The relative efficiencies of some periodontal partial recording selections

Assessing periodontitis in populations: a systematic review of the validity of partial-mouth examination protocols

OBJECTIVE

To estimate bias associated with partial-mouth periodontal examination (PMPE) protocols regarding estimates of prevalence, severity and extent of clinical attachment loss (CAL), pocket depth (PD) and gingival recession (REC).

MATERIAL AND METHODS

A search was made for articles published in English, from 1946 to 2012, which compared PMPE versus full-mouth periodontal examination protocols for CAL or PD ≥ 4 mm or REC ≥3 mm thresholds. PMPE protocols were evaluated for sensitivity of estimates of periodontitis prevalence, relative biases for severity and extent estimates.

RESULTS

A review of the literature identified 12 studies which reported 32 PMPE protocols. Three PMPE protocols which had sensitivities ≥85% and relative biases ≤0.05 in absolute values for severity and extent estimates were as follows: (1) half-mouth six-sites, (2) diagonal quadrants six-sites and (3) full-mouth mesiobuccal-midbuccal-distobuccal (MB-B-DB). Two other PMPE protocols (full-mouth and half-mouth mesiobuccal-midbuccal-distolingual) performed well for prevalence and severity of periodontitis; however, their performance in estimates of extent was unknown.

CONCLUSIONS

Among the 32 PMPE protocols listed, the half-mouth six-sites and full-mouth MB-B-DB protocols had the highest sensitivities for prevalence estimates and lowest relative biases for severity and extent estimates.

Partial recording protocols for periodontal disease assessment in epidemiological surveys

The objective of the present study was to compare the reliability of four partial-mouth protocols for assessing shallow, moderate, and deep sites for periodontal pocket depth and clinical attachment levels. Periodontal pocket depth and clinical attachment level measurements were recorded for 156 subjects (age > 30). The four models of partial-mouth protocols compared were: Model I: all sites per tooth in the random half-mouth protocol randomly selecting one maxillary and mandibular quadrant, Model II: buccal sites in a full-mouth protocol, Model III: buccal sites in the random half-mouth protocol randomly selecting one maxillary and mandibular quadrant, Model IV: all sites per tooth using Community Periodontal Index teeth. In comparison with full mouth examination, Model I did not show significant differences for periodontal pocket depth and clinical attachment level parameters. Models II and III were different for some periodontal pocket depth means, and Model IV significantly overestimated all clinical parameters related to periodontal disease. Model I appears to be adequate to substitute for the full-mouth examination to assess the prevalence and severity of chronic periodontal disease in adults.

Validity and reliability of partial examination to assess severe periodontitis

OBJECTIVES

To compare the extent and severity index (ESI) with a gold standard represented by actual readings of loss of attachment on six sites around all teeth present (excluding third molars).

METHODS

Five standardized dentists (kappa=0.6) examined 712 subjects > or =20 years of age at a dental school (1993-1995). Sensitivity, specificity, positive and negative predictive values, and true and apparent prevalence were established.

RESULTS

True severe periodontitis prevalence was 95.8%. ESI underestimated the severity (0.1 mm), extent (4%), and prevalence (16%) of periodontitis. The severity, as established by ESI, coincided 23.4% with the gold standard. ESI failed to identify 16.7% of subjects with severe periodontal disease, but specificity and positive predictive value were very high.

CONCLUSIONS

The underestimation of severe periodontitis through ESI may lead to inadequate recommendations for further treatment. Accurately identifying subjects with severe periodontitis requires a full-mouth examination. Because the ESI relies on measurements taken on only 28 periodontal sites to estimate the periodontitis status of the entire mouth, the validity and reliability of ESI may be modified by the prevalence of severe periodontal disease and the distribution of disease according to age and operational definitions.

Partial- or Full-Mouth Approaches to Assessing the Prevalence of and Risk Factors for Periodontal Disease in Young Adults

BACKGROUND

While partial-mouth recording is often used in epidemiological studies of periodontal disease because of the efficiencies afforded in data collection, there has been no investigation of the extent to which information is lost in studies of young adults using the combined attachment loss (CAL) approach.

METHODS

A random sample of 25- and 26-year-olds was periodontally examined at 3 sites per tooth in all 4 quadrants. The analysis obtained full-mouth prevalence estimates for gingival recession (GR), probing depth (PD), and CAL. The half-mouth analyses took 3 forms: 1) estimates from each of the left and right sides were obtained and compared; 2) estimates were obtained separately and compared for quadrants 1 and 3 (upper right and lower left), and quadrants 2 and 4 (upper left and lower right); and 3) estimates were obtained from a diagonal half-mouth count, whereby quadrants 1 and 3 were analyzed for study participants whose identification number was odd, and quadrants 2 and 4 were analyzed for the remainder. The utility of the half-mouth and full-mouth approaches in analytical epidemiology was examined by estimating the strength of the association between periodontitis prevalence and smoking, male gender, and episodic use of dental care.

RESULTS

Of the 169 participants examined, 100 (59.2%) were female, 54 (32.0%) were smokers, and 78 (46.2%) were episodic dental visitors. The difference in prevalence estimates obtained from the different methods was considerably greater for GR than for PD and CAL. The unadjusted odds ratio (OR) for the prevalence of 1 or more teeth with > or = mm of CAL among smokers was 2.3 (95% confidence interval [CI] 1.0, 5.3) using the full data set and 2.4 (95% CI 0.9, 6.1) using the diagonal half-mouth approach. Similarly close odds ratios were observed for males and, to a lesser extent, for episodic dental visitors.

CONCLUSIONS

Wherever possible, full-mouth data should be collected for descriptive epidemiological studies of periodontal disease, but where resource and time constraints mean that half-mouth examinations must be used, analytical studies of periodontitis should not be unduly affected by the loss of information. However, where the primary focus of the latter is upon gingival recession, the full-mouth design should be used in order to capture all relevant information, and attention should be directed to making economies in other areas of the data collection process.

FH. A influência do sexo e da idade na prevalência de bolsas periodontais

Este trabalho teve como objetivo avaliar a influência dos fatores de risco na prevalência de bolsas periodontais em pacientes atendidos na clínica do terceiro e quarto anos da Faculdade de Odontologia de Piracicaba - Unicamp. Foram avaliados 100 pacientes através do levantamento dos dados contidos nas fichas clínico-anamnésicas, sendo consideradas bolsas de profundidade: 3 mm, 5 mm, 7 mm e 10 mm, de acordo com o sistema diagnóstico WS (SALLUM; SALLUM27, 1996). Os resultados foram comparados entre as profundidades de sondagem e as variáveis idade, sexo, bem como sua distribuição por sextantes. Observou-se maior prevalência de bolsas periodontais no sexo masculino, bem como maior profundidade de sondagem em pacientes acima de 31 anos. A distribuição de bolsas periodontais entre os sextantes foi homogênea.

Prevalence of periodontal disease in a health maintenance organization and comparisons to the national survey of oral health

The purposes of this study were to: 1) characterize the demographics, oral health behavior, and periodontal status of a health maintenance organization sample; 2) investigate the relationship between the location of posterior proximal measurement sites and prevalence estimates for periodontal disease; and 3) compare the prevalence of persons with pockets > or = 4 mm in the present sample to the 1985 NIDR Survey of Oral Health. The sample consisted of 1,090 adults attending a large health maintenance organization. All proximal sites in one randomly selected posterior dental sextant were examined for probing depth using a constant force probe. Demographic, medical, and behavioral factors were determined by questionnaire. Results indicated that the sample consisted primarily of medically and periodontally-healthy middle-aged adults with good oral hygiene habits. Overall, the mean probing depth was 2.95 mm with 10.1% of sites/subject > or = 4 mm. A larger percent of subjects had probing depths with pockets > or = 4 mm at lingual proximal sites than buccal proximal sites. Prevalence of subjects with pockets > or = 4 mm at mesio-buccal sites in the present study was similar to NIDR Region III data (15.3% vs. 17.4% respectively). However, when data from all posterior sites were included, the overall prevalence rate in the present sample increased to 36.8%. These findings indicate that disease prevalence is dependent on the location of surfaces measured and conservatively indicate that NIDR survey data may have underestimated the prevalence of persons with periodontal pockets > or = 4 mm by at least 20%.

Utility of Ramfjord index teeth to assess periodontal disease progression in longitudinal studies

The feasibility of using the Ramfjord index teeth to estimate whole-mouth periodontal disease activity was investigated. Whole-mouth examinations were carried out semi-annually over a 36-month period in 98 maintenance patients previously treated for adult periodontitis. Recurrent periodontitis was defined as either a 3-mm or greater probing depth increase from baseline, or a 2-mm or greater probing depth increase together with 2-mm or greater of relative attachment loss measured from a reference stent. Whole-mouth disease activity was compared to Ramfjord index teeth data, with and without adjustment. Adjustment was made by multiplying disease activity rates on Ramfjord index teeth by the ratio formed from the sum of all teeth present over the sum of all Ramfjord index teeth in the study population. Without adjustment, Ramfjord index teeth markedly underestimated subjects with recurrent disease activity when compared to whole-mouth findings. However, with adjustment, the hypothesis that upper and lower limits on whole-mouth incidence of recurrent periodontitis could be estimated from Ramfjord index teeth disease-activity rates were not rejected (P > 0.20, z-test) at any 6-month interval. At 5 of 6 examinations, the % of disease active subjects as determined from whole-mouth evaluations was below the upper limit for disease incidence calculated, with 95% confidence, from point estimates derived from adjusted Ramfjord index teeth data. Partial-mouth examinations with appropriate adjustment of Ramfjord index teeth data may be useful for assessing periodontal disease progression in longitudinal population studies of human periodontitis.

Periodontal disease morbidity quantification. I. Optimal selection of teeth for periodontal bone loss surveys

The assessment of alveolar bone loss with bite-wing radiographs is attractive because bite wings are relatively convenient, inexpensive, and available. The choice of teeth used influences the validity of global bone loss assessments based on partial mouth measurements. The objective of this study was to validate periodontal bone loss indices based on a few teeth. The mandibular posterior teeth were considered as a basis for abbreviated indices. The optimum number of teeth included was evaluated, and the utility of abbreviated indices was determined experimentally. The teeth from 75 skulls were measured from the cemento-enamel junction (CEJ) to the alveolar bone at six locations per tooth. The subsets of teeth which best represent the average whole mouth bone loss were found with all-possible-subsets regression analysis. Bone loss data from 179 prehistoric skulls were used to test the validity of selected teeth indices. Bone loss measurements from the mandibular posterior areas were representative of full-mouth bone loss measurements. Mandibular second premolars plus any other mandibular posterior teeth were the optimal combination of tooth for an abbreviated index. This subset is suitable for use with bite-wing radiographs.

Systematic errors in estimating prevalence and severity of periodontal disease

Partial-mouth scores are often used in epidemiologic studies to estimate the prevalence and severity of periodontal disease. Such estimates systematically underestimate the prevalence of disease, but the bias can be in either direction for disease severity. Three large data sets containing full-mouth examinations (mesiobuccal, midbuccal, distobuccal, and midlingual (MBDL) sites per tooth) for either attachment loss or probing pocket depths were used to investigate the magnitudes of systemic error that occur by employing four specific partial-mouth scores (M, MB, MBD, and MBDL sites per tooth), which are based on the random half-mouth technique. For prevalence of disease the sensitivity of a partial score was a function of the disease level in the population. All four partial scores were sensitive enough to adequately portray true prevalence using the 2-mm demarcation value, the MBD and MBDL scores might still be considered adequate for the 4-mm value, but none of these partial scores were adequate for the 7-mm value. For disease severity the MBDL score produced unbiased estimates, the others were biased. The relative biases for the MB and MBD scores were all under 10% (in absolute value), but the M score produced severe relative biases, 24% for probing pocket depths and -12% for attachment loss.

Partial mouth recording of plaque, gingivitis and probing depth in adolescents

Selection of teeth representative of the whole dentition has been used in clinical and epidemiological investigations. The present study was carried out to assess the relationship between 3 different subsets of teeth and the whole dentition for the plaque index, gingival index and probing depth. The selections were: the subset described by Ramfjord (16, 21, 24, 36, 41, 44), the CPITN Alternative I subset (17, 16, 11, 26, 27, 37, 36, 31, 46, 47) and the CPITN Alternative II subset (16, 11, 26, 36, 31, 46). The comparisons were performed on data obtained for 15-year-old adolescents. A strong correlation was observed between the whole dentition and each of the subsets for all assessments. The distribution of scores of the Ramfjord selection and the whole dentition was not statistically different. Corresponding comparisons showed that the distribution of scores of the CPITN selections and the whole dentition was statistically different. Plaque and gingival index scores of these selections underestimated 0 scores and overestimated 2 + 3 scores. Probing depths less than or equal to 2 mm were underestimated and probing depths greater than or equal to 4 mm overestimated. The bias associated with the CPITN Alt I was more pronounced than that of the CPITN Alt II subset of teeth in the adolescents examined.

The efficiency of half-mouth examinations in estimating the prevalence of periodontal disease

Several studies, including the NIDR 1985 national survey of working adults, have used periodontal examinations of only two quadrants of the mouth to estimate the prevalence of periodontal conditions. To investigate the efficiency of half-mouth periodontal examinations, I compared the results from the examination of all teeth in a sample of 477 dentate elderly people with scores that would have been obtained if randomly selected pairs of quadrants had been examined instead. In this elderly dentate population, relatively little information would have been lost if diagonal half-mouth or same-side half-mouth scores instead of whole-mouth scores had been used to estimate the number or proportion of teeth with periodontal conditions. However, the proportion of people with the less prevalent conditions, i.e., deep pocketing and mobility, was underestimated slightly. Slightly less efficiency was also noted for the less prevalent conditions. These findings suggest that half-mouth recording may be useful for prevalence surveys, but cannot be recommended for incidence surveys or clinical trials, where incremental changes may be small.

The use of six selected teeth in population measures of periodontal status

Selected teeth have been used to represent the entire dentition in many epidemiological and clinical investigations. The present study sought to assess the relationship between the six selected teeth described by Ramfjord and the entire dentition for the Plaque Index, Gingival Index, Calculus Index and Loss of Attachment. The computations were performed on measurements obtained in investigations of the natural history of periodontal disease in Norway and Sri Lanka. A consistently strong correlation was observed between the tooth subset and whole mouth for all indices in both populations. This relationship persisted even though single members or pairs of the subset of teeth were removed from the calculations. Some bias, however, was observed with all indices. Plaque and gingival indices obtained from the six teeth underestimated whole mouth scores in the low range (less than 1.0) and overestimated scores in the high range (greater than 2.0). Use of the tooth subset for calculus and loss of attachment consistently overestimated scores for the entire dentition.

Dental caries and periodontal disease in an Indochinese refugee population

Caries and periodontal disease data from 205 Indochinese refugee 12-to-19-year-olds were obtained and were analyzed on the basis of sex, ethnic group, and access to dental care. A mean DMF score of 6.2 and a mean P.I. score of 1.2 were recorded for the total sample. Greater caries experience was noted in females and in the Vietnamese teenagers.

Partial-mount recording of plaque and periodontal pockets

Plaque ananand pocket depths were recorded in milimetres from the tissue margin, coronally or apically, respectively. Plaque and pocket depths were recorded by examining only a segment of the dentition using eight different combination of teeth. These results d the results obtained from full-mouth examinations in the same individuals were compared. All eight methods of partial-mouth recording gave results that were good in terms of both relative and absolute value when compared to the total-mouth index. The results were valid irrespective of the method chosen. The anterior tooth index was preferred because this segment of the dentition was the easiest to examine. It eliminated the difficulty of making the decision of which teen to substitute when any of the other teeth were missing and produced results for plaque scores and pocket scores that were very good estimates of the total-mouth index.