Maintenance of gingival health post professional care

Abstract

Oral hygiene habits are strongly associated with general health behaviours; good oral self care should result in good dental health. Clinical dental hygiene services have limited long range probability of success if the patient is not diligent in the daily procedures of personal care to remove and control dental plaque. Therefore, it is important to help make the individual aware of their own ability to control and maintain good oral health after a dental prophylaxis through oral care instruction and the use of select antimicrobials to maintain the gingival health. This paper reviews the evidence outlining the relative roles of prophylaxis and correct oral self-care in maintaining gingival health.

MAINTENANCE OF GINGIVAL HEALTH

It is generally accepted that gingivitis is a reversible inflammation of the superficial gingiva caused by the accumulation of biofilm colonising bacteria at the gingival margin. Plaque induced gingivitis in the absence of clinical attachment loss is the most common form of periodontal disease affecting 50–90% of the population1., 2.. As early as 1965, the importance of plaque in the establishment of gingivitis was identified³ and it was demonstrated that a thorough tooth cleaning could result in the re-establishment of gingival health. Based on this it is recognised that plaque control is an integral part of maintaining the gingival health. In the 1970s, Axelsson and Lindhe4., 5., 6. reported the effects of performing professional prophylaxis with oral care instruction 20 times/year over a period of two years on children age 7–14 years. This regime resulted in a significant increase in the frequency of a score of 0 in the Löe Silness Gingival Index⁷and a disappearance of the score of 2 in this population (described as glazing, redness or bleeding on pressure); 70% of all sites examined in the test population were scored as 0. Conversely, in those children who did not receive the instruction and biweekly dental prophylaxis there was an increase in the individual scores of 2. The difference in the gingival index between groups after two years was highly statistically significant at P < 0.0014., 6.. A second study by Badersten et al.⁸ incorporated monthly prophylaxes administered to a test group of children versus a group which received no prophylaxis over a period of a year. Both groups performed classroom brushing. A statistically significant decrease in gingivitis was reported for the group which received the monthly prophylaxis as compared to the group that received instruction only.

Conversely, Suomi et al.⁹ studied young male cadets receiving dental prophylaxes at varying frequencies over a three year period with no additional oral hygiene instructions. These were as follows: Group 1 yearly cleanings, Group 2 cleanings every six months and Group 3 cleanings every four months. After three years all subjects were re-examined for gingival health. The results indicated that the group receiving more frequent prophylaxes had only a trend toward less gingival inflammation than those groups receiving less frequent cleanings. The conclusion of these authors was that “although the value of periodic thorough removal of supra- and subgingival calculus deposits and plaque by the dentist or dental hygienist cannot be minimized it is increasingly apparent that the daily removal of plaque is the single most important step for good periodontal health”. Numerous studies have been conducted confirming the effects of clinical dental hygiene services but have indicated that they have limited long range probability of success if the patient does not cooperate in the daily procedures of care. Educational and clinical services therefore are mutually dependent in the total dental hygiene care of the patient. Clinical studies have repeatedly demonstrated that removing and subsequently preventing the re-formation of plaque are important elements in maintaining health and controlling periodontal disease. Dental hygiene services have been rendered to patients to include but not limited to patient/client education, supra- and subgingival scaling and polishing as appropriate which has been shown to reduce gingivitis⁸.

While conducting a study designed to train examiners in using gingival indices Sturzenberger et al.¹⁰ reported that within 7–10 days after a dental prophylaxis one can see the greatest decrease in gingival inflammation. Clinical gingival health is identified by minimal sulcus depth, stippling, gingival colour of pale or coral pink with a knife edge that adapts closely around the tooth with no evidence of bleeding when probed.¹¹ These criteria are incorporated into various gingival indices which have been used in trials to measure the changes resulting from a dental prophylaxis.

Svatun et al.12., 13. reported that consistent daily plaque control was necessary to maintain gingival health post a dental prophylaxis. It was demonstrated that in a population of 102 dental nurses with mild to moderate gingivitis (mean number of bleeding sites for the groups was approximately 25) who were given professional dental prophylaxis and oral hygiene instruction that all but one subject were able to achieve excellent gingival health in four weeks. Excellent gingival health was described as fewer than six bleeding sites. Post this phase, subjects were divided into two groups: one receiving a test dentifrice (zinc citrate/triclsoan) the other receiving a placebo. Those using the test dentifrice were able to maintain a statistically significantly superior level of gingival health than those using a placebo dentifrice. The study design employed a dental prophylaxis at baseline followed by a four-week pre-experimental phase of oral hygiene instruction to bring subjects to a pre-determined level of gingival health based on number of bleeding sites. This study design had been designed specifically to capture the maintenance of gingival health.

CURRENT PRODUCT SCIENCE AND TESTING

As discussed previously, maintaining the levels of health achieved through professional cleaning and instruction can be assisted through chemical plaque control. In the studies of Svatun et al12., 13. the population was a group of ‘young health conscious individuals’ who ultimately used a test dentifrice to help maintain gingival health. As Pizzey et al.¹⁴ states ‘most of the population fail to carry out meticulous oral hygiene, and thus the incorporation of additional antimicrobial actives in toothpastes as an adjunct to mechanical plaque control has been proposed.15., 16. This journal supplement describes a novel dentifrice system, incorporating o-cymen-5-ol (a tasteless isomer of thymol) and zinc chloride which has been developed and tested to aid in the maintenance of gingival health.

These dentifrices have been tested in two clinical studies reported in this issue by Kakar et al.17., 18., but unlike the studies of Svatun and Saxton11., 12. the group of subjects enrolled in these studies represent a greater age range and are more diverse. The Kakar studies in this issue17., 18. describe the use of a standard dentifrice¹⁶, and a gel to foam dentifrice¹⁸ containing 0.1%w/w o-cymen-5-ol and 0.6%w/w zinc chloride to maintain gingival health following a pre-experimental phase of dental prophylaxis and oral hygiene instruction prior to study treatment compared to a regular sodium fluoride/ silica based dentifrice control. The pre-experimental phase brought subjects to their optimum gingival health prior to commencing study treatment and achieved significant reductions between the pre-prophylaxis visit and the treatment commencement visit of 76.8% reduction in MGI, and a reduction of 69.4% in BI¹⁶ or 84.7% reduction in MGI, 66.2% reduction in BI¹⁷ (P < 0.0001 in both cases). While Kakar et al.17., 18. also report the mean gingival index following the use of this experimental dentifrice as is traditionally reported, Butler et al.¹⁹ reports a statistical approach which increases the ability to understand what this means in the treatment of patients on an everyday basis. By performing an additional analysis on modified gingival index and bleeding index scores, Butler et al. graphically represents in a meaningful way what effects products can have on the maintenance of gingival health by demonstrating the scores at a number of individual gingival sites that increased, decreased or showed no change over the course of treatment.

DISCUSSION

Clinically healthy gingivae are described as coral pink, stippled, minimal sulcus depth and firm with no bleeding upon probing. Perfect clinical health is the absence of any inflammation which includes no bleeding on probing. Unfortunately few people can demonstrate this level of gingival health even after a dental prophylaxis and dental education. With the aid of a dentifrice containing additional antimicrobial ingredients, the level of plaque can be controlled and the gingival health achieved after a prophylaxis can be maintained to a greater extent than with a control dentifrice. The effects of a dental prophylaxis are profound but limited and good oral hygiene instruction and a use of a suitable dentifrice containing antimicrobial ingredients can help maintain the benefits achieved with this procedure.

CONFLICT OF INTEREST AND SOURCE OF FUNDING

The work described in this manuscript was funded by GlaxoSmithKline Consumer Healthcare. The author is employed by GSK but confirms no potential conflicts of interest.