Download Oral hygiene habits and oral health in cystic fibrosis

Oral hygiene habits and oral health
in cystic fibrosis
J.K.M. APS*, G.O.G. VAN MAELE**, L.C. MARTENS*
ABSTRACT. Aim The present study was designed to investigate oral hygiene habits and fluoride use in cystic
fibrosis (CF) homozygotes, heterozygotes and healthy controls as a function of caries experience (DMF-T) and
oral cleanliness (dental plaque, dental calculus and gingival bleeding). Methods Oral hygiene habits in CF
homozygotes (n=42), heterozygotes (n=48) and healthy controls (n=62) were used in a multivariate analysis with
caries experience (DMF-T) and oral cleanliness (dental plaque, calculus and gingival bleeding) as response
variables. Results CF homozygotes had a significantly lower caries experience (p≤0.001) and less gingival
bleeding sites (p≤0.02). Oral hygiene habits were not significantly different between the three groups, except for
intake of fluoride supplements. Significantly more CF homozygotes had received fluoride supplements. Oral
hygiene habits did affect caries experience or oral hygiene differently in each study group. Conclusion No matter
what oral hygiene habits were, CF homozygotes had an overall better oral health status. Apparently they seemed
to possess intrinsic salivary compensatory mechanisms, as the significant higher use of fluoride supplements
appeared not to be responsible for the better oral health.
KEYWORDS: Oral hygiene, Oral health, Cystic fibrosis
Introduction
Cystic fibrosis (CF) is the most common lethal
autosomal recessive inherited disease in Caucasians.
About 4% to 5% of the Caucasian population is
heterozygous for the CFTR (cystic fibrosis
transmembrane regulator) gene, which is located on
the long arm of chromosome 7 (7q31). Although
several hundreds of genetic mutations are known, the
most common mutation in Western Europe is DeltaF508. The prevalence of the disease is 1 in every
2,000 live new born children. In essence, the disease
affects all exocrine glands (including the salivary
glands) and renders their respective secretions more
viscous than under healthy conditions. CF patients
consequently suffer from gastro-intestinal (due to
pancreatic insufficiency) and respiratory problems.
Because of this, they are compelled to have
supplemental pancreas enzymes with every meal,
*Department of Paediatric Dentistry and Special Care
**Department of Medical Informatics and Statistics
Ghent University, Belgium
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 4/2002
drink and snack, supplemental vitamins (A,D,E and
K) if necessary, frequent antibiotics (per os, via
aerosols and IV) and daily expectorantia and
mucolytica (mostly via aerosols) [Hughes and
Griffith, 1984; Tsui, 1991; Webb, 1991; Aitken,
1993; Grundy et al., 1993; Hodson, 1993; Vay Liang
et al., 1993; Sheppard and Ostegaard, 1996; Hilman,
1997].
Literature published in the 1980s and at the
beginning of the 1990s claimed that CF youngsters
(mean age 7.0 years) had significantly less caries
experience than control subjects [Kinirons, 1983;
Kinirons, 1985; Kinirons, 1989; Fernald et al.,
1990]. This was attributed to their higher salivary
buffer capacity, higher salivary calcium
concentration and their frequent use of antibiotics. A
more recent age matched control study, performed
on a CF group with a wider age range (mean age
16.3 years) [Martens et al., 2001], reported no
significant differences in caries experience between
CF homozygotes and healthy controls. Due to lack
of diagnostic tools, no information on CF
heterozygotes was available in the 1980s and as a
consequence they were unavoidably included in the
healthy control study groups.
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J.K.M. APS, G.O.G. VAN MAELE, L.C. MARTENS
Recently, a study was published in which CF
homozygotes, CF heterozygotes and healthy controls
were compared [Aps et al., 2001]. No significant
differences in caries experience between the three
groups considered were found. Nevertheless, CF
homozygotes had significantly less salivary mutans
Streptococci counts. In a continuing study [Aps et
al., 2001], on a larger sample of CF homozygotes,
CF heterozygotes and healthy controls, it was shown
that CF heterozygotes had significantly larger
restorations than CF homozygotes, while the latter
had also a significantly lower caries experience than
healthy controls. CF homozygotes were also
reported to have significant less bleeding gingival
sites than CF heterozygotes and controls.
Several presumptions, dealing with compensatory
salivary mechanisms inherent to their disease, were
mentioned in these reports, which could serve as an
explanation for CF homozygotes experiencing less
dental decay than others, despite the assumption of
them running a high caries risk (e.g. frequent in
between sucrose rich snacks and drinks and daily
aerosols). From an analysis of their dietary habits
[Aps et al., 2001] it was concluded that CF
homozygotes may experience positive benefit from
consuming lots of dairy products, whether
sweetened or not. But as caries is a multifactorial
infectious disease, other aspects of influence should
be investigated also.
The present study, therefore, aimed to investigate
oral hygiene habits and fluoride use in CF
homozygotes, heterozygotes and healthy controls as
a function of caries experience (DMF-T) and oral
cleanliness (dental plaque, dental calculus and
gingival bleeding).
Materials and methods
Patient selection. Both CF homozygotes (n=42,
16.2±8.1 years) and genetically proven CF
heterozygotes (n=48, 29.5±15.9 years) were
recruited through the Belgian Association for the
Fight Against Cystic Fibrosis. The higher mean age
of the CF heterozygotes can be explained by the fact
that the CF heterozygote group consisted of parents
and mainly older brothers and sisters of CF
homozygotes. Healthy controls (n=62, 19.9±11.5
years), excluding subjects suffering from
cardiovascular,
genito-urinary,
neurological,
endocrine or infectious diseases, were recruited from
the Ghent University Dental out-patient clinic and
from the CF patients’ and CF heterozygotes’
environment. The study was approved by the Ghent
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University’s medical ethical committee and for all
subjects an informed consent was obtained.
Caries experience and oral cleanliness. Caries
experience was expressed as DMF-T and DMF-S and
was recorded at the level of cavitation. Prior to the
study, the investigator (JA) was calibrated. Oral
cleanliness was expressed as the number of teeth (-T)
and surfaces (-S) with dental plaque (PI-T/-S), dental
calculus (CI-T/-S) and gingival bleeding (BL-T/-S). A
more extensive and detailed description of the
methodology was published elsewhere [Martens et al.,
2001; Aps et al., 2001]. All teeth, except for the third
molars, were included in the recording of the oral
cleanliness parameters. Consequently, the mean
number of teeth with plaque, calculus and gingival
bleeding in every study group was obtained.
Patient questionnaire. To avoid misunderstandings,
unanswered questions and any tendency to biases,
every study subject was questioned by the same
investigator (JA). By interviewing these subjects, the
investigator was able to obtain objective information
about their oral hygiene and dietary attitudes. All
answers were dichotomized as “yes” or “no”
immediately while entering the data in the database
(Microsoft Access 2000, Microsoft Corporation).
Statistical analysis. Appropriate statistical analysis
was performed by means of the SPSS program. A
Kruskal-Wallis test was used to investigate differences
in caries experience and oral cleanliness between the
three groups of subjects. Subsequently a MannWhitney U test was used to investigate these data
between two subject groups at a time. A Pearson Chisquared test was used to investigate differences in oral
hygiene habits. Regression analysis with the oral
hygiene habits as co-variables and caries experience,
dental plaque, dental calculus and gingival bleeding as
response variables was performed. The level of
significance was chosen at p=0.05.
Results
Caries experience and oral cleanliness. It can be
seen from the data in Table 1 that CF homozygotes
had a significant lower caries experience than CF
heterozygotes (p<0.001) and healthy controls
(p=0.011). This was as well as a significant lower
mean number of teeth with gingival bleeding than
CF heterozygotes (p=0.014) and healthy controls
(p=0.019). CF heterozygotes had experienced
significantly more extractions than CF homozygotes
(p<0.001) and controls (p=0.008). They also had
significantly more restored teeth than CF
homozygotes (p=0.043).
EUROPEAN JOURNAL OF PAEDIATRIC
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ORAL HYGIENE HABITS IN CYSTIC FIBROSIS
CF homoz
CF heteroz
Control
Kruskal-Wallis
Mann-Whitney U
test
test
P values
A↔B↔C
A↔B
A↔C
B↔C
n=42
-A-
n=48
-B-
n=62
-C-
DMF-T
D-T
M-T
F-T
4.05±5.35*
0.31±0.78
0.26±0.89
3.52±4.63
9.94±8.12
0.48±1.09
3.62±6.92
5.88±6.01
6.97±6.11
0.61±1.33
0.94±2.13
5.34±5.17
<0.001**
0.562
<0.001
0.100
<0.001
0.462
<0.001
0.080
0.011
0.288
0.067
0.043
0.060
0.740
0.008
0.903
Plaque
Calculus
GB***
3.62±5.67
1.93±3.05
0.24±0.79
2.63±4.44
2.77±3.82
2.35±5.15
2.85±3.87
2.10±3.46
1.15±2.38
0.514
0.423
0.033
0.258
0.244
0.014
0.617
0.875
0.019
0.453
0.276
0.619
*=mean±SE
**=significant at p<0.05
***=gingival bleeding
TABLE 1 - Caries experience (DMF-T) and oral cleanliness (gingival bleeding, dental plaque and dental calculus on tooth level)
in CF homozygotes, CF heterozygotes and healthy controls.
I brush ≥2/day
I never brush my teeth
I brush in the morning
I brush in the evening
I use ≤pea size toothpaste
Fluoride toothpaste
Electrical toothbrush
Fluoride rinse
Fluoride supplements
Chlorhexidine rinse
I floss
I use toothpicks
CF homoz
n=42
-A-
CF heteroz
n=48
-B-
Control
n=62
-C-
91%
0%
76%
71%
38%
100%
24%
0%
64%
5%
10%
14%
90%
2%
56%
79%
50%
96%
25%
6%
38%
2%
23%
23%
94%
5%
69%
87%
50%
97%
18%
5%
47%
5%
18%
24%
Pearson Chi-squared test
P values
A↔B↔C A↔B
A↔C
B↔C
0.736
0.306
0.118
0.140
0.434
0.436
0.610
0.283
0.037*
0.725
0.239
0.444
0.341
0.533
0.038
0.272
0.378
0.282
0.547
0.147
0.010
0.450
0.077
0.220
0.413
0.208
0.296
0.042
0.160
0.353
0.304
0.280
0.059
0.679
0.189
0.162
0.341
0.411
0.112
0.196
0.518
0.589
0.244
0.532
0.218
0.411
0.331
0.530
*= significant at p=<0.05
TABLE 2 - Descriptive data on oral hygiene habits in CF homozygotes, CF heterozygotes and healthy controls and the appropriate statistical analyses results.
Oral hygiene habits. The data in Table 2 show that
only the fact of having received any fluoride
supplements was significantly different between the
three groups (p=0.037). Significantly more CF
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 4/2002
homozygotes than CF heterozygotes (p<0.01) had
used fluoride supplements (either drops or tablets).
Effects of oral hygiene habits on caries experience
within each group. CF homozygotes who brushed
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J.K.M. APS, G.O.G. VAN MAELE, L.C. MARTENS
their teeth in the morning (p=0.009), as well as those
who brushed in the evening (p=0.016) or those who
used toothpicks (p=0.002), had a significantly higher
DMF-T. Caries experience was significantly higher
in CF heterozygotes who did not receive any fluoride
(p=0.028) or who used dental floss (p=0.002).
Healthy controls who used a fluoride containing
toothpaste (p=0.038), or those who never got
fluoride supplements (p=0.050) had a significantly
higher caries experience. The same was observed in
control subjects who used dental floss (p=0.002) or
toothpicks (p=0.033).
Effects of oral hygiene habits on oral cleanliness.
CF homozygotes who used an electrical toothbrush
experienced significantly more dental calculus
(p=0.042) than those who used a regular toothbrush.
CF heterozygotes who did not brush in the evening
presented with significantly more dental calculus
(p=0.015), as did those who never received any
fluoride supplements (p=0.013) or never used
toothpicks (p=0.002). CF heterozygotes who did not
get any fluoride supplements also experienced
significantly more plaque (p=0.047), as did those
who used toothpicks (p=0.036). In addition, using
toothpicks also resulted in significantly more
gingival bleeding (p=0.018) in this group.
Healthy control subjects who brushed their teeth in
the morning (p=0.029), or who never received
fluoride supplements (p=0.019), or those who used
toothpicks (p=0.031) experienced significantly more
dental calculus than those who did the opposite.
Gingival bleeding was significantly higher in those
healthy controls who brushed less than twice a day
(p=0.044) or never received any fluoride
supplements (p=0.004).
Discussion
It was interesting that CF homozygotes, a group of
medically compromised individuals, who could be
supposed to run a high caries risk due to their dietary
obligations and medication intake, had a
significantly lower caries experience than CF
heterozygotes and healthy controls (Table 1). Recent
literature suggests that CF homozygotes may in
some way be protected against dental decay and that
certain salivary mechanisms may be involved
[Martens et al., 2001; Aps et al., 2001; Aps et al.,
2002a; Aps et al., 2002b]. On the other hand, it was
remarkable to note that CF heterozygotes, who are
not clinically affected by the CFTR gene, apparently
ran a higher caries risk than healthy controls and CF
homozygotes. They also had experienced
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significantly more extractions than the others, and in
a previous report [Aps et al., 2002b] it was recorded
that the extensiveness of their restorations (factor FS in the DMF-S index) was significantly larger.
The number of teeth with hypertrophic and/or
hyperaemic gingival margins was significantly lower
in CF homozygotes than in CF heterozygotes. On the
other hand it should be emphasised that the number
of teeth covered with plaque was the highest in CF
homozygotes, although the difference between the
three groups was not significant. While plaque in
general is expected to induce gingival inflammation,
it was suggested earlier that dental plaque in CF
homozygotes is probably composed of other microorganisms than in CF heterozygotes and control
subjects [Aps et al., 2002b], which could explain
why they had significantly less bleeding sites than
CF heterozygotes and controls. Perhaps this
supposed less pathogenic plaque flora could also be
responsible for CF homozygotes experiencing
significantly less dental decay. Undoubtedly,
medication intake (for example antibiotics) plays an
important role in this, but it remains a domain which
needs further research [Van Nieuw Amerongen,
1990; Kinirons, 1992; Maguire et al., 2002].
This study showed that very little differences can
be found between these three groups regarding their
oral hygiene habits. Only the fact of having received
fluoride supplements of any kind (droplets or
tablets) was significantly different. Sixty four
percent of CF homozygotes, against 38% CF
heterozygotes and 48% healthy controls had received
fluoride supplements. Probably their paediatricians
may have prescribed this “medication” additionally
to their already extensive list of obligatory
medications, inherent to their medical condition.
This could be interpreted as a kind of overtreatment
or reassurance of the patients’ parents. However, the
effect of fluoride supplements within the CF
homozygote group did not result in a significant
lower caries experience. It can therefore be
concluded that the importance of oral hygiene habits
should not be exaggerated too much when explaining
the significant differences in caries experience and
overall oral health between CF homozygotes, CF
heterozygotes and healthy controls.
The effects of oral hygiene habits on caries
experience and oral cleanliness in every study group
were rather unexpected, illogical and consequently
no clear conclusions could be drawn. It should not be
forgotten that oral hygiene measurements are the
result of certain oral cleanliness features. It may well
be possible that certain individuals had started using
EUROPEAN JOURNAL OF PAEDIATRIC
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ORAL HYGIENE HABITS IN CYSTIC FIBROSIS
dental floss or toothpicks quite recently, because
their dentist had advised them to do so. Other oral
hygiene habits, except for the use of fluoride
supplements, may have had an influence in the same
way. Caries experience provides information about
an individual’s past and present experience with
dental decay, while an enquiry into oral hygiene
attitudes reports mainly the present habits; this in
turn could be based on advice from the dentist, who
decided to do so after numerous repetitive dental
treatments. Consequently, looking for explanations
and relations between caries experience and current
oral hygiene habits may be confusing.
Using the illustrative device of a pentagon, the
impact of brushing habits, fluoride supplements, use
of dental floss and toothpicks on caries experience
and oral cleanliness can be visualised. The surface
area of the pentagon is a measure of these oral
hygiene habits on oral health (Fig. 1, 2). These
pentagons can be drawn for all oral cleanliness
parameters. When brushing habits, use of fluoride
supplements, dental floss and toothpicks were
considered, whatever the oral hygiene habits of CF
homozygotes were, they seemed to be of little
influence on caries experience. The latter illustrated
once more possible intrinsic compensatory
mechanisms, mentioned before.
The same may hold true for dental calculus and
gingival bleeding. CF homozygotes seemed however
to generate, although not significantly, more plaque
FIG. 1 - Schematic representation of the effect of: a) NOT brushing in the morning or NOT brushing in the evening or NOT
having had fluoride supplements or NOT using dental floss or toothpicks on caries experience (mean DMF-T); b) brushing in
the morning or brushing in the evening or having had fluoride supplements or using dental floss or toothpicks on caries experience (mean DMF-T), in a population of children who were CF homozygotes, CF heterozygotes or healthy controls.
FIG. 2 - Schematic representation of the effect of: a) NOT brushing in the morning or NOT brushing in the evening or NOT
having had fluoride supplements or NOT using dental floss or toothpicks on dental plaque (mean PI); b) brushing in the morning or brushing in the evening or having had fluoride supplements or using dental floss or toothpicks on dental plaque (mean
PI), in a population of children who were CF homozygotes, CF heterozygotes or healthy controls.
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 4/2002
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J.K.M. APS, G.O.G. VAN MAELE, L.C. MARTENS
FIG. 3 - Effect of: a) «I NEVER did receive fluoride supplements» on caries experience (mean DMF-T), gingival bleeding (mean
BI), dental calculus (mean CI) and dental plaque (mean PI); b) «I DID receive fluoride supplements» on caries experience
(mean DMF-T), gingival bleeding (mean BI), dental calculus (mean CI) and dental plaque (mean PI), in a population of children who were CF homozygotes, CF heterozygotes or healthy controls.
than the other subjects (Fig. 2), irrespective of their
oral hygiene habits.
Although the only significant difference in oral
hygiene habits between the three groups was the use
of fluoride supplements, this did not seem to
influence caries experience differences between the
three groups (Fig. 3). These quadrangles show that
whether CF homozygotes did receive fluoride
supplements or not did not affect their caries
experience significantly. The fact that CF
homozygotes who received fluoride supplements
showed, although not significantly, more teeth with
calculus should be interpreted as coincidental. No
correlations between fluorides and dental calculus
have been reported before.
Conclusion
These present findings reinforce once more the
assumption that CF homozygotes may possess some,
as yet not identified, intrinsic salivary compensatory
mechanisms [Martens et al., 2001; Aps et al., 2002a,
2002b], which render them less vulnerable for poor
oral health status, as it did not seem to matter what oral
hygiene habits they had. Fluoride supplements did not
make the difference either between these three study
groups. Nevertheless, it should always be remembered
that caries is a multifactorial infectious disease and
186
that many other factors, such as medication [Van
Nieuw Amerongen, 1990; Kinirons, 1992; Kankaala et
al., 1998; Kargül et al., 1998], which in CF patients in
particular will play an important role, should be
included in assessing caries risk in every population of
medically compromised patients.
Acknowledgements
This study was financially supported by the Fund for
Scientific Research, Flanders (grant number:
3.00014.98) and logistically supported by the Belgian
Association for the Fight against Cystic Fibrosis.
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