Evaluation of reliability and reproducibility of dental indices

The Clinical Effect of a Propolis and Mangosteen Extract Complex in Subjects with Gingivitis: A Randomized, Double-Blind, and Placebo-Controlled Clinical Trial

This study investigated the efficacy and safety of a propolis-mangosteen extract complex (PMEC) on gingival health in patients with gingivitis and incipient periodontitis. A multicentered, randomized, double-blind, placebo-controlled trial involving 104 subjects receiving either PMEC or placebo for eight weeks was conducted. The primary focus was on the changes in inflammatory biomarkers from gingival crevicular fluid (GCF), with clinical parameters as secondary outcomes. The results revealed that the PMEC group showed a significantly reduced expression of all measured GCF biomarkers compared to the placebo group (p < 0.0001) at 8 weeks, including substantial reductions in IL-1β, PGE2, MMP-8, and MMP-9 levels compared to the baseline. While clinical parameters trended towards improvement in both groups, the intergroup differences were not statistically significant. No significant adverse events were reported, indicating a favorable safety profile. These findings suggest that PMEC consumption can attenuate gingival inflammation and mitigate periodontal tissue destruction by modulating key inflammatory mediators in gingival tissue. Although PMEC shows promise as a potential adjunctive therapy for supporting gingival health, the discrepancy between biomarker improvements and clinical outcomes warrants further investigation to fully elucidate its therapeutic potential in periodontal health management.

Effectiveness of Waterpik® for oral hygiene maintenance in orthodontic fixed appliance patients: A randomised controlled trial

OBJECTIVE

To establish whether the use of a WaterPik® alongside a manual toothbrush (WaterPik® + MTB) is more effective for maintaining oral hygiene compared to the use of a manual toothbrush alone (MTB) in patients wearing fixed orthodontic appliances.

DESIGN

A single-centre, two-arm, parallel-group, single-blind, randomised controlled clinical trial with a 1:1 allocation ratio.

SETTING

Orthodontic department at York Hospital, York Teaching Hospitals NHS Foundation Trust, UK.

PARTICIPANTS

A total of 40 fit and well participants, aged 10-20 years, being treated with upper and lower fixed orthodontic appliances.

METHODS

Participants were randomly allocated, using stratified block randomisation, to the control group (MTB) or intervention group '(Waterpik® + MTB)'. Plaque, gingival and interdental bleeding indices were recorded at baseline, 8 weeks, 32 weeks and 56 weeks. A generalised linear mixed model was used to assess differences between groups.

RESULTS

An interim analysis of results was performed with 40 patients recruited and 85% of data collected. The overall mean differences between the groups were as follows: plaque index = 0.199 (P = 0.88, 95% confidence interval [CI] -0.24 to 0.27); gingival index = -0.008 (P = 0.94, 95% CI -0.22 to 0.20); and interdental bleeding index = 5.60 (P = 0.563, 95% CI -13.22 to 24.42). No statistical difference between the two groups was found for any variable. The trial was stopped at this point.

CONCLUSIONS

In terms of oral hygiene, our study did not find evidence to support the claim of benefit of using a Waterpik® in addition to a manual toothbrush for patients wearing fixed orthodontic appliances.

Thermographic Examination of the Gingiva of 16 Dogs

Gingivitis is a common periodontal disease in dogs and refers to inflammation of the gingiva. Gingival Index (GI), Papillary Bleeding Index (PBI) and Plaque Index (PI) are oral indices that describe the health status of the gingiva and which are based on human observation. Thermal changes due to inflammation are expected in gingivitis. Thermographic imaging, a wide-spread diagnostic tool in veterinary science, can be used for identification when there is abnormal body surface temperature in an area of the animal body. In this study, oral examination results and thermographic images obtained from 458 teeth from 16 dogs were used. Firstly, a thermal imaging procedure for diagnosis of gingival diseases of dogs was defined. Secondly, reference surface temperatures of tissues for each oral indices were determined. And thirdly, statistically significant thermal differences between the levels of each index was compared. The statistical analysis showed that there are significant thermal differences in some index levels and that presence or absence of plaque is an important etiologic factor in thermal examination of gingivitis. The study showed that thermographic images can be used to determine thermal changes in oral tissues of dogs with gingivitis.

Psychologically informed oral health interventions in pregnancy and type 2 diabetes: A scoping review

Introduction

Oral health is a critical aspect of gestational diabetes management. Gestational diabetes is high blood glucose levels during pregnancy and is managed like type 2 diabetes with diet and physical activity interventions. This scoping review sets out to discuss why oral health support should also become part of gestational diabetes management.

Objectives

The primary objective was to synthesise the existing psychologically informed oral health interventions for pregnant women and individuals with type 2 diabetes, and the extent to which these interventions map on to the COM-B Model. No literature exists on oral health interventions in gestational diabetes, why studies with type 2 diabetes populations were selected instead. The secondary objective was to identify the precise outcomes targeted in the interventions.

Methodology

The Joanna Briggs Institute's Methodology for Scoping Reviews was used to conduct this review. The populations of interest were pregnant women and individuals with type 2 diabetes, and eligible concepts were psychologically informed oral health interventions. Quasi-experimental and experimental designs were considered. The Ovid Interface including Embase, Medline, Global Health, APA PsychInfo, Health Management Information, Maternity, Infant Care Database, the Cochrane Library, and CINAHL was used as information sources. The study selection followed the PRISMA guidelines. The first search was conducted on the week commencing the 25th of July 2022, with a follow-up search conducted on the 10th of October 2022.

Results

28 records were included for synthesis. The most frequently assessed psychological outcome was oral health knowledge and the most frequently assessed oral clinical outcome was Plaque Index. All studies used an educational intervention approach, while psychological capability in the COM-B Model was targeted in all interventions by increasing oral health knowledge among the participants. The Health Belief Model was the most frequently used theory in the interventions.

Conclusion

The results demonstrate that oral health is a recognised aspect of pregnancy and type 2 diabetes. The findings from this review and a qualitative interview study which is under development will inform the first oral health intervention for women with gestational diabetes in the United Kingdom.

Reductions in clinical inflammation and oral neutrophils with improving oral hygiene

OBJECTIVE

This study compared the effects of oral hygiene with a toothpaste formulated with zinc (test) to a fluoride dentifrice (control) for effects on oral polymorphonuclear leukocyte (PMN) as a measure of whole mouth inflammation along with effects on clinical parameters of dental plaque and gingivitis.

MATERIALS AND METHODS

Adults (age range 18-60 years, n = 212) completed this double-blind, parallel design study. After washout, a baseline oral rinse sample was evaluated for PMN prior to clinical assessments for gingivitis and dental plaque. Subjects were randomly assigned to brush twice daily with either the test or the control toothpaste. Post-treatment evaluations repeated all baseline assessments after 4-week, 6-week and 12-week use of dentifrice with all assessments conducted 12 hours after brushing.

RESULTS

PMN reductions in the test were 16.8%, 18.7% and 42.5% at the 4-week, 6-week and 12-week evaluations respectively and significantly different from the control (p < 0.05). The test toothpaste also demonstrated progressively increasing reductions in gingivitis and dental plaque that ranged from 7.6 to 33.3% and 2.3 to 9.1% respectively versus the control (p < 0.05).

CONCLUSIONS

The test dentifrice demonstrated progressive reductions in oral PMN representing whole mouth inflammation in conjunction with improvements in oral hygiene as compared to the control toothpaste.

CLINICAL RELEVANCE

A hallmark of oral inflammation includes the accumulations of PMN in the afflicted gingival regions to reduce the influences of proliferating microorganisms. Brushing with a zinc dentifrice demonstrated progressive reductions in oral PMN and improvements in oral hygiene as evidenced by progressively lower dental plaque and gingival indices.

Anti-Bacterial and Anti-Inflammatory Effects of Toothpaste with Swiss Medicinal Herbs towards Patients Suffering from Gingivitis and Initial Stage of Periodontitis: from Clinical Efficacy to Mechanisms

Objective: To distinguish clinical effects and mechanisms of sodium monofluorophosphate plus xylitol and herbal extracts of Swiss medicinal plants (Chamomilla recutita, Arnica montana, Echinacea purpurea, and Salvia officinalis). Materials and Methods: A 2-month-long comparative clinical study of toothpaste containing 1450 ppm sodium monofluorophosphate and xylitol (control, 15 patients) and toothpaste additionally containing extracts of the medicinal herbs (experiment, 35 patients) was performed on patients with gingivitis and the initial stage of periodontitis. Clinical indices of gingivitis/periodontitis were quantified by Loe & Silness’s, CPITN, OHI-S, and PMA indexes. The pro-inflammatory and anti-inflammatory interleukins, nitrites/nitrates, total antioxidant activity, and bacterial pattern characteristic for gingivitis and periodontitis were quantified in the gingival crevicular fluid and plaque. In the in vitro tests, direct anti-bacterial effects, inhibition of catalase induction in Staphylococcus aureus, in response to oxidative burst of phagocytes, and intracellular bacterial killing were determined for the toothpastes, individual plant extracts, and their mixture. Results: Experimental toothpaste was more efficient clinically and in the diminishing of bacterial load specific for gingivitis/periodontitis. Although the control toothpaste exerted a direct moderate anti-bacterial effect, herbal extracts provided anti-inflammatory, anti-oxidant, direct, and indirect anti-bacterial actions through inhibition of bacterial defence against phagocytes. Conclusions: Chemical and plant-derived anti-bacterials to treat gingivitis and periodontitis at the initial stage should be used in combination amid their different mechanisms of action. Plant-derived actives for oral care could substitute toxic chemicals due to multiple modes of positive effects.

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.

Assessment of the capacity of a pyrophosphate-based mouth rinse to inhibit the formation of supragingival dental calculus. A randomized double-blind placebo-controlled clinical trial

Background

This study aimed to analyze the efficacy of an anti-calculus mouth rinse and its possible adverse effects on the mucosa and teeth.

Material and Methods

This randomized double-blind placebo-controlled clinical trial included 40 patients with treated and managed periodontal disease, all with a history of rapid calculus formation. Patients used a pyrophosphate-based test mouth rinse (B) or a placebo (A). A range of parameters were measured for: saliva (saliva flow, pH and chemical composition); calculus (Volpe-Manhold [V-M] index, weight, and volume); adverse effects on mucosa and teeth; and the patients’ subjective perceptive of mouth rinse efficacy.

Results

The test mouth rinse B produced reductions in urea, uric acid, and phosphorous, calcium, saliva flow, and increases in pH. V-M index and calculus weight decreased after using the test mouth rinse. Calculus volume decreased with both mouth rinses. No changes to the mucosa or teeth were observed. Patients perceived that the test mouth rinse was more effective.

Conclusions

The test/B and placebo mouth rinses both modified certain parameters in saliva composition, particularly reductions in urea, uric acid, and phosphorous. Calcium tended to increase after using the test-B mouth rinse. The results did not demonstrate the anticalculus efficacy of the pyrophosphate-based mouth rinse or positive effects on saliva flow or composition. This field requires further research, as no product has been developed that prevents calculus formation completely.

Key words:Dental calculus, anticalculus mouth rinse, Volpe Manhold index.

Assessment of the test-retest reliability of human gingival blood flow measurements by Laser Speckle Contrast Imaging in a healthy cohort

OBJECTIVE

The reliability of gingival blood flow measured by Laser Speckle Contrast Imaging is unknown. Our aim was to investigate the effect of factors inherent in oral mucosa measurement on intra-day and inter-day reliability.

METHODS

Gingival blood flow was measured in seventy healthy subjects. First, measurements were obtained by varying the incidence angle of imaging, using a lip retractor. Second, 3 snapshots were taken with closure of the mouth in-between, and lips were retracted by a dental mirror. These were repeated 1 week later. Third, snapshots were taken either by direct view or using a mirror. Reliability was assessed based on coefficient of variation.

RESULTS

Unlike retraction of the lips and the mirror, the incidence angle had an effect on mean blood flow. The coefficient of variation within a subject was 6.4% with the mouth constantly open. With retraction, the intra-session, and the inter-day coefficient of variation were 8.3% and 10.5%, respectively. The coefficient of variation was 11.9% by alternating direct and indirect imaging.

CONCLUSIONS

Laser Speckle Contrast Imaging has good short- and long-term reliability regardless of lip retraction or an indirect view. This technique seems to be appropriate for the long-term clinical non-invasive follow-up of gingival microcirculation.

Review of Studies Assessing Plaque Accumulation and Gingival Inflammation in Dogs

Periodontal disease is difficult to measure objectively. Many indices measuring plaque accumulation and gingivitis have been designed for humans, the Silness and Löe plaque index and Turesky modification of the Quigley and Hein plaque index being examples of well-accepted systems. It may, however, be beneficial to consider new or modified measurement systems for dogs, and such veterinary modifications need to be supported and clearly identified. This article reviews the origins of clinical periodontal indices now in common use in studies that examine the effectiveness of oral hygiene products.

The association between bronchial asthma and periodontitis: A case-control study in Jordan

OBJECTIVE

Our aim is to study the association between bronchial asthma (BA) and periodontitis in Jordan.

METHODS

A case control study of 260 subjects; 130 with BA and 130 without BA (controls) were recruited at a university hospital in Jordan. BA cases were physician-diagnosed and on anti-asthma medications for 12 months. Periodontitis was defined as the presence of ≥ 4 teeth with ≥ 1 site with probing pocket depth (PPD) ≥ 4 mm and clinical attachment level (CAL) ≥ 3 mm.

RESULTS

Mean age of participants was 45.3 years (range, 18-65) and 58.1% were females. Patients with BA had lower education and tended to live in rural areas. Periodontitis was present in 52 (40.0%) patients with BA and 26 (20.0%) in the control group, p < 0.005. Binary logistic regression indicated that patients with BA were more likely to have periodontitis than controls [adjusted odd ratio (OR) = 2.91, 95% CI (1.39-6.11), p = 0.005]. Patients with BA had higher percentage of sites with: PPD ≥ 3 mm, CAL ≥ 3 mm, and CAL ≥ 4 mm than controls, p < 0.05. The risk of periodontitis [OR = 5.27, 95% CI (1.59-17.51)] and CAL ≥ 3 mm were higher in patients on oral corticosteroids compared to inhaled corticosteroids, p < 0.05.

CONCLUSIONS

Adult Jordanians with bronchial asthma are at higher risk of periodontitis, particularly those on oral corticosteroids. Large and longitudinal studies are needed to better understand this significant association.

Improving Oral Hygiene for Veterans With Dementia in Residential Long-term Care

Oral hygiene care is neglected in long-term care (LTC) due to patient-, staff-, and systems-level barriers. A dementia-specific oral hygiene program, implemented and evaluated in a Department of Veterans Affairs LTC unit, addressed barriers to oral care at multiple levels. Improved staff competency, access to oral care supplies, and standardized documentation systems were accompanied by reduced oral plaque and gingivitis, demonstrating the feasibility and benefits of direct care staff providing improved oral hygiene in LTC.

The Influence of a Bifidobacterium animalis Probiotic on Gingival Health: A Randomized Controlled Clinical Trial

BACKGROUND

There is growing interest in the use of probiotics in periodontal therapy; however, until now, most research has focused on lactobacilli probiotics. The aim of this study is to evaluate the effect of 4-week use of yogurt supplemented with Bifidobacterium animalis subsp. lactis DN-173010 versus a placebo yogurt, followed by a 5-day non-brushing period.

METHODS

Individuals were included in this single-mask, randomized, controlled study if probing depth (PD) was ≤3 mm and attachment loss was ≤2 mm. After professional prophylaxis, they were randomized into two groups receiving yogurt containing either placebo or B. animalis for 28 days, followed by a 5-day non-brushing period. Outcome measures were plaque index (PI), gingival index (GI), bleeding on probing (BOP), PD, gingival crevicular fluid (GCF) volume, and total amount and concentration of interleukin (IL)-1β in GCF. These were measured at baseline, after 28 days of study product use, and subsequently after 5 days of plaque accumulation.

RESULTS

Fifty-one patients were analyzed. No intergroup differences could be detected before and after intake of study products. However, after plaque accumulation, significantly better results for all parameters were seen in the probiotic group compared with the control group (P <0.001): lower PI and GI, less BOP, less increase in GCF volume, and lower IL-1β total amount/concentration.

CONCLUSION

The use of a probiotic yogurt supplemented with B. animalis can have a positive effect on plaque accumulation and gingival inflammatory parameters after refraining from oral hygiene practices.

The effects of power toothbrushing on periodontal inflammation in a Canadian nursing home population: A randomized controlled trial

OBJECTIVES

The aim of this study was to investigate whether twice-daily use of a rotating-oscillating power toothbrush (Oral-B Professional Care 1000^™ ) in nursing home (NH) residents over a 6-week period, compared to usual care (UC), would reduce periodontal inflammation.

METHODS

In this repeated measures single-blinded randomized controlled trial, 59 residents of one NH in Winnipeg, Canada, were randomized to receive either twice-daily tooth brushing with a rotating-oscillating power toothbrush (PB) or UC by caregivers. Consent was obtained from residents or their proxies. Participants had some natural teeth, periodontal inflammation, non-aggressive behaviour, no communicable diseases, were non-smokers and non-comatose. Outcomes were measured at baseline and 6 weeks, which included: inflammation (MGI, Lobene), bleeding (PBI, Loesche) and Plaque (Turesky). Comparisons of group changes in outcomes were analysed using an ANOVA with a repeated measure.

RESULTS

Of 59 original study participants, one withdrew, one died prior to study commencement and three died before study completion. All oral parameters improved significantly for the remaining 54 residents over time (P<.0001), with no differences between groups.

CONCLUSIONS

These results demonstrate that it is possible for caregivers to improve periodontal inflammation of residents over a 6-week period. Despite no significant group differences, periodontal inflammation of all study participants improved significantly, particularly in the reduction of bleeding, a direct measure of periodontal inflammation, which is a unique finding.

Effects of Standardised Fermented Papaya Gel on Clinical Symptoms, Inflammatory Cytokines, and Nitric Oxide Metabolites in Patients with Chronic Periodontitis: An Open Randomised Clinical Study

The clinical efficacy of topical administration of standardised fermented papaya gel (SFPG), known to have antioxidant and anti-inflammatory properties, versus conventional therapy was evaluated in a group of 84 patients with moderate-to-severe periodontitis, randomly assigned to control group (n = 45) undergoing traditional pharmacologic/surgical protocols or to experimental group (n = 39), additionally treated with intragingival pocket SFPG (7 g) applications (15 min daily for 10 days). Patients undergoing SFPG treatment showed significant (P < 0.05), durable improvement of three major clinical indices of disease severity: reduced bleeding (day 7), plaque and gingival conditions (day 14), and consistent gingival pocket depth reduction (day 45). Proinflammatory nitric oxide metabolites reached normal values in plasma (day 14) and gingival crevicular fluid (GCF) at day 45 with SFPG applications compared to controls that did not reach normalisation. Levels of highly increased proinflammatory (IL-1B, IL-6) and suppressed anti-inflammatory (IL-10) cytokines normalised in the SFPG group by days 14 (plasma) and 45 (GCF), but never in the control group. Although not acting directly as antibiotic, SFPG acted in synergy with human granulocytes blocking adaptive catalase induction in S. aureus in response to granulocyte-derived oxidative stress, thus enhancing intracellular bacterial killing.

Establishment of a new marginal plaque index with high sensitivity for changes in oral hygiene

BACKGROUND

Although several plaque indices exist, they rarely assess in detail the plaque adjacent to the gingival margin, an area most important for periodontal health. This study aims to develop a new marginal plaque index (MPI) and to assess its validity and treatment sensitivity compared to the internationally accepted Turesky modification of the Quigley and Hein Index (TQHI).

METHODS

Data from two studies with n = 64 and n = 67 participants, respectively, are reported here. Convergence of MPI with TQHI and concurrent and predictive validity with papillary bleeding index were assessed, as was treatment sensitivity to a treatment of proximal hygiene (study 1) or toothbrushing (study 2), respectively.

RESULTS

Convergent validity with TQHI is very good. Concurrent and predictive validity parameters of the MPI are similar to the TQHI. The treatment sensitivity of MPI exceeds TQHI by far. This results in a reduction by >70% of the sample size needed to discover significant treatment effects. As expected, the largest treatment sensitivity was observed for proximal MPI measures in study 1, whereas study 2 showed largest effects for cervical measures.

CONCLUSIONS

MPI appears to be a valid plaque-scoring system that assesses plaque at the gingival margin. It responds with high sensitivity to treatments aimed at plaque reduction at the gingival margin. Its treatment sensitivity and capacity to differentiate between proximal and cervical plaque make it a promising tool for periodontal research.

The effectiveness of propolis on gingivitis: a randomized controlled trial

BACKGROUND

A randomized, double-blind, controlled clinical trial was conducted to evaluate the effectiveness of a propolis rinse on induced gingivitis by using the co-twin study design.

METHODS

Twenty-one twin pairs (n=42) were enrolled in a gingivitis study with oral hygiene promotion (14 days) and gingivitis induction (21 days). During the gingivitis induction phase, one member of the twin pair was randomly assigned to a 2% typified propolis rinse, and the other was assigned a color-matched 0.05% sodium fluoride plus 0.05% cetylpyridinium chloride rinse (positive control). Patients rinsed twice daily with 20 mL for 30 seconds for 21 days. Gingivitis was measured on days -14 (baseline), 0 (after hygiene phase), and 21 (after no-hygiene phase) by using the Papillary Bleeding Score (PBS) and by standard digital imaging of the gum tissues (G-parameter).

RESULTS

The 38 persons who completed the study (age 13-22 years) were well balanced according to PBS at baseline and G-parameter after the initial hygiene phase. After 21 days without oral hygiene, the propolis rinse and positive control rinse groups did not differ significantly for average PBS measurements or G-parameter.

CONCLUSIONS

Use of a 2% typified propolis rinse was equivalent to a positive control rinse during a 21-day no-hygiene period.

Randomized, double-blind, placebo-controlled clinical trial on the effects of propolis and chlorhexidine mouthrinses on gingivitis

OBJECTIVE

The aim of this study was to compare the effects of typified propolis and chlorhexidine mouthrinses on gingival health in a randomized double-blind placebo-controlled clinical trial.

MATERIAL AND METHODS

Sixty participants were randomized to 3 mouthrinse study groups: 1) 2% typified propolis (n = 20); 2) 0.12% chlorhexidine (n = 20), and 3) placebo (n = 20). Participants rinsed unsupervised twice a day for 28 days. The Papillary Bleeding Score (PBS) was measured on the mesio-buccal surfaces of all teeth at baseline and 28 days thereafter. Co-variance analysis was employed to compare PBS average values and the number of sites with PBS ≥ 2 among study groups. Sub-group analysis was further applied to participants who were < 40 years-old.

RESULTS

The results show efficacy of propolis mouthrinse when comparing before and after treatment protocols significantly for a reduction of mean PBS scores. For younger participants propolis mouthrinse was superior to all groups in reducing mean PBS scores and significant when compared to 0.12% chlorhexidine mouthrinse.

CONCLUSION

The efficacy of 2% typified propolis mouthrinse was demonstrated in reducing the levels of gingival inflammation. These results need to be duplicated by other investigators under similar study protocols.

Examiner alignment and assessment in clinical periodontal research

Periodontal research typically relies on clinical examiners to assess variables such as gingival inflammation, plaque scores or probing depths as a means of determining treatment outcomes or for performing group comparisons. The quality of the gathered information is dependent, to a large extent, on the skills of the examiner(s) and on the validity of the assessment methods that are used. Attempts have been made to increase the objectivity of periodontal assessments, for example by introducing scoring systems for gingival inflammation, but within these systems there is often considerable scope for variation when interpreting the scoring criteria, leading to subjectivity when assigning scores to individual periodontal sites. This has led to an awareness of the importance of examiner alignment and assessment to improve the data quality by standardizing techniques and improving examiner reliability. Examiner alignment and assessment is used in preference to the term 'examiner calibration' because calibration implies comparison with an accurate or 'gold' standard, which is not available in periodontal research. In this review, we consider the historical perspective that led to the development of clinical scoring systems for periodontal research using gingival inflammation as an example. A clinical protocol for undertaking examiner alignment and assessment is presented, and we review the common sources of error and bias that can lead to difficulties in aligning examiners, and consider how they can be eliminated. It is particularly important that subjects who are recruited to the examiner alignment and assessment study present with a comparable level of disease to the subjects who will ultimately be recruited to the planned clinical trial. Another challenge in examiner alignment and assessment is applying appropriate statistical tests to assess the outcome of the alignment exercise. In the periodontal literature, the statistic kappa is frequently used to confirm an adequate degree of examiner agreement, but kappa is bound to significant restrictions when applied for this purpose. Through the use of case studies, we present different approaches to data analysis from calibration studies, focusing on continuous variables (such as probing depths and attachment levels) or ordinal data (such as gingival or plaque indices), to enable a correct, although frequently conservative, interpretation of data generated during examiner alignment and assessment studies.

Reliability and discriminatory power of methods for dental plaque quantification

Objective

This in situ study evaluated the discriminatory power and reliability of methods of dental plaque quantification and the relationship between visual indices (VI) and fluorescence camera (FC) to detect plaque.

Material and Methods

Six volunteers used palatal appliances with six bovine enamel blocks presenting different stages of plaque accumulation. The presence of plaque with and without disclosing was assessed using VI. Images were obtained with FC and digital camera in both conditions. The area covered by plaque was assessed. Examinations were done by two independent examiners. Data were analyzed by Kruskal-Wallis and Kappa tests to compare different conditions of samples and to assess the inter-examiner reproducibility.

Results

Some methods presented adequate reproducibility. The Turesky index and the assessment of area covered by disclosed plaque in the FC images presented the highest discriminatory powers.

Conclusions

The Turesky index and images with FC with disclosing present good reliability and discriminatory power in quantifying dental plaque.

Study protocol of the Center for Oral Health Research in Appalachia (COHRA) etiology study

BACKGROUND

People in Appalachia experience some of the worst oral health in the United States. To develop effective intervention and prevention strategies in Appalachia, we must understand the complex relationships among the contributing factors and how they affect the etiology of oral diseases. To date, no such comprehensive analysis has been conducted. This report summarizes the characteristics of the sample and describes the protocol of a study determining contributions of individual, family, and community factors to oral diseases in Appalachian children and their relatives.

METHODS/DESIGN

Families participated in a comprehensive assessment protocol involving interviews, questionnaires, a clinical oral health assessment, a microbiological assessment, and collection of DNA. The design of the study is cross-sectional.

CONCLUSION

Due to its multilevel design and large, family-based sample, this study has the potential to greatly advance our understanding of factors that contribute to oral health in Appalachian children.

Oral and salivary changes in patients with end stage renal disease (ESRD): a two year follow-up study

OBJECTIVES

To compare oral health, salivary flow rate, xerostomia and thirst in end stage renal disease (ESRD) patients remaining on dialysis treatment and after renal transplantation.

DESIGN

Longitudinal observation.

SETTING

ESRD patients recruited from dialysis centres in Amsterdam, The Hague and Utrecht, The Netherlands.

METHOD

At baseline and after two years, salivary flow rates, xerostomia and thirst were determined in 43 ESRD patients. The number of decayed missing filled teeth/surfaces (DMFT/DMFS) was recorded, and periodontal status assessed.

RESULTS

After renal transplantation (n = 20), the salivary flow rate increased significantly from UWS = 0.30 +/- 0.21 ml/min to 0.44 +/- 0.29 ml/min (p <0.001) and the level of xerostomia and thirst decreased. After two years, the percentage of bleeding on probing in dialysis patients (n = 23) decreased from 29.5 +/- 25.4% to 10.3 +/- 12.3%, (p <0.05). No differences in DMFT and DMFS were observed between dialysis and renal transplant patients.

CONCLUSIONS

DMFT, dental plaque, gingival bleeding and periodontal indices did not change remarkably after two years, comparing dialysis and renal transplant patients. Renal transplantation enhances salivary flow and decreases symptoms of xerostomia and thirst, and hence enhances the potential to improve the quality of life of affected individuals.

Assessment of treatment responses to dental flossing in twins

BACKGROUND

The purpose of this study was to assess treatment responses to dental flossing in twins.

METHODS

The study was a two-treatment, examiner-blind, randomized parallel group, controlled study. Fifty-one twin pairs between 12 and 21 years of age were randomized to a 2-week supervised and unsupervised treatment regimen consisting of 1) tongue brushing and toothbrushing (TB) and 2) TB + flossing (TB + Fl). Clinical endpoints were gingival bleeding (papillary bleeding score [PBS]) and oral malodor (levels of volatile sulfur compounds [VSC]). Analysis of variance and covariance methodologies were employed to analyze the data.

RESULTS

Baseline average PBS values were 1.352 and 1.345 for the TB + Fl and TB groups, respectively (P=0.937). After 2 weeks of treatment, the TB + Fl group had a statistically significant decrease in PBS values of 0.558 (41.5% versus baseline), whereas the TB group showed no improvement from baseline. The change from baseline for the TB + Fl group was superior to that for the TB group (P<0.001). Similar findings were observed for the number of baseline papillary bleeding sites. Baseline average intraoral halimeter values were 45.91 and 41.75 for the TB+Fl and TB groups, respectively (P=0.504). Both treatment regimens demonstrated highly statistically significant reductions in intraoral halimeter values versus baseline (all P<0.001) and the difference between treatment groups was not statistically significant (P=0.339). Similar findings were found for expired air.

CONCLUSIONS

In a well-matched twin cohort, tongue and toothbrushing plus flossing significantly decreased gingival bleeding after 2 weeks.

Dental and periodontal status and risk for progression of carotid atherosclerosis: the inflammation and carotid artery risk for atherosclerosis study dental substudy

BACKGROUND AND PURPOSE

Dental and periodontal disease are potentially involved in the pathogenesis of atherosclerosis. We investigated whether dental and periodontal status is associated with the presence and future progression of carotid stenosis.

METHODS

We randomly selected 411 of 1268 participants from the prospective Inflammation and Carotid Artery Risk for Atherosclerosis Study and evaluated dental and periodontal status and oral hygiene at baseline measuring three World Health Organization-validated indices: DMFT (decayed, missing, filled teeth), SLI (Silness-Löe Index), and CPITN (community periodontal index for treatment needs), respectively. The degree of carotid stenosis was measured by duplex ultrasound at baseline and after median 7.5 months (range=6 to 9 months) to identify patients with progressive carotid stenosis.

RESULTS

DMFT (P<0.01), SLI (P=0.048), CPITN (P=0.007), and edentulousness (P=0.007) were associated with the baseline degree of carotid stenosis. Atherosclerosis progression was observed in 48 of 411 patients (11.7%). DMFT (adjusted odds ratio [OR]=1.11, 95% CI=1.01 to 1.22, P=0.032) and SLI (adjusted OR=1.77, 95% CI=1.09 to 2.79, P=0.021), but not CPITN (adjusted OR=1.51, 95% CI=0.89 to 2.45, P=0.16) were significant predictors of disease progression, irrespective of traditional cardiovascular risk factors and the baseline degree of stenosis. Edentulous patients had a significantly increased risk for disease progression as compared with patients with teeth (adjusted OR=2.10, 95% CI=1.06 to 4.16, P=0.33).

CONCLUSIONS

Dental status, oral hygiene, and particularly tooth loss are associated with the degree of carotid stenosis and predict future progression of the disease.

The oral health status of dentate patients with chronic renal failure undergoing dialysis therapy

OBJECTIVE

The aim of this study was to compare the oral health status of chronic renal failure (CRF) patients on renal replacement therapy with a matched reference population.

DESIGN

Cross-sectional study.

SUBJECTS

Forty-two dentate CRF patients--aged 25-52 years old--were matched with a reference group of 808 dentate subjects.

METHODS

The oral health was assessed using decayed missing filled (DMF) indices, simplified oral hygiene index and periodontal status. An oral health questionnaire was used to assess self-reported dental problems. Student t-tests and chi-square tests were performed to compare the CRF patients with the controls.

RESULTS

All index-scores in the CRF patients were comparable with the controls except for number of teeth covered with calculus that was significantly higher (P < 0.05) in CRF patients (4.1 +/- 2.6) than in controls (3.0 +/- 2.9). The self-reported oral health questionnaire revealed a trend for increased temporomandibular complaints in CRF patients (16.7%vs 5.7% in controls; P = 0.06) as well as bad taste (31.0%vs 6.8% in controls, P = 0.08).

CONCLUSIONS

For most dental aspects, the oral health of CRF patients is comparable with controls.

Inter-individual variation in the plaque formation rate of young individuals

OBJECTIVES

The aim of the present study was to describe the inter-individual variation in the plaque formation rate of 38 young adults.

METHODS

The plaque formation rate was estimated by employing a quantitative plaque percent index (P% index). A substantial inter-individual variation in the plaque formation rate was observed. The possible contributions of stimulated salivary flow rate, buffer capacity, diet and smoking to the variation in plaque formation were estimated by regression analysis.

RESULTS

The control variables explained only 2.5% of the variance in the plaque formation rate. Neither associations nor the total model were significant. The present method of measuring plaque presented as a simple and time-effective procedure.

CONCLUSIONS

It is suggested that the observed variation in the plague formation rate between the young individuals can be regarded as a biological function which is possibly an inherent individual characteristic. Studies with larger sample sizes are required to confirm the findings of the present study.

A 0.05% cetyl pyridinium chloride/0.05% chlorhexidine mouth rinse during maintenance phase after initial periodontal therapy

BACKGROUND

Chlorhexidine (CHX) mouth rinse/spray can still be considered the gold standard in the chemical prevention of plaque formation and development of gingivitis. The product unfortunately has some side effects, such as extrinsic tooth staining, poor taste, taste disturbance, sensitivity changes in tongue, pain and irritation because of the alcohol content. These side effects led to the search of new formulations.

METHODS

In this double-blind, randomized, long-term, parallel study, 48 moderate periodontitis patients rinsed for 6 months (starting immediately after a "one-stage, full-mouth" disinfection) with one of the following products: CHX 0.2%+alcohol (Corsodyl), CHX 0.05%+ cetyl pyridinium chloride (CPC) 0.05% and no alcohol (Perio-Aid Maintenance, a new formulation), or the placebo of the latter. After 1, 3 and 6 months a series of clinical and microbiological parameters were recorded for the supra- and subgingival area as well as for saliva.

RESULTS

Although there was a significant treatment impact (mechanical debridement) in all groups, both CHX solutions further decreased both plaque and gingivitis indices (p<0.001 and p<0.05, respectively), when compared with placebo. This was also reflected by additional reductions in the number of CFU/ml of aerobic and especially anaerobic species and by a suppression of Streptococcus mutans (versus an overgrowth for the placebo), in all niches. Differences between both CHX solutions were never encountered. The subjective ratings were slightly in favour of the new CHX-CPC formulation when compared with the other CHX-alcohol formulation, especially for taste of the product (p<0.05), but less impressive for the staining of teeth and tongue.

CONCLUSIONS

The results of this study demonstrated the potential of a new CHX 0.05%+CPC 0.05% non-alcoholic formulation as an effective antiplaque agent for long-term use with reduced subjective side effects.

The influence of gingival margin recession on loss of clinical attachment in alcohol-dependent patients without medical disorders

BACKGROUND

The objective of this study was to examine the effects of alcohol and cocaine misuse on periodontal status in a group of alcohol-dependent patients.

METHODS

Forty verified alcoholics, either exclusively (n = 10) or with cocaine abuse (n = 30), and a matched comparison group of 25 non-alcoholic subjects, 14 of whom abused cocaine, were entered in the study. All subjects were free from systemic illnesses. Blood levels of gamma glutamyl transpeptidase (GGTP), a liver enzyme indicator of alcohol drinking, were determined. A comprehensive periodontal examination was performed on 6 sites per tooth. The gingival index (GI) and plaque index (PI) were recorded. Attachment levels (AL) were computed as probing depth (PD) plus gingival margin level (GM).

RESULTS

No statistically significant differences were noted between the groups for average AL, PD, GM, GI, and PI. In alcoholics, Pearson correlation showed a positive association between GGTP levels and loss of periodontal attachment (P<0.05). A series of regression analyses predicting AL from selected periodontal and demographic factors showed that alcoholics manifest AL by greater increases in GM than non-alcoholics (P<0.07). Severe alcohol use as measured by GGTP >51 iu/l worsens PI (P<0.07), which adversely impacts GM, GI, PD, and ultimately AL. No significant associations were found between cocaine use and AL.

CONCLUSIONS

The results suggest that persistent alcohol abuse increases periodontitis development by heightening the loss of attachment through recession of gingival margins.

The prevalence of BANA-hydrolyzing periodontopathic bacteria in smokers

Smoking has been identified as a risk factor for development of periodontal disease and a strong indicator for treatment failure in periodontal patients. This study examined 172 patients categorized as current smokers (n=55), previous smokers (n=38) or individuals that had never smoked (n=79). A total of 670 interproximal plaques collected with a wooden toothpick were analyzed for hydrolysis of the synthetic trypsin substrate benzoyl-DL-arginine naphthylamide (BANA). About 95% of the BANA hydrolysis by plaque is due to the presence of one or more of the periodontopathogens, P. gingivalis, T. denticola or B. forsythus. Gingival health was measured using the papillary bleeding score (PBS). Current smokers had less gingival bleeding than previous smokers or those who had never smoked (20% versus 41% and 25%, respectively). Plaque removed from non-bleeding sites in current smokers were 11x more likely to have a positive BANA reaction when compared to plaque removed from non-bleeding sites in individuals who never smoked. A significant positive relationship exists between smoking and colonization by the BANA periodontopathogens. Smoking may select for these periodontopathic species in the plaque and may be one reason why smoking is a risk factor in periodontal disease development.

Cost-effective design for dental randomized clinical trials with longitudinal observations

In general, randomized clinical trials (RCT) in dentistry involve longitudinal observations. In such studies, the total cost is a function of the number of study subjects and visits, the study duration, and the type and number of examinations at each visit. In this paper, we derived the minimum cost design for longitudinal RCTs with 2 treatment arms and multiple visits. We optimized the number of subjects, visits and repeated measurements under the constraints of the requirements for statistical significance, power and minimum total study cost. A SAS macro was written and made available on the World Wide Web, so interested clinical investigators can easily find optimal designs. The application of the program is illustrated using an example.

The relationship between dental disease and cerebral vascular accident in elderly United States veterans

We report here information obtained from a cross-sectional study of 401 veterans, who were at least 60 years of age, which showed that several dental/oral conditions can be significantly associated with the diagnosis of a cerebral vascular accident (CVA), when included in a multivariate logistic regression model with and without many of the known risk factors for a CVA. The dental findings relative to the prevalence of dental caries and periodontal disease were not distinctly different between the subjects with and without a CVA in the bivariate analysis. A higher stimulated salivary flow was negatively associated with a CVA in the multivariate models. The plaque index and oral hygiene habits relating to brushing, flossing, and frequency of having teeth cleaned by a dentist/hygienist were significantly associated with a CVA in the bivariate analysis. Among these oral hygiene parameters, *needing help in brushing one's teeth" and the reported annual visit to the dentist/hygienist for teeth cleaning remained significant in the multivariate models involving the dependent-living subjects. The need for help in brushing one's teeth could reflect the fact that many subjects had reduced manual dexterity as a result of the CVA and required this extra care. However, the finding that those dependent-living individuals who reported that they did not have their teeth cleaned at least once a year were 4.76 times more likely to have had a CVA, suggests that a pattern of oral neglect might be associated with developing a CVA. The implications of this in terms of an intervention strategy for CVA warrants further consideration. However, caution is recommended because the data were obtained from a convenience sampling of older veterans and may not be generalizable to other populations.

Assessing the relationship between dental disease and coronary heart disease in elderly U.S. veterans

Several recent studies have shown a link between dental disease and coronary heart disease. The authors studied 320 U.S. veterans in a convenience sample to assess the relationship between oral health and systemic diseases among older people. They present cross-sectional data confirming that a statistically significant association exists between a diagnosis of coronary heart disease and certain oral health parameters, such as the number of missing teeth, plaque benzoyl-DL-arginine-naphthylamide test scores, salivary levels of Streptococcus sanguis and complaints of xerostomia. The oral parameters in these subjects were independent of and more strongly associated with coronary heart disease than were recognized risk factors, such as serum cholesterol levels, body mass index, diabetes and smoking status. However, because of the convenience sample studied, these findings cannot be generalized to other populations.

A comparison of the site-specificity of supragingival and subgingival calculus deposition

The aims of the present study on 40 patients were to quantitate by the Volpe-Manhold method, the amount of supragingival (SPR) calculus, to determine qualitatively the amount of subgingival calculus (SBG), and to determine the association between supragingival and subgingival calculus on vestibular and lingual surfaces of all the teeth except third molars. Kappa values for intraexaminer reproducibility varied between 0.863 and 0.738. There was marked site-specificity of SPR calculus scores, with the highest values by far on the lingual aspects of the lower anterior teeth: central incisor, lateral incisor, and canine, respectively. Although the grades for SBG calculus were higher on the lingual surfaces than on the vestibular surfaces of 25 of the 28 teeth, there was much less site-specificity than for SPR calculus. For the teeth as a whole, there were significant associations (P < 0.001), as tested by chi-square or Fisher's exact test, between SPR and SBG grades on both vestibular and lingual surfaces, between SPR grades on vestibular and lingual surfaces, and between SBG grades on vestibular and lingual surfaces. However, for individual teeth, or groups of similar teeth, only a few of the above associations were statistically significant.

The optimization of the BANA test as a screening instrument for gingivitis among subjects seeking dental treatment

Porphyromonas gingivalis, Treponema denticola and Bacteroides forsythus have been implicated in periodontal disease and each possesses an enzyme capable of hydrolyzing the synthetic trypsin substrate, BANA. We have used a chairside test for BANA hydrolysis to diagnose an anaerobic periodontal infection in patients with advanced forms of clinical disease using a 15-min/55 degrees C incubation protocol. However, the BANA test performance is dependent upon the length and temperature of incubation. In the present study, we have evaluated a 5-min/35 degrees C, a 5-min/55 degrees C and a 15-min/55 degrees C incubation protocol to determine whether the performance of the BANA test could be optimized using plaque samples obtained from subjects seeking dental treatment. Logistic regression models were tested with age, smoking status, and gingivitis scores as covariates. The best fitting model obtained with the 5-min/35 degrees C protocol had a sensitivity of 71%, a specificity of 68%, a false-positive proportion of 9%, a false-negative proportion of 65%, and an overall accuracy of 80%. When maximum likelihood estimates were obtained in this model, plaques from individuals who reported that they currently smoked were 9.57x, and those who quit smoking were 4.73x more likely to have a positive BANA score than someone who never smoked. Plaques were 4.55x more likely to be BANA-positive if they were removed from sites with gingivitis. These findings indicate that the performance of the BANA test is best using the 5-min/35 degrees C incubation protocol.

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.

Examiner agreement on caries detection and plaque accumulation during dental surveys of elders

Indices used to evaluate plaque accumulation and coronal caries have been widely accepted in epidemiological studies, yet their reliability cannot be guaranteed. The aim of this study was to evaluate the reliability of clinical criteria used in coronal and root caries diagnosis and oral hygiene evaluation as applied in elders. Nineteen elderly subjects, 73 years old on average, were examined at a first appointment by two independent examiners. They were re-examined two weeks later. Plaque accumulation was evaluated using the Plaque Index (PI) and coronal and root caries were detected according to the WHO criteria and Fejerskov et al. (1991), respectively. Recurrent caries was recorded as recommended by WHO and by probing at the interface tooth-restoration. Inter- and intra-examiner agreement was evaluated using kappa statistics. The PI score showed good reliability except for examiner b, for whom a simplification of the 4-point scale in 3-point scale improved significantly the reliability. The prevalence of coronal caries was very low and intra- and inter-examiner agreement was poor. Most of the root caries lesions were covered by plaque and the kappa values indicated only poor agreement. Recurrent caries were found with good agreement using WHO criteria but the detection with the probe was not reliable. In conclusion, it seems that examiners should be trained carefully to maximise their reliability and that plaque should be removed to obtain reliable diagnoses of caries. Retraining and calibration may be necessary for surveys continuing over a long period.

Dental findings in geriatric populations with diverse medical backgrounds

OBJECTIVE

To determine whether there is a difference in the oral/dental health in older persons with different life styles and medical status.

STUDY DESIGN

Survey (cross-sectional study) included four groups: (1) subjects (n = 123) living in a residential retirement home or community dwelling; (2) subjects (n = 218) seeking dental treatment at a Veterans Affairs Dental Outpatient Clinic; (3) subjects (n = 132) resident in a VA long-term care facility; and (4) subjects (n = 81) recently admitted to a VA acute care ward with a diagnosis of cerebral vascular accident or other neurologic problem. Each subject answered questions on medical and dental health and dietary preferences in a comprehensive interview. They were given a comprehensive dental examination that included measurements of stimulated salivary flow and minor salivary gland output.

RESULTS

The data from groups 2 and 3 confirmed previous reports that independent living subjects have better oral/dental health than dependent living subjects. The data from groups 1 and 4, obtained from geriatric populations on the opposite ends of the medical health/disease continuum provide new information that suggests that good medical health and good oral/dental health are linked. The subjects in group 1 were very healthy as judged by their longevity; 54% were > or = 80 years and they had low reported prevalence of medical disease. Only 6% were edentulous and the dentate persons were missing 4.5 teeth. In contrast, over 50% of the patients in group 4 were < 70 years; they had an edentulous rate of 49% and among the dentate persons had an average 12 missing and 5 decayed teeth.

CONCLUSIONS

The medically healthy persons had excellent dental health whereas the sickest persons were either edentulous or had many missing teeth.