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Gingival Bleeding and Calculus Among 12-Year-Old Chinese Adolescents: a Multilevel Analysis

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Gingival Bleeding and Calculus Among 12-Year-Old Chinese Adolescents: a Multilevel Analysis Chen et al. BMC Oral Health (2020) 20:147 https://doi.org/10.1186/s12903-020-01125-3 RESEARCH ARTICLE Open Access Gingival bleeding and calculus among 12- year-old Chinese adolescents: a multilevel analysis Hong Chen1,2†, Rui Zhang1,2†, Ran Cheng2,3, Ting Xu1,2, Tao Zhang1,2, Xiao Hong2,3, Xing Zhao5, Yunyun Wu5, Li Cheng2,3 and Tao Hu2,4* Abstract Background: Gingivitis is a common oral health problem, and untreated gingivitis can progress to periodontitis. The objectives of this study were to (1) explore associated factors of gingival bleeding and calculus among 12-year- old adolescents; (2) find predictive models for gingivitis management. Methods: Four thousand five hundred twenty-five subjects aged 12 in Sichuan Province were investigated. The questionnaire and clinical examination were applied in schools, and two-level logistic regression models were constructed to interpret the effect of individual and contextual factors on Chinese adolescents’ gingival bleeding and calculus. Results: 46.63% (95%CI: 40.71, 51.60) and 66.94% (95%CI: 56.85, 67.45) of the subjects presented gingival bleeding and calculus, respectively. For the gingival bleeding cases, the model showed the significant associated indicators were hukou (OR = 0.61, 95% CI: 0.52–0.72), family size (OR = 1.41, 95% CI: 1.19–1.68), parental educational level (father: OR = 0.53, 95% CI: 0.45–0.63; mother: OR = 0.71, 95% CI: 0.59–0.86), tooth-brushing frequency (OR = 0.35, 95% CI: 0.26–0.48), dental floss use (OR = 0.58, 95% CI: 0.41–0.83), sugar-containing drink consumption (OR = 2.11, 95% CI: 1.80–2.49), and dental visit (OR = 1.44, 95% CI: 1.19–1.74). It also confirmed that gender (OR = 1.32, 95% CI: 1.13– 1.54), hukou (OR = 0.69, 95% CI: 0.59–0.82), family size (OR = 1.34, 95% CI: 1.12–1.59), parental educational level (father: OR = 0.46, 95% CI: 0.39–0.54; mother: OR = 0.65, 95% CI: 0.59–0.82), tooth-brushing frequency (OR = 0.57, 95% CI: 0.42–0.78), dental floss use (OR = 0.66, 95% CI: 0.48–0.90) and sugar-containing drink consumption (OR = 1.30, 95% CI: 1.11–1.53) were associated factors for dental calculus. Conclusions: Gingival bleeding and calculus were common in western Chinese adolescents. Socio-demographic factors including gender, hukou and family factors are strong determinants of gingival health in Chinese adolescents. In addition, health-related lifestyle behaviors such as healthy diet, good hygiene care and more dental visits are good predictors of better gingival status. Keywords: Oral health, Gingival bleeding, Dental calculus, Adolescents, Cross-sectional study * Correspondence: [email protected] †Hong Chen and Rui Zhang are co-first authors. 2State Key Laboratory of Oral Diseases, Sichuan University, Chengdu, PR China 4Professor in Department of Preventive Dentistry, West China School of Stomatology, Sichuan University, Chengdu, Sichuan, PR China Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Chen et al. BMC Oral Health (2020) 20:147 Page 2 of 12 Background demonstrated in Taiwan [20], Australia [21], Germany Oral diseases are the most common noncommunicable [22], Japan [23], and the United States [24]. Twelve years diseases, and have become alarming public health prob- has been recommended by World Health Organization lems worldwide [1]. Gingivitis, one of the most common (WHO) as the indicator age group for international oral health problems, is a mild form of periodontal disease benchmarking of adolescents’ oral health [25, 26]. Little [1, 2]. Plaque-induced gingivitis is considered to be the is known about the prevalence of gingival bleeding and most prevalent type of gingivitis [3, 4]. The clinical symp- calculus in adolescents with large sample size in western toms of gingivitis include redness, oedema and bleeding at China. Therefore, the present study aimed to investigate the gingival margin [5]. During puberty (girls, 11–13 years; the associated factors for gingival bleeding and dental boys, 13–14 years), periodontal tissues may have an ampli- calculus in 12-year-old adolescents and to build predict- fied response to local factors: dental plaque, calculus, food ive models for gingivitis management and treatment debris, and materia alba [6]. And regular removal of these planning. local factors can prevent the occurrence and progression of early gingival disease [7, 8]. Methods Dental calculus (mineralized biofilms), located along Study design the gingival margin, is an important gingivitis- This cross-sectional study was a part of the Fourth Na- contributing factor [9, 10]. Calculus can’t be removed tional Oral Health Survey in China [27–29]. It was a easily from the surface of teeth and provides a substra- school-based survey conducted from 07/01/2015 to 09/ tum for plaque retention in the vicinity to the gingiva [9, 17/2016. Ethics approval was obtained from the Stomato- 10]. Calculus can also be a surrogate indicator of long- logical Ethics Committee of the Chinese Stomatological term exposure to biofilm and poor oral hygiene practices Association and the Ethics Committee of West China [11]. Its presence, along with gingival inflammation, is Hospital of Stomatology, Sichuan University (Approval associated with the initiation and progression of early- No. 2014–003). onset periodontitis [10]. Gingivitis and periodontitis can be considered as a Survey sampling continuum of the same inflammatory process, and The target population was selected from about 1, 018, untreated gingivitis can progress to periodontitis compli- 500 adolescents at the age of 12 years in Sichuan Prov- cated with further tissue destruction and bone reabsorp- ince. Sichuan Province is located in western China and tion [2, 3, 12]. Therefore, gingivitis management of represents one of the largest provinces with regard to adolescents is a prevention strategy for advanced peri- area and population [27, 28]. A complex, multi-stage odontal diseases that might persistently play a crucial sampling design [27–29] was used to select participants role in reducing the periodontal disease burden [2, 4]. who were representative of the province’s population. In The greatest share of oral health problems is attributable the first stage, six regions (Guang’an District, Chuanshan to the social conditions in which people live and work, District, Jinniu District, Da County, Yibin County and Pi referred to as the social determinants of health (SDH) County) were obtained from 181 regions with [13–15]. There are huge disparities in the level of eco- probability-proportional-to-size (PPS) method (Fig. 1). nomic development and the availability of healthcare re- And then a random sampling of schools was selected in sources in China [16]. The contextual differences are associated with several clinical outcomes of various oral diseases and could thus be related to gingivitis. Other in- dividual SDH factors associated with gingivitis include sex and ethnic inequalities [13, 14], family factors [14, 17], and health behaviors [14, 17, 18]. Therefore, it is im- portant to identify associated individual and contextual factors whose modification can reduce the prevalence of gingival bleeding and calculus in the future, and further, to provide advises on controlling such factors for main- taining a good quality of life [19]. Traditional periodontal examinations are resource- intensive, and a large-scale screening for adolescents is infeasible in China [20]. Recently, self-reported question- naires have been proposed to predict the probability in periodontal surveys. And the validation of prediction Fig. 1 The schematic diagram of Sichuan Province models based on self-reported questionnaires were Chen et al. BMC Oral Health (2020) 20:147 Page 3 of 12 the second stage in each region selected in the first stage respective smaller sample sizes (N ≤ 1318 and N ≤ 1249) [27, 28]. In the third stage, a computer-generated ran- would be calculated. dom number method was used for examinees selection at the aged 12 years [27]. A letter of invitation and informed consent form were Questionnaire sent to the guardian of potential participants firstly, em- The questionnaire was distributed to 4800 partici- phasizing that the participation was voluntary. Partici- pants in 12 years old in Sichuan Province. Every par- pants and their statutory guardians were required to ticipant was asked to fill an interviewer-administered sign informed consent forms. Adolescents with serious questionnaire with the guidance of trained dental stu- physical or psychological illness or disadvantages, who dents in their schools. The independent variables were unable or unwilling complete the examination and were composed of individual (intermediate SDH) and questionnaire, were excluded. Ultimately, a random sam- contextual (regions) factors associated with health ple of 4525 students completed the survey; this number (Table 1)[13–15].
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