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Effects of Continuous Oral Health Care on Periodontal Disease in Adults in Jeju Island, South Korea
Int J Clin Prev Dent 2024;20(1):1-11
Published online March 31, 2024;  https://doi.org/10.15236/ijcpd.2024.20.1.1
© 2024 International Journal of Clinical Preventive Dentistry.

Ha-Min Oh1, Ja-Won Cho2, Da-Hui Kim3

1Department of Oral Health, College of Health Science, Dankook University, Cheonan, 2Department of Preventive Dentistry, College of Dentistry, Dankook University, Cheonan, 3Department of Dental Hygiene, Andong Science College, Andong, Korea
Correspondence to: Da-Hui Kim
E-mail: plusoten@naver.com
https://orcid.org/0000-0003-0226-0212
Received February 18, 2024; Revised March 12, 2024; Accepted March 14, 2024.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Objective: This preventive care program aimed to determine the improvement of periodontal disease and self-care ability of adults with gingivitis and periodontal disease when they received professional oral care and personalised oral care education on a regular basis.
Methods: A total of 91 subjects (34 males and 57 females) underwent oral examinations (phase contrast microscopy, halitosis, periodontal pocket measurement, gingival bleeding test, and oral hygiene performance index test) before treatment. Non-surgical periodontal treatment (scaling, root planing, polishing) and professional oral care (Watanabe method, gingival massage) were performed according to the periodontal status (periodontal pockets 3 mm or less, 4-5 mm, 6 mm or more).
Results: The results of the pocket depth index showed that the prophylactic periodontal treatment (grade 1) and comprehensive periodontal treatment (grade 3) groups had the highest pocket depth maximum and average pocket depth average indices in tooth 16, and the values were statistically significantly reduced after treatment (p<0.05). The analysis of the gingival bleeding index for all subjects showed a statistically significant decrease in the gingival bleeding index from the first treatment with a score of 2.88, 1.41 at the second treatment, 0.76 at the third treatment, and 0.34 at the fourth treatment (p<0.05).
Conclusion: The results of this study showed that the periodontal status of the subjects was improved with a significant increase in the bacterial plaque control scores and a significant improvement in the periodontal status after the implementation of personalised professional oral care considering the characteristics of each group and repeated oral education and management.
Keywords : oral health, periodontal disease, Jeju
Introduction

The structure of modern society is becoming increasingly complex, and as a result it is no longer possible to live as a human being by solving basic rituals alone [1]. Humanity is fundamentally derived from health, and in particular, masticatory disorders and oral dysfunction caused by oral diseases are important factors in reducing the quality of life. Therefore, there is a need to rationally manage physical and oral health in accordance with the changing times.

The most threatening causative factor for oral health is dental plaque, the deposition of which leads to gingivitis in 100% of cases [2]. Dental plaque is a bacterial film that adheres to the surface of the tooth and provides a favourable environment for bacteria to proliferate because it has the right temperature and moisture on the inside and a rich glyco-protein film that blocks it on the outside. Several enzymes in the biofilm, which forms in the fissure or gingival third of the tooth, act as environmental factors that destroy periodontal tissue and perpetuate periodontal disease [1-3]. Periodontal disease is an inflammatory immune disease that develops in the tissues surrounding the teeth and slowly progresses to destroy the alveolar bone [1]. Because it causes no pain or discomfort in the early stages, it is difficult to detect and often goes undetected, leading to recurrent episodes throughout life. Periodontal disease has been recognised as the most common oral health problem in the last 500 years [4] and has been reported to be closely associated with living environment, diet, lifestyle, oral habits, oral hygiene knowledge and attitudes [5]. The reason why these periodontal diseases account for such a high proportion of oral diseases and their prevalence is not decreasing is due to the inability to effectively brush according to the oral condition [6].

Toothbrushing is the most widely practiced personal oral hygiene method worldwide [7]. During the process of tooth brushing, tooth tissue is affected by the duration of brushing, the number of brush strokes, the strength of the bristles, the abrasiveness of the toothpaste, the quality of the toothbrush, and the individual’s brushing technique [2,8]. In most cases, inflammation confined to the gingiva can be cleared by brushing [2], but because the average person has difficulty mastering the different brushing techniques suggested by professionals, unremoved plaque will eventually cause tooth loss. However, since various brushing methods have different effects in nature [9], when providing oral health education to individuals, systematic, customized, repeated education and ongoing oral health care that considers individual oral characteristics and management capabilities step by step is effective in improving the ability to manage dental bacterial film [9,10].

Recently, as the trend of dental care has shifted from treatment to prevention and maintenance in developed countries, there has been a growing interest in continuous oral health care, and the need for professional bacterial film management through preventive care programs has been raised [11]. Globally, the number of people with periodontal disease is steadily increasing every year, and Korea’s oral health status ranks at the bottom of the 28 OECD member countries based on the OECD Health Index [11]. In addition, although preventive tartar removal has been covered by insurance for all people over the age of 20 in Korea since July 2013 [12], the number of people with gingivitis and periodontal disease increased by about 50% from 10.47 million in 2013 to 15.74 million in 2018 [13].

Oral health problems are mainly associated with disparities in dental untreated rates and oral health indicators based on socioeconomic status, such as income and education level [14], and oral hygiene status varies according to regional characteristics [15]. In Jeju Island, periodontal disease was the most common among the four chronic diseases among Jeju residents in 2017, with 249,000 people utilizing medical institutions, and the per capita medical expenditure for periodontal disease increased by 162.0% compared to 2007. In addition, it was found that about one-third of adults living in Jeju Island have related periodontal diseases and perceive their periodontal health as poor [14]. Therefore, this study aimed to determine the impact of providing expert oral care services and customized oral care education services according to graded oral conditions on individual oral health status by targeting adults in a community with insufficient knowledge and information about and low access to oral preventive health care services.

Materials and Methods

1. Study subjects

His study was conducted on patients who visited a dental clinic in Seogwipo City, Jeju Special Self-Governing Pro-vince, from August 1, 2017 to July 31, 2019.

1) Selection criteria and ratings

We selected 91 patients (34 males and 57 females) who were over 20 years old and under 70 years old, who visited the clinic with halitosis and periodontal disease, and received a continuous oral health care program. The selected patients were divided into three groups according to periodontal evaluation.

(1) Prophylactic periodontal treatment: gingivitis (perio-dontal pockets of 3 mm or less).

(2) Partial periodontal treatment: early periodontal disease (4-5 mm periodontal pockets).

(3) Overall periodontal treatment: advanced periodontal disease (pathologic periodontal pockets larger than 6 mm).

2) Excludes

Patients were excluded from the study if they met the following criteria.

(1) Those with less than 24 residual teeth.

(2) Localized denture, total denture wearers.

(3) uncontrolled hemorrhagic systemic disease.

2. Methods

1) Assess oral hygiene

The gender, date of birth, and age of the patients were recorded in the chart as basic information. Oral examinations were performed at the initial visit and continued on an ongoing basis to assess periodontal status before and after treatment, and detailed records of weekly professional oral care were recorded. The oral hygiene status and periodontal disease needs assessment of the subjects are shown in Table 1.

Table 1 . Oral hygiene assessment items

RatingPreventive periodontal therapy (n=54)Partial periodontal therapy (n=19)General periodontal therapy (n=18)
Oral examination panorama taking1 week, 4 weeks1 week, 5 weeks1 week, 8 weeks
Phase contrast microscopy (DCS600E, Dr. Prevent, Korea)1 week, 4 weeks1 week, 5 weeks1 week, 8 weeks
Measure bad breath (Breathview AIOBIO, Korea)1 week, 4 weeks1 week, 5 weeks1 week, 8 weeks
Measuring periodontal pockets depth1 week, 4 weeks1 week, 5 weeks1 week, 8 weeks
Oral environmental hygiene assessment (PHP index)Weekly (4 times)Weekly (5 times)Weekly (8 times)
Gingival bleeding indexWeekly (4 times)Weekly (5 times)Weekly (8 times)

2) Professional oral care

The study subjects were categorized according to the periodontal pocket depth test results. Non-surgical periodontal treatments such as scaling, root planing, and polishing were performed according to the periodontal class, and customized oral products and brushing education were provided in consideration of Professional Tooth Care (PTC), individual brushing performance, and oral habits (Table 2).

Table 2 . Professional oral care

RatingPreventive periodontal therapy (n=54)Partial periodontal therapy (n=19)General periodontal therapy (n=18)
Number of treatments4-week program5-week program8-week program
Oral prophylaxis (scaling)1 time1 time1 time
Root planing-2 times4 times
Professional tooth cleaning4 times5 times8 times
Finger gingival massage4 times5 times8 times
Teach oral care product selection and use4 times5 times8 times

3) Customized oral hygiene management education by grade

After identifying the subjects’ brushing method, lifestyle, and selection of oral products, the deficiencies that prevent plaque from being removed are corrected weekly [2].

(1) Apply a bacterial film colorant to the teeth and have them rinse gently with water.

(2) Check plaque adhesion with the subject.

(3) Allow the person to brush freely and observe the charac-teristics.

(4) Teach the person how to brush in areas where plaque is not removed and select a personalized oral care product.

(5) Have the patient demonstrate the instructed brushing method in the mouth.

4) Professional oral healthcare
(1) Professinoal tooth cleaning (PTC)

Professionals perform interdental cleaning in the subject’s oral cavity, which has the effect of cleaning between the teeth and massaging the teeth at the same time, centering on the Watanabe method (toothpick method) in a dental clinic (Table 3).

Table 3 . Choose a graded brushing method

Management tiersChoose a graded brushing method
Preventive periodontal therapy (n=54)Modified Stillman’s method+toothpick method
Partial periodontal therapy (n=19)Bass’ method+Stillman’s method
General periodontal therapy (n=18)Fone’s method+Charter’s method


① Watanabe method (toothpick method)

(a) Bristle position

Use a 2×4 toothbrush with the bristles facing the occlusal surface (cutting edge) and position the bristles at the tooth-gingival interface with the anterior labial surface at an angle of 30° to the long axis of the tooth, 50° for premolars, and 70° for molars. For the lingual surface, position the toothbrush at an angle and diagonally, and then position the head of the toothbrush toward the adjacent surface so that the bristles are applied between each tooth. Use the three bristles at the end of the toothbrush.

(b) Brushing motion

Hold the toothbrush lightly in a pencil grip and apply pressure, and on the buccal surface, move the toothbrush in the lingual direction, centering between the teeth and pushing it toward the adjacent surface, and then repeat the motion. On the lingual surface, use the front of the toothbrush to slide obliquely to the neighboring surface and retreat when the bristles come out into the buccal gingival area [16].

(2) Gingival finger massage

Gingival finger massage was performed after professional oral care at each visit. Using the thumb and index finger, gently massage the gingival tissue in a clockwise circular motion for about 10 times. Starting from the front, rub the entire gingiva thoroughly.

(3) Intra-gingival cleaning

Use a 2% solution of Hexamedine Sol to clean the gingival fissure. A 5 ml plastic syringe and a 27 G endodontic needle were inserted into the periodontal pocket for cleaning and disinfection, and the effectiveness was not evaluated [17].

5) Graded selection of brushing methods

During the initial toothbrushing education, the site and extent of biofilm attachment and formation are examined, and the patient’s brushing performance is evaluated to correct oral habits and brushing methods. At the next visit, the toothbrushing education is repeated in a form that compensates for the deficiencies after the biofilm test. To see the effectiveness of brushing, we excluded the use of toothpaste during brushing (Table 3).

(1) Bass’ method

It is effective in treating periodontal disease and preventing gingivitis. Bristle positioning using a soft bristle toothbrush with two rows of bristles, place the bristles in the periapical area with the bristles facing the root end and the side of the bristles at 45° from the long axis of the tooth, and apply light pressure so that part of the bristles enter the gingival sulcus. Make short back and forth motions in the gingival sulcus at a speed of about 4 times per second, with about 20 strokes per area. The vibrations should be performed without the bristles bending [16].

(2) Charter’s method

It is effective for cleaning interdental areas and massaging the gingiva. Place the bristles on the cervix at a 45° angle to the long axis of the tooth with the bristles facing the occlusal surface (cutting edge). Apply light pressure to the tooth surface, interdental and adjacent surfaces, and the base of the artificial tooth with short oscillations back and forth [16].

(3) Stillman’s method

This method is recommended for patients with extensive gingivitis due to its high gingival massage effect. Use a soft bristle toothbrush with 3 to 4 rows of bristles and place it on the attached gingiva with the bristles facing the root tip and the side of the bristles at 45° from the long axis of the tooth. Brush from the attachment gingiva to the occlusal surface (cutting edge) with short back and forth oscillations while applying slight lateral pressure [16].

(4) Modified Stillman’s method

Use 3 to 4 rows of soft bristles and place the bristles on the attachment gingiva with the bristle cross-section facing the root tip and the bristle side at 45° to the long axis of the tooth. Apply slight lateral pressure and move from the attachment gingiva to the gingival margin with short back and forth oscillations, then perform the rotary method [16].

(5) Fones’ method

It can thoroughly clean the labial and lingual surfaces of the teeth and is highly practical. Point the bristles of the toothbrush toward the teeth and position them at right angles to the labial surface of the anterior teeth. On the labial (buccal) side of the teeth, brush the teeth and gingival area in a large circular motion while bite down with the upper and lower cutting kite. The buccal occlusal side of the teeth should be placed parallel to the dentition and brushed in a back-and-forth reciprocating motion, and the lingual side should be brushed by tilting the toothbrush slightly to the lingual side [16].

6) Oral examination items

At the initial visit, the general characteristics, oral health behaviors (brushing frequency, method, oral hygiene aids), and oral health education experiences of the subjects were investigated. Periodontal disease screening and oral hygiene environmental assessment were performed by a dental hygienist with 17 years of experience in preventive work.

(1) Phase contrast microscopy

The oral microbiology examination using phase contrast microscopy is performed twice to observe changes in the oral microbiota: the first and fourth time. The method of observing oral bacteria was as follows. The buccal, lingual, subgingival, and subgingival bacterial membranes of teeth 17, 16, 26, 27, 36, 37, 46, and 47 were collected using a micro-brush. A wide smear of the collected bacterial membrane was made on a slide glass, and then 1 drop of normal saline was added to spread the bacterial membrane evenly. The collected samples were observed using a phase contrast microscope (DCS 600E, Dr. Prevent, Korea). The amount and activity of oral bacteria were recorded with a 400× objective lens, and the results were checked on a monitor [16].

(2) Halitosis test

Bad breath was measured twice, the first and fourth time, to observe changes. Breathview AIOBIO (Breathview AIOBIO, Korea) is a system that measures halitosis by analyzing volatile sulfur compounds (hydrogen sulfide, and methylmercaptan) with an exhaled gas analyzer. By comparing the amounts of the two gas components, it not only shows the level of halitosis but also differentiates between physiological and pathological halitosis, which helps in diagnosis [16].

(3) Oral hygiene competency test

The best method of investigation is to examine the entire tooth surface, and the tooth surface of the anterior teeth, excluding prosthetized teeth and third molars, was evaluated. The bacterial film coloring agent used to measure the bacterial film management was 2-TONE Disclosing Solution applied to a micro-brush. The Patient Hygiene Performance index (PHP index) and the Modified Patient Hygiene Performance index (M-PHP index) were measured by dividing the examined tooth surface into five sections: periapical, distal, gingival, mesial, and incisal, and scoring each section as 1 if the biofilm was present and 0 if it was not.

(4) Intraoral photographs

The bacterial film attached to the teeth and gingiva is not easily distinguished by the naked eye, so it is stained with a bacterial film colorant to observe it. The oral condition of the subjects is photographed at 1 before starting the continuous oral care program and at 4 after completion of the treatment to compare the changes in oral condition. Intraoral photographs will be taken of the labial and lingual surfaces of the upper and lower anterior teeth, and the buccal and lingual surfaces of the upper and lower premolars before treatment. The second photograph is taken after staining the gingival bacterial membrane and the third photograph is taken after professional oral care (Figure 1).

Figure 1. Intraoral photography.
(5) Periodontal pocket measurement

The periodontal pocket depth index was evaluated for 6 teeth after examining the anterior teeth as an indicator of treatment effect. The maximum value (Pocket Depth Maximum) and the average value (Pocket Depth Average) of the 16th, 11th, 26th, 46th, 31st, and 36th teeth were divided into two parts. The The probe is inserted parallel to the long axis of the tooth using a WHO probe with a light force of about 0.25 N (20 to 30 g weight, enough to slightly discolor the skin when applied to the inside of the nail). Insert the probe proximally at six sites per tooth (buccal proximal, buccal central, buccal distal, buccal distal, palatal proximal, palatal central, palatal distal) using the waking technique (as if walking on the base of the periodontal pocket) and measure the depth from the gingival margin to the base of the periodontal pocket to the nearest millimeter. However, when measuring the adjacent surface, the angle of the probe should be slightly inclined toward the midline [18].

(6) Gingival bleeding test

When the gingiva is stimulated with the Watanabe method (toothpick method), the degree of bleeding and pain perception is scored and evaluated from 0 to 4 points.

0: No bleeding

1: Oozing from the gingival fissure

2: Bleeding that stops and starts

3: Continuous bleeding on brushing stimulation

4: Persistent bleeding and pain on brushing stimulation

(7) Statistical analysis

Statistical analysis was performed by ANOVA using IBM SPSS Statistics 24.0 (IBM Inc. Armonk, New York, USA), and Mann-whitney’s U test was used for post hoc testing. The significance level was set at 0.05 and two-tailed tests were performed. p-values for all analyses are presented to 4 decimal places, and p-values <0.05 for all analyses were considered significant.

7) IRB approval

This study is a retrospective study, and an exemption from review was requested from the Institutional Review Board (IRB) of Dankook University (IRB: DKU 2019-05-023), and medical records of patients who received the Continuous Oral Health Care Program were used.

Results

1. Change in periodontal disease assessment among subjects receiving professional oral care

The change in periodontal pocket depth index, gingival bleeding index, and breathview index for all subjects receiving professional oral care is shown in Table 4. In the pocket depth index, tooth #16 had the highest values for the maximum pocket depth and the average pocket depth. The average value of pocket depth average in tooth 16 changed to 2.60±1.57 after treatment, and the maximum value of pocket depth maximum in tooth 16 decreased to 3.82±2.70 after treatment, which was statistically significant (p<0.05). The gingival bleeding index was 2.88 in the first treatment, 1.41 in the second treatment, 0.76 in the third treatment, and 0.34 in the fourth treatment, with a statistically significant difference in bleeding index from the first treatment (p<0.05). Breathview’s halitosis measurement showed that hydrogen sulfide decreased to 176.26±24.60 Ng/ml after treatment, and methyl mercaptan decreased to 39.14±9.09 Ng/ml after treatment, which was statistically significant (p<0.05). The PHP index changed to 3.30±2.39 after treatment, and the M-PHP index decreased to 35.12±25.49, which was statistically significant (p<0.05).

Table 4 . Comparison of periodontal disease assessments in professional oral care candidates (N=91)

BeforeAfterp-value


MeanSDMeanSD
Pocket depth#162.600.491.570.34<001
Average#112.180.431.210.28<001
#262.580.521.500.31<001
#462.590.431.520.36<001
#312.110.391.140.20<001
#362.530.451.460.27<001
Pocket depth#163.821.322.700.94<001
Maximum#113.421.172.100.72<001
#263.771.322.470.82<001
#463.681.212.460.91<001
#313.151.021.920.70<001
#363.801.352.440.72<001
BleedingVisit 22.880.961.410.71<001
Visit 30.760.50<001
Visit 40.340.40<001
HS176.26279.1324.6014.85<001
MM39.1473.769.094.31<001
PHP3.300.492.390.43<001
sPHP3.260.622.340.50<001
mPHP35.127.7525.496.43<001

HS: volatile sulfur compounds: hydrogen sulfide (H2S), MM: methyl-mercaptan (CH3SH), SD: standard deviation, p-value: p-value by ANCOVA adjusted by baseline.



2. Comparison of periodontal disease assessment by gender in professional oral care subjects

Table 5 shows the periodontal disease assessment indexes of female subjects from the first to the fourth periodontal examination. Pocket Depth Average changed to 2.53±1.51 after treatment in tooth 16, and Pocket Depth Maximum changed to 3.65±2.56 after treatment in tooth 16, a statistically significant difference (p<0.05). The gingival bleeding index was 2.85 in the first treatment, 1.41 in the second treatment, 0.73 in the third treatment, and 0.29 in the fourth treatment, with a statistically significant decrease in bleeding index from the first treatment (p<0.05). Breathview’s halitosis measurement showed that hydrogen sulfide (H2S) changed to 186.53±23.93 Ng/ml after treatment, and methyl mercaptan (CH4S) decreased to 34.19±8.96 Ng/ml after treatment, which was statistically significant (p<0.05). The oral hygiene performance (PHP index) changed to 3.25±2.33 after treatment, and the modified oral hygiene performance (M-PHP index) decreased to 34.46±24.88, which was statistically significant (p<0.05).

Table 5 . Comparing periodontal disease assessments by gender (female) (N=57)

BeforeAfterp-value


MeanSDMeanSD
Pocket depth#162.530.431.510.29<001
Average#112.120.371.170.23<001
#262.520.491.470.30<001
#462.510.321.460.28<001
#312.010.361.110.15<001
#362.430.361.410.22<001
Pocket depth#163.651.162.560.87<001
Maximum#113.210.822.050.55<001
#263.651.232.420.80<001
#463.470.892.300.71<001
#312.890.671.820.57<001
#363.471.002.330.55<001
BleedingVisit 22.850.951.410.78<001
Visit 30.730.51<001
Visit 40.290.37<001
HS186.53318.0723.9311.52<001
MM34.1933.928.964.19<001
PHP3.250.412.330.38<001
sPHP3.190.552.230.46<001
mPHP34.467.8824.886.34<001

HS: volatile sulfur compounds: hydrogen sulfide (H2S), MM: methyl-mercaptan (CH3SH), SD: standard deviation, p-value: p-value by ANCOVA adjusted by baseline.



Table 6 shows the periodontal disease evaluation indexes from the first to the fourth period in male subjects. In the periodontal pocket depth index, tooth 16 showed the highest value, and the periodontal pocket depth index was statistically significantly reduced after treatment (p<0.05). Breathview’s halitosis measurement showed a statistically significant decrease in methyl mercaptan (CH4S) to 47.44±9.29 Ng/ml after treatment, but with a standard deviation of 113.01, the difference is not statistically significant.

Table 6 . Comparing periodontal disease assessment by gender (male) (N=34)

BeforeAfterp-value


MeanSDMeanSD
Pocket depth#162.720.571.670.38<001
Average#112.290.491.270.34<001
#262.680.551.550.32<001
#462.720.541.620.45<001
#312.270.401.200.26<001
#362.700.531.530.33<001
Pocket depth#164.121.532.941.01<001
Maximum#113.761.562.180.94<001
#263.971.452.560.86<001
#464.031.572.741.14<001
#313.591.332.090.87<001
#364.351.672.620.92<001
BleedingVisit 22.940.991.410.59<001
Visit 30.810.49<001
Visit 40.420.43<001
HS159.06200.8225.7419.34<001
MM47.44113.019.294.56.053
PHP3.380.602.510.49<001
sPHP3.380.722.510.53<001
mPHP36.247.5326.536.55<001

HS: volatile sulfur compounds: hydrogen sulfide (H2S), MM: methyl-mercaptan (CH3SH), SD: standard deviation, p-value: p-value by ANCOVA adjusted by baseline.



3. Comparison of periodontal disease evaluation in prophylactic periodontal treatment subjects

In the group of patients with grade 1 gingivitis (periodontal pockets of 3 mm or less), the results are shown in Table 7. In the pocket depth index, tooth 16 had the highest values for both the maximum and average values (Pocket Depth Maximum and Pocket Depth Average). The changes in the results of the pocket depth index, gingival bleeding index, breathview index, and oral environmental management ability (PHP index) index were all statistically significant (p<0.05) from pre- to post-treatment values.

Table 7 . Changes in periodontal status in prophylactic periodontal treatment candidates (N=54)

BaseAfter 4 weekp-value


MeanSDMeanSD
Pocket depth#162.460.371.510.25<001
Average#112.050.291.140.12<001
#262.420.361.430.23<001
#462.450.321.490.25<001
#311.950.271.090.11<001
#362.410.361.420.22<001
Pocket depth#163.280.632.410.57<001
Maximum#112.940.491.930.43<001
#263.330.642.220.46<001
#463.260.522.190.52<001
#312.850.451.810.44<001
#363.310.722.200.45<001
BleedingVisit 22.801.031.410.64<001
Visit 30.740.47<001
Visit 40.290.33<001
HS190.54221.5025.5912.16<001
MM31.9320.779.673.62<001
PHP3.330.492.420.39<001
sPHP3.350.652.350.46<001
mPHP36.437.3926.225.59<001

HS: volatile sulfur compounds: hydrogen sulfide (H2S), MM: methyl-mercaptan (CH3SH), SD: standard deviation, p-value: p-value by ANCOVA adjusted by baseline.



4. Comparison of periodontal disease evaluation in partial periodontal treatment subjects

The results of the early periodontal disease (4-5 mm periodontal pockets) group in Grade 2 are shown in Table 8. In the pocket depth index, tooth 46 had the highest mean value (Pocket Depth Average), which changed to 2.68±1.55 after treatment. In the Pocket Depth Maximum index, tooth #36 had the highest value and changed to 4.05±2.42 after treatment, a statistically significant difference (p<0.05). Breathview’s halitosis measurements showed that hydrogen sulfide (H2S) changed to 225.74±23.47 Ng/ml after treatment, with a standard deviation of 479.26±23.90 Ng/ml. Methyl mercaptan (CH4S) changed to 59.00±7.21 Ng/ml after treatment, with a standard deviation of 154.84±5.55 Ng/ml, which is not statistically significant.

Table 8 . Changes in periodontal status in partial periodontal therapy candidates (N=19)

BaseAfter 5 weekp-value


MeanSDMeanSD
Pocket depth#162.600.621.590.51<001
Average#112.250.601.310.43<001
#262.590.521.560.45<001
#462.680.491.550.57<001
#312.220.481.190.32<001
#362.530.401.440.37<001
Pocket depth#164.001.672.841.21<001
Maximum#113.531.122.160.90<001
#263.791.232.470.84<001
#463.681.422.631.12<001
#313.110.881.790.71<001
#364.051.432.420.61<001
BleedingVisit 22.930.841.190.77<001
Visit 30.650.56<001
Visit 40.270.48<001
HS225.74479.2623.4723.90.078
MM59.00154.847.215.55.152
PHP3.260.552.300.54<001
sPHP3.170.542.270.56<001
mPHP34.165.7024.686.23<001

HS: volatile sulfur compounds: hydrogen sulfide (H2S), MM: methyl-mercaptan (CH3SH), SD: standard deviation, p-value: p-value by ANCOVA adjusted by baseline.



5. Comparison of periodontal disease evaluation in overall periodontal treatment subjects

The periodontal disease evaluation index of the advanced periodontal disease group (pathologic pockets of 6 mm or more) in grade 3 is shown in Table 9. In the pocket depth index, tooth 16 had the highest values in the maximum and average values (Pocket Depth Maximum and Pocket Depth Average), which were statistically significantly reduced after treatment (p<0.05). The gingival bleeding index was 3.08 at treatment 1, 1.63 at treatment 2, 0.94 at treatment 3, and 0.54 at treatment 4, with a statistically significant decrease from treatment 1 (p<0.05). Breathview’s halitosis measurements showed that hydrogen sulfide (H2S) changed to 81.22±22.83 Ng/ml after treatment, and methyl mercaptan (CH4S) changed to 39.83± 9.33 Ng/ml after treatment. The values of PHP index and modified oral environmental management index (M-PHP index) were statistically significantly reduced after treatment (p<0.05).

Table 9 . Change in overall periodontal status of periodontal treatment candidates (N=18)

BaseAfter 8 weeksp-value


MeanSDMeanSD
Pocket depth#163.050.391.700.31<001
Average#112.500.391.310.35<001
#263.030.671.660.29<001
#462.890.481.580.37<001
#312.460.361.250.21<001
#362.890.561.590.27<001
Pocket depth#165.281.363.441.10<001
Maximum#114.721.642.560.98<001
#265.061.983.221.17<001
#464.941.593.111.23<001
#314.111.682.391.09<001
#365.001.883.170.99<001
BleedingVisit 23.080.851.630.81<001
Visit 30.940.52<001
Visit 40.540.45<001
HS81.2258.2022.839.70<001
MM39.8338.229.334.43.002
PHP3.250.452.410.44<001
sPHP3.080.622.380.59<001
mPHP32.229.9324.178.73<001

HS: volatile sulfur compounds: hydrogen sulfide (H2S), MM: methyl-mercaptan (CH3SH), SD: standard deviation, p-value: p-value by ANCOVA adjusted by baseline.



6. Change in gingival bleeding in response to stimulation by the toothpick method

There was no difference between each grade, but all subjects showed a significant decrease in the bleeding index from the 1st to the 2nd period and a gradual decrease from the 2nd to the 4th period, and the bleeding almost disappeared after treatment.

Discussion

Periodontal disease is the leading cause of tooth loss in adults over the age of 35. However, no other chronic disease can be prevented as easily and effectively as periodontal disease [19]. Therefore, early treatment and maintenance are important, and systematic, personalised, repeated education and ongoing oral health care that takes into account the patient’s oral characteristics and ability to manage the disease in stages during oral health education are effective in changing the ability to manage the bacterial film on the teeth [20]. The incremental dental care (IDC) system is a dental practice management method that aims to provide regular preventive care according to the patient’s oral condition, to treat oral diseases detected at an early stage, and to maintain and improve the oral health status of the managed patients at the highest level at all times under given conditions and circumstances [21]. Since most people have never experienced perfect oral hygiene, they tend to evaluate their oral hygiene and oral care skills from the subject’s perspective in terms of the time and money they spend on oral care. However, achieving and maintaining the best oral health for a person is a collaborative effort between the professional and the person being managed. It is an ongoing process involving all citizens [16,22] and these repeated interventions are effective in improving the oral environment. Woo and Kim [23] reported that brushing education delivered as a one-time intervention had little effect on actual dental biofilm control and regressed after one month. Slots J and Jorgensen MG [24] reported that patients who receive regular professional care maintain a higher level of attachment gingiva than patients who receive irregular care, which promotes healthy gingival conditions, demonstrating the importance of continuity of care.

If not removed, the bacterial film on the teeth can become thicker over time and can only be removed by physical methods such as brushing. For this reason, many countries, including Korea, have promoted proper tooth brushing techniques through education and various media [25,26]. In Korea, the ‘333 rule’ has long been promoted as a public awareness campaign to publicise the importance of oral hygiene [24], but it is only a recommendation to brush well, and the management of bacterial film on teeth has been left to individual habits. As a result, the majority of Koreans not only do not know the correct oral care methods, but also fail to select appropriate oral products, making it almost impossible to completely remove dental bacterial film at the individual level [27].

Currently, the majority of Koreans practice a uniform rotary brushing method as recommended by oral health education media. Many textbooks and oral health education media in Korea emphasise and recommend only the rotary method, and the subjects in this study generally practised the rotary method, but it is not expected to improve the hygiene of the gingival margins and adjacent surfaces [2,9]. On the other hand, other countries do not refer to a specific brushing method, but rather describe toothbrush movements or starting points [25] and emphasise effective cleaning of the gingival fissure and interdental spaces. In fact, previous studies by Choi and Park [28] have also shown that the rotary method is ineffective in removing the bacterial film on teeth compared to the bath method [29,30]. Therefore, in this study, oral education was performed using the Bath, Stillman, Charters and Ponds methods, which may irritate the gingiva, taking into account the periodontal status of the subjects. In fact, in this study, the Bath method alone was sufficient to achieve a sufficient brushing effect.

Although adults are fully aware of the importance of oral care, they are an age group characterised by poor behaviour change and difficulty in changing their usual lifestyle. This factor leads to uncooperative attitudes and often results in unsuccessful oral education [31]. Therefore, it is important to use various motivational methods to build commitment in order to achieve positive behaviour change in patients [32]. In addition, an individual’s oral environment and brushing performance change with age, and oral living conditions and brushing performance vary from person to person. Therefore, a one- size-fits-all educational approach that does not take into account an individual’s oral environment is unlikely to improve oral hygiene and periodontal disease and is often unsuccessful. Similarly, patients attending the dentist’s office are of different ages, oral conditions and diseases, so education should be tailored to their needs to motivate them and achieve the best educational effect [33]. In this study, the subjects were motivated by the management process of continuous oral health care, in which the subjects themselves experienced the cleanliness and improvement in per.

Conclusion

This preventive care program was conducted to evaluate the improvement of periodontal disease in adults with gingivitis and periodontal disease after receiving periodic oral health care at a dental clinic. The subjects were divided into grades according to their periodontal status, and each grade received professional oral care by performing non-surgical periodontal treatments such as scaling, root planing, and polishing. In addition, after identifying the oral care habits of the subjects, we provided them with customized oral education by grade to improve their oral health every week. The periodontal pocket depth index, oral environment management ability (PHP index) index, modified oral environment management ability (M-PHP index) index, and bad breath (Breathview) index were measured twice before and after treatment, and the gingival bleeding index was checked weekly, and the following results were obtained.

1. Periodontal pocket depth index

Preventive periodontal treatment (grade 1) and overall periodontal treatment (grade 3) groups showed the highest values of pocket depth maximum and average values (pocket depth average) in tooth 16, and the values were statistically reduced after treatment (p<0.05). In the Partial Periodontal Treatment (grade 2) group, the highest pocket depth average was found in tooth 46, which changed to 2.68±1.55. In the Pocket Depth Maximum, the highest value was found in tooth 36, which changed to 4.05±2.42, a statistically significant difference (p<0.05).

2. Gingival bleeding index

After 4 weeks of the professional oral care program, the gingival bleeding index decreased to 2.80±0.29 in preventive periodontal treatment (grade 1) (p=2.51), partial periodontal treatment (grade 2) decreased to 2.93±0.27 (p=2.66), and overall periodontal treatment (grade 3) decreased to 3.08±0.54 (p=2.54), a statistically significant difference (p<0.05).

The analysis of the gingival bleeding index of all subjects showed a statistically significant decrease in the gingival bleeding index from the first treatment, with 2.88 points in the first treatment, 1.41 points in the second treatment, 0.76 points in the third treatment, and 0.34 points in the fourth treatment (p<0.05).

3. Bad breath index (Breathview)

1) In prophylactic periodontal treatment (grade 1), hydrogen sulfide (H2S) decreased by 190.54±25.59 Ng/ml, and methyl mercaptan (CH4S) decreased by 31.93±9.67 Ng/ml, which is statistically significant (p<0.05).

2) In the partial periodontal treatment (grade 2), hydrogen sulfide (H2S) decreased by 225.74±23.47 Ng/ml and methyl mercaptan (CH4S) decreased by 59.00±7.21 Ng/ml, but it is difficult to consider the difference statistically significant due to the significantly higher halitosis index of a small number of subjects.

3) In the overall periodontal treatment (grade 3) group, hydrogen sulfide (H2S) decreased by 81.22±22.83 Ng/ml, and methyl mercaptan (CH4S) decreased by 39.83±9.33 Ng/ml, which was statistically significant (p<0.05).

4. Oral environmental management ability (PHP index) index

PHP index decreased to 3.33±2.42 in the prophylactic periodontal treatment (grade 1) group and 3.26±2.30 in the partial periodontal treatment (grade 2) group. In the overall periodontal treatment (grade 3) group, it decreased to 3.25±2.41, which was statistically significant after treatment (p<0.05).

5. Improved oral environmental control (M-PHP index) index

The M-PHP index decreased to 36.43±26.22 in the prophylactic periodontal treatment (grade 1) group and 34.16±24.68 in the partial periodontal treatment (grade 2) group. In the comprehensive periodontal treatment (grade 3) group, it was 32.22±24.17, which was significantly reduced after treatment (p<0.05).

In all groups of subjects, professional oral care and graded oral education improved the subjects’ oral care ability and improved gingivitis and periodontal disease without any difference in oral health care characteristics.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

References
  1. Han SJ, Kang BW, Kang HK, Kim KS, Kim SS, Kim SA, et al.: Preventive dentistry. Koonja Publishing, Paju, 2015.
  2. Park BJ: A periodical book. Jiseong Publishing, Seoul, 2001.
  3. Ramberg P, Axelsson P, Lindhe J: Plaque formation at healthy and inflamed gingival sites in young individuals. J Clin Periodontol 22: 85-8, 1995.
    Pubmed CrossRef
  4. Kelner RM, Wohl BR, Deasy MJ, Formicola AJ: Gingival inflammation as related to frequency of plaque removal. J Periodontol 45: 303-7, 1974.
    CrossRef
  5. Kang MS, Kim CY, Kim HG, Kim BI: Influence of self-perception, attitude, behavior and knowledge about oral health on caries experience and periodontal treatment need. J Korean Acad Oral Health 18: 144-68, 1994.
  6. Kim JB, Choi EG, Moon HS, Kim JB, Kim DK: Public Health Dentistry. 4th ed. Komoonsa, Seoul, 2004.
  7. Cugini M, Warren PR: The oral-B crossaction manual toothbrush: a 5-year literature review. J Can Dent Assoc 72: 323, 2006.
  8. Oh HM, Lee MG, Lee CH: Oral health care program for the disabled persons using the toothpick tooth-brushing method. Int J Clin Prev Dent 12: 243-8, 2016.
    CrossRef
  9. Eom MR, Jeong DB, Park DY: Enhancement of plaque control score following individualized repeated instruction. J Korean Acad Oral Health 33: 10-8, 2009.
  10. Yang HY: The effects of professional tooth cleaning and dental health education on dental clearances and dental health behaviors. J Korea Acad-Ind Coop Soc 10: 3895-3901, 2009.
    CrossRef
  11. Kim JB, Choi EG, Moon HS, Kim JB, Kim DK: Public Health Dentistry. 5th ed. Komoonsa, Seoul, 2012.
  12. Health Insurance Review & Assessment Service: 2012 National Health Insurance Statistical Yearbook [Internet]. HIRA, Seoul.
  13. HIRA Bigdata Open portal: Disease statistics of public interest periodontal disease and gingivitis [Internet]. Health Insurance Review & Assessment Service, Wonju.
  14. Korean Statistical Information Service: Regional medical use statistics [Internet]. KOSIS, Gwangju.
  15. Lee MS: Problems and improvement measures for oral health projects in Korea. People Power Party, Seoul, 2014.
  16. Kang BW, Kim JY, Kim JH, Moon SE, Han SJ, et al.: Preventive Dental Hygiene Practices. 2nd. Komoonsa, Seoul, 2019.
  17. Kim YS, Oh MJ: The effect of following oral health care on implant patients. J Dent Hyg Sci 9: 491-6, 2009.
  18. Kim SA, Kim KM, Kim EH, Kim JH, Lee MH: Oral prophylaxis. Daehannarae, Seoul, 2018.
    CrossRef
  19. Noh HJ, Park SY: Cost-benefit analysis of periodontal disease prevention - focusing preventive scaling. J Health Info Stat 27: 50-65, 2002.
  20. Sheiham A: Public health aspects of periodontal diseases in Europe. J Clin Periodontol 18: 362-9, 1991.
    Pubmed CrossRef
  21. Shin SC: Clinical preventive care program through analysis of characteristics of each subject. J Korean Dent Assoc 47: 260-71, 2009.
  22. Stabholz A, Mann J, Berkey D: Periodontal health and the role of the dental hygienist. Int Dent J 48: 50-5, 1998.
    Pubmed CrossRef
  23. Woo HS, Kim DK: The effect of TBI on PHP index of workers need scaling. J Korean Acad Oral Health 34: 65-71, 2010.
  24. Slots J, Jorgensen MG: Efficient antimicrobial treatment in periodontal maintenance care. J Am Dent Assoc 131: 1293-304, 2000.
    Pubmed CrossRef
  25. Kremers L, Lampert F, Etzold C: [Comparative clinical studies on 2 toothbrushing methods - roll and bass technic]. Dtsch Zahnarztl Z 33: 58-60, 1978.
    German.
  26. Kim CH, Kim GM, Lee JY, Kwon HK, Kim BI: A comparison of tooth brushing methods recommended in different countries. J Korean Acad Oral Health 39: 195-200, 2015.
    CrossRef
  27. Park DY: Dental clinic's dental biofilm management plan and basic self-care methods. J Korean Dent Assoc 45: 12-20, 2007.
  28. Choi YK, Park DY: Public health dentistry: comparison of rolling method with Bass method toothbrushing practices for efficacy in plaque removal and degree of easiness. J Korean Acad Oral Health 32: 329-38, 2008.
  29. Kim SH: The effect of plaque control (tooth brushing instruction) for oral health improvement on periodontitis patients. J Korean Soc Dent Hyg 11: 293-301, 2011.
  30. Choi YH, Lee JH, Lee SG: Geographical disparities for oral health status in Korean adults. J Korean Acad Oral Health 33: 243-53, 2009.
  31. Han GS, Choi JS, Hong HK, Lee MJ, Bae KH: The effect of professional tooth cleaning and plaque control instruction according to the characteristics of subjects. J Korean Acad Oral Health 32: 453-63, 2008.
  32. Shin JC, Jin KN: The factors influencing the visit to the dental clinic for scaling. Health And Social Science 21: 97-115, 2007.
  33. Ahn JK, Kim JB: An experimental study on the effects of the toothbrushing instructional methods. J Korean Acad Oral Health 9: 127-34, 1985.


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