A clinical procedure for determining the proficiency of gingivitis examiners

Maintenance of gingival health post professional care

Oral hygiene habits are strongly associated with general health behaviours; good oral self care should result in good dental health. Clinical dental hygiene services have limited long range probability of success if the patient is not diligent in the daily procedures of personal care to remove and control dental plaque. Therefore, it is important to help make the individual aware of their own ability to control and maintain good oral health after a dental prophylaxis through oral care instruction and the use of select antimicrobials to maintain the gingival health. This paper reviews the evidence outlining the relative roles of prophylaxis and correct oral self-care in maintaining gingival health.

Adjunctive treatment with subantimicrobial doses of doxycycline: effects on gingival fluid collagenase activity and attachment loss in adult periodontitis

OBJECTIVES

The therapeutic effects of doxycycline and other tetracyclines in the treatment of periodontitis involve, at least in part, mechanisms that are unrelated to their antimicrobial activity. Previous clinical studies have shown that doxycycline administered orally, at doses below those needed for antimicrobial efficacy, to human subjects with adult periodontitis resulted in significantly reduced collagenase activity in gingival crevicular fluid (GCF) and in extracts of inflamed gingival tissues. The purpose of the present study was to identify clinically effective dosing regimens using subantimicrobial dose doxycycline (SDD) as an adjunctive therapy in patients with adult periodontitis.

MATERIAL AND METHODS

A total of 75 adult men and women qualified for enrollment into the three-part, placebo-controlled, double-blind, parallel-group study. Patients were stratified based on repeatedly exhibiting pathologic levels of periodontal attachment (ALv) and GCF collagenase activity at several appointments prior to baseline. Patients were administered a scaling and prophylaxis, then 1 of 5 treatment schedules for 12 weeks (part I), followed by a 12-week period of no drug therapy (part II), a second scaling and prophylaxis, and 12 additional weeks of treatment (part III). Primary determinants of efficacy included reductions in GCF collagenase activity and changes in relative ALv.

RESULTS

66 patients completed the 1st 12 weeks (part I) of the 3-part, 36-week study; 51 patients completed the entire 36-week study. From baseline to week 12 (part I), treatment with specially formulated SDD capsules (20 mg) 2x daily (1 x every 12 h) for up to 12 weeks was shown to significantly reduce GCF collagenase activity and to improve ALv, effects not seen in patients treated with placebo. Continuous drug therapy over the 12-week treatment period was needed to maintain and maximize the reduction in GCF collagenase and the improvement in ALv. Improvements in periodontal disease parameters occurred without the emergence of doxycycline-resistant micro-organisms. In patients administered an "on-off-on" regimen of SDD over 36 weeks (parts I-III), essentially no attachment loss occurred in patients receiving the highest of these SDD regimens (20 mg 2x daily during part I and 20 mg 1 x daily in part III), whereas patients administered placebo capsules experienced a mean attachment loss of approximately 0.8 mm at the 24- and 36-week time periods.

CONCLUSIONS

Doxycycline administered at subantimicrobial doses led to improvements in disease parameters, with no apparent side effects, and appears to have significant potential as an oral adjunctive therapy in the long-term management of adult periodontitis.

Treatment with subantimicrobial dose doxycycline improves the efficacy of scaling and root planing in patients with adult periodontitis

BACKGROUND

In a previous study, subantimicrobial dose doxycycline (SDD) significantly improved clinical parameters associated with periodontal health in patients with adult periodontitis (AP) when used as an adjunct to a maintenance schedule of supragingival scaling and dental prophylaxis. In this double-blind, placebo-controlled, parallel-group, multicenter study, the efficacy and safety of SDD were evaluated in conjunction with scaling and root planing (SRP) in patients with AP.

METHODS

Patients (n = 190) received SRP at the baseline visit and were randomized to receive either SDD 20 mg bid or placebo bid for 9 months. Efficacy parameters included the per-patient mean changes in clinical attachment level (CAL) and probing depth (PD) from baseline, the per-patient percentages of tooth sites with attachment loss (AL) > or = 2 mm and > or = 3 mm from baseline, and the per-patient percentage of tooth sites with bleeding on probing. Prior to analysis, tooth sites were stratified by the degree of disease severity evident at baseline

RESULTS

In tooth sites with mild to moderate disease and severe disease (n = 183, intent-to-treat population), improvements in CAL and PD were significantly greater with adjunctive SDD than with adjunctive placebo at 3, 6, and 9 months (all P <0.05). In tooth sites with severe disease, the per-patient percentage of sites with AL > or = 2 mm from baseline to month 9 was significantly lower with adjunctive SDD than with adjunctive placebo (P<0.05). Improvements in clinical outcomes occurred without detrimental shifts in the normal periodontal flora or the acquisition of doxycycline resistance or multiantibiotic resistance. SDD was well tolerated, with a low incidence of discontinuations due to adverse events.

CONCLUSIONS

The adjunctive use of SDD with SRP is more effective than SRP alone and may represent a new approach in the long-term management of AP.

A comparison of 3 clinical indices for measuring gingivitis

A clinical study was conducted among 200 adult males and females to compare the intrusive gingival index (GI) for estimating gingivitis with the nonintrusive and only visually applied papillary-marginal-gingivitis index (PMGI). The GI examinations were performed by a senior examiner with long experience and a junior examiner, while the PMGI was graded by only a senior examiner with long experience. A 4th examiner was included for grading bleeding sites by gentle intrusion at the orifice of the gingival crevice. Following the baseline examination by all examiners, the subjects were randomly assigned to either a group that received an oral prophylaxis immediately or to a group that received an oral prophylaxis 6 weeks after the baseline. All subjects were regraded by all examiners 4 days after the 2nd group received a prophylaxis. This delayed prophylaxis design created a difference in the responses between treatment groups. Both the GI examiners and the PMGI examiner concluded there was significantly less gingivitis in the group receiving a prophylaxis second. There were also significantly fewer bleeding sites in the group receiving a prophylaxis second as determined by both GI examiners and the bleeding-sites examiner.

A procedure for evaluating the reliability of a gingivitis index

A methodology is presented for assessing the reliability of an ordinarily-scaled index and is illustrated by using data from a clinical trial in which gingival inflammation was assessed with the PMGI index, independently, by 5 examiners. One of the examiners was an experienced examiner, the others newly trained. All subjects were evaluated by each examiner initially and at the end of the study period. The reliability of the average score per subject, maximum score per subject, and the % of affected sites per person are estimated by the intraclass correlation coefficient. Procedures are presented that utilize various forms of the weighted kappa statistic for dissecting patterns in examiner agreement for specific sites, types of site, all sites, and for the individual components and categories of the index. It is shown how these procedures can be useful for training and calibrating multiple examiners, who will be using such an index in a clinical study, so that adequate reliability levels can be realized.

Statistical transformations of indices of gingivitis measured non-invasively

An index (PMGI) that combines the Massler-Schour (PMA) and Löe-Silness (GI) indices for non-invasive scoring of gingivitis was applied in 2 independent comparative clinical studies. 4 statistical transformations of the scores of individual papillary and marginal units were analyzed: the whole-mouth mean, its square root, the proportion of units judged to be inflamed, and its arc sin transformation. According to the criteria of how closely the transformations produced approximately normal distributions, and of how successful they were in detecting treatment differences, the square root transformation performed the best.