Effects of oral hygiene measures on clinical and microbiological parameters of periodontal disease

Effects of oral hygiene measures on clinical and microbiological parameters of periodontal disease

Bruno Loos, Noel Claffey and Max Crigger School of Dentistry, Loma Linda University, Loma Linda. CA.USA

Loos B, Claffey N and Crigger M: Effects of oral hygiene measures on clinical and microbiological parameters of periodontal disease. J Clin Periodontol 1988; 15: 211-216. Abstract. The effects of a 12-week period of oral hygiene alone on gingival conditions and subgingival microflora in 15 patients with severe periodontitis were investigated. Clinical measurements and plaque samples from selected sites were taken at week 0 (baseline), week 6, and week 12. Plaque samples were also taken at week 13, that is, 1 week following debridement. At week 0, the patients were instructed in supragingival plaque control and at week 6, the hygiene regimen was supplemented with the subgingival use of a toothpick device. At week 12, the patients received a full mouth supra- and subgingival debridement under local anesthesia. In those patients who complied with oral hygiene instructions (subgroup A), the gingival condition improved moderately while no improvement was found in less compliant patients (subgroup B). No significant changes were noted in the subgingival microflora in either subgroups A or B throughout the 12-week period of oral hygiene alone. However, significant reductions for all microbial parameters were found 1 week after debridement. Therefore, while moderate clinical improvements followed oral hygiene alone, no measurable changes in the subgingival microflora were observed concomitantly.

A subgingival microflora with a high proportion of spirochetal, motile, and gram-negative microorganisms has been associated with periodontal disease (Listgarten & Helldcn 1978, Slots 1979, Van Paienstein Helderman 1981, Loesche & Laughon 1982, Slots 1982. Greenstein & Poison 1985). Shifts from high to low proportions of microbes have been observed as a consequence of periodontal therapy: (1) spirochetes (Listgarten et al. 1978, Slots et al. 1979, Singletary et al. 1982, Lindhe et al. 1983a. 1983b, Rosling et al. 1983, Loesche et al. 1984, 1985, Magnusson et al. 1984, Braatz et al. 1985, Hinrichs et al. 1985. MacAlpine et al. 1985, Rams et al. 1985); (2) gram negative microorganisms, the Bacteroides species in particular (Slots et al. 1979. Singletary et al. 1982. Loesche et al. 1984. 1985, Hinrichs et al. 1985). While the effects of a combined therapy of oral hygiene instruction and root debridement on the subgingival microflora have been studied extensively, few studies have been reported on the effects of oral hygiene alone. Smulow et al.

(1983) found significant decreases in the number of spirochetes, facultative and obligatory anaerobes, and Bacteroides species after a 3-week period of professional daily supragingiva! plaque removal. In contrast, Kho et al. (1985), after an 18-week period of oral hygiene alone, found no significant differences in the microflora from baseline values. Moreover, in the control groups of studies in which oral hygiene instruction was the only therapy adtninistered, it appeared that percentages of subgingival spirochetes were not affected (Listgarten et al. 1978, Lindhe et al. 1983a. 1983b). Controversy exists concerning the clinical response to oral hygiene therapy. Several studies have reported varied or limited improvement in probing or bleeding parameters after oral hygiene measures (Listgarten et al. 1978, Hellden et al. 1979, Cercek et al. 1983, Lindhe et al. 1983a. 1983b, Smulow et al. 1983, Badersten et al. 1984, Kho et al. 1985). In the present study, we monitored the subgingival microflora in deep

Key words: orai hygiene; sulibgingival microflora; periodontitis. Accepted for publicatio

1987

periodontal pockets over a 12-week period of oral hygiene alone. During the second 6-week portion of this 12-week period, the patients were instructed in the submarginal use of a tooth-pick. The aims of the present investigation were: (1) to study the clinical and microbiological effects of recommended supra- and subgingival oral hygiene procedures in otherwise untreated periodontitis patients; (2) to compare the microbiological results during this oral hygiene period with those immediately following a single episode of root debridement. Material and Methods Sublects

15 patients, 31-65 years of age with a mean age of 42 years with severe periodontitis were selected. None of the patients had received any periodontai therapy for at least 5 years. Their dentitions exhibited periodontal attachment loss, inflamed gingiva. supra- and subgingival calculus and generalized bleeding on probing. The patients had

Loos et al. no history of any systemic condition known to atTect periodonlal conditions. Any form of antibiotic therapy administered to the patient in the 6 months preceding the start of the study, excluded the patient from participation. All available teeth in the patients were included in the study, except for third molars and teeth with periodontal pockets extending to the apex of the roots.

patients were again monitored weekly until the plaque control was satisfactory. Supra- and subgingival debridement was provided under local anesthesia using an ultrasonic instrument (Cavitron-Dentsply with TFI-10 tip. Dentsply International, York, PA, USA). The power setting was maximal and water spray was adjusted to the preference of the operator.

Experimental design (Fig. 1)

Clinical measurements

The study utilized a longitudinal, sequential observational approach. At week 0, baseline microbiological samples and measurements were taken, after which oral hygiene instructions were given. After 6 weeks, clinical measurements and microbiological samples were again taken and previous oral hygiene methods were supplemented with methods directed at subgingival areas. Again, after 6 additional weeks, at week 12, measurements and samples were taken and a single episode of full mouth crown and root debridement was provided. At week 13, 1 week after debridement, final microbiological samples were taken.

Recordings were obtained from 6 sites around the non-molar teeth: mesiobuccal, midbuecal, distobuccal, mesiolingual, midlingual, and distohngual. For Maxillary molars, 8 sites were measured: mesiobuccal, mid-aspect of mesiobuccal root, buccal furcation, midaspect of distobuccal root, distobuccal. mesiolingual furcation, mid-aspect of palatal root, and distolingual furcation. For mandihular molars, 10 sites were recorded: mesiobuccal. midbuecal of mesial root, buccal furcation, midbuecal of distal root, distobuccai, mesiolingual, midlingual of mesial root, lingual furcation, midlingual of distal root, and distolingual.

Therapy

The patients were given oral hygiene instructions including the use of a multitufted soft toothbrush, dental tloss or tape, synthetic yarn and interdental brushes. The patients plaque control was monitored weekly. At week 6, in an attempt to improve subgingival oral hygiene, the daily use of a Perio-Aid* (Marquis Dental Mfg. Co., Aurora, CO, USA) was instituted. The patients were taught to gently insert the tip of the Perio-Aid* below the gingival margin as deeply as possible and to move the device intrasulcularly around as much of the tooth circtimference as possible. The

Dental plaque: presence or absence of dental plaque was scored after staining with a disclosing solution (Frythrosine 2%, Oral Health Products, Tulsa. OK, USA). Stained plaque present along the gingival margin that could easily be removed with the tip of a periodontal probe was recorded. Full mouth plaque scores were calculated as a percentage of surfaces examined. Bleeding on probing: records of presence or absence of bleeding on probing were taken during the course of measurements of probing depth and probing attachment level (see below). Full mouth bleeding scores were calculated as a percentage of surfaces examined.

Fif!. I. Flow chart ol experimental design. week 0

baseline plaque samples clinical measurements supragingival oral hygiene instructions

week 6

plaque samples clinical measurements instruction in use of the Perio Aid*

week 12

plaque samples clinical measurements full moulh root debridement

week 13

plaque samples

Probing depth and probing attachment level: measurements of probing depth and probing attachment level were made using an electronic, pressure sensitive probe (Electronic Periodontal Probe, Model 200A, Vine Valley Research, Middlesex, NY, USA) with a probing force of 0.50 N. A probe tip having I mm increments and 0,4 mm diameter was used (LL20, Hu Friedy, Chicago, IL). Measurements were made to the nearest 0.5 mm. A vacuum adapted, I.O mm thick soft acrylic onlay (Scheu-Dental, Iserlohn. BRD) was used to provide reference points for the probing attachment measurements. For proximal surfaces, the placement of the probe was guided by the interdental indentations of the onlay, and the probe was directed apically toward the perceived location of the apex of the root. Midbuecal and midlinguai sites were measured by placing the probe at these locations and directing it longitudinally along the root surface. For furcation sites, the probe tip was guided by the furcal groove.

Microbiologicai samples

From each subject a minimum of 3 and maximum of 6 sites, all of which had an initial probing depth of 6.0 mm or more, were chosen for bacteriological monitoring. A total of 88 sites were studied. The sample sites were isolated with cotton rolls, cleaned supragingivally with curettes, and dried with cotton pellets. A plaque sample of the subgingival microflora was taken with 3 consecutive sterile fme endodontic paper points. Each paper point was inserted until resistance was encountered and kept in place for 10 seconds. They were immediately transferred into a test tube containing 2 ml sterile prereduced Ringer's solution as a transport medium. The material was dispersed by means of sonication for 20 seconds.

Laboratory procedures

Culturing: immediately after clinical sampling and dispersion, samples were serially diluted in 10-fold steps. 0.1 ml from each of the dilutions were spread with a sterile bent glass rod over the surface of prereduced blood agar plates enriched with hemin and menadione. The plates were incubated anaerobically in GasPak'5 jars at 37X for 7 days (BBL* GasPak® Anaerobic Systems, Becton, Dickinson and Company,

Effects of oral hygiene Cockeysville, MD. USA). Anaerobic indicator envelopes were always included. The time elapsed from clinical samphng to closing the lid of the GasPak® jar never exceeded 30 min. Blood agar plates with 20 to 200 colonies were selected for counting. The black-pi gmen ted colonies were counted first. To distinguish between Bacteroides gingivalis and other black-pi gmen ted bacteroides. long-wave ultraviolet light was used (Chromato Vue Cabinet Model CC-60. L.W. 365 mm, U. V. P. Inc., San Gabriel, CA). Colonies of Bacteroides intermedlus, Bacteroides melartlnogenicus. and Bacteroides levii fluoresced whereas colonies of Bacteroides gingivalls did not (Slots & Reynolds 1982). Direct hemagglutination tests with sheep erythrocytes were done to positively identify Bacteroides gingivalis colonies (Slots & Genco 1979, Okuda et al. 1981). Finally, all other colonies on the plate were enumerated, and total numbers of colony forming units and the percentages of all black-pigmented colony forming units and Bacteroides gingivalis were calculated. Microscopy: from the original sample an aliquot was analyzed under a phase contrast microscope. In a PetrofT-Hausser bacteria counter (Hausser Scientific, Blue Belt, PA, USA) different morphological types of microorganisms as described by Listgarten & Hellden (1978) were enumerated and the total number of bacteria per sample was calculated. If microorganisms were sparse, enough grid squares were examined to count at least 100 microbes. Analysis of data

The chnical data for subgroups A and

B (See Results) were compared at each time point using a Student (-test. Patient means rather than site means were used. For the sampled sites, both clinical and microbiologic parameters were subjected to a 2-way analysis of variance to establish the residual mean square. The classification independent variables for the analysis of variance were the time point and the subject. Subject variation was accounted for in this manner. Once the mean square error was obtained, Tukey's multiple comparison procedure was utilized, where the confidence intervat is computed for the pairwise comparison regarding the population means U\ and [/, where

Sub.iect

WeekO

Week 6

Week 12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

65 28 87 81 89 40 78 87 93 87 94 86 79 91 72

3 13 14 7 9 25 33 35 25 41 52 47 64 69 71

3 7 6 16 25 20 25 29 43 40 31 26 17 27 54

mean S.D.

77 42

33 47

24 43

T=n~"^qk, n-k /)