J Clin Periodontol 2013; 40: 948–954 doi: 10.1111/jcpe.12135

Frequency of mechanical removal of plaque as it relates to gingival inflammation: a randomized clinical trial

Tatiana M. P. Pinto, Guilherme C. de Freitas, Danilo A. Dutra, Karla Z. Kantorski and Carlos H. Moreira Division of Periodontology, Department of Stomatology, Dental School, Federal University of Santa Maria, Santa Maria, Brazil

Pinto TMP, de Freitas GC, Dutra DA, Kantorski KZ, Moreira CH. Frequency of mechanical removal of plaque as it relates to gingival inflammation: a randomized clinical trial. J Clin Periodontol 2013; 40: 948–954. doi: 10.1111/jcpe.12135.

Abstract Aim: This single blind, randomized clinical trial evaluated the relationship between frequency of mechanical removal of plaque (MRP) and gingival inflammation. Materials & Methods: Fifty-two patients (maximum 5% of sites with gingival bleeding and no history of periodontitis) were randomized to different frequencies of MRP: 12, 24, 48 and 72 h. Plaque index (PlI) and gingival index (GI) were evaluated at baseline, 15 and 30 days. Intra- and inter-group differences were determined by repeated measures ANOVA and mixed models ANOVA, respectively, both followed by Tukey’s test. Results: The mean GI between baseline and 30 days remained statistically unchanged in the 12 h (0.51  0.17 versus 0.63  0.23, p = 0.137) and 24 h (0.43  0.19 versus 0.59  0.21, p = 0.052) groups, but increased significantly in the 48 h (0.48  0.18 versus 0.84  0.21, p = 0.001) and 72 h (0.55  0.20 versus 0.94  0.25, p = 0.000) groups. At 30 days, the average percentage of sites with GI scores of 1 and 2 was significantly higher in the 48 and 72 h than in the 12 and 24 h groups (p < 0.05). Conclusions: Frequencies of mechanical removal plaque up to 24 h may prevent an increase in the severity of gingival inflammation over a period of 30 days in patients with no history of periodontitis.

Conflict of interest and source of funding statement The authors declare no conflict of interests related to this study. This study was supported by the Foundation for Post-Graduate Education (CAPES), Brasilia, Brazil. The clinical trial registration number: NCT 016 308 37. Name of the trial register: frequency of oral hygiene.

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Plaque-induced gingivitis is an inflammation caused by the accumulation of microorganisms around the gingival margins (L€ oe et al. 1965, Mariotti 1999). Prevention and treatment of this disease are important, due to its high prevalence in many populations (Albandar et al. 1999, Susin et al. 2004). Plaque-induced gingivitis is considered the most common oral disease in dentate subjects (Mariotti 1999) and the most

Key words: dental plaque; gingivitis; periodontal diseases; toothbrushing Accepted for publication 19 June 2013

frequent type of periodontal disease (Page & Baab 1985). Gingivitis has been implicated as a precursor of periodontitis (Lindhe et al. 1975). A cohort study by Sch€ atzle et al. (2003)in Norway showed that patients who maintained gingival health [gingival index (GI) score 0] over 26 years had an average cumulative clinical attachment loss that was less than 2 mm, whereas sites with bleeding on probing (GI score of 2)

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Frequency of oral hygiene had an average clinical attachment loss greater than 3 mm. Moreover, Lang et al. (2009) observed that teeth associated with inflamed gingiva had a significantly greater risk of tooth loss than teeth associated with healthy or mildly inflamed gingiva. Hugoson et al. (2008) observed that improvements in plaque control reduced the prevalence of both gingivitis and moderate periodontitis in four cross-sectional studies conducted over 30 years in Sweden. Thus, preventing gingivitis may indirectly prevent the loss of tooth support. The main mechanism of gingivitis prevention is self-performed mechanical control of plaque. The effectiveness of this procedure is highly dependent on an individual’s ability to remove plaque from all tooth surfaces and the frequency with which this procedure is performed (Jepsen 1998). One study evaluated the brushing frequency required to maintain gingival health and reported that plaque removal every 48 h prevented gingivitis (Lang et al. 1973), whereas a second study found that a brushing frequency of 24 h, but not 72 h, was consistent with gingival health (Kelner et al. 1974). In these studies, the participants were dental students with knowledge of the aetiology and pathogenesis of gingivitis, and, above all, periodic plaque removal was supervised by a hygienist, resulting in complete removal of plaque at each brushing. The European Workshop on Mechanical Plaque Control (1998) has recognized that meticulous removal of plaque every 24 h would be adequate to prevent gingivitis. However, as most individuals do not completely remove plaque at each brushing, higher frequencies may be beneficial to gingival health (Addy & Adriaens 1998, Jepsen 1998). The American Dental Association (ADA 1995) has recommended that brushing be performed twice a day, a recommendation that appears to be followed by most people. On the basis of earlier studies (Lang et al. 1973, Kelner et al. 1974), we hypothesized that oral hygiene frequencies of 12 and 24 h would not result in an increase in gingival inflammation. The aim of this study was to assess the relationship between the frequency of

mechanical plaque removal and the gingival status of individuals with a maximum of 5% of sites with gingival bleeding at baseline and no history of periodontitis. Materials and Methods Study design

This study was a blind randomized clinical trial. Sample

Potential participants were nondental students, with a minimum age of 18 years, registered at the Federal University of Santa Maria in the city of Santa Maria, RS, Brazil, from May 2011 to December 2011. Subjects who presented papilla filling completely the inter-dental space, with at least 24 teeth, and in the maximum 15% of sites with gingival bleeding after probing (ADA 1998) were eligible. The exclusion criteria were as follows: dental appliance and/or orthodontic fixtures, pregnancy, smoking, xerostomia, diabetes mellitus, psychomotor disturbances, administration of anti-inflammatory or antibiotics agents within the previous 3 months, and periodontitis (Tonetti & Claffey 2005). The subjects were informed of the purpose of the study. Volunteers were interviewed about their health conditions and habits, and were clinically screened to verify eligibility. Sample size

The literature does not establish which parameter(s) and the prevalence and extension that should be present for gingivitis to be considered clinically significant. As a result, we presumed gingival health and gingivitis the presence of gingival bleeding (GI score of 2 or 3) at ≤5% and ≥15% of the sites, respectively. The sample size was calculated considering a difference of 10% in the mean percentages of sites with gingival bleeding between gingival health and gingivitis and a standard deviation of 8.50, and allowing a 20% loss to follow-up. It was defined that 13 subjects per group would be necessary to provide an 80% power with an a of 0.05.

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Ethical considerations

Eligible subjects provided informed consent. This study was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee in Research of the Federal University of Santa Maria, RS, Brazil (CAAE: 0186.0.243.0010). Training of examiners

Two examiners (TMPP and DAMD) were trained to evaluate Plaque Index (PlI) (Silness & L€ oe 1964) and GI (L€ oe 1967) by a single clinician (gold standard) using a periodontal probe with mm markings (Williams, Neumarâ, S~ ao Paulo, SP, Brazil). Pre-experimental period

All participants received required dental treatment and were instructed on the mechanical removal of plaque (MRP) using a toothbrush and dental flossing in areas with visible plaque or gingival bleeding. No specific technique of toothbrushing was preferred. The goal of the pre-experimental period (maximum 30 days) was to ensure gingival health (≤5% of sites with GI = 2). Participants were provided with coronal polishing using a rubao Paulo, ber cup (Microdontâ, S~ SP, Brazil) and abrasive paste (Pumice Stone) at baseline and prior to randomization. Randomization and experimental groups

The randomization of patients was generated by a computer program (Random Allocation Software, version 1.0, available at http://mahmood saghaei.tripod.com/Softwares/randal loc.html), and maintained using opaque envelopes numbered in series. The participants were randomized into four experimental groups, differing in frequency of MRP (every 12, 24, 48, or 72 h). The randomization process was performed by an investigator (GCF) not involved in the clinical evaluations. In addition to receiving instructions regarding the frequency of MRP, the participants received a printout showing the dates to perform oral hygiene. One investigator (GCF) called the participants on days that oral hygiene was not scheduled.

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Experimental period

The experimental period was 30 days. At baseline, each participant received a soft multi-bristle toothbrush (OralBâ Indicatorâ Plus, size 30; Gross-Gerau, Germany), dental floss (Oral-Bâ Essential Floss tarpaulin; Gross-Gerau, Germany) and dentifrice (OralBâ Pro-Health; Gross-Gerau, Germany). To standardize the amount of dentifrice per brushing (0.5 g), subjects were instructed to apply the dentifrice so that it transversely covered the width of the toothbrush bristles at a point. At the end of study, the dentifrice tubes were weighed (Digital Balance Scale Professional-Mini, model 1480, Tanita Corporation, Japan) to evaluate the compliance of subjects with their scheduled brushing frequencies. All subjects received a fluoridated solution (sodium fluoride 0.05%) to use twice a day.

Secondary outcomes included alterations in PlI scores and changes in the average percentage of sites with different GI scores. Statistical analysis

All analyses were performed per protocol. PlI and GI data were reported as means, standard deviations and confidence intervals (95%). Average proportions (%) of sites with different GI scores were calculated. Normal distribution of the data was evaluated by the Shapiro–Wilk test. Intra- and inter-group differences were determined by repeated measures ANOVA and Tukey’s test, and mixed models ANOVA and Tukey’s test, respectively. Trend analysis among groups of the changes (D) in GI from baseline to 30 days was

evaluated through linear regression. All statistical analyses were performed using SPSS, v.13.0 (SPSS Inc., Chicago, IL, USA). Differences were considered statistically significant at p < 0.05. Results

Fifty-two subjects were randomized between July 2011 and January 2012; three, however, did not complete the study (Fig. 1). The experimental period was completed in February 2012. Table 1 summarizes the baseline demographic and clinical characteristics of the included subjects. No statistically differences in the periodontal clinical parameters were observed among the experimental groups at baseline (p > 0.05 for all cases).

Methods of evaluation

PlI (Silness & L€ oe 1964) and GI (L€ oe 1967) were evaluated at baseline, and at 15 and 30 days, at six sites for each tooth (mesiobuccal, buccal, distobuccal, mesiolingual, lingual and distolingual), with the exception of the third molars. Prior to examinations, the surfaces of each tooth were dried with compressed air and cotton rolls. The examiners were blinded to the brushing frequency. An examiner (DAMD) assessed the PlI. The scoring was performed immediately before the scheduled brushing so that the maximum plaque situation was assessed. Then, each subject performed oral hygiene without supervision, and a second examiner (TMPP) evaluated the GI. Different examiners for PlI and GI were used to maintain the blinding of the GI examiner. Upon the completion of study, participants were instructed to return at their habitual frequency of oral hygiene. Adverse effects

Each participant completed a questionnaire regarding changes in their oral tissues at 15 and 30 days. Outcomes

The primary outcome was the increase in mean GI in each group.

Fig. 1. Study flowchart. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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Frequency of oral hygiene Table 2 shows the mean, standard deviation and confidence interval (95% CI) of PlI and GI for all the groups. PlI remained consistent in the 12 h group over the entire experimental period. The other groups showed an increase in PlI for the first 15 days. After this period, the plaque levels remained stable. Mean GI between baseline and 30 days remained statistically unchanged in the 12 h (p = 0.137) and 24 h (p = 0.052) groups, but increased significantly in the 48 h (p = 0.001) and 72 h (p = 0.000) groups. When the sites were categorized according to surface position (free and proximal surfaces), there was no change in the results verified in the whole sample (Table 3). Mixed models ANOVA and Tukey’s test showed that subjects of the 12 h group present a significantly lower GI than subjects in the 72 h group (p = 0.018). No statistical differences were observed among the 12, 24 and 48 h groups, and the 72 h group was consistent only with the 48 h group (p = 0.838). Changes (D) in mean GI from baseline to 30 days were of 0.11 (0.17), 0.16 (0.21), 0.35 (0.22) and 0.30 (0.21) for 12, 24, 48 and 72 h groups, respectively. Trend analysis among groups of the changes (D) in GI from baseline to 30 days is represented in Fig. 2. A linear trend in the GI changes between baseline and 30 days was demonstrated. The GI changes between the 12 and 24 h groups were comparable with the changes verified between 48 and 72 h groups. However, the changes between the 24 and 48 h groups were approximately two times higher. All groups showed a significant reduction in sites with GI scores of 0 between baseline and 30 days, with mean percentage reductions of healthy sites (GI = 0) in the 12, 24, 48 and 72 h groups of 8.8%, 13%, 26.8% and 27.5%, respectively. These sites started to show visual inflammatory changes (score 1) or bleeding upon probing (score 2 or 3). In these four groups, the mean percentages of sites that started to show visual changes were 6.7%, 9.6%, 18.2% and 16.2%, respectively, and the mean percentages that developed gingival bleeding were 2.1%, 3.3%, 8.7% and 11.2%, respectively.

Table 1. Demographic and clinical parameters of the individuals included in this study 12 h group (n = 13) Demographic parameters Age (years)* 23.3  4.47 Gender, n (%) Female 9 (69.2) Male 4 (30.8) Habits, n (%) Daily frequency of toothbrushing Up to three 9 (69.2) More than three 4 (30.8) Dental floss frequency (weekly) Daily 4 (30.8) Up to three* 7 (53.8) Not used 2 (15.4) Visits to the dentist 6 months 2 (15.4) Yearly 6 (46.1) Rarely 5 (38.5) Oral hygiene orientation Yes 12 (92.3) No 1 (7.7) Periodontal parameters PlI* 0.20  0.43 GI* 0.51  0.17 PD* (mm) 1.41  0.14 CAL* (mm) 1.42  0.13

24 h group (n = 13)

48 h group (n = 13)

72 h group (n = 13)

23.53  4.91

22.61  4.75

22.31  3.14

9 (69.3) 4 (30.7)

10 (76.9) 3 (23.1)

10 (76.9) 3 (23.1)

9 (69.2) 4 (30.8)

9 (69.2) 4 (30.8)

11 (84.6) 2 (15.4)

6 (46.2) 6 (46.2) 1 (7.6)

10 (76.9) 2 (15.4) 1 (7.7)

5 (38.5) 5 (38.5) 3 (23)

5 (38.4) 4 (30.8) 4 (30.8)

9 (69.2) 2 (15.4) 2 (15.4)

2 (15.4) 7 (53.8) 4 (30.8)

12 (92.3) 1 (7.7)

11 (84.6) 2 (15.4)

12 (92.3) 1 (7.7)

0.16 0.43 1.43 1.45

   

0.12 0.19 0.17 0.18

0.16 0.51 1.40 1.41

   

0.08 0.18 0.17 0.18

0.20 0.55 1.47 1.48

   

0.10 0.20 0.14 0.14

Oral hygiene orientation: if subjects received professional instruction about their toothbrushing during their life. Periodontal clinical parameter data among groups were compared by ANOVA, Post hoc Tukey. No statistical difference in the periodontal clinical parameter was observed among experimental groups (p > 0.05 for all cases). *Mean  standard deviation. PlI, plaque index; GI, gingival index; PD, probing depth; CAL, clinical attachment level. Table 2. Mean  standard deviation (95% CI) PlI and GI during the experimental period

Baseline PlI GI 15 days PlI GI 30 days PlI GI

12 h group (n = 12)

24 h group (n = 13)

48 h group (n = 11)

72 h group (n = 13)

0.20  0.13 (0.12–0.28) 0.51  0.17 (0.40–0.63)

0.16  0.12 (0.08–0.23) 0.43  0.19 (0.31–0.55)

0.15  0.08 (0.09–0.20) 0.48  0.18 (0.36–0.60)

0.20  0.10 (0.13–0.26) 0.55  0.20 (0.42–0.67)

0.29  0.14 (0.20–0.39) 0.50  0.20 (0.37–0.63)

0.43  0.25* (0.28–0.59) 0.60  0.22 (0.47–0.74)

0.74  0.38* (0.48–0.99) 0.81  0.19† (0.67–0.94)

0.77  0.32* (0.58–0.96) 0.83  0.20† (0.71–0.96)

0.31  0.13 (0.23–0.40) 0.63  0.23 (0.48–0.78)

0.41  0.18* (0.30–0.52) 0.59  0.21 (0.47–0.72)

0.67  0.25* (0.50–0.84) 0.84  0.21† (0.70–0.99)

0.80  0.30* (0.63–1.00) 0.94  0.25† (0.79–1.09)

Repeated measures ANOVA and Post hoc Tukey determined intra-group differences. *Significant difference in relation to baseline for PlI (p < 0.05). † Significant difference in relation to baseline for GI (p < 0.05). CI, confidence interval, PlI, plaque index; GI, gingival index.

Figure 3 shows inter-group comparisons of the average percentage of sites with different GI scores at 30 days. The 48 and 72 h groups

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had significantly lower percentages of healthy sites and a higher percentage of sites with inflammation than did the 12 and 24 h groups. There were

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Table 3. Mean  standard deviation (95% CI) PlI and GI at baseline and at 30 days for free and inter-proximal surfaces

Free surfaces Baseline PlI GI 30 days PlI

12 h group (n = 12)

24 h group (n = 13)

48 h group (n = 11)

72 h group (n = 13)

0.15  0.15 (0.05–0.24) 0.29  0.14 (0.20–0.38)

0.12  0.09 (0.06–0.18) 0.24  0.14 (0.16–0.33)

0.09  0.08 (0.03–0.15) 0.24  0.09 (0.18–0.31)

0.18  0.11 (0.10–0.25) 0.32  0.21 (0.19–0.45)

0.38  0.21* (0.25–0.51) 0.40  0.23 (0.26–0.54)

0.50  0.21* (0.36–0.65) 0.73  0.30† (0.52–0.94)

0.70  0.32* (0.50–0.90) 0.81  0.38† (0.58–1.04)

0.18  0.14 (0.09–0.26) 0.52  0.22 (0.38–0.66)

0.18  0.09 (0.11–0.24) 0.60  0.23 (0.44–0.76)

0.21  0.10 (0.15–0.28) 0.66  0.22 (0.53–0.79)

0.42  0.20* (0.30–0.54) 0.69  0.21 (0.56–0.82)

0.76  0.29* (0.56–0.96) 0.90  0.19† (0.76–1.03)

0.85  0.32* (0.65–1.04) 1.00  0.20† (0.88–1.12)

0.26  0.12* (0.18–0.34) GI 0.42  0.19 (0.30–0.54) Inter-proximal surfaces Baseline PlI 0.23  0.13 (0.14–0.31) GI 0.63  0.20 (0.50–0.76) 30 days PlI 0.34  0.16 (0.24–0.45) GI 0.74  0.26 (0.57–0.90)

Repeated measures ANOVA and Post hoc Tukey determined intra-group differences. *Significant difference in relation to baseline for PlI (p < 0.05). † Significant difference in relation to baseline for GI (p < 0.05). CI, confidence interval, PlI, plaque index; GI, gingival index.

than recommended. At the end of the study, when asked about adherence to the scheduled frequency of toohbrushing, only one subject in the 72 h group reported having performed oral hygiene two times in addition to those recommended. Self-reported oral changes were observed in all groups. The oral changes most cited were gingival bleeding associated with the use of dental floss, bad breath, sensation of teeth covered with plaque and bad taste. These effects were more prevalent in the 48 and 72 h groups than in the 12 and 24 h groups. Discussion

Our results indicate that MRP every 12 or 24 h does not result in a significant increase in gingival inflammation. No significant alterations in the mean GI occurred in the 12 and 24 h groups between baseline and 30 days. The mean GI significantly increased in the 48 and 72 h groups over the same period. In addition, the mean percentage of sites with GI

Fig. 2. Trend analysis of the changes (D) in gingival index from baseline to 30 days through linear regression.

no significant differences between the 12 and 24 h groups in the percentages of sites with GI scores of 0 (p = 0.43), 1 (p = 0.30) and 2 (p = 0.95). No significant differences were observed in the percentages of sites with scores of 0 (p = 0.09) and 1 (p = 0.71) between the 48 and 72 h groups. However, the average percentage of sites with GI scores of 2 was significantly higher in the 72 h group than in the 48 h group (p = 0.05). Considering the dentifrice amount used per brushing (0.5 g), subjects of the 12, 24 , 48 and 72 h groups

Fig. 3. Mean percentage of sites with different gingival index scores at 30 days. *Indicates a significant difference among groups. Mean and standard deviation.

should consume during 30 days 30, 15, 7.5, and 5.5 g, respectively. The average weight of dentifrice consumed during the study by participants in the 12, 24, 48 and 72 h groups was 30.33  8.98, 19.09  7.69, 16.54  8.50 and 9.32  4.86 g, respectively. These results indicated that subjects in the 48 and 72 h groups consumed more dentifrice

scores of 1 and 2 over 30 days was approximately two times higher in the 48 and 72 h groups (26.8% and 27.5%) than in the 12 and 24 h (8.8% and 13%). Within each group, the rate of sites with a GI score 1 was higher than the rate of sites with score 2, indicating that the increase in mean GI in the 48 and 72 h groups was

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Frequency of oral hygiene more related to the appearance of erythema and edema at the gingival margin than to the presence of bleeding. During the development of gingivitis, Lang et al. (1973) showed that visual signs of inflammation, such as edema and erythema preceded gingival bleeding. The results of this study support previous findings, which indicated that MRP every 24 h was compatible with gingival health (Kelner et al. 1974), but did not confirm other results indicating that plaque removal every 48 h was consistent with gingival health (Lang et al. 1973). This divergence might be due to methodological differences. In the study of Lang et al. (1973), brushing was performed with the aid of disclosing solution and supervised by a hygienist, resulting in complete plaque removal. Thus, after each brushing, the plaque formation process was initiated by the adhesion of pioneer species, which may explain why individuals with a 48 h frequency of oral hygiene did not develop gingivitis. In this study, higher mean GI values were observed when compared with the Lang et al. study after 30 days. This divergence most likely occurred due to the lack of professional intervention during toothbrushing. The experimental period of our study (30 days) was considered sufficient to identify changes in plaque and gingivitis in the four groups. In the 48 and 72 h groups, changes in plaque and gingivitis scores at 15 days were maintained at 30 days, confirming that 3 weeks of brushing at a frequency of 72 h was sufficient for the development of gingivitis (Lang et al. 1973). One of the limitations inherent in this study was the absence of compliance of individuals to their randomized frequencies of MRP, especially in the 48 and 72 h groups. To enhance compliance, subjects were informed in writing of the dates they should perform oral hygiene, and were called by one of the researchers on the days not scheduled for oral hygiene. At the end of the 30 days period, the dentifrice tubes were weighed to determine if brushing was performed at the intended frequency, and subjects were asked about compliance. It was found that the average con-

sumption of dentifrice was higher than recommended in the 48 and 72 h groups, indicating that their toothbrushing frequency may have been increased or they used more dentifrice at each brushing. However, our results clearly demonstrated differences between these groups and the 12 and 24 h groups. Thus, even if there were problems with compliance, differences in outcomes were detected. Another limitation of this study is the sample of patients used. University students probably have a better knowledge of oral health than the overall population, especially in a developing country. This can limit the external validity of our results. In the present study, the toothbrushing technique and the duration of each toothbrushing session were not standardized. This probably means each subject continued his/her oral hygiene habits. However, the individuals’ standard oral hygiene was standardized setting a maximum pattern of gingival inflammation at baseline (5% of the sites with bleeding after probing), independent from the brushing technique or the time used for it. Our experimental protocol was designed taking into account that studies about the comparison of the plaque-removing efficacy of different toothbrushing methods showed small or no differences (Jepsen 1998, Egelberg 1999). At 15 and 30 days, subjects in all four groups, especially the lower frequency groups, reported oral changes. However, these adverse effects were not relevant and did not cause individuals to drop out of the study. In our study, subjects with a maximum of 15% of sites with gingival bleeding after probing were eligible. Furthermore, subjects had to have a maximum of 5% of sites with gingival bleeding after probing to initiate the experimental period. Therefore, our results should be interpreted with caution, as they can be attributed only for subjects with adequate oral hygiene and without a history of periodontitis. Finally, we can conclude that a frequency of MRP of up to 24 h does not result in an increase in gingival inflammation in patients with an adequate method of oral hygiene and no history of periodontitis.

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References Addy, M. & Adriaens, P. (1998) Consensus report of group A: epidemiology and etiology of periodontal diseases and the role of plaque control in dental caries. In: Lang, N. P., Attstr€ om, R. & L€ oe, H. (eds). Proceedings of the European Workshop on Mechanical Plaque control, pp. 99–101, Chicago: Quintessence. Albandar, J. M., Brunelle, J. A. & Kingman, A. (1999) Destructive periodontal disease in adults 30 years of age and older in the United States, 1988-1994. Journal of Periodontology 70, 13–29. American Dental Association (ADA) (1995) Oral health topics. Chicago, IL. Available at http:// www.ada.org/2624.aspx. (accessed 20 June 2010). American Dental Association (ADA) (1998) Acceptance program guidelines: toothbrushes. Chicago, IL: Council on Scientific Affairs. Available at http://www.ada.org/1321.aspx. (accessed 20 June 2010). Egelberg, J. (1999) Toothbrushing methods. In: Oral Hygiene Methods, The Scientific Way, 1st edition, pp. 13–19, Malmo¨: OdontoScience. Hugoson, A., Sj€ odin, B. & Norderyd, O. (2008) Trends over 30 years, 1973-2003, in the prevalence and severity of periodontal disease. Journal of Clinical Periodontology 35, 405– 414. Jepsen, S. (1998) The role of manual toothbrushes in effective plaque control: advantages and limitations. In: Lang, N. P., Attstr€ om, R. & L€ oe, H. Proceedings of the European Workshop on Mechanical Plaque control. pp. 121–137, Berlin: Quintessence. Kelner, R. M., Wohl, B. R., Deasy, M. J. & Formicola, A. J. (1974) Gingival inflammation as related to frequency of plaque removal. Journal of Periodontology 45, 303–307. Lang, N. P., Cumming, B. R. & L€ oe, H. (1973) Toothbrushing frequency as it relates to plaque development and gingival health. Journal of Periodontology 44, 396–405. Lang, N. P., Sch€ atzle, M. A. & L€ oe, H. (2009) Gingivitis as a risk factor in periodontal disease. Journal of Clinical Periodontology 36 (Suppl. 10), 3–8. Lindhe, J., Hamp, S.-E. & L€ oe, H. (1975) Plaqueinduced periodontal disease in beagle dogs. A 4-year clinical, roentgenographical and histometrical study. Journal of Periodontal Research 10, 243–255. L€ oe, H. (1967) The gingival index, the plaque index and the retention index systems. Journal of Periodontology 38(Suppl.), 610–616. L€ oe, H., Theilade, E. & Jensen, S. B. (1965) Experimental gingivitis in man. Journal of Periodontology 36, 177–187. Mariotti, A. (1999) Dental plaque-induced gingival diseases. Annals of Periodontology 4, 7–19. Page, R. C. & Baab, D. A. (1985) A new look at the etiology and pathogenesis of early-onset periodontitis. Cementopathia revisited. Journal of Periodontology 56, 748–751. Sch€ atzle, M., L€ oe, H., B€ urgin, W., Anerud, A., Boysen, H. & Lang, N. P. (2003) Clinical course of chronic periodontitis. I. Role of gingivitis. Journal of Clinical Periodontology 30, 887–901. Silness, J. & L€ oe, H. (1964) Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal conditions. Acta Odontologica Scandinavica 22, 121–135. Susin, C., Dalla Vecchia, C. F., Oppermann, R. V., Haugejorden, O. & Albandar, J. M. (2004)

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Periodontal attachment loss in an urban population of Brazilian adults: effect of demographic, behavioral, and environmental risk indicators. Journal of Periodontology 75, 1033– 1041. Tonetti, M. S. & Claffey, N.; European Workshop in Periodontology group C (2005) Advances in the progression of periodontitis

Clinical Relevance

Scientific rationale for the study: Toothbrushing remains the principal measure for maintaining oral health. Principal findings: No statistical differences were observed in the mean

and proposal of definitions of a periodontitis case and disease progression for use in risk factor research. Group C consensus report of the 5th European Workshop in Periodontology. Journal of Clinical Periodontology 32(Suppl. 6), 210–213.

GI between baseline and 30 days in the 12 and 24 h groups. A significant increase was verified in the 48 and 72 h groups. Practical implications: For patients with a maximum of 5% of sites with gingival bleeding after probing at

Address: Karla Zanini Kantorski Rua Marechal Floriano 1184, 7º andar Periodontia, 97015-372 Santa Maria, RS Brazil E-mail: [email protected]

baseline and no history of periodontitis, frequencies of mechanical removal plaque every 12 or 24 h may prevent an increase in the severity of gingival inflammation over a period of 30 days.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Frequency of mechanical removal of plaque as it relates to gingival inflammation: a randomized clinical trial.

This single blind, randomized clinical trial evaluated the relationship between frequency of mechanical removal of plaque (MRP) and gingival inflammat...
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