Improvement of oral hygiene in patients with rheumatoid arthritis
Helge Risheim\ Vibeke Kjaerheim' and Pal Arneberg^ 'Department of Cariology and 'School of Dental Hygiene, Dental Faculty, University o' Oslo, Oslo, Norway
Risheim H, Kjcerheim V, Arneberg P: Improvement of oral hygiene in patients wilh rheumatoid arthritis. Seand J Dent Res 1992: 100: 172-5.
Programs in power toothbrushing, manual toothbrushing with conventional fluoride toothpaste and with a chlorhexidine/fluoride gel has been evaluated for plaque removal in an observer blind cross-over clinical trial on 14 rheumatoid arthritis patients. All three regimes lead to considerable improvement in oral hygiene. The use of an electric toothbrush was slightly more effective than a manual brush. Brushing with a chlorhexidine/fluoride gel gave the best results, but its clinical use is limited by unacceptable taste, discoloration and possibly adverse soft tissue effects.
Daily plaque removal should be the basis of rational prevention of caries (1) and periodontal disease (2), Disease and infirmity may prevent the undertaking of simple manual tasks such as toothbrushing. In subjects suffering from rheumatoid arthritis (RA), swelling, and tenderness of the joints may impair manual dexterity. The disease affects women two to three times more often than men, and often starts in the fourth or fifth decade (3), In a recent study (4) 3 out of 4 subjects with RA reported constant or periodic problems with performing oral hygiene. Affection of the salivary glands often reduce salivary flow in this group of patients (5) and make them susceptible to caries (6), Good oral hygiene is therefore of particular value. The use of an electric toothbrush requires less manual dexterity and strength than the use ofa manual brush (7), and may therefore be useful for RApatients. However, most studies indicate little difference between manual and power brushing (for review 8), The plaque inhibiting effect of chlorhexidine has been clearly documented (9), and may, in combination with fluoride (10), provide an important caries preventive potential in RA-patients, This clinical trial was designed to test the plaque reducing effect of three oral hygiene regimes in RApatients by: 1: Instruction in traditional manual toothbrushing, 2: Instruction in the use of an electric toothbrush, 3: Instruction in manual brushing using a fluoride/chlorhexidine gel as a toothpaste. Material and methods study group
Ten out of 33 RA patients from the Oslo region reporting problems with daily oral hygiene in a
Key words; chlorhexidine; oral hygiene; rheumatoid arthritis; toothbrushing H. Risheim, Department of Cariology, Dental Faculty, University of Oslo, PO Box 1109, Blindern, N-0317 Oslo 3, Norway Accepted for publication 30 June 1991
dental health survey (4) volunteered for the study. Seven additional volunteers were recruited among RA patients visiting the rheumatism hospitals in Oslo, Two subjects had less than 10 surfaces with a continuous rim of plaque along the gingival margin (score 2) and were excluded for this reason. Another withdrew because she did not want to change her method of brushing. Eleven women and three men, all suffering from RA, completed the study. The mean age ofthe participants was 50 yr (S,D, ± 7yr).
study design and experimental regimens
At an initial screening, plaque scores were recorded as described below and the subjects were informed about the purpose of the study. A 2-week control period in which the subjects were told to continue brushing their teeth as usual were then followed by three consecutive 2-week experimental periods in an observer blind randomized sequence. All registrations were made by the same examiner (H.R.). At the start of each control and experimental period, the vestibuiar and lingual surfaces of the teeth were professionally cleaned with a soft rotating rubber cup and pumice. Interdental cleaning was not performed. The subjects were given instructions as described below and their compliance was supervised by the instructor. Experimental regimes: 1. Manual toothbrushing - A multitufted soft brush, with a 2,4 x 1 cm brush head and a slightly contra angled handle (Compact soft, Jordan, Oslo, Norway) was used together with the subject's habitual dentifrice. The subjects were instructed in the horizontal brushing technique, with emphasis on short
OHI in rheumatic patients brushing movements and correct positioning ofthe brush head in the different areas of the mouth, 2. Electric toothbrushing - A rechargeable electric toothbrush with a 1,9 x 0,8 cm soft brush head performing combined vertical and horizontal brush movements at a frequency of 3300 per min (Braun dental d3) was used with the subject's habitual dentifrice. The subjects were instructed in correct positioning of the brush in the different areas of the mouth, and given the manufacturers' written instructions, 3. Manual toothbrushing with a fluoride/chlorhexidine gel. Toothbrush and instructions as in regime 1, The gel contained 0,2% sodium fluoride, 1% chlorhexidine digluconate, 3% carboxymethylcellulose and flavor, but no abrasives. Examination parameters
At the end of the control and experimental periods, the buccal and lingual surfaces of all teeth, except third molars, were coated with a disclosing solution (Rondell, Astra, Sweden), The extent of plaque was recorded according to a modifled Greene & Vermillion index (the original score 1 subdivided in two scores): Score 0, No plaque disclosed on the tooth surface. Score 1, Isolated areas of plaque covering less than 1 /3 of the tooth surface but without a continuous rim of plaque adjacent to the gingival margin. Score 2, Areas of plaque covering less than 1/3 of the tooth surface, forming a continuous rim of plaque adjacent to the gingival margin. Score 3. Plaque deposits covering more than 1/3 ofthe tooth surface adjacent to the gingival margin and less than 2/3 of the tooth surface. Score 4, Plaque covering more than 2/3 of the tooth surface. Mobility of the shoulder-, elbow-, wrist-, and flnger-joints was evaluated by the examiner as normal, moderately impaired, or strongly impaired. For proportions of plaque free surfaces Wilcoxon paired sum rank test was used for statistical testing, and two-tailed t-tests were used in the analysis of mean plaque scores. The significance level of the tests was set to P
Helge Risheim\ Vibeke Kjaerheim' and Pal Arneberg^ 'Department of Cariology and 'School of Dental Hygiene, Dental Faculty, University o' Oslo, Oslo, Norway
Risheim H, Kjcerheim V, Arneberg P: Improvement of oral hygiene in patients wilh rheumatoid arthritis. Seand J Dent Res 1992: 100: 172-5.
Programs in power toothbrushing, manual toothbrushing with conventional fluoride toothpaste and with a chlorhexidine/fluoride gel has been evaluated for plaque removal in an observer blind cross-over clinical trial on 14 rheumatoid arthritis patients. All three regimes lead to considerable improvement in oral hygiene. The use of an electric toothbrush was slightly more effective than a manual brush. Brushing with a chlorhexidine/fluoride gel gave the best results, but its clinical use is limited by unacceptable taste, discoloration and possibly adverse soft tissue effects.
Daily plaque removal should be the basis of rational prevention of caries (1) and periodontal disease (2), Disease and infirmity may prevent the undertaking of simple manual tasks such as toothbrushing. In subjects suffering from rheumatoid arthritis (RA), swelling, and tenderness of the joints may impair manual dexterity. The disease affects women two to three times more often than men, and often starts in the fourth or fifth decade (3), In a recent study (4) 3 out of 4 subjects with RA reported constant or periodic problems with performing oral hygiene. Affection of the salivary glands often reduce salivary flow in this group of patients (5) and make them susceptible to caries (6), Good oral hygiene is therefore of particular value. The use of an electric toothbrush requires less manual dexterity and strength than the use ofa manual brush (7), and may therefore be useful for RApatients. However, most studies indicate little difference between manual and power brushing (for review 8), The plaque inhibiting effect of chlorhexidine has been clearly documented (9), and may, in combination with fluoride (10), provide an important caries preventive potential in RA-patients, This clinical trial was designed to test the plaque reducing effect of three oral hygiene regimes in RApatients by: 1: Instruction in traditional manual toothbrushing, 2: Instruction in the use of an electric toothbrush, 3: Instruction in manual brushing using a fluoride/chlorhexidine gel as a toothpaste. Material and methods study group
Ten out of 33 RA patients from the Oslo region reporting problems with daily oral hygiene in a
Key words; chlorhexidine; oral hygiene; rheumatoid arthritis; toothbrushing H. Risheim, Department of Cariology, Dental Faculty, University of Oslo, PO Box 1109, Blindern, N-0317 Oslo 3, Norway Accepted for publication 30 June 1991
dental health survey (4) volunteered for the study. Seven additional volunteers were recruited among RA patients visiting the rheumatism hospitals in Oslo, Two subjects had less than 10 surfaces with a continuous rim of plaque along the gingival margin (score 2) and were excluded for this reason. Another withdrew because she did not want to change her method of brushing. Eleven women and three men, all suffering from RA, completed the study. The mean age ofthe participants was 50 yr (S,D, ± 7yr).
study design and experimental regimens
At an initial screening, plaque scores were recorded as described below and the subjects were informed about the purpose of the study. A 2-week control period in which the subjects were told to continue brushing their teeth as usual were then followed by three consecutive 2-week experimental periods in an observer blind randomized sequence. All registrations were made by the same examiner (H.R.). At the start of each control and experimental period, the vestibuiar and lingual surfaces of the teeth were professionally cleaned with a soft rotating rubber cup and pumice. Interdental cleaning was not performed. The subjects were given instructions as described below and their compliance was supervised by the instructor. Experimental regimes: 1. Manual toothbrushing - A multitufted soft brush, with a 2,4 x 1 cm brush head and a slightly contra angled handle (Compact soft, Jordan, Oslo, Norway) was used together with the subject's habitual dentifrice. The subjects were instructed in the horizontal brushing technique, with emphasis on short
OHI in rheumatic patients brushing movements and correct positioning ofthe brush head in the different areas of the mouth, 2. Electric toothbrushing - A rechargeable electric toothbrush with a 1,9 x 0,8 cm soft brush head performing combined vertical and horizontal brush movements at a frequency of 3300 per min (Braun dental d3) was used with the subject's habitual dentifrice. The subjects were instructed in correct positioning of the brush in the different areas of the mouth, and given the manufacturers' written instructions, 3. Manual toothbrushing with a fluoride/chlorhexidine gel. Toothbrush and instructions as in regime 1, The gel contained 0,2% sodium fluoride, 1% chlorhexidine digluconate, 3% carboxymethylcellulose and flavor, but no abrasives. Examination parameters
At the end of the control and experimental periods, the buccal and lingual surfaces of all teeth, except third molars, were coated with a disclosing solution (Rondell, Astra, Sweden), The extent of plaque was recorded according to a modifled Greene & Vermillion index (the original score 1 subdivided in two scores): Score 0, No plaque disclosed on the tooth surface. Score 1, Isolated areas of plaque covering less than 1 /3 of the tooth surface but without a continuous rim of plaque adjacent to the gingival margin. Score 2, Areas of plaque covering less than 1/3 of the tooth surface, forming a continuous rim of plaque adjacent to the gingival margin. Score 3. Plaque deposits covering more than 1/3 ofthe tooth surface adjacent to the gingival margin and less than 2/3 of the tooth surface. Score 4, Plaque covering more than 2/3 of the tooth surface. Mobility of the shoulder-, elbow-, wrist-, and flnger-joints was evaluated by the examiner as normal, moderately impaired, or strongly impaired. For proportions of plaque free surfaces Wilcoxon paired sum rank test was used for statistical testing, and two-tailed t-tests were used in the analysis of mean plaque scores. The significance level of the tests was set to P
