|Zimmer, Stefan: Kariesprophylaxe als multifaktorielle Präventionsstrategie |
In these days, politics is aimed at enhancing dental prophylaxis by supporting non professional oral hygiene measures. In addition, special programs are developed and carried out which focus on caries prevention in high risk groups as part of dental group prophylaxis.
There are two different strategies for the care of groups with high caries risk. One of them is aimed at identifying high risk children in school mass examinations and referring them to dentists in private practice for individual prophylaxis. This approach bares the risk of loosing children from socially deprived homes because after being identified, they do not take action in going to their dentist. This is why the sickness insurance fund is turning this attempt down: It is rather recommended to provide high risk children with increased numbers of fluoride varnish applications as part of general group prophylaxis. Studies one and two of this thesis examine the efficacy of both approaches to reduce caries in high risk children.
Since general improvement of domestic oral hygiene cannot be obtained by mere motivation and instruction, it seems appropriate to enhance the applied dental supplies in order to make oral hygiene more effective. This aim was recently pursued by industrial branches, which developed manual toothbrushes with specially designed heads and new power toothbrushes. In this thesis, studies three through five are dealing with the efficacy of some of those new developments.
A random sample of 419 children with high caries risk was included into this prospective study. After stratification according to caries-relevant parameters they were randomly assigned to a test and a control group. The test group received professional toothcleaning four times a year. This included the application of a low dose fluoride
241varnish (Fluor-Protector, 0.1% fluoride). At the baseline and after two years, the D1-4MFS, the Quigley Hein Index (QHI) and the Papillary Bleeding Index (PBI) were gathered. Caries increment and the change of QHI and PBI were calculated for both groups. 318 subjects participated at the final examination with 187 subjects in the test group and 131 subjects in the control group.
A statistically significant difference in caries increment between test and control group could only be seen for initial carious lesions (D1,2S. p<0.001). For established lesions no difference could be seen (D3,4MFS). In both groups, there was no change in PBI between the baseline and the final examination. QHI turned significantly worse (p<0.001) in both groups (test group: -0.31; control group: -0.68).
In a socially deprived borrow, application of a high-dose fluoride varnish (Duraphat, 2.26% fluoride) was offered three to four times a year to children with high caries risk. This was done in the school within the group prophylaxis. 269 Children from six primary schools in the borrow of Linden/Limmer in Hannover were assigned schoolwise to a test (n = 116) and a control group (n = 143). Children of the test group received fluoride application for four years, starting in first class. Control group children did not receive fluoride prophylaxis. DMFT was risen at the baseline and after four years. From these data, caries increment was calculated for both groups. Separate analysis was performed for children who attended the program for a minimum of two times per year, resulting in a minimum of eight fluoride applications for the whole study period (n = 67).
Children who had received at least two fluoride applications per year showed 37% less caries increment as compared to the control group (0.99 DMFT in the test group vs 1.40 DMFT in the control group, p<0.05) after an observation period of four years.
A newly developed manual toothbrush with a three-part head (Superbrush) was compared to a powerbrush with oscillating head (Braun Plak Control D5) and a conventional manual toothbrush (Elmex Super 29/39). The study was carried out in an examiner-blinded crossover design. 36 subjects were randomly assigned to three groups. After professional toothcleaning, each group started with a different type of toothbrush. After one week of application, the Quigley-Hein-Plaque Index in the Turesky modification (QHI), the Approximal Plaque Index (API) and the Papillary Bleeding Index(PBI) were gathered. This was followed by a one-week wash-out period. Then the subjects switched to a another type of toothbrush. The process was repeated until every subject had used every toothbrush.
The Superbrush was statistically significantly superior in preventing gingivitis and in removing plaque (p<0.001). No difference could be seen between Braun Plak Control and the conventional manual toothbrush. In the final examination medians of the indices were found to be 0.84 (Superbrush) vs. 1.56 (Braun) and 1.56 (Elmex) for the QHI, 0.69 (Superbrush) vs. 0.87 (Braun) and 0.94 (Elmex) for the API and 0.36 (Superbrush) vs. 0.55 (Braun) and 0.57 (Elmex) for the PBI.
Two sonically activated power toothbrushes (Water Pik Sonic Speed and Sonicare) were compared to a conventional manual toothbrush (Elmex sensitive) considering the efficacy in plaque removal and gingivitis prevention. The study was carried out in a examiner-blinded crossover design. 36 subjects were randomly assigned to three groups. The following indices were gathered: Quigley-Hein Index (QHI), Approximal Plaque Index (API), and Papillary Bleeding Index (PBI). This was followed by a professional tooth cleaning. Then, every group started with a different type of brush. After
243two weeks of application, indices were risen again, followed by a two week wash-out period. The proceeding was repeated in the same manner until every subject had used every type of toothbrush. For statistical analysis, the differences of the indices between baseline and final examination were calculated.
Both sonically activated power-toothbrushes were in all cases statistically significantly superior to the manual toothbrush (p<0.001). The medians of changes were as follows (negative value = deterioration): QHI: 1.48 (Sonic Speed); 1.27 (Sonicare); 0.35 (Elmex); API: 0.39 (Sonic Speed); 0.45 (Sonicare); 0.14 (Elmex); PBI: 0.31 (Sonic Speed) ; 0.49 (Sonicare); 0.13 (Elmex).
Three power toothbrushes with oscillating heads (Krups Biocare Family, Krups Biocare Program, Braun Plak Control Ultra D9) and one Krups power toothbrush which was combined with a water jet (Krups Biocare Jetpack) were compared with a manual toothbrush (Elmex Super 39) regarding the effectiveness in plaque removal and gingivitis prevention. The study was carried out in a examiner-blinded crossover design. 50 subjects were randomly assigned to five groups. Three days after professional toothcleaning the following indices were risen: QHI, API, and PBI. Successively, every group started domestic tooth cleaning with a different system. After eleven days, indices were gathered again, followed by a two-week wash-out period. The process was repeated in the same way, but every group continued with a different tooth-cleaning system. The study was carried out until every subject had run through every system. The increments of the indices between baseline and final examination were calculated.
The Biocare Program was statistically significantly superior to all other systems when regarding the PBI (p<0.01). For the QHI, a difference could only be seen between
244Biocare Program (p<0.001) and Braun Plak Control (p<0.05), respectively and the manual toothbrush. For the API, no difference could be seen among the groups. The medians of change of indices were as follows (negative value means deterioration): QHI: 0.02 (Family); 0.25 (Family); 0.07 (Jetpack); 0.05 (Braun) and -0.18 (Elmex); API: 0.00 (Family); 0.00 (Program); -0.08 (Jetpack); -0.07 (Braun) and -0.04 (Elmex); PBI: 0.00 (Family); 0.09 (Program); 0.00 (Jetpack); -0.04 (Braun) and -0.17 (Elmex).
From the studies concerning children with high caries risk, it may be concluded that regular class-wise application of Duraphat fluoride varnish as a part of group prophylaxis seems to be more suitable for the care of these children than an individualized program with quarterly professional toothcleaning combined with application of a low dose fluoride varnish. From the three studies dealing with the effectivity of new types of toothbrushes, it may be concluded that the manual toothbrush Superbrush and the sonically activated power-toothbrushes were in a clinically relevant manner superior to a conventional manual toothbrush. It may be recommended to rather use those toothbrushes than the conventional one. For the other examined power-toothbrushes, no such clinical superiority was established. It may be concluded that the results of the present studies may contribute to an effective prophylaxis in children with high caries risk and to an improved oral hygiene on the basis of oral self care.
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