41. Diagnosis / Indices – Indices & Epidemiology

Classical Periodontal Literature Review

Rapid Search Terms

A. Indices and Scoring Methods

B. Epidemiology of Periodontal Diseases

Study Questions:

  • Develop a table listing common tissue, plaque, and bleeding indices and their characteristics. Be able to define each.
  • Would you use indices in your practice? Defend your answer.
  • Should indices or actual measurements be used in research? Why?
  • Are partial mouth scores as accurate as whole mouth scores ?
  • What is the difference between statistical vs clinical significance?
  • What is regression towards the mean?
  • Which are The Ramjford Teeth?  What do they represent and why are they significant?
  • Are stents essential for epidemiologic or other clinical research?
  • Discuss trends in prevalence and severity of adult periodontitis.
  • Are retrospective studies equally strong and important as prospective studies?
  • Is bone loss a better or worse indicator of advancing periodontal disease than attachment loss?
  • Is periodontal disease progression a continuous process?
  • What is the clinical practical relevance of the late 1980’s study of the prevalence of periodontal disease in the U.S.?

Topic Overview

  1. Albandar JM. Underestimation of periodontitis in NHANES surveys. J Periodontol. 2011 Mar;82(3):337-41.
  2. Albandar JM. Periodontal disease surveillance. J Periodontol. 2007 Jul;78(7):1179-81
  3. Albander J. Periodontal diseases in North America. Peridontol 2000, 29: 31-69, 2002
  4. Albander J. Global risk factors and risk indicators for periodontal disease. Periodontol 2000. 29: 177 – 206, 2002
  5. Cobb , C, Carrara, A., et al: Periodontal referral paterns, 1980 versus 2000: A Preliminary study. J Periodontol 2003; 74: 1470 – 1474
  6. McGuire M, Scheyer, E. A Referral Based periodontal Practice – Yesterday, Today, and Tomorrow. J Periodontol 2003; 74: 1542-1544.
  7. Lee JH, Bennett DE, Richards PS, Inglehart MR. Periodontal referral patterns of general dentists: lessons for dental education. J Dent Educ. 2009 Feb;73(2):199-210.
  8. Dockter KM, Williams KB, Bray KS, Cobb CM. Relationship between prereferral periodontal care and periodontal status at time of referral. J Periodontol. 2006 Oct;77(10):1708-16.

Tissue Indices

  1. Loe H. The gingival index. the plaque index, and the retention index system. J Periodontol. 38:610-617, 1967.
  2. Dowsett , S, Eckert, G. et al: The applicability of half-mouth examination to periodontal disease assessment in untreated adult populations. J Periodontol 2002, Sep; 73(9): 975 – 81

Plaque Indices

  1. O’Leary T, Drake RB, Naylor JE: The plaque control record. J Periodontol 43:38; 1972.

Bleeding Indices

  1. Caton JG, Polson AM: The interdental bleeding index: A simplified procedure for monitoring gingival health. Compend. Cont. Educ. Dent. 6(2):88-92, 1985.
  2. Barendregt DS et al. Comparison of the bleeding on marginal probing index and the Eastman interdental bleeding index as indicators of gingivitis. J Clin Periodonto 2002; 29: 195 – 200.
  3. Newbrun E. Indices to measure gingival bleeding. J Periodontol 67:555-561, 1996.(Review)


  1. Persson R, Svendsen, Daubert K. A longitudinal evaluation of periodontal therapy using the CPITN index. J Clin Periodontol. 16:596-574, 1989.

Study Design & Reliability

  1. Gettinger G, et al: The use of six selected teeth in population measures of periodontal status. J. Periodontol. 54:155 -, 1983.
  2. Clark , C et al.: Reliability of attachment level measurements using the cementoenamel junction and a plastic stent. J Periodonto 58: 115, 1987
  3. Carlos , J, et al.: Attachemnt loss versus pocket depth as indicators of periodontal disease: A methodologic note. J Periodont Res 22: 524, 1987
  4. Egelberg , J: The impact of regression towards the mean on probing changes in studies of the effect of periodontal therapy. J Clic Periodontol 16: 120- 123, 1989
  5. Lynch , S.: Methods for evaluation of regenerative procedures. J Periodontol 63: 1085 – 1092, 1992
  6. Gunnsolley , J., Elswick R., et al: Equivalence and superiority testing in regeneration clinical trials. J Periodontol 69: 521 – 527, 1998.
  7. Rethman , M and Nunn, M: Clinical versus statistical significance. J Periodontol 70: 700 – 702, 1999
  8. Gunsolley J et al: Is loss of attachment due to root planning and scaling insites with minimal probing depths a statistical or real occurrence: J Periodontol 2001 Mar: 72(3): 349-53
  9. Kingman A, Susin C, Albandar JM. Effect of partial recording protocols on severity estimates of periodontal disease. J Clin Periodontol. 2008 Aug;35(8):659-67, 2008. Epub 2008 May 30.
  10. Lynch S., eta al: New composite endpoints to assess efficacy in periodontal therapy clinical trials. J Periodntol 2006; 77: 1314 – 1322

Incidence and Prevalence of Periodontal Disease

  1. Eke Pl, Dye BA, Wei L et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res 2012;91;914-920
  2. Schatzle M, Loe, H., Lang, N et al: Clinical course of chronic periodontitis. J Clinc Periodontol 2003; 30(10):909-918.
  3. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of severe periodontitis in 1990-2010: a systematic review and meta-regression. J Dent Res. 2014 Nov;93(11):1045-53.

Progression of Disease

  1. Loe H, et al: The natural history of periodontal disease in man. The rate of periodontal destruction before 40 years of age. J. Periodontol. 49:607- , 1978.
  2. Loe H, Anerud A, Boysen H, Morrison E. Natural history of periodontal disease in man. Rapid, moderate, and no loss of attachment in Sri Lankan laborers 14 to 46 years of age. J. Clin. Periodontol. 13:431-440, 1986.
  3. Hugoson A, Laurell L. A prospective longitudinal study on periodontal bone height changes in a Swedish population. J Clin Periodontol 27:665-674, 2000.
  4. Ship JA, Beck JD. Ten-year longitudinal study of periodontal attachment loss in healthy adults. Oral Surg, Oral Med, Oral Pathol 81:281-290, 1996.
  5. Reddy MS, Geurs NC, Jeffcoat RL, Proskin H, Jeffcoat MK. Periodontal disease progression. J Periodontol 71:1583-1590, 2000.
  6. Van der Velden U, Abbas F, Armand S, Loos BG, Timmerman MF, Van der Weijden GA, et al. Java project on periodontal diseases. The natural development of periodontitis: risk factors, risk predictors and risk determinants. J Clin Periodontol. Aug;33(8):540-8, 2006.
  7. Shepherd S. Alcohol consumption a risk factor for periodontal disease. Evid Based Dent 2011;12(3):76
  8. Gorman A, Kaye Ek, Apovian C, Fung T, Nunn M, Garcia R; Overweight and obesity predict time to periodontal disease progression in men. J Clin Periodontol 2012; 39:107-114
  9. Mdala I, Olsen I, Haffajee AD, Socransky SS, Thoresen M, de Blasio BF. Comparing clinical attachment level and pocket depth for predicting periodontal disease progression in healthy sites of patients with chronic periodontitis using multi-state Markov models. J Clin Periodontol. 2014 Sep;41(9):837-45.


  1. Landry RG, Jean M. Periodontal Screening and Recording (PSR) Index: precursors, utility and limitations in a clinical setting. Int Dent J. Feb;52(1):35-40. 2002 Review.

Topic Overview

Topic: Diagnosis

Authors:  Albandar, J.M.

Title: Underestimation of periodontitis in NHANES surveys

Source:  J Periodontol. 2011; 82(3):337-41

DOI: 10.1902/jop.2011.100638

Type: Commentary

Keywords:   Nutrition surveys; periodontal attachment loss; periodontal diseases; periodontitis index, epidemiology; periodontitis.

Purpose: To discuss the underestimation of periodontitis in NHANES surveys.

Discussion: National surveys looking at periodontal disease often use partial-mouth exams to collect data. This enables more data to be collected from large numbers of patients with the available means/resources. However, we have seen that studies using partial mouth exams underestimate the prevalence of periodontitis. In order to be able to estimate the amount of underestimation expected in the study, a sub-group would need to undergo full-mouth examination. Using data from other surveys which including full-mouth probing, estimates have been made to adjust for underestimation in NHANES data.

Eke et al. found that NHANES protocols may underestimate periodontal disease by at least 50%.

Conclusion: Based on the NHANES III (1988 to 1994) data and adjusting for the bias caused by the examination protocol, it is estimated that 48.2% or approximately half of the United States population aged ≥30 years has periodontitis and 30% have >5mm attachment loss. Efforts should be made to modify protocols so that underestimation can be calculated when NHANES data is released.


Topic: Disease surveillance

Authors: Albandar

Title: Periodontal disease surveillance

Source: J Periodontol. 2007 Jul;78)7):1179-81

DOI: 10.1902/jop.2007.070166

Type: Discussion

Keywords: charting, diagnosis, disease progression, prognosis, disease activity

Discussion: Some concern has been raised, primarily in the public health service, that large population studies of periodontal disease are not affordable using the conventional

approach of disease assessment. There are two important issues in the surveillance of periodontitis: the case definition of periodontitis and the adequacy of using surrogates of periodontitis for surveillance. Numerous definitions and classifications of periodontitis have been put forward during the past several years; this process has evolved in a pace parallel to the increase in the understanding of disease pathogenesis and the shift in paradigm of periodontal diseases. Using a combination of CAL and PD in the case definition of periodontitis may greatly improve the method’s validity compared to definitions that use only one of these two variables. For example, the use of PD alone tends to overestimate the prevalence and extent of periodontitis in young subjects and to severely underestimate the disease in older age groups. The proposed case definitions of periodontitis require that CAL and PD be present at the same site. Tooth loss due to periodontitis introduces another, often overlooked, problem in the assessment of periodontitis in population studies. Paradoxically, individuals with tooth loss due to severe supporting tissue loss are likely to be misclassified as having better periodontal status than those with fewer missing teeth, because the missing teeth tend to have the most severe periodontal attachment loss. The effect of tooth loss on the identification of periodontitis should be addressed in future studies.
Conclusion: There is a need for more studies to investigate the adequacy of measurable variables of periodontitis. In this regard, two potential approaches may emerge: an index that combines multiple variables and a multiple variable variance model. In either case, the methodology needs to undergo appropriate testing to determine its validity in large patient populations. The development of suitable biologic assays of active periodontitis and biologic markers of increased risk for disease is a promising future direction in the surveillance of periodontitis in populations.


Topic: Periodontal diseases

Authors : Albandar J. 

Title: Periodontal diseases in North America

Source: Periodontol 2000, 29: 31-69, 2002

Type: Epidemiological study

Keywords: Periodontal diseases, Epidemiology, North America

Purpose: To provide a comprehensive evaluation of the distribution of various types of periodontal diseases in North America

Periodontal disease in the U.S.A.

Prevalence and severity of disease:

· Among dentate persons aged 30 years and older and with ≥6 remaining teeth, about 35% had chronic periodontitis (one or more teeth with attachment loss and probing depth of ≥3 mm).

Age relationship:

With increasing age there is a corresponding increase in the percentage of persons having attachment loss of 3mm and an involvement of more teeth.

Oral health behaviors:

Poorer oral hygiene among males than females, and in blacks than whites.

Disparities: significant disparities in the periodontal health status among Americans.

Compared to whites and Mexican-Americans, blacks have the highest prevalence and severity of periodontitis, the highest prevalence, extent and severity of attachment loss and probing depth, and show higher levels of dental calculus and gingival recession.

Mexican-Americans have somewhat better periodontal status than blacks, though significantly worse than whites. Also, studies have consistently shown that males have poorer periodontal health than females. A similar trend seems to occur among senior age groups

Disparities in periodontal status appear to occur largely between the poor and the rich. Populations with a lower socioeconomic level cannot afford dental treatment. These populations often lack healthy attitudes and behaviors for oral health, as well as for systemic health.


Tobacco smoking is an important risk factor for the development of destructive periodontal diseases and also makes diseases management more difficult

Topic : Risk factors and indicators

Authors: Albander J  [ps2id id=’Albander2′ target=”/]

Tittle: Global risk factors and risk indicators for periodontal disease.

Source Periodontol 2000. 29: 177 – 206, 2002

: Discussion article/review of literature

Rating : Good

Keywords : contributing factors, prevalence

Discussion: Author states that chronic periodontitis is a multifactorial disorder.

Microbial dental plaque biofilms are the principal etiological factor of periodontitis, whereas several other local and systemic factors have important modifying roles in its pathogenesis. Of the ones mentioned here, only a few may be true risk factors possessing a causal relationship with the initiation and/or progression of attachment loss. There is overwhelming evidence that both smoking and diabetes are important risk factors.

· Prevalence of Periodontal disease à 34.5% of population with teeth have the presence of attachment loss of 3 mm or more plus at least 3 mm probing depths.

Oral Hygiene

· Lovdal et al and Schei et al – both showed a higher prevalence and severity of perio disease in patients with poor oral hygiene

· NHANES I – the level of oral hygiene was an important risk indicator for the level of periodontitis. Poorer oral hygiene in males and black population.

· Haffajee – low sensitivity and high specificity for plaque and inflammation for periodontal attachment loss

· Axelsson and Lindhe – a high specificity of good oral hygiene and absence of gingival inflammation as predictors of periodontal stability.


· Associated between 2 and 7 fold increase in risk for having periodontal loss

· Dose-Effect Relationship – Heavy smoking consistently associated with more severe disease than light

· Martinez-Canut – saw an increase in prevalence of attachment loss from smoking one cigarette (0.5%), 2-10 (5%), and 11-20 (10%) daily

· Tomar and Asma – showed that smoking was associated with a significantly higher risk for having periodontitis in current smokers (OR=4) and in former smokers (OR=1.7) compared to nonsmokers. Among current smokers, persons who smoked >31 cigaretts/day had ab OR=5.9 and those who smoked 9 cigarettes/day had an OR=2.8 à suggesting a dose–response relationship between number of cigarettes smoked per day and the odds of periodontitis.


· All studies agree – more attachment loss, deeper probing depths, more recession, more BOP in diabetics

· NHANES III increase in the prevalence, extent, and severity of attachment loss with increasing age

· NHANES III – moderate and advanced disease increases to 65 years of age, then remains steady to age 80


· NHANES Ibetter periodontal status reported for females than males, higher probing depth and more plaque accumulation in males

· NHANES I – higher occurrence rate of periodontitis in blacks vs. whites, highest among black males.

· NHANES III – blacks > Mexicans > whites


· – increased susceptibility of northern Europeans to IL1 gene polymorphisms (OR of 18.9)


· Drury – prevalence of inflammation and loss of attachment >4 increased with a decrease in socioeconomic level

· NHANES III – socioeconomics contribute to oral health problems

· Nordyred – negative financial situation had higher risk, OR=2.2 for alveolar bone loss


· Genco – Found that psychosocial measures of stress, particularly those associated with financial strain and distress and manifesting as depression, were significant risk indicators

for severe chronic periodontitis. Estimated a significantly higher risk for having greater clinical attachment loss (OR=1.7) and alveolar bone loss (OR=1.7) associated with financial strain after adjusting for age, gender, and cigarette smoking.

Found that individuals with financial strain who also had inadequate coping behavior had a higher risk for having severe attachment loss (OR=2.2) and alveolar bone loss (OR=1.9) than individuals with low levels of financial strain with a similar coping behavior.

· Multiple studies that link stress with acute necrotizing periodontal disease

Overwhelming evidence that both smoking and diabetes mellitus are important risk factors for periodontal tissue loss.

Topic: Referral patterns

Authors: Cobb, C, Carrara, A., 

Title: Periodontal referral patterns, 1980 versus 2000: A Preliminary study.

Source: J Periodontol 2003; 74: 1470 – 1474

Type: Preliminary study


Keywords: comparison studies; dental offices; office management; periodontal diseases/trends; referral and consultation

Purpose: To compare the differences in referral patterns to the periodontal offices from 1980 to 2000.

Method: Retrospective chart analysis on 782 patient charts from 3 periodontal practices (Florida, Missouri, and Arizona). Random selection looked at: gender, age at initial exam, smoking status, ADA case type, number of missing teeth excluding wisdom teeth, and number of teeth planned for extraction. Approximately 50% of all dental records examined did not contain a complete data set and were therefore excluded.

ADA case type

Type I: gingivitis

Type II: slight chronic periodontitis (PD 3-4 mm and radiographic evidence of resorption of the interproximal crestal lamina dura)

Type III: moderate periodontitis (PD 4-6 mm and radiographic evidence of alveolar bone resorption, Class I/II mobility, Class I/II furcation involvement)

Type IV: advanced periodontitis (PD 4- > 7 mm, Class II/III mobility, Class I/II/III furcation involvement)

Type V: variety of periodontal diseases such as aggressive periodontitis, necrotizing periodontal disease, non-responding (refractory) periodontitis


1) Increase in the average age of patients at the time of the initial examination

2) Decrease in the percentage of patients using tobacco at the time of the initial interview

3) Increase in the percentage of periodontal Case Type IV patients with a concomitant decrease in the number of periodontal Case Type III patients

4) Increase in the average number of missing teeth per patient at the initial examination

5) Increase in the average number of teeth scheduled for extraction per periodontal treatment plan.

Conclusion: Although fewer patients used tobacco, referral patients had greater loss of teeth, more severe disease, and required more extractions. Possible explanations include:

1) General dentists referring only the severe cases

2) delayed diagnosis

3) lack of recognition of diseases severity

4) delayed referral

5) inappropriate treatment or even lack of treatment

6) increased use or inappropriate use of local drug delivery resulting in disease masking

7) patient anxiety or fear

8) increased extractions and placement of implants

9) negative financial consideration


Topic: Referral trends

Authors : McGuire M, Scheyer, E.

Title: A Referral Based Periodontal Practice – Yesterday, Today, and Tomorrow

Source: J Periodontol 2003; 74: 1542-1544

Type: Discussion

Rating : Good

Keywords: referral

Purpose Discussion article on the referral based periodontal practice through different periods of time.

Discussion: Periodontists depend on general dentists. One of the most important issues for the periodontist establishing a practice is being referred periodontal patients at the appropriate time in their disease process. This remains to be a problem like it was 20 years ago.

Cobb evaluated the difference in referral patterns in 1980 vs. 2000, and found thatpatients referred in 2000 were older, had more missing teeth, more severe disease, had less incidence of cigarette smoking, and required more extraction of teeth than those referred in 1980. Cobb shows that prevalence rates are not reflective of the periodontal care that is delivered. The majority of periodontal disease still remains untreated.

Reasons for undertreatment : patient’s lack of accessibility to care, poor economic status, managed care, patient anxiety/fear, patient non-acceptance of treatment/referral and the control of the primary dentist to initiate the referral.

Since 1980 practice management seminars have been been encouraging GPs to partake in soft tissue management protocols, and non-surgical treatment is looked upon as a much more important income center in the business model of today’s general practice. Student loans of recent graduate also play a role in that, since doctors prefer to delay referrals. Today many periodontal courses in dental schools are taught by hygienists. Because of the general practice model use in some dental schools, there is far less opportunity for contact between dental students and periodontists. Many of the young dentists do not understand what periodontists do.

Reasons for why majority of referrals have increased disease severity + need for extractions:

The success of periodontal treatment delivered in the general practice is not properly reassessed and dental implants have greatly increased in popularity.

Etiology and classification of disease are much more complex, providing the specialist with better knowledge to diagnose, establish accurate prognoses, and successfully treat periodontal disease.

The periodontal – systemic link is the only “wild card” on the horizon that would possibly reverse the trends discussed.

Conclusion: Today’s successful referral base practice depends on the strength of outreach programs to the general dentist for education pertaining to diagnosis, prognosis and treatment, and also for information about periodontists’ abilities to expand treatment opportunities involving oral plastic surgery, regeneration, dental implants and other advanced therapies. It is essential that our specialty continues to educate general dentists and hygienists to ensure that the periodontal population is well treated. As periodontists we do not want to abandon our heritage, but we cannot depend on referrals for periodontitis to be the foundation for our practices in the future.


Topic: Periodontal referrals

Authors: Lee JH, Bennett DE, Richards PS

Title: Periodontal referral patterns of general dentists: lessons for dental education

Source: J Dent Educ. 2009; 73(2): 199-210

Type: survey

Keywords: referrals, periodontal disease, Comprehensive care, dental education, general dentist, periodontist

Purpose: To explore factors related to periodontal referral patterns from general dentists. To compare dentists who refer few patients to dentists who refer more patients in their referral considerations. To assess how general dentists’ perception of dental school preparation affects their referral decisions.

Methods: The survey was adapted from prior research.  The survey had 4 parts:

  1. Sociodemographic, educational background and practice characteristics
  2. How dentist care for patients with periodontal disease
  3. Number of patients requiring periodontal treatment
  4. type of care provided
  5. the factors when considered when referring patients for periodontal treatment.
  6. Dental education prepared them well to provide periodontal treatment, whether they had received any postgraduate education about periodontal treatment, and whether they intended to attend any continuing education courses about periodontal therapy.

The survey was mailed to 500 members of the Michigan Dental association. 160 members responded (32%). The population was predominantly male (77%) and white (96%) and 66% practiced in solo practice. 13 percent were situated in rural areas, 23 percent in small towns, 34 percent in moderate-sized cities, 21 percent in suburbs, and 10 percent in large cities.


  • Patient Diagnosis
  • 33% diagnose 0-5 pts/week
  • 34% diagnose 6-10 pts/week
  • 33% diagnose >10 pts/week
  • 59% of dentists reported that they personally do not treat their periodontal patients
  • 7% of dentist reported that they treat >5 patients per week for periodontal disease
  • 54% of dentists reported that their hygienists treat >5patients per week for periodontal disease
  • Periodontal Referrals
  • 69% refer between 1-5 patients per week
  • 23% refer no patients
  • 7 % refer >5 patients per week
  • Most dentists indicated that their patients receive non-surgical care. While they “sometimes” utilize systemic or local antibiotics.
  • 7% of dentists never provide periodontal surgery.
  • Dentists who made referrals more often considered oral hygiene a bigger factor.
  • Dentists who referred more patients reported that their dental education had prepared them less well than dentists who referred fewer patients.
  • Dentists who referred fewer patients were less interested in continuing education on periodontal therapy than those dentists who referred more patients.

Discussion: Third of Dentist surveyed said they had 0-5 new perio patients a week; this is below the average incidence rate of disease.  Dental educators should seriously consider how future dentists should be educated about making appropriate periodontal treatment decisions, actual providing optimal treatment, and referring periodontal patients in a timely fashion.

Topic: standard of periodontal care

Author: Dockter KM, Williams KB, Bray KS, Cobb CM

Title: Relationship between prereferral periodontal care and periodontal status at time of referral.

Source:J Periodontol. 2006 Oct;77(10):1708-16.

DOI: 10.1902/jop.2006.060063

Type: Clinical

Purpose: To evaluate pre-referral periodontal care and periodontal status at the time of referral.


  • 100 patients from 3 different private practices in Kansas City, Missouri
  • Patients were newly referred from general dentists and had not been previously treated by a periodontist.
  • Patients exhibited type II level of disease or above were included, excluding patients with aggressive or necrotizing disease.

Type I: gingivitis with no clinical or radiographic evidence of attachment loss

Type II: chronic periodontitis of slight severity characterized by probing depths of 3 to 4 mm and radiographic evidence of resorption of the interproximal crestal lamina dura

Type III: moderate chronic periodontitis characterized by probing depths of 4 to 6 mm, radiographic evidence of alveolar bone re- sorption, Class I or II tooth mobility, and Class I or II furcation involvement

Type IV: chronic periodontitis of advanced severity characterized by probing depths of 4 to >7 mm, Class I, II, or III tooth mobility, and Class I, II, or III furcation involvement.

  •  Three components were examined
  • A clinical chart audit (health history, and periodontal status)
  • Disease classification based on a clinical exam
  • Patient response questionnaire.
  • Probing depths, bleeding points (BOP), furcation involvement and mucogingival problems were assessed.

Results: 100 participants with a mean age of 50 and equally split gender, 86% Caucasian, 6.4% African American, and 5.7% Latino. Participants’ personal oral hygiene was reported as daily brushing for 42.3% of case type III and 31.1% of case type IV; daily flossing was slightly higher in case type III at 65.4% versus 58.3%; and case type IV used some type of interproximal aid slightly more at 50.0% compared to 46.2%.


  • The majority of all periodontal patients were prescribed the same treatment.
  • Implying a lack of discrimination between the severity of disease and treatment received.
  • Periodontitis prevalence rates are inconsistent with the treatment prescribed.
  • The majority of periodontitis remains untreated.
  • Dentistry is failing in several areas concerning periodontal patients.
  • Timely diagnosis of disease, appropriate treatment of disease, & timely referral for treatment of disease


  1. Disease severity did not affect the periodontal treatment provided by the general dental practices.
  2. Subjects with more severe disease reported only a slightly higher incidence of SRP
  3. The average number of dental cleanings received in the general dental office was less than the standard for a 2-year period
  4. Dentists were more likely to provide for patients with moderate disease
  5. Hygienists were more likely to provide care to patients with severe disease
  6. Patients generally made their initial periodontal evaluation appointment within a year of diagnosis


Tissue Indices

Topic: periodontal indices

Title: The gingival index, the plaque index, and the retention index system.

Author: Loe H.

Source: J Periodontol 38:610-617, 1967.

Type: Review article


Keywords: plaque index, gingival index, retention index.

Gingival Index: measures qualitative changes in the gingival soft tissues.

0= Normal

1= Mild inflammation – slight color change, slight edema, no BOP

2= Moderate inflammation – redness, edema, glazing, BOP

3= Severe inflammation–marked redness & edema, ulceration, spontaneous BOP

· Each of the 4 gingival areas of the tooth is given a score from 0-3, this is the GI for the area. The scores from the four areas of the tooth may be added and divided by 4 to give the GI for the tooth. By adding the indices for the teeth and dividing by the total number of teeth examined, the GI for the individual is obtained. Subjects with mild inflammation usually score from 0.1-1.0, those with moderate inflammation from 1.1-2.0, and an average score between 2.1-3.0 signifies severe inflammation.

Plaque Index (0-3) distinguishes between the severity and location of the soft debris aggregates.

0= no plaque in the gingival area

1= a thin film of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may only be recognized by running a probe across the tooth surface.

2= moderate accumulation of soft deposits within the gingival pocket, on the gingival margin and/or adjacent tooth surface, which can be seen by naked eye.

3= abundance of soft matter (1-2mm thick) within the gingival pocket and/or on the gingival margin and adjacent tooth surface.

Plaque Index scores consider only differences as to thickness of soft tissue deposits in the gingival area of the tooth surfaces and no attention is paid to the coronal extension of the plaque.

Retention Index (0-3) measures roughness of tooth surface.

Retention Index: assessment of the main retentive factors and quality of the surface at the gingival aspect

0= no caries, no calculus, no imperfect margins in a gingival location

1= supragingival cavity, calculus or imperfect margin of dental restoration.

2= subgingival cavity, calculus or imperfect margin of dental restoration.

3= large cavity, abundance of calculus or grossly insufficient marginal fit of dental restoration in a supra-g and/or sub-g location.

No disclosing solution was used for any of the measurements


Topic: Epidemiology of Periodontal Disease

Authors: Dowsett, S, Eckert, G. et al

Title: The applicability of half-mouth examination to periodontal disease assessment in untreated adult populations.

Source: J Periodontol 2002, Sep; 73(9): 975 – 81

Type: Retrospective Study

Rating : Good

Keywords: Disease progression; periodontal diseases/diagnosis; periodontal pockets; periodontal attachment; periodontal index; full-mouth assessment; partial-mouth assessment.

Whole mouth exams are standard for assessment of periodontal disease in most epidemiologic studies, but often key teeth are cited for a partial exam to save time & provide a larger sample size. This can erroneously depict disease patterns. Past studies have shown that periodontal disease exhibits bilateral symmetry.

: To assess if half-mouth exam design (random diagonal quadrants) provides a more accurate depiction of periodontal disease over a limited partial mouth exam of index teeth (the Ramfjord teeth).

Clinical data from whole mouth exams of untreated indigenous Indians from Guatemala (dental care limited to extractions) of 3 previous studies (single trained examiner in each). PD & CAL compared for 292 subjects; GI & PI only available for 113. Data analyzed 3 ways: whole mouth exam, half-mouth exam, & Ramfjord teeth (max R/mand L 1st molar, max L/mand R 1st pre, max L/mand R CI – #3, #9, #12, #19, #25, #28); each then compared avg, 35-44 yo, 45-54 yo, 55-64 yo.

For mean PI & GI, both half-mouth exams showed 95-99% correlation to full mouth exam, whereas Ramfjord teeth showed 92-95%. For PD & CAL, half mouth design had ~98% correlation, whereas Ramfjord teeth showed 89-98% correlation, depending on the age range. Overall, half-mouth design appeared to have a better correlation with actual periodontal disease presents. Lower correlation was found in both designs when PD & CAL 5 mm (lowest 74% for half mouth, lowest 48% for Ramfjord assessment)

Both study designs are adequate as time-saving techniques for periodontal disease assessment, but as severity of disease increases, the sensitivity of Ramfjord design significantly decreases.


Plaque Indices

Topic: O’Leary plaque score

Authors :O’Leary TJ, Drake RB, Naylor JE.

Title: The plaque control record

Source: J Periodontol. 1972 Jan;43(1):38. DOI: 10.1902


Keywords: plaque control record, plaque index,

Purpose: The plaque control record was developed to give therapists a simple method of recording presence of plaque on individual tooth surfaces. The form also allows the patient to visualize their own progress in learning plaque control.


Use a disclosing solution (like Bismark Brown Iodine Stain) on the first appointment.

After patient rinses, use an explorer to detect soft accumulations on stained surfaces.

Record presence of plaque at M, B, D, L.

Soft plaque accumulations on soft tissue (not at the dentogingival junction) are not recorded.

Divide the number of plaque containing surfaces by the total number of available surfaces.

Carry out the same procedure in the subsequent appointment.

Conclusion: Author claims this method can be used to help motivate patients over a period of time, if used in the subsequent appointment to determine the patients progress in learning oral hygiene procedures.

Surgical procedure is not carried out until the patients reaches 10% or less. If this is not achieved after 3 or 4 sessions, the treatment is either terminated or drastically revised.

Bleeding Indices

Topic: Interdental Bleeding Index

Author: Caton JG, Polson AM

Title: The inderdental bleeding index: A Simplified procedure for monitoring gingival health.

Source: Compend. Cont. Educ. Dent. 6(2):88-92, 1985.

Type: Discussion


Keywords: interdental bleeding, gingival health

Purpose : To compare the histology of the interproximal tissues in the presence and absence of bleeding after a defined stimulus.


-A wooden interdental cleaner was inserted between the teeth from the facial aspect, and the interdental papilla was depressed 1-2mm.

-The interdental cleaner was inserted and removed 4 times. The presence or absence of bleeding was recorded within 15 seconds.

-15 bleeding and 15 non-bleeding biopsies were obtained from 30 patients and processed

-The sites showed pocket depth ≤ 3mm and radiographic bone loss of ≤ 20%


-The results show that bleeding specimens contained a significantly greater percentage of inflamed gingival connective tissue than non-bleeding (55% vs. 18%). These bleeding areas were collagen depleted.

-The index offers the advantage of assessing the inflammatory status of the otherwise inaccessible mid-interproximal region.

BL: Bleeding sites contain SSD more inflammatory cells and have less collagen than non-bleeding sites. IBI can be used to monitor gingival health.


Topic: bleeding on probing

Authors : Barendregt DS et al.

Title: Comparison of the bleeding on marginal probing index and the Eastman interdental bleeding index as indicators of gingivitis

Source: J Clin Periodonto 2002; 29: 195 – 200

Type: Clinical study

Rating : Good

Keywords: gingivitis, plaque, probe, bleeding index

Purpose: To compare the Eastman interdental bleeding (EIB) and the bleeding on marginal probing index (BOMP).

Methods: BOMP: a Williams periodontal probe was inserted in the gingival crevice in approximately 2mm of depth and was run at an angle of about 60o to the longitudinal axis of the tooth. Presence or absence of bleeding was scored within 30 sec after probing.

: Inserting a wooden interdental cleaner between the teeth from the facial side aspect and depressing the interdental tissues 1-2 mm. Cleaner was inserted and removed four times and bleeding was recorded within 15 sec.

Experiment 1 : 45 volunteers having moderate gingivitis and absence of periodontal breakdown were evaluated. PD less than 5mm and more than 20 teeth were required. Plaque index was assessed before the gingival indices. Split mouth design was utilized in two contralateral quadrants.

Experiment 2 : Both indices were compared within the experimental gingivitis model and the sensitivity to detect treatment effect was evaluated. 25 volunteers in good general health with at least 20 teeth, PD less than 5mm, and no interdental recession were used. At baseline the desired degree of gingival inflammation was 25% or less of sites bleeding on marginal probing. Both indices were assessed in 4 sites in all teeth except for the central incisors. Subjects were requested not to brush the lower arch for 21 days but were allowed to continue brushing the upper arch. In order to introduce a treatment effect they were instructed to floss the one lower quadrant and the other one used as control. After 21 days the 25 subjects were scored for plaque and gingival bleeding, using the two indices in the same order.

Results: Experiment 1: No statistically significant difference was found between the proportions of bleeding sites of the two indices. The correlation between BOMP index and plaque was higher than with the EIB index and plaque.

Experiment 2 : At baseline BOMP index was 14% and 12% respectively for treatment and non-treatment sites and EIB index was 23% and 21%. All subjects received a professional prophylaxis at baseline, therefore after 21 days the amount of plaque increased from zero to 0.67 at treatment sites and to 1.57 at non-treatment sites. BOMP index increased to 38% and 69% and EIB index to 30% and 73% between treatment and non-treatment sites.

No significant difference was found between day 0 and day 21 in the treatment sites for the EIB index.

Conclusion: The ability of BOMP and EIB indices to assess the level of gingival inflammation appears to be comparable.


Topic: Periodontal diseases

Authors Newbrun E 

Title: Indices to measure gingival bleeding

Source: J Periodontol 67:555-561, 1996

Type: Review

Keywords: Gingivitis/diagnosis, gingival index, gingival hemorrhage, periodontal disease, smoking, bleeding indiex.

· Gingival bleeding is an objective, easily assessed sign of inflammation that is associated with several periodontal diseases. Not only bleeding is an objective sign of early gingivitis and other forms of periodontal disease, but it also precedes the more subjective signs such as discoloration and swelling. The equipment needed for testing is cheap and simple.

· Many bleeding indices have been devised, some assess bleeding as simply present or absent, whereas others use grading in an attempt to assess severity of bleeding. The choice of which index to use depends on whether the purpose is an epidemiological survey, a clinical study, diagnosis and treatment, or patient motivation. Bleeding may be elicited manually with toothpicks, dental floss or a periodontal probe, but a controlled-force probe, although more expensive, causes less trauma and less false-positive bleeding from healthy tissues.

· Because the bleeding response may be either slow or immediate, most indices call for a wait of 10 to 30 sec before assessment. The angulation of probing can affect number of bleeding sites. Probing to the bottom of the pocket results in higher bleeding scores than does probing of the marginal gingiva.

· A maximum force of 0.25N is suggested to avoid trauma to clinically healthy gingival tissues. Electronic calibrated pressure-sensitive probes are expensive and more time consuming to use than conventional hand probes.

· As regards to reproducibility, bleeding is a response to trauma, however mild and that a second trauma would probably disturb any clot and restart bleeding.

· As a predictor of periodontal disease progression, bleeding on probing has low sensitivity owing to a high frequency of false-positive responses, but has high specificity in that failure to bleed indicates health

· There is evidence that smokers have less, or delayed, gingival bleeding when compared with non-smokers; therefore smoking needs to be controlled for in studies of gingival bleeding.

· Measurement of gingival bleeding tendency should be an integral part of a comprehensive oral examination. In clinical practice, the use of a graded bleeding index is more likely to identify sites that are at risk of further destructive activity.



Topic : Periodontal index

Authors Persson R, Svendsen, Daubert K.

Tittle: A longitudinal evaluation of periodontal therapy using the CPITN index.

Source J Clin Periodontol. 16:596-574, 1989.

: Clinical study

Rating : Good

Keywords : Periodontal index


Code 0 dx: no sign of pathology

tx: no need for treatment

Code 1 dx: bleeding after gentle probing

tx: OHI

Code 2 dx: presence of calculus or overhangs

tx: scaling and elimination of defective margin

Code 3 dx: presence of 1 or more pockets of 4-5mm

tx: root planing w/ or w/out anesthesia

Code 4 dx: presence of 1 or more pockets >6mm

tx: complex tx (may include sx)

Code X dx: missing sextant, <2 teeth present

Purpose : To evaluate the use of the community periodontal index of treatment needs (CPITN) on the effects of periodontal therapy.

Methods : 3 year retrospective study. Each sextant in 123 patients (85F, 38 M, mean age 46.6 yrs old) exhibiting moderate to advanced adult periodontitis was examined for OH, BOP, REC, PD, defective restorations, and calculus. Initial tx completed w/ OHI, prophylaxis, and SRP. Sx or non-sx tx performed, then SPT q3 months. Pts re-examined annually and clinical data was acquired at initial examination, re-evaluation, and at 1- and 3- year follow-up visits.

The CPITN index was employed retrospectively to describe initial disease severity and subsequent outcome oftherapy. Each sextant was given a score that recorded the condition of the worst affected site in that sextant . Sextants with fewer than 2 teeth were scored as missing.


· Few sextants had an initial CPITN Code 0, however the prevalence of sextants with an initial CPITN Code 4 was high.

· Posterior sextants with CPITN Code 4 were more likely treated with surgery than sextants with CPITN Code 3.

· Although surgery appeared to be more effective than non-surgical therapy in reducing the CPITN Codes for posterior sextants at 1 year, there were no differences between sx and non-sx tx at the 3-year examination.

· Anterior sextants were treated with a non-surgical approach regardless of CPITN Code at either initial examination or reevaluation.

· The outcome of therapy in this study using the CPITN index is comparable to other studies utilizing mean pocket depth and attachment level.

Conclusions : CPITN index does not prescribe specific therapeutic interventions, but does provide a useful tool to monitor patients in the treatment of periodontitis.


Study Design and Reliability

Topic: Ramfjord teeth and periodontal disease diagnosis
Authors: Gettinger G, Patters M.R, Testa M.A, Loe H, Anerud A, Boysen H, Robertson P.B

Title: The use of six selected teeth in population measures of periodontal status.

Source: J. Periodontol. 54:155 – 159, 1983.

Type: Retrospective


Keywords: Ramfjord teeth

Purpose: To assess the relationship between the six Ramfjord teeth (3, 9, 12, 19, 25, 28) and the entire dentition for the PI, GI, Calculus index and ALoss

Method: Data were obtained in the course of studies on the natural history of periodontal disease in Norway and in Sri-Lanka. PI, GI, calculus index (CI) and CAL were measured for both groups. For the present study, only data obtained from individuals with a complete dentition to the 2nd molar were included. Regression and correlation analysis was performed on each index for the six teeth vs. the entire dentition. Pearson and Spearman correlation methods were employed.

Result: Measurements obtained from the 6 teeth were strongly correlated with those of the whole dentition. Deviation: when using the PI & GI on 6 teeth, low scores (scores 0-1) actually underestimate disease, while high scores (2-3) tend to overestimate it. Perfect agreement was located at a GI score of 1 and 1.5 for the Norwegian and Sri Lankan populations, respectively. Calculus & attachment loss tend to be overestimated for the whole dentition. CALoss of 2, 4, and 6mm overestimated CAL loss for the whole dentition by 0.5, 1, and 1.6mm respectively.

Conclusion: The Ramfjord index was highly correlated with the mean whole mouth assessments for PI, GI, CI and CAL. Deviation can be always expected.

Accoridng to Gettinger, the Ramfjord teeth

Was highly correlated with mean whole mouth assessments for periodontal parameters

Was not highly correlated with mean whole mouth assessments for periodontal parameters

Low scores using PI and GI underestimated disease while high scores overestimated disease

High scores using PI and GI underestimated disease while low scores overestimated disease

A and C


Topic: Reliability

Authors Clark, C et al

Title: Reliability of attachment level measurements using the cementoenamel junction and a plastic stent.

Source: J Periodontology 58: 115, 1987

Type: Clinical

Rating : Good


Purpose: To compare examiner reliability for AL measurements using the CEJ as reference point and a custom-made plastic occlusal stent.

Materials and methods: Patients with advanced periodontal disease who were part of 6-month trial to assess the benefits of adjunctive antibiotic therapy participated in the study. Duplicate measurements were taken at baseline or prior to the first cleaning appointment. Pressure sensitive probe was used to assess the probing forces of both examiners. Each patient had 2-3 teeth that were measured and 4 measurements/ tooth were taken. Data when CEJ was used as a reference point were analyzed separately when CEJ was visible and when it was sub-gingival.

Results: 17% of baseline data using the CEJ could not be used because CEJ was covered by calculus. The mean PD was over 7mm. Intra-examiner duplicate examination results demonstrate that for PD, stent and CEJ paired readings, 83%, 89% and 72% respectively, of the measurements were within 1mm of one another. For inter-examiner readings 76%, 84% and 69% were within 1mm of one another. For intra- and inter-examiner readings, PD and CEJ measurements demonstrate more readings of 3mm or more difference, thus indicating greater variability.

Conclusion: Data suggest increased reproducibility of AL measurements using the custom occlusal stent.

Topic: Periodontal indices

Title: Attachment loss versus pocket depth as indicators of periodontal disease: A methodological note

Author: Carlos, J, et al

Source: J Periodont Res 22: 524, 1987

Type: Review article

Keywords: indicator of disease, attachment loss, pocket depth, prognosis

Purpose: To compare attachment loss and pocket depth as indicators of periodontal disease.

Materials and methods:

Analyzed a recent epidemiologic study of the oral health of US adults.

Analyzed data from the mesial sites (14 sites per person) from a sample of 15,132 persons aged 18-60+.

Buccal sites were excluded to minimize situations where toothbrushing-associated recession may have been present.


Data was distributed among age ranges.

Of the 14 mesial sites, the most severe PD & AL were categorized as either 4-6mm or 6 + mm, then grouped by age.

Beyond age 34 the prevalence of these moderate and deep pockets tends to remain stable, there is only a weak correlation between pocket depth and increasing age. In contrast, there is a steady increase in the proportion of persons with moderate and severe attachment loss with advancing age.


PD measurements alone are inadequate to establish the amount of periodontal destruction.

As apical migration occurs, recession can occur, leading to no change in PD even though the disease is progressing.

AL provides a more accurate estimate of periodontal disease progression.

Topic: Epidemiology of Periodontal Disease

Authors :Egelberg, J

Title: The impact of regression towards the mean on probing changes in studies of the effect of periodontal therapy.

Source: J Clin Periodontol 16: 120- 123, 1989

Type: Statistical study

Keywords: periodontal therapy; probing depth; probing attachment level; regression towards the mean.

To evaluate the magnitude of the regression towards the mean (RTM) effect relative to the true changes following the periodontal therapy.

2 groups of adults with moderate to advanced periodontitis treated with plaque control and root debridement. Group 1: 49 subject (2532 sites from incisors, cuspid and bicuspid) and group 2: 8 subjects (1034 sites from entire dentition) were included to compare the duplicated initial and 3 months probing data. Regression lines were calculated for observed changes in PD of the individual sites. Regression lines adjusted for the RTM effect, were also calculated.

PD sites sub-grouped into shallow (3.5 mm), moderately deep (4-6.5 mm) and deep (7 mm). For the extreme subgroups of recorded shallow and deep sites, the RTM effect was found max of 0.6 mm. SD of the difference between duplicated probing measurement for the 2 groups of subjects under study range from 0.78 to 1.03. These values compare well with corresponding data from the other studies. For the PD changes in shallow sites and for the PAL changes in both shallow and deep sites, the RTM accounts for a larger proportion of the observed mm changes.

It seems prudent to be careful about the interpretation of these changes in the clinical studies, where the RTM effect has not been adjusted for. Whenever possible, duplicated initial recording should be taken to allow determination of and subsequent adjustment for the RTM effect.


Topic: indices and scoring methods

Authors :Lynch S,

Title: Methods for evaluation of regenerative procedures.

Source: J Periodontol. 1992 Dec;63(12 Suppl):1085-92. DOI: 10.1902

Type: review

Keywords: wound healing; periodontal disease/therapy

Purpose: To provide an overview of the most well-accepted methods for evaluating periodontal wound healing procedures and materials.

Discussion: a few basic definitions;

Regeneration: is defined as the reproduction of a lost or injured part. Reconstitution of the periodontal attachment apparatus including gingival attachment, cementum, PDL and alveolar bone around teeth with a deficient periodontium.

New Attachment: The reunion of connective tissue with a root surface that has been deprived of its PDL. This formation occurs by the formation of new cementum with inserting collagen fibers.

Regeneration differs from new attachment in that alveolar bone formation is pre-requisite in regeneration of the periodontium.

The methods described are applicable for evaluation of the procedures aimed at achieving both regeneration and new attachment. When possible, measurements should be made by same investigator using a calibrated /automated probe.

5 Major methods used to evaluate regenerative procedures:

Soft tissue measurements that have been appropriately utilized to evaluate the effects of regenerative procedures include: Free gingival margin (FGM), Probing attachment level (PAL/CAL), PD, horizontal furcation probing depth (HFPD), stent to CEJ (S-CEJ)

Appropriate hard tissue measurements from a fixed reference point: crestal height of bone, bone loss, defect depth, open horizontal furcation probing depth, furcation defect volume

Radiographic assessment of hard tissue : length of bone gain/loss w/in defect, length of crestal bone gain/loss

Histologic evaluation : amount of new bone, length of new cementum, percent defect fill, length of crestal bone resorption/formation

Other end points: GI, BI, PI, and mobility, BOP, dehiscence, other complications specific to test material.

Safety and efficacy of regenerative materials should be initially evaluated in animal studies. They must then be tested in well controlled human clinical trials. If clinical end points indicate that a regenerative material enhances healing of soft and hard tissue, limited histological evaluation of human biopsy material may be needed.


Topic: Regeneration Clinical Trials

Author: Gunnsolley J, Elswick R

Title: Equivalence and superiority testing in regeneration clinical trials

Source: J Periodontol 69: 521 – 527, 1998.

Type: Report

Keywords: Clinical trials; therapeutic equivalency; therapeutic similarity

Background: Superiority testing is to determine if a new therapy is superior to the established treatment. Equivalence trials are used to determine if the new product has similar therapeutic properties

Purpose : to investigate sample size requirements for both equivalence and superiority studies investigating products used in regeneration.


-Criteria to choose the studies:

1.The studies chosen had to report attachment gain, sample size, and either a standard error or a standard deviation.

2.The studies had to be a randomized clinical trial comparing at least 2 materials.

3.Studies were further limited to those that evaluated therapies consisting of either a surgical control or surgical procedures utilizing DFDBA, porous hydroxyapatite or an ePTFE membrane.

– Sample size estimation, superiority testing, equivalence testing were analyzed for the studies.


-The studies suggest that both osseous bone grafting material and guided tissue regeneration with ePTFE membranes are more effective than debridement alone.


-A criterion of a 20% difference between groups of the total therapeutic effect resulted in sample sizes, which ranged from 64 to 127 in equivalence clinical trials.

-Equivalence clinical trials require much larger sample sizes than have been previously reported and larger than superiority trial.

– Clinical trials investigating periodontal regeneration have much smaller sample sizes than ones required for significant equivalence trials


Topic: Clinical versus statistical significance

Authors : Rethman M, Nunn, M

Title: Clinical versus statistical significance

Source: J Periodontol 70: 700 – 702, 1999

Type: Review

Keywords: clinical significance, statistical significance

Purpose: To discuss a few concepts that help determine the clinical value of statistically based conclusions.

Conclusion: In the past, investigators have collected data on a number of outcome measures in the hope that one or more would yield a “statistically significant” result. The problem with this is that it leads to a high risk of incorrectly finding significant differences that actually do not exist. The ADA standards should be used to verify the equivalence of a new therapy. According to these, the new therapy should be 90% as effective as the conventional therapy with 80% power. Example: If a conventional therapy reduces probing depth by 1.50mm with a standard deviation of 0.80mm, a new therapy should show a reduction of 1.35mm with 80% power, in 353 patients. Clinical context is important to formulate an opinion regarding the clinical significance of a statistically significant result. All factors, such as morbidity, treatment cost, expected results should be taken into consideration by the clinicians and adjusted to the clinical frame.


Topic: Loss of attachment due to root planning and scaling.

Authors: Gunsolley J et al No Article

Title: Is loss of attachment due to root planning and scaling insites with minimal probing depths a statistical or real occurrence

Source: J Periodontol 2001 Mar: 72(3): 349-53

Type: Clinical study

Keywords: Periodontal attachment, planning, regression analysis, scaling, periodontal probes

Background Regression to the mean is a common phenomenon in statistics that suggests that extreme values will moderate the next time they are recorded, an example would be that if a 9 mm attachment loss is measured, then the next time it will be more likely measured as 6 mm. The rationale being that the original measure containing a 3 mm error and the perceived change is not real.

Purpose To estimate the effect that regression towards the mean has on perceived change in attachment level after root planning and scaling when sites are characterized into sites with shallow, moderate, and deep periodontal pockets. The results suggest that the majority of the loss in attachment level in the initially shallow sites and some of the gain in attachment level in the deeper sites is not real and due to regression towards the mean.

Material and methods Each participant was required to have a minimum of 20 teeth, at least 1 quadrant with all teeth present and a minimum of 8 sites with a minimum of 5mm PD and 2mm of attachment loss. 12 patients completed the study. Patients were probed at baseline by 2 examiners, then they repeated the probings 2 weeks later. Two quadrants randomly selected for SRP (the two remaining were not treated), 4 to 6 weeks later a re-eval examination was done by the treating periodontist and an examiner blinded to which quadrants were scaled and root planed.

Result With both examiners the 2-week second baseline exam showed regression to the mean mimicking attachment loss, and deep sites showed regression to the mean mimicking attachment gain even with no treatment provided.

Both shallow non-scaled and scaled sites had similar differences in repeat measures (-0.28mm, -0.25mm), which were also similar to and not statistically different from changes after therapy for both non-scaled (-0.21mm) and scaled sites (-0.08). Since the regression towards the mean effect, shown in the repeat examinations, exceeded any loss of attachment due to therapy, perceived loss of attachment due to therapy appears to be artificial. Regression towards the mean explain little of the changes at moderate sites. After therapy regression to the mean was responsible for 30% of the attenuation of deep pockets, and most of the increase in probing depth of shallow pockets.

Initial PD (mm) N non-scaled sites Non-scaled sites differences in repeat exam Non scaled sites change over time N scaled sites Scaled sites differences in repeat exam Scaled sites change over time
-0.28 -0.21 -0.25 -0.08

Conclusion Regression to the mean should be accounted for in analyzing data. Studies should be designed in such a manner that the regression towards the mean effect should be estimated. Repeat measurements must be taken to allow the estimation of measurement error phenomenon.


Topic: Partial reading protocols

Authors Kingman A, Susin C, Albandar JM

Title: Effect of partial recording protocols on severity estimates of periodontal disease.

Source: J Clin Periodontol.2008 Aug;35(8):659-67, 2008. Epub 2008 May 30.

Type: Clinical study

Rating : Fair

Keywords : Periodontal attachment, scaling, recording

Background In large surveys and epidemiological studies investigators use a partial recording protocol (PRP) involving the examination of a subset of intraoral sites

Purpose To evaluate the degree of bias of periodontal disease severity estimates for specific partial recording protocols in epidemiological studies.

Material and methods 1586 patients (14-103 years old, mean 35 years old, 1465 dentate), from the metropolitan area of Porto Allegre, Brazil, were recruited for the study. Over 20 PRPs were studied regarding their ability to assess mean PD, mean CAL and recession compared to comprehensive evaluation.

Study focused on 8 PRPs:

4 half mouth PRPs: 2 site (MB-B), 3 site (MB-B-DB or ML-L-DL) and six site (MB–B–DB–ML–L–DL) PRP.

4 full moth PRPs: 2 site (MB-B), 3 site (MB-B-DB or ML-L-DL) and six site (MB–B–DB–ML–L–DL) PRP on six Ramfjord teeth (teeth #3, #9, #12, #19, #25, and #28). No replacements for missing Ramfjord teeth were made.

Full mouth PRPs are based on an average of 22 teeth/mouth and half mouth PRPs 11 teeth/mouth.

· Result True full mouth mean CAL was 1.56mm for this study population.

· The relative biases for the PRPs ranged between -4.6%- 0.9% for CAL and -7.4%- 0.1% for PD.

· The smallest bias observed was for the 3 site, half mouth MB-B-DB PRP (0.4%).

· Mean CAL for the Ramfjord PRP had a 0.04mm (2.8%) positive bias for CAL and -0.04mm (-1.9%) negative bias for PD.

· NSS biases between the 8 PRPs studied in estimating mean CAL

· Any PRP whose bias exceeded 6% is SS.

Conclusion Findings suggest that the severity of disease may be better be reflected by the mean CAL or mean PD than by the prevalence of disease using some fixed maximum cut-off value for CAL or PD if only PRP-based clinical assessments are available. The mean CAL or mean PD measures of disease are much

less susceptible to misclassification than those based on some variation of the maximum attachment level or PD measurement for the subject.

Topic: Composite endpoints

Authors: Lynch S, Laving P, Genco R, Beasley W, Wisner-Lynch L

Title: New composite endpoints to assess efficacy in periodontal therapy clinical trials

Source: J Periodontol 2006; 77: 1314 – 1322

Type: Randomized clinical trial


Keywords: Bone regeneration; endpoint determination; periodontics; randomized clinical trial; wound healing

Background: CAL and bone height (radiographic or clinical) are two accepted endpoint measurements in periodontal treatment; however, neither has been shown to be more predictive of long term success than the other. It has been proposed that a composite endpoint analysis combining clinical and radiological parameters using a statistical test could be useful at determining endpoints.

Purpose: To provide evidence supporting a composite endpoint as the primary endpoint for periodontal therapy trials (CAL and either linear bone growth or percent bone fill).


Benchmark of success was set according to previous systematic review (change in CAL 2.67 mm, mean radiographic change in linear bone growth 1.1 mm, % bone fill 14.1%). Data for composite endpoint analysis was derived from a clinical trial evaluating two concentrations of recombinant human platelet-derived growth factor-BB (rhPDGF-BB) with beta-tricalcium Phosphate ( β-TCP plus buffer) as follows: Group I: β-TCP + 0.3mg/ml rhPDGF-BB

Group II, β-TCP + 1.0mg/mlrhPDGF-BB

Group III β-TCP + buffer.

The composite endpoints was at 6 months.

Results: Group I demonstrated SSD from Group III for CAL/LBG composite endpoint, 61.7% of sites in group I vs 30.4% sites in group III met the composite endpoint benchmark (P< 0.001). For CAL/%BF composite endpoint 70% of sites of sites in group I vs 44.6% of sites in group III met the composite endpoint bench mark (P = 0.003). A non-significant trend was observed for group II vs group III with 40% and 55% of sites meeting the CAL/LBG and CAL/%BF composite endpoints respectively.

Conclusion: Composite endpoints are advantageous in periodontal clinical trials where no single efficacy endpoint has been established as the most important. A composite endpoint, combining outcome that measures both the hard and soft tissues of periodontium may be preferable for assessing efficacy of periodontal regenerative therapies.

Critque: Without testing other composite endpoints, how can we know that these are the best composite endpoints to choose?


Incidence and Prevalence of Periodontal Disease

Topic: Incidence and Prevalence of Periodontal Disease

Authors : Eke Pl, Dye BA, Wei L et al

Title: Prevalence of periodontitis in adults in the United States: 2009 and 2010

Source: J Dent Res 2012;91;914-920

Type: Review

Rating : Good


Purpose: To provide estimates on the prevalence, severity and extent of periodontitis in the adult US population from data collected during NHANES 2009-2010.

Materials and methods: Gingival recession, and PD were measured at 6 sites per tooth for all teeth by dental hygienists. Total of 3741 adults 30 years of age or older participated in the examination.

Severe periodontitis: 2 or more IP sites with 6mm or more AL and 1 or more IP sites with 5mm or more PD.

Moderate periodontitis: 2 or more IP sites with 4mm or more AL or 2 or more IP sites with 5mm or PD (not on the same tooth).

Mild periodontitis: 2 or more IP sites with 3mm or more AL and 2 or more IP sites with 4mm or more PD (not on the same tooth) or 1 site with 5mm or more.

Total periodontitis was the sum of severe, moderate and mild periodontitis.

Other classifications were also used for comparison with other studies. Extent of disease was also recorded.

Results/BL: Total prevalence of periodontitis in 2009-2010 was 47.2%.

Mild, moderate and severe cases were 8.7%, 30% and 8.5% respectively. Total prevalence ranged from 24.4% in adults 30-34 y.o. to 70.1% in adults more than 65 years old. Significantly higher in males than females and in Mexican Americans than other ethnicities.

Prevalence was highest among persons with lowest educational status, increased with increasing poverty and highest among smokers.

The high prevalence of periodontitis in the adult U.S. population, the disparities among socio-demographic levels, coupled with the potential economic cost for prevention and treatment, suggest periodontitis as an important dental public health problem, especially among our aging population.


Topic: Periodontal indices progression of disease

Title: Clinical course of chronic periodontitis

Author: Schatzle M, Loe, H., Lang, N et al

Source: J Clinc Periodontol 2003; 30(10):909-918

Type: Review article


Keywords: attachment loss, prognosis, progression of disease

Purpose: o assess the rate of attachment loss during various stages of adult life in a well-maintained population.

Materials and methods:

· Data originated from a 26-year longitudinal study of Norwegian males who received regular and adequate dental care and practiced daily oral home care.

· Initial examination included 565 individuals aged 16-34 years. Subsequent examinations took place in 1971, 1973, 1975, 1981, 1988 and 1995 covering the age range of 16–59 years.

· The average observation period of a patient was approximately 6 1/2 years, with a range of 2–26 years.

· The subjects were divided into 9 age groups (<20, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59 years). At each appointment the participants answered questions regarding personal general health and dental care.

· Clinical examination: PI, GI, CAL, retention index, REC. The mean rate of attachment loss was calculated as the difference between the individual mean CAL loss of all sites of a participant between two examinations divided by the years between examinations.

· The level for sites with CAL loss was set at 2mm or more. Analysis consisted of sites with 1) initial loss of attachment (first occurrence of 2mm or more of CAL loss), 2) sites with CAL loss recorded in previous examination 3) reversed sites with recorded CAL loss at a previous survey and had less than 2mm of CAL loss at one of the following surveys.


· The mean individual cumulative attachment loss ranged from 0.14mm at 16-19 years of age to 2.44mm in the 55-59-year-old subjects.

· At 20-21 years, 92% of the sites had never been affected by CAL loss, 8% of the sites were affected by CAL loss and 0.33% of the sites reversed.

· During the subsequent 10, 20 and 30 years the proportion of healthy sites continued to decrease and that of the sites with CAL loss increased.

· As the individuals approached 60 years, the % of healthy sites dropped to 24%, sites with CAL loss increased to 69% and 7% of the sites had reversed.

· Only gingival recession (without PD QUOTE  2mm) had occurred in 99% of the buccal and lingual sites before the age of 25 years. Thereafter, REC was present in more than 90% of these sites.

· The mean rate of annualized CAL loss before 20 years was 0.09mm/year. The highest annual rate of CAL loss occurred before 35 years of age (0.08-1mm/year), after which the mean annual rate decreased to about 0.04-0.06mm/year for the next three decades of life.

· During fifties and on approaching 60 years of age, a trend towards an increased rated of loss took place but there was no SSD. The risk of converting a healthy site to a site with CAL loss appeared to be small before 20 years of age (1%).

· The risk then steadily increased with age and reached a pick of 7% at the age of 35 years, then stabilized at 4-5% before reaching another peak (6%) at the age of 55-59 years.


· Over a 26-year period, 25% of the subjects went through adult life with health and stable periodontal conditions, remaining 75% developed slight to moderately progressing periodontitis with progression rates varying between 0.02 and 0.1mm/year with a cumulative mean loss of attachment of 2.44mm as they approached 60 years of age.

· The annual mean rate and mean annualized risk of initial CAL loss were highest between 16 and 34 years of age


Topic: Incidence and Prevalence of Periodontal Disease

Authors:  Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W

Title: Global burden of severe periodontitis in 1990-2010: a systematic review and meta-regression

Source:  J Dent Res. 2014 Nov;93(11):1045-53.

DOI: 10.1177/0022034514552491
Type: Review

Keywords:  periodontal diseases, oral health, world health, statistics, prevalence, incidence.

Purpose: To consolidate all epidemiologic data about severe periodontitis (SP) and, subsequently, to generate internally consistent prevalence and incidence estimates for all countries, 20 age groups, and both sexes for 1990 and 2010.

Material and methods:

  • The systematic search of the literature following the Cochrane handbook for qualifying articles between 01/1980 and 12/ 2010 yielded 6,394 citations.
  • SP definition: Community Periodontal Index of Treatment Needs (CPITN) of 4, CAL >6mm, PD >5mm.
  • After screening titles and abstracts, 5,881 citations were excluded, leaving 513 for full-text review.
  • Another 441 publications were further excluded following the validity assessment.
  • A total of 72 studies, including 291,170 individuals (aged 15 years or older in 37 countries) were included in the meta regression based on modeling resources of the Global Burden of Disease 2010 Study.


  • Severe periodontitis was the sixth-most prevalent condition in the world, affecting 10.8%, or 743 million people worldwide.
  • Between 1990 and 2010, the global age-standardized prevalence of SP was static at 11.2%.
  • The age-standardized incidence of SP in 2010 was 701 cases per 100,000 person-years, a nonsignificant increase from the 1990 incidence of SP.
  • Prevalence increased gradually with age, showing a steep increase between the third and fourth decades of life that was driven by a peak in incidence at around 38 years of age., while the prevalence of SP reaches its peak at age 40 and remained stable at older ages.
  • There were considerable variations in prevalence and incidence between regions and countries.


  • SP poses an enormous public health challenge
  • Policy makers need to be aware of a predictable increasing burden of SP due to the growing world population associated with an increasing life expectancy and a significant decrease in the prevalence of total tooth loss throughout the world from 1990 to 2010.


Progression of Disease

Topic: Epidemiology of Periodontal Disease

Authors:Loe H et al

Title: The natural history of periodontal disease in man. The rate of periodontal destruction before 40 years of age

Source: J. Periodontol. 49:607, 1978.

Type: Longitudinal study

Rating : Good

Keywords: attachment loss, pattern and rate of loss of periodontal support

The purpose of this longitudinal study was to describe the frequency, pattern and rate of loss of periodontal support from adolescence to approximately 40 years of age.

Norwegian group: 565 males, 17-30+ years old, w/ maximum exposure to conventional dental care. Sri Lankan group: 480 male tea workers, 15-30+ years old w/ no exposure to dental care. (toothbrushing was unknown). Both groups underwent exams at 1969, 1971, 1973 and 1975 (with subsequent exams to follow)

Norway group : at baseline, mean attachment loss of 17y/o was 0.06mm. Attachment loss when present occurred mainly on the B surfaces of max 1st PM’s and M’s. At 37+ years old the mean attachment loss was 1.6mm. The mean annual rate of attachment loss for different teeth in mandible and maxilla was 0.07-0.13mm.

Sri Lanka group: only 20% of the 15 year old subjects showed no attachment loss. Mean loss was 0.17mm. Above 21 years old, all participants showed attachment loss of various degrees. At 31 years old the mean attachment loss was 3.11mm w/ 65% of the surfaces measuring 2-9mm. Mean rate of AL in both jaws was 0.2-0.24mm / yr. Rate of destruction was SSD increased during the late 20’s and throughout the 30’s.

Without oral hygiene or SPT periodontal disease progresses approximately 3x faster.


Topic: natural history of perio disease

Authors: Löe H, Anerud A, Boysen H, Morrison E.

Title: Natural history of periodontal disease in man. Rapid, moderate, and no loss of attachment in Sri Lankan laborers 14 to 46 years of age.

Source: Clin. Periodontol. 13:431-440, 1986.

Type: review

Rating : good

Keywords: natural history; periodontal disease; loss of attachment; tooth loss;

Purpose: to describe the initiation, rate of progress of periodontal disease and consequent tooth loss in a population never exposed to prevention or treatment of dental diseases.

Methods: 480 male tea laborers in Sri Lanka enrolled. At the initial exam in 1970 the age of patients ranged from 14-31. Exams were performed every few years by the same 2 examiners. At the last exam in 1985, there were 161 patients (28-46 years old) from the original study. The subjects didn’t perform any OH and displayed large aggregates of plaque, calculus. All gingival units were inflamed.

Results: 3 sub-populations were identified;

1) individuals with rapid progression of periodontal disease (RP, 8%)

2) moderate progression (MP, 81%)

3) no progression (NP, 11%)

% of population
Loss of Attachment at age 35 <1 mm
Loss of Attachment at age 45 ~ 13 mm
Annual rate of destruction 0.1-1 mm 0.05-0.5 mm 0.05-0.09 mm
Tooth loss at age 45 7 teeth

Discussion: this population was virtually caries free, and essentially all missing teeth were lost due to perio disease.

Conclusion: In a population never exposed to prevention or treatment, the majority (81%) of population show moderate progression of periodontal disease, while small percentage will either have no perio disease or show a progressive pattern of disease.


Topic: Periodontal bone height & natural rate of bone loss

Author: Hugoson A, Laurell L.

Title: A prospective longitudinal study on periodontal bone height changes in a Swedish population

Source: J Clin Periodontol 27:665-674, 2000.

Type: Longitudinal study


Keywords: epidemiology; longitudinal; radiology; periodontal bone height

Purpose : to assess longitudinal changes in periodontal bone height in an adult population over a period of 17 years


– A random sample of 1000 patients aged 3-70 from Jonkoping-Sweden was taken in 1973 and examined clinically and radiographically.

-In 1989, patients from this study were invited for another examination that included bone height measurements on FMX, and full mouth plaque & gingivitis scores.

-429 patients examined in 1973 and 1990.

-Clinical Examination, Plaque, Gingivitis, alveolar bone height (x-ray) for each interproximal site, a bone score was calculated as the % of the tooth length.

-15641 sites were examined twice.


-Plaque: There was a tendency towards lower plaque scores in 1990 as compared with 1973. The mean plaque scores decreased significantly in the older age groups and were about the same level in all other age groups.

-Gingivitis: There was a tendency towards reduced gingivitis scores between 1973 and 1990.

-Bone Score: Mean bone score values decreased with age.


-From the age of 20 years on there was a general pattern of bone height reduction over time corresponding of 0.1 mm per year.

-Less the 5% of individuals showed sites with severe bone loss indicating progressive periodontal disease.

-Around 80% of individuals 30 years or older had 1-5 or more sites with a bone loss of 2-3 mm or more.

-16.9% of the population 15 years of age and above, exhibited multiple sites with severe bone loss over the 17 years period.

-Loser individuals and sites could not be identified in advance based on previous bone loss.

Bottom Line: Since the oral hygiene standard of the individuals was very high, it is reasonable to suggest that there is a natural, biological, continuous alveolar bone resorption-taking place after the age of 30 years.


Topic: Progression of periodontal disease

Authors : Ship JA, Beck JD

Title: Ten-year longitudinal study of periodontal attachment loss in healthy adults

Source: Oral Surg, Oral Med, Oral Pathol 81:281-290, 1996

Type: Longitudinal study

Rating : Good

Keywords: age, disease progression, longitudinal study

Purpose: To examine the prevalence and incidence of several periodontal parameters over a 10-year period in 95 generally healthy adults and to identify risk factors for periodontal disease progression.

Methods: 95 subjects (29-76 years old) were evaluated in this study. All were non-smokers who received regular dental care. Glycemic status was assessed. 4 sites (mesiobuccal, midbuccal, distolingual, and midlingual) on 28 teeth were probed. Recession, pocket depth, and attachment level were assessed at visit one and again approximately 10 years later by a second examiner. Results were statistically analyzed and compared.

Results: No gender differences were detected. Over the 10-year period, the medical status of the participants worsened. Overall, changes in the periodontal measurements over the 10 year study were slight. Attachment loss increased with age group (20% increase in the oldest age group). Recession also increased with age. Measurements were unaffected by glycemic status over ten years.

Conclusion: Periodontal disease destruction as measured by AL, occurs over time, but it is not related to the age of a person in a generally healthy adult. Periodontitis is not a natural consequence of the aging process in healthy adults and advanced age is not an accurate predictor of attachment loss.


Topic: Periodontal diseases Progression

Authors: Reddy MS, Geurs NC, Jeffcoat RL, Proskin H, Jeffcoat MK.

Title: Periodontal disease progression

Source: J Periodontol 71:1583-1590, 2000.

Type: clinical study

Keywords: Bone loss/diagnosis, dental models, periodontal attachment loss/diagnosis, periodontics, progression, non-invasive.

Background: Techniques for diagnosing periodontal disease include the measuring PD with a periodontal probe (standardized 1 mm increments). A change of 2-3 mm is necessary to indicate disease progression and rule out operator error. Therefore, meaningful small changes in attachment to the tooth are not detected by this method because they are within the error of the measurements being made.

Purpose: To examine the natural history of untreated adult periodontitis progression and model periodontal disease activity over time. Also, to compare multiple alternative models to assess to what extent do clinical variables contribute to a model of periodontal progression.

Material and methods: 44 patients (mean age 45.8 years, 70% women, 50% European American, 34% African American, 16% Asian American) with moderate-advanced periodontitis (radiographic bone loss 30-50%, >4 mm attach loss or PD at affected sites) were examined for 18 months. CAL, PD, gingival and plaque indices were obtained monthly. Standardized radiographs were taken at baseline, at 6,12 and 18 months. Patients received no care other than a prophylaxis every 3 months. Attachment level was measured with occlusal and a modified automated probe. The probe had a rounded tip used to prevent penetration of the probe into the connective tissue. Controlled force was applied. At baseline and at 6,12 and 18 months standardized vertical bite-wing radiographs were taken. Bone loss was recorded with digital subtraction x-ray.

Results: Baseline PD averaged 4.65 mm. 22.8% sites lost attachment whereas 5.4% gained. The majority of the sites (71.7%) demonstrated NSS change. The mean attachment loss for losing sites was 2.1 mm, whereas the mean gain was 0.97mm. The mean time to lose 1 mm of attachment was 8.4 months. Molar sites behave differently than others and maxillary molar sites had the most significant progression of periodontitis.

The general model for predicting disease progression including CAL, PI, PD and GI had poor predictive power (61.8% sensitivity). A considerably stronger significant model occurred when the rate of CAL loss over 6 months, baseline PI and GI were included. Specificity ruling out progression was 83.3% and the sensitivity was 70.9%. A significant model also resulted when bone loss during the first 6 months and baseline PD were included. The sensitivity in predicting disease progression was 80% and the specificity in ruling out progressive disease was 93.9%.

Model Sensitivity Specificity
Baseline clinical indicators (PI, PD, GI) 61.8% 68.5%
6 month AL (baseline PI, GI) 70.9% 83.3%
6 month DSR* (baseline PD) 80.0% 93.9%

*Digital subtraction radiography (bone loss)

Conclusion: Baseline measurements (PD, CAL, GI, PI) do not predict disease activity. Short term (6 months) measures of periodontal disease progression improve ability to model attachment loss over longer time period (18 months) in untreated periodontitis patients. These data support the theory that periodontitis progression more closely follows a continuous progression pattern of destruction when attachment levels are measured in 1 month intervals. If all attachment loss occurred as random effects, this would not be the case.

Smallchanges in CAL and in bone height may be highly indicative of future AL when used along with measures of PI and GI. At this time, accuracy of these changes with clinical periodontal exams is not reliable as operator error can account for more than the changes present.


Topic : Risk factors for development of periodontitis

Authors: Van der Velden U, Abbas F

Tittle: Java project on periodontal diseases. The natural development of periodontitis: risk factors, risk predictors and risk determinants.

Source J Clin Periodontol. Aug;33(8):540-8, 2006.

: Longitudinal study

Rating : Good

Keywords risk factors, risk predictors, periodontal breakdown

Purpose : To study the value of the baseline clinical, microbiological and background variables as possible risk factors, risk predictors and risk determinants for future periodontal breakdown; and to describe the changes in the clinical condition over 15 years of period.

Methods : Longitudinal, prospective study, 255 inhabitants (age ranges 15-25 years old) were selected at a tea state on Western Java, Indonesia. Baseline exam includes evaluation of plaque, BOP, calculus, PD, AL and presence of Aa, P.gingivalis, P. intermedia , Spirochetes and motile bacteria was carried out in 1987 (baseline) and follow up exams in 1994 and 2002. When all clinical measurements were completed, the deepest bleeding pocket without clinical loss of attachment was selected and sampled. After carefully removing the supragingival plaque with a curette, a subgingival sample was taken using a nerve broach wound with cotton and heat sterilized. Samples from the tongue and the buccal gingiva were obtained by sweeping a sterile swab under continuous pressure over the total surface. In 2002, 128 subjects could be retrieved from the original group.


  • The mean attachment loss doubled b/w 1987 and 1994 but was almost tripled b/w 1994 and 2002 (0.33 mm in 1987, 0.72 mm in 1994 and 1.97 mm in 2002).
  • No difference found in attachment loss b/w smokers and non-smokers.
  • Subgingival calculus and subgingival presence of Aa are considered risk factors.
  • Age is considered as a risk determinant for the onset of the perio disease.
  • The number of sites with a probing depth >5mm and the number of sites with recession were identified as risk predictors and male gender as a risk determinant for the progression of the disease.

Conclusions : This study might support a strategy to screen children and young adult for Aa to prevent of onset of periodontal disease.


Topic: alcohol and periodontal disease

Authors: Shepherd S.

Title: Alcohol consumption a risk factor for periodontal disease

Source: Evid Based Dent 2011;12(3):76

Type: Commentary


Keywords: alcohol

Purpose: Commentary on article “Relationship of alcohol dependence and alcohol consumption with periodontitis: A systematic review” by Amaral et al

Method: Medline, LILACS, SciELO, and Cochrane Central Register of Controlled Trials search

Results :11 cross-sectional and 5 longitudinal observational studies met the inclusion criteria. 7/12 studies reported positive associations between alcohol intake and periodontitis. There is evidence to suggest alcohol consumption is a risk indicator for periodontitis. The confounding effect of plaque was taken into account in only 6 studies. Smoking was considered in all studies.

Conclusion: Evidence to suggest alcohol consumption is a risk indicator for periodontitis.

Commentary: The paper offers a well-conducted systematic review. However, meta-analysis shouldn’t have been done due to heterogeneity of studies (method for assessing alcohol consumption, disease criteria). Only English studies were included, leaving out possibly 7 relevant studies.


Topic: Progression of Disease obesity and periodontal disease

Authors : Gorman A, Kaye Ek

Title: Overweight and obesity predict time to periodontal disease progression in men.

Source: J Clin Periodontol 2012; 39:107-114

Type: Clinical

Rating : Good

Keywords: body mass index; obesity; overweight; periodontal disease; waist circumference; waist circumference-to-height ratio

Purpose: 1)To examine he association of multiple obesity – related characteristics of males with periodontal disease progression controlling for multiple risk factors. 2) To evaluate whether waist circumference (WC) and waist – height ratio (WHtR) are related to periodontal disease independently of BMI which may suggest a specific role or visceral fat.

Materials and methods: Characteristics of patients participating in the Dept of Veterans Affairs Dental Longitudinal Study (DLS) were used. 1038 medically healthy, white males in the VA Dental Longitudinal Study who were monitored every 3 years with oral and medical examinations between 1969 and 1996.

Periodontal disease progression in an individual was defined as having 2 or more teeth advance to levels of alveolar bone loss ≥40%, probing pocket depth ≥5mm, or clinical attachment loss ≥5mm after baseline. Alveolar bone loss (ABL) was measured on dental radiograph. PDs were measured at 6 sites per tooth and 3rd molars were excluded.

Statistical analysis estimated hazards of experiencing periodontal disease progression events due to overweight/obesity status, controlling for age, smoking, education, diabetes, recent periodontal treatment, recent prophylaxis, and number of filled/decayed surfaces.

Results: The mean BMI increased 1.6 kg/m2 and waist circumference-height ratio increased 4.5% during follow-up. The number of teeth that remained free of periodontal disease declined, more so in men who were obese. In multivariate each unit increase in BMI was associated with a 5% increase in the hazard of experiencing an alveolar bone loss progression event. An increment of 1 cm WC was associated with 1-2% increases in the hazards of experiencing PPD and CAL progression events, and each 1% increment in baseline WHtR was associated with 3% increase in the hazard of experiencing periodontal disease progression events as defined by all three periodontal disease indicators. PPD, CAL, and ABL progression events were 40%, 52% and 60% higher, respectively, among obese men relative to ideal weight men. The concurrent use of BMI and WHtR to estimate hazard ratios show increased chance of experiencing PPD, CAL and alveolar bone loss progression events among men with a high waist-height ratio relative to low ratio in the absence of obesity.

Conclusion: Both overall obesity and central adiposity are associated with an increased hazards of periodontal disease progression events in men. These obesity measures may be potentially useful predictors of future periodontal disease progression by themselves or in combination.


Topic: Progression of Disease

Authors: Mdala I, Olsen I, Haffajee AD, Socransky SS, Thoresen M, de Blasio BF

Title: Comparing clinical attachment level and pocket depth for predicting periodontal disease progression in healthy sites of patients with chronic periodontitis using multi-state Markov models.

Source:  J Clin Periodontol.  Sep;41(9):837-45.
Type: Statistics

Keywords: antibiotics; chronic periodontitis; multi-state Markov models; periodontal therapy

Background: multi-state Markov model: assumes that the study subjects exist in one of a finite set of health states.  the Markov approach allows for a flexible representation where progression and regression may be estimated separately and influence of risk factors on particular transitions can be studied.

This study proposes two continuous Markov models for periodontal disease progression.  The model includes three disease states: health, gingivitis and chronic periodontitis and allows for gingivitis recovery. The disease states are based on: clinical attachment level (CAL) or periodontal pocket depth (PD) in combination with bleeding on probing (BOP).  CAL is an indicator of cumulative tissue destruction, including past periodontal disease, while PD is an indicator of current disease status

Purpose: 1.) compare the use of CAL versus PD in periodontal disease dynamics of healthy periodontal sites in patients with chronic periodontitis 2.) to assess the influence of various characteristics on transition from disease progression and regression.

Material and methods:

– Data from healthy sites in 1,124 mesiobuccal sites in patients having treatment for chronic periodontitis

  • Health = CAL/PD < 4mm or PD < 4mm and no BOP at baseline

– Patients randomized to

  • ) SRP
  • ) SRP + surgery + amoxicillin + metronidazole
  • ) SRP + surgery + tetracycline
  • ) SRP + surgery
  • ) SRP + amoxicillin + metronidazole + tetracycline
  • ) SRP + amoxicillin + tetracycline
  • ) SRP + tetracycline
  • ) SRP + surgery + amoxicillin + metronidazole + tetracycline

– subjects analyzed at baseline, 3, 6, 18, 24 months

– after treatment, study sites classified into disease states (focused on the first occurrence of chronic periodontitis (“first hitting time”) and ignored further potential recovery due to the short duration of the study)

  • Health = CAL/PD < 4mm and no BOP
  • Gingivitis = CAL/PD < 4mm and BOP
  • Chronic periodontitis = CAL/PD > 4mm with or without BOP
  • a healthy site can either advance to gingivitis (slow progression) or advance directly to chronic periodontitis (fast progression)


Models based on CAL + BOP 

- Over the 2 years, 327 sites progressed from healthy state to gingivitis and 89 sites had rapid progression from health to chronic periodontitis

  • in comparison, 182 gingivitis states progressed to health and 12 chronic sites progressed to gingivitis
  • Most transitions (87-97%) were from health to the gingivitis state

– mean average time spent in health 2.7 years, and gingivitis was .5 years before transition

– the likelihood health would transition to gingivitis was 87% and to chronic periodontitis was 13%

– the likelihood gingivitis would transition to health was 96% and to chronic periodontitis was 4%

– the number of sites in the gingivitis state stabilizes at 11– 12%

– The model estimates that approximately 5% and 10% of the healthy sites will have developed chronic periodontitis in 1 and 2 years

Characteristic Influence in model based on CAL + BOP 

– disease severity was associated with a 7% increase per site in gingivitis and 15% increase per site in chronic periodontitis with CAL > 4 mm at baseline in the risk for fast progression and progression

– Smoking was associated with fast progression from health to chronic periodontitis with a hazard ratio of 2.11

  • Same seen in PD + BOP model

– Gingival redness was associated with increased risk of transition from health to gingivitis by factor of 2.15

  • PD + BOP model was factor of 2.13

– male gender was associated with increased risk of transition from health to gingivitis by factor of and 1.51

  • PD + BOP model was 39% increase

– With age, the risk for transiting from health to gingivitis decreased by 3%.

  • PD + BOP model was decrease by 2%

Models based on PD + BOP

– 391 sites progressed from healthy state to gingivitis and 26 sites experienced rapid progression from health to chronic periodontitis

  • In comparison, 227 sites progressed from gingivitis to health and 7 sites from gingivitis to chronic periodontitis

-mean average time spent in health 2.7 years, and gingivitis was .4 years before transition

– the likelihood for a healthy site to transition to gingivitis was 97% and to chronic periodontitis was 3%

– the likelihood for gingivitis to transition to health was 98% and to chronic periodontitis was 2%

– the number of sites in the gingivitis state stabilizes at 11–12%

– The model estimates that 1% and 3% of the healthy sites will develop chronic periodontitis in 1 and 2 years 


– the CAL + BOP model predicted higher probabilities for fast progression and progression from gingivitis compared to the PD + BOP model.

  • For the PD + BOP model, the effects of gingival redness and severity on fast progression were not found strong.   In addition, no general effect of smoking, or gender was obtained.
  • Gingival redness to be associated with fast progression in the PD + BOP model only.

– disease severity, measured by the number of sites with chronic periodontitis (CAL/ PD > 4 mm) at baseline, was associated with fast progression and progression from the gingivitis state.

– Smoking increased the rate of fast progression, but had no significant effect on slow progression through the gingivitis state

*Limitation = short duration, so only few events of chronic periodontitis onset and it is possible that these transitions occurred in particular frail sites, which may not be representative of the general long-term disease dynamics of healthy sites in this group of patients


Topic: Probing, Patient Screening

Title: Periodontal Screening and Recording (PSR) Index: precursors, utility and limitations in a clinical setting

Author: Landry RG, Jean M.

Source: Int Dent J. Feb;52(1):35-40. 2002

Type: Review article

Keywords: periodontal screening, recording, probing, diagnosis.

Purpose: To review studies examining PSR (Periodontal Screening and Recording) index, describe PSR method, discuss applications and limitations.


The index is used to measure gingival bleeding on probing, calculus accumulation and probing depth.

These parameters are evaluated using a periodontal probe with 0.5mm diameter ball tip and a colored band extending from 3.5mm to 5.5mm from the tip.

Information is collected and scored by dividing the mouth into 6 sextants. Each tooth is scored from Code 0 to Code 4 but only the highest score of the sextant is recorded.

The periodontal health of a sextant is thus assessed by the highest score, which corresponds to the most important clinical sign and designates a recommended treatment plan.

Advantages: simple, reliable, reproducible periodontal index for screening purposes.

Disadvantages : PSR can underestimate the level of periodontal involvement. PSR does not measure epithelial attachment. PSR uses PD to estimate the attachment loss. Tooth mobility and furcation involvement are not evaluated. PSR is basically a screening examination, and care should be taken when interpreting the scores.

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