Toothbrushing Performance and Oral Cleanliness after Brushing in 12-Year-Old Children.

OBJECTIVES: Nationwide prevention programs in Germany aim to promote oral health. The group prevention program starts in kindergarten and ends when the children are about 12 y old. While in a recent study, toothbrushing behavior of 12-y-old children was analyzed, the present study's objective was to examine the children's ability to achieve oral cleanliness and to analyze how toothbrushing behavior and compliance with the toothbrushing recommendations taught in the group prevention programs predict oral cleanliness. METHODS: Twelve-year-old randomly selected children (N = 174) were asked to brush their teeth to the best of their abilities, and simultaneously a video was recorded for behavioral analyses. Plaque levels were measured before and immediately after toothbrushing. In addition, dental status and gingival bleeding were assessed. RESULTS: After brushing to the best of their abilities, there was plaque on 50% (±24.72%) of all measured sites at the gingival margin (Marginal Plaque Index). Regression analyses revealed approximately 22% of the variance of marginal plaque on the outer surfaces to be explained by the time brushed by circular movements (ß = -0.41;P < 0.001) and the number of sextants brushed for at least 7.5 s (ß = -0.171; P < 0.05). Circular movements explained most additional variance (ΔR2 = 0.113; P < 0.001). With respect to inner surfaces, none of the behavioral aspects explained any variance of oral cleanliness. CONCLUSION: Despite regular group prevention measures, 12-y-old children show limited skills to clean their teeth adequately. Furthermore, none of the recommended behaviors relates to oral cleanliness after toothbrushing at inner surfaces. As a consequence, it is necessary to explore further which behavioral sequences effectively improve oral cleanliness. KNOWLEDGE TRANSFER STATEMENT: This study illustrates that children's compliance to toothbrushing recommendations is not necessarily related to toothbrushing effectiveness. Clinicians should therefore assess the effectivity of recommendations individually and provide individual guidance for improvement.

High Plaque Levels after Thorough Toothbrushing: What Impedes Efficacy?

OBJECTIVES: Previous studies have shown high levels of dental plaque after toothbrushing and poor toothbrushing performance. There is a lack of evidence about what oral hygiene behavior predicts persistent plaque. The present cross-sectional study thus relates toothbrushing behavior to oral cleanliness after brushing and to gingivitis. METHODS: All young adults from a central town in Germany who turned 18 y old in the year prior to the examination were invited to participate in the study. They were asked to clean their teeth to their best abilities while being filmed. Videos were analyzed regarding brushing movements (vertical, circular, horizontal, modified Bass technique) and evenness of distribution of brushing time across vestibular (labial/buccal) and palatinal (lingual/palatinal) surfaces. Dental status, gingival bleeding, and oral cleanliness after oral hygiene were assessed. RESULTS: Ninety-eight young adults participated in the study. Gingival margins showed persistent plaque at 69.48% ± 12.31% sites (mean ± SD) after participants brushed to their best abilities. Regression analyses with the brushing movements and evenness of distribution of brushing time as predictors explained 15.2% (adjusted R2 = 0.152, P = 0.001) of the variance in marginal plaque and 19.4% (adjusted R2 = 0.194, P < 0.001) of the variance in bleeding. Evenness of distribution of brushing time was the most important behavioral predictor. CONCLUSION: Even when asked to perform optimal oral hygiene, young German adults distributed their brushing time across surfaces unevenly. Compared with brushing movements, this factor turned out to be of more significance when explaining the variance of plaque and bleeding. KNOWLEDGE TRANSFER STATEMENT: Results of this study can help clinicians and patients understand the meaning of specific behavioral aspects of toothbrushing for oral cleanliness and oral health.

Toothbrushing and flossing behaviour in young adults--a video observation.

OBJECTIVES: Video observation studies of habitual oral hygiene from the 1970s revealed a striking neglect of brushing oral surfaces and unsystematic brushing patterns with frequent movements between areas. These findings were not systematically followed up; furthermore, nothing is known about whether subjects are able to floss sufficiently. Therefore, the aim of this video study was to analyse the performance of habitual toothbrushing and flossing. METHODS: A random sample of 101 18-year-olds was included. Toothbrush and floss were provided; habitual brushing/flossing was videotaped in a standardised setting and analysed with the video coding software INTERACT. Parameters of interest were toothbrushing duration, type of brushing strokes, brushing patterns, flossed interproximal spaces and flossing technique. RESULTS: The mean brushing duration was 156.0 ± 71.1 s; duration differed only slightly between the upper and lower jaw as well as between the right, left and anterior areas. However, oral surfaces were brushed distinctly shorter than vestibular surfaces (27.1 ± 27.8 s versus 72.1 ± 31.8 s; p ≤ 0.001). Participants brushed different areas of the mouth with different types of strokes, predominantly with horizontal and circular strokes. Brushing movements frequently alternated between areas (45.1 ± 22.4) not randomly but accumulated within a jaw with a tendency to move from the right to the left. Half of the participants flossed, but only one performed sufficiently. CONCLUSIONS: There was a significant neglect of brushing oral surfaces and insufficient use of floss. Brushing patterns were similar to those observed in the 1970s. CLINICAL RELEVANCE: Understanding habitual oral hygiene behaviour is essential for improving oral hygiene instruction strategies.

Comparison of experimental gingivitis with persistent gingivitis: differences in clinical parameters and cytokine concentrations.

BACKGROUND AND OBJECTIVE: Experimental gingivitis has been studied extensively as a well-controlled laboratory model of gingivitis. It is unclear, however, how experimental gingivitis compares with persistent plaque and gingivitis in more naturalistic settings. The present study compares both conditions in a randomized controlled design. MATERIAL AND METHODS: Twenty-six students suffering from plaque and gingivitis were randomly assigned to either a persistent gingivitis or an experimental gingivitis condition. Subjects with persistent gingivitis continued their habitual (i.e. insufficient) oral hygiene behaviour, resulting in persistence of plaque and gingivitis. Experimental gingivitis consisted of initial prophylaxis and subsequent total neglect of oral hygiene. Crevicular interleukin-1beta and interleukin-8 and clinical data were assessed weekly. RESULTS: After 4 wk, subjects with experimental gingivitis showed significantly more plaque accumulation (p = 0.005), higher interleukin-1beta (p = 0.037), and lower interleukin-8 (p = 0.043) concentrations than subjects with persistent gingivitis. Whereas in experimental gingivitis we observed considerable fluctuations in clinical and immunological parameters over the 4-wk period, persistent gingivitis was characterized by little fluctuation, indicating that we were monitoring an inflammatory steady state. CONCLUSION: The data indicate that conditions observed after 4 wk of experimental gingivitis are not comparable with persistent gingival inflammation in a naturalistic setting. Results are discussed with respect to current studies, indicating that chronic inflammation may reflect a stage of down-regulated pro-inflammatory response.

Effects of academic stress on oral hygiene--a potential link between stress and plaque-associated disease?

BACKGROUND: While there seems to be a common belief that psychosocial stress affects oral hygiene behavior, this assumption has rarely been proved. The present study thus aims to analyse stress effects on oral hygiene. MATERIAL AND METHODS: 16 matched pairs of medical students each consisting of 1 student participating in a major academic exam and 1 control without current academic stress, were formed on the basis of baseline plaque levels. At baseline, a professional tooth cleaning was performed. On the last day of exams, students answered questionnaires about oral hygiene during the exams and were afterwards asked to attend for a 2nd dental examination, of which they had no prior knowledge. RESULTS: On the last day of exams, approximately 6 weeks after professional tooth cleaning, 20.9+/-18.3% of control students' sites but only 10.5+/-9.3% of exam students' sites were found to be free of any plaque (p=0.022). Differences were most obvious at oral, as compared to vestibular, sites. Exam students reported a reduction in thoroughness (p=0.019) but not of frequency of oral hygiene behavior. CONCLUSION: The study strongly supports the assumption that psychosocial stress may induce neglect of oral hygiene and increase of plaque accumulation.

Methodological considerations in the assessment of gingival crevicular fluid volume.

In 4 studies on gingival crevicular fluid volume (GCFV) determination, the reliability of measurements, influences of plaque, circadian rhythms and stability over 24 h were examined. Samples were taken at 2 sites with a modified intracrevicular method. Reliability (n=40): repeated GCFV determinations within 5 min revealed good reliability coefficients (r(tt)>0.80). Influences of supragingival plaque (n=80): repeated GCFV determinations within 5 min with plaque removal between measurements in fourty subjects, the other subjects serving as control, revealed no group differences with respect to the differences between measurements. Circadian rhythms (n=20): GCFV was assessed 6x throughout the day. Repeated measures ANOVA revealed no significant time effect. Stability over 24 h under constant clinical conditions (n=20): measures were taken at 16:00 h on 2 consecutive days, several disturbing variables were kept constant. Retest correlations revealed a low stability (i.e., high variability) of GCFV measures under constant clinical conditions (r(tt)=0.38 for tooth 11 and r(tt)= -0.25 for tooth 26). It is concluded that GCFV determination can be done with high reliability, the validity of measurements neither being affected by supragingival plaque nor by diurnal rhythms. The low stability of measurements questions the validity of GCFV for diagnostic purposes.

Prolonged reduction of salivary immunoglobulin A (sIgA) after a major academic exam.

OBJECTIVE: In a previous study we observed a continuous reduction of salivary IgA concentration ([sIgA]) during a period of academic stress. This reduction of sIgA concentration exceeded the stress period by at least 1 week. The present study aimed to replicate and extend our previous finding. In particular, we wanted to examine the time of recovery of [sIgA] alterations associated with academic stress. METHOD: Twenty-seven participants in a major medical exam and 27 controls not participating in any exam during the study provided daily saliva samples (immediately after awakening), from the 6th day prior to their last exam until the 14th day afterwards, for analysis of salivary IgA. Data were averaged for the last weeks of exams and the first and second week after exams, respectively. RESULTS: A prolonged reduction of sIgA in exam students as compared to controls was observed. Fourteen days post-stress sIgA concentrations of exam students were still significantly lower than control levels (P=0.004). No recovery was observable. At the same time exam students and controls did not differ in terms of self-reported stress and recovery. CONCLUSIONS: Psychological and immunological stress effects may be dissociated, the latter considerably exceeding the stress period. A closer look at the temporal dynamics of stress-induced immune alterations might increase our understanding of psychoimmuno relationships.

After-effects of stress on crevicular interleukin-1beta.

BACKGROUND: In a previous study, we found stress to increase crevicular interleukin-1beta (Il-1beta) secretion induced by supragingival plaque. While in that study, stress and plaque were presented concomitantly, we now wondered whether a consecutive presentation of these 2 factors would still exert stress effects. METHOD: 39 medical students participated in the study; 18 took part in a major exam while the remaining 21 served as controls. From the day after the last exam, students neglected oral hygiene in 2 antagonistic quadrants for 21 days (experimental gingivitis), while they maintained perfect hygiene at the remaining sites. Crevicular fluid samples were taken at days 0, 5, 8, 15, 18, and 21 of experimental gingivitis. RESULTS: A significant effect of pre-exposure to academic stress on crevicular Il-1beta concentration was found (area under the curve: p=0.042), the effect size, however, being smaller than in our previous study when stress and plaque were presented concomitantly. CONCLUSIONS: It is concluded that pre-exposure to stress may persistently alter the immunological effects of microbial challenge to the periodontium.

Increase of crevicular interleukin 1beta under academic stress at experimental gingivitis sites and at sites of perfect oral hygiene.

This study analyses the effects of academic stress on crevicular interleukin-1beta(I1-1beta) both at experimental gingivitis sites and at sites of perfect oral hygiene. I1-1beta is thought to play a predominant role in periodontal tissue destruction. 13 medical students participating in a major medical exam (exam group) and 13 medical students not participating in any exam throughout the study period (control group) volunteered for the study. In a split-mouth-design, they refrained from any oral hygiene procedures in two opposite quadrants for 21 days (experimental gingivitis) while they maintained perfect hygiene levels at the remaining sites. Crevicular fluid was sampled for further I1-1beta analysis at teeth 5 and 6 of the upper jaw at days 1, 5, 8, 11, 14, 18 and 21 of the experimental gingivitis period. Exam students showed significantly higher I1-1beta levels than controls both at experimental gingivitis sites (area under the curve, exam group: 1240.64+/-140.07; control group: 697.61+/-111.30; p=0.004) and at sites of perfect oral hygiene (exam group: 290.42+/-63.19; control group: 143.98+/-42.71; p = 0.04). These results indicate that stress might affect periodontal health by increasing local I1-1beta levels especially when oral hygiene is neglected.

Increase in gingival inflammation under academic stress.

Several correlational questionnaire studies have observed a positive relationship between psychological stress and periodontal diseases. This paper analyses the effects of academic stress on periodontal health in a prospective quasi-experimental design. 26 medical students participating in a major exam and the same number of medical students not participating in any exam throughout the study period volunteered for the study. Bleeding on probing was assessed 4 weeks prior to the exam period (baseline) and at the last day of the exam. Severe deterioration in gingival health from baseline to the last exam day were observed more frequently in exam students than in controls (p=0.014). 6 exam students but only 1 control person developed a severe gingivitis at at least one formerly healthy tooth throughout the study period. These results further support the hypothesis that psychological stress is a significant risk factor for periodontal inflammation. Future studies should examine factors mediating this relationship.

Dynamics of stress-related decrease of salivary immunoglobulin A (sIgA): relationship to symptoms of the common cold and studying behavior.

The dynamics of stress-related decrease of salivary Immunoglobulin A (sIgA) were examined with respect to whether an increase of upper respiratory tract (URT) symptoms can be observed concurrently with or subsequent to sIgA alterations and whether one can use students' studying behavior during academic examinations to predict changes in sIgA. From a 2-part medical examination of 42 students, daily measures of sIgA were obtained, and symptoms of URT infections and studying behavior were determined by means of questionnaires. Assessment periods began 7 days before each part of the academic examination began and lasted until the 6th day afterward. A control group of 24 medical students who were not undergoing examinations also responded to all questionnaires. A progressive suppression of sIgA, outlasting the examination period by more than 6 days, was observed. Time spent studying explained a significant proportion in sIgA variation. However, no relationship between sIgA and URT symptoms was observed, nor did students who took academic examinations differ from untested controls in symptom rates.

Amino Acid Effects on Post-Stress Ulcers: Relationship to Brain Serotonin, 5-HIAA and Norepinephrine.

To replicate and extend results of earlier studies on amino acid effects on post-stress ulcers, rats were subjected to i.p. injections of (a) saline, (b) tryptophan, (c) tyrosine + valine or(d) tryptophan + tyrosine + valine, either 30 minutes before or immediately after one hour of water restraint stress. Gastric lesions, brain norepinephrine, serotonin and 5-hydroxyindoleacetic acid (5-HIAA) were examined after one hour of poststress rest. We hypothesised that post-stress lesions could be aggravated by central noradrenergic hypoactivity and serotonergic hyperactivity during the post-stress period. Other studies have indicated that tyrosine + valine reduces central serotonergic activity, while additional tryptophan blocks this effect. We therefore expected post-stress lesions to be reduced in tyrosine + valine but not in tryptophan + tyrosine + valine treated animals. Although these expectations were met tentatively in animals injected prior to stress, thus replicating tyrosine + valine effects we had observed earlier, opposite results were found in animals treated post-stress. The brain analyses indicate that the data cannot be explained by a norepinephrine/serotonin imbalance hypothesis. The time dependency of the effects underlines the need for caution in clinical applications of these amino acid treatments.

Adrenocortical responses to repeated parachute jumping and subsequent h-CRH challenge in inexperienced healthy subjects.

The present study examined the adrenocortical response to 3 consecutive parachute jumps and a poststress h-CRH challenge. Fifteen participants in a parachute-jumping course took saliva samples for later cortisol analysis every 20 min throughout the day, when they accomplished their very first 3 parachute jumps and throughout a control day. The effects of an h-CRH challenge on salivary cortisol were assessed in the evening of the jumping day and on a control day. Parachute jumping induced 3 distinct highly significant adrenocortical responses. The respective cortisol increases for the first, second, and third jump were 39.4 +/- 26.5 nmol/1, 31.4 +/- 21.4 nmol/l, and 16.5 +/- 11.9 nmol/l. Cortisol responses to the first and second jump did not differ but the response to the third jump was significantly reduced [t(13) = 3.11; p = 0.008]. Two groups of subjects were identified, "decreasers," whose response decreased from one to the other jump, and "increasers," whose response remained unchanged or increased. The magnitude of the preceding cortisol response of decreasers exceeded that of increasers significantly by about 30 nmol. The mean adrenocortical effects of the poststress h-CRH challenge and the time-matched challenge on a control day did not differ although, in 4 subjects, the poststress adrenocortical response to h-CRH was completely suppressed.