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The study design of national surveys of periodontal disease often uses partial-mouth examination protocols to rationalize the need for resources so that the collection of data from a large number of subjects can be achieved within the available means without significantly sacrificing precision and validity. Studies show that surveys that use partial examination protocols underestimate the prevalence of periodontitis, and the amount of underestimation varies depending on the number and type of sites examined, the case-definition of periodontal disease, tooth loss, and prevalence and severity of the disease. If a survey uses a partial-mouth examination it is recommended that the amount of underestimation be assessed in the same sample. This could be achieved by performing a full-mouth examination on a randomly selected subsample. Inflation factors should be calculated and used to adjust for the underestimation in disease prevalence because of the use of partial examination. Based on the NHANES III (1988 to 1994) data and adjusting for the bias caused by the examination protocol, it is estimated that approximately half of the United States population aged ≥30 years has periodontitis.

Background: We present an approach to examiner calibration study design where the number of calibration subjects is based on a specified margin of error (half-width of the 95% confidence interval [CI]) of the percentage of agreement (exact and within 1 mm) for both intra- and interexaminer reliability assessments., Methods: An experienced standard examiner (S) trained three dental hygienists (A, B, and C) in correct procedures for obtaining a variety of periodontal measures. Duplicate measurements of probing depth (PD [mm]) and the free gingival margin to the cemento-enamel junction (CEJ-GM [mm]) were obtained in a pilot study to design a formal examiner calibration study, where sample sizes were adjusted for the effects of within-subject clustering of binary indices of agreement., Results: Within-subject clustering of agreement indices resulted in an approximate four-fold increase in the variance of the estimates of percentage of agreement with the standard. PD and CEJ-GM percentage of exact agreement measurements (95% CI) for each examiner-standard pair, respectively, were as follows: AS=55% (48%, 61%) and 70% (62%, 78%); BS=52% (45%, 59%) and 73% (63%, 82%); and CS=55% (50%, 61%) and 72% (65%, 79%). The corresponding 95% CIs unadjusted for the effects of clustering underestimated the margin of error associated with the estimates of exact agreement by as much as 57% for PD and 68% for CEJ-GM., Conclusion: Failure to account for dependence among site-level agreement indices results in a false sense of precision in the resulting reliability estimates and can lead to faulty inference.

Background: Successful treatment of molar furcation defects remains a challenge in clinical practice. Knowledge of anatomic factors facilitates predictable management of furcation involvement lesions. The degree of success in managing furcation involvement is inversely related to the horizontal probing depth. The depth of the horizontal component of attachment loss can vary depending on the external tooth-surface reference points used. However, the anatomical factors affecting horizontal component of attachment loss have not been previously assessed. Therefore, this study determined the bucco-lingual measurements of the cemento-enamel junction and the mesial and distal roots and at the level of root separation., Methods: One hundred extracted permanent human mandibular first (N = 50) and second (N = 50) molars were studied. Four horizontal bucco-lingual widths were measured with calibrated calipers: 1) furcation entrance/roof (FE); 2) cemento-enamel junction level (CEJ); 3) mesial root width (MRW); and 4) distal root width (DRW)., Results: The mean widths at FE, CEJ, MRW, and DRW were, respectively, 5.53 +/- 0.45 mm, 8.71 +/- 0.54 mm, 8.57 +/- 0.54 mm, and 7.97 +/- 0.65 mm in the first molars and 5.61 +/- 0.65 mm, 8.40 +/- 0.65 mm, 7.95 +/- 0.88 mm, and 7.16 +/- 0.84 mm in the second molars. Analysis of variance revealed significant differences between FE and the other variables tested. The results showed that the bucco-lingual width of the furcation roof is considerably shorter than the MRW and DRW. The difference in the mean bucco-lingual dimension between FE and the other measurements occurred in all teeth evaluated and varied between 0.7 and 4.30 mm., Conclusions: Our findings demonstrate that clinical measurements of horizontal probing depth that use the external surfaces of roots as reference points overestimate the true anatomical component of furcation involvement in mandibular molars. Conversely, positive treatment outcomes in these teeth may be underestimated. This has implications not only for clinical practice but also for clinical research studies evaluating treatment outcomes.

Background: Although unreliability of periodontal measurements is considered mainly to concern attempts to detect true changes in longitudinal studies, it is also a source of variability that may substantially decrease the precision of estimates obtained in cross-sectional studies. This study assessed the effects of measurement errors on estimates of prevalence, extent, and severity of clinical attachment loss., Methods: Four examiners performed repeat attachment level recordings in 128, 122, 134, and 133 adolescents, respectively, who participated in a study of clinical attachment loss among 9,162 high school students from Santiago, Chile. A total of 48,954 duplicate recordings were made. Two examiner teams carried out repeat examinations among 292 and 254 subjects, respectively, corresponding to a total number of 51,600 duplicate recordings for interexaminer reliability assessment., Results: A sizeable imprecision was noted regarding prevalence estimates, particularly at the > or = 1 mm level, whereas examiners were reasonably consistent in the assessment of the number of sites with clinical attachment loss. Ninety-five percent of the differences regarding the number of sites with clinical attachment loss > or = 1 mm were in the range from -5 to 5 sites for intraexaminer comparisons, and from -9 to 8 sites for interexaminer comparisons. These differences should be seen in light of the number of sites affected, which ranged from 0 to 85 sites., Conclusions: Examiner variation may preclude comparisons of prevalence estimates between studies. Valid comparisons may be made between studies of extent estimates provided that uniform parameters are used to express the extent of periodontal breakdown.

Background: Maintenance of implants is imperative, since implants, like teeth, are susceptible to bacterial plaque accumulation and calculus formation, and thus at risk of developing peri-implant mucositis or peri-implantitis., Methods: This study determined the clinical effects of chlorhexidine treatment on peri-implant mucositis at 1 and 3 months as determined by the modified plaque index, the modified sulcus bleeding index, clinical attachment level, and probing depth. Through DNA probes, the effect of chlorhexidine on the microbial flora of mucositic lesions was also evaluated. The population consisted of 16 adult male and female subjects (ages 34 to 76). After the baseline examination, the subjects received a dental prophylaxis and were randomly assigned to the test or control group. Subjects in the test group received antiseptic therapy (Treatment 1), which included mechanical cleansing and oral hygiene instructions supplemented by the local irrigation with chlorhexidine 0.12%, using a plastic syringe, and the topical application of a 0.12% chlorhexidine gel. The subjects in the control group received only mechanical cleansing and oral hygiene instructions (Treatment 2)., Results: Both modalities of treatment were effective in reducing peri-implant mucositis and probing depths, and improving attachment levels. The trends suggested that mechanical cleansing alone may be sufficient to treat and reduce peri-implant mucositis at 1 and 3 months after treatment. The addition of chlorhexidine to mechanical debridement did not enhance the results as compared to mechanical debridement alone., Conclusions: Mechanical debridement as well as mechanical debridement supplemented with chlorhexidine can be beneficial to patients with peri-implant mucositis. Both treatments resulted in a reduction of plaque, inflammation, and probing depth, as well as a gain in clinical attachment level, and are effective in suppressing or eradicating the pathogenic bacteria often associated with peri-implant inflammation.

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.

Background: Probing bone measurements as an alternative to open bone measurements to evaluate regenerative procedures in furcation defects do not seem to be used as yet. The purpose of the present study was to investigate the reliability of probing bone measurements in such defects., Methods: Fifteen patients scheduled for surgical treatment of a total of 30 mandibular molars with buccal or lingual Class II furcation defects were studied. During treatment, duplicate vertical and horizontal recordings of probing attachment levels, probing bone levels, and open bone levels were taken by independent examiners., Results: Deviations of both vertical and horizontal recordings between the first and second examiners were within +/-1 mm in 90% to 100% of examined sites for all 3 measurements. Standard deviations of differences between pairs of duplicate recordings were also similar for the 3 measurements both for vertical and horizontal defect dimensions and amounted to 0.7 to 0.9 mm. On average, vertical and horizontal open bone levels were 0.9 to 1.1 mm deeper than probing bone levels. Probing bone levels, in turn, were 1.1 to 1.5 mm deeper than probing attachment levels., Conclusions: In view of the consistency demonstrated between probing bone level and open bone level measurements in mandibular Class II defects, coupled with the additional discomfort for the patient of a reentry surgery and a possible reentry traumatic effect, open bone level measurements do not seem necessary or even justified to evaluate effects of periodontal therapy in these defects, and can be substituted by probing bone measurements.

Background: Previous studies have shown that the use of index teeth may underestimate the prevalence of chronic periodontitis in adults. However, there is little information on the effect of using index teeth to estimate the prevalence of early periodontitis in younger adults and the effect this may have on planning treatment needs and health care resources. The aim of this study was to compare full mouth examination with partial examination using index teeth in a group of young British males., Methods: One hundred subjects aged between 16 and 20 years (mean 17 years) on entry to the study were examined at baseline, 12 months later, and 30 months later. Lifetime cumulative attachment loss (LCAL) > or =1 mm was measured on the mesio-buccal, disto-buccal, mesio-lingual, and disto-lingual surfaces of all teeth, excluding third molars. All data were entered into a database. The indices used to express LCAL were prevalence, defined as the percentage of subjects with LCAL > or =1 mm, 2 mm, or 3 mm, and extent, defined as the percentage of sites with LCAL > or =1 mm, 2 mm, or 3 mm. Two sets of index teeth were chosen to compare with full mouth recordings, Ramfjord index teeth and the Periodontal Index for Treatment (PIT) teeth., Results: The prevalence of LCAL > or =1 mm was similar (approaching 100%) for the full mouth and both partial mouth recordings. However, as LCAL increased from a minimum of 1 to 3 mm, partial mouth recording resulted in an underestimation of the prevalence of disease. LCAL > or =2 mm was underestimated by up to 22% and LCAL > or =3 mm by up to 36%. The extent of LCAL was less affected by partial mouth recording, in that the percentage of sites with no sign of early attachment loss was underestimated by up to 11%. However, the percentage of sites with LCAL > or =1 mm and 2 mm were overestimated by 11% and, 7% respectively., Conclusions: These data indicate that the use of index teeth in epidemiological studies which include young adults may result in an underestimation of the prevalence of early periodontitis and an overestimation of the extent.

Background: The diagnosis and treatment of early-onset forms of periodontitis (EOP) represent a major challenge to periodontists. In this case report, we describe a multidisciplinary approach for the treatment of a patient with severe generalized juvenile periodontitis (GJP). Our approach incorporates clinical laboratory evaluation with conventional concepts of periodontal pathogenesis and therapeutics to diagnose and effectively treat EOP., Methods: The 17-year-old female patient presented with clinical and radiographic evidence of severe attachment loss. Microbiological testing showed the presence of known periodontal pathogens including Actinobacillus actinomycetemcomitans, Prevotella intermedia, and Porphyromonas gingivalis. Routine immunological tests did not reveal any of the functional defects thought to play a role in the pathogenesis of EOP After initiation of therapy, which consisted of scaling and root planing, supplemented with administration of systemic antibiotics, a reduction in probing depth and gain in clinical attachment could be demonstrated. Microbiological testing was used to monitor the composition of the periodontal microbiota and to adjust antimicrobial therapy accordingly., Results: Using a non-surgical approach to treatment, except for 2 root amputations performed without flap reflection, we have been able to stabilize this patient's periodontal condition over the course of a 2-year follow-up period., Conclusions: This treatment strategy provides an efficacious alternative to more aggressive forms of therapy and should therefore be considered for the treatment of patients with severe EOP.

Background: The objective of this investigation is to use noninvasive, state-of-the-art, diagnostic techniques to measure periodontal disease progression and model periodontal disease activity over time. In this investigation, digital subtraction radiography and an electronic controlled force periodontal probe capable of attachment level measurement were used to measure bone loss and attachment loss, respectively. The use of these nearly continuous measures of attachment and bone loss allowed detection of small amounts of disease activity and provided data to be used in modeling of the disease process over time., Methods: Forty-four patients were studied for 18 months. Examinations used clinical attachment level measures at 1-month intervals and quantitative radiology at 6-month intervals. The sites were analyzed by regression for statistically significant changes. These data were used to determine sites of periodontal disease activity for testing various models of periodontal disease progression., Results: Overall 22.8% of sites lost attachment, 5.4% gained, and 71.7% demonstrated no statistically significant change. The mean time to lose 1 mm of attachment was 8.4 +/- 0.6 months. In the first model tested a step-wise discriminant analysis was used to determine whether or not baseline measurements of plaque (PI), gingival inflammation (GI), attachment loss, and probing depth (PD) could be used to derive a satisfactory model for disease progression. Although the overall model was statistically significant with PI, PD, and GI contributing to the model (Wilks' lambda = 0.859, F = 5.71, P <0.0012), its predictive power was relatively weak. A considerably stronger significant model resulted when the rate of attachment loss over the first 6 months, baseline PI, and baseline GI were included (Wilks' lambda = 0.712, F = 14.17, P<0.00001). A significant model also resulted when bone loss during the first 6 months and baseline probing depth were included (Wilks' lambda = 0.438, F = 61.48, P<0.00001). When the last model was applied to each site, the sensitivity in predicting disease progression was 80.0% and the specificity in ruling out progressive disease was 93.9%., Conclusions: This study indicates that clinically significant progression of attachment loss in posterior tooth sites occurs as a frequent event in adult periodontitis. The modeling data also suggest that short-term (6 month) measures of periodontal disease progression greatly improve the ability to model attachment loss over a longer period in untreated periodontitis patients.

The American Academy of Periodontology has developed the following parameter on the treatment of chronic periodontitis with slight to moderate loss of periodontal supporting tissues. Patients should be informed of the disease process, therapeutic alternatives, potential complications, expected results, and their responsibility in treatment. Consequences of no treatment should be explained. Failure to appropriately treat chronic periodontitis can result in progressive loss of periodontal supporting tissues, an adverse change in prognosis, and could result in tooth loss. Given this information, patients should then be able to make informed decisions regarding their periodontal therapy.

The American Academy of Periodontology has developed the following parameter on the treatment of chronic periodontitis with advanced loss of periodontal supporting tissues. Patients should be informed of the disease process, therapeutic alternatives, potential complications, expected results, and their responsibility in treatment. Consequences of no treatment should be explained. Failure to appropriately treat chronic periodontitis can result in progressive loss of periodontal supporting tissues, an adverse change in prognosis, and could result in tooth loss. Given this information, patients should then be able to make informed decisions regarding their periodontal therapy.

Background: When measuring periodontal disease, various types of equipment for making objective measurements of tooth mobility have been proposed. However, these devices and methodology are insufficient in terms of reliability. An innovative method using vibrational theories to assess the periodontal attachment level of natural teeth is presented in this study., Methods: Modal testing technique, a non-destructive and time-saving method, was used for non-invasive and quantitative measurement of the natural frequencies of the upper central incisor in vivo and in vitro. A finite element model was established, and modal testing experiments were simulated to assess the relationship between bone level and teeth., Results: The first dominant natural frequency of healthy human upper central incisors ranges from 710 Hz to 3,360 Hz, with an average of 1,701+/-679 Hz. Both in vitro experiment and finite element simulation showed that lowering of the attachment level causes a significant decrease in the natural frequencies, and a strong relationship (r = -0.99, P <0.01) was observed between the frequency and the bone level height., Conclusions: Our results suggested that natural frequency is an important parameter for assessing the periodontal condition and that the modal testing technique is a useful supplemental method for assessing the attachment conditions of the periodontium.

Background: In previous studies, we demonstrated that increased levels of immunoglobulin A (IgA) in gingival crevicular fluid (GCF) may be "protective", while increased levels of the polymorphonuclear lysosomal enzyme, beta-glucuronidase, in GCF were associated with increased risk of disease activity. In this study, we examined the effect of scaling and root planing (SRP) on the levels of beta-glucuronidase, IgG, and IgA in GCF over a 24-week period and compared these to clinical attachment loss (CAL)., Methods: Twenty-nine patients with periodontal disease were examined for attachment level, probing depth, plaque, and bleeding on probing at 6 sites per tooth. GCF was collected from the mesial aspect of all teeth excluding third molars and analyzed for beta-glucuronidase, IgG, and IgA. After baseline data were collected, each patient received SRP, and GCF was collected again at 2, 4, 6, 8, 12, and 24 weeks post-SRP while clinical data were obtained at 4, 8, 12, and 24 weeks. In addition, we analyzed whether the magnitude of the IgA response to SRP would affect the rate of periodontal disease progression by examining GCF IgA levels at 2 time intervals: 2 to 4 weeks post-SRP and 6 to 12 weeks post-SRP., Results: Seventeen patients (58.6%) exhibited at least 1 site losing > or =2.5 mm of CAL during the 24-week study. Beta-glucuronidase in GCF was significantly decreased at 2 weeks following SRP and then demonstrated a gradual increase throughout the study period. Levels of IgA in GCF significantly increased following SRP, reaching a peak at 6 weeks and then gradually decreasing throughout the study. Furthermore, we found an inverse relationship between GCF IgA levels at 6 to 12 weeks post-SRP and the occurrence of CAL., Conclusions: These results support the hypothesis that maintenance of high levels of IgA in GCF may be "protective" against periodontal attachment loss. Furthermore, levels of beta-glucuronidase appear to be a more sensitive indicator of gingival inflammation than clinical measures.

Background: A standard treatment strategy for periodontal infections often consists of 4 consecutive sessions of scaling and root planing (per quadrant, at 1- to 2-week intervals), without proper disinfection of the remaining intra-oral niches for periodontopathogens. This could theoretically lead to a reinfection of previously disinfected pockets by bacteria from an untreated region/niche. This study aimed to investigate, over an 8-month period, the clinical benefits of a one stage full-mouth disinfection in the control of severe periodontitis., Methods: Sixteen patients with early-onset periodontitis and 24 patients with severe adult periodontitis were randomly assigned to test and control groups. The control group was scaled and root planed, per quadrant, at 2-week intervals and given standard oral hygiene instructions. A one stage full-mouth disinfection (test group) was sought by scaling and root planing the 4 quadrants within 24 hours in combination with the application of chlorhexidine to all intra-oral niches for periodontopathogens. Besides oral hygiene, the test group also rinsed twice daily with a 0.2% chlorhexidine solution and sprayed the tonsils with a 0.2% chlorhexidine spray, for 2 months. The plaque index, gingival index, probing depth, bleeding on probing, gingival recession, and clinical attachment level were recorded at baseline and at 1, 2, 4, and 8 months afterwards., Results: The one stage full-mouth disinfection resulted, in comparison to the standard therapy, in a significant (P <0.001) additional probing depth reduction and gain in attachment up to 8 months. For initial pockets > or =7 mm, the "additional" probing depth reduction at the 8 month follow-up was 1.2 mm for single-rooted and 0.9 mm for multi-rooted teeth, with corresponding additional gains in attachment of 1.0 mm and 0.8 mm, respectively. The additional improvements were observed for all subgroups (adult periodontitis, generalized early-onset cases, smokers), with the largest differences in the non-smoking adult periodontitis patients., Conclusions: These findings suggest that a one stage full-mouth disinfection results in an improved clinical outcome for the treatment of chronic adult or early-onset periodontitis as compared to scaling and root planing per quadrant at 2-week intervals.

Background: Site-specific attachment level change, detected from sequential physical probing measurements, is currently the most common method of determining the progression/regression or stability of disease status in subjects with chronic adult periodontitis. The sensitivity and accuracy of detection is dependent on the type of probe used, the recording method, the measurement error, and the method of data analysis. In recent years, there has been world-wide interest in developing instruments and methods to minimize measurement error. Published data report disturbingly wide variation in the prevalences and rates of site-specific attachment level change which are difficult to reconcile with biological likelihood. The present paper aims to summarize the salient points from the key studies and to compare the results., Methods: The literature between 1982 and 1997 was reviewed for studies in which site-specific attachment level change was detected by physical probing methods in patients with chronic adult periodontitis., Results: The review documents 23 studies by probe generation, compares methods and results and summarizes the results according to the thresholds and probe type used. The 23 studies used an array of probe types from the 3 probe generations., Conclusions: From this review, we conclude that: 1) There are surprisingly few papers which have addressed the question of site-specific attachment level change in untreated chronic adult periodontitis. 2) There are considerable differences in the probes used, in the thresholds achieved, in the number of measurements taken, in the number of subjects and sites studied, and in the duration of the studies. Valid comparisons between studies are, therefore, rarely possible. 3) Only 8 out of 23 papers from 1982 to 1997 have adequate data. Most papers report only losing sites and therefore ignore many of the measurements recorded. Only one paper describes losing sites, gaining sites, and sites showing exacerbation/remission patterns of change. 4) The range of changes described show such variation that it has to be concluded that we cannot reliably detect site-specific attachment level change by physical probing and thus, at the end of the 20th century, we have no clear idea of the natural history of this disease.

Background: Longitudinal site-specific attachment level change (SSAC), identified from serial relative attachment level measurements (RAL), is the principal indicator of progression/regression of periodontal diseases. Many variables confound RAL reproducibility and affect measurement error. The Option-4 algorithm was designed to reduce measurement error and improve accuracy and sensitivity of SSAC detection. The study aimed to evaluate the performance of the Option-4 algorithm., Methods: A precalibrated clinician recorded full mouth RAL with a third generation disc probe on 4 occasions over 6 months in 16 subjects (mean age 48.1 years) with moderately advanced chronic adult periodontitis (2,312 sites). Option-4 allowed up to 4 RAL recordings per site per visit until 2 values had differences < or =1.0 mm and their mean was < or =1.0 mm from the previous visit mean: the clinician made the selection if these criteria were unfulfilled., Results: Within-visit agreement < or =1.0 mm was > or =99.6%: all within-visit correlation coefficients = 0.98 (P<0.001). At each visit, mean difference in Option-4 values was < 0.05 mm, mean absolute difference (ignoring direction) was < or =.34 mm. Mean site-specific variances ranged from 0.092 mm2 to 0.097 mm2 across all visits. Subject thresholds for site-specific attachment level change (from estimated 95% confidence limits of visit 1 data) ranged from 0.52 mm to 0.67 mm. Linear SSAC (by linear regression) and between-visit patterns of SSAC were investigated. SSAC was detected in 100% subjects and at 51.0% measured sites. Linear SSAC (R2 > or =0.90: P < or =0.05) occurred at 105 sites (4.5%): 32 sites (1.4%) deteriorated, 73 sites (3.1%) improved. Between-visit SSAC occurred at 1,074 sites (46.5%): 391 sites (16.9%) deteriorated, 295 sites (12.8%) improved, and 388 sites (16.8%) showed exacerbation/remission patterns., Conclusions: The Option-4 algorithm produced high RAL agreement. Site-specific attachment level change was detected in both directions in 100% subjects and at 51.0% measured sites.

Detection of periodontal disease progression occurs when a predetermined threshold of attachment loss is exceeded during longitudinal monitoring. The incidence of disease progression in a population may be dependent on the method and threshold utilized to identify significant changes in attachment level measurements. The aim of this study was to investigate the effect of utilizing different methods and thresholds on the incidence of disease progression in an untreated periodontitis population. The relationship between baseline clinical parameters and disease progression was also examined. A total of 411 interproximal sites in 46 individuals were monitored monthly over a 6-month period. Disease progression was determined by the cumulative sum (CUSUM) method and by the absolute change in relative attachment level between months 0 and 6 utilizing 3 different thresholds for attachment level change (0.58 mm, 1.16 mm, and 1.74 mm) based upon examiner repeatability using an automated probe. Utilizing the CUSUM method, 49 of 411 sites (11.9%) demonstrated attachment loss over the 6-month observation period. When attachment level changes > or = 0.58 mm, > or = 1.16 mm, and > or = 1.74 mm were used to identify disease progression, the percentage of sites exhibiting deterioration were 19.5%, 8.8%, and 2.9%, respectively. These results demonstrate that the apparent incidence of disease progression was dependent on the method and threshold utilized to detect progressive sites. When utilizing the CUSUM and 0.58 mm thresholds a significant (P < 0.05), but weak relationship (r = -0.26) was observed between baseline relative attachment level measurements and sites exhibiting disease progression. This finding suggests that sites with significant but relatively less attachment loss may be more likely to experience further breakdown compared to sites with a history of greater periodontal destruction.

The aim of this study was to investigate the reliability of the assessment of clinical furcation parameters (horizontal attachment levels [CAL-H], class of furcation invasion). Replicate measurements of CAL-H and furcation class were performed within 14 days in 420 molars of 105 patients with advanced periodontitis using a Nabers- (n=50), a TPS- (n=30) and a PCPUNC15-probe (n=25). Validity of clinical assessments was assessed by intrasurgical measurements. The standard deviation of single measurements (s) was calculated as a measure of the reproducibility of CAL-H measurements and weighted kappa-coefficients (Kw) to estimate the agreement of furcation class assessments. The s ranged from 0.55 to 1.13 mm (Nabers), 0.55 to 1.02 mm (TPS), and 0.58 to 1.11 mm (PCPUNC15). For all probes, a statistically significantly smaller measurement error was observed in buccal and lingual sites than in mesiolingual and distolingual furcations (P < 0.005). The Kw ranged from 0.59 to 0.89 (Nabers), 0.50 to 0.80 (TPS), and 0.53 to 0.72 (PCPUNC 15). Multiple linear regression analysis identified distolingual location, probing depth (PD) and CAL-H as factors influencing the variability of CAL-H measurements. Whereas there was no statistically significant difference between pre- and intrasurgical CAL-H measurements using the Nabers probe, the TPS and PCPUNC15 probe underestimated CAL-H for distolingual furcations (P < 0.025). Using the Nabers probe, no asymmetries between pre- and intrasurgically obtained class of furcation involvement were revealed, while the TPS and PCPUNC15 probe underestimated furcation degrees (P < 0.1). Multiple linear regression analysis identified distolingual location and height of furcation, as well as PD, vertical attachment level (CAL-V) and type of probe, as factors influencing the validity of CAL-H measurements. Clinical diagnosis of furcation lesions using the 3 mm incrementally marked Nabers probe provides reproducible and valid information about furcation invasion.

Diagnosis of periodontal disease progression involves recording two probing attachment level measurements over an adequate time interval. A diagnostic instrument which exhibits less measurement variability allows for increased sensitivity and earlier disease detection. Traditionally, a manual probe with an occlusal stent of the cementoenamel junction (CEJ) as a reference landmark has been the method of choice. Automated probes that use an occlusal disk as the reference landmark have been developed as an alternative means of measure. The aim of this study was to compare the variability of these two probing methods. Four hundred eleven (411) interproximal sites in 46 untreated periodontitis patients were monitored by a single examiner over a 6-month period. Each site was measured on a monthly basis, first with an automated probe (AP) followed by a manual probe (MP) in combination with a custom-fabricated acrylic stent. Measurement variability of the two probing methods was also compared over a 7-day interval. The AP measurements were significantly more variable than the MP measurements (P < 0.001) when considering the variability between two passes at the same visit. Over the 6-month period, the MP measurements demonstrated significantly more variability than the AP measurements (P < 0.001). It was also noted that MP measurements exhibited more variability at sites with frequent bleeding during the 6 months of the study (P = 0.006). The results of this study demonstrate that AP may have less variability of attachment level measurements over a 6-month period and may be less influenced by local inflammatory changes. However, future comparison studies should include multiple examiners to reduce examiner bias and should alternate the probing method to reduce bias created by local tissue changes from multiple probings.

Physical periodontal measurement is plagued by many confounders which result in aberrant values. Replicate measurements can reduce the number of aberrant values, the measurement error, and the variance of site-specific measurements. This study aimed to reduce the variance of site-specific measurements by using a new clinical algorithm (the Option-4 algorithm) for an automated disk probe. A single clinician recorded full-mouth relative attachment levels (RAL) at one visit in 32 patients (mean age 45.5 years) with moderately advanced chronic adult periodontitis. RAL was recorded over two passes at six sites per tooth (4,675 sites). The algorithm accepted the first and second pass RALs (RAL1 and RAL2) if their difference was < or = 1 mm, otherwise a maximum of two further RALs (RAL3 and RAL4) were recorded until the difference between any two RALs was < or = 1 mm (SAL1 and SAL2): 4,048 sites (86.6%) required two recordings, 580 sites (12.4%) required three recordings and 47 sites (1%) required four recordings. Correlation coefficients for RAL1 and RAL2 and SAL1 and SAL2 (4,675 sites) were both > or = 0.91 (P = 0.00). Site-specific variances were calculated for RAL1 and RAL2 and SAL1 and SAL2. The mean of the RAL1/RAL2 site-specific variances (A) was 0.45 mm2 (range 0.00 mm2 to 35.28 mm2) whilst the mean of the SAL1/SAL2 variances (B) was 0.09 mm2 (range 0.00 mm2 to 0.5 mm2): the respective medians were 0.08 mm2 and 0.02 mm2. The study demonstrated high intra-examiner RAL reproducibility. The Option-4 algorithm produced an 80% reduction in the mean site-specific variance of RAL1/RAL2 (Y) and a 75% reduction in the median site-specific variance of RAL1/RAL2 (y = [(A - B)/A] x 100).

This study compared relative attachment levels (RAL) and probable crevice depths (PCD) from 6 periodontal probes (1 third, 4 second, and 1 first generation). A single clinician recorded RAL and PCD in 6 patients with chronic adult periodontitis (mean age 48.2 years) during two visits (interval: 1 week) using a Latin square examination order. Replicate measurements were recorded at the 4 interproximal sites of the Ramford index teeth to examine intra-probe differences. Additional single measurements were recorded at similar sites of units 11, 26, 31 and 46 to investigate interprobe differences. Intra-probe RAL and PCD reproducibility was < or = 1 mm at > 94% of the sites. All intra-probe Pearson correlation coefficients were > 0.85 (P = 0.00). Inter-probe RAL and PCD agreement was < or = 1 mm at > 49% of the sites for RAL and > 61% of the sites for PCD. All inter-probe Pearson correlation coefficients were > 0.42 (P = 0.00) for RAL and > 0.49 (P = 0.00) for PCD. Analyses of variance showed significant differences in RAL and PCD between the first generation probe and the second generation probes (P < 0.005); in RAL between the third generation probe and the first and second generation probes (P = 0.0354); and in PCD between the third generation probe and the first and second generation probes (P = 0.0475). Inter-probe differences were clinically significant in the recorded percentages of pockets > or = 4 mm and > or = 6 mm. Significant inter-probe differences were found in RAL and PCD which have clinical importance in data interpretation and comparison.

Concluding that the clinical attachment level at a periodontal site is stable, while in reality it is progressing at a clinically relevant rate, is an example of a false-negative conclusion. No guidelines are currently available to evaluate the likelihood for false-negative conclusions in periodontal clinical trials that monitor disease progression by means of clinical attachment levels. The goal of this study was to estimate the amount of linear disease progression in clinical attachment levels that cannot reliably be detected, when it is truly present. This rate is called the critical linear rate; rates equal to or below this critical linear rate cannot reliably be detected. An equation for determining the critical linear rates for various clinical situations is presented and may provide a rule-of-thumb guideline for the interpretation of negative conclusions. If the critical linear rate for a study is larger than what is considered a clinically relevant disease progression rate, negative conclusions should be interpreted with caution; clinically relevant disease progression might be present, but the diagnostic tools used were too insensitive to detect it. False-negative conclusions may be important in diagnostic trials where low sensitivity can translate into lack of clinical utility.

The reaction of the periodontium to a defined percussive force applied in an orofacial direction can be evaluated by a mobility meter. The elastic and viscous characteristics of the periodontium are evaluated by the device from the contact time between tapping head and the tooth, and reported as a numeric value called the PTV. In this study, the relation between PTVs and bone loss (BL), clinical attachment level (CAL), probing depth, bleeding on probing, and plaque and gingival indices were evaluated in 35 patients with moderate to advanced periodontal disease. The effects of gender, smoking, and initial periodontal therapy on PTVs were also evaluated. Repeated measures analysis of variance was used to determine whether the relationship between PTVs with CAL and BL was dependent on tooth type. Stepwise multiple linear regression was used to test which of the clinical parameters and bone loss would produce the highest predictive value with PTVs. The effects of gender and smoking on PTVs were examined by analysis of covariance. The changes in clinical parameters and PTVs before and after treatment were evaluated by repeated analysis of variance. PTVs were found to give the highest predictive value with bone loss. However, the correlation was observed to be dependent on the location of the tooth in the jaw and the tooth type. Interproximal and midpoint clinical attachment level measurements showed that PTVs correlated more strongly with the overall support, rather than the support on the direction of the percussive movement. No pronounced differences of PTVs were noted between gender. PTVs of smokers were observed to be higher than non-smokers. There was no significant change of PTVs after the initial phase of periodontal therapy. This cross-sectional study shows that the mobility meter evaluation was primarily related to the amount of bone loss while being significantly affected by the location of the tooth in the jaw. Factors such as severity of gingival and sulcular inflammation, oral hygiene, and gender do not seem to have an effect on PTVs.

This study describes the variations in the reproducibility of attachment level recordings for different subjects at different examinations. Twenty patients with different degrees of periodontal disease were recruited and examined bi-monthly for their attachment levels using an electronic probe in two quadrants and a conventional probe in the other two quadrants. At each of the 7 examinations attachment level recordings were repeated with the appropriate probe after approximately 30 minutes. Results demonstrate that the reproducibility of attachment level recordings was slightly better for the conventional probe than for the electronic probe. Attachment level recording reproducibility varied considerably between subjects and between examinations for the same subject. Aggregation of attachment level recordings in the form of mean tooth values or mean individual values reduced the range of the differences, but considerable between-subject and between-examination variation was still seen. These results indicate that no single uniformly valid estimate of attachment level reproducibility exists which can be used to set diagnostic thresholds such that a minimum number of incorrect diagnoses are made.

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

Periodontal health reflects a balance between harmful and protective elements in the gingival margin area. The total plaque mass, specific periodontopathogens, and local environmental factors may challenge this balance. The aim of this retrospective study was to evaluate the effect of proximal root grooves as a risk factor in periodontal attachment loss. One-hundred and three (103) extracted, formalin-stored, single-rooted teeth showing loss of attachment and having one non-grooved and one grooved proximal root surface were selected for the study. Following staining in 0.1% toluidine blue to visualize attached periodontal ligament remnants, the teeth were examined in a light microscope under incident light. On each tooth, loss of attachment was measured along the long axis of the root from the cemento-enamel junction to the most coronal level of the stained periodontal ligament remnants on mesial as well as on distal surfaces. Incisors and premolars were grouped separately. For both groups, a statistically significant greater loss of attachment was present on grooved than on non-grooved surfaces (P < 0.0001). Generally, there was a direct relationship between groove location and maximum loss of attachment. The results indicate that proximal root grooves should be considered in periodontal diagnosis, prognosis, and treatment planning.

Objective, reliable, and valid diagnostic criteria are required for studies of HIV-associated periodontal conditions. A set of diagnostic criteria were devised based on a literature review and the clinical experience of the authors. Validity was assessed by comparison with clinical photographs and the criteria were evaluated and refined for ease of use and objectivity. To assess the reliability of the criteria, 9 experienced examiners were shown 20 clinical photographs accompanied by brief vignettes of clinical information. Each examiner was asked to identify signs evident in a particular area of the photograph and to record a diagnosis. Five examiners were then trained and calibrated in the use of the criteria. Finally, all 9 examiners were shown the original 20 photographs and asked to identify signs and record diagnoses. The examiners showed only fair reliability in the recognition of clinical signs, made diagnoses intuitively, and had only fair agreement on the diagnosis of periodontal diseases. The inter-examiner reliability of examiners trained and calibrated in the use of the criteria increased and was greater than among untrained examiners. Rigid diagnostic criteria are essential in epidemiologic studies. Inter-examiner reliability will be increased if examiners are trained in their use and calibrated in the recognition of clinical signs. Diagnostic criteria should be modified as understanding of the diseases they classify increases. The proposed criteria will enhance the value of studies of HIV-associated periodontal changes and will contribute to that understanding.

Porphyromonas gingivalis in subgingival plaque is an important risk factor for future periodontal attachment loss in susceptible adults. The elimination of P. gingivalis is usually concomitant with a healing process. Therefore, it should be valuable to have an easy chairside method to follow the effect of periodontal treatment on P. gingivalis detection as well as on its eventual reappearance during the maintenance period. We have previously reported the stimulation of amidolytic activity of P. gingivalis by the addition of glycyl-glycine to the assay buffer. In this study we determined the proportions of P. gingivalis, Prevotella intermedia, Actinobacillus actinomycetemcomitans, Fusobacterium nucleatum, Capnocytophaga spp, Campylobacter rectus, and Eikenella corrodens by cultivation technique and the amidolytic activity, using N-benzoyl-L-arginine-p-nitroanilide (BAPNA) as substrate, in gingival exudate before and during a 3-year treatment and maintenance period. P. gingivalis was the only species yielding a high and persistent correlation to stimulated amidolytic activity (P values < or = 0.0001) on both site (r = 0.5) and subject (r = 0.8) level. Testing pure cultures of suggested periodontal pathogens for effect of glycyl-glycine on amidolytic activity, we found that of P. gingivalis to be 5.9-fold increased. The amidolytic activity of Treponema denticola was only slightly stimulated (ratio with/without glycyl-glycine = 1.2) and that of Capnocytophaga slightly inhibited (ratio with/without glycyl-glycine = 0.8). The outcome of this study has the potential to be used for the development of a simple, rapid, and inexpensive assay for a qualitative and quantitative determination of P. gingivalis in gingival crevicular fluid.