Oral hygiene and periodontal status of 12 and 15-year-old Greek adolescents. a national pathfinder survey

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1 Oral hygiene and periodontal status of 12 and 15-year-old Greek adolescents. a national pathfinder survey G. Vadiakas*, C. J. Oulis*, K.Tsinidou*, E. Mamai-Homata** and A. Polychronopoulou** Department of Paediatric Dentistry, **Department of Preventive and Community Dentistry, Dental School, University of Athens Key words: Oral hygiene, periodontal conditions, adolescents Postal address: Assoc Prof C. Oulis, Department of Paediatric Dentistry, University of Athens, Greece. cjoulis@dent.uoa.gr abstract aim: To investigate oral hygiene and periodontal status of 12- and 15-year old Greek adolescents, in relation to sociodemographic and behavioural parameters. methods: A stratified cluster sample of year old and year old adolescents of Greek nationality were selected and examined by calibrated examiners. Periodontal and oral hygiene status were assessed using the Community Periodontal Index (CPI) and the simplified Debris Index (DIs) respectively. The socio-demographic and behavioural data collected included region,, gender, parental educational level, tooth brushing frequency and reason for dental attendance. REsulTs: The majority of adolescents aged 12 (75.0%) and 15-years (61.4%) had fair oral hygiene levels. The most frequently observed condition in both ages was calculus with or without bleeding (42.8% in the younger and 53.3% in the older age group). Bleeding on probing was found in 41.5% of the 12-year-olds and in 30.0% of the 15-year-olds. The occurrence of shallow and/ or deep periodontal pockets was very low (0.2%). Multivariable modelling revealed that gender, and tooth brushing frequency were strongly associated with oral hygiene status in both ages; girls, those living in urban areas and brushing teeth more frequently had significantly lower DI-s. was also associated with periodontal status in both ages, while living in urban areas was associated with better periodontal health only in the 15-year-olds. CONClusIONs: The study demonstrated that oral hygiene conditions among Greek children and adolescents are not satisfactory and that the occurrence of gingivitis is high. More efforts on oral health education and oral hygiene instruction are needed to improve their periodontal and oral hygiene status. Introduction The prevalence and severity of oral diseases are influenced by a number of different variables, such as the implementation of preventive programmes, patients oral health education and behaviour, patients and dentists attitudes toward oral health, as well as the availability, accessibility and quality of dental care. Some of these variables may change over time and therefore the oral health of a population may also change. For this reason the World Health Organization suggests the surveillance of oral diseases that can be accomplished by regular clinical oral health surveys, conducted every 5 6 years, by well calibrated examiners, in the same communities or settings in each country, and in certain indicator ages and age groups, using standard criteria for recording clinical conditions [Petersen et al., 2005]. Several countries have adopted this suggestion and carry out population surveys on a regular basis, in order to investigate trends in the epidemiology of oral diseases. However, although there are plenty of data concerning caries experience for school children and periodontal disease prevalence and severity for adults, information on the periodontal health in children and adolescents is insufficient. In the United Kingdom national surveys of children s dental health are conducted every ten years using consistent criteria that allow comparisons between the surveys. According to the results of these surveys a higher proportion of children appeared to have gingival inflammation, plaque and calculus in 2003 than 10 and 20 years before, despite their better tooth brushing behaviours [White et al., 2006]. These findings indicate that more studies are needed to identify trends in the periodontal and oral hygiene status of children and adolescents. These studies may also give us some indications of future health risks of these cohorts [White et al., 2006] since there is evidence that periodontal health at younger ages is positively associated to periodontal condition at later ages [Clerehugh et al., 1995; Lu et al., 2011] and that increased presence of plaque and gingivitis in adolescence is associated with progressive periodontitis in later years [Mombelli et al., 1995]. In Greece, national oral health pathfinder surveys have been conducted in 1985 and This paper presents the findings of the survey of 2005 concerning the periodontal and oral hygiene status of 12- and 15-year-old adolescents in relation to socio-demographic and behavioural parameters. methods A stratified cluster sample of 12- year-old children and 15-year-old adolescents was selected according to the World Health Organization guidelines for national pathfinder surveys [WHO, 1997], including also for comparative reasons the regions in which a previous WHO national pathfinder survey was carried out [Moller and Marthaler,1988]. Namely the study covered two large cities (Athens and Thessaloniki), six counties (Achaia, Chania, Evros, Ioannina, Kastoria, and Larissa), two islands in the Aegean Sea (Lesbos and Naxos), and one island in the Ionian Sea (Kefallinia). Three communities with different socio-economic backgrounds were selected randomly within each of the large cities, while one urban and one rural community were selected randomly within each county or island. Therefore, the survey was conducted in 24 sites (15 urban and 9 rural). European archives of Paediatric Dentistry 13 (Issue 1)

2 G. Vadiakas*, C. J. Oulis*, K.Tsinidou*, E. Mamai-Homata** and A. Polychronopoulou** In each site two schools were randomly selected and at least 50 children from each age were examined. The final sample consisted of 2481 children of Greek nationality, year olds and year olds living in urban and rural areas. All data were obtained in agreement with the Greek ethical regulations and parental consent was required for the children to participate. Prior to the survey, a meeting was organised in Athens Dental School to train and calibrate five examiners. Inter-examiner reliability and agreement was assessed with an experienced investigator as the gold standard. For the examined indices, levels of concordance were very good (kappa coefficient >0.85). The examinations were conducted in the classrooms of the selected schools under artificial light using dental mirrors and the WHO periodontal probe. The recorded variables were periodontal and oral hygiene status. The periodontal conditions were measured using the Community Periodontal Index (CPI) [WHO, 1997]. The oral hygiene status was recorded by means of the simplified Debris Index (DI-s) [Greene and Vermillion, 1964]. Socio-demographic (region,, gender, father s and mother s education) and behavioural (tooth brushing frequency and reason for dental attendance) data possibly related to periodontal and oral hygiene status were obtained from children and the school registers. The classification of education was based on the total number of years of education and was categorised into four levels: less than six years of education (primary education), nine years of education (secondary education-high school), twelve years of education (secondary education-lyceum), more than twelve years of education (higher education). Due to the skewed distribution of the simplified Debris Index data, the corresponding descriptive statistics and analyses were based on the following groupings: 1) Good (score ), 2) Fair (score ) and 3) Poor (score ) [Greene, 1967]. Community Periodontal Index data were also ordered, thus, for both indices the ordinal nature of the data was taken into account in all analyses. Univariate and multivariate models were fitted through ordinal logistic regression analyses. The multilevel structure of the data was taken into account in all models by treating the regions as fixed effects and using robust standard errors which were adjusted for the clustering of children within the same school. All reported probability values were based on two-sided Wald tests and compared to a significance level of 5%. All analyses have been performed using Stata 10.1 (Stata Corp. TX, USA). Results Oral hygiene as expressed by the DI-s value averaged 0.92±0.47 in those aged 12 years (Table 1) and 0.74±0.47 in those aged 15 years (Table 2). Good oral hygiene levels were recorded in 21.5% of the 12-year olds and in 37.2% of the 15-year-olds. The percentage of those with poor oral hygiene level was low ( 3.5%) in both ages. Univariate analysis of the data (Tables 1 and 2) showed that the DI-s score, at both ages, was significantly lower in girls and in those whose parents had a higher educational attainment. Also, the DI-s were lower in those living in urban areas compared to those living in rural ones, the difference reaching significance level only in the 15-year-olds. Significant differences were also observed between the surveyed areas. Among the 12-yearolds, the highest DI-s values were found for those living in Kastoria County (1.22±0.43), while among the 15-year-olds for those living in Achaia County (1.07±0.26). Tooth brushing frequency significantly affected Di-s index level, while reason for dental attendance was a significant predictor of DI-s only among the 12-year-olds. The distribution of adolescents by CPI scores and sociodemographic and behavioural characteristics is presented in Tables 3 and 4. As can be seen, a relatively small percentage of adolescents, comparable for both ages (approximately 16%), exhibited a healthy periodontium. Bleeding on probing indicative of an inflammatory gingival disease was found in 41.5% of the 12-year olds and in 30% of the 15-year olds. The percentage of those with calculus deposits was higher in the older age group (53.3%). Gingival pockets, which were recorded only in 15-year-olds, were found in 0.2% of the subjects examined and in two out of the 11 regions (Evros County and Thessaloniki). According to the results of the univariate analysis (Tables 3 and 4) there were no significant differences in the periodontal condition of adolescents by, gender, parental educational level, tooth brushing frequency and reason for dental attendance. The results of the multivariate regression analysis for DI-s (Table 5) revealed that for both ages, gender, and tooth brushing frequency remained significant predictors of oral hygiene status. Girls, those living in urban areas and brushing teeth at least once a day had significantly better oral hygiene. Also, the oral hygiene status of the 12-year olds was influenced by mother s educational level; having a mother of high educational attainment increased the probability for low DI-s scores. Table 6 demonstrates the results of multivariate analysis for periodontal status. Tooth brushing frequency was significantly associated with periodontal status at both ages. Furthermore, 15-year-olds living in rural areas showed worse periodontal conditions compared to those living in urban ones. 12 European archives of Paediatric Dentistry 13 (Issue 1). 2012

3 Oral hygiene and periodontal status of adolescents Table 1. Observed oral hygiene status of 12-year-old Greek adolescents measured using the simplified Debris Index (DI-s) according to sociodemographic and behavioural parameters. Oral Hygiene level of adolescents (%) N DI-s mean (sd) Good (score ) Fair (score ) Poor (score ) Achaia (0.14) Athens (0.50) Chania (0.56) Evros (0.36) Ioannina (0.36) Kastoria (0.43) Kefallinia (0.12) Larissa (0.39) Lesbos (0.45) Naxos (0.53) Thessaloniki (0.56) Rural (0.43) Urban (0.48) Wald test for ordinal DI-s categories: p>0.05 Boys (0.48) Girls (0.46) Wald test for ordinal DI-s categories: p<0.01 Fathers education 6 years or less (0.47) years (0.46) years (0.49) More than 12 years (0.46) mothers education 6 years or less (0.45) years (0.50) years (0.47) More than 12 years (0.46) Wald test for ordinal DI-s categories: p<0.01 Never/occasionally (0.49) Once a day (0.44) More than once a day (0.48) Pain/problem (0.44) Treatment (0.48) Check-up/prevention (0.48) Total (0.47) European archives of Paediatric Dentistry 13 (Issue 1)

4 G. Vadiakas*, C. J. Oulis*, K.Tsinidou*, E. Mamai-Homata** and A. Polychronopoulou** Table 2. Observed oral hygiene status of 15-year-old Greek adolescents measured using the simplified Debris Index (DI-s) according to sociodemographic and behavioural parameters. 14 Oral Hygiene level of adolescents (%) N DI-s mean (sd) Good (score ) Fair (score ) Poor (score ) Achaia (0.26) Athens (0.45) Chania (0.60) Evros (0.33) Ioannina (0.34) Kastoria (0.45) Kefallinia (0.17) Larissa (0.40) Lesbos (0.46) Naxos (0.53) Thessaloniki (0.49) Rural (0.49) Urban (0.46) Wald test for ordinal DI-s categories: p<0.05 Boys (0.47) Girls (0.47) Fathers education 6 years or less (0.47) years (0.46) years (0.46) More than 12 years (0.48) mothers education 6 years or less (0.47) years (0.47) years (0.47) More than 12 years (0.47) Never/occasionally (0.47) Once a day (0.46) More than once a day (0.45) Pain/problem (0.47) Treatment (0.50) Check-up/prevention (0.45) Wald test for ordinal DI-s categories: p>0.05 Total (0.47) European archives of Paediatric Dentistry 13 (Issue 1). 2012

5 Oral hygiene and periodontal status of adolescents Table 3. Observed periodontal conditions of 12-year-old Greek adolescents measured using the Community Periodontal Index (CPI) according to socio-demographic and behavioural parameters. CPI of adolescents (%) with highest score N 0 - Healthy 1 - Bleeding 2 Calculus Achaia Athens Chania Evros Ioannina Kastoria Kefallinia Larissa Lesbos Naxos Thessaloniki Wald test for ordinal CPI categories: p<0.001 Rural Urban Boys Girls Fathers education 6 years or less years years More than 12 years mothers education 6 years or less years years More than 12 years Never/occasionally Once a day More than once a day Pain/problem Treatment Check-up/prevention Total European archives of Paediatric Dentistry 13 (Issue 1)

6 G. Vadiakas*, C. J. Oulis*, K.Tsinidou*, E. Mamai-Homata** and A. Polychronopoulou** Table 4. Observed periodontal conditions of 15-year-old Greek adolescents measured using the Community Periodontal Index (CPI) according to socio-demographic and behavioural parameters. 16 CPI of adolescents (%) with highest score N 0 = Healthy 1 = Bleeding 2 = Calculus 3+4 = Gingival pocket Achaia Athens Chania Evros Ioannina Kastoria Kefallinia Larissa Lesbos Naxos Thessaloniki Wald test for ordinal CPI categories: p<0.001 Rural Urban Boys Girls Fathers education 6 years or less years years More than 12 years mothers education 6 years or less years years More than 12 years Never/occasionally Once a day More than once a day Pain/problem Treatment Check-up/prevention Total European archives of Paediatric Dentistry 13 (Issue 1). 2012

7 Oral hygiene and periodontal status of adolescents Table 5. Odds ratios and 95% confidence intervals (C.I.) derived from multivariate ordinal logistic regression with simplified Debris Index (DI-s) scores as the dependent variable in 12- and 15-year-old Greek children and adolescents. Risk indicators** 12-year-olds 15-year-olds Odds ratio 95% C.I. p-value Odds ratio 95% C.I. p-value Achaia <0.001 Athens* 1 1 Chania NS Evros Ioannina NS NS Kastoria < <0.001 Kefallinia <0.001 Larissa NS NS Lesbos < <0.001 Naxos NS NS Thessaloniki <0.001 Rural Urban* 1 1 Boys* 1 1 Girls <0.001 mother s education 6 years or less* years NS NS 12 years NS NS More than 12 years NS Never/occasionally* 1 1 Once a day More than once a day <0.001 Pain/problem NS NS Treatment NS Check-up/prevention* 1 1 *Reference category **Father s education eliminated due to co-linearity with mother s education NS= not significant European archives of Paediatric Dentistry 13 (Issue 1)

8 G. Vadiakas*, C. J. Oulis*, K.Tsinidou*, E. Mamai-Homata** and A. Polychronopoulou** Table 6. Odds ratios and 95% confidence intervals (C.I.) derived from multivariate ordinal logistic regression with Community Periodontal Index (CPI) scores as the dependent variable in 12- and 15-year-old Greek children and adolescents. Risk indicators** 12-year-olds 15-year-olds Odds ratio 95% C.I. p-value Odds ratio 95% C.I. p-value Achaia < <0.001 Athens* 1 1 Chania NS NS Evros NS NS Ioannina NS NS Kastoria NS NS Kefallinia NS NS Larissa NS NS Lesbos < <0.001 Naxos < <0.001 Thessaloniki NS NS Rural NS Urban* 1 1 Boys* 1 1 Girls NS NS mother s education 6 years or less* years NS NS 12 years NS NS More than 12 years NS NS Never/occasionally* 1 1 Once a day NS More than once a day Pain/problem NS NS Treatment NS NS Check-up/prevention* 1 *Reference category **Father s education eliminated due to co-linearity with mother s education NS= not significant 18 European archives of Paediatric Dentistry 13 (Issue 1). 2012

9 Oral hygiene and periodontal status of adolescents Discussion This study is part of the 2nd National Pathfinder Survey on the oral health of the Greek population and presents its findings concerning the periodontal and oral hygiene status of adolescents aged 12 and 15 years. Since the simplified pathfinder sampling methodology developed by WHO was used [WHO, 1997], the sample cannot be characterised as random, but it can be considered as illustrative of the whole population, as it ensures the participation of a satisfactory size of people living in representative urban and rural areas of Greece. Furthermore, the thorough training and calibration of the examiners participating in the study ensures the reliable recording of the study parameters. Periodontal health was assessed by means of the Community Periodontal Index (CPI) that measures the prevalence and severity of periodontal diseases [WHO, 1997]. Although the CPI has attracted much criticism [Jenkins and Papapanou, 2001; Leroy et al., 2010] it is an easy to use index [Benigeri et al., 2000] and it constitutes the major source of descriptive epidemiological data on periodontal diseases in many countries, allowing international comparisons. The results of the study revealed that three out of four 12-yearold and three out of five 15-year-old adolescents had fair oral hygiene levels as measured by the simplified debris index (DI-s). Therefore, the oral hygiene conditions of Greek adolescents cannot be considered as satisfactory. Dental plaque has been significantly associated with the severity of periodontal diseases [Corbet and Davies, 1993; Khader, 2006], although its exact role is not fully understood, particularly in areas where the quantity and quality of plaque accumulation is taken into account [Grossi et al., 1995]. Nevertheless, dental plaque is considered today the primary aetiologic factor of chronic gingivitis, while chronic periodontitis is now seen as resulting from a complex interplay of bacterial infection and host response, often modified by behavioural factors (Lopez et al., 2006). In view of these concepts, our findings about the oral hygiene status of Greek adolescents may indicate an increased risk for periodontal diseases in the future. The finding that the majority of subjects examined had fair oral hygiene level is in accordance with those of other studies that have used the DI-s for the determination of the oral hygiene status [Almeida et al., 2003; Deepak et al., 2010] and reflects their tooth brushing habits. In our survey, regular tooth brushing ( 2 times per day) was reported by only 31.5% of those aged 12 years and by 40.4% of those aged 15 years [Vadiakas et al., 2011]. However, international data on oral hygiene practices show that although most people claim to practice oral hygiene measures daily, their oral hygiene conditions are far less than satisfactory [Corbet et al., 2002]. Therefore, it seems that Greek adolescents are in need of oral hygiene instruction in order to brush their teeth more often and effectively. The observation that the 15-year-old adolescents had better oral hygiene status than the younger ones could be attributed to their better oral hygiene habits. The data of the study concerning the periodontal status of subjects examined have shown that the most frequently observed condition in both ages was calculus with or without bleeding. However, the proportion of adolescents with calculus was much greater in those aged 15 than in those aged 12 years. These findings are in accordance with those observed in most other countries [Wang et al., 2002; Almeida et al., 2003; Campus et al., 2007; Lu et al., 2011; WHO, 2011], although in some surveys bleeding on probing was highly prevalent [Plancak and Aurer-Kozelj, 1992; WHO, 2011]. They also reflect the need for scaling and oral hygiene instruction of the surveyed population. The percentage of adolescents with shallow or deep pockets was very low as in most other studies [WHO, 2011], indicating that periodontal attachment loss is infrequent at the age of 15 years. However, a relatively high prevalence of shallow pockets has been reported in some studies [Plancak and Aurer-Kozelj, 1992; Schiffner et al., 2009] and it is recommended that children and adolescents should receive periodic periodontal evaluation as a component of routine dental visits [Califano, 2003]. It is well documented that although dental plaque biofilm is the main aetiological factor of gingivitis and periodontitis, other modifying and risk factors are also important to the initiation and progression of these diseases [Axelsson et al., 2002]. Among the various risk factors, socio-demographic characteristics such as gender,, socio-economic status and place of residence have been associated with the prevalence and severity of periodontal diseases [Albandar, 2002], as well as with the oral hygiene status of individuals of all ages [Koposova et al., 2010; Mamai-Homata et al. 2010]. Our study partly confirmed these associations. Boys had significantly higher DI-s scores than girls at both ages and this can be attributed to their poorer oral hygiene practices. Regular tooth brushing ( 2 times per day) was reported by 22% of the boys and 40% of the girls aged 12 years and by 28% of the boys and 50% of the girls aged 15 years [Vadiakas et al., 2011]. The findings that adolescents living in urban areas and having mothers of higher educational attainment were more likely to have lower DI-s scores emphasise the role of socio-demographic variables in oral hygiene status. Although living in an urban area was a significant determinant for a better periodontal status in the 15-year-olds, the study failed to show a direct relationship between periodontal diseases and gender and mother s educational level. This lack of correlation may be due to the age-related dependence of periodontal diseases severity. Should the age range of our study sample extend to late adolescence, such relationships could possibly show up in our results. The area of residence was also a factor that seemed to influence oral hygiene and periodontal conditions in the population studied. The differences in the DI-s and CPI scores among different regions may reflect differences in socio-economic status, health culture and oral health attitudes and behaviours. European archives of Paediatric Dentistry 13 (Issue 1)

10 G. Vadiakas*, C. J. Oulis*, K.Tsinidou*, E. Mamai-Homata** and A. Polychronopoulou** Our study showed that frequent tooth brushing was associated with a better oral hygiene status and a healthier periodontium. Although not practiced regularly by a significant part of the population studied (20-25%), tooth brushing regimens of at least once a day were reported by most adolescents. Such a finding supports the view, that tooth brushing at home is a well accepted measure for oral prevention among children [Marinho et al., 2004]. Conclusions The results of the present study show that similar to other studies a small percentage of Greek children and adolescents had a healthy periodontium, while the majority of them had calculus with or without bleeding. Since their oral hygiene status cannot be considered as satisfactory there is room for improvement. Therefore, a community approach to controlling periodontal diseases should be based mainly on oral health education programmes addressed to children and parents. Furthermore, local dental practitioners should more intensively educate children and their parents about the importance of maintaining a healthy periodontium, provide oral hygiene instructions and encourage appropriate treatment. acknowledgments The authors are deeply indebted to all the people from the different regions of Greece, who either as examiners or members of the board, or coordinators of the local dental societies, contributed to the completion of this coordinated epidemiological survey, conducted as part of the National Program Assessment and Promotion of the Oral Health of the Hellenic Population which was carried out under the auspices of the Hellenic Dental Association and the coordination of Assoc. Prof. Constantine Oulis, in collaboration with the Dental Schools of Athens and Thessaloniki. 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