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Effectiveness of oral hygiene techniques on plaque and gingivitis in patients placed in intermaxillary fixation
Effectiveness of oral hygiene techniques on plaque and gingivitis in patients placed in intermaxillary fixation Barbara A. Phelps-Sandall, San Francisco, Calif. DEPARTMENT
OF PERIODONTOLOGY,
R.D.H.. B.A., M.Ed.,*
UNIVERSITY
and Susan J. Oxford,**
OF CALIFORNIA
AT SAN FRANCISCO
Twenty-one patients undergoing reconstructive maxillofacial surgery volunteered to learn and practice specific oral hygiene techniques while in intermaxillary fixation in order to compare the effectiveness of different regimens. Oral irrigation was taught to all subjects; one third of the subjects were also instructed in the use of the sulcus brush, and another third were instructed in the use of the Perio-Aid. Scoring was done every 2 weeks for a &week period, with measurements taken of the amount of plaque and the amount of inflammation present in papillary, marginal, and attached gingiva. Results show that the group employing only the Water Pik had less inflammation in the attached gingiva than the group using the Perio-Aid and less plaque accumulation and papillary inflammation than the group using the sulcus brush. While more research is necessary to confirm these results, the simplest home care regimen, use of the Water Pik only, appears to offer the best way for intermaxillary fixation patients to remove plaque and minimize inflammation during convalescence.
R
econstructive surgery patients who are placed in intermaxillary fixation for the duration of the healing process have a difficult time maintaining good oral hygiene.’ The appliances that hold the mandibular arch in tight occlusion against the opposing teeth cause increased plaque retention and soft-tissue irritation. The security of the wires (or elastics) prevents any accessto lingual surfaces and limited access to facial and interproximal surfaces, thus making plaque-removal procedures difficult. Reconstructive surgery patients are usually kept in intermaxillary fixation for a period of 6 weeks.’ During this time, sensitivity, diet, limited access,and other incurred injuries can all have an effect on the quality of personal oral hygiene procedures that are performed. Once the appliances are removed, muscular trismus may interfere with toothbrushing and flossing.* Since gingivitis takes but 10 to 21 days to develop,3it follows that gingivitis and signs of periodontal disease can result during convalescence. Therefore, it is reasonable to assume that some oral hygiene care procedures for daily plaque removal Oral irrigators were contributed ny, Fort Collins, Colo. *Lecturer **Student.
by Teledyne Water Pik Compa-
may be more beneficial than others for fixation patients. Research in the area of daily oral care for patients in intermaxillary fixation is extremely limited. In the literature there is little if any, mention of oral home care related to maxillofacial surgery or facial injuries. Some nursing care texts and manuals4+5do include information on oral care for such patients, but this is usually limited to swabbing or rinsing the mouth, and both of these techniques are known to be ineffective in total plaque removal.* Since research and available information on oral hygiene for fixation patients is minimal, the effects of various procedures on plaque accumulation and gingivitis should be considered in the determination of acceptable postoperative home care instructions, so that discomfort can be eliminated. If an effective regimen is followed, patients will be able to maintain an optimal level of oral health during convalescence. LITERATURE
REVIEW
In their texts on maxillofacial surgery many authors make no mention of oral care for patients while they are undergoing intermaxillary fixation.6-‘0 Some authors acknowledge that oral hygiene should 487
488 Phelps-Sandal1 and Oxford be attended to in the case of fixation but give no indications as to what should be done.“-‘3 Others do not discuss oral hygiene measuresexcept to say that they should be employed to prevent infection.14Some do state that the teeth should be cleaned but say nothing about daily oral hygiene.15SchultzI stands apart from his colleagues by mentioning oral irrigation and the use of a soft toothbrush to keep teeth, gingiva, and arch bars free of plaque. He does not, however, give any details on how an oral-irrigation device should be used or which brushing methods are best suited for cleaning around fixation apparatus. Research that has been done on plaque and gingivitis in orthodontically banded mouths can be directly applied to fixation patients. Nevertheless, it must be kept in mind that intermaxillary fixation patients are unique becauseof restricted accessto all surfaces of the teeth. Plaque control should be of primary importance, however, since contamination from the oral cavity is one of the principal causesof infected wounds; thus, there is a high risk of potential gross infection in patients undergoing this type of surgery. In addition, the degree of oral health is a factor that influences the local defense mechanisms against infection.14 Both appropriate plaque-removal devices and proper technique are important to the maintenance of oral hygiene. Small, soft, multitufted toothbrushes are known to be effective around appliances.* A brushing technique that emphasizes sulcular cleaning is important to prevent gingivitis in orthodontic patients. The Bass technique, being the method of choice,” would probably be effective for fixation patients. Oral irrigation, while not known to thoroughly remove plaque, coupled with toothbrushing is an effective means of disorganizing harmful bacteria’* and is, therefore, recommendedby someauthorities for mouths in fixation.“-‘3 However, care must be taken to keep the pressure of pulsating water devices below 70 p.s.i. in order to avoid causing added injury to soft tissue.19Interproximal cleaning with floss is quite possible for orthodontic patients since the development of floss threaders,20,2’but it is impossible for intermaxillary fixation patients. However, Perio-Aids, designed for subgingival and interdental plaque removal, can be useful in removing plaque from between the teeth.* While detailed instructions must be given in the use of the PerioAid, and a high degree of manual dexterity is required, it can be speculated that fixation patients might attain the same promising results that orthodontic patients have with this device. The lack of information available on home care techniques specifically for fixation patients is impres-
Oral Surg. November, 1983
sive. While much can be related from other areas of oral hygiene, more direct sources of information should be available. Perhaps a specific body of literature has not developed because fixation is a temporary situation. However, the patient’s health and comfort should not be sacrificed. If information were available concerning the permanent effects of fixation on individual periodontiums, perhaps more research would be initiated. METHOD
Twenty-one volunteer subjects were selected from the reconstructive surgery patients admitted to the University of California at San Francisco Medical Center and randomly assigned to one of three groups. All subjects were conscious, ambulatory, able to perform their own oral hygiene procedures, and at least 14 years old. Group 1 served as the control group, and subjects were given the standard instructions that all reconstructive surgery patients at this facility receive in the use of the Water Pik. Group 2 subjects were given instructions for using the Water Pik, coupled with instructions in the use of the Perio-Aid. Group 3 subjects were given instructions in the use of the Water Pik along with instructions in sulcus brushing. Water Piks, PerioAids, and sulcus brushes were provided. Written instructions** on the appropriate home care techniques were sent home with subjects of each group. All patient education was given individually by the same dental hygiene student and immediately followed up with a photographic presentation of the home care techniques. All subjects were asked to use each aid at least once a day. Individuals’ questions concerning home care techniques were answered as they came up at each scoring appointment. The Papillary Marginal Attached Gingival Index23 developed by Massler was used for assessmentof gingivitis. Green and Vermillion’s Simplified Oral Hygiene Index23 served for the debris scoring. Instead of the six surfaces suggested for these indices, all facial surfaces of existing teeth were examined visually as far posteriorly as the first permanent molars for each index. Base line scoring was not possible. Each subject, however, was scored at 2-, 4-, and 6-week intervals by the primary investigator, who was unaware of the group assignments of the various subjects. RESULTS
The 6-week readings only were used in analyzing the data. The Kruskal-Wallis one-way analysis of variance was run on the means for each of the three groups on all four measures of the Oral Hygiene
Oral hygiene techniques for patients in intermaxillary
Volume 56 Number 5
Table
fixation
489
I. Kruskall-Wallis one-way analysis of variance Group
No. in group Oral Hygiene Index* Papillary gingiva* Marginal gingiva* Attached gingiva* PMA*
Corrected
1
2
3
4 4.00 4.50 5.50 4.00 5.13
6 8.58 8.25 9.08 10.17 8.50
5 10.50 10.50 8.70 8.60 9.70
for
Chi-squared
ties
Signijcance
4.882 4.082 1.728 4.88 1 2.455
0.087 0.130 0.422 0.087 0.293
*Mean rank
Index (OHI), papillary gingiva (P), marginal gingiva (M), and attached gingiva (A). For OH1 and A, a significant difference of p = 0.087 was found. No significant difference (p > 0.01) occurred for P, M, or the total means of PMA (Table I). The Mann-Whitney U test was done as a followup multiple comparison. Between Groups 1 and 2, the only significance found for which Group 1 had a lower mean rank was for the attached gingiva (p = 0.0172). Between Groups 1 and 3, Group 1 had a lower mean rank in OH1 (p = 0.0139) and in P (p = 0.0838). None of the other comparisons showed significant differences between Groups 1 and 3. (See Table II). Kendal rank correlation coefficients correlating OH1 with P, M, A, and PMA revealed no significant differences from zero, with p > 0.3 for all measures. DISCUSSION
Fifteen of the twenty-one volunteers completed the study. Several of the subjects did not require fixation for the full 6 weeks of convalescence.The data on these persons were included in the results, however, since the trauma from their surgery did restrict the amount of jaw movement possible. Measurements of these subjects were taken only on facial surfaces, as was the case with the volunteers undergoing fixation, even though there was limited access to lingual surfaces. Comparison of the results of Group 1 and Group 2 reveals that the only significant difference lies in the condition of the attached gingiva, with the control subjects (Group 1) displaying less inflammation. Comparison of results between Group 1 and Group 3 shows significant differences in plaque accumulation and papillary inflammation. The control group displayed less plaque and less inflammation. One explanation for these results is that the Perio-Aid and the sulcus brush may be too large and bulky for a mouth under fixation and therefore, when used, caused trauma to soft tissue. If that is the case,
Table II. Mann-Whitney U test, follow-up multiple comparison Corrected for ties 2-tailed p
Between 1 and Between 1 and
groups 2 groups 3
OHI
P
M
A
PMA
0.2008
0.1332
0.2008
0.0172
0.1356
0.0139
0.0838
0.3272
0.1797
0.2683
then the increased sensitivity in traumatized areas would cause a patient to avoid touching tender gingiva with a home care aid, and plaque removal would not be complete, thus accounting for the presence of more debris in subjects using the sulcus brush. Another possible explanation for these results is that perhaps it takes more time and practice to develop the skill needed to use a Perio-Aid or sulcus brush than are required for learning to use a Water Pik. After all, a Water Pik merely requires the patient to direct a stream of water at the proper angle to a tooth surface, whereas use of a Perio-Aid and sulcus brush requires more coordinated movement of the wrist and fingers. Since gross motor skills can be mastered sooner than fine motor skills, it may have been easier for subjects to learn the technique of using a Water Pik, thus resulting in more plaque removal, less trauma, and less inflammation. One other factor that may account for the control group having less attached gingival inflammation than Group 2 and less plaque and papillary inflammation than Group 3 is that the control subjects may have spent more time working with the Water Pik” when doing oral hygiene procedures, since they had only one task to perform. Since Groups 2 and 3 each had two different tasks to accomplish daily, some subjects may have rushed through procedures becausemore time was required to complete the two techniques. This could result in incomplete plaque removal and self-induced trauma from quick, uncon-
490
Phelps-Sandal1 and Oxford
trolled movements. The final results would be increased plaque accumulation and inflammation. Therefore, dividing subjects’ attention between the modalities may have decreased the effectiveness of both techniques. CONCLUSION
Becauseof the diversity of subjects taking part in this study, it would have been beneficial to gather base line data for OH1 and PMA on each subject before surgery. However, volunteers could not be identified until the night before their surgical procedures, making collection of base line data impractical. While more studies with larger populations should be performed to challenge or confirm this information, these results indicate that the Water Pik alone can benefit the health of oral tissue in intermaxillary fixation patients. This study cannot conclude that the Perio-Aid and sulcus brush are not beneficial for patients undergoing fixation, but the results do help to reinforce the need for individualization of home care techniques for every patient. The authors would like to express their gratitude to Teledyne Water Pik Company for their generous contribution of oral irrigators; to William Ware, D.D.S., and his staff for their complete cooperation; and to Ann Scarff, R.D.H., for her help, enthusiasm, and support. REFERENCES
I. Communication on 10/24/80 with William H. Ware, D.D.S., Professor and Chairman. Division of Oral and Maxillofacial Surgery, School of Dentistry, University of California, San Francisco Calif. 94143. 2. Wilkins, Esther: Clinical Practice of the Dental Hygienist, ed. 4, Philadelphia, 1976, Lea & Febiger, pp. 307-326, 337-339, 357-361, 609-612. 3. Loe, H., Theilade, E., and Jensen,S.: Experimental Gingivitis in Man, J. Periodontol. 36:177 1965. 4. Brunner, Lillian S.: Lippincott Manual of Nursing Practice, Philadelphia, 1974, J.B.Lippincott Company, pp. 462-473. 5. Shafer, K.N., et al.: Medical Surgical Nursing, St. Louis, 1975, The C.V. Mosby Company, pp. 640. 6. Paparella, M.M., Shumrick, D.A.: Otolaryngology, Vol. III, Philadelphia, 1973, W.B. Saunders Company, pp. 403-440. 7. Beumer, J., Curtis, T., and Firtell, D.: Maxillofacial Rehabil-
Oral Surg. November, 1983 itation: Prosthodontic and Surgical Considerations, St. Louis, 1979, The C.V. Mosby Company, pp. 408-418. 8. Morgan, D., Hall, W., and Vamvas, S.: Diseases of the Temporomandibular Apparatus: A Multidisciplinary Approach, St. Louis, 1977, The C.V. Mosby Company, pp. 326-341. 9. Sisson, George A., and Tardy, M. Eugene (editors): Plastic and Reconstructive Surgery of the Face and Neck, Vol. 2, New York, 1977, Grune & Stratton, pp. 196-209. IO. Irby, W.B.: Facial Trauma and Concomitant Problems: Evaluation and Treatment, ed. 2, St. Louis, 1979, The C.V. Mosby Company, pp. 46-73. I I. Ballantyne, J., and Groves, J.: A Synopsis of Otolaryngology, ed. 3, Bristol, John Wright & Sons, Ltd., pp. 343-345. 12. Archer W.H.: Oral and Maxillofacial Surgery, 5th. edition. Vol. III, Philadelphia, 1975, W.B. Saunders Company, pp. I ,358-l ,359. 13. Snow, J.B.: Introduction to Otorhinolaryngology, Chicago, 1979, Yearbook Medical Publishers, Inc., pp. 124-125. 14. Conlev. John J. (editor): Comolications of Head and Neck Surgery, Philadelphia, 1979,W: B. Saunders Company, pp. 3, 99- 123. 15. Rees,Thomas D., and Wood-Smith, Donald: Cosmetic Facial Surgery, Philadelphia, 1973, W. B. Saunders Company, pp. 494-5I I. 16. Schultz, R. C.: Facial Injuries, ed. 2, Chicago, 1977, Yearbook Medical Publishers, pp. 12-40, 313-314. 17. Zachrisson, B.: Oral Hygiene for Orthodontic Patients: Current Concepts and Practical Advice, Am. J. Orthod. 66:487497, 1974. 18. Hurst, J., and Madonia, J.: The Effect of Oral Irrigation Devices in the Oral Hygiene of Orthodontic Patients, J. Am. Dent. Assoc. 81:678-687, 1970. 19. Hugoson, A.: Effect of the Water Pik Device on Plaque Accumulation and Development of Gingivitis, J. Clin. Periodontol. 595-104, 1978. 20. Schwaninger, Bernhard, and Vickers-Schwaninger, Nancy: Developing an Effective Oral Hygiene Program for the Orthodontic Patient: Review, Rationale, and Recommendations, Am. J. Orthod. 75:447-452, 1979. 21. Trebitsch, F.: Flossguide:An Instrument for Inserting Dental Floss Underneath Bridges or Bars, Aust. Dent. J. 23187-188, 1978. 22. Bauman, Richard: Survey of Dentists’ Attitudes Regarding Instructions for Home Care for Patients Who Wear Dentures, J. Am. Dent. Assoc. 100:206-208, 1980. 23. Darby, Michele L., and Bowen, Denise M.: Research Methods for Oral Health Professionals:An Introduction, St. Louis, 1980, The C.V. Mosby Company, pp. 95, 97-99. Reprint requests to:
Barbara A. Phelps-Sandall, R.D.H., M.Ed. Department of Periodontology University of California 425-C San Francisco, CA 94143
OF PERIODONTOLOGY,
R.D.H.. B.A., M.Ed.,*
UNIVERSITY
and Susan J. Oxford,**
OF CALIFORNIA
AT SAN FRANCISCO
Twenty-one patients undergoing reconstructive maxillofacial surgery volunteered to learn and practice specific oral hygiene techniques while in intermaxillary fixation in order to compare the effectiveness of different regimens. Oral irrigation was taught to all subjects; one third of the subjects were also instructed in the use of the sulcus brush, and another third were instructed in the use of the Perio-Aid. Scoring was done every 2 weeks for a &week period, with measurements taken of the amount of plaque and the amount of inflammation present in papillary, marginal, and attached gingiva. Results show that the group employing only the Water Pik had less inflammation in the attached gingiva than the group using the Perio-Aid and less plaque accumulation and papillary inflammation than the group using the sulcus brush. While more research is necessary to confirm these results, the simplest home care regimen, use of the Water Pik only, appears to offer the best way for intermaxillary fixation patients to remove plaque and minimize inflammation during convalescence.
R
econstructive surgery patients who are placed in intermaxillary fixation for the duration of the healing process have a difficult time maintaining good oral hygiene.’ The appliances that hold the mandibular arch in tight occlusion against the opposing teeth cause increased plaque retention and soft-tissue irritation. The security of the wires (or elastics) prevents any accessto lingual surfaces and limited access to facial and interproximal surfaces, thus making plaque-removal procedures difficult. Reconstructive surgery patients are usually kept in intermaxillary fixation for a period of 6 weeks.’ During this time, sensitivity, diet, limited access,and other incurred injuries can all have an effect on the quality of personal oral hygiene procedures that are performed. Once the appliances are removed, muscular trismus may interfere with toothbrushing and flossing.* Since gingivitis takes but 10 to 21 days to develop,3it follows that gingivitis and signs of periodontal disease can result during convalescence. Therefore, it is reasonable to assume that some oral hygiene care procedures for daily plaque removal Oral irrigators were contributed ny, Fort Collins, Colo. *Lecturer **Student.
by Teledyne Water Pik Compa-
may be more beneficial than others for fixation patients. Research in the area of daily oral care for patients in intermaxillary fixation is extremely limited. In the literature there is little if any, mention of oral home care related to maxillofacial surgery or facial injuries. Some nursing care texts and manuals4+5do include information on oral care for such patients, but this is usually limited to swabbing or rinsing the mouth, and both of these techniques are known to be ineffective in total plaque removal.* Since research and available information on oral hygiene for fixation patients is minimal, the effects of various procedures on plaque accumulation and gingivitis should be considered in the determination of acceptable postoperative home care instructions, so that discomfort can be eliminated. If an effective regimen is followed, patients will be able to maintain an optimal level of oral health during convalescence. LITERATURE
REVIEW
In their texts on maxillofacial surgery many authors make no mention of oral care for patients while they are undergoing intermaxillary fixation.6-‘0 Some authors acknowledge that oral hygiene should 487
488 Phelps-Sandal1 and Oxford be attended to in the case of fixation but give no indications as to what should be done.“-‘3 Others do not discuss oral hygiene measuresexcept to say that they should be employed to prevent infection.14Some do state that the teeth should be cleaned but say nothing about daily oral hygiene.15SchultzI stands apart from his colleagues by mentioning oral irrigation and the use of a soft toothbrush to keep teeth, gingiva, and arch bars free of plaque. He does not, however, give any details on how an oral-irrigation device should be used or which brushing methods are best suited for cleaning around fixation apparatus. Research that has been done on plaque and gingivitis in orthodontically banded mouths can be directly applied to fixation patients. Nevertheless, it must be kept in mind that intermaxillary fixation patients are unique becauseof restricted accessto all surfaces of the teeth. Plaque control should be of primary importance, however, since contamination from the oral cavity is one of the principal causesof infected wounds; thus, there is a high risk of potential gross infection in patients undergoing this type of surgery. In addition, the degree of oral health is a factor that influences the local defense mechanisms against infection.14 Both appropriate plaque-removal devices and proper technique are important to the maintenance of oral hygiene. Small, soft, multitufted toothbrushes are known to be effective around appliances.* A brushing technique that emphasizes sulcular cleaning is important to prevent gingivitis in orthodontic patients. The Bass technique, being the method of choice,” would probably be effective for fixation patients. Oral irrigation, while not known to thoroughly remove plaque, coupled with toothbrushing is an effective means of disorganizing harmful bacteria’* and is, therefore, recommendedby someauthorities for mouths in fixation.“-‘3 However, care must be taken to keep the pressure of pulsating water devices below 70 p.s.i. in order to avoid causing added injury to soft tissue.19Interproximal cleaning with floss is quite possible for orthodontic patients since the development of floss threaders,20,2’but it is impossible for intermaxillary fixation patients. However, Perio-Aids, designed for subgingival and interdental plaque removal, can be useful in removing plaque from between the teeth.* While detailed instructions must be given in the use of the PerioAid, and a high degree of manual dexterity is required, it can be speculated that fixation patients might attain the same promising results that orthodontic patients have with this device. The lack of information available on home care techniques specifically for fixation patients is impres-
Oral Surg. November, 1983
sive. While much can be related from other areas of oral hygiene, more direct sources of information should be available. Perhaps a specific body of literature has not developed because fixation is a temporary situation. However, the patient’s health and comfort should not be sacrificed. If information were available concerning the permanent effects of fixation on individual periodontiums, perhaps more research would be initiated. METHOD
Twenty-one volunteer subjects were selected from the reconstructive surgery patients admitted to the University of California at San Francisco Medical Center and randomly assigned to one of three groups. All subjects were conscious, ambulatory, able to perform their own oral hygiene procedures, and at least 14 years old. Group 1 served as the control group, and subjects were given the standard instructions that all reconstructive surgery patients at this facility receive in the use of the Water Pik. Group 2 subjects were given instructions for using the Water Pik, coupled with instructions in the use of the Perio-Aid. Group 3 subjects were given instructions in the use of the Water Pik along with instructions in sulcus brushing. Water Piks, PerioAids, and sulcus brushes were provided. Written instructions** on the appropriate home care techniques were sent home with subjects of each group. All patient education was given individually by the same dental hygiene student and immediately followed up with a photographic presentation of the home care techniques. All subjects were asked to use each aid at least once a day. Individuals’ questions concerning home care techniques were answered as they came up at each scoring appointment. The Papillary Marginal Attached Gingival Index23 developed by Massler was used for assessmentof gingivitis. Green and Vermillion’s Simplified Oral Hygiene Index23 served for the debris scoring. Instead of the six surfaces suggested for these indices, all facial surfaces of existing teeth were examined visually as far posteriorly as the first permanent molars for each index. Base line scoring was not possible. Each subject, however, was scored at 2-, 4-, and 6-week intervals by the primary investigator, who was unaware of the group assignments of the various subjects. RESULTS
The 6-week readings only were used in analyzing the data. The Kruskal-Wallis one-way analysis of variance was run on the means for each of the three groups on all four measures of the Oral Hygiene
Oral hygiene techniques for patients in intermaxillary
Volume 56 Number 5
Table
fixation
489
I. Kruskall-Wallis one-way analysis of variance Group
No. in group Oral Hygiene Index* Papillary gingiva* Marginal gingiva* Attached gingiva* PMA*
Corrected
1
2
3
4 4.00 4.50 5.50 4.00 5.13
6 8.58 8.25 9.08 10.17 8.50
5 10.50 10.50 8.70 8.60 9.70
for
Chi-squared
ties
Signijcance
4.882 4.082 1.728 4.88 1 2.455
0.087 0.130 0.422 0.087 0.293
*Mean rank
Index (OHI), papillary gingiva (P), marginal gingiva (M), and attached gingiva (A). For OH1 and A, a significant difference of p = 0.087 was found. No significant difference (p > 0.01) occurred for P, M, or the total means of PMA (Table I). The Mann-Whitney U test was done as a followup multiple comparison. Between Groups 1 and 2, the only significance found for which Group 1 had a lower mean rank was for the attached gingiva (p = 0.0172). Between Groups 1 and 3, Group 1 had a lower mean rank in OH1 (p = 0.0139) and in P (p = 0.0838). None of the other comparisons showed significant differences between Groups 1 and 3. (See Table II). Kendal rank correlation coefficients correlating OH1 with P, M, A, and PMA revealed no significant differences from zero, with p > 0.3 for all measures. DISCUSSION
Fifteen of the twenty-one volunteers completed the study. Several of the subjects did not require fixation for the full 6 weeks of convalescence.The data on these persons were included in the results, however, since the trauma from their surgery did restrict the amount of jaw movement possible. Measurements of these subjects were taken only on facial surfaces, as was the case with the volunteers undergoing fixation, even though there was limited access to lingual surfaces. Comparison of the results of Group 1 and Group 2 reveals that the only significant difference lies in the condition of the attached gingiva, with the control subjects (Group 1) displaying less inflammation. Comparison of results between Group 1 and Group 3 shows significant differences in plaque accumulation and papillary inflammation. The control group displayed less plaque and less inflammation. One explanation for these results is that the Perio-Aid and the sulcus brush may be too large and bulky for a mouth under fixation and therefore, when used, caused trauma to soft tissue. If that is the case,
Table II. Mann-Whitney U test, follow-up multiple comparison Corrected for ties 2-tailed p
Between 1 and Between 1 and
groups 2 groups 3
OHI
P
M
A
PMA
0.2008
0.1332
0.2008
0.0172
0.1356
0.0139
0.0838
0.3272
0.1797
0.2683
then the increased sensitivity in traumatized areas would cause a patient to avoid touching tender gingiva with a home care aid, and plaque removal would not be complete, thus accounting for the presence of more debris in subjects using the sulcus brush. Another possible explanation for these results is that perhaps it takes more time and practice to develop the skill needed to use a Perio-Aid or sulcus brush than are required for learning to use a Water Pik. After all, a Water Pik merely requires the patient to direct a stream of water at the proper angle to a tooth surface, whereas use of a Perio-Aid and sulcus brush requires more coordinated movement of the wrist and fingers. Since gross motor skills can be mastered sooner than fine motor skills, it may have been easier for subjects to learn the technique of using a Water Pik, thus resulting in more plaque removal, less trauma, and less inflammation. One other factor that may account for the control group having less attached gingival inflammation than Group 2 and less plaque and papillary inflammation than Group 3 is that the control subjects may have spent more time working with the Water Pik” when doing oral hygiene procedures, since they had only one task to perform. Since Groups 2 and 3 each had two different tasks to accomplish daily, some subjects may have rushed through procedures becausemore time was required to complete the two techniques. This could result in incomplete plaque removal and self-induced trauma from quick, uncon-
490
Phelps-Sandal1 and Oxford
trolled movements. The final results would be increased plaque accumulation and inflammation. Therefore, dividing subjects’ attention between the modalities may have decreased the effectiveness of both techniques. CONCLUSION
Becauseof the diversity of subjects taking part in this study, it would have been beneficial to gather base line data for OH1 and PMA on each subject before surgery. However, volunteers could not be identified until the night before their surgical procedures, making collection of base line data impractical. While more studies with larger populations should be performed to challenge or confirm this information, these results indicate that the Water Pik alone can benefit the health of oral tissue in intermaxillary fixation patients. This study cannot conclude that the Perio-Aid and sulcus brush are not beneficial for patients undergoing fixation, but the results do help to reinforce the need for individualization of home care techniques for every patient. The authors would like to express their gratitude to Teledyne Water Pik Company for their generous contribution of oral irrigators; to William Ware, D.D.S., and his staff for their complete cooperation; and to Ann Scarff, R.D.H., for her help, enthusiasm, and support. REFERENCES
I. Communication on 10/24/80 with William H. Ware, D.D.S., Professor and Chairman. Division of Oral and Maxillofacial Surgery, School of Dentistry, University of California, San Francisco Calif. 94143. 2. Wilkins, Esther: Clinical Practice of the Dental Hygienist, ed. 4, Philadelphia, 1976, Lea & Febiger, pp. 307-326, 337-339, 357-361, 609-612. 3. Loe, H., Theilade, E., and Jensen,S.: Experimental Gingivitis in Man, J. Periodontol. 36:177 1965. 4. Brunner, Lillian S.: Lippincott Manual of Nursing Practice, Philadelphia, 1974, J.B.Lippincott Company, pp. 462-473. 5. Shafer, K.N., et al.: Medical Surgical Nursing, St. Louis, 1975, The C.V. Mosby Company, pp. 640. 6. Paparella, M.M., Shumrick, D.A.: Otolaryngology, Vol. III, Philadelphia, 1973, W.B. Saunders Company, pp. 403-440. 7. Beumer, J., Curtis, T., and Firtell, D.: Maxillofacial Rehabil-
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Barbara A. Phelps-Sandall, R.D.H., M.Ed. Department of Periodontology University of California 425-C San Francisco, CA 94143