Periodontal treatment needs assessed by the use of clinical and radiographic criteria

Success rates in periodontal treatment as related to choice of evaluation criteria. Presentation of an evaluation criteria staircase for cost-benefit use

BACKGROUND, AIMS

The aim of the present investigation was to determine the success rates of treatment of 36 patients with moderate to advanced periodontal disease as related to different clinical and radiographic criteria.

METHOD

The treatment comprised oral hygiene education, subgingival scaling and root planing, and when judged indicated, periodontal surgery. An "evaluation criteria staircase" comprising 5 levels was introduced to be utilized for evaluation of the treatment results in 4 proximal sites (1 in each quadrant) which were followed for 3 years. The highest level of the staircase (level 1) is the most challenging and comprises the traditonal criteria for "perfect" periodontal health, while the lower levels are gradually less demanding.

RESULTS

At the follow-up examination 3 years after active treatment, 52.1% of the experimental sites fulfilled the criteria for successful treatment according to level 1. On the lowest level (level 5) which only required no further loss of alveolar bone for treatment to be considered "successful", the number of such treated sites reached 95.1%. The present data showed that even if level 5 was accepted as the evaluation criterion for "success", resulting in very few failed sites (4.9%), these sites may demand considerable extra clinical time and costs for retreatment because of their distribution among many individuals (13.2%). This clinical time increases substantially if higher levels of success are desired. From a cost-benefit point of view, it is therefore of utmost importance that not only patient compliance but also disease resistance and the value of the affected tooth for the dentition are taken into consideration when the indications for retreatment are weighed. This is especially important since many sites were found to be non-progressive for a long time, even though they did not exhibit perfect periodontal health.

CONCLUSIONS

It is suggested that the "evaluation criteria staircase" presented in this paper might be a helpful clinical instrument for decision-making in individually designed and site-related retreatments of patients with periodontal disease.

Impact of endodontic conditions on marginal bone loss

This study was undertaken to examine the extent to which the marginal alveolar bone may be influenced by the condition of the dental pulp. A total of 115 pairs of contralateral teeth were observed in 87 patients (25 to 45 years old) in which the test tooth, but not the control tooth, was either endodontically treated or not treated but with a periapical radiolucency. The distance from the cemento-enamel junction to the marginal bone level was measured using intraoral radiographs. The condition of the endodontic filling, the periapical status, and the presence of root canal post were also assessed. With clinical parameters similar between teeth in the two groups in terms of visible plaque, bleeding on probing, probing depth, and attachment level, the results showed a somewhat (mean value 0.1 mm; SD 0.7) larger reduction of the alveolar bone support in test than control teeth. This difference was not statistically significant on a patient level. Hence, this study failed to demonstrate a correlation between a reduced marginal bone support and endodontic status.

Treatment of periodontal disease in older adults

The literature does not indicate that older adults differ from younger individuals in their response to periodontal treatment. However, in older adults, it is more common to find compromised general conditions that may negatively affect the patient's ability to maintain an adequate standard of self-performed plaque control. Although this can be compensated for partly by a carefully designed program for supportive therapy, the prevention and/or elimination of clinical signs of periodontal inflammation may not always be a reachable goal of periodontal therapy in older adults, particularly in those who are frail and functionally dependent. For many patients, a more realistic goal may be the control of disease progression in order to preserve a functional and comfortable dentition throughout life and hence, the decision making process regarding therapeutic levels for the individual patient must include factors such as the amount of remaining periodontal support, the risk for disease progression, demands for oral health and life expectancy.

Periodontal diseases: epidemiology

1. The interpretation of epidemiological data of periodontal disease is difficult, due to inconsistencies in the methodology used. It is not possible, therefore, to accurately assess if the prevalence of the periodontal diseases shows a world-wide decline. As long as the disease is assessed through accumulated clinical attachment loss, retention of the natural dentition in older ages entails increased prevalence in these cohorts. Contemporary epidemiological studies should ideally employ full-mouth examination of the periodontal tissues. Partial recording estimates are generally biased, especially when the prevalence of the disease is low. 2. Early-onset periodontitis is infrequent in all populations. Adult periodontitis is rather prevalent; however, advanced disease affects limited subfractions of the population (probably less than 10 to 15%). Although prevalence figures vary with race and geographic region, in most cases, the progression pattern of the disease seems compatible with the retention of a functional dentition throughout life. 3. Of a plethora of behavioral and environmental risk markers identified by multi-variate analysis, smoking and presence of certain subgingival microorganisms have been proven to be true risk factors. The same holds true for diabetes mellitus, a systemic condition that confers a risk for periodontal disease which is independent of the effect of other significant factors. 4. In certain cases, periodontal infections appear to have a systemic impact on the host. Most recent data indicate that periodontal disease may confer risk for coronary heart disease and pre-term low birth weight.

A clinical survey of periodontal conditions in Greece

The present study used full-mouth clinical assessments of plaque, calculus, bleeding on probing, probing pocket depth and probing attachment level to evaluate the periodontal conditions in a rural (A) and an urban (B) sample of 25-64 year old Greek adults, comprising 190 and 373 subjects, respectively. 13% of the subjects in sample (A) and 8% in sample (B) were edentulous, while mean values of teeth present in the four age cohorts ranged between 19.8-12.6 and 23.3-18.3, respectively. A poor level of oral hygiene was recorded in both samples with high plaque, calculus and bleeding scores. Deep pocketing was more pronounced in the rural than in the urban sample; between 1.7 and 8.0% of all sites probed showed a PPD of > or = 6 mm and between 20 and 51.2% of the subjects in each age cohort had at least one deep pocket. Corresponding figures for the urban sample was 0.6-4.7% and 15.1-49.2%. However, the prevalence of severe attachment loss was of comparable magnitude in both samples; between 2.8-25.7% of the sites in sample (A) and 2.8-20.6% in sample (B) displayed a PAL of > or = 6 mm, while 32.5-72.1% and 31.8-73.8% of the subjects, respectively, had at least one severely affected site. It was further found that the distribution of advanced disease in the samples was skewed; 14.4% of the subjects in sample (A) and 9.5% in sample (B) accounted for 75% of all deep pockets, while 21.8 and 19.4% of the subjects, respectively, accounted for 75% of all sites with PAL of > or = 6 mm. Multiple regression revealed that male sex and high plaque and bleeding scores had a significant, positive influence to the amount of attachment loss on a subject level.

A radiographic survey of periodontal conditions in Greece

The present study used radiographic assessments to evaluate the pattern of destructive periodontal disease ina rural and an urban sample of 25-64 year old Greek adults. The rural sample (A) comprised 190 subjects and the urban sample (B) 400 subjects. 13% of the subjects in sample A and 8% in sample B were edentulous. Full-mouth intraoral radiographs were obtained from the 503 dentate subjects and were examined with respect to (i) number and type of teeth present, and (ii) alveolar bone level (ABL), i.e., the distance between the cementoenamel junction and the alveolar bone crest at the approximal tooth surfaces. The results revealed that alveolar bone loss was ubiquitous in both samples. Pronounced bone loss, however, (i.e., a subject mean ABL of > or = 6 mm) affected 18% (sample A) and 8% (sample B) of the individuals. Although an ABL of > or = 6 mm was scored at 7.2 sites/subject in sample A and at 4.5 sites/subject in sample B, more than 10 such sites were found in 23% (A) and 11% (B) of the examined subjects. 25% of the subjects in the rural sample (A) and 12% in the urban sample (B) accounted for 75% of the total number of tooth sites with pronounced bone loss. Multiple regression revealed that age and number of remaining teeth were the parameters most strongly correlated with the amount of bone loss on both the individual subject and the tooth site level. The present findings (i) demonstrated a high prevalence and severity of destructive periodontal disease in these 2 samples. and (ii) confirmed the skewed distribution of advanced disease in the population.

Extent and severity of periodontal destruction based on partial clinical assessments

The aim of the present study was (i) to identify the 10 approximal tooth sites that provide Extent and Severity estimates of clinical attachment loss which are maximally coherent to the full mouth scores, and (ii) to evaluate the applicability of such a partial recording system. Data from two subject samples, comprising 192 subjects aged 30-64 yr (sample A) and 175 subjects aged 35-80 yr (sample B), were involved in the development and the evaluation of the system, respectively. Approximal probing attachment loss (PAL) measurements were available from all subjects. A PAL value of > 1 mm was required for a tooth site in order to qualify for the Extent and Severity computations. A full mouth bivariate Extent and Severity Index (FESI) was firstly calculated for every subject in sample A. Multiple regression models applied on data derived from the same sample identified the 10 approximal tooth sites which provided the best correlation to the full-mouth scores (correlation coefficients between partial and full mouth scorings of Extent and Severity 0.85 and 0.88, respectively). All tooth types were found to be represented in this set of sites and the ratio of mesial/distal sites was 6/4. The applicability of a partial recording system (PESI) based on these sites was evaluated in sample B. Fully comparable estimates between PESI and FESI values were obtained, but the degree of correlation varied at different ages. Further adjustments by means of regression models failed to increase the validity and reliability of the PESI.(ABSTRACT TRUNCATED AT 250 WORDS)

An analysis of the subgingival microflora in randomly selected subjects

The aim of this study was to describe the presence of some microbial species in the subgingival microflora of a randomly selected subject sample. A further objective was to analyze the association between some microbiological characteristics and the periodontal conditions of the subjects. A total of 171 individuals aged 30-65 years were included. A pooled subgingival plaque sample was obtained from the mesial aspect of the 6 Ramfjord teeth by the use of the paper-point method. The samples were processed and analyzed according to standardized procedures. The periodontal condition of the subjects was examined clinically and included assessment of plaque, gingivitis, probing pocket depth and probing attachment level. The results showed that 81% of the subjects were positive for Campylobacter rectus, 80% for Fusobacterium nucleatum, 77% for Streptococcus sanguis, 72% for Streptococcus mitis, 66% for Eikenella corrodens, 58% for Prevotella intermedia, 32% for Capnocytophaga, 27% for Selenomonas, 25% for Actinobacillus actinomycetemcomitans, 14% for Porphyromonas gingivalis and 13% for Streptococcus mutans. Small differences in the periodontal conditions were observed between subjects harboring P. gingivalis, A. actinomytecomitans or > 5% P. intermedia and the rest of the sample. Similarly small differences in the clinical parameters were revealed when the subjects were grouped according to proportions of disease-associated and health-associated species in their subgingival samples.

Preservation of probing attachment and alveolar bone levels in 2 random population samples

The present study is an attempt to elucidate the relation between ageing and loss of periodontal tissue support, by studying the occurrence of probing attachment and alveolar bone loss in two samples of randomly selected individuals. The 1st sample was recruited in Japan and comprised 319 subjects aged 20-79 years. The 2nd sample was recruited in Sweden and comprised 192 subjects aged 30-65 years. All individuals underwent a radiographic and a comprehensive clinical examination, including recordings of probing attachment level. Within the 2 samples, subsamples of individuals whose periodontal status indicated minimal experience of destructive periodontal disease were selected. In these particular subsamples, it was revealed that a substantial proportion of tooth surfaces, also in older subjects, remained with no attachment or alveolar bone loss. To a lesser extent, this could be also observed when the entire samples were analyzed, despite the presence of abundant plaque and gingival inflammation. The results indicated that intact supporting periodontal tissues can be retained in subjects of increased age and corroborate the suggestion that loss of clinical attachment and alveolar bone is not an obligatory consequence of ageing.

Evaluation of a radiographic partial recording system assessing the extent and severity of periodontal destruction

The purpose of the present study was to evaluate the validity and reliability of a partial radiographic bivariate index system (PESI-2). The principles of the index were applied to data from a random sample of 192 industrial employees aged 30-65 yr. Estimates of Extent and Severity of radiographic bone loss provided by the PESI-2, as well as adjusted estimates by means of simple regression models, were compared to values obtained by a full mouth radiographic examination. It was shown that the values provided by the PESI-2 were of rather high validity and reliability. The use of the adjusting models resulted in increased validity of the severity estimates and enhanced reliability of both components of the bivariate. The results verified the applicability of the PESI-2 in epidemiologic research of destructive periodontal disease.

Extent and Severity Index based on assessments of radiographic bone loss

The purpose of the present study was to develop a partial recording system based on the principles of the Extent and Severity Index, aiming at describing the degree of radiographic alveolar bone loss on a population level. The data analyzed were derived from a subject sample comprising 531 individuals aged 25-75 yr. In these subjects alveolar bone level (ABL) was radiographically assessed at all approximal tooth surfaces. An ABL value of greater than 2 mm was required for a tooth site to be included in the computation of a full mouth bivariate Extent and Severity Index (FESI). A partial recording index (PESI-2) based on 18 ad hoc selected tooth sites depicted in one periapical and one vertical bitewing radiograph was evaluated in comparison with the FESI as well as with partial recording indices based on the 9 and 18 tooth sites which displayed the highest correlation with full mouth scores (PESI-9 and PESI-18, respectively). It was shown that all three partial recording systems generated values reasonably close to the full-mouth scores. However, the fitness of all partial indices varied with age. The potential of the partial indices to predict full-mouth scores could be further enhanced via simple regression models. Such an evaluation should, ideally, be carried out in an independent subject sample.

Periodontal characteristics in individuals with varying form of the upper central incisors

It has been suggested that the variation in the morphology of the human periodontium may be related to the shape and form of the teeth. Furthermore, the severity of symptoms of periodontal disease have been proposed to differ among these various morphologic entities or "biotypes". The aim of the present study was (i) to identify individuals with markedly different crown forms and (ii) to determine probing pocket depth, probing attachment level and amount of gingival recession that had occurred at different teeth and tooth surfaces in such individuals. Clinical photographs of the maxillary incisor tooth region of 113 subjects who had been recruited for a long-term study on periodontal disease were available. The length (CL) and width (CW) of the crowns were determined and the CW/CL ratio was calculated for each tooth. 10% in each tail, 11 subjects in each group, were arbitrarily chosen as having either a long-narrow (N) or a short-wide (W) form of the central incisors. The probing pocket depth, probing attachment level and gingival recession data available from all subjects and subjects in groups W and N were compared and analyzed using the Student t-test and multiple regression analysis. The result from the analyses demonstrated that: (1) subjects with a long-narrow form of the upper central incisors had experienced more recession of the gingival margin at buccal surfaces than subjects who had a short-wide tooth form; (2) there was a significant influence of the CW/CL-ratio on the probing attachment level (p less than 0.05) and the amount of gingival recession (p less than 0.01) on buccal tooth surfaces.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiology of periodontal disease

The epidemiological studies of the 50s and 60s have used visual diagnosis for gathering data to describe prevalence and severity of periodontal diseases within a population. Well-defined index systems were developed and loss of connective tissue attachment from a fixed landmark was established. More recently, the CPITN which had been designed to examine treatment needs in populations was also used erroneously to assess information about prevalence and severity. While data gathered on the basis of the CPITN are rather inconclusive, all the recent epidemiological surveys which used the full spectrum of clinical measurements yielded a rather low proportion of the population of industrialized countries affected by severe periodontal disease. Apparently, quite a large proportion of most populations show signs of gingivitis, but little loss of connective tissue attachment. Only a low percentage is at risk from periodontal disease progression and hence, would need advanced periodontal therapy. While epidemiological surveys used to determine signs and symptoms of inflammation and hence, treatment goals had been defined towards eliminating these symptoms, more recent decision making models for treatment planning have redefined treatment goals: the maintenance of all natural teeth in the dentition in a state of function throughout life. These proposed models are the first attempts to identify subjects at high risk from periodontal disease progression using conventional, but standardized radiography and hereby supplementing clinical data. One of these models is discussed in detail.