Printer Friendly

Comparison between a simplified and a conventional biofilm index in relation to caries activity and gingivitis in the primary dentition.

Abstract

Aim: This was to compare a simplified biofilm index with a conventional one in relation to caries activity and gingivitis in the primary dentition. Study design: Observational, cross-sectional. Methods: The sample consisted of 90 children aged 10 to 57 months-old. A single examiner performed all examinations. Two visible biofilm indices, one simplified (BF1) and the other conventional (BF2), were used. Gingival bleeding was assessed after flossing all proximal surfaces and each tooth surface was classified for caries, including non-cavitated lesions. Results: According to BF1, half of the sample (45-50%) had thick biofilm. BF2 showed a mean value of 21.8% (SD [+ or -] 16.5); 12 (13.3%) children had gingival bleeding and the mean percentage of bleeding surfaces was 0.9% (SD [+ or -] 2.5). Caries was present in 36 (40.0%) children and the mean value of active lesions was 2.1 (SD [+ or -] 4.3). The association between visible biofilm and gingival bleeding was significant (p=0.01), except when BF1 was associated with the gingival index (p=0.08). The association between BF1 and BF2 with caries activity was highly significant (p[less than or equal to]0.001). Conclusion: Both biofilm indices may be used when the outcome being measured is caries. In the primary dentition, though, the conventional index (BF2) is better suited for studies about gingivitis.

Key words: visible biofilm; early childhood caries; gingivitis; dentition, primary.

Introduction

For many years, studies concerning early childhood caries (ECC) have assumed that bottle feeding at night and prolonged breastfeeding were the main risk factors for caries in young children [Hallonsten et al., 1995; Oulis et al., 1999]. However, the lack of a clear association between bottle feeding practices or weaning age and ECC has encouraged researchers to include an evaluation of other risks factors, emphasizing the multifactorial aetiologic process involved in this disease [Tinanoff, 1998].

Different factors, such as socioeconomic status, educational level, oral health knowledge and behaviours, dietary habits and oral hygiene practices, have been assessed in a number of investigations [Dini et al., 2000; Ramos-Gomez et al., 2002; Stecksen-Blicks et al., 2004; Vachirarojpisan et al., 2004]. However, dental caries is not a classical infectious disease caused by a specific group of microorganisms. It reflects an imbalance between dental enamel and biofilm that occurs in areas where biofilm is allowed to mature and therefore acquires cariogenic properties [Fejerskov, 2004]. Due to the role of biofilm in the development of dental caries, it becomes clear that the assessment of oral hygiene (OH) quality is important in studies about ECC. Several surveys, though, have evaluated OH only by means of habits or frequency of tooth brushing and the data on the relationship between these variables and ECC are controversial [Dini et al., 2000; Rosenblatt and Zarzar, 2004; Stecksen-Blicks et al., 2004; Vachirarojpisan et al., 2004]. The assessment of OH based on whether children had their teeth cleaned more frequently or not has proved to be insufficient to establish its quality [Habibian et al., 2001]. Furthermore, asking parents when their child started tooth bruhsing or how often tooth brushing are performed is subject to recall and response bias [Reisine and Douglass, 1998].

Besides being a prerequisite for caries occurrence [Thylstrup, 1998; Fejerskov, 2004], dental biofilm is the direct cause of gingivitis [Loe, 2000]. As previously reported in a classical study about experimental gingivitis in man, the withdrawal of all measures of OH resulted in the accumulation of abundant biofilm and in the development of marginal gingivitis [Loe et al., 1965]. As some patients may improve oral hygiene just before a dental appointment, the assessment of the gingival condition seems to be a reliable and valid measure about the quality of biofilm control [Ekstrand et al., 1998].

In spite of the well established role of biofilm in the aetiology of gingivitis, some studies have demonstrated a higher tendency to develop gingival inflammation among adults than in preschool children, under comparable biofilm conditions [Matsson, 1978; Matsson and Goldberg, 1985]. Moreover, the degree of gingivitis in children has not been directly related to the amount of biofilm [Bimstein et al., 1985].

Thus, the aim of this study was to compare a simplified biofilm index with a conventional one in relation to caries activity and gingivitis in the primary dentition.

Materials and Methods

Sample selection. The sample consisted of 90 selected healthy patients, of both sexes, aged between10 to 57 months-old. All subjects were outpatients of the Paediatric Ambulatory of the University Hospital of the Rio de Janeiro State University.

Clinical evaluation. The examinations were not previously scheduled. Parents were invited to participate while they were waiting for an ordinary appointment with the paediatrician. A single examiner performed all oral examinations in a dental office, under artificial light and using mouth mirrors, exploratory probes, dental floss and gauze. An assistant was responsible for recording the scores. Children remained seated either in the dental chair or in their parent's lap. Clinical assessments included biofilm, gingival bleeding and caries activity. The examiner was trained for biofilm and calibrated for gingival bleeding (Kappa=0.92) and caries activity (kappa=0.90).

Indicies. Two visible biofilm indices were employed. One was 'simplified' [Ribeiro et al., 2002] and the other 'conventional' [Ainamo and Bay, 1975]. The simplified index, called in this study BF1, was modified by reducing the number of scores from 6 to 4 in order to facilitate its application in very young children. It gives a score to each patient according to the amount of visible biofilm accumulated (absent, thin or thick) in anterior and/or posterior teeth (Table 1). The conventional index, called in this study BF2, gives a score 0 for absent or 1 for present biofilm for all the mesial, buccal and lingual surfaces. Results regarding BF2 were recorded in a specific form and expressed as the percentage of tooth surfaces with visible biofilm.

Gingival bleeding was assessed by flossing all proximal surfaces [Caton and Polson, 1975; Tinoco and Gjermo, 1992]. The results were expressed as a gingival index (score 0 for absence and score 1 for presence of gingival bleeding in at lest one surface) and as the mean percentage of surfaces that bled. After biofilm removal, each tooth surface was classified according to a visual-tactile caries diagnostic system which differentiates between active and inactive caries lesions at both the cavitated and non-cavitated levels [Nyvad et al., 1999].

Statistical analysis. The data were analyzed in SPSS software release 8.0 for Windows. The following tests were used: Chi-square for the association between two nominal variables, Mann Whitney for a numerical and a dichotomous variable and Spearman's correlation for two numerical variables. Statistical level of significance was set at 5%.

Results

According to BF1, 11 (12.2%) of the children had a score of 0, no visible biofilm; 34 (37.8%) scored 1, thin biofilm in anterior and/or posterior teeth; 25 (27.8%) scored 2, thick biofilm in anterior or posterior teeth; and 20 (22.2%) scored 3, thick biofilm in both anterior and posterior teeth. The BF2 assessment revealed that the percentage of surfaces with biofilm ranged from 0 to 83.3%, with a mean of 21.8% (SD [+ or -] 16.5).

There were 12 children (13.3%) who had gingival bleeding (score 1) in at least one proximal surface. The mean percentage of surfaces that showed gingival bleeding after being flossed ranged from 0 to 12.5%, with a mean of 0.9% (SD [+ or -] 2.5).

Caries activity was present in 36 (40%) children. The total of active lesions per child ranged from 0 to 26, with a mean of 2.1 (SD [+ or -] 4.3).

Overall, the gingival bleeding was associated with the presence of visible biofilm. Table 2 shows a statistically significant association (p=0.01) between BF1 and gingival bleeding when the mean percentage of gingival bleeding was considered. It can be observed that children with higher scores of BF1 also showed higher mean percentages of bleeding surfaces. Although the same situation has been noted when the gingival index was used, the association failed to show a significant value (p=0.08).

When BF2 was associated with the gingival index and with the mean percentage of bleeding surfaces, statistically significant associations were found. Among the children without gingival bleeding, the mean percentage of BF2 was 19.7, while among those with gingival bleeding it increased to 35.6 (p=0.01, Table 3). The correlation between BF2 and the mean percentage of surfaces with gingival bleeding was also statistically significant (rs=0.28 / p=0.008).

The association between visible biofilm and caries activity showed a highly significant value when all situations were taken into account. The presence of caries activity and the mean number of active carious lesions were significantly higher among the children with scores 2 and 3 of BF1 (p [less than or equal to] 0.001, Table 4). Among the children without caries activity, the mean percentage of BF2 was 14.1, while among those with caries activity it increased to 33.5 (p<0.001, Table 5). Moreover, the correlation between BF2 and the mean number of active carious lesions was also statistically significant (rs= 0.66 / p<0.001).

Discussion

Despite the fact that the role of dental biofilm has already been established in the initiation, progression and arrest of carious lesions, several studies still focus their attention on the OH habits and frequency of tooth brushing when evaluating the status of OH in the primary dentition. The lack of association between parental reports of tooth brushing frequency and the presence of visible biofilm described by Habibian et al. [2001] supports this kind of assessment and seems poorly determined if biofilm control is being performed efficiently.

As classical studies have shown that accumulations of biofilm lead to the development of marginal gingivitis, the gingival condition assessment is recommended to avoid misleading results regarding the OH quality. The gingival assessment performed in this study followed the criteria proposed by Tinoco and Gjermo [1992] and Caton and Polson [1985], who claimed that the interproximal area was the primary site of periodontal pathology.

This study found a low prevalence of gingival bleeding, which is in agreement with other previous reports [Grindefjord et al., 1993; Wendt et al., 1994; Santos and

Soviero, 2002; Pienihakkinen et al., 2004], and reinforces the fact that there is an age-related difference in the gingival inflammatory reactivity [Matsson, 1978; Matsson and Goldberg, 1985]. Although few children and few surfaces presented gingival bleeding in this study, it was possible to detect a statistically significant association between BF1 and BF2 and the percentage of bleeding surfaces. Sayegh et al. [2005] have also demonstrated that children with four or more sites with biofilm had 8.6% more chance to develop gingivitis. However, when it comes to the gingival index, a statistically significant association was found with BF2, but not with BF1, possibly because the low number of cases with gingival bleeding had a negative influence on the association of two categorical and simplified indices (BF1 and gingival index). The results for BF2 suggest this index is more appropriate than BF1 when the outcome measure is gingivitis.

The prevalence of caries and the mean number of active lesions found in this study was 40% and 2.1 (SD [+ or -] 4.3), respectively, similar to other studies [Mattos-Graner et al., 1998; Santos and Soviero, 2002; Stecksen-Blicks et al., 2004]. The association between presence of biofilm and caries activity was considered highly significant when both indices were used. A higher prevalence of caries and number of active lesions were observed in the group of children with thick biofilm (scores 2 and 3) and with higher percentage of surfaces with biofilm. Despite the great variety of criteria used to assess biofilm in this age group, the association between caries and biofilm was expected as other studies involving infants and preschool children have shown similar associations [Wendt et al., 1994; Mattos-Graner et al., 1998; Santos and Soviero, 2002; Sayegh et al., 2005]. The results obtained when associating BF1 and BF2 with caries activity suggest that the simplified index (BF1) is appropriate in studies where the outcome being measured is ECC. Additionally, as it gives a score to the patient and not to each tooth surface, dispensing with specific forms and calculations, its assessment is quicker, as reported in a previous study [Santos and Soviero, 2006]. This characteristic is particularly interesting when dealing with very young children as well as in large scale epidemiological studies.

The index BF1 also enables information about the biofilm thickness to be recorded, and this may be of clinical relevance. It is well accepted that a thin biofilm has a microbiological diversity, with a predominance of aerobic bacteria, and tends not to be associated with caries. On the other hand, as biofilm ages, there is a reduction in oxygen and a progressive shift from mainly aerobic to anaerobic species. It leads to an imbalance in the equilibrium between tooth surface and biofilm fluid and therefore to the enamel demineralization [Thylstrup, 1998; Fejerskov, 2004]. The results of the present study corroborate these affirmations once the percentage of children with caries activity increased from 5.9% among those with thin biofilm to 90% among those with thick biofilm, suggesting that the presence of only thin biofilm can be regarded as an acceptable level of OH. As for the index BF2, the literature has yet to establish an acceptable percentage of surfaces with biofilm.

Conclusion

It is suggested that both the simplified (BF1) and the conventional (BF2) biofilm indices may be used when the outcome being measured is caries. In the primary dentition, though, the conventional index (BF2) is better suited for studies about gingivitis.

Acknowledgments

This study was approved by the Ethical Committee of the Biomedical Center of the Rio de Janeiro State University (967-CEP/HUPE). All parents signed informed consent forms and received information on caries prevention and control. The authors would like to thank Professor Ronir Raggio Luiz for his valuable contribution to the statistical analysis.

References

Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975; 25: 229-235.

Bimstein E, Lustmann J, Soskolne WA. A clinical and histometric study of gingivitis associated with the human deciduous dentition. J Periodontol 1985; 56: 293-296.

Caton JC, Polson AM. The interdental bleeding index: a simplified procedure for monitoring gingival health. Compend Contin Educ 1985; 6: 88, 90-92.

Dini EL, Holt RD, Bedi R. Caries and its association with infant feeding and oral health-related behaviours in 3-4-year-old Brazilian children. Community Dent Oral Epidemiol 2000; 28: 241-248.

Ekstrand KR, Bruun G, Bruun M. Plaque and gingival status as indicators for caries progression on approximal surfaces. Caries Res 1998; 32: 41-45.

Fejerskov O. Changing paradigms in concepts on dental caries: consequences for oral health care. Caries Res 2004; 38: 182-191.

Grindefjord M, Dahllof G, Ekstrom G, Hojer B, Modeer T. Caries prevalence in 2.5-year-old children. Caries Res 1993; 27: 505-510.

Habibian M, Roberts G, Lawson M, Stevenson R, Harris S. Dietary habits and dental health over the first 18 months of life. Community Dent Oral Epidemiol 2001; 29: 239-246.

Hallonsten AL, Wendt LK, Mejare I et al. Dental caries and prolonged breastfeeding in 18-month-old Swedish children. Int J Paediatr Dent 1995; 5: 149-155.

Loe. Oral hygiene in the prevention of caries and periodontal disease. Int Dent J 2000; 50: 129-139.

Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol 1965; 36: 177-187.

Matsson L. Development of gingivitis in pre-school children and young adults. J Clin Periodontol 1978; 5: 24-34.

Matsson L, Goldberg P. Gingival inflammatory reaction in children at different ages. J Clin Periodontol 1985; 12: 98-103.

Mattos-Graner RO, Zelante F, Line RCSR, Mayer MPA. Association between caries prevalence and clinical, microbiological and dietary variables in 1.0 to 2.5-year-old Brazilian children. Caries Res 1998; 32: 319-323.

Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic system differentiating between active and inactive caries lesions. Caries Res 1999; 33: 252-260.

Oulis CJ, Berdouses ED, Vadiakas G, Lygidakis NA. Feeding practices of Greek children with and without nursing caries. Pediatr Dent 1999; 21: 409-416.

Pienihakkinen K, Jokela J, Alanen P. Assessment of caries risk in preschool children. Caries Res 2004; 38:156-162.

Ramos-Gomez FJ, Weintraub JA, Gansky SA, Hoover CI, Featherstone JDB. Bacterial, behavioral and environmental factors associated with early childhood caries. J Clin Pediatr Dent 2002; 26: 165-173.

Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Community Dent Oral Epidemiol 1998; 26: 32-44.

Ribeiro AA, Portela M, Souza IP. Relation between biofilm, caries activity and gingivitis in HIV+children. Pesqui Odontol Bras 2002; 16: 144-150.

Rosenblatt A, Zarzar P. Breast-feeding and early childhood caries: an assessment among Brazilian infants. Int J Paediatr Dent 2004; 14: 439-445.

Santos APP, Soviero VM. Caries prevalence and risk factors among children aged 0 to 36 months. Pesqui Odontol Bras 2002; 16: 203-208.

Santos APP, Soviero VM. Comparison between two visible biofilm indices in the primary dentition. J Clin Pediatr Dent 2006; 30: 292-295.

Sayegh A, Dini EL, Holt RD, Bedi R. Oral health, sociodemographic factors, dietary and oral hygiene practices in Jordanian children. J Dent 2005; 33: 379-388.

Stecksen-Blicks C, Sunnegardh K, Borssen E. Caries experience and background factors in 4-year-old children: time trends 1967-2002. Caries Res 2004; 38: 149-155.

Thylstrup A. When is caries caries, and what should we do about it? Quintessence Int 1998; 29: 594-598.

Tinanoff N. Introduction to the Early Childhood Caries Conference: initial description and current understanding. Community Dent Oral Epidemiol 1998; 26: 5-7.

Tinoco NMB, Gjermo P. Comparison of the effectiveness of three different methods in detection of changes in gingivitis in primary dentition. Community Dent Oral Epidemiol 1992; 20: 84-86.

Vachirarojpisan T, Shinada K, Kawaguchi Y, et al. Early childhood caries in children aged 6-19 months. Community Dent Oral Epidemiol 2004; 32: 133-142.

Wendt LK, Hallonsten AL, Koch G, Birkhed D. Oral hygiene in relation to caries development and immigrant status in infants and toddlers. Scand J Dent Res 1994; 102: 269-273.

A. P. Santos, V. M. Soviero

Dept. Community and Preventive Dentistry, School of Dentistry, Rio de Janeiro State University, Rio de Janeiro, Brazil.

Postal address: Dr. A.P.P. dos Santos. Roberto Silveira, 187/201, Centro, Petropolis--Rio de Janeiro, Brasil, CEP: 25685-040.

Email: ana.paulapires@uol.com.br
Table 1. Description of the visible dental biofilm index
scores * (BF1).

 0 Absence of visible biofilm.

 1 Thin biofilm, easily removed, in anterior
 and/or posterior teeth, visible just after
 drying with gauze.

 2 Thick biofilm, firmly adhered, in anterior or
 posterior teeth, visible without drying,
 associated or not to thin biofilm on other teeth.

 3 Thick biofilm, firmly adhered, in anterior
 and posterior teeth, visible without drying.

* The original index was proposed by Ribeiro et al. [2002].

Table 2. Association between visible biofilm, expressed
by the simplified index (BF1), and gingival bleeding,
expressed by the gingival index and by the mean
percentage of bleeding surfaces in a group of Brazilian
pre-school children.

 Gingival Bleeding

 Gingival Index Total
 BF1 bleeding Total
 GI=0 GI=1 surfaces

 mean [+ or -]
 n % n % SD. n %
 %

 0 11 100.0 0 0 0 0 11 12.2

 1 32 94.1 2 5.9 0.3 1.1 34 37.8

 2 20 80.0 5 20.0 1.4 3.1 25 27.8

 3 15 75.0 5 25.0 1.8 3.6 20 22.2

 p
value [chi square] p = 0.08 [r.sub.s] = 0.27 / p = 0.01

GI=0--No gingival bleeding.
GI=1--Gingival bleeding in at least one surface

Table 3. Association between visible biofilm, expressed by
the mean percentage of dental surfaces with biofilm (BF2),
and the gingival index in a group of Brasilian pre-school
children.

 Gingival Index

BF2
 GI = 0
mean %
 mean [+ or -] SD min max

 19.7 [+ or -] 14.4 0 73

total 78 (86.7%)

p value Mann-Whitney p = 0.01

 Gingival Index

BF2
 GI = 1
mean %
 mean [+ or -] SD min max

 35.6 [+ or -] 22.4 8.3 83

total 12 (13.3%)

p value Mann-Whitney p = 0.01

GI=0--No gingival bleeding.
GI=1--Gingival bleeding in at least one surface

Table 4. Association between visible biofilm, expressed by
the simplified index (BF1), and caries activity in a group of
Brasilian pre-school children.

 Caries Activity
 BF1 Total active
 Yes No Lesions Total

 n % n % Mean [+ or -] SD n %

 0 0 0 11 100 0.0 [+ or -] 0.0 11 12.2

 1 2 5.9 32 94.1 0.1 [+ or -] 0.4 34 37.8

 2 16 64 9 36 2.1 [+ or -] 2.5 25 27.8

 3 18 90 2 10 6.7 [+ or -] 6.9 20 22.2

p
value [chi square] p < 0.001 [r.sub.s] = 0.75 / p = 0.001

Table 5. Association between visible biofilm, expressed by
the mean percentage of dental surfaces with biofilm (BF2),
and caries activity in a group of Brasilian pre-school children.

 Caries Activity
BF2
 Yes
mean
% Mean [+ or -] SD min max

 33.5 [+ or -] 15.5 12.1 83.3

Total 36 (40.0%)

p
value Mann-Whitney p < 0.001

 Caries Activity
BF2
 No
mean
% Mean [+ or -] SD min max

 14.1 [+ or -] 12.0 0 66.7

Total 54 (60.0%)

p
value Mann-Whitney p < 0.001
COPYRIGHT 2007 European Academy of Paediatric Dentistry
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2007 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Santos, A.P.; Soviero, V.M.
Publication:European Archives of Paediatric Dentistry
Date:Dec 1, 2007
Words:3552
Previous Article:Enamel mineral concentration in diabetic rodents.
Next Article:Dental caries pattern and predisposing oral hygiene related factors in Nigerian preschool children.


Related Articles
A comparison of knowledge of local analgesia, pulp therapy and restoration of primary molar teeth amongst dental students, dentists and dental...
A 7 year survival analysis of caries onset in primary second molars and permanent first molars in different caries risk groups determined at age two...
Minimally invasive dentistry: are you using it in practice?
Levels of oral disease in a sample of children with disability; a study carried out immediately before comprehensive dental treatment under general...
Long-term predictive value of salivary microbial diagnostic tests in children.
Dental caries pattern and predisposing oral hygiene related factors in Nigerian preschool children.
A guideline framework for undergraduate education in Paediatric Dentistry.
Oral health of children with intractable epilepsy attending the UK National Centre for Young People with Epilepsy.
Caries prevalence and tooth surface distribution in a group of 5-year-old Italian children.

Terms of use | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters