Oral hygiene and periodontal status of 12 and 15-year-old Greek adolescents. A national pathfinder survey.
Abstract: AIM: To investigate oral hygiene and periodontal status of 12- and 15-year old Greek adolescents, in relation to sociodemographic and behavioural parameters. METHODS: A stratified cluster sample of 1,224 12-year old and 1,257 15-year old adolescents of Greek nationality were selected and examined by calibrated examiners. Periodontal and oral hygiene status were assessed using the Community Periodontal Index (CPI) and the simplified Debris Index (DIs) respectively. The socio-demographic and behavioural data collected included region, location, gender, parental educational level, tooth brushing frequency and reason for dental attendance. RESULTS: The majority of adolescents aged 12 (75.0%) and 15-years (61.4%) had fair oral hygiene levels. The most frequently observed condition in both ages was calculus with or without bleeding (42.8% in the younger and 53.3% in the older age group). Bleeding on probing was found in 41.5% of the 12-year-olds and in 30.0% of the 15-year-olds. The occurrence of shallow and/ or deep periodontal pockets was very low (0.2%). Multivariable modelling revealed that gender, location and tooth brushing frequency were strongly associated with oral hygiene status in both ages; girls, those living in urban areas and brushing teeth more frequently had significantly lower DI-s. Tooth brushing frequency was also associated with periodontal status in both ages, while living in urban areas was associated with better periodontal health only in the 15-year-olds. CONCLUSIONS: The study demonstrated that oral hygiene conditions among Greek children and adolescents are not satisfactory and that the occurrence of gingivitis is high. More efforts on oral health education and oral hygiene instruction are needed to improve their periodontal and oral hygiene status.

Key words: Oral hygiene, periodontal conditions, adolescents
Article Type: Report
Subject: Dental care (Surveys)
Dental care (Demographic aspects)
Dental hygiene (Surveys)
Dental hygiene (Demographic aspects)
Periodontal disease (Surveys)
Periodontal disease (Control)
Periodontal disease (Care and treatment)
Periodontal disease (Demographic aspects)
Mouth (Care and treatment)
Mouth (Surveys)
Mouth (Demographic aspects)
Authors: Vadiakas, G.
Oulis, C.J.
Tsinidou, K.
Mamai-Homata, E.
Polychronopoulou, A.
Pub Date: 02/01/2012
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: Feb, 2012 Source Volume: 13 Source Issue: 1
Topic: Event Code: 350 Product standards, safety, & recalls
Organization: Organization: World Health Organization
Geographic: Geographic Scope: Greece Geographic Code: 4EUGR Greece
Accession Number: 279612744
Full Text: Introduction

The prevalence and severity of oral diseases are influenced by a number of different variables, such as the implementation of preventive programs, patients' oral health education and behaviour, patients' and dentists' attitudes toward oral health, as well as the availability, accessibility and quality of dental care. Some of these variables may change over time and therefore the oral health of a population may also change. For this reason the World Health Organization suggests the surveillance of oral diseases that can be accomplished by regular clinical oral health surveys. These should be conducted every 5-6 years, by well calibrated examiners, in the same communities or settings in each country, and in certain indicator ages and age groups, using standard criteria for recording clinical conditions [Petersen et al., 2005].

Several countries have adopted this suggestion and carry out population surveys on a regular basis, in order to investigate trends in the epidemiology of oral diseases. However, although there are plenty of data concerning caries experience for school children and periodontal disease prevalence and severity for adults, information on the periodontal health in children and adolescents is insufficient. In the United Kingdom national surveys of children's dental health are conducted every ten years using consistent criteria that allow comparisons between the surveys. According to the results of these surveys a higher proportion of children appeared to have gingival inflammation, plaque and calculus in 2003 than 10 and 20 years before, despite better tooth brushing behaviours [White et al., 2006]. These findings indicate that more studies are needed to identify trends in the periodontal and oral hygiene status of children and adolescents. Such studies may also give us some indications of future health risks of these cohorts [White et al., 2006]. There is also evidence that periodontal health at younger ages is positively associated to periodontal condition at later ages [Clerehugh et al., 1995; Lu et al., 2011]. Accordingly increased presence of plaque and gingivitis in adolescence is associated with progressive periodontitis in later years [Mombelli et al., 1995].

In Greece, national oral health pathfinder surveys have been conducted in 1985 and 2005. This paper presents the findings of the survey of 2005 concerning the periodontal and oral hygiene status of 12- and 15-year-old adolescents in relation to socio-demographic and behavioural parameters.

Methods

A stratified cluster sample of 12- year-old children and 15-year-old adolescents was selected according to the World Health Organization guidelines for national pathfinder surveys [WHO, 1997]. The survey also included, for comparative reasons, the regions in which a previous WHO national pathfinder survey was carried out [Moller and Marthaler,1988].

This study covered two large cities (Athens and Thessaloniki), six counties (Achaia, Chania, Evros, Ioannina, Kastoria, and Larissa), two islands in the Aegean Sea (Lesbos and Naxos), and one island in the Ionian Sea (Kefallinia). Three communities with different socio-economic backgrounds were selected randomly within each of the large cities, while one urban and one rural community were selected randomly within each county or island. Therefore, the survey was conducted in 24 sites (15 urban and 9 rural). In each site two schools were randomly selected and at least 50 children from each age examined. The final sample consisted of 2,481 children of Greek nationality, 1,224 12-year olds and 1,257 15-year olds living in urban and rural areas. All data were obtained in agreement with the Greek ethical regulations and parental consent was required for the children to participate.

Prior to the survey, a meeting was organised in the Athens Dental School to train and calibrate five examiners. Interexaminer reliability and agreement was assessed with an experienced investigator as the gold standard. For the examined indices, levels of concordance were very good (Kappa coefficient >0.85). The examinations were conducted in the classrooms of the selected schools under artificial light using dental mirrors and the WHO periodontal probe.

The recorded variables were periodontal and oral hygiene status. The periodontal conditions were measured using the Community Periodontal Index (CPI) [WHO, 1997]. The oral hygiene status was recorded by means of the simplified Debris Index (DI-s) [Greene and Vermillion, 1964].

Socio-demographic (region, location, gender, father's and mother's education), behavioural (tooth brushing frequency and reason for dental attendance) data possibly related to periodontal and oral hygiene status were obtained from children and the school registers. The classification of education was based on the total number of years of education and was categorised into four levels: less than six years of education (primary education), nine years of education (secondary education-high school), twelve years of education (secondary education-lyceum), more than twelve years of education (higher education).

Due to the skewed distribution of the simplified Debris Index data, the corresponding descriptive statistics and analyses were based on the following groupings: 1) Good (score 0.0-0.6), 2) Fair (score 0.7-1.8) and 3) Poor (score 1.9-3.0) [Greene, 1967]. Community Periodontal Index data were also ordered, thus, for both indices the ordinal nature of the data was taken into account in all analyses.

Univariate and multivariate models were used through ordinal logistic regression analyses. The multilevel structure of the data was taken into account in all models by treating the regions as fixed effects and using robust standard errors which were adjusted for the clustering of children within the same school. All reported probability values were based on two-sided Wald tests and compared to a significance level of 5%. All analyses have been performed using Stata 10.1 (Stata Corp. TX, USA).

Results

Oral hygiene as expressed by the DI-s value averaged 0.92 [+ or -] 0.47 in those aged 12 years (Table 1) and 0.74 [+ or -] 0.47 in those aged 15 years (Table 2). Good oral hygiene levels were recorded in 21.5% of the 12-year olds and in 37.2% of the 15-year-olds. The percentage of those with poor oral hygiene level was low ([less than or equal to] 3.5%) in both ages. Univariate analysis of the data (Tables 1 and 2) showed that the DI-s score, at both ages, was significantly lower in girls and in those whose parents had a higher educational attainment. Also, the DI-s were lower in those living in urban compared with those living in rural areas, the difference reaching significance level only in the 15-year-olds.

Significant differences were also observed between the surveyed areas. Among the 12-year-olds, the highest DI-s values were found for those living in Kastoria County (1.22 [+ or -] 0.43), while among the 15-year-olds for those living in Achaia County (1.07 [+ or -] 0.26). Tooth brushing frequency significantly affected Di-s index level, while a reason for dental attendance was a significant predictor of DI-s only among the 12-year-olds.

The distribution of adolescents by CPI scores and sociodemographic and behavioural characteristics is presented in Tables 3 and 4. As can be seen, a relatively small percentage of adolescents, comparable for both ages (approximately 16%), exhibited a healthy periodontium. Bleeding on probing indicative of an inflammatory gingival disease was found in 41.5% of the 12-year olds and in 30% of the 15-year olds. The percentage of those with calculus deposits was higher in the older age group (53.3%). Gingival pockets, which were recorded only in 15-year-olds, were found in 0.2% of the subjects examined and in two out of the 11 regions (Evros County and Thessaloniki). According to the results of the univariate analysis (Tables 3 and 4) there were no significant differences in the periodontal condition of adolescents by location, gender, parental educational level, tooth brushing frequency and reason for dental attendance.

The results of the multivariate regression analysis for DI-s (Table 5) revealed that for both ages, gender, location and tooth brushing frequency remained significant predictors of oral hygiene status. Girls, those living in urban areas and brushing teeth at least once a day had significantly better oral hygiene. Also, the oral hygiene status of the 12-year olds was influenced by mother's educational level; having a mother of high educational attainment increased the probability for low DI-s scores. Table 6 demonstrates the results of multivariate analysis for periodontal status. Tooth brushing frequency was significantly associated with periodontal status at both ages. Furthermore, 15-year-olds living in rural areas showed worse periodontal conditions compared to those living in urban ones.

Discussion

This study is part of the 2nd National Pathfinder Survey on the oral health of the Greek population and presents its findings concerning the periodontal and oral hygiene status of adolescents aged 12 and 15 years. Since the simplified pathfinder sampling methodology developed by WHO was used [WHO, 1997], the sample cannot be characterised as random, but it can be considered as illustrative of the whole population, as it ensured the participation of a satisfactory size of people living in representative urban and rural areas of Greece. Furthermore, the thorough training and calibration of the examiners participating in the study ensured the reliable recording of the study parameters. Periodontal health was assessed by means of the Community Periodontal Index (CPI) that measures the prevalence and severity of periodontal diseases [WHO, 1997]. Although the CPI has attracted much criticism [Jenkins and Papapanou, 2001; Leroy et al., 2010] it is an index that is easy to use [Benigeri et al., 2000] and it constitutes the major source of descriptive epidemiological data on periodontal diseases in many countries, allowing international comparisons.

The results of the study revealed that three out of four 12-year-old and three out of five 15-year-old adolescents had fair oral hygiene levels as measured by the simplified debris index (DI-s). Therefore, the oral hygiene conditions of Greek adolescents cannot be considered as satisfactory. Dental plaque has been significantly associated with the severity of periodontal diseases [Corbet and Davies, 1993; Khader, 2006]. But its exact role is not fully understood, particularly in areas where the quantity and quality of plaque accumulation is taken into account [Grossi et al., 1995]. Nevertheless, dental plaque is considered today the primary aetiologic factor of chronic gingivitis, while chronic periodontitis is now seen as resulting from a complex interplay of bacterial infection and host response, often modified by behavioural factors (Lopez et al., 2006). In view of these concepts, our findings about the oral hygiene status of Greek adolescents may indicate an increased risk for periodontal diseases in the future.

The finding that the majority of subjects examined had fair oral hygiene level is in accordance with those of other studies that have used the DI-s for the determination of the oral hygiene status [Almeida et al., 2003; Deepak et al., 2010] and reflects their tooth brushing habits. In our survey, regular tooth brushing (>2 times per day) was reported by only 31.5% of those aged 12 years and by 40.4% of those aged 15 years [Vadiakas et al., 2011]. However, international data on oral hygiene practices show that although most people claim to practice oral hygiene measures daily, their oral hygiene conditions are far from satisfactory [Corbet et al., 2002]. Therefore, it seems that Greek adolescents are in need of better oral hygiene instruction in order to brush their teeth more often and effectively. The observation that the 15-year-old adolescents had better oral hygiene status than the younger ones could be attributed to their better oral hygiene habits.

The study data concerning the periodontal status of subjects examined showed that the most frequently observed condition in both ages was calculus with or without bleeding. However, the proportion of adolescents with calculus was much greater in those aged 15 than in those aged 12 years. These findings are in accordance with those observed in most other countries [Wang et al., 2002; Almeida et al., 2003; Campus et al., 2007; Lu et al., 2011; WHO, 2011], although in some surveys bleeding on probing was highly prevalent [Plancak and Aurer-Kozelj, 1992; WHO, 2011]. The results also reflect the need for scaling and oral hygiene instruction of this Greek population.

The percentage of adolescents with shallow or deep pockets was very low as in most other studies [WHO, 2011], indicating that periodontal attachment loss was infrequent at the age of 15 years. However, a relatively high prevalence of shallow pockets has been reported in some studies [Plancak and Aurer-Kozelj, 1992; Schiffner et al., 2009] and it is recommended that children and adolescents should receive periodic periodontal evaluation as part of routine dental visits [Califano, 2003].

It is well documented that although dental plaque biofilm is the main aetiological factor of gingivitis and periodontitis, other modifying and risk factors are also important to the initiation and progression of these diseases [Axelsson et al., 2002]. Among the various risk factors, socio-demographic characteristics such as gender, location, socio-economic status and place of residence have been associated with the prevalence and severity of periodontal diseases [Albandar, 2002], as well as with the oral hygiene status of individuals of all ages [Koposova et al., 2010; Mamai-Homata et al. 2010]. Our study partly confirmed these associations. Boys had significantly higher DI-s scores than girls at both ages and this can be attributed to their poorer oral hygiene practices.

Regular tooth brushing ([greater than or equal to] 2 times per day) was reported by 22% of the boys and 40% of the girls aged 12 years and by 28% of the boys and 50% of the girls aged 15 years [Vadiakas et al., 2011]. The findings that adolescents living in urban areas and having mothers of higher educational attainment were more likely to have lower DI-s scores emphasise the role of socio-demographic variables in oral hygiene status.

Although living in an urban area was a significant determinant for a better periodontal status in the 15-year-olds, the study failed to show a direct relationship between periodontal diseases and gender and mother's educational level. This lack of correlation may be due to the age-related dependence of periodontal diseases severity. Should the age range of our study sample extend to late adolescence, such relationships could possibly show up in our results. The area of residence was also a factor that seemed to influence oral hygiene and periodontal conditions in the population studied. The differences in the DI-s and CPI scores among different regions may reflect differences in socio-economic status, health culture and oral health attitudes and behaviours.

Our study showed that frequent tooth brushing was associated with a better oral hygiene status and a healthier periodontium. Although not practiced regularly by a significant part of the population studied (20-25%), tooth brushing regimens of at least once a day were reported by most adolescents. Such a finding supports the view, that tooth brushing at home is a well accepted measure for oral prevention among children [Marinho et al., 2004].

Conclusions

The results of the present study show that similar to previous reports a small percentage of Greek children and adolescents had a healthy periodontium, while the majority of them had calculus with or without bleeding. As their oral hygiene status cannot be considered as satisfactory there is room for improvement. Therefore, a community approach to controlling periodontal diseases should be based mainly on oral health education programs addressed to children and parents. Furthermore, local dental practitioners should more intensively educate children and their parents about the importance of maintaining a healthy periodontium, provide oral hygiene instructions and encourage appropriate treatment.

Acknowledgments

The authors are deeply indebted to all the people from the different regions of Greece, who either as examiners or members of the board, or coordinators of the local dental societies, contributed to the completion of this coordinated epidemiological survey, conducted as part of the National Program "Assessment and Promotion of the Oral Health of the Hellenic Population" which was carried out under the auspices of the Hellenic Dental Association and the coordination of Constantine Oulis, in collaboration with the Dental Schools of Athens and Thessaloniki. This Program was sponsored by a Colgate-Palmolive grant.

References

Albandar JM. Risk factors and risk indicators for periodontal diseases. Pri odontology 2000, 2002, 29: 517-532.

Almeida CM, Petersen PE, Andre SJ, Toscano A: Changing oral health status of 6-and 12-year-old schoolchildren in Portugal. Community Dent Health, 2003; 20: 211-216.

Axelsson P, Albandar JM, Rams TE. Prevention and control of periodontal diseases in developing and industrialized nations. Periodontology 2000, 2002; 29:235-246.

Benigeri M, Brodeur JM, Payette M, Charbonneau A, Ismail AI. Community periodontal index of treatment needs and prevalence of periodontal conditions. J Clin Periodontol, 2000; 27:308-313.

Califano JV. Research, Science and Therapy Committee American Academy of Periodontology. Position paper: periodontal diseases of children and adolescents. J Periodontol, 2003; 74:1696-1704.

Campus G, Solinas G, Cagetti MG et al. National pathfinder survey of 12-year-old children's oral health in Italy. Caries Res, 2007; 41:512-517.

Clerehugh V, Worthington HV, Lennon MA, Chandler R. Site progression of loss of attachment over 5 years in 14 to 19-year-old adolescents. J Clin Periodontol, 1995; 22:15-21.

Corbet E, Davies W. The role of supragingival plaque in the control of progressive periodontal disease. J Clin Periodontol, 1993; 20:307-313.

Corbet EF, Zee KY, Lo EC. Periodontal diseases in Asia and Oceania. Periodontol 2000, 2002; 29:122-152.

Deepak PB, Tarulatha RS, Mallikarjun K. Study of oral hygiene status and prevalence of gingival diseases in 10-12 year school children in Maharashtra, India. J Int Oral Health, 2010; 2:21-26.

Greene JC, Vermillion JR. The simplified oral hygiene index. J Amer Dent Ass, 1964; 68:7-13.

Greene JC. The oral hygiene index-development and uses. J Periodontol, 1967 (suppl); 38:625-637.

Grossi SG, Genco RJ, Machtei EE. Assessment of risk for periodontal disease. II. Risk indicators for alveolar bone loss. J Periodontol, 1995; 66:23-29.

Jenkins WM, Papapanou PN. Epidemiology of periodontal disease in children and adolescents. Periodontology 2000, 2001; 26:16-32.

Khader YS. Factors associated with periodontal diseases in Jordan: principal component and factor analysis approach. J Oral Science, 2006; 48:77-84.

Koposova N, Widstrom E, Eisemann M, Koposov R, Eriksen M. Oral health and quality of life in Norwegian and Russian school children: A pilot study. Stomatologija, Baltic Dental and Maxillofacial Journal, 2010; 12:10-16.

Leroy R, Eaton K.A, Savage A. Methodological issues in epidemiological studies of periodontitis--How can it be improved? BMC Oral Health, 2010; 10:8. Available at: www.biomedcentral.com/1472-6831/10/8 doi: 10.1186/1472-6831-10-8.

Lopez R, Fernandez O, Baelum V. Social gradients in periodontal diseases among adolescents. Community Dent Oral Epidemiol, 2006; 34:184-196.

Lu HX, Wong MCM, McGrath C. Trends in oral health from childhood to early adulthood: a life course approach. Community Dent Oral Epidemiol, 2011; 39:352-360.

Mamai-Homata E, Polychronopoulou A, Topitsoglou V, Oulis C, Athanassouli T. Periodontal diseases in Greek adults between 1985 and 2005--Risk indicators. Int Dent J, 2010; 60: 293-299.

Marinho VCC, Higgins JPT, Sheiham A, Logan S. One topical fluoride (toothpastes, or mouthrinses, or gels, or varnishes) versus another for preventing dental caries in children and adolescents. Cochrane Database of systematic Reviews, 2004, Issue I.

Moller, I.J. Marthaler, T. National Oral Pathfinder Survey. Report on a visit to Greece. 1988: WHO regional office for Europe, Copenhagen.

Mombelli A, Rutar A, Lang NP. Correlation of the periodontal status 6 years after puberty with clinical and microbiological conditions during puberty. J Clin Periodontol, 1995; 22:300-305.

Petersen PE, Bourgeois D, Bratthall D, Ogawa H. Oral health information systems--towards measuring progress in oral health promotion and disease prevention. Bull World Health Organ, 2005; 83:686-693.

Plancak D, Aurer-Kozelj J. CPITN assessment of periodontal treatment needs in the population of Zagreb, Croatia. Int Dent J, 1992; 42:441-444.

Schiffner U, Hoffmann T, Kerschbaum T, Micheelis W. Oral health in German children, adolescents, adults and senior citizens in 2005. Community Dent Health, 2009; 26:18-22.

Vadiakas G, Oulis CJ, Tsinidou K, Mamai-Homata E, Polychronopoulou A. Socio-behavioural factors influencing oral health of 12 and 15 year old Greek adolescents. A national pathfinder survey. Eur Archs Paediatr Dent, 2011; 12:139-145.

Wang H, Petersen PE, Bian J, Zhang B. The second national survey of oral health status of children and adults in China. Int Dent J, 2002; 52:283-290.

White DA, Chadwick BL, Nuttall NM, Chestnutt IG, Steele JG. Oral health habits amongst children in the United Kingdom in 2003. Br Dent J, 2006; 200:487-491.

World Health Organization.: Oral health surveys. Basic methods. 1997; 4th ed. Geneva: WHO.

World Health Organization. Global Oral Data Bank. Periodontal country profiles. Available at: www.dent.niigata-u.ac.jp/prevent/perio/perio.html (accessed 7/6/2011).

G. Vadiakas *, C. J. Oulis *, K. Tsinidou *, E. Mamai-Homata ** and A. Polychronopoulou **

Department of Paediatric Dentistry, **Department of Preventive and Community Dentistry, Dental School, University of Athens

Postal address: Assoc Prof C. Oulis, Department of Paediatric Dentistry, University of Athens, Greece.

Email: cjoulis@dent.uoa.gr
Table 1. Observed oral hygiene status of 12-year-old Greek
adolescents measured using the simplified Debris Index
(DI-s) according to socio-demographic and behavioural
parameters.

                               N         DI-s
                                     Mean (SD)

Region

Achaia                       100    1.04 (0.14)
Athens                       160    0.87 (0.50)
Chania                       104    1.01 (0.56)
Evros                        100    0.66 (0.36)
Ioannina                     101    0.80 (0.36)
Kastoria                     101    1.22 (0.43)
Kefallinia                   101    1.02 (0.12)
Larissa                      101    0.78 (0.39)
Lesbos                       100    0.58 (0.45)
Naxos                        102    0.88 (0.53)
Thessaloniki                 154    1.16 (0.56)

Wald test for ordinal DI-s categories: p<0.001

Location
Rural                        248    0.94 (0.43)
Urban                        976    0.91 (0.48)

Wald test for ordinal DI-s categories: p>0.05

Gender
Boys                         580    0.99 (0.48)
Girls                        644    0.86 (0.46)

Wald test for ordinal DI-s categories: p<0.01

Father's education
6 years or less              287    0.94 (0.47)
9 years                      257    0.98 (0.46)
12 years                     366    0.93 (0.49)
More than 12 years           310    0.83 (0.46)

Wald test for ordinal DI-s categories: p<0.001

Mother's education
6 years or less              247    0.98 (0.45)
9 years                      241    1.00 (0.50)
12 years                     449    0.90 (0.47)
More than 12 years           283    0.85 (0.46)

Wald test for ordinal DI-s categories: p<0.01

Tooth brushing
frequency
Never/occasionally           321    1.06 (0.49)
Once a day                   518    0.89 (0.44)
More than once a day         382    0.84 (0.48)

Wald test for ordinal DI-s categories: p<0.001

Reason for
dental attendance
Pain/problem                 224    0.93 (0.44)
Treatment                    424    1.00 (0.48)
Check-up/prevention          557    0.86 (0.48)

Wald test for ordinal DI-s categories: p<0.001

Total                      1,224    0.92(0.47)

                                   Oral Hygiene level
                                   of adolescents (%)

                            Good          Fair       Poor
                          (score       (score      (score
                        0.0-0.6)      0.7-1.8)    1.9-3.0)

Region

Achaia                       0.0          99.0        1.0
Athens                      27.5          70.6        1.9
Chania                      23.1          69.2        7.7
Evros                       44.0          56.0        0.0
Ioannina                    30.7          69.3        0.0
Kastoria                     4.0          89.1        6.9
Kefallinia                   0.0         100.0        0.0
Larissa                     22.8          77.2        0.0
Lesbos                      45.0          55.0        0.0
Naxos                       25.5          66.7        7.8
Thessaloniki                14.3          75.3       10.4

Wald test for ordinal DI-s categories: p<0.001

Location
Rural                       14.5          81.0        4.4
Urban                       23.3          73.5        3.3

Wald test for ordinal DI-s categories: p>0.05

Gender
Boys                        17.2          78.1        4.7
Girls                       25.3          72.2        2.5

Wald test for ordinal DI-s categories: p<0.01

Father's education
6 years or less             17.8          77.4        4.9
9 years                     14.8          81.3        3.9
12 years                    22.1          74.0        3.8
More than 12 years          29.0          69.4        1.6

Wald test for ordinal DI-s categories: p<0.001

Mother's education
6 years or less             16.6          78.1        5.3
9 years                     15.4          79.0        5.4
12 years                    22.7          74.4        2.9
More than 12 years          28.3          70.3        1.4

Wald test for ordinal DI-s categories: p<0.01

Tooth brushing
frequency
Never/occasionally          12.1          80.7        7.2
Once a day                  22.4          75.9        1.7
More than once a day        27.7          69.4        2.9

Wald test for ordinal DI-s categories: p<0.001

Reason for
dental attendance
Pain/problem                20.1          77.7        2.2
Treatment                   15.6          79.2        5.2
Check-up/prevention         25.9          71.3        2.9

Wald test for ordinal DI-s categories: p<0.001

Total                       21.5          75.0        3.5

Table 2. Observed oral hygiene status of 15-year-old Greek
adolescents measured using the simplified Debris Index (DI-s)
according to socio-demographic and behavioural
parameters.

                                              Oral Hygiene level
                                              of adolescents (%)

                   N        DI-s        Good       Fair       Poor
                            Mean       (score     (score     (score
                            (SD)       0.0-0.6)   0.7-1.8)   1.9-3.0)

Region

Achaia           100    1.07 (0.26)        0.0       98.0        2.0
Athens           150    0.58 (0.45)       53.3       46.7        0.0
Chania           111    0.93 (0.60)       31.5       64.0        4.5
Evros            114    0.51 (0.33)       63.2       36.8        0.0
Ioannina         105    0.60 (0.34)       46.7       53.3        0.0
Kastoria         104    0.95 (0.45)       27.9       70.2        1.9
Kefallinia       101    1.00 (0.17)        2.0       97.0        1.0
Larissa          105    0.75 (0.40)       25.7       74.3        0.0
Lesbos           108    0.42 (0.46)       63.0       37.0        0.0
Naxos            104    0.63 (0.53)       42.3       54.8        2.9
Thessaloniki     155    0.82 (0.49)       40.0       57.4        2.6

Wald test for ordinal DI-s categories: p<0.001

Location
Rural             252    0.85 (0.49)       23.0       74.2        2.8
Urban            1005    0.71 (0.46)       40.8       58.2        1.0

Wald test for ordinal DI-s categories: p<0.05

Gender
Boys             549    0.82 (0.47)       30.1       68.7        1.3
Girls            708    0.68 (0.47)       42.8       55.8        1.4

Wald test for ordinal DI-s categories: p<0.001

Father's education

6 years or less     271    0.79 (0.47)       29.5       67.9        2.6
9 years             220    0.86 (0.46)       25.9       71.8        2.3
12 years            350    0.74 (0.46)       37.7       61.7        0.6
More than 12 years  407    0.65 (0.48)       48.2       51.1        0.7

Wald test for ordinal DI-s categories: p<0.001

Mother's education

6 years or less     248    0.75 (0.47)       33.5       64.9        1.6
9 years             199    0.85 (0.47)       26.6       70.9        2.5
12 years            480    0.74 (0.47)       39.2       59.8        1.0
More than 12 years  323    0.68 (0.47)       43.7       55.4        0.9

Wald test for ordinal DI-s categories: p<0.001

Tooth brushing frequency

Never/occasionally    224    0.96 (0.47)       18.3       79.5      2.2
Once a day            524    0.75 (0.46)       34.0       65.1      1.0
More than once a day  507    0. 64 (0.45)      49.1       49.5      1.4

Wald test for ordinal DI-s categories: p<0.001

Reason for dental attendance

Pain/problem            205    0.73 (0.47)       38.0       59.5    2.4
Treatment               475    0.77 (0.50)       37.5       61.3    1.3
Check-up/prevention     559    0.73 (0.45)       36.7       62.3    1.1

Wald test for ordinal DI-s categories: p>0.05

Total                  1,257   0.74 (0.47)       37.2       61.4    1.4

Table 3. Observed periodontal conditions of 12-year-old
Greek adolescents measured using the Community Periodontal
Index (CPI) according to socio-demographic and behavioural
parameters.

                                    CPI of adolescents (%)
                                      with highest score

                          N      0--       1--        2--
                               Healthy   Bleeding   Calculus
Region

Achaia                  100       0.0       14.0       86.0
Athens                  160      20.0       35.6       44.4
Chania                  104      26.9       39.4       33.7
Evros                   100      11.0       35.0       54.0
Ioannina                101      16.8       45.5       37.6
Kastoria                101       0.0       55.4       44.6
Kefallinia              101       1.0       47.5       51.5
Larissa                 101      27.7       23.8       48.5
Lesbos                  100      47.0       37.0       16.0
Naxos                   101      24.8       58.4       16.8
Thessaloniki            154       2.6       58.4       39.0

Wald test for ordinal DI categories: p<0.001

Location
Rural                   247      19.4       37.2       43.3
Urban                   976      14.9       42.5       42.6

Wald test for ordinal DI categories: p>0.05

Gender
Boys                    580      14.7       41.0       44.3
Girls                   643      16.8       41.8       41.4

Wald test for ordinal CPI categories: p>0.05

Father's education

6 years or less         286      16.8       40.9       42.3
9 years                 257      15.2       45.1       39.7
12 years                366      15.3       41.8       42.9
More than 12 years      310      15.5       38.7       45.8
Wald test for ordinal CPI categories: p>0.05

Mother's education

6 years or less         247      13.8       38.1       48.2
9 years                 241      16.6       45.2       38.2
12 years                448      15.6       43.8       44.4
More than 12 years      283      16.6       43.8       39.6
Wald test for ordinal CPI categories: p>0.05

Tooth brushing frequency

Never/occasionally      320      10.0       47.2       42.8
Once a day              518      17.4       39.6       43.1
More than once a day    382      18.3       39.3       42.4
Wald test for ordinal CPI categories: p>0.05

Reason for dental attendance

Pain/problem            224      18.8       40.6       40.6
Treatment               423      13.5       46.1       40.4
Check-up/prevention     557      16.0       38.6       45.4

Wald test for ordinal CPI categories: p>0.05

Total                  1,223     15.8       41.5       42.8

Table 4. Observed periodontal conditions of 15-year-old
Greek adolescents measured using the Community Periodontal
Index (CPI) according to socio-demographic and behavioural
parameters.

                           CPI of adolescents (%) with highest score

                                                               3+4 =
                                0 =       1 =        2 =      Gingival
                       N      Healthy   Bleeding   Calculus    pocket

Region
Achaia                 100       0.0        8.0       92.0        0.0
Athens                 150      21.3       23.3       55.3        0.0
Chania                 111      22.5       19.8       57.7        0.0
Evros                  114      13.2       28.1       57.9        0.9
Ioannina               105      15.2       21.9       62.9        0.0
Kastoria               104       0.0       47.1       52.9        0.0
Kefallinia             101       1.0       43.6       55.4        0.0
Larissa                105      20.0       25.7       54.3        0.0
Lesbos                 108      53.7       30.6       15.7        0.0
Naxos                  104      34.6       44.2       21.2        0.0
Thessaloniki           155       3.9       38.1       57.4        0.6

Wald test for ordinal CPI categories: p<0.001

Location

Rural                  252      17.9       32.1       50.0        0.1
Urban                 1005      16.4       29.6       53.8        0.2

Wald test for ordinal CPI categories: p>0.05

Gender
Boys                   549      14.0       31.3       54.5        0.2
Girls                  708      18.8       29.1       52.0        0.1

Wald test for ordinal CPI categories: p>0.05

Father's education

6 years or less        271      16.6       35.1       48.3        0.0
9 years                220      13.2       33.2       53.6        0.0
12 years               350      16.9       29.1       53.7        0.3
More than
  12 years             407      18.2       25.8       55.8        0.2

Wald test for ordinal CPI categories: p>0.05

Mother's education

6 years or less        248      17.3       31.0       51.6        0.0
9 years                199      14.1       35.2       50.8        0.0
12 years               480      17.1       29.6       53.1        0.2
More than
  12 years             323      16.7       26.6       56.3        0.3

Wald test for ordinal CPI categories: p>0.05

Tooth brushing frequency

Never/
  occasionally         224      10.3       35.7       54.0        0.0
Once a day             524      17.2       28.1       54.8        0.0
More than
  once a day           507      19.1       29.6       50.9        0.4

Wald test for ordinal CPI categories: p>0.05

Reason for dental attendance

Pain/problem           205      15.6       28.3       56.1        0.0
Treatment              475      15.6       33.1       51.4        0.0
Check-up/
  prevention           559      18.2       28.3       53.1        0.4

Wald test for ordinal CPI categories: p>0.05

Total                1,257      16.6       30.0       53.3        0.2

Table 5. Odds ratios and 95% confidence intervals (C.I.)
derived from multivariate ordinal logistic regression with
simplified Debris Index (DI-s) scores as the dependent
variable in 12-and 15-year-old Greek children and
adolescents.

Risk indicators **                          12-year-olds

                                Odds ratio    95% C.I.    p-value
Region
Achaia                               3.15    1.21-8.15     0.018
Athens *                                1
Chania                               1.06    0.48-2.35        NS
Evros                                0.39    0.20-0.76     0.006
Ioannina                             0.70    0.32-1.51        NS
Kastoria                             4.89    2.19-10.89   <0.001
Kefallinia                           3.94    1.61-9.60     0.003
Larissa                              1.22    0.19-7.79        NS
Lesbos                               0.26    0.13-0.55    <0.001
Naxos                                0.60    0.19-1.87        NS
Thessaloniki                         3.57    1.57-8.12     0.002
Location
Rural                                1.87    1.25-2.80     0.002
Urban *                                 1
Gender
Boys *                                  1
Girls                                0.61    0.44-0.86     0.005
Mother's education
6 years or less *                       1
9 years                              1.32    0.79-2.23        NS
12 years                             0.74    0.45-1.22        NS
More than 12 years                   0.56    0.33-0.96     0.034
Tooth brushing frequency
Never/occasionally *                    1
Once a day                           0.47    0.30-0.75     0.002
More than once a day                 0.39    0.23-0.68     0.001
Reason for dental attendance
Pain/problem                         1.36    0.92-1.99        NS
Treatment                            1.43    1.01-2.03      0.05
Check-up/prevention *                   1

Risk indicators **                          15-year-olds

                                Odds ratio    95% C.I.    p-value
Region
Achaia                              15.36    6.58-35.88   <0.001
Athens *                                1
Chania                               1.73    1.21-2.49     0.003
Evros                                0.63    0.44-0.91     0.015
Ioannina                             1.05    0.51-2.17        NS
Kastoria                             2.68    1.88-3.84    <0.001
Kefallinia                          13.70    6.98-26.92   <0.001
Larissa                              2.87    0.72-11.42       NS
Lesbos                               0.38    0.26-0.56    <0.001
Naxos                                0.93    0.67-1.28        NS
Thessaloniki                         1.86    1.32-2.63    <0.001
Location
Rural                                1.65    1.23-2.22     0.001
Urban *                                 1
Gender
Boys *                                  1
Girls                                0.64    0.51-0.81    <0.001
Mother's education
6 years or less *                       1
9 years                              1.04    0.65-1.67        NS
12 years                             0.74    0.45-1.21        NS
More than 12 years                   0.70    0.40-1.21        NS
Tooth brushing frequency
Never/occasionally *                    1
Once a day                           0.58    0.36-0.95     0.031
More than once a day                 0.30    0.19-0.50    <0.001
Reason for dental attendance
Pain/problem                         0.75    0.56-1.02        NS
Treatment                            0.84    0.64-1.10        NS
Check-up/prevention *                   1

* Reference category

** Father's education eliminated due to co-linearity with
mother's education

NS = not significant

Table 6. Odds ratios and 95% confidence intervals (C.I.)
derived from multivariate ordinal logistic regression with
Community Periodontal Index (CPI) scores as the dependent
variable in 12-and 15-year-old Greek children and
adolescents.

                                  12-year-olds

Risk indicators **      Odds ratio    95% C.I.    p-value

Region

Achaia                     7.64      4.24-13.76   <0.001
Athens *                    1
Chania                     0.49      0.23-1.02      NS
Evros                      1.46      0.67-3.19      NS
Ioannina                   0.81      0.37-1.78      NS
Kastoria                   1.37      0.74-2.53      NS
Kefallinia                 1.52      0.85-2.75      NS
Larissa                    0.97      0.03-30.55     NS
Lesbos                     0.17      0.08-0.36    <0.001
Naxos                      0.28      0.16-0.49    <0.001
Thessaloniki               1.17      0.66-2.08      NS

Location

Rural                      1.22      0.88-1.69      NS
Urban *                     1

Gender

Boys *                      1
Girls                      0.85      0.65-1.11      NS

Mother's education

6 years or less *           1
9 years                    0.82      0.56-1.21      NS
12 years                   0.92      0.65-1.32      NS
More than 12 years         0.76      0.53-1.09      NS

Tooth brushing frequency

Never/occasionally *        1
Once a day                 0.70      0.56-0.87     0.001
More than once a day       0.61      0.45-0.84     0.002

Reason for dental attendance

Pain/problem               0.78      0.57-1.07      NS
Treatment                  0.83      0.61-1.12      NS
Check-up/prevention *       1

                                  15-year-olds

Risk indicators **      Odds ratio    95% C.I.    p-value

Region

Achaia                     7.39      3.67-14.88   <0.001
Athens *                    1
Chania                     0.78      0.36-1.73      NS
Evros                      1.27      0.61-2.64      NS
Ioannina                   1.36      0.61-3.01      NS
Kastoria                   1.30      0.72-2.32      NS
Kefallinia                 1.10      0.56-2.15      NS
Larissa                    0.95      0.20-4.51      NS
Lesbos                     0.10      0.04-0.27    <0.001
Naxos                      0.21      0.11-0.41    <0.001
Thessaloniki               1.51      0.80-2.85      NS

Location

Rural                      1.64      1.06-2.55     0.026
Urban *                     1

Gender

Boys *                      1
Girls                      0.89      0.69-1.14      NS

Mother's education

6 years or less *           1
9 years                    0.83      0.63-1.09      NS
12 years                   0.94      0.64-1.37      NS
More than 12 years         0.92      0.66-1.29      NS

Tooth brushing frequency

Never/occasionally *        1
Once a day                 0.97      0.70-1.35      NS
More than once a day       0.72      0.52-1.00     0.047

Reason for dental attendance

Pain/problem               0.95      0.65-1.37      NS
Treatment                  0.92      0.70-1.21      NS
Check-up/prevention *

* Reference category

** Father's education eliminated due to co-linearity
with mother's education

NS= not significant
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.