QUINTESSENCE INTERNATIONAL
PERIODONTOLOGY
Periodontal risk and recall interval evaluation after a
program of comprehensive supragingival plaque control
Juliane Pereira Butze, MScVPatrfcia Daniela M e lch io rs A ngst, MScVRui V ice n te O p p e rm a n n , PhD1
Sabrina C arvalho Gomes, PhD3
Objective: To investigate if a comprehensive supragingival
control can modify the periodontal risk and suggested recall
interval overtime, using an adaptation of an available model
o f periodontal risk assessment (PRA, Perio-Tools® website).
Method and Materials: Single-arm clinical trial data (visible
plaque and gingival bleeding indexes, periodontal probing
depth, bleeding on probing, and clinical attachment level from
baseline (day 0, T0), day 30 (T,), and day 180 (T2) from 50 mod-
erate-to-severe periodontitis patients (25 never-smokers; 25
smokers) submitted to a comprehensive supragingival plaque
control regimen for 180 days were subjected to a secondary
analysis using an adaptation of the PRA. The periodontal risk
(high, medium, or low) and suggested recall interval were
calculated per patient and at each experimental time. General
Key words: biofilm, dental scaling, periodontitis, risk
It is generally recognized th a t risk assessment strategy
is an im p o rta n t to o l in th e p re v e n tio n o f d e stru ctive
form s o f p e rio d o n ta l disease. H owever, in establishing
patient's risk th e clinician is o fte n challenged by a large
set o f clinical and laboratoriai data, m aking it d iffic u lt to
dra w a clear p ictu re o f th e actual risk th a t th e p a tie n t
1PhD Student, Graduate Program, Dental School, Federal University o f Rio Grande
do Sul, Porto Alegre, RS, Brazil.
2Fu 11 Professor, Department of Conservative Dentistry, Dental School, Federal
University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
Associate Professor, Department of Conservative Dentistry, Dental School, Fed­
eral University o f Rio Grande do Sul, Porto Alegre, RS, Brazil.
C o rre s p o n d e n c e : D r Sabrina C arvalho Gomes, Rua R am iro Barcelos,
2492, Bairro Santana, P orto Alegre, Rio G rande d o Sul, 90035-003 Brazil.
Email: sa brin a go m e s.p erio@ gm ail.com
VOLUME 46 ■ NUMBER 9 • OCTOBER 2 0 /5
Juliane Pereira
Butze
2/
linear models and the Cochran test were used for statistical
analysis, considering the dependence of the data. Results: All
patients were at high risk at baseline. At T,, 20% migrated to
medium-risk (P = .002). A tT2, 38% and 8% exhibited medium-
and low-risk, respectively (P < .001). The reduction between
T, and T2 was significant (P = .001). The mean recall interval
increased from 3.0 ± 0.0 (T0) to 3.6 + 1.2 (T,), and 4.9 ± 2.6
months at T2 (P < .003). The effect that smoking habit exerted
on risk was limited to the first 30 days, and no effect on recall
interval was observed. Conclusion: The oral hygiene condi­
tion is an important indicator that influences the risk and the
recall interval over time, thus deserving attention when evalu­
ating the individual periodontal prognosis. (Quintessence int
2015;46:765-772; doi: 10.3290/j.qi.a34176)
presents.13 In a d d itio n , th e clinician is also challenged
by th e need fo r o b je ctive criteria to establish th e fre ­
q uency o f th e recall a p p o in tm e n ts . It is clear th a t a
m o d e l o r a c o m p u te r p ro g ra m to m easure th e p e ri­
o d o n ta l risk and to he lp th e clinician to establish a
recall interval w o u ld be very helpful,4 and some propos­
als to m eet th is clinical need are available in th e lite ra ­
tu re . M ost o f th e m , acco rd in g to Lang e t al,4 are based
on th e P eriodontal Risk C alculator (PRC) o r th e Peri­
o d o n ta l Risk Assessment (PRA). Page et al5 suggested
th e PRC in 2003. From an analysis o f 523 radiographs
taken over 15 years, th e a uthors calculated th e a m o u n t
o f alveolar b one loss experienced by each p a tie n t, and
used these data to e stim ate th e in d ivid u a l p e rio d o n ta l
765
QUI NTESSENCE I NT ERNATI ONAL
Butze et al
risk. Based on the results, the authors concluded that
the estimated risk scores generally predicted the future
periodontal status with good precision and validity.
Also in 2003, Lang and Tonetti6 proposed the PRA,
available at the Perio-Tools® website (http://www.peho-
tools.com). According to the authors, the method helps
the clinician to determine the risk for disease progres­
sion on the subject level, and also the frequency of the
periodontal maintenance appointments. The method
estimates susceptibility to periodontal disease progres­
sion by considering not only the periodontal support
levels (eg, radiographic exams), as seen in the PRC, but
also the infection level (bleeding on probing [BOP]),
prevalence of residual periodontal probing depth
(PPD > 5 mm), number of teeth lost, patient's systemic
condition and age, as well as environmental and behav­
ioral factors (eg, smoking habit).
Nevertheless, these models do not include measure­
ments commonly used in the literature to assess the
oral hygiene performance such as plaque and gingivitis
indexes. It is well known that one of the most important
reasons for treatment failure and relapse of periodontal
disease in treated patients in spite of professional peri­
odic debridement is the inadequate daily control of the
supragingival biofilm.7'12 Furthermore, Gomes et al13'14
have shown that clinical and microbiologic conditions
of the subgingival area are significantly changed by the
performance of adequate oral hygiene alone. For the
clinician it is important to establish the impact of oral
hygiene on assessing patient periodontal risk as well as
to suggest time intervals for the maintenance of peri­
odontal health in treated patients. The aim of the pres­
ent study was to investigate if a sole supragingival
6-month plaque control regimen on moderate-to-
advanced periodontal patients could alter the results of
an adaptation of the PRA tools (Perio-Tools® website).
METHOD AND MATERIALS
Study design
This descriptive-analytic study constituted a secondary
analysis of a single-arm clinical trial published in 2007,13
which was in accordance with the Helsinki Declaration
766
of 1975, as revised in 1983, and was approved by the
Research Ethics Committee of the Sao Paulo State Uni­
versity at Araraquara (# 32/03).
Briefly, in the single-arm clinical trial 50 patients (25
smokers, 25 never-smokers) were selected from among
those referred to periodontal treatment at the Dentistry
Faculty, between July 2003 and August 2004. The inclu­
sion criteria were as follows:
• absence of any systemic condition that could inter­
fere with periodontal treatment (eg, diabetes, need
for antibiotic prophylaxis)
• no antibiotic or anti-inflammatory use in the past 3
months, and no use of chemical agents for supra­
gingival biofilm control
• no previous periodontal treatment
• not pregnant or using hormones
• presence of at least 12 teeth
• clinical diagnosis of gingivitis associated with
plaque accumulation and moderate-to-severe gen­
eralized chronic periodontitis15
• four or more teeth having one site with a PPD16 of 3
to 5 mm and another four teeth with at least one
site with PPD of 6 to 10 mm, as well as positive
results for Visible Plaque Index (VPI)17 and Gingival
Bleeding Index (GBI),17 BOP,16 and clinical attach­
ment loss (CAL).16
One single calibrated examiner (weighted ± 1 mm
Kappa values for PPD and CAL up to 0.92, before and
during the study)13 performed the periodontal exams
(VPI, GBI, PPD, BOP, and CAL) at days 0, 30, and 180
(full-mouth; six sites per tooth) (Fig 1). The examiner
was not involved with the selection of patients and
treatment. Nevertheless, due to the nature of the clin­
ical study it was not possible to attest that the examiner
was blinded to the experimental period.
The demographic characteristics (age, sex, and
number of cigarettes per day) and periodontal indica­
tors (VPI, GBI, BOP, and CAL) of the patients included in
this secondary analysis, as previously reported,13 are
shown in Table 1 (n = 50). In addition, the number of
sites with PPD > 5 mm per patient, at each examin-
VOLUME 46 • NUMBER 9 • OCTOBER 2015
 QUINTESSENCE INTERNATIONAL
Butze et al

—
Day -7 Day 0 Day 30 Day 180
• Patient • Periodontal clinical • Periodontal clinical • Periodontal
screening evaluation evaluation clinical
• Full-mouth supragin­ • Full-mouth supragingival evaluation
gival plaque control plaque control
• Oral hygiene • Oral hygiene
instructions reinforcement

.Day 0_________________________________________ ________________________________________ Day 180,

Every week
• Visible supragingival plaque and marginal bleeding assessments
• Oral hygiene reevaluation and reinforcement

Fig 1 Flowchart of the study.

Table 1 Demographic characteristics (at baseline) and periodontal indicators at baseline (day 0, T0) and at 30
(Tn) and 180 days (T2) for the total sample, and according to the smoking status (never-smokers and
smokers)

Variable Total (n = 50) Never-smokers (n = 25) Smokers (n = 25)

Age (years, m ean ± SD) 46.36 ± 6 .2 5 46.80 ± 7.06 45.92 ± 5.43

Sex (% m en) 48 40 56

C ig a rette s/d a y (mean ± SD) NA NA 19.44 ± 1 1 .6 3

To T T2 To T, T To T T
21.28 21.28 21.28 21.38 21.38 21.38 21.20 21.20 21.20
Teeth (n; m ean ± SD)
± 3 .7 4 ± 3 .7 4 ± 3 .7 4 ± 3 .8 4 ± 3 .8 4 ± 3 .8 4 ± 3 .7 3 ± 3 .7 3 ± 3 .7 3

VPI (positive sites; 89.51 28.48 7.19 91.10 31.99 8.70 88.50 24.96 6.40
m ean ± SD) ± 1 1 .4 2 ± 1 9 .9 3 ± 8 .2 2 ± 8 .1 9 ± 1 9 .9 7 ± 9 .4 2 ± 1 3 .9 6 ± 1 9 .6 5 ± 6 .8 3

GBI (p ositive sites; 79.30 8.38 1.28 83.80 12.34 2.20 76.10 4.42 0.30
m ean ± SD) ± 16.71 ± 9 .3 7 ± 2 .3 9 ± 13.08 ± 10.63 ±3.01 ± 1 8 .6 9 ± 5 .7 9 ± 0 .8 7

BOP (p ositive sites; 120.94 60.00 29.94 121.84 61.32 27.72 120.04 58.68 32.16
m ean ± SD) ± 2 5 .1 6 ± 3 1 .8 5 ± 2 1 .7 7 ± 22.80 ± 30.07 ± 17.26 ± 2 7 .7 6 ±34.11 ± 25.68

PPD > 5 m m (positive sites; 43.32 27.16 19.56 39.60 24.24 17.16 47.00 30.08 21.96
m ean ± SD) ± 2 0 .5 5 ± 18.44 ± 15.66 ± 16.75 ± 16.30 ± 12.37 ± 2 3 .5 3 ± 20.27 ± 18.32

3.82 3.56 3.35 3.43 3.19 3.02 4.20 3.93 3.67

CAL (m m ; m ean ± SD)
± 1 .0 6 ± 1.07 ± 1.10 ± 0 .8 7 ± 0 .8 7 ± 0 .9 2 ± 1 .1 0 ± 1 .1 4 ± 1.18

NA, not applicable.

ation, was recovered from the original study,13 and
presented in Table 1.
All subjects were submitted to a protocol of a com­
prehensive weekly supragingival plaque control w ith­
out subgingival intervention for 180 days. This supra­
gingival control consisted o f an initial full-m outh
supragingival debridement with hand curettes (Gracey
1-2,11-12,13-14; Neumar), temporary cavity filling, res­
toration adaptations, hopeless-teeth and root extrac­
tions, and endodontic treatments. Participants received
oral hygiene instructions according to individual needs,
identified by means of the supragingival indexes (VPI
and GBI). From day 0 onward, plaque control and gingi­
val inflammation were reevaluated weekly and oral

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QUI NTESSENCE I NT ERNAT I ONAL
Butze et al
Figs 2a and 2b Clinical aspect o f a participant from the 180-day comprehensive supragingival plaque control clinical study: (a) at
baseline and (b) after 180 days.
hygiene reinstructions were given, individually, over
time. Dental floss and interdental brushes were also
prescribed accordingly. Toothbrushes and fluoride
toothpastes (CloseUp, Unilever) were provided to the
participants during the experimental period.
Figure 2 shows the clinical aspect of a participant at
baseline and at the end of the 180-day comprehensive
supragingival plaque control regimen.13
Instruments and measurements
The primary outcome of this secondary analysis was
the periodontal risk of patients who had undergone
supragingival control. Periodontal risk was evaluated
using the Periodontal Risk Assesment6tool (version 3.1)
available at the Perio-Tools® website. However, the PRA
was adapted, as the original version uses alveolar bone
loss (ABL) based on radiographs and, in the current
investigation, the mean CAL was used.
Once the patient's data (Table 1) were entered, the
tool generated a m ultifunctional diagram called a
"polygon". The polygon surface was constructed on the
basis of demographic factors (eg, patient's age, number
of teeth), existence of systemic conditions (eg, type I or
II diabetes mellitus, polymorphisms, stress), number of
missing teeth, periodontal indicators (eg, number of
sites with PPD>5mm, the mean CAL replacing the
ABL, number of sites with positive BOP), information
about the periodontal examination (eg, number of sites
examined per tooth), and behavioral factors (eg, smok­
768
ing habit and the level of exposure). Based on the poly­
gon surface information, the tool defined the patient's
periodontal risk (high, medium, or low) and their sug­
gested recall interval (Reclnt).
Statistical analysis
Initially, descriptive analysis of the data generated the
means and standard deviations (SDs) for Reclnt and the
absolute frequencies for the categorical variable (peri­
odontal risk) at an individual level. These variables were
then calculated considering the total sample (n = 50), at
each experimental moment (T0 = day 0; T ^ d a y 30;
T2= day 180). Confidence intervals (95% Cl) were esti­
mated for Reclnt. The analysis also included compari­
sons between smokers (n = 25) and never-smokers
(n = 25).
In sequence, the Kolmogorov-Smirnov test was
used to verify the normal distribution of the data. Intra­
group comparisons were performed by means of Gen­
eral Linear Models for repeated measures, with Bonfer-
roni post-hoc test (if applicable), for quantitative
variable, and by means of Cochran test, with McNemar
post-hoc tests (if applicable), for categorical variable.
The SPSS v.18.0 program (SPSS) was used to analyze
the data, considering the individual as the unit of analy­
sis. Differences were considered statistically significant
for P < .05.
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Table 2 Periodontal risk score and suggested recall interval (Reclnt; in months) for patients in the total sam­
ple, and according to the smoking status (never-smokers and smokers), at baseline (T0) and after 30
days (T,) and 180 days (T2) of a comprehensive supragingival plaque control based on the results of an
adaptation in the Periodontal Risk Assessment (PerioTools®)

Total (n = 50) Never-smokers (n = 25) Smokers (n = 25)

To T, t2 T0 T, t2 T„ T, t2
High [n (%)] 50(100) 40 (80) 27 (54) 25 (100) 18(72) 12(48) 25 (100) 22 (88) 15(60)
Medium [n (%)] 0 10(20) 19(38) 0 7(28) 9(36) 0 3(12) 10(40)
Low [n (%)] 0 0 4(8) 0 0 4(16) 0 0 0
Risk
P value T,,-!, .002 .016 .250
P value T,-T2 .001 .031 .039
Pvalue T0-T2 < 0.001 < 0.001 0.002
3.0 ± 0.0 3.6 ± 1.2 4.9 ± 2.6 3.0 ± 0.0 3.8 ± 1.4 5.5 ± 3.2 3.0 ±0.0 3.4 ± 0.9 4.2 ± 1.5
Mean ± SD (95% Cl) (3.000 - (3.259- (4.149 - (3.000 - (3.357 - (4.514- (3.000 - (2.877- (3.194-
3.000) 3.941) 5.571) 3.000) 4.323) 6.526) 3.000) 3.843) 5.206)
Reclnt p value T0-T, .003

Rvalue T,-T2 <.001

Pvalue T0-T2 <•001

RESULTS DISCUSSION

All individuals showed a high periodontal risk at base­
line (Table 2). At day 30, 20% of patients exhibited
medium risk (P = .002). After 180 days, about half ofthe
patients presented medium (38%) or low (8%) risk
[P < .001). The comparison between 30 and 180 days
was also significant (P = .001).
Reductions in the periodontal risk for smokers were
not significant after 30 days of supragingival plaque
control (P = .250). At the final examination, 40% of the
smokers had changed to medium risk (P = .002)
(Table 2). The decrease of periodontal risk observed for
never-smokers was significant from day 30 onwards.
Between days 0 and 30, 28% of never-smokers
migrated to medium risk (P= .016). At the final examin­
ation, 52% of never-smokers had changed risk category
(36% medium, 16% low) (P< .001).
The results related to the Reclnt also are shown in
Table 2. The mean Reclnt increased from 3.0 months at
baseline to 3.6 months at day 30, and 4.9 months at day
180 (all comparisons with P < .003). Smoking status did
not influence this outcome (P = .094).
The present study showed that the supragingival
plaque control significantly modified the assessment of
the periodontal risk and the recall interval suggested
by an adaptation ofthe PRA. These results suggest that
determination of periodontal individual risk and main­
tenance recall can be improved when simple and avail­
able oral hygiene methods are incorporated in the daily
clinical routine, even when a well-known risk factor, like
tobacco exposure, is present.
Clinical data from a study where the supragingival
control was the sole treatment to test the hypothesis
that the supragingival environment could modify the
subgingival one were used in the present investiga­
tion.13 Herein, at baseline, the PRA results classified as
high risk the entire group of patients. However, by day
30 of supragingival plaque control a significant reduc­
tion of 20% in the high-risk PRA score was observed.
Interestingly, as long as the supragingival control was
performed, additional and significant reductions in
scores of an adaptation of PRA were observed. At T2,
the proportion of high-risk patients was reduced to

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almost 50%. The m edium -risk patients increased from
10 to 19 patients between T, and T2, w hile the low-risk
also increase from 0 to 4 patients. Possibly, the results
observed here were determ ined by the effect o f the
supragingival control in reducing PPD and BOP, since
the other variables (number o f teeth, smoking habit,
systemic co nd itio n) were n ot m odified during the
study. It is im portant to emphasize th a t the proposed
model o f supragingival regimen consisting o f 6 months
o f weekly appointm ents is tim e-consum ing and ques­
tionable as a clinical protocol. In fact, th e greatest
reductions in the clinical variables were observed in the
first 30 days. If a clinical recom m endation could be
drawn from this observation it is th a t short-term effec­
tive oral hygiene w ill determ ine significant reductions
in the inflam m atory parameters associated w ith peri­
odontal disease. The experim ental design o f the pres­
ent study cannot rule out the possible influence o f the
Hawthorne effect on the results. This effect is known to
be present in studies o f similar nature. The response of
the individual is a result o f participation in the study
but also a result o f the knowledge acquisition associ­
ated w ith behavioral orientations provided throughout
the study.18While the Hawthorne effect seems to be o f
short duration, knowledge acquisition requires a larger
exposure tim e but results in more permanent changes
in habits. In this sense, a reduction o f almost 50% in the
high-risk category, based solely on oral hygiene orien­
tation, underscores one im p orta nt perspective to the
clinician in the management o f the periodontal patient
over tim e. Also, these results favor discussions on the
lim itations o f models th a t aim to investigate risk or
determ ine recall intervals w ith o u t evaluating the oral
hygiene scores.
The individuals involved on the single-arm trial,13
besides th eir periodontal condition, were systemically
healthy. The addition o f the analysis o f systemic condi­
tions to evaluate risk and consultation interval would
be very interesting and helpful to the clinician, and
would meet more criteria considered by the PRA (Perio-
Tools®). However, it is believed th a t the hom ogeniza­
tion o f sample regarding the systemic condition pro­
vided the o p p o rtu n ity to discuss at least one very
770
im portant and known risk factor, smoking.3'1924 When
smoking status was considered, only the never-smok-
ers showed significant risk m odification during the first
30 days o f plaque control. At day 30, 88% o f smokers
and 72% o f never-smokers were at high-risk. Both
reductions represented a m igration to the medium-risk
category. From day 30 onward, the periodontal risk of
both smokers and never-smokers were similar and sig­
nificantly m odified. The PRA to o l also indicates the
"ideal" recall frequency. In fact, no "ideal frequency"
between appointm ents for periodontal maintenance
has been suggested in the literature.3'4 Traditionally, an
empirical approach has been used to justify the interval
between appointm ents, w ith clinical indicators (eg,
PPD, BOP, and CAL) and physical or subjective condi­
tions being used.19'2a25‘27The suggestion for recall inter­
val varied over tim e in the present study. According to
the patient status at baseline, the recall appointm ents
should occur every 3 months. After being subm itted to
supragingival control, however, the suggested recall
interval increased to 3.6 months at T, and to 4.9 months
at T2. Smoking status did not determ ine differences in
the frequency o f recall interval.
Periodontal disease is known to relapse in noncom-
pliant patients.19'20'2526 Am ong other reasons this may
happen because the patient is not adequately m oti­
vated or because the professional has not been able to
draw a precise picture o f the patient needs.320Thus, risk
assessment models may represent an im p orta nt tool
th a t the clinician may use to directly determ ine prog­
nosis as well as offer protocols o f maintenance for the
treated patient.4 In this sense, initiatives such as PRA
are very im p orta nt as an auxiliary tool for the profes­
sional. In particular, PRA is composed o f clinical, labora­
tory, and dem ographic data known to influence the
establishment and progression o f periodontal disease.6
Based on the evaluation o f each patient this tool allows
the professional to assess risk on an individual basis.
Herein, an adaptation o f the PRA model was used.
According to the PRA, the CAL calculation depends on
the extension of ABL that should be taken at a posterior
to o th w ith the greatest CAL value. This calculation,
however, may represent a relevant concern when con-
VOLUME 46 • NUMBER 9 • OCTOBER 2015

sidering the assessment of risk, first because it is not
possible to guarantee radiographic standardization for
all patients; second, because if the site with the great­
est CAL is a buccal or lingual/palatal one, it is not pos­
sible to measure the ABL;28'29 and third, because it is not
possible to assume that all patients present posterior
teeth. Nevertheless, the gold-standard method for eval­
uating periodontal damage is the assessment of CAL.30
Bearing all these observations in mind, the present
study used the full-mouth periodontal examination31 of
the CAL instead of radiographic measures to feed the
tool. The other variables, however, were used as pro­
posed by the PRA tool.
It is also important to highlight that the PRA was
developed to assess risk in treated patients, ie patients
that have completed the periodontal therapy, not only
the supragingival control phase.6 On the other hand,
the results of the present study showed that PRA
responds to clinical changes in the status of patients
also when only part of the periodontal treatment was
performed. To the best of our knowledge, models pro­
posed to assess periodontal risk do not include direct
assessment of oral hygiene such as plaque and gingival
indexes. Within the limits of the present proposal, the
impact of the supragingival control on the PRA results
were assessed in order to promote a discussion on the
need to incorporate oral hygiene evaluation on a regu­
lar basis in daily clinical practice. Failures in periodontal
treatm ent as well as recurrence of the disease in
treated patients are commonly associated with poor
oral hygiene, subgingival therapy deficiency, and/or
systemic conditions that may influence the imbalance
between bacteria and host.3'2123 The present results
suggest that a comprehensive supragingival control
that altered subgingival parameters was able to alter
the periodontal risk indications of PRA. Several studies
have shown that this control is an important interven­
tion to reduce subgingival treatment failure, prevent­
ing or minimizing loss of attachment in the long term.7'
12 Recent inform ation also suggests that the
supragingival environment is determinant to the sub­
gingival stability, from both clinical and microbiologic
standpoints . 13' 14'32
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Butze et al
The PRA has received some criticism. According to
Jansson and Norderyd, 33 the PRA tool seems to overes­
timate the periodontal risk due to the difficulties in
establishing appropriate and/or representative thresh­
olds and adequate correlations between the variables
evaluated in the model. Lang et al4 observed that even
if available tools may predict periodontitis progression,
no data are available on the impact that such risk
assessment may have on patient management. Fur­
thermore, although the idea of using the risk assess­
ment tools to determine the frequency of recall
appointments is rational and may help in treatment
planning, such suggestions remain unsubstantiated.
Accordingly, the results of the present study indicate
that both the risk assessment and patient management
may be better implemented if systems such as PRA
incorporate in their set of data information on the oral
hygiene status of the patients and its effect on gingival
and periodontal health.
CONCLUSION
Within the limits of the present study, the results illus­
trate that supragingival plaque control was able to
significantly modify the risk of the periodontal patients,
as well as the suggested recall interval derived from a
risk assessment tool. These results emphasize the role
of the clinician in health education, prom oting
improvement in the prognosis of a periodontal patient
irrespective of remaining difficulties related to risk and
recall interval determinants. Future studies might try to
explore the impact of the supragingival indicators
when included in models that aim to assess the indi­
vidual risk of the development of CAL, in order to add
to the clinical management of a periodontal patient.
ACKNOWLEDGMENTS
Funding fo r th e original study (Gomes e t al13) was provided by the
National Counsel ofT echnological and S cientific D evelopm ent (CNPq)
and C om m ittee for P ostgraduate Courses in H igher Education (CAPES)
Foundation (n. 0550/04-3), Brasilia, Federal District (DF), Brazil. The to o th ­
brushes and toothpastes were a donation from the Unilever, Valinhos, SP,
Brazil. The present investigation was entirely supported by the authors.
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VOLUME 46 ■ NUMBER 9 • OCTOBER 2015
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