ࡱ> 57234q` 1bjbjqPqP .::&hBhBhB8B4DWvEH"HHHIIIuuuuuuu$_yh{0.20 for all) these results were not shown. As the calculus index didnt show variability at the time point of temporary luting for its analysis Friedman ANOVA was used. P<0.05 was considered as statistically significant for all analyses. Results Mean indexes of oral hygiene are shown in Table 2. Data in Table 2 show a statistically significant temporary dynamics for the OOHI with significant progressive improvement (lower values) from baseline till one month after treatment and with mild progressive non-significant detriment till final endpoint (12 months after treatment). The same temporal dynamics was shown for all individual indexes (PI, CI, GI) altogether and for mandible and maxilla separately (Pd"0.001 for all except for PI for maxilla, P=0.197). All indexes were slightly worse in mandible than in maxilla (statistically non-significant for all time points except for baseline for PI, CI, GI and OOHI; P=0.019, P=0.041, P=0.045, P=0.009; respectively]). GIs were somewhat worsen at 14 days post baseline (not significantly). Statistically significant difference for OOHI was found between subgroups according to the type of fixed prosthodontic appliance (C, FPD and C+FPD) with significantly best results for C and worst for C+FPD subgroup (P=0.001). Temporal dynamics was statistically significant (P=0.018) and comparable (P=0.438 for the interaction type of appliance*time) (Figure 1). Almost the same associations were found for PI (P=0.027 for the type of appliance; P=0.001 for temporal dynamics; P=0.096 for the interaction type of appliance*time), and GI (P=0.004 for the type of appliance; P=0.048 for temporal dynamics; P=0.627 for the interaction type of appliance*time). For CI no significant association was found for the type of appliance (P=0.290) and for the interaction type of appliance*time (P=0.079), but with a significant temporal dynamics (P<0.001). No statistically significant (P=0.083) association was found for OOHI for the constructive material of the appliance (CFM, AM-G, AM-Ag-Pd), although the best OOHI was connected with CFM and worst with AM-Ag-Pd. Temporal dynamics was statistically significant (P<0.001) and comparable (P=0.124 for interaction material*time) (Figure 2). Comparable associations were found also for GI (P=0.126 for material; P<0.001 for temporal dynamics; P=0.628 for interaction material*time), and for CI (P=0.053 for material; P<0.001 for temporal dynamics; P=0.958 for interaction material*time). For PI statistically significant association was found for the type of material used for appliance (P=0.007) together with the statistically significant temporal dynamics (P<0.001) but without significant interaction for material*time (P=0.109). Statistically significant association was also found for OOHI and placement of prosthodontic appliance (maxilla, mandible or both) with significantly worst results in a subgroup with appliances in both maxilla and mandible (P=0.012). Temporal dynamics was also statistically significant (P<0.001) and comparable between subgroups (P=0.691 for interaction placement*time) (Figure 3). Comparable associations were found for PI (P=0.017 for placement; P<0.001 for temporal dinamics; P=0.626 for interaction placement*time), and for GI (P=0.036 for placement; P=0.014 for temporal dinamics; P=0.401 for interaction placement*time). For CI we havent found a significant association with the placement of prosthodontic appliance (P=0.413) nor for interaction placement*time (P=0.686), but temporal dynamics was statistically significant (P<0.01). Also a statistically significant association was found for OOHI and age (subgroups based on quartiles for age) with best values connected with the youngest quartile and worst with oldest one (P=0.002). All age quartiles showed comparable (P=0.132 for interaction age*time) temporal dynamics (P<0.001) (Figure 4). Comparable associations were found for GI (P=0.007 for age; P<0.001 for temporal dynamics; P=0.269 for interaction age*time). For OI no significant difference was found between age quartiles (P=0.347) nor for interaction age*time (P=0.197). For CI significant difference was found between age quartiles with the best results for youngest and worst for oldest quartile (P=0.001). Temporal dynamics (P<0.001) together with interaction age*time (P=0.008) were statistically significant (youngest quartile having significantly best baseline). Discussion There are many studies on this topic indicating that prosthodontic appliances favour plaque accumulation and have a negative impact on gingival condition due to insufficient aftercare49,50, although there are authors reporting no statistically significant difference in the plaque index values between teeth with crowns and control teeth30. In this study, the frequency of plaque found during the preliminary visit was higher than that found in other periods, after prosthodontic treatment. The decrease of PI and CI in the first month was statistically significant. After 6 and 12 months a mild insignificant increase of PI was registered. The most of patients presented with the plaque index values of 0 and 1 during the reexaminations, thus indicating that they maintained a satisfactory level of oral hygiene. This could be contributed to the reexamination and reinstruction scheme. Reinstruction is detected as an important factor, since patients in other investigations show lower plaque scores after reinstruction51. It is concluded that professional advice and instruction and reinstruction seems very important in order to obtain good plaque control51. In our study the oral hygiene instructions were given directly after C and/or FPD application. Patients were reinstructed and reminded of the importance of oral hygiene after 14 days, after one month, six months and 12 months. Patients were probably more motivated for hygiene level improvement directly after the appointments which resulted in lower PI values at the first month visit due to close-meshed reexamination. Based on our results we can hypothesize that the motivation wore down between the third and fourth and fourth and fifth visit because of much longer time periods between checkups with no feedback in between. An contributing factor could also be the use of special end-tufted and interdental brushes. The results of other investigators indicate that the daily use of interdental brush is effective in reducing interproximal plaque and gingivitis scores52 and in combination with a toothbrush it is more effective in the removal of plaque from proximal tooth surfaces than a toothbrush used alone or in combination with dental floss53. It has shown that only interdental brushes permit a good plaque control at the proximal areas of the abutment teeth54. With regard to gingival index, an increase was found between the baseline visit examination and 14 days after the temporary fixing. The reason might be the fact that clinical procedures during prosthodontic work caused damage and the period of 14 days after manipulation was too short to allow for the irritated gingiva to heal completely. Factors related to the prosthetic restorations such as the marginal edge of the crown, poor adaptation of the marginal edge, poor contours of the restoration and rough margins are often connected with inflammation of periodontal tissue55. It is necessary to point out that higher GI scores are found when the crown margins are located subgingivally as compared to location at the gingival margin or supragingivally6. The anatomic reconstruction of the crown with a perfect marginal adaptation will provide an adequate environment for maintaining the health of surrounding periodontal tissues. However, in our research, by maintaining a satisfactory oral hygiene, the condition of soft tissues enhanced after one month and maintained stable thought next two temporal points. Other studies have demonstrated that insufficient oral hygiene is an important factor in the development of inflammatory changes in the oral mucosa beneath bridge pontics56. The period of monitoring in this study was too short to make reliable conclusions as other studies show that length of use of crowns influenced significantly the level of oral hygiene and gingival reaction23,57,58. Thereby periods of five years and longer are considered as critical. The prevalence of calculus as a consequence of plaque in a population is a measure of the oral hygiene level and frequency of regular professional dental care. The Calculus Index in this survey fell to zero in the first month. Levels of calculus and location of formation have been shown to be affected by oral hygiene habits, access to professional care, diet, age, ethnic origin and time since last dental cleaning. Considering the fact that all patients were submitted to professional oral cleaning, including removal of dental calculus just before prosthodontic treatment, and the period of one month was too short for new calculus formation, especially under improved hygiene routine, our findings could be expected. A statistically significant difference was found depending on the type of fixed prosthetic appliance (C, FPD or C+FPD), whereby patients with single crowns showed best, and patients with C+FPDs the worst results. Other studies were in accordance to our findings and indicate that plaque accumulation, and consequently the incidence of tooth decay was bigger in fixed denture abutment teeth compared to single crowns4. One of the reasons could be the occasionally difficult access for dental hygiene instruments into the interproximal areas adjacent to fixed partial denture abutment teeth. It should be pointed out that during our research the patients provided with C+FPD were the ones who mostly avoided checkups and only 13% of the original group attended to all examinations. Considering the fact that in the end they showed the worst oral hygiene and gingival condition, it can be presumed that they neglected oral health more than other participants. Fixed prosthetic appliances may be made of different materials. Our patients usually opt for either ceramic fused-to-metal or acrylic veneer on metal, whereby the metal in this system can be gold or silver-palladium alloy. Acrylic veneers are often used due to financial reasons, as they are much cheaper than ceramics. Our examination revealed no significant difference in oral hygiene status among patients with fixed appliances made of different materials. This is in accordance to other clinical studies which demonstrate that the amount of plaque on the test specimens of different dental materials shows no consistent differences59. The same study demonstrated that patients maintaining a high standard of oral hygiene are able to prevent the development of inflammatory changes in the alveolar mucosa in contact with fixed bridge pontics irrespective of the pontic material used58. But it should be mentioned that there are also studies revealing that the degree of in vivo plaque formation and gingival condition differ among materials60-63. A statistically significant difference was found depending on the placement of the fixed prosthodontic appliance (upper dental arch, lower dental arch, both dental arches), whereby the worst results were found in patients with fixed appliances in both the upper and lower jaws. Considering the fact that probably inappropriate oral hygiene had led to the requirement for such extensive rehabilitation in the first place, this results could be understandable. Comparison of the indexes among the age groups revealed that the youngest group showed best results, while the oldest group had the worst oral hygiene. It should be pointed out that the youngest patients had the significantly best starting point, i.e. the lowest indexes at the preliminary examination, while the changes during time were comparable for all age groups. Other studies also revealed a poor state of oral hygiene among elderly people64-66. This could be due to reduced manual skill, or less motivation in the maintenance of adequate personal hygiene, as well as difficulties to access professional dental care67. Many of the older people suffer from dementia and are no longer capable of caring for their oral hygiene independently. In this context, it is important to provide assistance with oral hygiene measures from the dental professionals point of view. Conclusion Altough most studies on this topic indicate that prosthodontic appliances have a negative impact on the oral hygiene level and gingival condition, our research showed that appropriate educational and motivational measures can lead to improved oral hygiene, even after the application of fixed dentures or single crowns. Presumably, the oral health in a group of adult patients can be kept acceptable by providing a prophylactic oral hygiene program. However, it should be mentioned that a significant part of initially recruited patients was lost to follow-up and that this can somewhat bias the results towards better oral hygiene. Patients with single crowns showed better oral hygiene levels than patients with FPDs or C+FPDs. Our results revealed no significant difference in oral hygiene status among patients with fixed appliances made of different materials. The worst hygiene levels were found in patients with fixed appliances in both jaws. Younger patients showed better hygiene levels than the older ones. Fixed prosthodontic work should be checked regularly. Check-ups contribute to a healthy periodontium and longer life span of fixed prosthodontics. Acknowledgements This research was supported by the Ministry of Science, Education and Sports of the Republic of Croatia under the Projects 065-0650446-0435 and a bilateral Project (Republic of Croatia - Republic of Slovenia) Research of the effectiveness of different treatments and materials in prosthodontic patients. References 1. BRAGGER U, AESCHLIMANN S, BURGIN W, HAMMERLE CH, LANG NP, Clin Oral Implants Res,12 (2001) 26. - 2. 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HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=%22Tolboe%20H%22%5BAuthor%5D" TOLBOE H,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=%22Isidor%20F%22%5BAuthor%5D" ISIDOR F,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=%22Budtz-J%C3%B6rgensen%20E%22%5BAuthor%5D" BUDTZ-JRGENSEN E,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kaaber%20S%22%5BAuthor%5D" KAABER S, Scand J Dent Res, 96 (1988) 442. - 60. OLSSON J, VAN DER HEIJDE Y, HOLMBERG K, Caries Res, 26 (1992) 428. - 61. SAVITT ED, MALAMENT KA, SOCRANSKY SS, MELCER AJ, BACKMAN KJ, Int J Periodontics Restorative Dent, 7 (1987) 22. - 62. ADAMCZYK E, SPIECHOWICZ E, Int J Prosthodont, 3 (1990) 285. - 63. BAU I I, BAU I M, STIPETI J, KOMAR , MEHULI K, BO}I D, KLAI B, ELEBI A, Coll Antropol, 26 (2002) 673. 64. VARGAS CM, YELLOWITZ JA, HAYES KL, J Am Dent Assoc, 61 (1960) 72. - 66. VIGILD M, BRINCK JJ, CHRISTENSEN J, Community Dent Oral Epidemiol, 21 (1993) 169. - 66. WARDH I, HALLBERG LR, BERGGREN U, Scand J Caring Sci, 14 (2000) 137. - 67. SCANNAPIECO FA, PAPANDONATOS GD, DUNFORD RG, Ann Periodontol, 3 (1998) 251. Corresponding author s address: S. Milardovi Department of Prosthodontics, School of Dental Medicine, University of Zagreb, Gundulieva 5, 10000 Zagreb, Croatia e-mail:  HYPERLINK "mailto:milardovic@sfzg.hr" milardovic@sfzg.hr Oralna higijena i stanje gingive kod pacijenata s fiksnoprotetskim radovima  12-mjese no praenje SA}ETAK Svrha ovog istra~ivanja je bila odrediti stupanj oralne higijene i stanje gingive kod pacijenata prije i nakon fiksnoprotetske terapije uz odgovarajue upute u oralnu higijenu te pratiti promjene kroz 12 mjeseci. Takoer je analizirano kako se imbenici poput vrste protetskog rada, materijala od kojeg je rad na injen, polo~aj u ustima, dob i spol odra~avaju na stupanj oralne higijene. Zubni lukovi su podijeljeni na sekstante te su zubi i gingiva pregledani koristei Indeks plaka i Indeks gingive prema Silnessu i Leu, dok je prisutnost mineraliziranih naslaga procijenjana Indeksom kamenca prema Greenu i Vermillionu. Prvi pregled je proveden prije protetskih zahvata, dok su kontrole izvrene 14 dana nakon privremenog cementiranja te mjesec dana, 6 i 12 mjeseci od trajnog cementiranja krunice i/ili mosta. Od 146 pacijenata koji su izvorno bili uklju eni u istra~ivanje 93 ih se odazvalo na sve kontrolne preglede te su samo njihovi podaci uzeti u obzir. Uzorak se sastojao od 60 ~ena i 33 muakaraca u dobi izmeu 21 i 95 godina (prosje na do 51.38). Ukupno 39 pacijenata imalo je samostalne krunice, 50 mostove, a 5 krunice i mostove. Indeks plaka kod prvog pregleda bio je vii u odnosu na ostale (P<0.001). Pacijenti sa samostalnim krunicama pokazali su bolji stupanj oralne higijene od onih s mostovima ili kombiniranim radovima (P=0.001). Prema rezultatima ovog istra~ivanjna nije bilo statisti ki zna ajne razlike u indeksima meu pacijentima s nadomjescima na injenim od razli itih materijala (P=0.083). Najloaiji stupanj oralne higijene imali su pacijenti s nadomjescima u obje eljusti (P=0.012). Mlai pacijenti su imali bolju oralnu higijenu od starijih (P=0.002). 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Za o ekivati je da bi se oralno zdravlje pacijenata bitno moglo unaprijediti uz odgovaraje profilakti ke mjere. TABLE 1 CRITERIA FOR CLASSIFYING THE ORAL HYGIENE LEVELS ScoresPlaque Index (PI)Calculus Index (CI)Gingival Index (GI)0No plaqueNo calculus presentNormal gingiva, no inflammation discoloration or bleeding1A film of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may be seen in situ only after application of disclosing solution or by using the probe on the tooth surface.Supragingival calculus covering not more than third of the exposed tooth surface.Mild inflammation, slight color change, mild alteration of gingival surface, no bleeding on pressure2Moderate accumulation of soft deposit s within the gingival pocket, or the tooth and gingival margin which can be seen with the naked eyeSupragingival calculus covering more than one third but not more than two thirds of the exposed tooth surface or the presence of individual flecks of subgingival calculus around the cervical portion of the tooth or both.Moderate inflammation, erythema and swelling, bleeding on pressure3Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin.Supragingival calculus covering more than two third of the exposed tooth surface or a continuous heavy band of subgingival calculus around the cervical portion of the tooth or both.Severe inflammation, erythema and swelling, tendency to spontaneous bleeding, perhaps ulceration TABLE 2 MEAN VALUES (SE) OF PLAQUE INDEX, CALCULUS INDEX, GINGIVAL INDEX AND OVERALL ORAL HYGIENE INDEX Plaque Index, mean (SE)Calculus Index, mean (SE)Gingival Index, mean (SE)Overall Oral Hygiene Index, mean (SE)Before treatmentMaxilla0.798 (0.079)0.286 (0.050)0.611 (0.084)0.565 (0.059)Mandible1.053 (0.073)0.439 (0.055)0.849 (0.084)0.780 (0.057)Overall0.884 (0.076)0.338 (0.048)0.673 (0.077)0.632 (0.056)Temporary luting (14 days)Maxilla0.659 (0.073)0.000 (0.000)0.715 (0.078)0.456 (0.047)Mandible0.785 (0.075)0.020 (0.015)0.801 (0.084)0.535 (0.051)Overall0.669 (0.071)0.011 (0.008)0.703 (0.076)0.460 (0.047)1 monthMaxilla0.603 (0.076)0.004 (0.004)0.567 (0.070)0.391 (0.045)Mandible0.650 (0.088)0.000 (0.000)0.679 (0.080)0.443 (0.054)Overall0.564 (0.079)0.000 (0.000)0.560 (0.070)0.375 (0.048)6 monthsMaxilla0.639 (0.082)0.067 (0.026)0.544 (0.075)0.417 (0.054)Mandible0.760 (0.089)0.073 (0.021)0.699 (0.086)0.511 (0.059)Overall0.638 (0.085)0.047 (0.015)0.562 (0.078)0.416 (0.055)12 monthsMaxilla0.679 (0.077)0.141 (0.035)0.552 (0.075)0.454 (0.055)Mandible0.739 (0.091)0.157 (0.030)0.675 (0,087)0.523 (0.062)Overall0.656 (0.084)0.118 (0.025)0.569 (0.079)0.447 (0.057)P-value*Maxilla0.197<0.0010.001<0.001Mandible<0.001<0.001<0.001<0.001Overall<0.001<0.001<0.001<0.001*P-value was calculated for the change over time using repeated measures analysis of variance (plaque index, gingival index, overall oral hygiene index) or using Friedman ANOVA for Calculus Index Fig 1. Least squares mean for overall oral hygiene index (OOHI) with 95% confidence intervals according to type of fixed prosthodontic appliance [crowns (C), fixed partial dentures (FPD), and crown(s) as well as fixed partial denture(s) (C+FPD)] Figure 2. Least squares mean for overall oral hygiene index (OOHI) with 95% confidence intervals according to type of material used for the appliance (ceramic fused-to-metal (CFM) or acrylic veneer on gold (AM-G) or acrylic veneer on silver-palladium alloy (AM-Ag-Pd)) Figure 3. Least squares mean for overall oral hygiene index (OOHI) with 95% confidence intervals according to placement of appliance in maxilla and/or mandible Figure 4. 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