Original papers

The relationship between oral hygiene level and gingivitis in children

Tamara Pawlaczyk-KamieńskaB–E, Natalia Torlińska-WalkowiakB–E, Maria Borysewicz-LewickaA,E,F
Department of Pediatric Dentistry, Poznan University of Medical Sciences, Poland

A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation;
D – writing the article; E – critical revision of the article; F – final approval of the article

Advances in Clinical and Experimental Medicine, ISSN 1899-5276 (print), ISSN 2451-2680 (online) Adv Clin Exp Med. 2018;27(10):1397–1401

Address for correspondence
Tamara Pawlaczyk-Kamieńska
Abstract
E-mail: [email protected] Background. The condition of the teeth, periodontium and oral mucosa determines directly and indirectly
the general health of the organism and, therefore, requires to be monitored. Childhood, especially the first
Funding sources years of life, is the time when proper health-promoting behaviors are formed, allowing the future prevention
None declared
of such diseases as dental decay and gingivitis. Studies concerning the gingival status and bleeding in children
Conflict of interest are scarce, although such knowledge can be useful in planning preventive programs.
None declared
Objectives. The aim of the study was to determine the relationship between oral hygiene level and the likeli-
hood of gingival bleeding.
Received on January 9, 2017 Material and methods. The examined group comprised 2856 children aged 7 years, living in an urban
Reviewed on January 17, 2017
Accepted on April 12, 2017
area in western Poland. The hygiene status was evaluated according to the simplified Debris Index (DI-S)
criteria and the periodontal status was evaluated according to the Community Periodontal Index (CPI) criteria.
Logistic regression analysis was used to determine the predictors of gingival bleeding.
Results. The average value of DI-S was 0.91; it was not significantly different between girls and boys. In more
than a half of the studied subjects (59.10%), oral hygiene was fair, in 12.46% – poor. Clinically healthy peri-
odontium was observed in 91.32% of cases, bleeding on probing was present in 7.46% of cases. Calculus was
detected in 1.22% of the children. Logistic regression analysis of the predictors of gingival bleeding showed
that children with fair and poor oral hygiene were respectively 6 and 25 times more likely to show bleeding
on probing compared to the children with very good oral hygiene.
Conclusions. In the studied group, it was noted that there is a need to promote oral hygiene, as it contributes
to the fall in gingivitis prevalence among schoolchildren.
Key words: gingivitis, oral hygiene, Polish children

DOI
10.17219/acem/70417

Copyright
© 2018 by Wroclaw Medical University
This is an article distributed under the terms of the
Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
 1398 T. Pawlaczyk-Kamieńska, N. Torlińska-Walkowiak, M. Borysewicz-Lewicka. Oral hygiene level and gingivitis

Introduction score was 0.3–0.6; “fair” when it  showed 0.7–1.8; and
“poor” when the score ranged between 1.9 and 3.0.6
The condition of the teeth, periodontium and oral mu- The periodontal status was assessed using the Com-
cosa determines directly and indirectly the general health munity Periodontal Index (CPI) according to the World
of the organism and, therefore, requires to be monitored. Health Organization (WHO) basic methods of oral health
Epidemiological studies indicate that  in  children and surveys.7 Recording of CPI was done in accordance with
adolescents the most often observed gingivitis is dental the  WHO guidelines for  the  population group under
plaque-induced gingivitis, which is a reversible and non- 15 years of age. To avoid recording false pockets, which
destructive form of periodontal disease.1,2 Poor oral hy- are common around erupting teeth, 3 codes were used:
giene and the accumulation of bacterial plaque is a known code 0 – healthy (no bleeding on probing and no calculus);
and important predisposing factor of gingivitis. However, code 1 – bleeding on probing (no calculus); code 2 – dental
the prevalence of destructive forms of periodontal disease calculus present. The evaluation was performed on 6 index
is lower in young individuals than in adults. Still, dental teeth (teeth 16, 11, 26, 36, 31, 46). According to the WHO
plaque accumulation in childhood and adolescence can classification, the highest CPI code was applied.8,9
be associated with the development of periodontal disease The  oral cavity was examined by  pediatric dentists
in later life.3 Children with healthy gingival tissues most in the school nurse consultation room, under artificial light,
likely progress to adult life with good periodontal health. using a dental mirror and a probe, according to the recom-
Therefore, the key concern is periodontal health and good mendations for oral epidemiological surveys by the WHO.7
oral hygiene in childhood.1–5 The same test conditions were kept for all examined chil-
Childhood, especially the first years of life, is the time dren. The practitioners were calibrated prior to the study
when proper health-promoting behaviors are formed, in order to control reliability. Calibration was performed
allowing the future prevention of such diseases as dental by the clinical examination of children who were not in-
decay and gingivitis. A fundamental element of preven- cluded in the study. The kappa value was 0.85 for the oral
tion are effective daily prophylactic-hygienic procedures hygiene status and 0.8 for the periodontal status, thus rep-
to remove dental plaque. Studies concerning the gingival resenting a satisfactory level of concordance. The obtained
status and bleeding in children are scarce, although such data was recorded in specially designed charts.
knowledge can be useful in planning preventive programs. The statistical analyses were performed using STATIS-
The aim of the study was to evaluate the hygiene and TICA v. 12 (StatSoft Inc., Tulsa, USA) and CytelStudio
periodontal status among children living in an urban area v. 10.0 (StatXact, Cambridge, USA) programs. Average val-
in western Poland, and to determine the relationship be- ues for quantitative data and the percentage for category
tween oral hygiene and the likelihood of gingival bleeding. data were determined. The χ2 test was used to determine
whether gender is related to the CPI value, oral cleanliness
(the DI-S value) and bleeding, as well as whether bleed-
Material and methods ing is related to DI-S. Logistic regression analysis was used
to identify independent risk factors, such as gender and oral
A total of 2856 generally healthy 7-year-olds entered hygiene (DI-S) for gingival bleeding (present or absent) ex-
the study (1408 girls and 1448 boys), representing 70% pressed in odds ratios (OR) and 95% confidence intervals
of the population attending the 1st year of elementary pub- (CI). The level of significance was set at 0.05 (Fig. 1).
lic schools in Poznań (about 550,000 inhabitants), Poland.
The schools were randomly selected; all 7-year-old children
who were at school on the days of examination were exam- Dental examination
ined. Children with medically compromising conditions of 2,856 7-year-olds
which could affect periodontal health were excluded from
the study. Parents or caregivers were asked to sign a writ-
ten statement of consent for their child’s participation
Assessing the oral
in the study. The studies were performed in the morning Assessing
hygiene status using
(9–11 a.m.). In order to minimize extra brushing efforts, the periodontal status
simplified Debris Index
the children were not informed in advance about the exact using Community
of Green and Vermillion
date of the oral examination. Periodontal Index (CPI)
(DI-S)
The oral hygiene status was assessed using the simplified
Debris Index (DI-S) of Green and Vermillon.6 The teeth
were examined as recommended by the index (the labial
surfaces of teeth 11, 16, 26, and 31, and the lingual surfaces Statistical analyses
of teeth 36 and 46). The criteria for classifying DI-S scores
of 0–3 were as follows: oral cleanliness was considered
“very good” if the DI-S score was ≤0.2; “good” if the DI-S Fig. 1. Methodology of the study
Adv Clin Exp Med. 2018;27(10):1397–1401 1399

The study was reviewed and approved by the Ethics Com- 2.95–5.61). Furthermore, children with fair and poor oral
mittee at Poznan University of Medical Sciences, Poland; hygiene were respectively 6 (p < 0.0001; OR: 6.08; 95%
it has been conducted in full accordance with the World CI: 2.96–14.49) and 25 (p < 0.0001; OR: 24.82; 95% CI:
Medical Association Declaration of Helsinki (No. 466/10). 11.77–60.02) times more likely to have bleeding on probing
compared to children with very good oral hygiene. There
was no significant dependence between very good and
Results good hygiene (p = 0.15) (Table 3).

The average DI-S value in the studied group was 0.91 Table 3. Logistic regression output with regard to the predictors
of bleeding on probing
and it was not significantly statistically different in girls
(DI-S = 0.87) and in boys (DI-S = 0.95). Very good oral Predictor OR 95% CI p-value
hygiene was noted in 23.14% of the children, fair oral hy- hygiene level* (DI-S)
giene in more than a half (59.10%) of the studied group Good (0.3–0.6) 2.80 0.71–9.83 0.150
and poor in 12.46% of the children. No statistically signifi- Fair (0.7–1.8) 6.08 2.96–14.49 <0.0001
cant dependence was observed between the distribution Poor (1.9–3.0) 24.82 11.77–60.02 <0.0001
of the oral hygiene status and gender (p = 0.066) (Table 1).
Predictors of bleeding on probing were determined as present vs absent;
OR – odds ratio; CI – confidence interval; DI-S – simplified Debris Index;
Table 1. Oral hygiene status (DI-S) * reference category: very good oral hygiene level (DI-S ≤ 0.2).
Score Female [%] Male [%] Total [%]
0.0–0.2 24.86 21.4 23.14
Discussion
0.3–0.6 5.40 5.18 5.28
0.7–1.8 58.52 59.67 59.10 Dental literature reports concerning oral hygiene in early
1.9–3.0 11.22 13.67 12.46 school children are scarce. In Poland, children start com-
DI-S – simplified Debris Index. pulsory education at 7 years of age. At this age, the first
permanent teeth usually erupt. Therefore, this age seems
to be the best to evaluate oral hygiene and the periodontal
Clinically healthy periodontium was observed in 91.32% status in children.
of the studied children. Bleeding on probing was present In  the  studies carried out among children in  Iran,
in 7.46% of cases and supragingival dental calculus in 1.22% the  average DI-S value was 1.19, among children from
of cases. Statistical analysis did not show a dependence be- Minsk (Belarus) it was 1.64, and in Kuwait, the DI-S value
tween the CPI value and gender (p = 0.669) (Table 2). was 1.5.1,10,11 Moreover, the inclusion of gender data into
the study provided a conclusion that oral hygiene in boys
Table 2. Periodontal status (CPI) was significantly better than in girls.11 In the quoted pub-
lications, the average value of DI-S showed worse oral hy-
Score [%] Female [%] Male [%] Total [%]
giene than in the studied population of western Poland,
0 91.55 91.09 91.32
where it was 0.91 for the population, with similar values
1 7.31 7.60 7.46 for boys and girls.
2 1.14 1.31 1.22 Numerous epidemiological studies show similar oral
CPI – Community Periodontal Index. hygiene status in children all over the world. In the stud-
ies by de Almeida et al., 799 Portuguese 6-year-olds were
examined for oral hygiene, of which 7.6% showed very good
A statistical analysis performed using the χ2 test con- oral hygiene status; good oral hygiene status was present
firmed a dependence between bleeding and the oral hy- in 16.5%, fair in 72.6% and poor in 3.3% of the studied
giene status (p < 0.0001). Among those children who showed children.12 On the other hand, Al-Mutawa et al. did not
bleeding, only 3.76% presented very good oral hygiene note very good oral hygiene in the group of 3294 children
on the day of the examination and 2.35% presented good – the DI-S value in that case was below 0.3. In the majority
oral hygiene. However, in more than a half of them (54.93%), of the studied population (67%), oral hygiene was assessed
hygiene was classified as fair, and in 38.96% as poor. as fair, and in 29.1% of cases – as poor.11 Krishnam et al.
Gender was not significantly associated with gingival evaluated oral hygiene in 5129 children, aged 5–12 years,
bleeding. Therefore, in this model, the only significant of  the  Eastern Ghats region of  southern India, using
variable was a range of the DI-S values (p < 0.0001). Logistic the simplified oral hygiene index (OHI-S) by Green and
regression analysis of the predictors of gingival bleeding Vermillion (good: 0.0–1.2; fair: 1.2–3.0; poor: 3.1–6.0).13
showed that children with poor oral hygiene were 4 times Good oral hygiene was present in 34.27% of the children,
more likely to have gingival bleeding compared to chil- 50.98% showed fair hygiene status and 14.7% were evalu-
dren with fair oral hygiene (p < 0.0001; OR: 4.0; 95% CI: ated as having poor oral hygiene. Anupriya et al. evaluated
 1400 T. Pawlaczyk-Kamieńska, N. Torlińska-Walkowiak, M. Borysewicz-Lewicka. Oral hygiene level and gingivitis

oral hygiene using the OHI-S in 1787 5–8-year-olds of Hi- 3.1% to 0.6% over 8 years, and the values for 12-year-olds de-
machal Pradesh in the northern India.14 Good hygiene was creased from 33.4% to 21%.19 In the studies by Chłapowska,
noted in 9.4%, fair in 63.6%, and poor in 26.8% of cases. carried out in the city of Poznań in 1995, dental calcu-
In our own studies, similarly to other authors’, the most lus was observed in  3.7% of  children aged 7 years and
numerous group of patients consisted of the students pre- in 26.7% of those aged 12 years.20 However, in the study
senting fair oral hygiene status (59.1%). undertaken 4 years later by Pawlaczyk-Kamieńska, which
The literature concerning the periodontal status included 521 children aged 12 years from the same area
in 7-year-old children presents varied results. The per- (Poznań), dental calculus was found in 26.3% of the chil-
centage of healthy periodontium at that age ranges be- dren.21 In the same educational setting of Poznań, 20 years
tween 9% and 80%.5,14–16 Składnik-Jankowska and Kacz- after the study made by Chłapowska, dental calculus was
marek evaluated the  periodontal status of  7-year-olds noted in 1.22% of children aged 7 years. The presented data
from southern Poland and found healthy periodontium displays a drop in the percentage of children with dental
in 80% of them, with no statistically significant difference calculus from 3.7% to 1.22%.20,21 Moreover, the data con-
between genders.15 A relatively high percentage of children firms the former reports of an increase in the percentage
with healthy periodontium (70.43%) was observed by Varas of people with dental calculus along with their age.
et al. in children aged 6–8 years (Santiago Metropolitan Re- The statistical analysis of our own results did not reveal
gion in Chile), while markedly lower values – 22.5% – were any correlation between gender and bleeding, although
reported by Dini et al. in Brazilian 7-year-olds.5,16 A still the research done by Gopinath et al. showed that males were
lower percentage was noted by Anupriya et al.: in only 9.4% 2.11 times more likely to develop gingivitis than females.22
of the children aged 5–8 years.14 Our own studies showed However, in our study, a correlation was found between
healthy periodontium to be present in 91.32% of the stud- the amount of bacterial plaque and the likelihood of bleed-
ied population of the 7-year-olds from a big city. Similarly ing, which confirms a relationship of gingivitis etiology and
to the quoted findings of other authors, no statistically sig- the oral hygiene status. In children with poor oral hygiene,
nificant difference was found here between girls and boys. the likelihood of bleeding on probing was 4 times higher
Different values concerning bleeding are reported than in children with fair oral hygiene. When children with
in some other studies. In the paper by Składnik-Jankowska fair oral hygiene were compared to those with very good
and Kaczmarek, bleeding on probing was present in 14.5% hygiene, it was revealed that the likelihood of bleeding was
of the 7-year-olds and this value was nearly 2 times higher 6 times higher in the fair oral hygiene group. Still, the chil-
than that obtained in our own studies (7.46%). Still higher dren with poor hygiene were 25 times more likely to develop
values were quoted by Varas et al., Anupriya et al. and Dini bleeding on probing than those with a very good hygiene
et al., who observed gingival bleeding in 27.49%, 71.9% and status. In 71.56% of the studied 7-year-old children living
76.8% of children, respectively.5,14,16 in Poznań, oral hygiene was evaluated as fair (59.1%) or poor
Contrary to our study, in the research by Arnlaugsson and (12.46%). Therefore, they have a 6 or 25 times lower chance
Magnusson, as well as Hemadneh and Ayesh, the gingival to maintain healthy periodontium in the future, compared
bleeding index (GBI) was used.2,4 Among Icelandic 6-year- to their counterparts showing very good hygiene (23.14%
olds of Reykjavik examined by Arnlaugsson and Magnusson, of the children). The study proved a correlation between
healthy gums were noted in 26% of the children.2 Similar the oral hygiene status and gingival bleeding. Therefore,
values were obtained by Hemadneh and Ayesh in Jordanian an improvement of daily hygienic procedures to remove
children, out of whom 30.6% had healthy gums.4 However, bacterial dental plaque seems of greatest importance in re-
the studies by Bossnjak et al., comprising Croatian children ducing the likelihood of periodontal disease in adult age.
aged 6–11 years, revealed that healthy gums were present Epidemiological studies provide the necessary knowl-
in 43% of the studied subjects.17 In the quoted studies, as well edge to formulate and implement programs of prophylaxis,
as in our own ones, there were no statistically significant which will bring about an improvement of oral health.
differences between girls and boys. It seems that the provision of dental education to children
Dental calculus occurs less often in children than in adults. with mixed dentition should also be a priority in order
In adolescent patients, supragingival deposit is mainly pres- to teach better skills of bacterial plaque removal.
ent. Składnik-Jankowska and Kaczmarek and Varas et al. Limitations of our study comprise the sample size and
noted this deposit in a small percentage of the examined participants. It might be possible that children with poor
children, 4% and 2.08%, respectively.5,15 A higher percent- oral hygiene were not given the consent for the examina-
age was reported by Anupriya et al. in 5–8-year-old Indian tion to  avoid any unpleasant comments. Furthermore,
children and Varenne et al. in 6-year-old African children some children probably did not participate in  the  re-
– 10.2% and 58%, respectively.14,18 search because of  strong dental fear. We  also did not
Based on epidemiological studies performed in Poland study the  socioeconomic status and educational level
in 1987 and 1995, Banach compared the prevalence of den- of the subjects, which could have led to a deeper analysis.
tal calculus among 7- and 12-year-olds.19 The percentage Nevertheless, we believe that our findings closely represent
of Polish 7-year-olds with dental calculus dropped from the population values.
Adv Clin Exp Med. 2018;27(10):1397–1401 1401

Conclusions 10. Shaghaghian S, Bahmani M, Amin M. Impact of oral hygiene on oral

health-related quality of life of preschool children. Int J Dent Hyg.
2015;13(3):192–198.
Among the  examined children living in  a  big city, 11. Al-Mutawa SA, Shyama M, Al-Duwairi Y, Soparkar P. Oral hygiene sta-
the majority show fair or poor oral hygiene. tus of Kuwaiti schoolchildren. East Mediterr Health J. 2011;17(5):387–391.
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status of 6-and 12-years-old schoolchildren in Portugal. Community
the likelihood of bleeding on probing. The performed study Dent Health. 2003;20(4):211–216.
has shown the need to treat and prevent periodontal pa- 13. Krishnam R, Vasanti D, Raghavendra J, Niranjani K, Saravana MS.
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An epidemiological study. J Int Oral Health. 2015;7(7):108–110.
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ta Bagwan block of Kangra, Himachal Pradesh. J Indian Soc Periodon-
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