The sample in the age groups 12 ± 1 and 15' ± 1 each was divided into one control and five experimental groups depending upon frequency of rendering instruc tions in oral hygiene and oral prophylaxis as follows:
Dental Prophylaxis Procedures in Control of Periodontal Disease in Lucknow (Rural) India
Control Group C Received no prophylaxis or instructions in tooth brushing. Experimental Groups la Received prophylaxis and tooth brushing in structions once a year. Ib Received prophylaxis and tooth brushing in structions twice a year. Ic Received prophylaxis and tooth brushing in structions four times a year. II Received prophylaxis only twice a year. Ill Received tooth brushing instructions only twice a year.
by TRIBHAWAN N . C H A W L A , BDS., LDS RCS., MS,, FICD.,* R A M S. N A N D A , BDS., MS., PH.D., FICD.,*
The 26 ± 2 years of age group, however, consisted of a control group C and one experimental group Ic. In order to avoid the bias and intermixing of subjects, the sample of control and different experimental groups was drawn from far apart schools and factories. The study lasted for a period of two years and the subjects in all of the groups were assessed for gingivitis, loss of attachment, calculus and plaque according to Ramfjord's criteria at the beginning, after one year, and at the end of second year of study. The assessments at the beginning and after one year of study were carried out by five examiners. However, the final assessment at the end of two years was done by a properly calibrated single examiner to eliminate interexaminer errors in evaluation and the analysis of data was based only on these observations from the remaining 1605 subjects due to 49% loss in the sample strength (Table 1). Standard oral prophylaxis, and instructions in tooth brushing twice a day, before the first meal and after the last meal, by the modified Stillman's method was rendered by five dentists to experimental groups. Their performance was regularly scrutinized to achieve opti mum treatment. The experimental subjects were also required to demonstrate their brushing procedures to ensure its effectiveness. One toothbrush of hard texture and one giant size tube of toothpaste were given to each subject of experimental groups l a , Ib, Ic and III, once every three months. Those who did not receive toothbrush and toothpaste were given a fountain pen as an incentive. For determining the statistical significance of the observed changes, a nonparametric statistical test ( K o l mogorov-Smirnow) was used instead of the "t" test as the distribution of the values was highly skewed. Direct comparison of the percentages for statistical signifi cances was not attempted, so as not to introduce some bias owing to the particular classification used for mild, moderate, severe; whereas i n the case of the Kolmogorov-Smirnov test, the entire range of values is taken into account.
K A M A L K . KAPOOR, BDS., MDS.,* 1-5
PREVALENCE OF periodontal disease in I n d i a has been reported close to one-hundred percent and of greater severity as compared to advanced countries. Strong correlation between the state of oral hygiene, as deter mined by the plaque and calculus accumulations, and periodontal disease also has been variously estab lished. Similarly, reduction in gingival inflammation is noted with improvement in oral hygiene. Based on these observations, frequent removal of dental deposits by tooth cleaning implements and regular professional oral prophylaxis has been emphasized. However, the optimum frequency with which such procedures should be practiced, had no reference in the literature. Conse quently, this investigation was envisaged to establish the optimum relative frequency with which tooth brushing and scaling procedures could be effective in the mainte nance of periodontal attributes.
MATERIALS A N D M E T H O D S
This investigation was initiated by selecting 2,950 male subjects; 1300 children of 12 ± 1 and 1300 of 15 ± 1 years of age from the rural schools, and 350 adults 26 ± 2 years of age from among the factory workers around the city of Lucknow. These subjects provided a homogeneous sample due to the uniformity in socioeconomic factors and total lack of awareness towards dental health care and the modern methods of achieving tooth cleanliness by a tooth brush and/or scaling. Only male subjects were considered due to nonavailability of female rural schoolgoing children.
This investigation was supported by PI 480 grant from the National Institute of Health, United States Public Health Service, under the aegies of the Indian Council of Medical Research, New Delhi. * Dental College and Hospital, King George's Medical College, Lucknow, India.
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Dental Prophylaxis Procedures in India
TABLE 1. Distribution of the Sample in Different Study Groups Sample at Initial Scoring Study Groups
Age groups in years 12 ± 1
15 ± 1
26 ± 2
Sample at Final Scoring
Age groups in years 14 ± 1
17 ± 1
28 ± 2
Control Experimental la
102 114 110
Prevalence of Periodontal Disease and Related Factors Percentage distribution of cases according to severity scores of gingivitis, loss of epithelial attachment, plaque and calculus at different ages is based on control group cases as 180 cases in 14 years, 137 in the 17 years, and 90 cases in the 28 years of age groups (Table 1 and Figs. 1 4). Gingivitis. Gingivitis (Fig. 1) was prevalent to the extent of mild and moderate in 93% of cases at 14 years, 98.5% of cases at 17 years, and 100% of cases at 28 years of age. The number of cases with severe gingivitis increased with age. The increase in gingivitis score was significant at 1 % level between 14 and 17 years of age and at 5% level between 17 and 28 years of age. Periodontitis. Hardly any children in 14 and 17 years of age groups had periodontitis (Fig. 2). However, nearly 83% of individuals i n the adult group exhibited perio dontitis. Epithelial Attachment. The loss of epithelial attach ment (Fig. 2) on the buccal aspect of teeth for different age groups indicated that 81% at 14 years, 69% at 17 years, and only 3% at 28 years of age were free from the apical migration of the epithelial attachment from the cemento-enamel junction. The 28 years of age group showed 86% of the cases having loss of attachment of more than 0.6 mm. A similar pattern also was seen with respect to distribution of cases for the loss of attachment on the mesial aspect of the teeth. Plaque. Nearly 65% of rural children and 44% of factory workers had plaque scores in the range of 2.0 to 2.4 (Fig. 3). This indicated that oral hygiene measures in the rural child sample were more primitive than those of the factory workers. Calculus. A moderate degree of calculus was present in an overwhelming majority of the cases i n all age groups (Fig. 4). The number of cases with calculus at the age of 17 years was significantly more than those at the age of 14 years. There was, however, no difference in the percentage of cases between 17 and 28 years of age
FIGURE 1. Percentage distribution of subjects (dark areas) according to range of gingivitis, mean severity scores in control (C) and experimental (la, lb, Ic, II, III) groups at different ages.
groups, indicating that the calculus deposits occurred to a moderate extent up to over 17 years of age and thereafter the deposition remained almost steady. Effect of Oral Hygiene Measures on Periodontal Attributes Gingivitis. The severity of gingivitis among control and various experimental groups at different ages are pre sented in Figure 1. Statistical significance of observed differences among different groups is shown in Table 2. Comparison of the experimental groups with controls, according to different severity grades of 14 years, indicated significant improvement (P < 0.01) in gingivi-
J. Periodontol. August, 1975
FIGURE 2. Distribution of subjects (dark areas) according to range of mean loss of epithelial attachment scores (in millimeters) on buccal and mesial aspects of teeth in Control (C) and experimental (la, Ib, Ic, II, III) groups at different ages.
FIGURE 3. Percentage distribution of subjects (dark areas) according to range of mean plaque severity scores in Control (C) and experimental (la, Ib, Ic, II, III) groups at different ages.
FIGURE 4. Percentage distribution of subjects (dark areas) according to range of mean calculus severity scores in Control (C) and Experimental (la, Ib. Ic, II, III) groups at different ages.
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Dental Prophylaxis Procedures in India
TABLE 2. Statistical Significance of Observed Differences among Different Groups Control and Experimental Groups
Age Groups (in years)
Gingivitis ** **
Plaque ** **
** ** **
** ** **
l a Ic
Ia l b
Loss of Attachment Mesial
N S = N o t Significantly different; * Significant at 0.05 level; ** Significant at 0.01 level.
tis in all of the experimental groups. O n comparing the groups l a and Ib, no significant change was found. However, Ic when compared with l a or Ib did show significant improvement in gingivitis (P < 0.05 and P < 0.01 respectively). The experimental groups of 17 years of age when compared with control cases showed a higher percentage of cases without gingivitis and marked reduction in the moderate score. The improvement in gingivitis score in all of the instances was significant (P < 0.01). N o progressive trend of improvement in gingivitis with more intensive schedules was noticeable. The comparisons of the experimental groups, belong ing to half yearly schedule, at both 14 and 17 years of age, did not show significant change in gingivitis between the groups Ib and II; however, significant deterioration (P < 0.01) in the gingivitis was observed between groups Ib and III; and between the groups II and III. Experimental Ic in 28 years of age group showed significant improvement (P < 0.01) over the correspond ing control group. Periodontitis. The cases, in 14 and 17 years of age groups, with periodontitis (Fig. 2) were so small that no meaningful information could be obtained. However, in the 28 years of age group, 75.5% of the cases had moderate and 7.8% had severe periodontitis. The quar terly prophylaxis and tooth brushing on experimental Ic of this group showed significant (P < 0.01) reduction in periodontitis as compared to controls (Table 2). Epithelial Attachment. The level of apical migration of epithelial attachment from the cemento-enamel junction, on the buccal and mesial aspects of teeth, was similar in all of the experimental groups of 14 and 17 years of age group subjects (Fig. 2). Only 3.9% of the control and 2.5% of the experimental groups had loss of attachment
more than 0.1 mm at 14 and 17 years of age. The number of cases, however, was too small and no effect of treatments could be evaluated. Further, the loss of attachment of less than 0.1 was regarded as questionable as it is based on a single score of 1 mm. Therefore, the results of quarterly oral hygiene measures (Ic) in 28 years of age group were analyzed and showed statistically significant improvement (P < 0.01) at all of the levels of infliction (Fig. 2). Plaque. Severity of the bacterial plaque accumulation among various study groups at different ages is reported in Figure 3. The statistical significance of observed differences among different groups is presented in table 2. The treatment groups l a , Ib, Ic and III at 14 and 17 years of age showed significant reduction (P < 0.01) in the number of cases with heavier plaque deposits when compared to their respective control groups. However, the cases of experimental group II, who did not receive any instructions in tooth brushing, showed significant difference when compared with their respective control cases. The experimental Ic cases in the 28 years old age group also showed significant improvement (P < 0.01) when compared with their control cases. The compara tive assessment between l a and Ib; l a and Ic; Ib and Ic among 14 and 17 years of age groups did not demon strate any significant difference. The results on comparing the groups Ib and II, demonstrate that the latter had significant accumulation of bacterial plaque (P < 0.05) at 14 years and (P < 0.05) at 17 years of age. There was no significant improvement in Ib when compared with III at both 14 and 17 years of age. However, marked improvement could be noticed when the respective groups II were compared with corresponding groups III (P < 0.01). Calculus. A s compared to the controls, all of the
Chawla, Nanda, Kapoor
experimental groups had significant reduction (P < 0.01) of calculus formation (Fig. 4 and Table 2). Both qualita tive as well as quantitative reduction in calculus forma tion was evident in the experimental groups receiving more intensive care, as the groups l b and Ic fared better than l a (P < 0.01). However, this difference was not so prominent in groups lb as compared to groups Ic. The groups on half yearly treatments (lb, II and III) showed that the subjects receiving combined treatment by scaling and tooth brushing had much better results (P < 0.01) than those who received either scaling or tooth brushing instructions alone. DISCUSSION
The most effective measures advocated for preventing and controlling periodontal disease are regular tooth brushing and frequent oral prophylaxis. However, the literature does not clearly state the minimum required frequency of rendering these procedures. This study, therefore, proposed to evaluate the effectiveness of tooth brushing and/or oral prophylaxis procedures to the extent that the measures will be economical and usable in public health programs. A t the start of this study a high percentage of cases with gingivitis (92.8) was noticed among the rural children which increased in prevalence and severity with age (Fig. 1), and all the factory workers at 28 years of age had periodontitis with at least some loss of epithelial attachment (Fig. 2). It was also noticed that the plaque scores were high (Fig. 3) and calculus deposits were mainly of moderate amounts (Fig. 4) in all of the three age groups. Moreover, although the prevalence and severity of periodontal disease appeared to increase with age, yet the amount of local deposits remained the same in all the three age groups. This suggested that it is not the higher amount of plaque and calculus but the duration of presence of these factors that may play an important role in this phenomenon. The results obtained from different experimental groups were analyzed in the light of gingivitis, loss of epithelial attachment, plaque and calculus, these attributes being more or less directly involved in the pathogenesis of periodontal disease. A n appreciable improvement in the gingival health shown by the experimental groups over control cases, in all of the three age groups, suggested that any type of treatment rendered to the patient will be beneficial. The insignificant difference between groups l b and II at both 14 and 17 years of age suggested that scaling twice a year alone could cure gingivitis and practically stop further loss of epithelial attachment to about the same extent as those who received the brushing instructions in addition to scaling. This was also confirmed by the analysis of group III cases where instructions i n brushing alone, without rendering scaling, failed to achieve such improvements. The combined beneficial effect of brush ing and scaling on the level of epithelial attachment was more discernible in the 28 years old factory workers
J. Periodontol. August, 1975
(Ic), as a significant number of cases had loss of epi thelial attachment as compared to the younger age group subjects. From these experiments it appeared that tooth brushing regimen alone had only a little benefit and it was significantly effective when combined with periodic scaling in curing gingivitis and loss of epithelial attachment. The experimental groups that received tooth brushing instructions, had significantly reduced bacterial plaque accumulation (P < 0.01). However, experimental group II, where only scaling was rendered twice a year without tooth brushing instructions, did not show any difference from the control cases. Experimental group III, where only tooth brushing instructions were imparted, showed the similar state of plaque deposit as in group l b where along with tooth brushing instructions, scaling was also carried out. The comparative assessment among experi mental group l a , l b , and Ic, where oral hygiene measures were progressively increased, did not demonstrate any significant difference on plaque accumulation. This em phasizes the importance of tooth brushing in reducing the bacterial plaque accumulation, irrespective of the num ber of times the instructions are rendered per year, provided the individuals learn it properly. Reduction in the severity of calculus formation in all experimental groups as compared to control cases in the respective age groups, indicated the beneficial effects of all types of treatment. Experimental groups l b and Ic, where both scaling and tooth brushing instructions were given twice and four times per year respectively, showed optimum beneficial effects in the calculus reduction than any other treatment groups. Therefore, it can be stated that scaling and tooth brushing instructions instituted at half-yearly intervals can produce maximum and most economic benefit with regard to calculus deposition. In summation, it appeared from this investigation that the removal of calculus was directly correlated with the improvement in periodontal health. The removal of bacterial plaque, alone, however, did not indicate such a correlation. This however, does not mean that removal of plaque may not be effective, and may be taken only to indicate that viable bacterial plaque, retained in and around the retention areas provided by calculus, unless removed may not evidently be as effective. Further, as bacterial plaque in due course is calcified into calculus, indirect benefit will also be achieved by keeping its formation to minimum, through regular brushing proce dures to minimize the formation of calculus retention areas. However, professional scaling, twice a year, without active patient cooperation in maintaining oral hygiene through tooth brushing, can also achieve higher standard of periodontal health. SUMMARY AND CONCLUSIONS
Frequent professional scaling and regular tooth brush ing are the main public health measures available for preventing and controlling periodontal disease but their
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frequency and efficacy are still incompletely understood. This investigation was carried out on 1,416 rural children and
189 factory workers in Lucknow area in the
groups 14 ± 1, 17 ± 1 and 28 ± 2 years of age to evaluate the optimum requirement of these measures to the extent they will be economical and usable in the public health programs. The prevalence of gingivitis and periodontal disease in Lucknow children and adult samples was found to vary between 93 to 100%. Periodontal
disease (including gingivitis and loss of
attachment) and calculus accumulation showed consider able reduction (P < 0.01) with any type of treatment. Scaling alone will not reduce the plaque formation for which regular tooth brushing is essential. Yearly brushing
maintain the oral hygiene thereby reducing the preva lence and severity of periodontal disease, plaque, and calculus accumulations. However, more intensive mea sures (quarterly prophylaxis) will further improve periodontal health and reduce calculus
The apical migration of the epithelial attachment can practically be stopped by rendering scaling half yearly, without any instructions in oral hygiene and elimination of dental plaque. ACKNOWLEDGMENTS
We thank Dr. S. P. Ramfjord, Project Adviser, Dr. Norman W. Littleton and Dr. Samuel Kakehashi, Project Officers, National Institute of Dental Research, United States, for their scientific and technical guidance. We are also thankful to Dr. R. M . Mathur, Lecturer in Dentistry, Dr. (Miss) P. Narang, Assistant Research Officer, Mr. P. A. George, Statistician, CDRI and Mrs. K. Puri, Social Worker for their constant help in completion of the work. Acknowledgment is also made of the services of doctors and other personnel who diligently assisted us. REFERENCES
1. Basu, M . K., and Dutta, A . N.: Report on the prevalence of periodontal disease in the adult population of Calcutta by Ramfjord's index. J Indian Dent Assoc, 35: 187, 1963. 2. Chawla, T. N . , Nanda, R. S., and Mathur, M . N.: Prevalence of periodontal disease in urban Lucknow (India) using the Ramfjord technic. J Indian Dent Assoc 35: 151, 1963. 3. Marshall-Day, C. D., and Shourie, K. L.: A roentgenographic study of periodontal disease in India. J. Am. Dent Assoc 39: 572, 1949. 4. Ramfjord, S. P.: The periodontal status of boys of 11-17 years old in Bombay, India. J Periodontol 32: 237, 1961. 5. Nanda, R. S., and Khurana, H . S.: Assessment of gingivitis in children. J Indian Dent Assoc 41:315, 1969.
Procedures in India
6. Lovdal, A., Arno, A . , and Waerhaug, J.: Incidence of clinical manifestations of periodontal disease in light of oral hygiene and calculus formation.J Am Dent Assoc 56:21, 1968. 7. Russell, A. L . , and Ayers, P.: Periodontal disease and socioeconomic status in Birmingham, Alabama. Am J Public Health 50: 206, 1960. 8. Greene, J. C : Periodontal disease in India. Report of an epidemiological study. J Dent Res 39: 302, 1960. 9. O'Leary, T. J . , Shannon, J. L., and Prigmore, J. R.: Clinical and systemic findings in periodontal disease. J Peri odontol 33: 243, 1962. 10. Greene, J. C : Oral hygiene and periodontal disease. Amer. J. Public Health. 53: 913, 1963. 11. Ash, M . M . , Gitlin, B. N . , and Smith, W. A.: Correla tion between plaque and gingivitis. J Periodontol 35:424, 1964. 12. Dunbar, J. B., and Others.: Survey of human periodon tal disease in Iceland. Arch Oral Biol 13: 387, 1968. 13. Sheiham, A.: The prevalence and severity of periodontal disease in surrey school children. Dent Pract 19:232, 1969. 14. Babulal, R., Powell, R. N., and Prophet, A. S.: Hydrolytic enzymes in developing gingival plaque. J Periodontol 41: 87, 1970. 15. Lovdal, A., and Others.: Combined effect of subgingival scaling and controlled oral hygiene on the incidence of gingivi tis. Acta Odontol Scand 19: 537, 1961. 16. Bjorn, H . , and Carlsson, J.: Observations on dental plaque morphogenesis. Odontol Revy 15: 23, 1964. 17. Alexander, A. G.: A study of distribution of supra and subgingival calculus, bacterial plaque and gingival inflamma tion in the mouths of 400 individuals. J Periodontol 42: 21, 1971. 18. Brandtzaeg, P. and Jamison, H . C : The effect of controlled cleansing of teeth on periodontal health and oral hygiene in Norwegian Army recruits. J Periodontol 35: 38, 1964. 19. Löe, H . E., Theilade, E., and Jensen, S. B.: Experimen tal gingivitis in man. J Periodontol 36: 177, 1965. 20. Koch, G . , and Lindhe, J.: The effect of supervised oral hygiene on the gingiva of children. The effect of tooth brushing. Odontol Revy 16: 327, 1965. 21. Saxe, S. R., and Others.: Oral debris, calculus and periodontal disease in beagle dog. Periodontics 5: 217, 1967. 22. Suomi, J. D., et al.: The effect of controlled oral hygiene procedures on the progression of periodontal disease in adults: Results after two years. J Periodontol 40:416, 1969. 23. Suomi, J. D., et al.: The effect of controlled oral hygiene procedures on the progression of periodontal disease in adults: Results after third and final year. J Periodontol42: 152, 1971. 24. Greene, J. C : Oral health care for the prevention and control of periodontal disease—Review of literature. World Workshop in Periodontics sponsored by the American Acad emy of Periodontology and the University of Michigan. 426, 1966. 25. Goldman, H . M . , and Cohen, D. W.: Periodontal therapy, 4th ed., 291, St. Louis, C. V. Mosby Co., 1968. 26. Lightner, et al.: Preventive periodontic treatment proce dures; results over 46 months. J. Periodontol 42: 555, 1971. 27. Ramfjord, S. P.: The periodontal disease index (PDI). / Periodontol 38: 602, 1967.