effect of controlled oral hygiene procedures on caries and ... · 136 axelsson and lindhe cal...

Journal of Clinical Periodontology: 1978: 5: 133—151

Key words: Prevention — curies - periiidunliiis — adiit/.i.• Accepted for publication: May 26, 1977,

Effect of controlled oral hygieneprocedures on caries and periodontal

disease in adults

p. AXELSSON AND J. LINDHE

Department of Periodontology, Eaculty of Odontology,University of Gothenburg, Sweden

Abstract. The present investigation was carried out to determine if the occurrence of cariesand the progression of periodontitis can be prevented in adults, and maintained at a highlevel of oral hygiene by regularly repeated oral hygiene instructions and prophylaxis. Anattempt was also made to study the progression of dental di.seases in individuals who re-ceived no special oral hygiene instruction but regularly received dental care of a traditionaltype. Two groups of individuals from one geographic site were recruited in 1971—72 forthe trial; 375 were assigned to a test and 180 to a control group. A baseline examinationrevealed that the socio-economic status, the oral bygiene status, the incidence of gingivitisand the caries experience were similar among the test and control participants prior to thestart of the study. During the subsequent 3-year period, the control patients were seenregularly once a year and given traditional dentai care. Tbe test group participants, ontbe otber hand, were seen once every 2 months during the first 2 years and once every3 months during the third year. On an individual basis tbey were instructed in a properoral hygiene technique and given a careful dental prophylaxis including scaling and rootplaning. Each prophylactic session was handled by a dentai hygienist. A re-examinationwas carried out towards the end of the third treatment year. The results of the trial ciearlyshowed that it is possible, by regularly repeated tooth cieaning instruction and prophylaxis,to stimulate adults to adopt proper orai bygiene habits. The findings also demonstratedthat persons who utilized proper oral hygiene techniques during a 3-year period badnegligible signs of gingivitis, suffered no loss of periodontal tissue attachment, and devel-oped practically no new carious lesions. The control patients, wbo during the same periodreceived merely symptomatic treatment, suffered from gingivitis, lost periodontal tisssuesupport and developed several new as well as recurrent, carious lesions. These resultsindicate that dental treatment is a highly ineffective means of curing caries and periodon-tal disease.

It has heen known for many years that among individuals in their natural resis-microorganisms, which colonize the tooth tance to piaque infection arc not appre-surface constitute the primary etiologie ciated and that the presence of variouscomponent for the two most important contributing and modifying factors in theoral diseases, dental caries and periodontitis progression of these diseases is overlooked,(for review see Page & Schroeder 1976 and Until recently, the bacterial infectionsTheilade & Theilade 1976). This statement causing the dental disorders were regardeddoes not imply, however, that differences as nonspecific in character, hut findings

AXELSSON AND LINDHE

reported during the last few years haverevealed the possibility of associating car-ies as well as gingivitis/periodontitis withspecific plaque infections. As a result, var-ious chemical agents, effective against cer-tain types of pathogenic microorganismsand their products, have been tested intrials aiming at caries and gingivitis/pcrio-dontitis prevention (An excellent review on"Chemotherapy of dental plaque infec-tions" was presented by Loesche 1976).Even if considerable information existsregarding the toxicology and effectivenessof a number of different antimicrobialdrugs, their introduction and use in "everyday" dentistry have not yet been recom-mended. Hence, therapy and prevention ofthe two major dental disorders have largelybeen focused on mechanical debridementof the plaque from the tooth surfaces. Anumber of longitudinal studies carried outin adults have been presented which dem-onstrate the effectiveness of mechanicalplaque control in the prevention of gingi-vitis and periodontal disease progression(e. g. Lovdal et al. 1961, Suomi et al. 1971,Ramfjord et a!. 1973, Lindhe & Nyman1975). To our knowledge, however, nolongitudinal study involving adults has sofar been published on the effect of theintroduction of proper oral hygiene habitson both dentai caries and periodontitis.

The aim of the present investigation wasto determine if the recurrence of cariesand the progression of periodontitis can beprevented in individuals maintained at aproper level of oral hygiene. An attemptwas also made to study the progression ofdental diseases in individuals who did notreceive any special oral hygiene instruc-tions, hut who received dental care of atraditional type annually.

Material and Methods

Two groups of individuals from one geo-

Table 1. Number of participants in the clinicaltrial divided into test/control and age groups.Only those individuals who remained in thestudy throughout the 3-year period have heenincluded in the analysisAnzahl der Teilnehmer an der klinischen Stu-die, eingeteilt in Test/Kontroll und Altersgrup-pen. Es wurden die Daten nur soldier Ver-suchspersonen analysiert, die wdhrend der Ge-samtversuchszeit von drei Jahren den Versuchs-gruppen angehort hatten

Nombre de participants a I'essai elinique: re-partition dans les groupes experimentaux (test)/temoins (control) et dans les groupes d'dge. Onn'a pris en consideration dans I'analyse queles sujets ayant continue a participer a l'etudependant les trois annees

Age

InIII

group

< 35 years36-50 years> 50 years

Total

In all

Test

13112865

324

Control

495453

156

480

graphic site (the city of Karlstad, Varm-land, Sweden; 100,000 inhabitants) wererecruited in 1971 for this trial; 375 wereassigned to a test and 180 to a controlgroup. The socio-economic status of thetwo groups of participants was similar.During the 3-year study, 51 individuals inthe test group (14 %) and 24 controls(13 %) were lost. This means that 324test and J56 control patients remained inthe program during the entire observationperiod (Table 1).

Participants were recruited using twomeans; one, being the recall list of threegeneral private practitioners, and the other,the waiting list of three large public dentalhealth clinics. Potential participants forthe test group were informed by letter ofthe purpose of the study and asked tovolunteer for the trial. Potential members

PREVENTION OF CARIES AND PERIODONTAL DISEASE 135

of the control group were informed thatif they agreed to receive a very detailedoral examination they would be recalledfor dental treatment to the public dentalhealth clinic once a year during the next3 years. Only those volunteers who hadsought and received dental treatment an-nually during the last 5 years were se-lected.

Within each test and control group, theindividuals were subdivided into three agegroups. Age group I consisted of patients35 years of age or less, group II containedpatients 36-50 years of age and group IIIcomprised patients who were more than 50years old. Table 1 gives the number of par-ticipants in the test and control groups, aswell as their distribution into age groups.

Baseline ExaminationIn the fall of 1971 and spring of 1972,when all members of the test and controlgroups had been recruited, tbey were sub-jected to a baseline examination which in-cluded assessments of oral bygiene status,gingival inflammation, periodontal diseaseand caries.

Oral hygiene status. The teeth were stainedwith a disclosing solution (Astra Rondell®,pellet) containing 4 % erythrosine. The pa-tient was asked to rinse the mouth vigor-ously with tap water. The presence or ab-sence of continuous plaque in the cervicalportion of four tooth surfaces (buceaLlingual, mesial, distal) of each individualtooth in the dentition was then determined.For each individual, the percentage ofsusceptible tooth surfaces accumulatingplaque was calculated.

Gingival inflammation. Bleeding on prob-ing was considered a clinical sign' ofgingival inflammation. The presence orabsence of gingivitis (bleeding on probing)in four gingival units (buccal, lingual, me-

sial, distal) around each single tootb wasassessed following probing. For each indi-vidual, the percentage of inflamed gingivalunits, in relation to the total number ofgingival units present, was calculated.

Periodontal disease. Pocket depths. Depthsof the clinieal periodontal pockets weremeasured with a flat graduated periodontaiprobe (Hu-Friedy®) on four surfacesaround each tooth. On the mesial (distal)surface, the pockets were measured bothat the mesio-buccal (disto-buccal) and themesio-lingual (disto-lingual) line angle. Ofthe two measurements, only the largestvalue was recorded. The pocket on the buc-cal tooth surface of single-rooted teeth wasalways assessed at the most buccal aspectof the crown. For molars, the eorrespond-ing measurements were made at the mostbuccal aspect of the mesial root. The pocketon the lingual surface was assessed at themost lingual aspect of the crown (root),with the exception of mandibuiar molarsfor wbieh the lingual pocket depth wasmeasured at the most lingua! aspect ofthe mesial root.

Pocket depth measurements were ad-justed to the nearest mm.

Attachment levels. The largest distancebetween the cemento-enamei junction (oranother well-defined landmark on thecrown of the tooth if the cemento-enameijunction was occupied by a restoration)and the bottom of tbe clinical pocket wasassessed at all buccal, lingual and mesialtooth surfaces according to the techniquedescribed by Ramfjord et al. (1968, 1973).The attachment level measurements weremade with the same graduated periodontaiprobe as the pocket depth measurementsand in the same locations. Tliese measure-ments were also adjusted to the nearestmm.

Dental caries. One week before the clini-

136 AXELSSON AND LINDHE

cal examination, four bite-wing radio-graphs (Ultra high speed®, Kodak), twoof each lateral segment of the jaws, weretaken of each subject. The parallelling longcone (Heliodont®, Siemens) technique wasused. The radiographs were, in conjunctionwith the clinical examination, studied sys-tematically and read through a Mattson'sMagnifier (Eiema- Schonander, Sweden).

Immediately prior to the clinical exam-ination, the teeth were carefully cleanedand dried with a blast of air. The area ofexamination was kept dry by placing cottonrolls in the vestibule. New plane mirrorsand new Maillefer® explorers No. 6 wereused for each patient.

The criteria for a caries diagnosis were:Clinical caries: Loss of tooth substancehaving reached the stage of cavitation thatcan be diagnosed with certainty with mir-ror and explorer and appearing on anotherwise intact (sound) tooth surface, pitsand fissures, not earlier restored, wherethe probe with a little pressure sticks andrequires a definite pull for removal (Koch1967 — Code 1). Radiographic caries. Weil-defined decrease in the radiopacity of theproximal enamel which is diagnosed radio-graphically hut cannot be verified clini-cally (Koch 1967 - Code 3). Recurrentcaries. Caries, according to the criteriastated for clinical caries, but occurring ona restored surface (Koch 1967 - Code 4).

DMF-teeth, DMF-surfaces. Followingexamination, each tooth (t) and each sur-face (s) was recorded as either healthy (S),decayed or filled (DF) or missing (M). Ifa tooth or a surface was hoth filled anddecayed the carious lesion was regardedas recurrent caries and included in therecurrent caries pool.

Radiographical ExaminationFor each patient, full-mouth radiographswere taken. A long cone technique wasutilized and the radiographs produced in

accordance with the method described byEggen (1969).

TreatmentFollowing the baseline examination, alicarious lesions were treated and all ill-fitting dental restorations adjusted. Eachpatient was also given a detailed case pre-sentation and a dental prophylaxis.

Plaque Control RegimenExcept for the case presentation and oralhygiene instructions given after the base-line examination, the control patients werenot involved in any dental health programduring the 3-year period. However, 12 and24 months after the baseline examination,the control patients were recalled to thepublic dental health clinic for examinationand to receive whatever dental treatmentthe examining dentist found indicated.During this treatment, there was no discus-sion about oral hygiene methods and thepatients were not encouraged to improvetheir oral hygiene habits.

The test group participants, on the otherhand, were given an entirely different typeof treatment. Once every 2 months through-out the first 2 years, these patients weregiven (1) instruction and practice in oralhygiene techniques and (2) a proper oralprophylaxis. During the third year, thepreventive treatment was provided onceevery 3 months.

Each prophylactic session was handledby a dental hygienist and required about30 minutes. During these sessions, the den-tal plaque was first stained with a disclos-ing pellet, and the Bass method of tooth-brushing demonstrated for each individualpatient. In addition, the patient was toldto use dental floss and toothpicks for inter-dental tooth cleaning. The patients oralhygiene technique was then checked and,if necessary, corrected. The oral hygiene


Group I<35 yrs

10

PLAQUE SCORE %

TEST GROUP CONTROL GROUP

Group 0 °36-50 yrs

Total Appr. Bu-TT Total Appf. Bu-LI

Group in> 50 yrs

Fig, 1. Diagram showing the percentage of tooth surfaces harbouring plaque at the baseline ex-amination (BL) and at the re-examination 3 yeare later {3 years). The patients of the test groupwere subjected to regularly repeated oral hygiene instruction and prophylaxis (once ever>' secondmonth during the first 2 years and once every 3 months during the third year), whereas the con-trols were given traditional, symptomatic dental care once every 12 months. Note the markedimprovment of the oral hygiene status of the test patients and the unchanged plaque scores inthe controls.Das Diagramm zeigt den prozentuellen Anteil dureh Plague verunreinigCer Zahnoberfldchen beider Ausgangsuntersuchung (BL) und bei der KontroUuntersuehung 3 Jahre spdter (3 years). DiePatienten der Testgruppe erhielten regelmassig wiederholte Instruktionen ilber die Teehnik oralerHygiene sowie Prophylaxcbehandlung (wahrend der ersten beiden Jahre einmal jeden zweiten,und wahrend des dritten Jahres einmal jeden dritten Monal). Die Kontroilgruppe erhielt einmaljahrlich traditionell-symptomatische Zahnbehandlung. Beachten Sie bitte die deutiiche Verbesse-rung des Standes der oralen Hygiene bei den Patienten der Testgruppe und die unverdndertenPlague-lndexwerte bei der Kontroilgruppe.

Diagramme montrant le pourcentage des faces dentaires presentant de la plaque a I'exameninitial (BL) et a I'examen final 3 ans plus lard (3 years). Les patients des groupes experimentaux(Test) recevaient des seances regulierement repetees d'instruclions d'hygiene bucco-dentaire etde nettoyage dentaire professionnel (tous les deux mois pendant les 2 premieres annees et tousles trois mois pendant la troisicme annee), tandis que les patients des groupes temoins (Control)recevaient les traitements dentaires symptomatiques traditionnels tous les 12 mois. Noter Vame-Uoration marquee de I'hygiene buccale des patients experimentaux et les valeurs inchangees pourla plaque chez les temoins.


GINGIVITIS SCORE %

Group I<35 yrs

50%

2S

Group n36-50 yrs

so%

Group in>50 yrs

TEST GROUP CONTROL GROUP

-

Total Interpr. Bu-LI

a.Total Interpr. Bu-Li

JL--

Total Interpr. Bu-Li

JL

Totai tnterpr. Bu-Li

r1 1Totai interpr. Bu-Li Total Interpr. Bu-Li

1• BL^ 3 yearsI S.E.

Fig. 2. Diagram showing the percentage of gingival units that were bleeding on gentle probing atthe baseline examination (BL) and the re-examination (3 years). Note that in the test group, atthe re-examination, almost all gingival units were clinically healthy. In the control groups, therev/as no improvement of the gingival condition between the two examinations.Das Diagramm zeigt den prozentuellen Anteil gingivaler Einheiten, die bei der Ausgangsunter-suchung (BL) und der Kontrolluntersuchung (3 years) nach vorsichtiger Sondierung bluteten. Be-achten Sie bitte, dass fast alle gingivalen Einheiten der Testgruppe bei der Koritrollunter.suchungklinisch gesund waren. Jn der Kontrollgruppe wurde keine Verbesserung des Zustandes der Gin-giva zwischen den beiden Untersuehungen festgestellt.Diagramme montrant le poureentage des unites gingivales gui presentaient un saignement lorsdu sondage prudent, d I'examen initial (BE) et d I'examen final (3-years). Noter que, dans lesgroupes experimentaux, presque toutes les unites gingivales etaient cliniguement saines a I'ex-amen final. Dans les groupes temoins, il n'y avait pas d'amelioration de l'etat gingival entre lesdeux examens.

instructions were repeated and checked ateach prophylactic session.

The teeth were then carefully scaled andthe root surfaces planed. Since only 30minutes were allocated for each session.

suhgingival scaling and root planing in mostinstances took three to four appointmentsto complete. Each prophylactic session wasconcluded with a professional tooth clean-ing program. The vestibular and lingual


Table 2. Pocket depths assessed in the test andcontrol groups at the baseline examination(1972)Tasehentiefen der Test- und Kontrollgruppe beider Ausgangsuntersuchung (1972)Profondeur des culs-de-sac mesurees dans lesgroupes experimentaux et dans les groupes te-moins a I'examen initial (1972)

Group

Surfaces

I TotalMesialBuccalDistalLingual

11 TotalMesialBuccalDistalLingual

III TotalMesialBuccalDistalLingual

Pocket depths

X

2.02.61.42.51,5

3,13.72.53.72,6

3.23,82.63,72,7

Test1972

S.E.

0,110,100,050.090.06

0.10O.]20.040.100.08

0.100.100.1 iO.!40,10

Control•

X

1,72.21.12.21.''

2.95-42.23.42.4

3.43.82.93.92.8

1972

S.E,

0,10O.il0,060.070.04

0.090.130.060,120.09

0.090.130.06O.!20.12

Mesial (Mesial, mesiales), buccal (Bukkat, ves-tibulaires), lingual (Lingual, linguales)

surfaees of all teeth were cleaned with theaid of a rotating rubber cup. A rotating,pointed bristle-brusb was used to eleantbe oeclusal fissures. Interdental cleaningwas tben earried out with dentai floss andreciprocating, interproximal tips (Eva Sys-tem®, Dentatus). Particular care was alsotaken to clean the interproximal contactareas. During the cleaning procedure, anabrasive paste containing sodium mono-fluorophospate (Pepsodent®) was used.

Re-examinationThe patients were re-examined 3 yearsafter the baseline examination. During the

re-examination, the parameters studied attbe baseline were recorded again.

Methods of Observational ErrorIn order to determine the observationalerror regarding tbe attachment level as-sessments, 10 randomly selected patientswere examined twice by one dentist at botbthe baseline examination and the re-exam-ination. At the re-examination, but not atthe baseline examination, another 10 ran-domly selected patients were subjected toduplicate recordings of primary and second-ary carious lesions. The duplicate record-ings were always made 10-14 days after tbefirst examination.

Differenees between examinations andgroups regarding plaque, gingivitis, pocketdepth, attachment level, DMF-teeth andsurfaces as well as recurrent caries, wereanalyzed using Student's t-test.

Results

The results from the baseline examinationrevealed only minor differences betweenthe various test and age-matebed controlgroups regarding plaque and gingivitisscores (Figs. 1 and 2), pocket depths (Table2), DMF-teeth (Table 3) and DF-surfaces(Table 4). Tbe individual mean pocketdeptli tended to increase with increasingage. The pockets at the interproximal sur-faces were consistently deeper than thoseat buceal and lingual surfaces. The totalnumber of remaining teeth gradually de-creased from around 26 in age group I« 35 years) to around 19 in age group 111O 50 years). Furthermore, the number ofintact (S) teeth decreased from aroundeight (7.9 test; 8.8 control) in age group Ito around four (3.5 test; 4.2 controls) inage group III. The total number of DF-surfaces did not vary markedly betweentbe different age and test/control groups.The approximal surfaees consistently re-


Table 3. Mean number (S. E.) of decayed, filled, missing (DME) and sound teeth in the test ancontrol groups at the baseline ex:amination.DF = decayed + filled, M = missing, S = sound, intact

Durehschniitliche Anzahl (S. E.) der zerstorten, gefUllten, fehlenden (DMF) und gesunden Zdhnein der Test- und Kontrollgruppe bei der Ausgangsuntersuchung.DF = zerstorte + gefilllte, M = fehlende, S = gesunde, intakte Zdhne

Nombre moyen (erreur-type = S. E.) de dents eariees, obturees, absentes (CAO) et de dentssaines dans les groupes experimentaux et temoins d I'examen initial.DE = eariees + obturees, M = absentes, S = saines, intactes

Group Test Control Difference

I TotalDFMS

II TotalDFMS

i l l TotalDFMS

Table 4. Mean number (S. E.) of decayed and filled (DF-s) tooth surfaces in the test and controlgroups at the baseline examination

Durchschnittliehe Anzahl (S. E.) zerstorter und gefUllter {DF-s) Zahnoberfidchen der Test- undKontrollgruppe bei der Ausgangsuntersuchung

Nombre moyen (erreur-type = S. E.) de faces dentaires eariees et obturees (DF-s) dans lesgroupes experimentaux et temoins d I'examen initial


26.9 (0.4)19.0 (0.4)1.1 (0.4)7.9 (0.5)

25.5 (0.2)20.3 (0.3)2.5 (0.3)5.2 (0.4)

19.3 (0.9)15.9 (0.7)8.7 (0.9)3.5 (0.4)

26.7 (0.6)17.9 (0.8)1.3 (0.5)8.8 (0.7)

23.5 (0.9)17.9 (O.S)4.5 (0.9)5.6 (0.8)

19.4 (1.3)J5.2 (1.1)8.7 (1.0)4.2 (0.7)

NSNSNSNS

NSP < 0.05

NSNS

NSNSNSNS

I I

ra

TotalApproximalBu -H LiOcclusal

TotalApproximalBu -i- LiOcclusa!

TotalApproxima!Bu + LiOcclusal

48.2 (3.7)25.4 (2.0)9.7 (0.7)

!3.1 (0,2)

57.6 (3.4)31.1 (0.8J13.8 (1.1)12.8 (1.2)

5L8 (2.4)25.2 (1.3)17.4 (1.0)9.2 (0.5)

41.3 (2.3)20.8 (1.9)7.3 (I.O)

13.2 (0.5)

47.9 (3.6)26.1 (2.0)11.1 (1.3)10.8 (0.9)

45.2 (4.3)22.7 (2.3)14.7 (1.7)7.8 (0.9)

NSNSNSNS

NSP < 0.05

NSNS

NSNSNSNS

ceived higher DF-values than the buccal groups II and III than in group I. Thereand lingua! surfaces. The number of smooth was a tendency for the control individualssurface lesions (DF) was larger in age of age group II to have a smaller number

PREVENTION OF CARIES AND PERIODONTAL DISEASE

POCKET DEPTH ALTERATIONS 1972-1975

141

Group I<35yrB

Group TL36-50 yrs mm

Group ni _>50yrs ^ ^

Total Mesial Buccal Distal Linqua)

Totai Mesial Buccal Distai Lingual

Total Mesial Buccai Distai Linquai

im Test group^ Control groupI S.E.

Eig. 3. Diagrammatic representation of pocket depth alterations between the baseline examinationand tbe re-examination. In the test groups, a reduction in pocket deptb occurred, while in tbecontrol group, pocket depth increased.Das Diagramm veranschaulicht die Veranderungen der Tasehentiefen zwischen Ausgangs- undKontrollunlersuchung. Bei der Testgruppe kam es zu einer Reduktion der Tasehentiefen, wdhrendbei den Messungen der Tasehentiefen der Kontrollgruppe erhohte Werte festgestellt wurden.Diagramme representant les alterations de la profondeur des culs-dc-sac entre I'examen initial etI'examen final. Dans les groupes experimentaux (Test), il s'est produit une reduction de la pro-fondeur des culs-de-sac, tandis que, dans les groupes temoins (Control), la profondeur des culs-de-sac avait augmente.

of DF-teeth and approximal DF-surfacesthan tbe test patients of tbe same age group(Tables 3 and 4).

The results of the baseline examinationthus revealed that the oral hygiene status,tbe incidence of gingivitis and the cariesexperience were similar among the testand tbe control participants prior to thestart of the preventive programs.

At the re-examination 3 years later, tbeoral hygiene status of al! three test grouppatients (Fig. 1) had markedly improved bycomparison with the baseline data. Thusthe total mean plaque scores had decreasedfrom 62.4 % to 17.4 % (I), 61.9 % to19.1 % (II) and from 63.0 % to 17.8 %(III), This decrease of the plaque scoreswas statistically significant (P <Z 0.001) for


ATTACHMENT LEVEL ALTERATIONS 1972- 1975

Group i<35yrs

0.5^

0 -

0.5

1

Group D36-50 yrs mm

0.5

Total Interpr. Buccal Linqual

innual Loss 0.17 mm


Annua) Loss 0.26 mmGroup 111> 50 yrs ^ ^

O.S —

O-

05

1 -


Annual Loss 0.3 mm

• TesI group(^ Conlrol groupI S.E.

Fig. 4. Diagrammatic illustration of attachment level alterations between tbe examinations in1971-72 and 1974-75. Note that tbe attacbment level remainded more or less unchanged intbe test group patients wbo regularly received oral bygiene instructions and prophylaxis, but in-creased significantly in tbe eontrol groups wbicb were given traditional, symptomatic dental care.Das Diagramm veranschaulicht die Verdnderungen des Attaehment-Niveaus zwischen den Un-tersuehungen 1971--72 und 1974-75. Beachten Sie bitte, dass das Attachment-Niveau der Tesl-gruppe, die regelmdssige Instruktionen und prophylaktische Behandlung erhielt im allgemeinenunverdndert verbiieb. Bei der KontroUgruppe, die traditioiiell-symptomatische Zahnbehandlungerhielt, wurde eine signifikante Senkung des Attachmentniveaus festgestellt.Diagramme representant Ies alterations du niveau de I'attaehement entre les examens de 1971-72et de 1974—75. Noter que le niveau de Vatlaehement restait plus ou moins inchange chez le.spatients des groupes experimentaux, recevant regulierement des instructions d'hygiene buccaleet des nettoyages dentaires professionnels, mais que le retrait etait signijicatij dans les groupestemoins qui reeevaient les soins dentaires symptomatiques traditionnels.

eaeh group. In the control groups there wasno obvious improvment in ora! hygiene be-tween the initial and final examination.

In accordance with the improved ora!hygiene of the three test groups at the re-examination the gingival inflammation

scores were markedly reduced (Fig. 2).The frequency of inflamed gingival unitshad decreased between the baseline ex-amination and the rc-examination from22.2 % to 1.7 % (1), 20.6 % to 1.3 % (II),and 24.7 % to 2.0 % (III). The degree of


Table 5. Attachment level alterations 1972-1975Anderungen des Attachment-Niveaus 1972-1975Modifications du niveau de l'attaehement 1972-1975

Group Test Control

S.E. S.E. Difference

TotalInterprox.BuccalLingual

+ O.i 0.05+ 0.1 OJ± 0 O.i+ 0,1 0,05

- 0.5 0.12- 0.3 0.1- 0.7 0.14- 0.4 0.09

Annual Loss 0.17 mm

P < 0.001P < 0.001F < 0.001P < 0.001

II TotalInterprox.BuccalLingual

+ 0.1 0.05-t-0.1 0.1-t- 0.1 0.05+ 0.1 0.05

- 0.8 0,16- 0.7 0.12- 1.0 O.!5- 0.9 0.13

Annual Loss 0.26 mm

P < 0.001P < 0.001P < O.OOlP < 0.001

in TotalInterprox,BuccalLingual

+ 0.!+ 0.1± 0± 0

0.050.10.050.05

- 0.9- 0.9- 1.1

0.150.130.140.16

Annual Loss 0.3 mm

P < 0.001F < 0.001P < 0.001P < 0.001

Annual loss (Jdhrlicher Verlust, retrait annuel)

improvement of the gingival condition wassimilar in all three groups of patients andhighly significant {P < 0.001). Tn fact, thegingival bleeding scores of around 1-2 %indicated that the test group patients hadclinically healthy gingivae. In the controlgroups, during the observation period, therewere no obvious changes in the number ofgingival units wbicb bled following gentleprobing.

In the test groups there was a significantreduction of clinical pocket depth betweenthe baseline examination and the re-exami-nation (Fig. 3). The mean pocket depthsdecreased from 2.0 to 1.5 mm (1), 3.1 to1.4 (II) and from 3.2 to 1.5 mm (III). Inall age groups the pocket depth reductionwas most pronounced in the interdentalareas. In the control groups there was acorresponding slight increase of pocketdepth (0.5 mm: I, 0.6 mm: II, 0.5 mm:III) hetween the two examinations.

Fig. 4 and Table 5 give the alterationin clinical attachment levels between thebaseline examination and the re-examina-tion 3 years later. In the test groups, therewere no alterations of the attachment level.In ai! three control groups, however, theclinical attachment level had shifted api-cally. In age group I, the loss of attachmentamounted to 0.5 (± 0.12) mm (buccal 0.7,lingual 0.4, mesial 0.3). The correspondingfigures for age groups II and III were 0.8(± 0.16) mm (buccal 1.0, lingual 0.9, me-sial 0.7) and 0.9 (± 0.15) mm (buccal 1.1,lingual 1.1, mesial 0.9). This means that,whereas the test group patients were ableto maintain the level of their periodontaltissue support, the control patients, duringthe observation period, lost some of theirattachment apparatus. There was a ten-dency among control patients for olderindividuals to lose attachment at a fasterannual rate than younger individuals. In


Table 6. Mean number (S. E.) of new decayed and filled tooth surfaces in the test and controlgroups between the baseline examination and re-examination 3 years later.(Bu — Li = Buccal and LingualDurchsclinitttiche Anzahl (S. E.) von neuen zerstorten und gefUltten Zahnoberfldchen zwischender Ausgangsuntersuchung und der Kontrotluntersuchung 3 Jahre spdter bei Test -und Kon-troUgruppe.(Bu - Ei = bukkal und tinguat)Nombre moyen (erreur-type = S. E.) de nouvelies faces dentaires cariees et obturees dans tesgroupes experimentaux et temoins entre l'examen initial et I'examen final 3 ans plus tard.(Bu — Ei = Buccal et tinguat}

Group

n

TotalApproximalBu - LiOcclusal

TotalApproximalBu - LiOcolusal

TotalApproximalBu - LiOcclusal

Test

0.1 (0.1)0.1 (0.1)00

oo

oo

0000

Control

4.6 (0.8)2.8 (0.4)1.7 (0.3)0.1 (0.1)

2.7 (0.5)1.7 (0.3)1.1 (0.3)

. 0

0.4 (0.1)0.2 (0.1)0.3 (0.2)0

Difference

P < 0.001P < 0.001P < 0.001

NS

P < 0.001P < 0.001P < 0.001

NS

P < O.OOINSNSNS

this context it should aiso he realized that,among the control patients, the majoritylost hetween 1-2 mm of attachment. Inage group I, 42.1 % lost on the averagebetween 1-2 mm of attachment. None lostmore than 2 mm. In age group II, 50 %lost between 1-2 mm of attachment and23.3 % lost more than 2 mm. The corre-sponding figures for age group III were69.5 % (1-2 mm) and 21.7 % ( > 2 mm).

The mean numher of new clinical andradiological carious surfaces plus filledsurfaces (DF), that were detected at there-examination, is presented in Table 6.Except for the patients of age group I,who developed 0.1 new DF-surface, thetest group participants did not develop anynew carious lesions during the 3 years thatthey were subjected to intense preventivecare. During the same 3-year period, thecontrols developed 4.6 ± 0.8 (I), 2.7 ± 0.5(II) and 0.4 ± 0.1 (III) new DF-surfaces.It should be observed that the numher of

new DF-surfaces was markedly lower in theolder age group than in the younger, andthat in age groups I and II the majority ofnew lesions appeared on approximal toothsurfaces. In an adult population, recurrentcaries is an important problem. The inci-dence of recurrent caries was more or lessnegligible in all test groups (total mean —0.2 ± 0.1) but in the control groups 5.3 ±1.2 (I), 5.7 ± 0.9 (II) and 4.8 ± 0.4 (III)recurrent carious surfaces were observedat the re-examination (Table 7). Most ofthe recurrent carious lesions occurred onapproximal tooth surfaces. If the meannumber of DF-surfaces and recurrentcarious surface are added, the control pa-tients during the 3 years of observationdeveloped 9.9 ± 1.2 (I), 8.4 ± 1.6 (II) and5.2 ± 0.4 (III) caries attacks. The corre-sponding figures for the test group patientswere 0.1 (I), 0.3 ± 0.1 (II) and 0.2 ± 0.1(III).

Tables 8 and 9 show that the attachment


Table 7. Mean number (S. E.) of tooth surfaces which displayed signs of recurrent caries duringthe 3 years of trialDurchschnittliche Anzahl (S. E.) der Zalinoberflachen mit Anzeichen von wiederauftretenderKaries wdhrend der 3 Versuchs jahreNombre moyen (erreur-type = S.E.) de faces dentaires presentant des signes de recidive decarie pendant les 3 annees de I'experience


I I

TotalApproximalBu + LiOeclusalTotalApproximalBu -F LiOeclusalTotalApproximalBu + LiOeclusal

0000

0.30.20.10

0.20.100.1

(0.1)(0.1)(0.1)

(0.1)(0.1)

(0.1)

5.3 (L2)3.0 (0.6)0.9 (0.3)1.5 (0.4)

5.7 (0.9)3.0 (0.7)1.2 (0.2)1.5 (0.3)

4.8 (0.4)2.5 (0.6)1.4 (0.4)0.9 (0.3)

P < 0.001P < 0.001P < 0.00!P < 0.001

P < 0.001P < 0.001P < 0.001P < 0.001

P < 0.001P < 0.001P < 0.001P < 0.001

Table 8. Errors inherent in the clinical attachment level assessments. The differences noted werecalculated from duplicate assessments of the attachment levels made at the baseline examination(I) as well as at the re-examination (II)IrrtUmer bei der klinischen Bestimmung der Attachment-Niveaus. Die festgestellten Messunter-schiede wurden aus Doppelbestimmungen der Attachment-Niveaus wahrend sowohl der Ausgangs-(!) als auch der Kontrolluntersuchung (II) errechnetErreurs inherentes a la mesure du niveau clinigue de I'attachement. Les differences notees ontete calculees a partir de doubles mesures du niveau de I'attachement, effectuees lors de I'exameninitial (I) ainsi que lors de I'examen final (II)

I

II

(10 patients3X196 surfaces)

(10 patients3X209 surfaces)

Surface

MesialBuccalLingualTotal


s. d. of a singleestimation

0.420.3S0.380.39

0.490,470.540.50

X

diff.

0.0050.0310.0200.019

0.005- 0.033

0- 0.010

Surface (Oberfldche, face), s. d. of a single estimation (SD der einzelnen Bestimmung, ecart-type d'une seule estimation), 10 patients 3X196 surfaces (10 Patienten 3X196 Oberfldchen, 10patients 3 X 196 faces)

level assessments were carried out with ahigh degree of reproducibility and that thepercentage of concordant measurementswere between 85 and 75 %. In this context

it should also be stressed that all discordantmeasurements remained within the 1-mmrange.

Table 10 shows that the consistency in


Table 9. Errors inherent in the clinical attachment level assessments. Number of concordant anddiscordant attachment level measurements carried out in 10 randomly selected patients at thebaseline examination (I) and the re-examination (11). None of the duplicate recordings differedmore tban 1 mm

Irrtiimer bei der ktinischeri Bestimmung der Attaehment-Niveaus. Anzahl iibereinstimmender undnicht-ilbereinstimmender Messungen der Attaehment-Niveaus bei 10 zufdlUg ausgewdhlten Pa-tienten, anldssUch der Ausgarigs- (I) und der Kontrolluntersuchung (11). Keiner der Doppelbe-stimmungen wich mehr als 1 mm ab

Erreurs inlierentes a la mesure du niveau clinique de Vattachement. Nombre de mesures eon-cordantes ou discordantes effectuees chez 10 patients choisis par tirage au sort, a I'examen initial(I) et a i'examen final (11). Aucune des doubles mesures ne divergeait de plus ct'l mm

I

I I



Concordantnieastirements

161168168497

160162157479

Discordantmeasurements

1

18171̂5t

ts202S70

2

17111240

24272778

Agreement%

82.1S5.785.7S4.5

76.677.57S.I76 .̂4

Concordant measurements (Obereinstimmende Messungen, mesures concordantes), discordantmeasurements (Nicht-iibereinstimmende Messungen, mesures discordantes), agreement % [Vber-einstimmung % , accord %)

Table 10. Reproducibility in caries diagnosis. Number of concordant (agreement) and discordant(nonagreement) carious surfaces calculated from duplicate recording of 10 randomly selected pa-tients from the control groups at the re-examinationWiederholbarkeit der Kariesdiagnostik. Anzahl iibereinstimmender und nicht-UbereinstimmenderRegistrierung von Doppelbestimmungen bei 10 zufdllig ausgesuchten Patienten der Kontroli-gruppe, anlasslich der Kontrolluntersuchung

Reproduclibitite du diagnostic de ta carie. Nombre de faces cariees concordantes (accord) ou dis-cordantes (desaccord), catcule a partir des doubles mesures faites chez 10 patients choisis partirage au sort parmi tes groupes temoins u t'examen finat

Non agreement AgreementAgreement j ^ ^ 2nd %

Secondary lesions 29 2 1 90.6Primary lesions 60 4 0 93.8

Agreement (Obereinstimmung, accord), nonagreement (Nicht-Obereinstimmung, desaccord),agreement % (Obereinstimmung %. accord %), secondary lesions (Sekunddre Lasionen, lesions.secondaires), primary lesions (Primdre Edsionen, lesions primaires)

X. c • u- 1. m o /w Discussionthe assessment of canes was high, 93.8 %for primary lesions and 90.6 % for second- The results of the present clinical trial haveary lesions. clearly shown that it is possible, with reg-

PREVENTION OE CARIES AND PERIODONTAL DISEASE 147

ulariy repeated tooth cleaning instructionand prophylaxis, to stimulate adults, youngas well as old, to adopt proper oral hygienehabits. The findings also demonstrate thatpersons who utilize proper oral hygienetechniques during a 3-year period havenegligible signs of gingivitis, display no lossof periodontal tissue attachment, and de-velop practically no carious lesions. Age-matched persons who did not receive pre-ventive but merely symptomatic treatmentduring the same 3 years, suffered fromgingivitis, lost periodontal tissue supportand developed several new as well as re-current, carious lesions.

In general, the observations made in thistrial confirm and extend those presented byLovdal et al. (1961) and Suomi et ai. (1971).Lovdal et al. (1961) showed that oral hy-giene instructions, combined with sub-gingival scaling twice a year during a 5-year period, were effective in reducinggingivai inflammation. Suomi et al. (1971)showed that individuals instructed in goodoral hygiene practice and given frequentoral prophylaxis (at 2-, 3- and 4-month in-tervals) had cleaner teeth, less gingiva! in-flammation and "a slower rate of apicalmigration of the epithelial attachment"'than individuals who during the observationperiod were not receiving these benefits.The present trial, however, goes a stepfurther by demonstrating tbat maintenanceof proper plaque control procedures is alsoeffective in preventing caries from devel-oping. The findings of this study, there-fore, also confirm results from elinicaltrials by, e. g. Lindhe & Axelsson (1973),Poulsen et al. (1976), Karlsson & Larsson(1976), Klock (1976) and Axelsson &Lindhe (1977) who showed that young in-dividuals (schoolchildren, aged 7-17 years)maintained free from plaque infections bymechanical means had only occasional signsof gingivitis and practically no caries.

The results of this and the previous stu-

dies referred to are encouraging becausethey not only reveal the decisive role playedby bacterial plaque in tbe etiology andpathogeneis of periodontitis and caries, butalso demonstrate that, in cbiidren as wellas in adults, a prophylactic program basedon mechanical plaque control may success-fully prevent the two major dental disor-ders from recurring. The significance ofplaque eontrol in periodontal disease treat-ment and prevention has been recognizedfor many years (for review see Loesche1976). Conflicting results bave been pre-sented, bowever, regarding improved ora!hygiene as a caries preventive measure (forreview see, e. g. Bibby 1966, McHugh etal. 1964, GiJlzow 1965, Berenie et al. 1973,Sutcliffe 1973). An expert committee (WHOscientific group 1972) recently concluded,"Brusbing of the teeth and other aids tooral hygiene are only likely to be effectiveas a earies preventive measure to the ex-tent - as yet undefined - tbat they areable to control the accumulation of dentalplaque. For this reason, their efficacy as apublic health measure to prevent cariesshould not be overempbasized". It is im-portant, bowever, to realize tbat tooth-brushing is not synonymous with propertooth cleaning. On the contrary, in manyinstances only buccal and lingual toothsurfaces arc properly cleaned by tootbbrushing leaving plaque on approximalsurfaces untouched. In such cases, inter-proximal caries and gingivitis develop. Aproper plaque eontrol program, however,includes measures which remove plaque onall tooth surfaces. Tbe present study andfindings reported earlier clearly demon-strate that proper plaque control measures(mechanical or chemical) are also highlyeffective in the prevention of caries.

It should not be inferred that the pre-ventive measures utilized in the presenttrial are tbe only or best means of pre-venting periodontitis and caries. Undoubt-


edly tbe procedures applied in this studymay be simplified and improved in severalways. With the present rapid developmentof new, potent antimicrobial compounds,it is likely that within a few years seleetivemeasures, wbicb are directed only againstcaries- and periodontitis-inducing bacteriain plaque, may be successfully used. Al-ready today considerable information existswith regard to the toxicity, effectivenessand cbaracteristics of some drugs wbichmay provide a basis for proper chemicalplaque control programs.

Tbe observations made in the controlgroup patients at the re-examination in1975 demonstrate tbat traditional dentalcare, i. e. symptomatic treatment, mainlyof caries, neither prevents the recurrenceof tbese lesions nor terminates tbe progres-sion of periodontitis. This finding is inclose accordance witb data presented byBjorn (1974). In 1965 and 1971 Bjomexamined the dental health status of in-dividuals, aged 25-65 years, who between1965 and 1971 bad s-ougbt dental treatmenton a yearly or sporadic basis. She foundthat tbe "sporadic dental care" group in1971 had developed slightly more recurrentcaries than the "yearly dental care" group.Sbe also noted that there was no differencebetween the groups regarding the incidenceof primary caries during the observationperiod. Furthermore, she reported tbat theproportion of individuals with calculus wassimilar in tbe two groups, and tbat duringthe 6-year period, a significant reductionof the periodontal bone height had oc-curred wbich was of tbe same magnitudein botb groups. Bjorn (1974) also concludedthat "the incidence of dental disease wasabout the same in the yearly and sporadicdental care groups". The findings presentedby Bjorn and those reported in this study,therefore, imply tbat symptomatic treat-ment has limited, if any, impact on therecurrence and progression of the two

major dental disorders. Similar results baverecently been presented from an examina-tion of a Danish population (Christensen1976). Taken together, these findings mustlead to tbe following question: Can tradi-tional dental care still be regarded as propertreatment? The facts seem to indicate tbatsymptomatic dental treatment is a highlyineffective means of curing caries andperiodontal disease.

The patients in the control groups of thepresent study lost around 0.17-0.3 mmperiodontal tissue attachment per toothsurface and year during tbe 3-year intervalbetween the two clinical examinations. Intbis context it should be realized that lossof periodontai tissue support was assessedby clinical measurements and by the useof a graduated probe. Recent reports (Ca-ton & Zander 1976, Armitage et al. 1977,Lindhe, Hamp & Schroeder 1977) have re-vealed that clinical assessment of the at-tachment level does not necessarily reflecttbe true location of tbe marginal termina-tion of tbe connective tissue attacbment.Hence, loss or gain of clinical attachment,assessed by clinical methods, must be in-terpreted with great caution. The annualattachment loss noted in this material issomewhat larger than that reported bySuomi et al. (1971) (O.I mm/year) butsubstantially smaller than the periodontaltissue breakdown observed by Rosling etal. (1976) in patients who did not carryout proper oral hygiene following perio-dontal surgery (around 1 mm/year duringthe first 2 years following treatment). Thedifferences in degree of attacbment loss be-tween the three studies, however, are mostlikely explained by differences in (1) com-position of patient material, (2) type oftreatment delivered and (3) methods usedto determine attachment levels. In thepresent trial the control patients were be-tween 20 and 71 years old whereas, in thestudy by Suomi et al., tbe participants were


between 18 og 43 years. Since in the presentstudy the annual attachment loss tendedto be larger in the older than in the youngerage group, one may speculate that the pro-gression of periodontitis is more rapid inolder than in younger plaque-infected in-dividuals. Similar observations were re-ported by Bjorn (1974) who noted thatduring a 6-year period the rate of alveolarbone loss was more rapid in the old thanin the younger age groups. If the attach-ment loss of the control patients in groupI of this study (i. e. <C 35 years) is com-pared with the corresponding figure re-ported by Suomi et al., it becomes obviousthat in both samples the average attachmentbreakdown during a 3-ycar period wassimilar, i. e. 0.3 mm. in the study by Ros-ling et al. (1976) the patients, aged 29-68years, were recruited because they had ad-vanced periodontal breakdown and "be-cause each of them had multiple osseousdefects", i. e. they were all individuals whowere highly susceptible to periodontitis.Rosling et al. postulated that surgicalpocket elimination in a plaque-infecteddentition will promote periodontal tissuebreakdown, possibly beyond the rate whichis normal for untreated patients of this agegroup.

Acknowledgements

The authors wish to acknowledge the skilfulwork by the dental hygienists Birgitta Ny-strom and Solgun Sandberg-Folke.

Zusammenfassung

Der Effekt kontrollierter oraler Hygienemass-nahmen auf das Vorkommen von Karies undparodontalen Krankheiten beim ErwachsenenDie vorliegende Untersuchung wurde vorge-nommen um festzustellen, oh das Vorkommenvon Karies und die Weiterentwicklung der Pa-rodontitis bei Erwachsenen verhindert werdenkann. Durch sowohl regelmassig wiederholte In-

struktionen in der Methodik oraier Hygiene alsauch prophylaktische Behandlung wurden Vor-aussetzungen fiir einen hohen Stand oraierHygiene geschaffen. Weiterhin wurde der Ver-such unternommen die Progression von Zahn-krankheiten bei solchen Probanden zu studie-ren, die keinerlei besondere Instruktionen Liberorale Hygiene, jedoch regeimassige traditionelleZahnhehandlung crhieiten. Fiir diese Unter-suchung wurden in den Jahren 1971-72 zweiGruppen gebildet, deren MitgHeder aus dergleichen geographischen Region stammten.

375 Probanden bildeten die Test- und 180Probanden eine Kontroilgruppe. Die Basis-untersuchung zeigte, dass der sozial-okonomi-sche Stand, der Standard der oralen Hygiene,das Vorkommen von Gingivitis und Karies vordem Versuchsbeginn, bei Test- und Kontroil-gruppe etwa gleieh war. Wahrend der dann foi-genden 3-Jahresperiode wurden die KontroU-patienten zu regelmassigen jahriichen KontroU-besuchen bestellt und traditionelle zahnarztli-ehe Behandlung wurde vorgenommen. Die An-gehorigen der Testgruppe hingegen wurdenwahrend der ersten beiden Versuchsjahre jedenzweiten Monat und wahrend des dritten Ver-suehsjahres jeden dritten Monat bestellt, Siewurden individuell in griindlicher oraler Hy-gienetechnik instruiert und mit sorgfaltigerprophylaktischer Therapie, die aueh Zahnstein-entfemung und Wurzelplanung einschloss, be-handclt. Die prophylaktische Behandlung wur-den einem Dentalhygienisten uberlassen. Ge-gen Ende des dritten Versuchsjahres wurdenKontroUuntersuehung en vorgenommen. DieErgebnisse dieser Studie zeigten eindeutig, dasses durchaus moglich ist durch wiederholteInstruktion liber die Teehnik der Zahnreini-gung und durch Prophylaxebehandlungen, Er-wachsene zu z wee km ass ig en oralhygienischenGewohnheiten zu stimulieren. Weiterhin zei-gen die Versuchsergebnisse, dass bei Personendie wahrend einer 3-jahrigen Periode zweck-massige orale Hygieneteehnik angewendet ha-ben nur unbedeutende klinische Zeichen vonGingivitis auftraten, dass kcin Verlust an pa-rodontal-geweblichem Attachment vor lag unddass praktiseh keine r.euen Karieslasionen be-obachtet wurden. Die Kontrollpatienten, diewahrend des gleichen Zeitabschnittes eine mehrsymptomatische Therapie erhielten, hattenGingivitis, verloren gingivaies Stlitzgevvebe undentwickelten sowohl neue als auch sekundarekariose Liisionen. Diese Ergebnisse zeigen,dass reparative Zahnbehandlung ais ein in-effektives Mittel zur Heilung der Karies- und

15Q AXELSSON AND LINDHE

der Parodontalkrankheit angesehen werdenmuss.

Resum§

Action sur la carie dentaire et sur tes affectionsparodontales de procedes d'hygiene bucco-den-taire avec surveillance, chez l'adulteLa presente etude a ete effectuee dans le butd'etabiir s'il est possible d'empecher les cariesdentaires et la progression des parodontites chezdes adultes dont l'hygiene bucco-dentaire estmaintenue a un niveau eleve grace a la repeti-tion reguli^re de seances d'enseignement etd'entrainement aux soins d'hygiene, et de net-toyage et polissage professionnels es dents. Dememe, une etude a ete entreprise sur Ia progres-sion des maladies dentaires chez des personnesne recevant pas d'enseignement special des soinsd'hygiene bucco-dentaire, mais recevant reguiid-rement des traitements dentaires du type habi-tuel. Deux groupes de personnes appartenant aune meme region geographique ont ete recru-tes pour les essais en 1971-1972; 375 sujets for-merent un groupe experimental et 180 sujetsun groupe temoin. Un examen initial a mLsen evidence le fait que Ie niveau socio-econo-mique, le niveau d'hygiene bucco-dentaire,l'incidence des gingivites et l'atteinte de lacarie dentaire etaient semblables chez les par-ticipants des deux groupes avant le debut deI'etude. Pendant la periode des trois anneessuivantes, les patients du groupe temoin ontete vus regulierement une fois par an et ontregu des traitements dentaires de la manierequi se pratique habituellement, Les participantsdu groupe experimental, par contre, etaienlconvoques tous les deux mois pendant les deuxpremieres annees et tous les trois mois pendantla troisieme annee. Au cours de ces seances,ils ont refu individuellement des instructionssur les procedes adequats de soins d'hygienehucco-dentaire, un entrainement pratique etun nettoyage dentaire minutieux, comprenantaussi i'ablation du tartre et !e polissage desraeines. Chacune de ces seances prophylaeti-ques etait menee par une hygieniste dentaire.Un examen final a ete effectue vers la fin dela troisieme annee de traitement. Les resultatsde cette etude ont montre clairement qu'il estpossihle, par des seances repetees regulierementd'instructions aux soins d'hygiene et de nettoy-age professionnel des dents, d'inciter les adul-tes a adopter des habitudes adequates d'hy-gifine bucco-dentaire. Les resultats ont amsimis en evidence que Ies personnes qui, pendant

une periode de 3 ans, pratiquaient des techni-ques adequates de soins d'hygiene, ont pre-sente des signes negligeables de gingivite,n'ont pas souffert de perte du tissu d'attache-ment parodontal et n'ont pratiquement pasete atteints de nouvelles caries. Les patientsdu groupe temoin, qui, pendant la memeperiode, recevaient un traitement puremenlsymptomatique, ont souffert de gingiviles, deperte des tissus de soutien parodontaux et ontete atteints de plusieurs earies nouvelles ainsique de recidives de caries. Ces re.sultats indi-quent que les traitements dentaires constituentun moyen remarquahlement inefficace de soig-ner la earie et les affections parodonlales.

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