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10 1902@jop 1965 36 3 177 PDF
10 1902@jop 1965 36 3 177 PDF
Page 5/177
Page 6/178 LÖE, THEILADE, JENSEN
TABLE 1
Mean Plaque Index at the start of the experiment, at the end of the period of no-cleansing and after recom-
mencement of tooth cleansing.
Start 0.76 0.95 0.54 0.23 0.58 0.17 0.60 0.33 0.35 0.11 0.00 0.52 0.43
End of no-cleansing
period 2.00 1.99 1.82 1.46 1.60 1.42 1.64 1.40 1.58 1.79 1.64 1.81 1.67
Final 0.17 0.11 0.21 0.06 0.18 0.02 0.19 0.28 0.10 0.05 0.50 0.14 0.17
As soon as inflammatory changes were udate will adhere to the film when re-
observed and a complete index and bacteri- moved. This material is stained with gen-
ological assessment had been made, the pa- tian violet for twenty seconds and the film
tients were given detailed instructions in thoroughly rinsed in running tap water
oral hygiene methods using brush and wood and air dried. The film is then embedded
massage sticks. This was begun the same in castor oil, a coverglass is applied and the
afternoon and continued once in the preparation sealed with paraffin. It is pos-
morning and once at night during the sible under the microscope to follow the
duration of the experiment. Assessment of curvature of the gingival margin and to
plaque and gingival condition continued localize the bacterial accumulations to spe-
during this "hygiene" period. A t a point cific points at the gingiva.
where the GI and PI scores approached
zero, the experiment was terminated. The The areas selected for bacteriological ex-
clinical examination was carried out by amination were the buccal gingival mar-
one examiner. gins of both premolars and the mesial part
of the first molar in the left maxilla. The
BACTERIOLOGICAL EXAMINATION bacteriological findings in each preparation
were recorded as the average of 5 separate
The bacterial flora at the gingival mar-
observations. Three observations were made
gin was examined at intervals in all twelve
corresponding to the gingival margin of
subjects from the start of the experiment
maxillary 4,5,6, and 2 observations corre-
until clinical gingivitis was diagnosed. A
sponding to the papillary areas between
final examination was performed when
maxillary 4,5 and maxillary 5,6. A t each
healthy gingival conditions had been re-
site the number of bacteria colonizing the
established. The number of bacteriological
area was registered using an 0 to
examinations varied from 6 to 10 according
score. Bacterial types were registered ac-
to individual variation in the length of the
cording to morphological criteria: Coccal
experimental period.
forms, short rods, filaments, fusobacteriae,
The bacteriological data are based on vibrios and spirochetes. The presence or ab-
microscopic examination of impression sence of leukocytes and the approximate
preparations and conventional bacterial
smears.
TABLE 2
The impression-technique was originally Mean Plaque Index for groups of teeth in the upper and
developed by Gins & Mattig ( 1 9 4 1 ) and lower jaws at the end of the no-cleansing period.
later slightly modified by Jensen (195 8 ) . A Groups of teeth Maxilla Mandible
piece of thin transparent plastic film, 0.02 -
Incisors 1.70 1.66
0.05 mm. thick is gently but firmly
pressed against the area of marginal gin- Premolars 1.65 1.70
giva to be examined. Bacterial plaque, Molars 1.73 1.62
desquamated epithelial cells and a certain
Total 1.70 1.65
amount of leukocyte-containing pocket ex-
Page 8/180 LÖE, THEILADE, JENSEN
TABLE 3
Mean Plaque Index for the different areas of maxillary and mandibular^ incisors, premolars and molars at
the end of the no-cleansing period.
size of leukocyte accumulations were noted ticed between the upper and lower jaw or
at each observation. between different groups of teeth (incisors,
premolars, molars, Table 2 ) . Also when
Bacterial smears were prepared as fol- mean scores for the different surfaces of
lows: Samples of plaque were collected the teeth were compared (Table 3 ) no
with a scaling instrument from the buccal marked variations seemed to exist in the
gingival margins of the teeth previously interproximal and buccal areas of the teeth.
mentioned. A t each examination scrapings The lingual surfaces, on the other hand,
were collected immediately after taking accumulated less debris. O f all areas in
the impression. Approximately the same both jaws the lingual areas of the upper
amount of debris was collected at each premolars showed the smallest amount of
sampling and suspended at once in 0.5 ml. plaque.
sterile saline. The suspension was kept in
ice water and ground in a tissue-homoge- A l l participants were well informed as
nizer at high speed for one mintue. Smears to the technicalities of tooth cleansing and
were made from this homogenized sus- consequently the scores dropped rapidly as
pension, air dried and stained with Gram soon as oral hygiene measures were rein-
stain. With the aid of a microscope 200 stated. The soft debris did not mature into
microorganisms were counted in each smear clinically detectable calculus and could be
and the percentages of different microbial removed by the subjects themselves. A t the
types were calculated. end of the experiment, the mean Plaque
Index for the whole group was somewhat
RESULTS
lower than that at the beginning (Table 1 ) .
Oral hygiene: The oral hygiene status at
the commencement of the experiment was Gingival condition: Gingival conditions
good. The mean Plaque Index for indi- at the start of the experiment were in gen-
eral very good. The Gingival Index for
vidual subjects is shown in Table 1. During
each of the twelve subjects is shown in
the period of no-cleansing all participants
Table 4. The mean Gingival Index for the
accumulated soft debris in large quantities,
group of subjects was 0.27 and the mean
which was expressed by an increase in mean
Plaque Index from 0.43 to 1.67. Periodontal Index was 0.19. Out of ap-
proximately one thousand gingival units
Taken as a whole, no major difference examined one pathological pocket was
in the tendency to form plaque was no- found.
EXPERIMENTAL GINGIVITIS Page 9/181
TABLE 4
Mean Gingival Index at the start of the experiment, at the end of the period of no-cleansing and
after recommencement of tooth cleansing.
Start 0.49 0.41 0.15 0.02 0.24 0.17 0.43 0.15 0.08 0.69 0.38 0.07 0.27
End of no-cleansing
period 1.23 1.23 0.92 0.96 0.90 1.05 1.12 0.99 0.90 1.12 0.98 1.23 1.05
Final 0.11 0.09 0.13 0.02 0.12 0.07 0.14 0.16 0.06 0.02 0.29 0.10 0.11
In the course of the "no-brushing" part area of the lower premolars regularly
of the experiment all the subjects devel- showed the best gingival condition.
oped gingivitis. The mean Gingival Index
increased from 0.27 to 1.05. Three sub- After recommencement of tooth cleans-
jects developed gingivitis within ten days, ing, gingival inflammation resolved in
whereas nine subjects took between fifteen about a week, during which the mean GI
and twenty-one days. No subjective symp- for the whole group dropped from 1.05 to
toms related to pain or bleeding were re- 0.11 (Table 4 ) . The corresponding figures
ported by the subjects, and objectively no for the Periodontal Index were 0.93 and
acute stage was observed during the de- 0.01.
tooth cleansing had been abolished. It was kocyte accumulations were usually very
characterized by the preponderance of fila- heavy during this phase which persisted for
mentous forms and slender rods, although varying intervals of time until clinical
cocci were still present in fairly large num- gingivitis was diagnosed.
bers (Figs. IB and 1C). According to mor-
phological criteria the filamentous bacteria The final bacteriological examination was
were predominantly leptotrichia and fuso- made when regular habits of oral hygiene
bacteria were found in varying numbers. had been resumed and healthy gingival con-
Leukocyte accumulations increased in size. ditions re-established. In ten of the twelve
In one of the twelve subjects examined this subjects the gingival flora at this time
type of microflora was present from the consisted predominantly of cocci and short
start of the experiment. rods. In two cases filamentous bacteria were
found in rather large numbers, but in no
While the transition from the first to case were vibrios or spirochetes observed.
the second phase of bacterial colonization
was rather easily observed, the transition Microscopic examination of the smears
from second to third phase was more indicated corresponding changes in the rel-
gradual and somewhat difficult to time. ative composition of the bacterial flora
during the experimental period. Smears
The bacterial flora in the last stage was
taken at the start of the experiment showed
characterized by the presence of vibrios
that the bacterial population in the very
and spirochetes (Figs. I D and I E ) . A t first
small amounts of plaque which could be
these organisms were often seen strictly
collected was dominated by gram-positive
localized to a single papilla or to the gingi-
cocci and short rods. These organisms ac-
val margin of a single tooth, but later they
counted for 90 - 100 per cent of the total
spread out to cover the total area exam-
organisms counted in nine out of twelve
ined. Cocci, rods and filamentous organ-
subjects. In two subjects the gram-positive
isms were still numerous. In two cases
cocci and short rods made up 80 per cent,
spirochetes were not found by microscopic and in one subject only 50 per cent of the
examination of impression preparations or bacteria counted.
smears, but large numbers of vibrios were
present. On an average the transition from By the time clinical gingivitis had de-
second to third phase took place six to ten veloped this composition of the gingival
days after tooth cleansing had ceased. Leu- flora had altered radically. In all subjects
TABLE 6
Mean Gingival Index for the different areas of maxillary and mandibulary incisors, premolars and molars at
the end of the no-cleansing period.
Fig. 2. Trends in the accumulation of soft debris during the periods of no oral hygiene and
oral hygiene.
Fig. 3. Trends in the changes in the microflora of the gingival margin during the periods of no
oral hygiene and oral hygiene.
Fig. 4. Trends in the gingival changes during the periods of no oral hygiene and oral hygiene.
EXPERIMENTAL GINGIVITIS Page 13/185
gram-positive cocci and short rods now showed plaque formation shortly after the
only accounted for 45 - 60 per cent of the toothbrushing had been withdrawn, and
microorganisms in the plaque along the the accumulation increased steadily during
buccal gingiva. The distribution of other the experimental period (Fig. 2). With ref-
bacteria constituting the remaining 40-55 erence to the fact that all participants lived
per cent of the flora, was as follows: on a standard Scandinavian diet which in-
cludes coarse bread and ample amounts of
Gram-negative cocci and short rods: fresh fruit, this observation would appear
22% (range 11-31%) to indicate that the concept of self cleans-
Gram-positive filaments: 10% (range ing with this type of diet is highly ques-
5 - 16%) tionable.
The lingual surfaces of maxillary pre-
Fusobacteria: 10% (range 4 - 1 5 % )
molars were the only gingival areas that
Vibrios: 6% (range 1-12%) occasionally were free of plaque formation.
This finding and the observation that lin-
Spirochetes: 1% (range 0-2%)
gual surfaces of all maxillary teeth scored
It is interesting to note that the origi- lower for soft deposits than other areas
nally predominating flora of gram-positive can most likely be explained by the cleans-
cocci and short rods was reduced to 50 - 70 ing effect of tongue movements.
per cent of the total flora during the first
The bacteriological examinations have
four - seven days of plaque formation and
clearly shown that essential changes occur
remained fairly constant at 45 - 60 per cent
in the bacterial flora of the gingival margin
throughout the rest of the experimental
during the period of plaque development.
period. Gram-positive filaments, fusobacte-
The number of microorganisms colonizing
ria, and gram-negative cocci and small rods
a clean and healthy gingiva is low and the
were conspicuous in the smears after two -
flora consists almost entirely of gram-
four days, while vibrios and spirochetes
positive cocci and short rods. During
generally were found a few days later.
plaque formation a general increase in the
DISCUSSION number of microorganisms takes place, and
in the course of a few days a definite
A n evaluation of the results of the pres- change in the composition of the flora oc-
ent study must take into account that curs. From a predominance of coccal forms
although the twelve subjects who partici- the microflora changes to a more complex
pated in the experiment made a rather population in which first filamentous bac-
homogenous group the gingival condition teria, and later vibrios, spirochetes and
at the start of the experiment varied to gram-negative cocci are prominent (Fig.
some degree. Moreover, the study was ham- 3). A similar sequence in bacterial coloni-
pered by the fact that the clinical and zation has been repeatedly observed in stud-
bacteriological examinations were not al- ies of early calculus formation (Mandel,
ways made on the same day and that the Levy & Wassermann 1957, Muhlemann &
length of the interval between examina- Schneider 1959, Turesky, Renstrup &
tions varied. Therefore, no statistical analy- Glickman 1961). This shift cannot be en-
ses have been made, and the tables and tirely explained by the increase in the
diagrams accordingly are intended more to amount of plaque. It is more reasonable to
show trends than specific data. assume that the increasing age of the
plaque causes alterations in the local en-
In spite of these obvious shortcomings
vironment which favors the growth of cer-
the present investigation has shown that
tain bacterial types.
the abolishing of tooth cleansing procedures
results in a rapid increase of oral debris. The present study has further demon-
Nearly all areas of all teeth investigatec strated that gingivitis is produced simply
Page 14/186 LOE, THEILADE, JENSEN
significant changes in the microflora invari- Hine, M. K.: The use of the toothbrush in the
treatment of periodontitis. J.A.D.A. 41:158-168,
ably took place during the aging of the 1950.
plaque. The fact that normal gingiva did Jensen, S. B.: En unders0gelse af gingivas bakterie-
not harbor these bacteria and that the flora ved forskellige former for marginale paraden-
change in the microflora occurred before topatier. Tandlasgebladet 62:9-30, 1958.
gingivitis was clinically diagnosed, may in- Loe, H . & J. Silness: Periodontal disease in preg-
dicate that these microorganisms play a nancy. I.Prevalence and severity. Acta Odont.Scand.
role in the initiation of periodontal inflam- 21:533-551, 1963.
mation. The observation that the time nec- Lovdal, A., A. Arno & J. Waerhaug: Incidence of
clinical manifestations of periodontal disease in light
essary to develop clinical gingivitis varied of oral hygiene and calculus formation. J.A.D.A.
between individuals could then be a re- 56:21-33, 1958.
flection of individual defense mechanism Mandel, I. D., B. M. Levy & B. H . Wassermann:
variability. Histochemistry of calculus formation. J.Periodont.
28:132-137, 1957.
Finally, this experiment has corroborated Muhlemann, H . R. & U. K. Schneider: Early cal-
the well known clinical experience that re- culus formation. Helv.Odont.Acta. 3:22-26, 1959.
moval of bacterial plaque causes resolution Ramfjord, S. P. & G. Kiester: The gingival sulcus
of gingival inflammation. Within a few and the periodontal pocket immediately following
days after oral hygiene procedures were re- scaling of teeth. J.Periodont. 25:167-176, 1954.
EXPERIMENTAL GINGIVITIS Page 15/187
T H E A M E R I C A N B O A R D OF P E R I O D O N T O L O G Y
1965 Diplomates
The American Board of Periodontology announces that the following candidates successfully passed the
Board examination given in April, 1965:
Dr. Gerald M. Bowers, Main Navy Dispensary, Washington, D.C.
Dr. Frederic M. Chacker, 1913 Walnut Street, Philadelphia, Pa.
Dr. Jerry Garnick, 517 Temple Building, Rochester, N.Y.
Dr. Alan H . Greene, 14077 Cedar Road, Cleveland, Ohio
Dr. Samuel Kakehashi, National Inst, of Dent. Res., N.I.H., Bethesda, Md.
Dr. Ralph R. Lobene, Forsyth Dent. Center, Boston, Mass.
Dr. William T. McKenzie, 2161 McGregor Blvd., Ft. Myers, Florida
Dr. Roland M. Meffert, 163 Farrel Drive, San Antonio, Texas
Dr. Richard C. Oliver, 1998 "D" Street, San Bernardino, Calif.
Dr. John S. Pfeifer, 702 East Walnut Street, Green Bay, Wis.
Dr. Arthur M. Quart, 54 Noxon Street, Poughkeepsie, N.Y.
Dr. George T . Raust, Jr., 23 64 Geary Street, San Francisco, Calif.
Dr. Martin Sternig, 65 Park Ave., Bayshore, L.I., New York
Dr. Lewis F. Townsend, Jr., 1611th USAF Dispensary, McGuire AFB, N.J.
Board Members are: Frank E. Beube, L.D.S., D.D.S., Vice-Chairman, 730 Fifth Ave., New York, N . Y . ;
Donald Kerr, D.D.S., M.S., Chairman, University of Michigan, School of Dentistry, Ann Arbor, Michigan;
John W. Neilson, D.D.S., M.S., University of Manitoba, Faculty of Dentistry, Winnipeg, Canada; Erwin
M. Schaffer, D.D.S., M.S., University of Minnesota, School of Dentistry, Minneapolis, Minnesota; Henry M.
Swenson, D.D.S., Indiana University, School of Dentistry, Indianapolis, Indiana; B. O. A. Thomas, D.D.S.,
Ph.D., Secy.-Treas., 8 50 Middlefield Road, Palo Alto, Calif.