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O riginal Paper
Caries Research
Caries Res 1996;30:29-33
Oral Hygiene as a Variable in Dental
Caries Experience in 14-Year-Olds
G. Rollet0
Public Dental Clinic, Lillehammer,
Department of Orthodontics, Faculty o f
Dentistry, University o f Oslo,
Department o f Pedodontics and
Caries Prophylaxis, Faculty of
Dentistry, University o f Oslo, Norway
FvflOQAfl ItO
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K ey W o rd s
A b stra c t
Caries experience
Consumption of sweets
Fluoride prophylaxis
Oral hygiene
The aim of the study was to examine the relationship between oral hygiene level
and caries experience in 14-year-olds using fluoride dentifrices on a regular ba­
sis. Oral hygiene expressed as Gingival Bleeding Points (GBP) was recorded in
267 individuals in the county of Lillehammer in Norway. Total caries experience
as DMFS and approximal carious lesions in the outer half o f the enamel (D ,), in
the inner half of the enamel (D2), in dentin (D3), and fdled approximal surfaces
were registered clinically and on standardized bite-wing radiographs. Using
multiple regression analysis, oral hygiene level expressed as GB1 was the only
factor that could account for variation in caries experience (DMFS). Any signif­
icant effect of consumption of sweets on caries experience could not be demon­
strated with the multivariate analysis. The average percentage of GBP (±SD) was
35.7± 10.0%. The individuals were divided into one group with good oral hygiene
(GBP<35.7%) and one group with poor oral hygiene (GBP>35.7%). Signif­
icantly fewer carious lesions and fdled approximal surfaces were demonstrated
in the group with good oral hygiene compared with the group with poor oral
hygiene. About 16% of the study population used fluoride tablets or fluoride
mouthrinses in addition to a fluoride toothpaste. Only in the good oral hygiene
group, additional fluoride resulted in a lower caries experience compared with
those using only a fluoride toothpaste. In the group with poor oral hygiene, addi­
tional fluoride did not result in lower caries experience. The study thus supported
the view that during regular fluoride exposure oral hygiene level is an important
variable to explain caries risk.
It is well documented that, during the last few decades,
not only the total caries prevalence has been reduced in the
Nordic and in many European countries but there has also
been a change in the distribution of caries in the dentition.
Caries in the anterior teeth has almost disappeared and is
increasingly becoming a pit and fissure phenomenon [Brunelle and Carlos, 1990; Kalsbeek and Verrips, 1990]. Caries
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reduction can be explained nearly exclusively by a fluoride
effect, and mainly by regular use of fluoride toothpastes
[Glass, 1986; Jenkins, 1985; Rolla et al., 1991], Still some
10-15% of the schoolchildren show rather high caries activ­
ity, and 50-75% of orthodontic patients [Gorelick et ah,
1982; Banks and Richmond, 1994] develop enamel demi­
neralization on the labial surfaces during fixed appliance
Bjorn Ogaard
Department of Orthodontics
Faculty o f Dentistry, University of Oslo
PO Box 1109 Blindem
N-0317 Oslo (Norway)
October 17.1994
Accepted after revision:
May 15,1995
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therapy. The caries picture is thus more complex today than
it used to be in the past.
Whereas the majority of studies concerning the relation­
ship between the level of oral hygiene and caries develop­
ment in the past showed no or little effect of oral hygiene,
more recent studies show an increased caries rate in patients
with insufficient oral hygiene [Bellini et al., 1981; StecksenBlicks and Gustafsson, 1986; Williams and Curzon, 1990;
Bjertness, 1991], In a recent study, 0gaard et al. [1994a]
showed that in 15-year-old Norwegians a clear relationship
existed between good oral hygiene expressed as nonbleeding
papillae, and low approximal caries development and pro­
gression. The reason for this change is uncertain and has at­
tracted little attention. It has been suggested that one reason
could be that the final pi 1 in plaque in patients with poor oral
hygiene could be so low that the enhancing effect on remincralization by fluoride was impaired [Rolla et al., 1991],
The aim of the present study was to examine the relation­
ship between dental caries and oral hygiene in 14-year-olds
using fluoride toothpastes regularly and additional fluoride
prophylaxis in the form of tablets or mouthrinses.
Consumption o f Sweets
The individuals were interviewed about the consumption of
sweets. Based on this information three groups were established: (1)
individuals consuming sweets daily (n = 71); (2) individuals consum­
ing sweets 3-4 days per week (n = 157). and (3) individuals consuming
sweets once a week (n = 13).
Caries Experience
The sample was also split into two groups according to low or high
caries experience. The demarcation point was set at DMFS = 6, which
was the average DMFS of the study population. The DMFS scores
were given from both clinical and radiographical evaluations. The
group with low caries experience (D M FSS6) comprised 164 individ­
uals, and the group with high caries experience (D M FS>6) com­
prised 103 individuals.
Statistical A na lysis
Differences between the mean values o f D|, D ., D, and FSA o f the
two groups were evaluated using t tests. Differences between high and
low caries level in individuals with good or poor oral hygiene were
estimated by yy statistics. A one-way analysis o f variance was used to
compare caries experience (DMFS) of the individuals according to
consumption of sweets. A multiple regression analysis was used to
study the influence of all the independent variables (GBI%, consump­
tion of sweets and use o f addition fluoride supplements) on the de­
pendent variable DMFS. All the data were processed using the Mini­
tab Data Analysis Software (Minitab Inc, 3081 Hnterprisc Drive, State
College. Pa., USA). The level of significance was set at 5%.
M a te ria ls and M e th o d s
Gingival /Heeding Index
Gingival Bleeding Index (GBI) by Ainamo and Bay [1975] was
used as a measure for the patients’ hygiene. A blunt pocket probe was
used for gentle probing of the orifice o f the gingival crevice. The pres­
sure used was about 20 g. If bleeding occurred within about 10 s after
testing, a positive finding was recorded. The number o f gingival bleed­
ing points (GBP) was recorded from the buccal, mesial and lingual
surfaces o f the teeth (84 sites). The number of positive findings was
then expressed as a percentage o f the maximum number o f sites.
Approximal Caries Data
Approximal caries data were recorded from standardized bite-wing
radiographs. Caries in the anterior teeth was recorded from clinical ex­
amination and on radiographs in addition if necessary. There were only a
few children in this age group with caries in their anterior teeth.
The following registrations were performed on premolars and mo­
lars: D| = approximal lesions in the outer half of the enamel; D: = ap­
proximal lesions in the inner half of the enamel; D s = approximal le­
sions in dentin and FSA = filled approximal lesions. The sum of ca­
rious approximal surfaces (D|+D-.+D 5) was calculated.
Caries Res 1996:30:29- 33
R e su lts
The average number of GBP calculated in percent for the
whole group was 35.7± 10.0. The group was divided into two
subgroups: group 1 with good oral hygiene (GBP<35.7%)
and group 2 with poor oral hygiene (GBP>35.7%). There
were 146 children in group I and 121 children in group 2. In
group 1 the mean number of GBP was 28.6±5.5%, and in
group 2 it was 44.3±7.0%.
The mean numbers of carious approximal surfaces at the
age o f 14 years are shown in table 1. Group I had significant­
ly fewer approximal lesions and fillings than group 2 with
many GBP.
Table 2 shows caries experience in the individuals con­
suming sweets daily, 3-4 days per week or only once per
week. The individuals consuming sweets daily had signif­
icantly higher caries experience than those few consuming
sweets only once per week (p = 0.03, one-way analysis of
variance). There was no significant difference in caries ex­
perience between those who consumed sweets daily or 3 4
days per week. Table 3 shows the result of the multiple re­
gression analysis. Oral hygiene status as BGI% was the only
factor that could account for variation in caries incidence
Mathicscn/Dgaard/Rol la
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This study was carried out at the Public Dental Service Center in
the town o f Lillehammer in the eastern part o f Norway. All 14-yearolds (n = 267) from the Dental Clinic in Lillehammer were examined
at their yearly dental checkups from April to June 1993. These children
came from the town o f Lillehammer and the surrounding areas (22,000
inhabitants), and all of them claimed to use fluoride toothpaste regu­
larly. About 16% o f the children used fluoride tablets or fluoride
mouthrinses in addition to fluoride toothpaste. The clinical and radiographical examinations were carried out by the same dentist (A.T.M.).
Mean GBP, %
D,+ D,+ D.,
1,4± 1.8
Level of significance obtained from t tests between the groups.
Table 2. Caries experience (DMFS) in 14-year-olds according to
frequency o f consumption o f sweets
Frequency of consumption
DMFS mean 1 SD
3-4 times per week
Once per week
a Statistically significantly different from daily consumers (one-way
analysis o f variance).
The x 2 test showed that only in case of good oral hygiene
supplements to fluoride toothpaste resulted in lower caries
experience (x2 = 8.69, p = 0.01). When oral hygiene was
poor, fluoride supplements apparently had no additional ef­
fect (x2 = 0.384, p<0.1).
D is c u s s io n
Caries has been markedly reduced among children in
Lillehammer in the last 30 years. From 1559 to 1984, Birkeland and Brageline [1987] found a decrease in MFS from
34.1 to 7.5 (78%). In the present study the mean number of
DMFS, excluding D| lesions, was 4.7, indicating a further
decrease in caries prevalence in the area. A continual de­
crease in caries prevalence among Norwegian children has
recently been reported by Haugejorden [1994]. Flowever, a
high prevalence of initial enamel lesions which are general­
ly not fdled was found in the present study. About 39% of all
the individuals had no initial lesions in the outer half of the
enamel (Di = 0) on approximal surfaces of molars and pre­
molars. This is comparable to a study from another district
in the same county, where only 34% o f 388 15-year-olds had
no initial lesions in the outer half of the enamel (D| = 0) on
approximal surfaces of molars and premolars (0gaard and
Oral Hygiene, Fluoride Exposure and Caries
Table 3. Results o f multiple regression analysis with categories of
variables: oral hygiene status as GBI, consumption o f sweets and use
o f fluoride supplements (fluorice mouthrinses or fluoride tablets) as
independent variables and DMFS as dependent variable
GBI, %
t ratio
Rosier, 1991], By taking the oral hygiene level into consid­
eration, almost 70% o f the children with poor oral hygiene
and 54% of children with good oral hygiene had one or
more lesions in the outer half of the enamel (D, > 0 ) on ap­
proximal surfaces of molars and premolars (fig. 1). Only
20% of the children with poor oral hygiene and 39% of the
children with good oral hygiene had no approximal lesions
at all (D|+D2+D3 = 0). The high prevalence of initial lesions
at the age of 14 shows that caries is a potential problem even
at an early age, and especially with poor oral hygiene.
The rationale for evaluating oral hygiene by registration
of bleeding points is that the gingival condition is thought to
be a better indicator of the oral hygiene level than the
amount of plaque at a certain day. A patient who brushes his
or her teeth before an appointment with the dentist may be
judged to have a good oral hygiene by a plaque index,
whereas the GBP index will give a more valid picture of the
current oral hygiene status of the patient.
A univariate analysis of the data shows a statistically sig­
nificant relationship between consumption of sweets and
caries experience (table 2). However, in a multivariate anal­
ysis of the data, taking oral hygiene level into account, no
relationship between consumption of sweets and caries
could be demonstrated. Thus, the statistical relationship
found after applying univariate analysis was probably the
Caries Res 1996;30:29-33
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Table 1. PercentageofG BP(±SD )and
mean (±SD ) D,, D;. D5, sum o f D |+D 2+D 3
and PSA in group I with good oral hygiene
(few GBP) and in group 2 with poor oral hy­
giene (many GBP)
result o f confounding. Sundin et al. [1983] have reported
that in a population exposed regularly to fluoride no strong
relationship exists between caries and consumption of
Using multiple regression analysis, oral hygiene level
was the only factor that could account for variation in caries
experience. This supports the findings by 0gaard et al.
[1994b] from another county in Norway that during regular
use of fluoride toothpaste oral hygiene is a good indicator
for evaluating caries risk. The fluoride factor is most likely
so strong that it can resist quite high exposure to sugar as
long as the oral hygiene level is reasonably good. Interest­
ingly, even during the pre fluoride era of the 1960s, the com­
bination of plaque removal and fluoride was more effective
than fluoride alone [Koch and Lindhe, 1970].
A relationship between social class and caries incidence
has been demonstrated [Hausen et al„ 1981]. No informa­
tion about social classes was available in the present study
as such information is getting increasingly more sensitive
for research purposes. However, the population in Lillehammer is fairly homogenous without any large differences
in socioeconomic factors. Furthermore, social class most
likely influences oral hygiene habits and is thus indirectly
accounted for in the present investigation.
Although all the children in this study claimed to use a
fluoride toothpaste regularly, the amount of fluoride that
each child obtained every day varied according to how often
teeth were brushed in a day. However, none o f these children
showed as much caries as the children did before fluoride
toothpaste came into general use in 1971. Very few tooth­
pastes without fluoride are sold in Norway.
About 16% of the children used fluor tablets or fluoride
mouthrinses in addition to fluoride toothpaste. In the group
with good oral hygiene, this resulted in less caries among
the children who used some fluoride in addition to fluoride
toothpaste. In the group with poor oral hygiene, no differ­
ence was found among those with fluoride in addition to
fluoride toothpaste and the others. Also Seppii and Tolonen
[1990] showed that simply increasing the number of fluo­
ride varnish applications in high-risk individuals did not re­
sult in greater caries reduction.
It may be speculated that the reduced clinical effect of
fluoride in the presence of poor oral hygiene is related to the
saturation level with respect to fluorapatite in the plaque
fluid. In the prefluoridc era even small amounts of plaque
were able to cause demineralization and caries develop­
ment. Only a perfect oral hygiene was able to inhibit caries
during this period, and the number of such patients was so
low that this effect did not appear in epidemiological statis­
tics. At present, when fluoride is used regularly, mostly as
fluoride-containing toothpaste, fluoride inhibits demineral­
ization and enhances remineralization during moderate
challenges. A certain amount of plaque is probably accept­
able under these conditions without caries occurring. The
reason for the difference in significance of oral hygiene in
relation to dental caries before and after the fluoride era is
then conceivably that small to moderate amounts of plaque
which gave caries in the prefluoride era do not produce car­
ies at present. The problem occurs when pH drops so low
that saliva is undersaturated also with respect to fluorapatite
[Larsen, 1990], This can be the situation during poor oral
hygiene and may explain why additional fluoride supple­
mentation does not give enhanced clinical effect [Ogaard et
al„ 1994b).
Based on the findings from the present study it is con­
cluded that oral hygiene is an important factor in the preven­
tion of caries in a population which is exposed to fluoride.
Good oral hygiene and fluoride use then appear to have syn­
ergistic effects.
R efe rences
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