SHORT COMMUNICATION

LA Chambrone
L Chambrone

Results of a 20-year oral hygiene

and prevention programme on caries
and periodontal disease in children
attended at a private periodontal
practice

Authors affiliations:
Luiz Armando Chambrone, Private practice,
Sao Paulo, Brazil
Leandro Chambrone, Division of Periodontics,
Department of Stomatology, School of
Dentistry, University of Sao Paulo, Sao
Paulo, Brazil

Abstract: Objectives: The objective of this study was to evaluate the

long-term effect of an oral hygiene and prevention programme on
caries and periodontal disease in a group of children attended at a
private periodontal practice. Methods: A total of 50 systemically
healthy children, 25 males and 25 females, 0313 years old, were
invited to join a long-term plaque control programme. All children had
no caries and had no evidence of clinical bone loss. The participants
were selected amongst children whose parents (mother, father or
both) were treated of gingivitis, aggressive periodontitis or chronic
periodontitis in a private periodontal practice. Subjects were
separated in groups according to their parents periodontal diagnosis,
i.e., gingivitis, aggressive periodontitis or chronic periodontitis. The
following outcomes were evaluated: a) probing depth, b) plaque (PI)
and gingival (GI) indexes. The plaque control programme applied
consisted of a regular maintenance regime at 6-to 12-month interval
with an experienced periodontist. Results: In total 30 subjects fulfilled
the 20-year period of maintenance. The mean recall frequency was
6.4 ( 3.1) months, and the mean PI and GI were 0.4 ( 0.3) and
0.3 ( 0.3) respectively. The average rate of caries lesions was 1.0
( 1.4). None of the patients exhibited clinical or radiographic
evidences of alveolar bone loss, and no tooth was lost by caries. In
addition, there were no statistically significant differences between
groups (P > 0.05). Conclusions: Adequate oral hygiene measures and
periodic professional plaque control led to low levels of dental plaque,
gingivitis and caries lesions.

Correspondence to:
Dr Leandro Chambrone
Disciplina de Periodontia Departamento
de Estomatologia
Faculdade de Odontologia Universidade
de Sao Paulo
Av. Prof. Lineu Prestes, 2227 Cidade
Universitaria
05508-000 Sao Paulo SP
Brazil
Tel.: Fax: 55 11 30858752
E-mail: chambrone@usp.br

Key words: caries; long-term maintenance; oral health; periodontal

disease
Dates:
Accepted 23 March 2010

Introduction
To cite this article:
Int J Dent Hygiene 9, 2011; 155158
DOI: 10.1111/j.1601-5037.2010.00455.x
Chambrone LA, Chambrone L. Results of a
20-year oral hygiene and prevention programme on
caries and periodontal disease in children attended
at a private periodontal practice.
 2010 John Wiley & Sons A/S

Dental plaque is a term that designates the diverse microbial community

found on a tooth surface as a biofilm, embedded in an extracellular matrix
of polymers of host and bacterial origin (1). Bacterial colonization of the
tooth surface by dental biofilm may lead to clinically significant infection
and may result in gingival inflammation, caries, alveolar bone loss and
tooth loss (24). On the other hand, both caries and periodontitis are considered multifactorial diseases caused by a complex interplay between
Int J Dent Hygiene 9, 2011; 155158

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Chambrone and Chambrone. Long-term plaque control in children

aetiological, environmental and host factors, and genetic predisposition (4, 5). As a result, subjects may differ in their
response to dental plaque (5).
Different studies have demonstrated the effectiveness of
long-term periodontal maintenance and plaque control programmes in preventing caries, periodontal disease and tooth
loss in patients with or without periodontitis (4, 6). However,
one further issue that was not previously evaluated in the literature may be discussed: is there any difference in the outcome
measures achieved by patients who underwent preventive
maintenance and whose parents received a diagnosis of gingivitis, aggressive or chronic periodontitis? Considering this condition, the objective of this study was to assess the incidence
of caries and periodontal disease in a sample of children who
followed a long-term oral hygiene and prevention programme
and whose parents underwent periodontal treatment at a
private periodontal practice.

Study population and methodology

Study population and participants selection

To reach the proposed objective, a set of patients with gingivitis, aggressive periodontitis or chronic periodontitis and who
underwent periodontal therapy in a Brazilian private periodontal practice was invited to enrol their children in a long-term
plaque control programme. Patients (parents) diagnoses were
based on the current classification system at the time of
patient admission (early 80s), therefore their records were
reviewed and reclassified according to 1999 AAP classification
system (7).
A total of 50 systemically healthy high-medium social class
children (25 males and 25 females; 0313 years old) joined the
programme. All children had no caries and had no evidence of
clinical bone loss. At the time of the initial examination, all
parents received detailed information about the proposed preventive programme and gave informed consent. This study
was conducted in accordance with the Helsinki Declaration.

maintenance protocol: (1) update of the medical and dental

histories; (2) dental examination and clinical measurements;
(3) review of the plaque removal efficacy performed by each
child, where children and parents were re-instructed and remotivated about the benefits of performing an adequate plaque
control. Teeth were stained with disclosure solution where
necessary to show the location of dental plaque. Oral hygiene
measures consisted of toothbrushing with a fluoride dentifrice
(at least twice a day) and dental flossing (at least once a day).
Furthermore, parents were instructed to perform the oral
hygiene of kids < 8 years old (i.e. toothbrushing and dental
flossing), or until the child was able to perform their own oral
hygiene alone; (4) review of the childs dietary habits, i.e. children and parents were re-instructed to avoid the ingestion of
food containing sugar between meals; (5) supragingival scaling,
tooth polishing and application of topical fluorides; and (6)
restorative procedures, where indicated. During maintenance
period, periapical and bitewing radiographs were taken as
needed.
In addition, most of the patients were examined in the same
way every time during the 20-years. For the primary dentition
of the very young children (i.e. 0305), it was not possible to
document probing depth at every maintenance appointment.
However, at final examination, all clinical measurements were
repeated.
Statistical analysis

Children were separated into groups according to their parents

periodontal diagnosis, i.e. gingivitis (G), aggressive periodontitis (AP) or chronic periodontitis. Descriptive statistics were
used to synthesize collected data. Differences between the
groups were analysed using a KruskalWallis One-Way anova.
The analyses were performed using the NCSS 2007 software
package (Number Cruncher Statistical System, NCSS, Kaysville, UT, USA). Differences at P < 0.05 were considered statistically significant.

Results
Clinical and radiographic measurements

At the initial examination, full medical and dental history was

obtained. Data included probing depth, plaque (PI) (8) and
gingival (GI) (9) indexes. Six sites around each tooth were
evaluated. Periapical and bitewing radiographs were taken as
needed to provide information about the level of the alveolar
bone and the occurrence of caries respectively. Probing depth
was recorded by the same investigator using a Williams-style
periodontal probe. The measurements were rounded to the
nearest 0.5 mm.
Oral hygiene and caries prevention programme

The plaque control programme applied consisted of regular

maintenance regime at 6-to 12-month interval with an experienced periodontist (L.A.C.). All participants followed a similar
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Int J Dent Hygiene 9, 2011; 155158

A total of 50 patients were invited to participate in the programme. In total 27 patients (90.0%) were above 06 years of
age and nine (30.0%) were between the ages of 11 and 13 at
the time of initial therapy. There were 16 females and 14
males ranging from 23 to 33 years of age. A total of 20 patients
(40.0%) discontinued their participation because of the lack of
interest in the prevention programme (these subjects did not
comply with maintenance schedule). Thus, the final sample
comprised of 30 patients who fulfilled the 20-year period of
maintenance (Table 1).
At the final examination, the mean recall frequency was 6.4
( 3.1) months, and mean PI and GI were 0.4 ( 0.3) and 0.3
( 0.3) respectively. The average rate of caries lesions (i.e. initial and manifest) was 1.0 ( 1.4). According to the number of
caries lesions during the period of preventive maintenance, 18
participants (60.0%) had no caries lesions, three (10.0%) had

Chambrone and Chambrone. Long-term plaque control in children

Table 1. Distribution of subjects according to age (n = 30)

Age

Initial examination,
n (%)

36
710
1113
Total

3
18
9
30

(10.0)
(60.0)
(30.0)
(100.0)

Table 2. Clinical measurements at 20 years evaluation (n = 30)

Plaque index
G
AP
CP
Gingival index
G
AP
CP
Caries lesions
G
AP
CP

P-value
(ANOVA)

Mean

SD

0.5
0.4
0.5

0.3
0.2
0.3

NS

0.2
0.3
0.4

0.1
0.2
0.5

NS

1.1
0.8
1.2

1.5
1.4
1.5

NS

SD, standard deviation; G, gingivitis group (n = 8); AP, aggressive

periodontitis group (n = 11); CP, chronic periodontitis group
(n = 11); NS, non-significant.

one caries lesions, one (3.5%) had two caries lesions, six
(20.0%) had three caries lesions and two (6.5%) had four caries
lesions. In total, 7 initial and 16 manifest caries lesions were
found. None of the patients exhibited clinical or radiographic
evidence of alveolar bone loss, and no tooth was lost by caries
lesions. In addition, there were no significant differences
between groups with regard to the clinical parameters
(Table 2).

Discussion
In this short-communication of a group of children maintained
by a plaque control programme during 20 years, none of the
patients showed clinical or radiographic evidence of destructive
periodontal disease. Besides, more than a half of the subjects
(60%) did not show the occurrence of caries lesions and 26.5%
of the patients (i.e. subjects with three and four caries lesions)
were responsible for most of the lesions (83.8%) during the
maintenance period. Furthermore, 30% of caries lesions were
initial, while 70% were manifest. This is in line with data from
previous surveys (4, 6), which demonstrated that preventive
programmes (i.e. plaque control programmes) can improve the
oral hygiene status and reduce the levels of caries lesions and
gingivitis in most subjects over long-term periods. Moreover,
there were no statistically significant differences in the clinical
parameters (i.e. plaque and gingival indexes) and in the number of caries lesion between G, AP and CP groups (Table 2).

This fact suggests that periodontal disease may be prevented

independently to genetic predisposition when an adequate plaque control is performed.
The relationship between plaque accumulation and progressive gingival inflammation around teeth was confirmed by Loe
et al. in 1965 (2). While options in the treatment and prevention of gingivitis emerge to be well established, the adsorption
of biomolecular pellicles, and the subsequent accumulation
and metabolism of bacteria on tooth surfaces, is still the main
stimulus for the induction of inflammatory processes. With
respect to periodontal diseases, periodontitis is the most significant of these infections because it may cause loss of attachment and tooth loss (4, 6, 7). Of the 30 subjects present at the
20-year follow-up examination, 11 (33%) were from the AP
group. Aggressive periodontitis is a multifactorial disease and it
may affect 5.5% (10) to 9.9% (11) of the Brazilian young population. In contrast to other forms of periodontal disease, the
amount of periodontal loss is not consistent with the presence
of dental plaque and the rate of progression is rapid (7). On
the other hand, both aggressive and chronic periodontitis are
preceded by marginal gingival inflammation. Moreover, the
development and progression of the disease may be affected
by the combination of dental plaque (e.g. type and amount of
plaque), environmental factors (e.g. smoking) and individual
host response (4, 6, 7). Consequently, an adequate plaque control will play a key role in the prevention of such diseases (4).
Studies comparing the effects of long-term preventive programmes in South America are scarce. With regard to cross-sectional studies evaluating the oral health conditions in young
Brazilian populations, the prevalence of caries has varied from
65.1% at the age of 15 (12) to 82.6% at the age of 18 (13). For
gingivitis, three previous studies evaluating the prevalence of
gingivitis in a sample of scholars, 0714 years old, showed that
the clinical signs of gingival inflammation were found in all
the examined subjects. However, the severity of gingivitis was
directly linked to the amount of dental plaque deposits and to
the presence of bleeding on probing (1416).
This study was completed at a private practice and may
have some inherent limitations, such as the sample size, the
lack of a parallel control group or blinded examinations. In our
study, given the small number of subjects, subgroup comparisons according to age were not performed. Also, children were
separated into groups according their parents periodontal diagnosis. It should be noticed that DNA sequencing models or
polymerase chain reaction were not the current methods used
to evaluate genetic predisposition at the time of children
admission. In the early 1980s, study designs examining the
genetic influence on periodontal disease included the association of disease with inherited tissue markers, as well as family
and population predisposition-based models (17). Of the available models, we opted to group the subjects based on their
parents periodontal diagnosis. Despite these limitations, the
results of this clinical survey demonstrated the positive effects
of oral hygiene and periodic periodontal maintenance.
In addition, as previously reported by another long-term
study (4) caution must be taken when comparisons are made,
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Chambrone and Chambrone. Long-term plaque control in children

for instance, with patients attended at dental hospitals, i.e.

public dental practice, where the subjects may present different clinical, environmental and socio-economic conditions from
those currently attended in a conventional private practice.
These conditions may cause more variability of the results
when extrapolated to longitudinal trials (18).
In summary, within the limits of this study, the selected
group of children submitted to a 20-year preventive programme at a private periodontal practice showed no periodontal tissue loss, no tooth loss, low levels of plaque and gingivitis
and a low prevalence of caries lesions.

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