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Received: 6 February 2018    Revised: 31 May 2018    Accepted: 10 June 2018

DOI: 10.1111/jcpe.12959

E PIDE MIOLOGY (COHORT STUDY

OR C A SE– CONTROL STUDY )

Prevalence of self-­reported gingival bleeding in a

representative sample of the Brazilian adolescent population

Paulo Nadanovsky1,2  | Ana Paula Pires dos Santos3 | Katia Vergetti Bloch4

1
Department of Epidemiology, National
School of Public Health, Oswaldo Cruz Abstract
Foundation (Fiocruz), Rio de Janeiro, Brazil Aim: To estimate the prevalence of self-­reported gingival bleeding in a representative
2
Department of Epidemiology, Institute
sample of 12-­to 17-­year-­old Brazilian adolescents.
of Social Medicine, Rio de Janeiro State
University, Rio de Janeiro, Brazil Materials and Methods: Sociodemographic and oral health information were ob-
3
Department of Community and Preventive tained through a self-­administered questionnaire of the Study of Cardiovascular Risk
Dentistry, Faculty of Dentistry, Rio de
Factors in Adolescents. The adolescents answered “yes” or “no” to the question “Do
Janeiro State University, Rio de Janeiro,
Brazil your gums bleed?”
4
Instituto de Estudos em Saúde Results: 74,589 of the 102,327 eligible adolescents answered the questionnaire and
Coletiva, Universidade Federal do Rio de
Janeiro, Rio de Janeiro, Brazil 18.4% (95% CI 17.5–19.3) reported having bleeding gums. The prevalence of self-­
reported gingival bleeding varied as following: 21.4% (95% CI 20.3–22.6) in girls and
Correspondence
Paulo Nadanovsky, Department of 15.3% (95% CI 14.3–16.4) in boys; 20.5% (95% CI 19.2–21.8) in older and 17.5% (95%
Epidemiology, National School of Public CI 16.4–18.6) in younger adolescents; 20.6% (95% CI 18.5–22.9) in Black people and
Health, Oswaldo Cruz Foundation (Fiocruz),
Rua Leopoldo Bulhões, 1480, CEP 21041- 17.1% (95% CI 16.1–18.1) in White people. Regarding mother’s level of education, the
210 Rio de Janeiro – RJ, Brazil. prevalences were 18.1% (95% CI 16.2–20.3), 17.6% (95% CI 16.4–18.9) and 19.3%
Emails: nadanovsky@ensp.fiocruz.br;
nadanovsky@ims.uerj.br (95% CI 17.9–20.9) for high, middle and low levels, respectively. For socioeconomic
status, the equivalent figures were 16.4% (95% CI 14.3–18.7), 18.4% (95% CI 17.5–
Funding information
The ERICA study was supported by the 19.4) and 23.0% (95% CI 17.3–29.9).
Brazilian Ministry of Health (Science and
Conclusion: Nearly one in five Brazilian adolescents reported having gingival bleed-
Technology Department) and the Brazilian
Ministry of Science and Technology ing, which might not be a serious condition, but reflect the disease and the adoles-
(Financiadora de Estudos e Projetos/
cents’ perception of oral health status.
FINEP and Conselho Nacional de Pesquisa/
CNPq) (grants FINEP: 01090421, CNPq:
565037/2010-2 and 405009/2012-7) KEYWORDS
adolescent, epidemiology, gingivitis, prevalence, self-report

1 | I NTRO D U C TI O N
Gingivitis is a gingival inflammation caused by the accumulation of
dental plaque. It can be influenced by several factors, such as sys-
temic disorders, blood dyscrasias, malnutrition and medications
(Armitage, 1999). It is characterised by inflammation of the marginal
gingiva without detectable loss of connective tissue attachment or
bone resorption. Clinically, there is redness and swelling of marginal
gingiva and bleeding on probing (Oh, Eber, & Wang, 2002). Gingivitis
and periodontitis (i.e., loss of connective tissue attachment or bone
resorption) are seen as a continuum of the same inflammatory
process. Although most gingivitis lesions do not progress to peri-
odontitis (Kinane & Attström, 2005), managing gingivitis is a primary
preventive strategy for periodontitis (Chapple et al., 2015).
Children and adolescents with higher levels of dental plaque had
higher risk of presenting gingivitis and periodontitis at the age of 32
(Broadbent, Thomson, Boyens, & Poulton, 2011). However, there is
scarce prospective evidence of the amount of plaque accumulation
necessary to cause periodontitis and that signs of gingivitis in child-
hood predicts risk of periodontitis. Thus, the extent to which gin-
gival inflammation and plaque accumulation can accurately predict
the individuals who will develop periodontitis is not well established.

952  |  wileyonlinelibrary.com/journal/jcpe

© 2018 John Wiley & Sons A/S. J Clin Periodontol. 2018;45:952–958.
Published by John Wiley & Sons Ltd
NADANOVSKY et al.
Periodontitis is consistently associated with negative impacts
on oral health-­related quality of life, and the greater the severity of
the disease the greater the impact (Buset et al., 2016; Ferreira, Dias-­
Pereira, Branco-­de-­Almeida, Martins, & Paiva, 2017). The impact of
gingivitis on oral health-­related quality of life is not as significant as
the impact of periodontitis. However, gingivitis has been linked to
pain as well as with difficulties related to toothbrushing and wear-
ing dentures, which points to an association between gingivitis and
oral discomfort (Ferreira et al., 2017). In children, there might be a
negative impact of gingival bleeding on both social interactions and
self-­esteem (Machado, Tomazoni, Ortiz, Ardenghi, & Zanatta, 2017).
Despite the cross-­sectional nature of these associations, which are
prone to reverse causation, it is difficult to think how oral health-­
related quality of life could affect gingivitis and periodontitis rather
than gingivitis and periodontitis affect oral health-­related quality of
life.
There are different ways of measuring gingivitis, one of which
is to clinically assess the presence of gingival bleeding on prob-
ing (BOP). In Brazil, the prevalence of gingivitis was 27% for
12-­year-­olds and 34% for 15-­to 19-­year-­olds, according to the
community periodontal index (CPI) (Brasil, 2011). A similar prev-
alence (33%) was found in 16-­to 19-­year-­olds in Albania (Laganà
et al., 2015). An alternative to clinical periodontal assessment is
self-­report, which is a method widely used to assess the preva-
lence of many medical conditions and health-­related behaviours
(Taylor & Borgnakke, 2007). It is advantageous as it is less time and
resource consuming and reflects the individual’s perception of her
own oral health status.
While clinically assessed gingival bleeding defines the condition
of the gum, self-­report is important because it expresses an illness
dimension related to the disease (Locker, 1988; Tsakos, Allen, Steele,
& Locker, 2012). We should expect that there is some association
between self-­reported and clinically assessed gingival bleeding, as
both are roughly measuring the same condition. These are two truly
complementary approaches, and, currently, it is not yet possible to
elect which one is more relevant.
We found no study of the prevalence of self-­reported gingival
bleeding in a national representative sample of any country. Thus,
the aim of this study was to estimate the prevalence of self-­reported
gingival bleeding in a representative sample of Brazilian adolescents.
2 | M ATE R I A L S A N D M E TH O DS
The Study of Cardiovascular Risk Factors in Adolescents
(Portuguese acronym, ERICA) is a school-­b ased cross-­sectional
multi-­center study which aimed to estimate the prevalence of car-
diovascular risk factors in a random sample of adolescents aged
12–17 years enrolled in private and public schools located in the
273 Brazilian municipalities with more than 100,000 inhabitants
(Bloch et al., 2015). Data were collected between March 2013 and
December 2014 and the questionnaire consisted of 105 questions
divided into 11 blocks: sociodemographic aspects, occupational
|
      953
Clinical Relevance
Scientific rationale for the study: First study that assessed
the prevalence of self-­reported gingival bleeding on a na-
tional basis. Gingival inflammation might influence the indi-
vidual perception of her own oral health status.
Principal findings: Nearly one in five Brazilian adolescents
reported that their gums bled.
Practical implications: Future research should investigate
the specific socio-­psychological and behaviour impact of
self-­reported gingival bleeding in adolescents, including
their care-­seeking behaviour.
activities, physical activity, eating habits, smoking, alcohol use, re-
productive health, oral health, sleep duration, physical morbidity
and mental health.
Information on sociodemographic characteristics and oral health-­
directed behaviours were obtained through a self-­
administered
questionnaire using an electronic device. Gingival bleeding was self-­
reported and the adolescents answered “yes” or “no” to the question
“Do your gums bleed?”
In this study, we analysed the following sociodemographic
variables: sex (girls or boys), age (12, 13, 14, 15, 16 or 17), mother’s
level of education (illiterate, 1–3 years of schooling, 4–7 years of
schooling, complete primary school, incomplete high school, com-
plete high school, incomplete university, complete university or
do not know), socioeconomic status (A—the highest, B, C, D or
E; these Brazilian criteria consider ownership of goods, presence
of housemaid and level of education of the head of the house-
hold), skin colour (white, black, brown, yellow, indigenous or not
reported), school type (public or private), school region (rural or
urban) and Brazilian macro-­regions (North, Northeast, Midwest,
Southeast or South). We categorised age into two groups (younger
12–15 and older 16–17), mother’s level of education into four
groups (high—incomplete or complete university, middle—incom-
plete or complete high school, low—illiterate to incomplete or
complete primary school and do not know) and socioeconomic
status (SES) into four groups (high—A, middle—B and C, low—D
and E and do not know).
The oral health-­directed behaviours were as follows: last visit to
the dentist (never, 6 months or more, less than 6 months or do not
know), daily toothbrushing frequency (none, once, twice, three times
or more than three times), use of toothbrush (yes or no), use of dental
floss (yes or no) and use of toothpaste (yes or no).
All participating students signed an assent form and brought
the informed consent form signed by their legal guardians (when
required by the local Research Ethics Committee). The study was
approved by the Research Ethics Committee of the Institution of the
Study Coordination Center (IESC/UFRJ – Process 45/2008) and by
each Brazilian state involved.
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954       NADANOVSKY et al.

The statistical analysis was performed using Stata 13.1®. The TA B L E   1   Prevalence (%) and 95% confidence intervals (CI) of
command svy (survey) was used to estimate the prevalences and self-­reported gingival bleeding by demographic, social and
their 95% confidence intervals (CI). All analyses were weighted con- geographic variables. ERICA, Brazil, 2013–2014

sidering the complex sampling plan that includes stratification and Self-­reported gingival bleeding
conglomeration.
% (95% CI) Total

All 18.4 (17.5–19.3) 74,589

3 |   R E S U LT S Sex
Female 21.4 (20.3–22.6) 41,225
According to the Brazilian Institute of Geography and Statistics Male 15.3 (14.3–16.4) 33,364
(http://www.ibge.gov.br/home/estatistica/populacao/projecao_ Age group (years)
da_populacao/2013/default.shtm), the estimated total population 12–15 17.5 (16.4–18.6) 48,460
of 12-­to 17-­year-­old Brazilians is 10,147,700. In the ERICA study, 16–17 20.5 (19.2–21.8) 26,129
74,589 of the 102,327 eligible adolescents answered the question
Mother’s level of education
on gingival bleeding (response rate = 72.9%). Among these, 18.4%
High 18.1 (16.2–20.3) 17,671
(95% CI 17.5–19.3) reported that their gums bled. The prevalence of
Middle 17.6 (16.4–18.9) 20,981
self-­reported gingival bleeding was significantly higher among girls
Low 19.3 (17.9–20.9) 18,163
(21.4%, 95% CI 20.3–22.6) than among boys (15.3%, 95% CI 14.3–
Do not know 18.3 (16.8–19.9) 17,774
16.4). There was also a statistically significant difference when older
adolescents (20.5%, 95% CI 19.2–21.8) were compared to younger SES

adolescents (17.5%, 95% CI 16.4–18.6). Adolescents from low SES High 16.4 (14.3–18.7) 6,336

and whose mother’s level of education was low had higher preva- Middle 18.4 (17.5–19.4) 43,597
lence of self-­reported gingival bleeding, but the differences were not Low 23.0 (17.3–29.9) 936
statistically significant, nor were the differences regarding skin col- Do not know 18.5 (17.2–20.0) 23,720
our, except when White people (17.1%, 95% CI 16.1–18.1) were com- Skin colour
pared to Black people (20.6%, 95% CI 18.5–22.9). The prevalence of White 17.1 (16.1–18.1) 26,477
self-­reported gingival bleeding was almost identical between adoles- Black 20.6 (18.5–22.9) 5,654
cents from private or public schools. However, this prevalence was
Brown 19.2 (17.8–20.7) 37,984
significantly higher among those attending schools in urban (18.7%,
Yellow 18.6 (15.0–22.9) 1,881
95% CI 18.0–19.5) than rural (9.7%, 95% CI 6.2–15.0) areas. At last,
Indigenous 15.6 (10.5–22.0) 561
we detected a statistically significant difference in the prevalence of
Not reported 16.2 (13.6–19.2) 2,032
self-­reported gingival bleeding between the macro-­region Midwest,
School type
which showed the lowest prevalence (15.9%, 95% CI 14.6–17.3) and
the macro-­region Southeast, which showed the highest prevalence State 18.3 (17.3–19.4) 58,707

(19.2%, 95% CI 17.6–21.0). Private 18.8 (17.3–20.4) 15,882

Table 1 shows the prevalence and 95% CI of self-­reported gingi- School region
val bleeding by sex, age group, mother’s level of education, SES, skin Rural 9.7 (6.2–15.0) 1,340
colour, school type, school region and Brazilian macro-­regions. The Urban 18.7 (18.0–19.5) 73,249
prevalence and 95% CI of self-­reported gingival bleeding stratified Macro-­region
by age and sex is depicted in Figure 1. North 17.1 (16.2–18.1) 15,073
Self-­reported gingival bleeding was higher among adolescents
Northeast 17.4 (16.3–18.5) 23,167
who had never visited the dentist (22.7%, 95% CI 19.9–25.6) and
Midwest 15.9 (14.6–17.3) 9,727
did not use dental floss (20.7%, 95% CI 19.7–21.8). The higher the
Southeast 19.2 (17.6–21.0) 17,080
toothbrushing frequency, the lower the prevalence of self-­reported
South 19.0 (17.3–20.8) 9,542
gingival bleeding. Use of toothbrush and toothpaste was almost uni-
versal (Table 2). Note. SES, socioeconomic status.

1996; Kallio & Murtomaa, 1997), most examined the participants

4 |  D I S CU S S I O N
We found that approximately one in five Brazilian adolescents re-
ported bleeding gums. There were previous reports on the preva-
lence of gingival bleeding. However, with few exceptions (Kallio,
clinically, but did not ask whether they perceived that their gums
bled (Abuhaloob & Petersen, 2017; Antunes, Peres, Frias, Crosato, &
Biazevic, 2008; Brasil, 2011; Campus et al., 2007; Fonseca, Ferreira,
Abreu, Palmier, & Vargas, 2015; Funieru et al., 2017; Gao et al.,
2014; Laganà et al., 2015; Nicolau, Marcenes, Bartley, & Sheiham,
NADANOVSKY et al. |
      955

F I G U R E   1   Prevalence (%) and 95%

confidence intervals (CI) of self-­reported
gingival bleeding by age and sex. ERICA,
Brazil, 2013–2014

TA B L E   2   Prevalence (%) and 95% confidence intervals (CI) of adolescents (Ayo-­Yusuf, Reddy, & van den Borne, 2008; Mattila
self-­reported gingival bleeding by oral health-­directed behaviours. et al., 2016) and in adults (Lintula et al., 2014), but none (at least to
ERICA, Brazil, 2013–2014
our knowledge) assessed it on a representative sample of any na-
Self-­reported gingival bleeding tion. Our study population was representative of the Brazilian ado-
lescent population who lived in the 273 cities of at least 100,000
% (95% CI) Total
inhabitants.
Last visit to the dentist
The prevalence of gingival bleeding in Brazil was assessed in a
Never 22.7 (19.9–25.8) 4,153 previous national survey (Brasil, 2011). However, that survey was
Six months or more 18.7 (17.2–20.2) 15,125 representative only for the 27 Brazilian capitals and assessed the
Less than 6 months 18.2 (16.9–19.6) 34,791 prevalence of clinical gingival bleeding. In that survey, 27% and
Do not know 17.5 (16.3–18.7) 20,520 34% of 12 and 15-­to 19-­year-­olds, respectively, presented gin-
Daily toothbrushing frequency gival bleeding. That prevalence was higher than the prevalence
None 23.8 (12.4–40.9) 168 of self-­reported gingival bleeding found in our study, which was

Once 23.1 (20.1–26.3) 2,816 19% for 12-­year-­olds and 17% for 15, 21% for 16 and 20% for
17-­year-­olds. This higher prevalence of clinically assessed when
Twice 21.8 (20.0–23.7) 20,561
compared to self-­reported gingival bleeding might be explained
Three times 17.4 (16.4–18.3) 34,245
by the way gingival bleeding was measured during clinical exam-
More than three 15.3 (13.6–17.2) 16,799
times
ination. The CPI index, used in that survey, evaluates BOP, that
is, the presence of bleeding after inserting a periodontal probe
Use of toothbrush
with standardised force in the gingival margin. This measurement
Yes 18.4 (17.6–19.4) 73,977
may provide higher levels of bleeding than self-­report assessment
No 10.9 (6.6–82.6) 612
of gingival bleeding, which most probably is only salient during
Use of dental floss
self-­p erformed oral hygiene, which should be physically gentler
Yes 16.3 (15.3–17.4) 38,813
to the gum than the hard periodontal probe. The clinical gingival
No 20.7 (19.7–21.8) 35,776 probing by the dentist may provoke too much bleeding, inadver-
Use of toothpaste tently making the CPI index too sensitive (i.e., generating an ex-
Yes 18.4 (17.5–19.3) 74,157 cess of false-­p ositive diagnoses). On the other hand, self-­report
No 12.6 (8.3–18.7) 432 may lack sensitivity (i.e., generating an excess of false-­n egative di-
agnoses). In essence, there is a conceptual problem, as there is no
well-­e stablished gold standard for gingival bleeding. Thus, it is not
2005; Petersen, Hoerup, Poomviset, Prommajan, & Watanapa, possible, in the current state of the art, to infer which prevalence
2001; Pitts, Chadwick, & Anderson, 2015; Rebelo, Lopes, Vieira, of gingival bleeding is more valid; the approximately 18% that we
& Parente, 2009; Tomazoni et al., 2017; Vadiakas, Oulis, Tsinidou, found or the nearly 30% found in the previous national survey.
Mamai-­Homata, & Polychronopoulou, 2012; Zhang, Xu, Liu, Lo, In addition, our question did not distinguish spontaneous bleed-
& Chu, 2015). Others assessed self-­reported gingival bleeding in ing from bleeding on brushing and frequency of bleeding. The
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956       NADANOVSKY et al.
prevalence of spontaneous and frequent bleeding may be more
relevant than bleeding on brushing or probing only.
The prevalence of clinically assessed gingival bleeding in Brazil
is similar to findings in other countries. In Albania, 33% of adoles-
cents aged 16–19 years presented gingival bleeding that is also mea-
sured by the CPI index (Laganà et al., 2015). In the United Kingdom,
40% of 15-­year-­olds presented gingival bleeding on probing, with
no differences among the UK countries (Pitts et al., 2015). When
clinically assessed, gingival bleeding tends to be more prevalent in
boys than in girls (Antunes et al., 2008; Funieru et al., 2017; Jenkins
& Papapanou, 2001). On the other hand, the prevalence of self-­
perceived bleeding gums when brushing teeth among 12-­year-­olds
in Finland was 23%; 27% in girls and 19% in boys, slightly higher
percentages when compared to our findings (Mattila et al., 2016).
We found higher prevalences of self-­reported gingival bleeding in
girls aged 14, 15, 16 and 17. The higher prevalence of self-­reported,
and lower of clinically assessed gingival bleeding in girls might re-
flect the fact that they are more concerned with health (Feldman,
Hodgson, Corber, & Quinn, 1986), and brush their teeth more fre-
quently (Maes, Vereecken, Vanobbergen, & Honkala, 2006; Mattila
et al., 2016; Vettore, Moysés, Sardinha, & Iser, 2012) than boys. This
makes girls more attentive to any signs and symptoms of diseases
and provides them with more opportunities to detect an episode of
gingival bleeding, and at the same time, lowers their risk of gingival
inflammation. However, in an adult population, men reported sig-
nificantly more often gingival bleeding than women (Lintula et al.,
2014).
We did not find differences in the prevalence of self-­reported
gingivitis related to mothers’ level of education or SES. This con-
trasts to findings from studies that clinically assessed gingival bleed-
ing and found more gingival bleeding among those with lower SES
(Antunes et al., 2008; Bastos, Boing, Peres, Antunes, & Peres, 2011;
Fonseca et al., 2015; Funieru et al., 2017; Tomazoni et al., 2017) and
among those whose mothers had fewer years of schooling (Funieru
et al., 2017; Tomazoni et al., 2017). In future studies, we intend to
investigate, in this data set, the extent to which self-­reported gingi-
val bleeding is related to eating and other habits which themselves
vary according to SES and maternal educational level. It is notewor-
thy, however, that the variables mother’s level of education and SES
had higher proportions of missing data as many adolescents did not
know how to answer these questions, and this may affect their valid-
ity. In any case, further analyses of these missing data suggested that
overall nonrespondents seemed to be similar to respondents, with
the exception that there were more young adolescents (12–15 years
old) than old adolescents (16–17 years old) among the nonrespon-
dents compared to the respondents, and the missing information
about mother’s level of education and SES seems not to have biased
the observed prevalence of gingival bleeding we found (Supporting
Information Tables S1 and S2). Skin colour is closely associated with
SES in Brazil, and we found more self-­reported gingival bleeding in
Black people than in White people, which is in agreement with previ-
ous studies that assessed gingival bleeding clinically (Antunes et al.,
2008; Fonseca et al., 2015).
Questions related to the number of teeth and the use and
need of prostheses have shown consistent validity according to
the clinical exam (Buhlin, Gustafsson, Andersson, Håkansson, &
Klinge, 2002; Ramos, Bastos, & Peres, 2013). Self-­reported gingi-
val bleeding and clinical gingival health appear to correlate in ad-
olescents. As expected, this correlation is far from perfect (Kallio
& Murtomaa, 1997; Taani & Alhaija, 2003). Self-­reported gingival
bleeding predicted, to a certain extent, the findings from clini-
cal exams, with values of sensitivity and specificity of the order
of 35%–42% and 76%–88%, respectively, according to Blicher,
Joshipura, and Eke (2005), and with values of sensitivity and spec-
ificity of the order of 75%–100% and 18%–43%, respectively,
according to Ramos et al. (2013). The differences in the reported
values of sensitivity and specificity between these two reviews
are probably due to differences in the self-­reported questions and
in the clinical gold standard used.
Gingival bleeding is not a major health problem. However, it may
be a nuisance. It causes bad breath (De Geest, Laleman, Teughels,
Dekeyser, & Quirynen, 2016) and hampers social well-­
being
(Krisdapong, Prasertsom, Rattanarangsima, & Sheiham, 2012). In
addition, in part it reflects inadequate oral hygiene, which in turn
increases the risk of periodontitis in a proportionally small, but
large number of people in the general population. Oral conditions,
including periodontitis, remain a major public health challenge all
over the world, with severe periodontitis affecting 7.4% of the global
population (Kassebaum et al., 2017). There may be an association
between prediabetes and gingival and/or periodontal bleeding on
gentle probing of the periodontal tissues (Andriankaja & Joshipura,
2014). Also, self-­reported use of lipid-­lowering agents has shown a
potential reduction effect on BOP levels, suggesting a connection
between these systemic agents and oral inflammation (Andriankaja
et al., 2015). Further large prospective studies should be carried out
to confirm these findings. It is therefore too early to speculate that
gingival bleeding increases the risk of prediabetes or any other sys-
temic disease as this association might be in the opposite direction.
Our study discovered that nearly one in five adolescents in Brazil
report gingival bleeding. There is no lack of oral hygiene among ado-
lescents in Brazil; almost all of them use toothbrush and toothpaste,
and report toothbrushing at least twice a day—93% in our study and
95% in a previous survey—(Vettore et al., 2012). Approximately half
of the adolescents reported flossing. There is some evidence that
flossing in addition to toothbrushing reduces the risk of gingivitis
compared to toothbrushing alone (Sambunjak et al., 2011). The pub-
lic health sector in cooperation with schools, industry and the media
need to implement population preventive strategies to improve the
quality of oral hygiene and reduce gingival bleeding in adolescents.
The relevance of this study is in the originality of assessing the
prevalence of self-­reported gingival bleeding in a representative sam-
ple of the adolescent population of a large nation. Future research
should investigate the specific socio-­psychological and behaviour
impact of self-­reported gingival bleeding in adolescents, including
their care-­
seeking behaviour. Furthermore, longitudinal studies
should assess the predictive value of adolescents self-­
reported
NADANOVSKY et al.
gingival bleeding, in addition to BOP, regarding the risk of developing
periodontitis in adulthood.
C O N FL I C T O F I N T E R E S T
The authors declare they have no conflict of interest.
ORCID
Paulo Nadanovsky  http://orcid.org/0000-0003-3345-9873
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section at the end of the article. 
How to cite this article: Nadanovsky P, dos Santos APP, Bloch
KV. Prevalence of self-­reported gingival bleeding in a
representative sample of the Brazilian adolescent population. J
Clin Periodontol. 2018;45:952–958. https://doi.org/10.1111/
jcpe.12959