384
4ustralian Dental Journal, December, 1975 Volume 20, No. 6
The oral health of a group of dental students Joan E. Stoner, M.D.S.
Lecturer in Periodontology, University of Manchester
ABSTRACT-The oral health of sixty-two dental students was examined over an interval of two or three years. The results are recorded and certain conclusions reached. (Received for publication July 1974. Revised version June, 1975)
Introduction
Few studies of the oral conditions of dental students have been reported in the literature. In the United States of America, Foskett's 2 carried out surveys on two groups of dental freshmen, Schour and Masslers examined dental students and other young adults; and fluctuation of gingivitis was studied in 25 male dental students by Hoover and Lefkowitz4. Two investigations of dental students were instituted at the University of
1 Foskett,
R. R.-Radiographic
studies of dental students.
Northw. Univ. Bull. Dent. Res.. 3621. 1617 (Feb.) 1936.
ZFoskett, R. R.-Radiographic
study of the teeth of sixtytwo dental students. Northw. Univ. Bull. Dent. Res., 44:2, 4-8 (Dec.) 1943. 3 Schour, I., and Massler, M.-Prevalence of gingivitis in young adults. J. D. Res., 27:6, 733-734 (June) 1948. 4 Hoover, ,D. R., and Lefkowitz. W.-Fluctuation in marginal gingivitis. J . Periodont. 36:4, 310-314 (July-Aug.) 1%5. 5 Lilienthal, B.-Some abnormal oral conditions present in young adults. Dent. J. Aust., 19:3, 78-81 (Mar.) 1947.
Sydney by Lilienthals and Barnard and Bradleys. Lilienthals included medical students in his sample. The only studies of the oral conditions of dental students which appear to have been carried out in the United Kingdom are Alexander's', 8 . 9 work at University College Hospital Dental School and Curson and Manson's'O investigation at the Royal BBarnard, P. D., and Bradley, D. J.-Dental conditions of senior dental students. Austral. D. J.. 115, 338-344 ( a t . ) 1966. 7 Alexander. A. G.-Periodontal aspects of conservative dentistry. Brit. D. J. 125% 111-114 (AUK.)1968. 8 Alexander, A. G.-Dental calculus and bacterial plaque and their relationship to gingival disease in 400 individuals. Brit. D. J., 129:8, 116-122 (AUK.)1970. 9 Alexander, A. G., and Tipnis, A. K.-The effect of irregularity of teeth and the degree of overbite and overjet on the gingival health. A study of 400 subwts. Brit. D. J., 128:6. 539-544 (June) 1970. locurson, I., and Manson. J. D.-A study of a group of dental students, including their diet and dental health. Brit. D. J., 119:9. 197-205 (Sept.) 1965.
Australian Dental Journal, December, 1975 Dental Hospital School of Dental Surgery. Curson and Mansonlo suggested that the dental student was in some respects typical of the healthy young adult group among the population, and in others atypical as he should be more aware of the problem of dental disease than his contemporaries. These authors expressed surprise that so little use has been made of dental students in dental epidemiology as they were an obvious captive group. An investigation of the periodontal tissues in a group of students at University College Hospital Dental School (U.C.H.) included a general oral survey, and, in view of the lack of information of the oral health of British dental students, it was considered that the observations made during the study should be reported. Materials and methods An incidence study of their periodontal conditions was carried out on a sample of 62 students whose ages ranged from 17 to 23 years. Fortyeight men and 14 women students at University College Hospital Dental School were examined. Sixty of the students were Caucasian, one was Aryan and another Negroid. The initial examination took place at the beginning of the preclinical course in October of two successive years, as the sample was taken from two annual intakes of dental students. The last examination was carried out during July, three and two years later in the case of the first and second groups of students respectively. Only the oral conditions observed at the initial and last examinations, an interval of two or three years, are recorded and discussed in this report. Each student was examined, seated in a dental chair, by standard lighting. Teeth present in the mouth were recorded. Any carious teeth were noted, but a probe was not used for the detection of caries. Occlusion was classified using Angle's system on the basis of the relationship of the first permanent molars and incisors. The presence of malaligned teeth was recorded. The condition of papillary, marginal and attached gingivae, buccally and lingually, in all regions of the mouth was observed. The criteria for the presence of gingival inflammation were bleeding on slight pressure, colour change from pink to red, alteration of surface texture by loss of stippling and occurrence of a glazed appearance, and the presence of swelling recognised by deviation from a knifelike edge at the gingiva1 margin. Inspection of the alveolar mucosae was made for the presence of high fraena and muscle attachments.
385
The presence of plaque and calculus was recorded after the teeth had been lightly dried with air syringe and using erythrosin disclosing solution (11.8 per cent aqueous solution in a 50 per cent solution with water) where there was doubt about the presence of plaque. Bitewing radiographs were taken of the posterior teeth and alveolar crests using a standard technique. A Philips Oralix machine (SOkV, 7mA) and Ilford standard no. 4.3 x 4 cm films were used. The tip of the cone was fixed at 4.0 cm from the film by a plastic film holder. The radiographic image was dimensionally equal to the object at this distance. The central X-rays were directed at right angles to the plane of the film by means of this device. The exposure time was 0.3 second and developing time 3 minutes at 68°F; the times were reduced in order to gain maximum definition of the alveolar crest. Preliminary work had been carried out on dry skulls in order to find the technique which would give the most accurate image of the crests". Results The students claimed that they had received regular dental treatment. All the students showed evidence of past caries experience but no gross caries was found on clinical observation at the initial examination. Twenty-seven students had lost a total of 77 permanent teeth. The distribution of students within Angle's classification for occlusion was 53 per cent Class I, 42 per cent Class 11, and 5 per cent Class 111. Malaligned teeth were common. Ten students had received orthodontic treatment during childhood or adolescence. Four students were advised at the initial examination to obtain an opinion regarding orthodontic treatment and in three cases an erupted canine was discovered. Only six students had fully erupted upper and lower third molars at the time of initial examination. Two students had third molars extracted before examination while 46 students had partially erupted, with one or more fully erupted, third molars in some cases, either at the initial or final examination. Extraction of 31 third molars had been carried out or arranged by the time of the final examination. Eight students did not have erupted or unerupted third molars and did not give a history of previous eruption. The majority of the students received any
11 Stoner, J.
E.-An investigation into the accuracy of measurements made on radiographs of the alveolar crests of dried mandibles. J. Periodont., 43:11, 699-701 (Nov.) 1972.
386 necessary students.
Australian Dental Journal, December, 1975 restorative
treatment
from
fellow
All students suffered from gingivitis both at the initial and final examinations. Inflammation was confined to the papillae and margins except in the case of three students who had localized inflammation of the attached gingivae at one of the examinations. A wide personal variation from a few inflamed units to generalised gingivitis was observed. Areas where the depth of attached gingiva appeared to be inadequate for the maintenance of the free gingiva in health were noted in 24 students (39 per cent). Thirteen students (20 per cent) had fraena and muscle attachments which transmitted a pull to the free gingiva. Three students (5 per cent) had marked gingival recession in the upper canine and premolar regions. At the initial and final examinations, plaque was evident in the mouths of all the subjects. Fifty-two students had supragingival deposits of calculus, usually in the lower anterior regions, and four had extensive subgingival deposits at the initial examination. Three students were wearing upper acrylic partial dentures when they were seen initially. Later, one had a bridge fitted while another had a denture of different design. The third student retained his original denture for the duration of the study. A woman student wore an acrylic bite guard at nights for the last ten months of the study. The four students who sought an orthodontic opinion after their initial examination were treated by means of removable appliances. Examination of the bitewing radiographs taken at the initial examination revealed 160 proximal carious lesions on 43 pairs of films. There were 77 proximal restorations of gold or amalgam which had overhanging margins at the cavosurface angle. Mesial or distal tilting was noted on 170 posterior teeth of 46 students. One hundred and seven pairs of adjacent teeth had a poor contact or a space between them. Eight women and 21 men (48 per cent) had resorption of one or more alveolar crests. The total number of resorbed crests was 55. These crests were associated with overhanging restorations (12 crests), tilted teeth (28 crests), and poor contacts (6 crests). The earliest sign of resorption observed was radiolucency at the crests. Four of the crests reflected to some extent the contour of the overhang. When crestal resorption occurred between tilted teeth, resorption was directed in the opposite direction from that of the tilt and was not observed at the centre of the crest. More
marked alveolar resorption was found around the upper first molars of one student. The final radiographs of four students showed resorption of crests which had appeared normal on the initial radiographs. Two crests between lower posterior teeth, which had shown resorption associated with overhanging margins of restorations initially, had a normal crest outline on the final radiograph. During the period of the study the restorations had been renewed and the margins appeared flush with the cavo-surface angle. Discussion The fact that some of the 62 dental students were free from gross dental caries could be attributed to regular dental care. However, 43 (69 per cent) students had proximal carious lesions and the depth of penetration varied from enamel breakdown to near pulpal exposure. The majority of these students had not had radiographic examination of their teeth before the study began and the findings indicate that bitewing radiographs should be taken at regular intervals during adolescence. Curson and Manson’s10 students (whose place in the dental course was not specified) and Barnard and Bradley’s0 final year students showed 80 per cent and 98 per cent caries prevalence respectively. These investigators used a probe for the detection of caries. U.C.H. students had lost 77 permanent teeth (mean per student 1.24). In many cases the reason for extraction was unknown; however, a history of extraction of carious teeth or extraction prior to orthodontic treatment was given by some students. Three male students had lost upper incisors during falls, fights and football. Thirtyfour first permanent molars had been extracted; in some mouths this was carried out in an attempt to assist eruption of impacted third permanent molars. It has been emphasised that first permanent molars should be retained whenever possible: early loss of these teeth from the lower arch may cause increased overbite with subsequent gingival trauma and excessive occlusal stress1z*l3. Nineteen students had experienced collapse of the lower arch and in some cases resultant collapse of the upper arch. The explanation for tilting of 83 posterior teeth appeared to have been extraction of adjacent molars or premolars. When alveolar crest resorption occurred adjacent to a tilted tooth, it was observed at the
12 Goldman,
H. M., and Cohen, D. W.-Periodontal
therapy.
St. Louis, C. V. Mosby Company, 4th ed., 1968 (p. 561). 13 Walrher, D. P.--Orthodontic notes. Bristol, John Wright
& Sons Ltd., 2nd ed., 1967 (p. 80).
Australian Dental Journal, December, 1975 acute angle formed by the tilted tooth and the sloping crest. This is significant because limited alveolar resorption at this position would cause an infra-bony periodontal pocket. Thirty-one third molars had been extracted or extraction arranged by the time of the final examination (mean no. of extracted teeth 0.5). In all cases extraction was necessary because of inadequate space. In other investigations, the mean number of extracted molars was 0.36 and 0.52. 5.
The prevalence of gingivitis was 100 per cent at the initial and final examinations. The persistent inflammation of 51 per cent of the papillae and 49 per cent of the margins which were inflamed at the initial and final examinations appeared to be associated with malaligned teeth, appliances and overhanging margins of restorations. A clinical impression gained was that gingival inflammation was only associated with malaligned teeth and appliances when plaque was present. It was found that some of the students required mucogingival surgery as a repair or prophylactic measure in view of the inadequate depth of attached gingiva and transmission of fraenal and muscle pulls to the free gingiva. Plaque was present in the mouth of every student at the initial and final examinations. The student’s response to oral hygiene instruction was unsatisfactory in view of the association of plaque with gingivitisa. 8 . 1 4 ~ 1 5 , 1 6 . Only 19 (31 per cent) of the 62 students had less plaque deposits at their final examinations, while 34 (55 per cent) had the same, and nine (14 per cent) had larger plaque deposits. Each student seemed to have a personal acceptance of his oral hygiene standard and it required great effort to improve it. A few students evoked more interest in the later stages of the incidence study when they had treated patients with periodontal disease. It should also be stated that dental treatment provided in the period of the survey had no beneficial effect on the gingival condition. The chief reason for concern when gingival inflammation is persistent is the possible extension of inflammation to the deeper periodontal tissues.
Sutcliffe, P.--Chronic anterior gingivitis, and epidemiolo. Bical study in school children. Brit. D. J.. 125:7, 47-55 (July) 1968. 16 Shiller, W. R.-Periodontal health of submarine school candidates: A correlative analysis. J. Periodont.. 37:3, 224-229 (May-June) 1966. 16 Miller, J.. and Hobson, P.-The relationship between malocclusion. oral cleanliness. ingival conditions and dental caries in school children. Brit. D. J.. 111:7, 43-52 (July) 1961. 14
387 There was radiographic evidence of early chronic marginal periodontitis in 29 students. Although this stage of alveolar resorption is reversible, as seen in the student who had satisfactory restorations to replace those with overhanging margins, there was no assurance that the resorptive process would not extend in the alveolar bone. Conclusions and Summary
The oral health of a group of 62 dental students was followed over a period of three years. Although no untreated dental caries was found on visual examination, bitewing radiographs revealed 160 proximal carious lesions. Seventy-seven permanent teeth had been lost by the time of the initial examination, and 3 1 third permanent molars were extracted or extraction planned by the end of the study. Gingivitis and dental plaque were observed in all the students, and factors associated with alveolar crest resorption were overhanging cervical margins of proximal restorations, mesial or distal tilting of teeth, and inadequate contact points. Despite their clinical training, coupled with personal dental health education, no overall improvement in the standard of oral cleanliness was found in these subjects. Three important observations can be made from this study:1. Unless dental students can be convinced that oral hygiene and gingival health are important, it appears unlikely that the incidence of periodontal disease will decrease in their patients. 2. Planned dental treatment is important and should commence in early childhood where necessary. Particular attention should be given to the time of extraction of permanent teeth, when this is unavoidable, in order to prevent tilting, malalignment and poor contact points which form sites for potential infra-bony pockets. 3. The value of bitewing radiographs for the detection of early proximal carious lesions and alveolar crest resorption has been shown. Acknowledgemenb
I should like to thank Professor A. S. Prophet for providing the facilities for this investigation to be carried out at University College Hospital Dental School. My thanks are due to Professor J. H. Jones for his advice in the preparation of this manuscript. Department of Oral Medicine, Turner Dental School, University of Manchester, Bridgeford Street, Manchester, M15 6FA. U.K.
4ustralian Dental Journal, December, 1975 Volume 20, No. 6
The oral health of a group of dental students Joan E. Stoner, M.D.S.
Lecturer in Periodontology, University of Manchester
ABSTRACT-The oral health of sixty-two dental students was examined over an interval of two or three years. The results are recorded and certain conclusions reached. (Received for publication July 1974. Revised version June, 1975)
Introduction
Few studies of the oral conditions of dental students have been reported in the literature. In the United States of America, Foskett's 2 carried out surveys on two groups of dental freshmen, Schour and Masslers examined dental students and other young adults; and fluctuation of gingivitis was studied in 25 male dental students by Hoover and Lefkowitz4. Two investigations of dental students were instituted at the University of
1 Foskett,
R. R.-Radiographic
studies of dental students.
Northw. Univ. Bull. Dent. Res.. 3621. 1617 (Feb.) 1936.
ZFoskett, R. R.-Radiographic
study of the teeth of sixtytwo dental students. Northw. Univ. Bull. Dent. Res., 44:2, 4-8 (Dec.) 1943. 3 Schour, I., and Massler, M.-Prevalence of gingivitis in young adults. J. D. Res., 27:6, 733-734 (June) 1948. 4 Hoover, ,D. R., and Lefkowitz. W.-Fluctuation in marginal gingivitis. J . Periodont. 36:4, 310-314 (July-Aug.) 1%5. 5 Lilienthal, B.-Some abnormal oral conditions present in young adults. Dent. J. Aust., 19:3, 78-81 (Mar.) 1947.
Sydney by Lilienthals and Barnard and Bradleys. Lilienthals included medical students in his sample. The only studies of the oral conditions of dental students which appear to have been carried out in the United Kingdom are Alexander's', 8 . 9 work at University College Hospital Dental School and Curson and Manson's'O investigation at the Royal BBarnard, P. D., and Bradley, D. J.-Dental conditions of senior dental students. Austral. D. J.. 115, 338-344 ( a t . ) 1966. 7 Alexander. A. G.-Periodontal aspects of conservative dentistry. Brit. D. J. 125% 111-114 (AUK.)1968. 8 Alexander, A. G.-Dental calculus and bacterial plaque and their relationship to gingival disease in 400 individuals. Brit. D. J., 129:8, 116-122 (AUK.)1970. 9 Alexander, A. G., and Tipnis, A. K.-The effect of irregularity of teeth and the degree of overbite and overjet on the gingival health. A study of 400 subwts. Brit. D. J., 128:6. 539-544 (June) 1970. locurson, I., and Manson. J. D.-A study of a group of dental students, including their diet and dental health. Brit. D. J., 119:9. 197-205 (Sept.) 1965.
Australian Dental Journal, December, 1975 Dental Hospital School of Dental Surgery. Curson and Mansonlo suggested that the dental student was in some respects typical of the healthy young adult group among the population, and in others atypical as he should be more aware of the problem of dental disease than his contemporaries. These authors expressed surprise that so little use has been made of dental students in dental epidemiology as they were an obvious captive group. An investigation of the periodontal tissues in a group of students at University College Hospital Dental School (U.C.H.) included a general oral survey, and, in view of the lack of information of the oral health of British dental students, it was considered that the observations made during the study should be reported. Materials and methods An incidence study of their periodontal conditions was carried out on a sample of 62 students whose ages ranged from 17 to 23 years. Fortyeight men and 14 women students at University College Hospital Dental School were examined. Sixty of the students were Caucasian, one was Aryan and another Negroid. The initial examination took place at the beginning of the preclinical course in October of two successive years, as the sample was taken from two annual intakes of dental students. The last examination was carried out during July, three and two years later in the case of the first and second groups of students respectively. Only the oral conditions observed at the initial and last examinations, an interval of two or three years, are recorded and discussed in this report. Each student was examined, seated in a dental chair, by standard lighting. Teeth present in the mouth were recorded. Any carious teeth were noted, but a probe was not used for the detection of caries. Occlusion was classified using Angle's system on the basis of the relationship of the first permanent molars and incisors. The presence of malaligned teeth was recorded. The condition of papillary, marginal and attached gingivae, buccally and lingually, in all regions of the mouth was observed. The criteria for the presence of gingival inflammation were bleeding on slight pressure, colour change from pink to red, alteration of surface texture by loss of stippling and occurrence of a glazed appearance, and the presence of swelling recognised by deviation from a knifelike edge at the gingiva1 margin. Inspection of the alveolar mucosae was made for the presence of high fraena and muscle attachments.
385
The presence of plaque and calculus was recorded after the teeth had been lightly dried with air syringe and using erythrosin disclosing solution (11.8 per cent aqueous solution in a 50 per cent solution with water) where there was doubt about the presence of plaque. Bitewing radiographs were taken of the posterior teeth and alveolar crests using a standard technique. A Philips Oralix machine (SOkV, 7mA) and Ilford standard no. 4.3 x 4 cm films were used. The tip of the cone was fixed at 4.0 cm from the film by a plastic film holder. The radiographic image was dimensionally equal to the object at this distance. The central X-rays were directed at right angles to the plane of the film by means of this device. The exposure time was 0.3 second and developing time 3 minutes at 68°F; the times were reduced in order to gain maximum definition of the alveolar crest. Preliminary work had been carried out on dry skulls in order to find the technique which would give the most accurate image of the crests". Results The students claimed that they had received regular dental treatment. All the students showed evidence of past caries experience but no gross caries was found on clinical observation at the initial examination. Twenty-seven students had lost a total of 77 permanent teeth. The distribution of students within Angle's classification for occlusion was 53 per cent Class I, 42 per cent Class 11, and 5 per cent Class 111. Malaligned teeth were common. Ten students had received orthodontic treatment during childhood or adolescence. Four students were advised at the initial examination to obtain an opinion regarding orthodontic treatment and in three cases an erupted canine was discovered. Only six students had fully erupted upper and lower third molars at the time of initial examination. Two students had third molars extracted before examination while 46 students had partially erupted, with one or more fully erupted, third molars in some cases, either at the initial or final examination. Extraction of 31 third molars had been carried out or arranged by the time of the final examination. Eight students did not have erupted or unerupted third molars and did not give a history of previous eruption. The majority of the students received any
11 Stoner, J.
E.-An investigation into the accuracy of measurements made on radiographs of the alveolar crests of dried mandibles. J. Periodont., 43:11, 699-701 (Nov.) 1972.
386 necessary students.
Australian Dental Journal, December, 1975 restorative
treatment
from
fellow
All students suffered from gingivitis both at the initial and final examinations. Inflammation was confined to the papillae and margins except in the case of three students who had localized inflammation of the attached gingivae at one of the examinations. A wide personal variation from a few inflamed units to generalised gingivitis was observed. Areas where the depth of attached gingiva appeared to be inadequate for the maintenance of the free gingiva in health were noted in 24 students (39 per cent). Thirteen students (20 per cent) had fraena and muscle attachments which transmitted a pull to the free gingiva. Three students (5 per cent) had marked gingival recession in the upper canine and premolar regions. At the initial and final examinations, plaque was evident in the mouths of all the subjects. Fifty-two students had supragingival deposits of calculus, usually in the lower anterior regions, and four had extensive subgingival deposits at the initial examination. Three students were wearing upper acrylic partial dentures when they were seen initially. Later, one had a bridge fitted while another had a denture of different design. The third student retained his original denture for the duration of the study. A woman student wore an acrylic bite guard at nights for the last ten months of the study. The four students who sought an orthodontic opinion after their initial examination were treated by means of removable appliances. Examination of the bitewing radiographs taken at the initial examination revealed 160 proximal carious lesions on 43 pairs of films. There were 77 proximal restorations of gold or amalgam which had overhanging margins at the cavosurface angle. Mesial or distal tilting was noted on 170 posterior teeth of 46 students. One hundred and seven pairs of adjacent teeth had a poor contact or a space between them. Eight women and 21 men (48 per cent) had resorption of one or more alveolar crests. The total number of resorbed crests was 55. These crests were associated with overhanging restorations (12 crests), tilted teeth (28 crests), and poor contacts (6 crests). The earliest sign of resorption observed was radiolucency at the crests. Four of the crests reflected to some extent the contour of the overhang. When crestal resorption occurred between tilted teeth, resorption was directed in the opposite direction from that of the tilt and was not observed at the centre of the crest. More
marked alveolar resorption was found around the upper first molars of one student. The final radiographs of four students showed resorption of crests which had appeared normal on the initial radiographs. Two crests between lower posterior teeth, which had shown resorption associated with overhanging margins of restorations initially, had a normal crest outline on the final radiograph. During the period of the study the restorations had been renewed and the margins appeared flush with the cavo-surface angle. Discussion The fact that some of the 62 dental students were free from gross dental caries could be attributed to regular dental care. However, 43 (69 per cent) students had proximal carious lesions and the depth of penetration varied from enamel breakdown to near pulpal exposure. The majority of these students had not had radiographic examination of their teeth before the study began and the findings indicate that bitewing radiographs should be taken at regular intervals during adolescence. Curson and Manson’s10 students (whose place in the dental course was not specified) and Barnard and Bradley’s0 final year students showed 80 per cent and 98 per cent caries prevalence respectively. These investigators used a probe for the detection of caries. U.C.H. students had lost 77 permanent teeth (mean per student 1.24). In many cases the reason for extraction was unknown; however, a history of extraction of carious teeth or extraction prior to orthodontic treatment was given by some students. Three male students had lost upper incisors during falls, fights and football. Thirtyfour first permanent molars had been extracted; in some mouths this was carried out in an attempt to assist eruption of impacted third permanent molars. It has been emphasised that first permanent molars should be retained whenever possible: early loss of these teeth from the lower arch may cause increased overbite with subsequent gingival trauma and excessive occlusal stress1z*l3. Nineteen students had experienced collapse of the lower arch and in some cases resultant collapse of the upper arch. The explanation for tilting of 83 posterior teeth appeared to have been extraction of adjacent molars or premolars. When alveolar crest resorption occurred adjacent to a tilted tooth, it was observed at the
12 Goldman,
H. M., and Cohen, D. W.-Periodontal
therapy.
St. Louis, C. V. Mosby Company, 4th ed., 1968 (p. 561). 13 Walrher, D. P.--Orthodontic notes. Bristol, John Wright
& Sons Ltd., 2nd ed., 1967 (p. 80).
Australian Dental Journal, December, 1975 acute angle formed by the tilted tooth and the sloping crest. This is significant because limited alveolar resorption at this position would cause an infra-bony periodontal pocket. Thirty-one third molars had been extracted or extraction arranged by the time of the final examination (mean no. of extracted teeth 0.5). In all cases extraction was necessary because of inadequate space. In other investigations, the mean number of extracted molars was 0.36 and 0.52. 5.
The prevalence of gingivitis was 100 per cent at the initial and final examinations. The persistent inflammation of 51 per cent of the papillae and 49 per cent of the margins which were inflamed at the initial and final examinations appeared to be associated with malaligned teeth, appliances and overhanging margins of restorations. A clinical impression gained was that gingival inflammation was only associated with malaligned teeth and appliances when plaque was present. It was found that some of the students required mucogingival surgery as a repair or prophylactic measure in view of the inadequate depth of attached gingiva and transmission of fraenal and muscle pulls to the free gingiva. Plaque was present in the mouth of every student at the initial and final examinations. The student’s response to oral hygiene instruction was unsatisfactory in view of the association of plaque with gingivitisa. 8 . 1 4 ~ 1 5 , 1 6 . Only 19 (31 per cent) of the 62 students had less plaque deposits at their final examinations, while 34 (55 per cent) had the same, and nine (14 per cent) had larger plaque deposits. Each student seemed to have a personal acceptance of his oral hygiene standard and it required great effort to improve it. A few students evoked more interest in the later stages of the incidence study when they had treated patients with periodontal disease. It should also be stated that dental treatment provided in the period of the survey had no beneficial effect on the gingival condition. The chief reason for concern when gingival inflammation is persistent is the possible extension of inflammation to the deeper periodontal tissues.
Sutcliffe, P.--Chronic anterior gingivitis, and epidemiolo. Bical study in school children. Brit. D. J.. 125:7, 47-55 (July) 1968. 16 Shiller, W. R.-Periodontal health of submarine school candidates: A correlative analysis. J. Periodont.. 37:3, 224-229 (May-June) 1966. 16 Miller, J.. and Hobson, P.-The relationship between malocclusion. oral cleanliness. ingival conditions and dental caries in school children. Brit. D. J.. 111:7, 43-52 (July) 1961. 14
387 There was radiographic evidence of early chronic marginal periodontitis in 29 students. Although this stage of alveolar resorption is reversible, as seen in the student who had satisfactory restorations to replace those with overhanging margins, there was no assurance that the resorptive process would not extend in the alveolar bone. Conclusions and Summary
The oral health of a group of 62 dental students was followed over a period of three years. Although no untreated dental caries was found on visual examination, bitewing radiographs revealed 160 proximal carious lesions. Seventy-seven permanent teeth had been lost by the time of the initial examination, and 3 1 third permanent molars were extracted or extraction planned by the end of the study. Gingivitis and dental plaque were observed in all the students, and factors associated with alveolar crest resorption were overhanging cervical margins of proximal restorations, mesial or distal tilting of teeth, and inadequate contact points. Despite their clinical training, coupled with personal dental health education, no overall improvement in the standard of oral cleanliness was found in these subjects. Three important observations can be made from this study:1. Unless dental students can be convinced that oral hygiene and gingival health are important, it appears unlikely that the incidence of periodontal disease will decrease in their patients. 2. Planned dental treatment is important and should commence in early childhood where necessary. Particular attention should be given to the time of extraction of permanent teeth, when this is unavoidable, in order to prevent tilting, malalignment and poor contact points which form sites for potential infra-bony pockets. 3. The value of bitewing radiographs for the detection of early proximal carious lesions and alveolar crest resorption has been shown. Acknowledgemenb
I should like to thank Professor A. S. Prophet for providing the facilities for this investigation to be carried out at University College Hospital Dental School. My thanks are due to Professor J. H. Jones for his advice in the preparation of this manuscript. Department of Oral Medicine, Turner Dental School, University of Manchester, Bridgeford Street, Manchester, M15 6FA. U.K.
