Influence of probing force on the reproducibility of bleeding tendency measurements

Comparative Assessment of the Periodontal Findings in Child Subjects With a Normal Body Mass Index and in Obese Subjects

BACKGROUND

Obesity in children is a concerning issue affecting a large population globally. Obesity and overweight are risk factors for various medical conditions, including periodontal diseases, hypertension, cerebrovascular disease, cardiovascular disease, and/or diabetes.

AIM

The study aimed to comparatively assess the periodontal findings in child subjects with a normal BMI and in obese subjects.

METHODS

The present observational study aimed to comparatively assess 216 school-going child subjects that were divided into two groups: non-obese (BMI<25) and obese, with BMI≥25 having equal gender distribution. In both groups, clinical attachment loss (CAL), probing depth (PD), and bleeding on probing (BOP) were assessed along with a questionnaire on oral hygiene and dietary habits. The data gathered were statistically analysed.

RESULTS

The study results showed that in obese subjects, significantly higher values were seen for probing depth, bleeding on probing, and plaque index compared to non-obese subjects with p<0.05. However, no significant difference was noted in the CAL of obese and non-obese subjects (p>0.05).

CONCLUSION

The periodontal status is compromised in obese subjects with higher values of probing depth, bleeding on probing, and plaque index compared to child subjects with normal weight. The level of CAL does not differ significantly between obese and non-obese child subjects.

The relationship between children's body mass index and periodontal status

Background

Childhood obesity is a serious medical condition that affects children and adolescents. Being overweight and obese are important risk factors for various adult diseases including diabetes, cardiovascular, and cerebrovascular disease, hypertension, and periodontal diseases. This study aimed to compare the periodontal findings in obese children with those exhibiting normal body mass.

Materials and Methods

In the present retrospective cohort study, 108 children, 12 years of age, were randomly assigned to the two groups with equal gender distribution, selected from the schools in Yazd, Iran: obese (body mass index [BMI] ≥25) and nonobese (BMI <25). After obtaining informed consent forms from their parents, each participant's demographic data and BMI were recorded, and periodontal indices were determined including plaque index (PI), bleeding on probing (BOP), pocket depth (PD), and clinical attachment loss (CAL). Then, a questionnaire on dietary and oral hygiene habits was completed by the participants. The data were collected and analyzed with a Chi-square test and t-test.

Results

The results showed statistically significantly higher mean PI, BOP, and PD in obese participants than nonobese participants (P < 0.05), with no statistically significant difference in CAL between the two groups (P > 0.05).

Conclusions

The periodontal indices of PI, BOP, and PD in obese children were significantly higher than in children with a normal weight. However, there was no statistically significant difference in CAL between the two groups.

Plaque-induced gingivitis: Case definition and diagnostic considerations

OBJECTIVE

Clinical gingival inflammation is a well-defined site-specific condition for which several measurement systems have been proposed and validated, and epidemiological studies consistently indicate its high prevalence globally. However, it is clear that defining and grading a gingival inflammatory condition at a site level (i.e. a "gingivitis site") is completely different from defining and grading a "gingivitis case" (GC) (i.e. a patient affected by gingivitis), and that a "gingivitis site" does not necessarily mean a "GC". The purpose of the present review is to summarize the evidence on clinical, biochemical, microbiologic, genetic markers as well as symptoms associated with plaque-induced gingivitis and to propose a set of criteria to define GC.

IMPORTANCE

A universally accepted case definition for gingivitis would provide the necessary information to enable oral health professionals to assess the effectiveness of their prevention strategies and treatment regimens; help set priorities for therapeutic actions/programs by health care providers; and undertake surveillance.

FINDINGS

Based on available methods to assess gingival inflammation, GC could be simply, objectively and accurately identified and graded using bleeding on probing score (BOP%) CONCLUSIONS: A patient with intact periodontium would be diagnosed as a GC according to a BOP score ≥ 10%, further classified as localized (BOP score ≥ 10% and ≤30%) or generalized (BOP score > 30%). The proposed classification may also apply to patients with a reduced periodontium, where a GC would characterize a patient with attachment loss and BOP score ≥ 10%, but without BOP in any site probing ≥4 mm in depth.

Gingival bleeding on repeat probing after different time intervals in plaque-induced gingivitis

The aim of this study was to assess agreement and association of gingival bleeding after repeated probing at different time intervals in subjects with gingivitis. Twenty adults participated. Periodontal probing (P approximately 1.27 MPa) was conducted at six sites of every tooth present. Probing was repeated in different quadrants immediately after the first probing (T0), after 1 h (T1), 4 h (T4), and 24 h (T24). A total of 3,459 sites were probed twice. The mean proportion of sites bleeding on probing (BOP) was 0.23 (standard deviation 0.08, range 0.10-0.41). Probing itself had a significant effect on the results of repeated probing. For T0 through T24, respective mean differences of proportions were 0.04, 0.04, 0.01, and -0.03. Ninety-five percent repeatability coefficients of proportions were 0.17-0.18. Estimates of overall kappa were 0.390, 0.234, 0.233, and 0.046 for T0 through T4, respectively. Adjusted two-level binary response models revealed odds ratios (95% confidence interval) for BOP at T0 through T4 of 6.52 (4.34, 9.80), 3.23 (2.19, 4.76), 3.80 (2.63, 5.50), and 2.68 (1.85, 3.89). It was concluded that a certain degree of agreement of site-specific bleeding scores in subjects with plaque-induced gingivitis could be observed only if probing was repeated at once. Adjusted associations between repeat BOP were weak in general, but strongest immediately after first probing. There appears to be a significant effect of probing itself, which may last for more than 1 h, whereas 24-h results are obtained under different conditions.

Examiner agreement on periodontal indices during dental surveys of elders

Indices used to evaluate periodontal health have been widely accepted in epidemiological studies, yet their reliability cannot be guaranteed. The aim of this study was to evaluate the reliability of periodontal indices applied on elders. 19 elderly subjects, 73-years-old on average, were examined at a 1st appointment by 2 independent examiners. They were re-examined 2 weeks later during a 2nd session. The examinations were performed in a dental chair with good illumination. Periodontal health was evaluated using the community periodontal index of treatment need, and tooth mobility was evaluated using 2 different indices. Inter and intra-examiner agreements were evaluated using kappa statistics. Taken as an overall measurement, the CPITN was a reliable assessment of periodontal treatment need in elders. Disagreement occurred mainly on the evaluation of bleeding and shallow pockets. The detection of fairly mobile teeth was reliable; however, the performance of the more sensitive scale was deceptive. it seems that, in the case of tooth mobility, a choice has to be made between sensitivity or reproducibility. It can be concluded that examiners should be trained carefully since the reliability of the CPITN and tooth mobility evaluation were good but close to a critical level for which an agreement is classified as poor.

Effect of gingival wall on resistance to probing forces

This study was conducted to determine whether the gingival tissue lateral to the periodontal sulcus contributes resistance to the advancement of a periodontal probe tip into the sulcus under different applied pressures. An electromechanical device was used to advance a probe tip 0.6 mm in diameter into the facial sulcus at a constant speed until resisting forces of 0.70 N were encountered. The device registered the resisting force and probe advancement simultaneously. The gingiva of all 2nd incisors, 2nd premolars, and 1st molars of 4 young adult male beagle dogs were tested. After the first measurement, the buccal gingiva of experimental sites were incised mesiodistally from the gingival margin to the alveolar crest and the sulcus was reprobed. 2 experimental and control quadrants were selected randomly resulting in 6 sets of both experimental and control data from each animal. The data were analyzed with analysis of variance. The analysis demonstrated significant variation from site to site, and dog to dog; therefore, only changes between the 1st and 2nd probings at the same sites could be compared. Less variability of probing distance in different animals occurred at higher forces; however, the incision had a significant effect on probing distance at these forces. The pressure at which probing distance had less variability among animals and least affected when the gingival sulcular wall was incised was estimated to be 106 N/cm2. This corresponds to 30 g force on the 0.6 mm diameter probe.

Histological location of a standardized periodontal probe in man

The purpose of this study was to locate the position of the periodontal probe tip using a pressure of 126 N/cm2 (force of 0.30N using a round periodontal probe tip with a diameter of 0.55 mm). The influence of gingival inflammation on this position was also studied. Subjects with three levels of periodontal health and disease were entered into the study and each contributed one experimental tooth. At each site a standardized probing system was used to place a probe into a clinical pocket. The probe tip was luted to the test tooth surface. The tooth with its gingival tissue and probe tip was extracted, fixed, and processed for histological measurements. Distances in mm were obtained from the cemento-enamel junction (CEJ) to the probe tip, to the base of the crevice/pocket, and to the most coronal connective tissue attachment. Analysis of the data indicated that clinical inflammation was not a factor in the placement of the probe tip at crevice/pocket's landmarks relative to the CEJ; however variability of probing may have caused the non-significance. The probing system placed the probe tip 0.66 mm apical to the base of the crevice/pocket and 0.06 mm coronal to the most coronal connective tissue attachment. These conclusions corroborated the results of the previous study in dogs which predicted probe placement of 0.44 mm apical to the base of the crevice using the standardized pressure of this probing system.

Reproducibility of periodontal probing using a conventional manual and an automated force-controlled electronic probe

A total of 1,128 sites in 15 periodontal maintenance patients were examined twice, 7 to 10 days apart, to evaluate reproducibility of periodontal probing by a conventional manual and an automated force-controlled electronic probe. Probing depths (PD) and relative attachment levels (AL) were recorded to the nearest 0.5 mm with both instruments. At each visit, all sites were probed first with the conventional and then with the electronic probe. Reproducibility of PD at shallow sites (PD < or = 3 mm) by the manual probe was 59.1% for exact agreement and 98.6% within +/- 1.0 mm variation. For the electronic probe, corresponding values were 41.3% and 91.5%, respectively. Reproducibility of PD measurements at deeper sites (PD > 3 mm), was 33.0% for exact match and 96.4% within +/- 1.0 mm for the manual and, correspondingly, 31.7% and 85.9% for the electronic probe. Reproducibility of AL followed a similar pattern, but was consistently lower than for PD. Reproducibility was consistently higher for anterior than for posterior sites and, for some comparisons, higher in the maxilla than in the mandible. These differences were smaller for the manual than for the electronic probe. Time required to complete the probing was longer for the conventional probe than for the electronic instrument. Under the prevailing study conditions, the automated force-controlled electronic probe failed to offer significant advantages over the conventional manual probe.

Measurement of attachment level in clinical trials: probing methods

Measurement of clinical attachment level has become a standard for judging clinical response in periodontal therapy. A number of probing methods and instruments have been developed in an attempt to address limitations in obtaining this measurement. First generation instruments include conventional periodontal probes; second generation probes utilize controlled forces; and third generation probes incorporate automated measurement, controlled forces, and computerized data capture. Various types of stents have been used and repeated measurement techniques have been proposed to reduce examiner error. Controlled force probes appear to have their greatest advantage in increasing inter-examiner repeatability. The use of measurement stents increases inter- and intra-examiner reliability. However, use of such stents may be limited to small sample studies of limited duration. Third generation instruments offer advantages in terms of automated measurement and data capture, increased resolution, and a more continuous measurement scale, but do not necessarily result in increased intra- or inter-examiner reliability. Examiner training and calibration are essential for any measurement instrument. Decisions for or against use of a particular instrument must be made on the basis of the needs of each clinical trial. At the present time, no commercially available instrument resolves all of the inherent limitations of clinical measurement of attachment.

Issues in the evaluation of clinical trials of periodontitis: a clinical perspective

The goals of clinical trials designed to establish claims for equivalency or superiority of treatment for periodontitis must be clearly stated and defined in terms of measurable and meaningful response variables. It is suggested that these clinical trials use designs that compare new treatment methods to basic periodontal therapy which consists of thorough scaling and root planing, oral hygiene instruction, and regular maintenance care. The primary response variable should be clinical attachment level. It is important to document changes in probing depth since this is a meaningful measure to many clinicians. Gingival inflammation and bleeding should be used as secondary response variables because these are not necessarily indicative of progressive periodontal destruction. Radiographic measures of disease may be useful as primary response variables if safe, reproducible and valid methods of measuring change are utilized. Microbiological monitoring should be a secondary response variable because of numerous questions concerning sampling methodology, quantitative expression of data, and meaningful interpretation in terms of relevance to disease activity. The length of periodontitis trials should be set at a minimum of 9 months if claims of superiority or equivalency are made compared to basic periodontal therapy. Calibration trials should be included and measurement error should be expressed in terms that are meaningful to the clinician while retaining statistical validity. Statistical methods for determining change should take into account site and subject heterogeneity, bursts of change and gradual change over time. It is important that statistical techniques be used that detect change as early as possible and that appropriate consideration be given to the clinical implications of the type, magnitude and duration of change in outcome variables.

Depth-force patterns of periodontal probing. Attachment-gain in relation to probing force

It was the purpose of this study to determine whether probing force had an influence on the amount of clinical attachment-gain assessed after treatment by scaling and rootplaning. A probing device was constructed which allowed simultaneous monitoring of probing force and probe penetration and which standardized the insertion pathway for repeated measurements. In 10 periodontal patients, 2 deep pockets were selected which were measured before and after periodontal treatment by scaling and root-planing. Depth-force plots were compared by superimposition. Depth values were determined at 5 different force levels (0.25, 0.50, 0.75, 1.00 and 1.25 N) on each plot and changes of clinical attachment levels were calculated. A significant relationship was seen between probing force and attachment level. The values obtained with 0.25 N were significantly different from the values obtained with higher forces (p less than 0.001). Slight, but non-significant differences were noted in the amount of attachment-gain obtained at the 5 force levels. At a probing force level of 0.25 N, there was 0.80 mm mean attachment gain. With 0.50 N, there was a gain of 0.70 mm; with 0.75 N the gain amounted to 0.67 mm in mean. At 1.00 N and at 1.25 N, a gain of 0.66 mm was recorded.

Evaluation of gingival bleeding following 4 types of periodontal therapy

This study evaluated the effects of 4 types of periodontal therapy (coronal scaling (CS), root planning (RP), modified Widman surgery (MW), and flap with osseous resectional surgery (FO] and subsequent maintenance care upon bleeding on probing (BOP). 75 individuals completed split mouth therapy and 2 years of maintenance followup. Data were obtained by 1 calibrated examiner prior to the initiation of therapy, following the hygienic phase and surgical phase of active therapy and yearly during maintenance care. All types of therapy reduced the prevalence of BOP. At the end of 2 years of maintenance therapy, regions greater than 5 mm treated by CS demonstrated a significantly (p less than 0.05) greater prevalence of BOP sites than regions treated by the other modalities. Generally, sites associated with deeper probing depths exhibited a greater tendency to bleed and sites with associated plaque accumulation bled more frequently. RP resulted in a significantly (p less than 0.05) higher % of bleeding sites that stopped following active therapy than did CS. Throughout the study, BOP was extremely dynamic, with 15-88% of sites converting to a new status between any 2 examination periods. This dynamic nature may explain the inability of previous investigations to establish BOP as a reliable predictor of periodontal breakdown.

Inter- and intra-examiner variability using standard and constant force periodontal probes

Current methods of measuring periodontal probing depths at specified sites by clinical means are subject to wide variation both within and between examiners. This paper reports an investigation into the influence of a constant-force periodontal probe on intra- and inter-examiner variability when measuring probing depths. 30 sites in 10 patients with untreated chronic adult type periodontitis were examined by 2 operators, firstly using a standard periodontal pocket probe then with a constant force probe. Neither examiner was aware of the others readings and were thus blind in relation to one another. Comparison of the recordings of the 2 operators using the standard probes showed significant differences between the operators (p less than 0.01) but this difference became insignificant when the constant force probe was used. One operator had a significant variation between his standard and constant force measurements (p less than 0.01), but the other did not. Overall there was a maximum variation of +/- 1 mm in 79.9% of recordings using the standard probe and this agreement was increased to 100% with the use of the constant pressure probe.

In situ lymphocyte subpopulations from active versus stable periodontal sites

The purpose of this study was to evaluate lymphocyte subset densities and distributions within gingival biopsies from active sites (greater than or equal to 2 mm clinical attachment loss within three months of biopsy) versus clinically similar but stable or healthy sites. Small interproximal gingival biopsies representing at least one of each of the above categories were obtained from each of 20 periodontal maintenance patients. Serial cryostat sections displaying a cross section of the gingiva were labeled with monoclonal antibodies for (1) pan T cells, (2) T cytotoxic/suppressor cells, (3) T helper/inducer cells and (4) pan B cells and were developed using an avidin-biotin-peroxidase system. Lymphocyte populations were enumerated in repeatable fields from the sulcular, middle and oral one-third of each section. Relative proportions of the same lymphocyte subsets were analyzed in peripheral blood samples from the same patients using direct immunofluorescence. Pan B cells were significantly more prevalent in infiltrates from active sites than in stable (P less than 0.05) or healthy (P less than 0.01) sites. The T/B cell ratio was also significantly lower in active than stable biopsies (P less than 0.05), and in active biopsies versus blood (P less than 0.05). The T helper/T suppressor cell ratio did not vary significantly between blood and any gingival tissue disease group or location, but a trend toward lower relative numbers of T helper cells in the sulcular infiltrates of active sites was noted. These results support the premise that active periodontal sites display elevated B cell populations and abnormal immune regulation possibly involving the T helper cell subset.

Constant force probing with and without a stent in untreated periodontal disease: the clinical reproducibility problem and possible sources of error

There is presently no satisfactory method of detecting periodontal disease activity at a specified site by means of clinical measurements. This study was designed to examine the possible sources of error with regard to probing measurement reliability. Intra-examiner reproducibility of probing measurements was studied at 766 sites in 10 patients with untreated periodontitis, using a 0.25 N hinged constant force probe (a) with a stent for guidance and landmark, and (b) without stent. The stent made little difference to overall reproducibility of probing depths, though it appeared to reduce variation in different areas. Repeated probing led to an increase in some measurements, perhaps by an effect on tissues. Reproducibility of probing depth was lower in deep pockets, and about 2% of all probing depth scores varied by 3 mm or more at the same site. 4 possible sources of measurement error were noted: visual and tactile observational error, positional error and tissue change. The results are discussed in relation to the clinical detection of periodontal disease activity.

Probing considerations in relation to susceptibility to periodontal breakdown

Both epidemiological and clinical studies indicate that not all individuals are equally susceptible to periodontal breakdown. Therefore, the clinical differences were investigated between subjects highly susceptible and subjects insusceptible to periodontal breakdown. The highly susceptible group consisted of patients with a diagnosis of juvenile periodontitis. The insusceptible group consisted of older individuals with gross amounts of plaque and no periodontal breakdown. Results indicated that a high value of the bleeding/plaque ratio may possibly act as a prognostic indicator for periodontal breakdown. However, longitudinal data are indispensable for substantiation of this hypothesis. Since longitudinal research takes many years, the experimental gingivitis model was chosen for further investigation. 4 groups of individuals were selected on the basis of a different history of inflammatory periodontal disease: 2 younger age groups without periodontal breakdown, having either a low or a high bleeding/plaque ratio--a hypothetically susceptible and a hypothetically insusceptible group, respectively; one older age group with presence of gross amounts of plaque, no periodontal breakdown and a low bleeding/plaque ratio--an insusceptible group; and an adult group who previously suffered from severe periodontal disease--a susceptible group. Results of the experimental gingivitis studies indicated that the older insusceptible group developed only small amounts of bleeding, whereas the younger hypothetically insusceptible group developed a comparable low bleeding index. The younger hypothetically susceptible group developed a much higher bleeding index comparable to that of the susceptible group, the periodontal patients. In conclusion, comparison of the results of the experimental gingivitis studies in subjects with differing histories of inflammatory periodontal disease supports the concept that the bleeding/plaque ratio may act as a prognostic indicator for periodontal breakdown.

Percent agreement, Pearson's correlation, and kappa as measures of inter-examiner reliability

Percent agreement and Pearson's correlation coefficient are frequently used to represent inter-examiner reliability, but these measures can be misleading. The use of percent agreement to measure inter-examiner agreement should be discouraged, because it does not take into account the agreement due solely to chance. Caution must be used in the interpretation of Pearson's correlation, because it is unaffected by the presence of any systematic biases. Analyses of data from a reliability study show that even though percent agreement and kappa were consistently high among three examiners, the reliability measured by Pearson's correlation was inconsistent. This study shows that correlation and kappa can be used together to uncover non-random examiner error.

Occurrence of gingival bleeding in smoker and non-smoker patients

The objective of the present investigation was to study the influence of cigarette smoking on the occurrence of gingival bleeding. The occurrence of bleeding was evaluated by probing at a standardized pressure of 60 g. The bleeding occurrence of each patient was indicated by the number of sites bleeding on probing as a percentage of the total. Twenty patients with moderate to severe periodontitis, 10 smokers and 10 non-smokers, participated in the study. The smoker patients had been regular smokers for at least 15 years, their present tobacco consumption being 20 cigarettes a day or more. The results showed that, although they had a significantly greater plaque index, smokers displayed a significantly lower bleeding occurrence than non-smokers, the average being 27% and 40%, respectively. The present findings suggest that gingival bleeding as measured by probing with a pressure of 60 g is reduced in smokers with periodontitis.

Observations on temperature and temperature patterns of the gingiva. II. Estimations of the error in measurement

The diagnostician may expect an error associated with the measurements of clinical parameters. It is important to know how precise these measurements are. The purpose of this study was to make an estimation of the measurement error by comparing repeated measures of the same site. Six dental hygiene students were examined for gingival and were recorded twice. The maximum error associated with 95% of the temperature data and the average error were calculated as 1.3 degrees C and 0.65 degrees C, respectively. The probabilities of making a correct assessment of pocket depth and of sulcular bleeding were computed to be 0.864 and 0.840, respectively. The need for repeated measures was statistically analyzed. It can be concluded from our data that the thermocouple thermometer used in this study is a suitable instrument for measuring the gingival temperature. However, it is necessary to acquire a higher level of precision for the assessment of pocket depth and sulcular bleeding. This can be accomplished by increasing the number of clinical measures on each point.

Longitudinal study of periodontal status in individuals aged 15 years in 1973 and 20 years in 1978 in Jönköping, Sweden

The aim of this investigation was to study the periodontal status at the ages of 15 and 20 years in the same individuals. Gingival and periodontal data from 100 adolescents in 1973 constituted the basic material. Eighty subjects could be reexamined in 1978. The mean number of teeth per subject was 27.1 both in 1973 and in 1978. Three individuals in 1973 and two in 1978 had no bleeding gingival units. There was a decrease between 1973 and 1978 in the number of subjects with a high number of inflamed gingival units. The buccal and lingual surfaces also showed lower prevalence of gingivitis, while the proximal surfaces showed a slight increase in prevalence. The prevalence of surfaces with plaque in 1978 was decreased for buccal and lingual surfaces but slightly increased for proximal surfaces. Sixty-six individuals in 1973 and 71 in 1978 had no pocketing. Altogether 75 tooth surfaces with pocketing were diagnosed in 1973 and 21 in 1978. Most of the pockets were located at the proximal surfaces of the molars. Four individuals with infrabony defects in one to two sites were found in 1973 and five in 1978. No progression of the bony defects found in 1973 seemed to have occurred during the 5-year period. In spite of the frequent proximal areas with gingivitis, very few 20-year-olds showed signs of marginal bone loss, which indicates that gingivitis does not necessarily lead to destructive periodontitis in young people.