Oral hygiene compliance and gingivitis expression in cigarette smokers JAN BERGSTROM Department of Periodontology, School of Dentistry, Karolinska Institutet, Stockholm, Sweden
Bergstrom J: Oral hygiene compliance and gingivitis expression in cigarette smokers. Scand J Dent Res 1990: 98: 497-503. Abstract — The compliance with an oral hygiene intervenlioo program and its effect on oral cleanliness and gingivitis was studied in smokers and non-smokers. The study group represented patients with regular dental attendance. It comprised 68 padents 21-60 yr of age, including 28 habitual smokers. The program included toothbrushing with an electric toothbrush for 12 months. Oral cleanlines,& was evaluated according to a percentage plaque index and gingivitis according to the percentage of bleeding sites. The compliance with the orai hygiene program was very high among smokers and non-smokers. Plaque index at baseline was very similar in smokers and non-smokers and remained .so during the conrse of the investigation. Following the introduction of the oral hygiene program, plaque index decreased in both groups, and there were no statistically significant differences between the two groups. In spite of the similarity in plaque index, gingival bleeding was significantly lower in smokers than non-smokers. The resnlts suggESt that smokers and non-smokers do not differ with respect to habitual oral hygiene or compliance with hygiene programs. In smokers, however, the clinical gingiwtis expression in response to plaque is suppressed. Key words: gingivitis; oral hygiene; smoking. J. Bergstrom, Department of Periodontology, School of Dentistry, Karolinska Institutet, Box 4064, 14104 Huddinge, Sweden. Accepted for publication 22 May 1990.
Glinical experience has long considered smoking to have a negative infltience on periodontal health. Epidemiologic and clinical research seem to confirm such a view, indieating more prevalent or severe disease io smokers (1—3). The association between smoking and periodontal disease is complicated by the possible influence of orai hygiene factors. Although the literature is in-
conclusive on this point, some observations indicate an inferior oral hygiene standard on the part of the smokers. The confounding itifluence of oral hygiene makes it difficult to discern the effect of smoking itself from that of plaque infection. The idea that the increased morbidity in smokers merely reflects a concotnitant elevated plaque level has recently been challenged (4, 5).
498
BERGSTROM
Smoking can facilitate plaque deposition and/or render plaque removal difficult. Current knowledge about the influence of smoking on plaque formation does not support the hypothesis that smoking interferes with the naturally occurring plaque accumulation rate on tooth surfaces (6—9). There seems to be little evidence that smoking makes oral cleanliness more difficult (10, 12). It remains a possibility that smokers care less about their oral health and therefore may b.e less modvated to keep up a satisfactory oral hygiene standard. Although much research has been devoted to personality and smoking, the knowledge about the relationship between orai hygiene behavior and smoking is limited (13). In fact, only few studies deal with the compliance with oral hygiene regimes or periodontal maintenance programs, and none of them considers the influence of smoking (14). The aim ofthe present study, therefore, was to elucidate whether the habitual oral hygiene standard and the compliance to a novel oral hygiene regime are different in smokers and non-smokers. Recent observadons of a lowered gingivitis expression in smokers concomitant with a greater severity of destructive periodontitis are intriguing (3-5, 15, 16). The present study, therefore, also aimed at investigating the influence of cigarette smoking on the cKnical gingivitis expression under experimental oral hygiene control.
Material and methods
smokers and non-smokers was 43.6 + 9.3 yr and 42.4+ 12.9 yr, respectively. The age difference between smokers and non-smokers was not statistically significant for the total sample or for the two observer specific subgroups. The- current average consumption of the smokers was 14.6 cigarettes/day, 11 smoking 1—10 cigarettes/day, 8 smoking 11-15 cigarettes/day and 9 smoking more than 15' cigarettes/day. The mean ( + SD) smoking duration was 20.3 ± 9.5 yr. There were no significant differences with respect to consumption or duration between the two observer specific subgroups. Plaque was scored for ail mesial,, distal, lingual, and buccal surfaces in the patient. Prior to recording of plaque the teeth were stained with plaque disclosing solution (Djaplac, Astra, Sweden). The number of surfaces exhibiting plaque was taken as percentage of total. Plaque was scored immediately before the beginning of the experiment (baseline) and after 1, 3, and 12 months during the experimental period. The gingival inflammation was expressed in terms of gingivai bleeding on probing. The mesial, distal, lingual, and buccal sites of all teeth were probed for bleeding witb a periodontal probe using gentle pressure. Probing was done to the bottom of the probeable pocket. The relative frequency of bleeding sites was used as the measure of gingivitis in the patient. Gingimtis was scored at baseline and after 3 and 12 months. The experiment involved oral hygiene intervention with an electrical toothbrush (Braun D3). The patients were introduced to the experimental schedule and instructed in the use ofthe toothbrush. They also received a written manual on the usage of the toothbrush. All clinical examinations were performed by two dental hygienists, each hygienist examining all patients of the same group. After an initial joint calibration procedure the hygienists examined their patients independently. Emphasis was put on standardizing the probng pressure as close as possible to 50 g. The examiners were left unaware that smoking was one aspect of the study. The smoking history ofthe patient was collected a posteriori. By and large the two observer specific groups were ofthe same magnitude, smokers contributing 40% and 42%, respectively.
78 patients, of whicb 29 were men and 49 women, volunteered to take part in the study. They were all regularly attending one of two private dental clinics in Stockholm. The patients were selected consecutively from the waiting lists. A few patients had been treated for slight to moderate periodontitis and were on a maintenance schedule. Most patients, bowever, did not have any periodontal problems. 28 patients were habitual smokers, whereas 40 had never STATISTICS smoked. 10 ex-smokers were excluded. The present study group according to age, gender, and smoking Two-tailed significance analysis of dififerences beis presented in Table 1. The mean ( + SD) age of tween snuokers and non-smokers with regard to
ORAL HYGIENE, GINGIVITIS AND SMOKING
499
Table 1 Study group. Distribution according to age, gender and smoking
21-40 yr
41-60 yr
Men
Women
Smoker Non-smoker
6 10
6 11
Total
16
17
mean bleeding occurrence and mean plaque index was performed with Student's t distribution. The patient constituted the analytical unit. The regression of gingiv,al bleeding on plaque was studied by means of least squares linear regression analysis.
Men
Total
Women
Men
Women
6 7
10 12
12 17
16 23
13
22
29
39
time,. The differences between groups, however, were not statistically significant either at baseline or at any of the other examinations. A similar pattern of plaque reduction over time was observed in both age and observer specific subgroups (Tables 2 and 3).
Results ORAL HYGIENE All smoker and non-smoker patients adhered to the intervention program and showed up at all examinations during the course of the investigation. Mean plaque index at baseline was 47.8% and 51.0% for smokers and nons,mokers, respectively. At the final observation the tneans were 22.7% and 27.0%, respectively. For both smoking groups there was a significant reduction of plaque over
GINGIVITIS EXPRESSION Mean gingiva! bleeding frequency at baseline was 16'.7%, in smokers and 3'0.2% iti non-smokers. The difference was statistically significant (r=2.99, P0.05 >0.05 >0.05
3 months 21^0 41-60 Total
17.9 19.9 19.0
3.54 2.31 1.98
22.7 25.3 23.7
2.75 3.87 2.22
1.07 1.20 1,56
> 0.05 > 0.05
12 months 21-40 41-60 Total
24.6 21.5 22,7
4.60 2.69 2.39
26.9 27.1 27.0
4.02 5.58 3.24
0.37 0:90 1.06
SEM
t
P
>0.05 >0.05 > 0.05
>0.05
500
BERGSTROM Table 3
Plaque index (%) at baseline, 3 months and 12 months. Mean + SEM according to examiner and smoking
Smoker
Non-smoker
Exatniner
Meati
SEM
Mean
SEM
t
P
Baseline 1 2
49.7 43.5
3.90 6.07
53.2 48.7
5.40 6.35
0.50 0.36
>0.05 >0.05
20.5 17.1.
2.7! 2.90
27.0 20.3
2.75 3.41
1.68 0.71
>0.05 >0.05
25.4 J9.6
3.42 3.21
32.2 22.0
4.74 4.24
1.15 0.45
> 0.05 >0.05
3 months 1 2
12 months 1 2
3.54 and 3.62, respectively, P
Bergstrom J: Oral hygiene compliance and gingivitis expression in cigarette smokers. Scand J Dent Res 1990: 98: 497-503. Abstract — The compliance with an oral hygiene intervenlioo program and its effect on oral cleanliness and gingivitis was studied in smokers and non-smokers. The study group represented patients with regular dental attendance. It comprised 68 padents 21-60 yr of age, including 28 habitual smokers. The program included toothbrushing with an electric toothbrush for 12 months. Oral cleanlines,& was evaluated according to a percentage plaque index and gingivitis according to the percentage of bleeding sites. The compliance with the orai hygiene program was very high among smokers and non-smokers. Plaque index at baseline was very similar in smokers and non-smokers and remained .so during the conrse of the investigation. Following the introduction of the oral hygiene program, plaque index decreased in both groups, and there were no statistically significant differences between the two groups. In spite of the similarity in plaque index, gingival bleeding was significantly lower in smokers than non-smokers. The resnlts suggESt that smokers and non-smokers do not differ with respect to habitual oral hygiene or compliance with hygiene programs. In smokers, however, the clinical gingiwtis expression in response to plaque is suppressed. Key words: gingivitis; oral hygiene; smoking. J. Bergstrom, Department of Periodontology, School of Dentistry, Karolinska Institutet, Box 4064, 14104 Huddinge, Sweden. Accepted for publication 22 May 1990.
Glinical experience has long considered smoking to have a negative infltience on periodontal health. Epidemiologic and clinical research seem to confirm such a view, indieating more prevalent or severe disease io smokers (1—3). The association between smoking and periodontal disease is complicated by the possible influence of orai hygiene factors. Although the literature is in-
conclusive on this point, some observations indicate an inferior oral hygiene standard on the part of the smokers. The confounding itifluence of oral hygiene makes it difficult to discern the effect of smoking itself from that of plaque infection. The idea that the increased morbidity in smokers merely reflects a concotnitant elevated plaque level has recently been challenged (4, 5).
498
BERGSTROM
Smoking can facilitate plaque deposition and/or render plaque removal difficult. Current knowledge about the influence of smoking on plaque formation does not support the hypothesis that smoking interferes with the naturally occurring plaque accumulation rate on tooth surfaces (6—9). There seems to be little evidence that smoking makes oral cleanliness more difficult (10, 12). It remains a possibility that smokers care less about their oral health and therefore may b.e less modvated to keep up a satisfactory oral hygiene standard. Although much research has been devoted to personality and smoking, the knowledge about the relationship between orai hygiene behavior and smoking is limited (13). In fact, only few studies deal with the compliance with oral hygiene regimes or periodontal maintenance programs, and none of them considers the influence of smoking (14). The aim ofthe present study, therefore, was to elucidate whether the habitual oral hygiene standard and the compliance to a novel oral hygiene regime are different in smokers and non-smokers. Recent observadons of a lowered gingivitis expression in smokers concomitant with a greater severity of destructive periodontitis are intriguing (3-5, 15, 16). The present study, therefore, also aimed at investigating the influence of cigarette smoking on the cKnical gingivitis expression under experimental oral hygiene control.
Material and methods
smokers and non-smokers was 43.6 + 9.3 yr and 42.4+ 12.9 yr, respectively. The age difference between smokers and non-smokers was not statistically significant for the total sample or for the two observer specific subgroups. The- current average consumption of the smokers was 14.6 cigarettes/day, 11 smoking 1—10 cigarettes/day, 8 smoking 11-15 cigarettes/day and 9 smoking more than 15' cigarettes/day. The mean ( + SD) smoking duration was 20.3 ± 9.5 yr. There were no significant differences with respect to consumption or duration between the two observer specific subgroups. Plaque was scored for ail mesial,, distal, lingual, and buccal surfaces in the patient. Prior to recording of plaque the teeth were stained with plaque disclosing solution (Djaplac, Astra, Sweden). The number of surfaces exhibiting plaque was taken as percentage of total. Plaque was scored immediately before the beginning of the experiment (baseline) and after 1, 3, and 12 months during the experimental period. The gingival inflammation was expressed in terms of gingivai bleeding on probing. The mesial, distal, lingual, and buccal sites of all teeth were probed for bleeding witb a periodontal probe using gentle pressure. Probing was done to the bottom of the probeable pocket. The relative frequency of bleeding sites was used as the measure of gingivitis in the patient. Gingimtis was scored at baseline and after 3 and 12 months. The experiment involved oral hygiene intervention with an electrical toothbrush (Braun D3). The patients were introduced to the experimental schedule and instructed in the use ofthe toothbrush. They also received a written manual on the usage of the toothbrush. All clinical examinations were performed by two dental hygienists, each hygienist examining all patients of the same group. After an initial joint calibration procedure the hygienists examined their patients independently. Emphasis was put on standardizing the probng pressure as close as possible to 50 g. The examiners were left unaware that smoking was one aspect of the study. The smoking history ofthe patient was collected a posteriori. By and large the two observer specific groups were ofthe same magnitude, smokers contributing 40% and 42%, respectively.
78 patients, of whicb 29 were men and 49 women, volunteered to take part in the study. They were all regularly attending one of two private dental clinics in Stockholm. The patients were selected consecutively from the waiting lists. A few patients had been treated for slight to moderate periodontitis and were on a maintenance schedule. Most patients, bowever, did not have any periodontal problems. 28 patients were habitual smokers, whereas 40 had never STATISTICS smoked. 10 ex-smokers were excluded. The present study group according to age, gender, and smoking Two-tailed significance analysis of dififerences beis presented in Table 1. The mean ( + SD) age of tween snuokers and non-smokers with regard to
ORAL HYGIENE, GINGIVITIS AND SMOKING
499
Table 1 Study group. Distribution according to age, gender and smoking
21-40 yr
41-60 yr
Men
Women
Smoker Non-smoker
6 10
6 11
Total
16
17
mean bleeding occurrence and mean plaque index was performed with Student's t distribution. The patient constituted the analytical unit. The regression of gingiv,al bleeding on plaque was studied by means of least squares linear regression analysis.
Men
Total
Women
Men
Women
6 7
10 12
12 17
16 23
13
22
29
39
time,. The differences between groups, however, were not statistically significant either at baseline or at any of the other examinations. A similar pattern of plaque reduction over time was observed in both age and observer specific subgroups (Tables 2 and 3).
Results ORAL HYGIENE All smoker and non-smoker patients adhered to the intervention program and showed up at all examinations during the course of the investigation. Mean plaque index at baseline was 47.8% and 51.0% for smokers and nons,mokers, respectively. At the final observation the tneans were 22.7% and 27.0%, respectively. For both smoking groups there was a significant reduction of plaque over
GINGIVITIS EXPRESSION Mean gingiva! bleeding frequency at baseline was 16'.7%, in smokers and 3'0.2% iti non-smokers. The difference was statistically significant (r=2.99, P0.05 >0.05 >0.05
3 months 21^0 41-60 Total
17.9 19.9 19.0
3.54 2.31 1.98
22.7 25.3 23.7
2.75 3.87 2.22
1.07 1.20 1,56
> 0.05 > 0.05
12 months 21-40 41-60 Total
24.6 21.5 22,7
4.60 2.69 2.39
26.9 27.1 27.0
4.02 5.58 3.24
0.37 0:90 1.06
SEM
t
P
>0.05 >0.05 > 0.05
>0.05
500
BERGSTROM Table 3
Plaque index (%) at baseline, 3 months and 12 months. Mean + SEM according to examiner and smoking
Smoker
Non-smoker
Exatniner
Meati
SEM
Mean
SEM
t
P
Baseline 1 2
49.7 43.5
3.90 6.07
53.2 48.7
5.40 6.35
0.50 0.36
>0.05 >0.05
20.5 17.1.
2.7! 2.90
27.0 20.3
2.75 3.41
1.68 0.71
>0.05 >0.05
25.4 J9.6
3.42 3.21
32.2 22.0
4.74 4.24
1.15 0.45
> 0.05 >0.05
3 months 1 2
12 months 1 2
3.54 and 3.62, respectively, P
