8 weeks follow-up. We included healthy participants or participants who had a well-defined medical condition.

DATA COLLECTION AND ANALYSIS

At least two review authors carried out selection of studies, data extraction and risk of bias independently and in duplicate. Consensus was achieved by discussion, or involvement of a third review author if required.

MAIN RESULTS

Nineteen studies met the criteria for inclusion in the review with data available for a total of 4232 participants. The included studies reported a wide variety of interventions, study populations, clinical outcomes and outcome measures. There was substantial clinical heterogeneity amongst the studies and it was not deemed appropriate to pool data in a meta-analysis. We summarised data by categorising similar interventions into comparison groups.Comparison 1: Any form of one-to-one OHA versus no OHAFour studies compared any form of one-to-one OHA versus no OHA.Two studies reported the outcome of gingivitis. Although one small study had contradictory results at 3 months and 6 months, the other study showed very low-quality evidence of a benefit for OHA at all time points (very low-quality evidence).The same two studies reported the outcome of plaque. There was low-quality evidence that these interventions showed a benefit for OHA in plaque reduction at all time points.Two studies reported the outcome of dental caries at 6 months and 12 months respectively. There was very low-quality evidence of a benefit for OHA at 12 months.Comparison 2: Personalised one-to-one OHA versus routine one-to-one OHAFour studies compared personalised OHA versus routine OHA.There was little evidence available that any of these interventions demonstrated a difference on the outcomes of gingivitis, plaque or dental caries (very low quality).Comparison 3: Self-management versus professional OHAFive trials compared some form of self-management with some form of professional OHA.There was little evidence available that any of these interventions demonstrated a difference on the outcomes of gingivitis or plaque (very low quality). None of the studies measured dental caries.Comparison 4: Enhanced one-to-one OHA versus one-to-one OHASeven trials compared some form of enhanced OHA with some form of routine OHA.There was little evidence available that any of these interventions demonstrated a difference on the outcomes of gingivitis, plaque or dental caries (very low quality).

AUTHORS' CONCLUSIONS

There was insufficient high-quality evidence to recommend any specific one-to-one OHA method as being effective in improving oral health or being more effective than any other method. Further high-quality randomised controlled trials are required to determine the most effective, efficient method of one-to-one OHA for oral health maintenance and improvement. The design of such trials should be cognisant of the limitations of the available evidence presented in this Cochrane Review.

Toothbrushing: to the best of one's abilities is possibly not good enough

BACKGROUND

Weaknesses in toothbrushing performance can be seen when young adults are instructed to perform habitual toothbrushing. Nothing is known about toothbrushing behavior when instructed to perform to the best abilities. The present study analyzes such behavior and compares it to habitual behavior.

METHODS

A random sample of N = 98 young adults born in 1995 was examined in 2014/2015.They were asked to perform oral hygiene to the best of their abilities in front of a camera. Videos were analyzed regarding details of brushing behavior. A quality index was developed which describes the extent of the neglect of brushing on palatinal and vestibular surfaces. Data were compared to those of an earlier study of young adults (born in 1992, examined in 2011, N = 101) who were asked to perform oral hygiene as they habitually do.

RESULTS

The 1995 cohort (best abilities) brushed their teeth significantly longer than the 1992 cohort (habitual brushing). This was due to significant longer brushing at vestibular and occlusal surfaces. Neglect of palatinal surfaces was similar in both cohorts. Groups did not differ regarding brushing movements. 40% of the brushing time on lateral surfaces was spent with scrubbing movements despite opposing advice in common oral hygiene instructions.

CONCLUSIONS

Toothbrushing to the best of one's abilities might still not be good enough. Young adults apparently lack a reasonable concept of what is meant by high quality toothbrushing. More efforts should thus be undertaken to explain them (and adults) this concept.

Periodontal health during orthodontic treatment with clear aligners and fixed appliances: A meta-analysis

BACKGROUND

Clear aligners have become increasingly popular because of their esthetics and comfort. The authors' aim in this systematic review was to compare periodontal health in patients undergoing orthodontic treatment with clear aligners with that of those undergoing orthodontic treatment with fixed appliances.

TYPES OF STUDIES REVIEWED

The authors systematically searched the PubMed, Web of Science, Cochrane Library, and Embase databases to collect related studies. After extracting data and assessing quality, the authors performed a meta-analysis and trial sequential analysis. The authors used the Grading of Recommendations Assessment, Development and Evaluation system to assess the quality of the evidence.

RESULTS

The authors included 9 studies in the quantitative synthesis analysis. Clear aligners were better for periodontal health, including plaque index (mean difference [MD], -0.53; 95% confidence interval [CI], -0.85 to -0.20; P = .001), gingival index (MD, -0.27; 95% CI, -0.37 to -0.17; P < .001), and probing depth (MD, -0.35; 95% CI, -0.67 to -0.03; P = .03), than were fixed appliances. However, the trial sequential analysis outcome indicated a false-positive meta-analysis result for probing depth. The authors downgraded the level of the evidence because of the risk of bias and inconsistency.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Clear aligners were better for periodontal health than fixed appliances and might be recommended for patients at high risk of developing gingivitis. However, high-quality studies still are required.

Effective professional intraoral tooth brushing instruction using the modified plaque score: a randomized clinical trial

Purpose

The purpose of this study was to evaluate the efficacy of the modified plaque score (MPS) for assessing the oral hygiene status of periodontitis patients.

Methods

A total of 116 patients were included in this study. After evaluation of the Löe and Silness gingival index (GI), Silness and Löe plaque index (PlI), O'Leary plaque control record (PCR), and MPS, patients were randomly assigned to either a conventional tooth brushing instruction (C-TBI) group (n=56) or a professional intraoral tooth brushing instruction (P-TBI) group (n=60). The MPS and clinical parameters were re-evaluated after scaling and a series of root planing. The convergent validity of MPS with the PlI and PCR was assessed. The measurement time for MPS and PCR was compared according to the proficiency of the examiner.

Results

After root planing, the GI, PlI, PCR, and MPS improved from their respective baseline values in both groups. Three different plaque indices including the MPS, showed significant differences between the C-TBI group and the P-TBI group after root planing. The MPS showed significant concurrence with the PCR and PlI. The mean time for PCR measurement was 2.76±0.71 times longer than that for MPS measurement after 2 weeks of training.

Conclusions

MPS seems to be a practical plaque scoring system compared with the PlI and PCR. These findings suggest that repetitive plaque control combined with an easily applicable plaque index (MPS) may facilitate more effective oral hygiene education and improved periodontal health.

The New Marginal Plaque Index May Allow a More Valid Assessment of Gingival Plaque Level Than the Turesky Modification of the Quigley and Hein Index

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Establishment of a new marginal plaque index with high sensitivity for changes in oral hygiene. Deinzer R, Jahns S, Harnacke D. J Periodontol 2014; 85(12):1730-8.

SOURCE OF FUNDING

The study was supported by a sponsorship from GABA International, Therwil, Switzerland.

TYPE OF STUDY/DESIGN

Observational case-control study.

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.

Validation of the Visible Occlusal Plaque Index (VOPI) in estimating caries lesion activity

OBJECTIVE

The present study appraises the construct validity of the Visible Occlusal Plaque Index (VOPI) along with its sub-types, convergent and discriminant validity.

METHODS

618 10-15year old Brazilian adolescents were included. The VOPI has a four-point ordinal scale ranging from no plaque to heavy plaque. VOPI scores and caries status on permanent molars were mapped and recorded at individual anatomical sites of the groove-fossa-system and at surface level. Outcomes were presence of sound site/surface and site/surface with active or inactive caries lesions (non-cavitated or cavitated).

RESULTS

Construct validity was assumed based on qualitative assessment as no plaque (score 0) and thin plaque (score 1) reflected the theoretical knowledge that a regular disorganization of the dental biofilm either maintains the caries process at sub-clinical levels or inactivate it clinically. The VOPI also showed convergent validity since the likelihood that anatomical sites with no or thin plaque had inactive lesions simultaneously with sites with thick plaque (score 2) or heavy plaque (score 3) having active lesions were overall significant (RR=1.0-7.8). At surface level, discriminant validity of the VOPI was evidenced with multivariable analysis (GEE), by its ability to discriminate between the groups of adolescents with different oral hygiene status; negative association between adolescents with thick and heavy plaque and those with sound occlusal surfaces was found (OR=0.3, p<0.001).

CONCLUSION

The VOPI has construct as well as convergent and discriminant validity and is therefore recommended as an additional clinical tool to estimate caries lesions activity and support treatment decisions.

CLINICAL SIGNIFICANCE

The Visible Occlusal Plaque Index is an additional clinical tool to the assessment of oral hygiene and caries lesion activity. The VOPI is recommended to standardize and categorize information on the occlusal biofilm, thus being suitable for direct application in research and clinical settings.

Effectiveness of Computer-Based Training on Toothbrush Skills of Patients Treated With Crowns: A Randomized Controlled Trial

BACKGROUND

This study was conducted to assess plaque removal skills in patients with fixed dental prostheses (FDP), and effectiveness of computer-based training (CBT) of different brushing techniques (Fones versus Bass technique in their common modifications).

METHODS

Ninety-three patients with FDP were randomly allocated to one of three training groups: 1) C (control group); 2) F (Fones technique group); and 3) B (Bass technique group). All patients received CBT of the basics of toothbrushing. Group C received no further instructions while groups F and B received additional CBT of the modified Fones or the modified Bass technique, respectively. Plaque levels were assessed immediately after patients had been asked to perform oral hygiene to the best of their abilities.

RESULTS

Prior to training, persistent plaque deposits were found at 80% of marginal sites of natural teeth immediately after patients had performed oral hygiene. Considerably fewer plaque deposits were found on FDP (43%). No significant group differences were observed 6 and 12 weeks after training, either for natural teeth or for FDP (all P >0.05).

CONCLUSIONS

Plaque removal skills are low in patients with FDP. Apparently, they do not profit from CBT of the techniques studied here. Studies observing their actual brushing behavior should be conducted to elucidate reasons for their deficits and to explore why CBT does not work in this group of patients.

Training in different brushing techniques in relation to efficacy of oral hygiene in young adults: a randomized controlled trial

AIM

This study aims to assess plaque scores after oral hygiene in an unselected sample of young German adults and to compare the effects of computer-based training of the Fones versus the modified Bass technique on these scores.

MATERIAL AND METHODS

Seventy 18- to 19-year olds received computer-based training of the Fones technique, the modified Bass technique or basic instructions of oral hygiene alone (control group). The marginal plaque index (MPI; percentage of sections adjacent to the gingiva showing plaque) and BOP were assessed at baseline and after 6, 12 and 28 weeks. MPI was assessed immediately after participants had been asked to perform oral hygiene to the best of their abilities.

RESULTS

At baseline, MPI levels of 83.3% ± 12.5 (mean ± SD) were observed. After 12 weeks, groups differed significantly (p < 0.05) with respect to MPI: Fones group: 70.3% ± 14.7; Bass group: 77.91 ± 14.37; control group: 79.3% ± 9.2. No differences in BOP were found.

CONCLUSIONS

High plaque levels at gingival margins after oral hygiene were observed in an unselected sample of young German adults. After 12 weeks, plaque levels after oral hygiene were slightly reduced in the group who had received training of the Fones technique but effects trailed off afterwards. The study failed to prove effects of the training on signs of gingival inflammation.