Discussion Topics
A. What are the likely future trends in disease activity research?
B. Dis B. Discuss the various theories of disease activity, and attempt to resolve the differences between them.
C. Account for the difference in disease activity between and within patients.
Bleeding on Probing-Diagnosis
Is bleeding on probing a valuable clinical sign?
Is bleeding on probing related to any other parameters or findings?
Lang N, et al: Bleeding on probing. A predictor for the progression of periodontal disease: J Clin Periodontol 1986;13:590-596
Caton J, Polson A, Bouwsma O, et al: Association between bleeding and visual signs of interdental gingival inflammation. J. Periodontol. 59:722-727, 1988.
Lang N et al: Absence of bleeding on probing. An indicator of periodontal stability. J Clin Periodontol 1990;17:714-721
Muller HP, Heinecke A, Eger T: Site-specific association between supragingival plaque and bleeding upon probing in young adults. Clin Oral Invest. 4:212-218, 2000.
Greenstein G. Current interpretations of periodontal probing evaluations: diagnostic and therapeutic implications. Compend Contin Educ Dent. 2005 Jun;26:381-2,384,387-90
Bleeding on Probing-Prognosticator
Is bleeding on probing more useful in determining health, presence of disease, or disease activity?
Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP: Relationship of gingival bleeding, gingival suppuration, and supragingival plaque to attachment loss. J. Periodontol. 61:347-351, 1990.
Van der Velden U, et al: Probing considerations in relation to susceptibility to periodontal breakdown. J. Clin. Periodontol. 13:894-899, 1986.
Greenwell, H. Position paper: Guidelines for periodontal therapy. J Periodontol. 2001 Nov; 72(11):1624-8
Gerber J, Tan W, Balmer T, Salvi G, Lang N: Bleeding on probing and pocket probing depth in relation to probing pressure and mucosal health around oral implants. Clin Oral Implants Res 2009;20:75-78
Bleeding on Probing-Histologic Changes
Does clinical bleeding on probing reflect specific histologic status?
Greenstein G, et al: Histologic characteristics associated with bleeding after probing and visual signs of inflammation. J. Periodontol. 52:420-425, 1981.
Caton J, et al: Cell populations associated with conversion from bleeding to nonbleeding gingiva. J. Periodontol. 59:7-11, 1988.
Bleeding on Probing-Effect of Treatment
Kalkwarf KL, Kaldahl WB, Patil KD, Molvar MP: Evaluation of gingival bleeding following 4 types of periodontal therapy. J. Clin. Periodontol. 16:601-608, 1989.
van Ooteghen R, et al: Bleeding on probing and probing depth as indicators of the response to plaque control and root debridement. J. Clin. Periodontol. 14:226- , 1987.
Joss A, Lang N. Bleeding on probing. A parameter for monitoring periodontal conditions in clinical practice. J Clin Periodontol 1994;21:402-408
Disease Activity-Determination
List the various means for determining disease activity and the pros and cons of each.
What are the criteria for the "ideal" determinant of disease activity?
Goodson JM: Clinical measurements of periodontitis. J Clin Periodontol 13:446-455, 1986.
Silva, N et al.: Characterization of progressive peridontal lesions in chronic periodontitis patients: Levels of chemokines, cytokines, matrix metalloproteinase-13, periodontal pathogens and inflammatory cells. J Clin Periodotol 2008; 35: 206 - 214
Greenstein G, Caton J: Periodontal disease activity: A critical assessment. J Periodontol 61: 543-552, 1990. (Review)
Van Dyke TE, Tohme ZN. Periodontal diagnosis: evaluation of current concepts and future needs. J Int Acad Periodontol. 2000 Jul;2(3):71-8. (Review)
Disease Activity-Predictors
Haffajee AD, et al: Clinical parameters as predictors of destructive periodontal disease activity. J Clin Periodontol 10:257-265, 1983.
Badersten A, Nilveus R, Egelberg J : Scores of plaque, bleeding, suppuration and probing depth to preduct probing attachment loss. Five years of observation following nonsurgical periodontal therapy. J. Clin. Periodontol. 17:102-107, 1990.
Claffey N, Nylund K, Kiger R, Garrett S, Egelberg J : Diagnostic predictability of scores of plaque, bleeding, suppuration and probing depth for probing attachment loss. 3.5 years of observation following initial periodontal therapy. J. Clin. Periodontol. 17:108-114, 1990.
Renvert S, Persson GR. A systematic review on the use of residual probing depth, bleeding on probing and furcation status following initial periodontal therapy to predict further attachment and tooth loss. J Clin Periodontol. 2002;29 Suppl 3:82-9; discussion 90-1 (Review)
Huynh-Ba G, Lang NP, Tonetti MS, Salvi GE. The association of the composite IL-1 genotype with periodontitis progression and/or treatment outcomes: a systematic review. J Clin Periodontol. 34:305-17, 2007 (Review)
Hausmann E, Jeffcoat M: A perspective on periodontal disease activity measurements. J Clin Periodontol. 15:134-136, 1988. (Review)
Disease Activity-Patterns
Do all periodontal diseases behave in a similar fashion? If not, why?
Haffajee A, Socransky S: Attachment level changes in destructive periodontal diseases. J. Clin. Periodontol. 13:461-472, 1986.
Lindhe J, Okamoto H, Yoneyama T, et al: Periodontal loser sites in untreated adult subjects. J Clin Periodontol. 16:671-678, 1989.
Breen HJ, Johnson NW, Rogers PA: Site-specific attachement level change detected by physical probing in untreated chronic adult periodontitis: Review of studies 1982-1997. J Periodontol. 70:312-328, 1999. (Review)
Disease Activity-Histology
Davenport RA, et al: Histometric comparison of active and inactive lesions of a dvanced periodontitis. J. Periodontol. 53:285-295, 1982.
Carvel RI, Carr RF: Clinico-pathologic correlation of 385 lesions of marginal destructive periodontitis. J. Periodontol. 53:328-333, 1982.
Bleeding on Probing in Diagnosis
Is bleeding on probing a valuable clinical sign?
Is bleeding on probing related to any other parameters or findings?
Topic: Bleeding on probing
Authors: Lang N, et al. Article
Title Bleeding on probing. A predictor for the progression of periodontal disease
Source: J Clin Periodontol 1986;13:590-596
Type: Retrospective clinical study
Keywords: Bleeding on probing, periodontal maintenance, attachement loss.
Purpose: To retrospectively evaluate periodontal maintenance over a 4 year period in patients treated for advanced periodontitis and to challenge the emphasis placed on bleeding on probing (BOP) as a clinical prognostic indicator for the identification of sites at risk for recurrent periodontal breakdown.
Methods: Retrospective study. 55 patients (30F/25M) were treated for advanced periodontitis (initial therapy and MWF) and placed on a 3-5 month maintenance program for 4 years. During the last 2 years of maintenance (at least 4 recall visits). Patients were evaluated for BOP, and sites that were positive were treated by SC/RP. Out of 7704, 1054 pockets had BOP and were subdivided into five categories by incidence of BOP during the last 4 recall appointments (0-4 out of 4 time of SPT), and also according to the presence or absence of clinical attachment loss.
Results: 2.5% of the sites bled on probing 100% or 75% of the time. 27% of the patients (15) regularly showed bleeding percentages greater than 16% but never exceeding 37.8%. These patients showed a significantly greater number of pockets with a probing depth of >5 mm. A significant correlation was found between an increasing incidence of BOP and loss of attachment.
|
% of pockets with loss of probing attachment (≥ 2 mm) or “no change” in two years in the categories with different incidences of bleeding on probing (BOP) |
|||
|
BOP |
Loss ≥ 2 mm |
No change |
Total |
|
4/4 |
30 |
70 |
100 |
|
3/4 |
14 |
86 |
100 |
|
2/4 |
6 |
94 |
100 |
|
1/4 |
3 |
97 |
100 |
|
0/4 |
1.5 |
98.5 |
100 |
Discussion:
Significantly more residual pockets 5 mm and significantly more sites losing 2 mm or more of probing attachment in 2 years were identified when mean bleeding on probing scores exceeded 16%.
If a mean BOP score exceeds 16%, recall interval should be shortened, if it lies below 10%, it may be prolonged.
Predictability for loss of probing attach increased from 1.5% in absence of BOP, to 30% with a BOP incidence of 100%.
A site which bleeds on probing at every recall visit still has a 70% chance of not losing probing attach.
Conclusion: Recall visits of 3-4 months have been chosen to guarantee optimal periodontal maintenance. If a mean bleeding score exceeds 16%, the recall interval should be shortened, and if it lies below 10%, it may be prolonged by 1 month. BOP still represents the most useful clinical predictor for disease activity during periodontal maintenance. This is backed by the fact that the predictability values for loss of probing attachment increase from 1.5% in absence of BOP, to 30% with BOP of 100%.
BL: BOP is a limited, however the most useful clinical predictor for disease "activity" during maintenance.
Topic: Bleeding on probing
Authors: Caton J, Polson A, Bouwsma O Article
Title: Association between bleeding and visual signs of interdental gingival inflammation.
Source: J. Periodontol. 59:722-727, 1988
Type: Clinical Trial
Rating: Good
Keywords: Pathogenesis, periodontitis
Purpose: To determine associations between bleeding and visual signs of interdental gingival inflammation
Methods: Interdental gingiva was examined in 82 healthy male college students (18-30 years old) for visual signs of inflammation. Following this examination the patients were studied in a split mouth design utilizing the Eastman Interdental Bleeding Index (EIBI/Caton) or the Papilla Bleeding Index (PBI/Mulleman).
Visual signs of inflammation: The presence or absence of inflammation was recorded. Any slight change from normal was assigned a positive score in order to reduce intraexaminer error to acceptable levels.
EIBI: A wooden interdental cleaner inserted b/w the teeth from the facial aspect, depressing the interdental tissues 1 to 2 mm. The cleaner was inserted and removed four times, and the presence or absence of bleeding within 15 seconds was recorded.
PBI: Sites were probed by insertion of the probe tip 2 mm into the interproximal sulci, or until resistance was met. The probe is gently moved along the sulcular surface from each line angle until the probe met the interproximal contact. The presence or absence of bleeding within 15 seconds was recorded.
Results:
Visual examination detected that 71.3% of the interproximal sites were inflamed.
Of the visually inflamed areas 51% bled with the PBI and 74% with the EIBI.
In the visually non-inflamed sites that bled, the EIBI detected 66.9% and the PBI 33.1% of these sites.
Conclusion: The EIBI is more reliable for identifying inflammatory lesions in the mid-interproximal gingival tissues than the PBI.
Topic: Bleeding on probing
Authors: Lang NP, Adler R, Joss A, Nyman S. Article
Title: Absence of bleeding on probing: An indicator of periodontal stability
Source: J Clin Periodontol 1990;17:714-721
Type: Longitudinal study
Rating: Good
Keywords: periodontal health, bleeding on probing, diagnosis, loss of probing attachment, maintenance care
Purpose: To determine the predictive value of absence of bleeding on probing for maintenance of periodontal health.
Method: Longitudinal study; 41 pts (14 males/27 females, 20-60 yo) in a maintenance program were examined for 2.5 yrs. The recall interval was between 2 and 6 months. BOP measured at each visit along with removal of supragingival plaque/calculus, only bleeding sites were reinstrumented. Pocket probing depths and attachment levels recorded at baseline and end of study. Disease progression defined as 2mm loss of attachment.
Results: 29% sensitivity and 88% specificity for frequent bleeding. Negative predictive value of disease progression was 98%, positive predictive value was 6%. 2.4% of all sites lost 2mm probing attachment. BOP rare in 1-3 mm PD and frequent in 6-9 mm PD.
Conclusion: Continuous absence of BOP is a reliable indicator for the maintenance of periodontal stability. The presence of BOP is not a good indicator of disease progression.
Topic: Bleeding on Probing
Authors: Muller HP, Heinecke A, Eger T Article
Title: Site-specific association between supragingival plaque and bleeding upon probing in young adults
Source: Clin Oral Invest. 4:212-218, 2000
Type: Clinical
Rating: Good
Keywords: supragingival plaque, gingivitis, risk factor analysis, GEE methods, site specificity
Purpose: To consider supra-g plaque as a risk factor for a leading symptom of gingival inflammation, bleeding on probing, in a group of young adults without destructive periodontal disease and to assess individual variation in the strength of the association.
Materials and methods: 127 systemically healthy subjects, 17-30 years old. Inclusion criteria: 1) no indication for antibiotic prophylaxis 2) no antibiotic therapy in the last 4 months 3) no medication affecting the periodontal tissues 4) no pregnancy or lactation 5) no destructive periodontal disease (PD less than 5mm, AL less than 2mm). 67 were smokers.
Participants were not allowed to brush their teeth prior to examination and periodontal conditions (PD, recession, BOP, PI) were assessed in 6 sites per tooth.
Results: There was no apparent differences in clinical parameters between smokers and non-smokers with the exception of BOP that was lower in smokers (29% vs 20%). BOP overall was observed in 25% of the cases but twice as many sites harbored plaque. Only 8% of sites bled in the absence of plaque. The risk of bleeding was increased 67% in the presence of plaque.
Subjects with strong and positive association between plaque and BOP had more gingival recession than subjects with no association.
According to the distribution of individual proportional attributable risks of supragingival plaque for bleeding, improving OH in order to reduce gingivitis would have a relatively profound effect on less than half of the population.
Conclusion: In this study a weak association between plaque and BOP was observed.
Topic: Probing evaluation
Authors: Greenstein G. No Article
Title: Current interpretations of periodontal probing evaluations: diagnostic and therapeutic implications.
Source: Compend Contin Educ Dent. 2005 Jun;26:381-2,384,387-90
Type: Discussion
Rating: Good
Keywords: Probing, diagnostic predictability, clinical attachment loss
Purpose: To re-evaluate the contemporary importance of probing depth measurements as a criterion or co-determinant on which therapeutic decisions could be based.
Discussion: The absence of clinical inflammation associated with stable PD and CAL reflects periodontal health. A healthy periodontium is often associated with shallow PDs but it is possible to have a healthy periodontium despite the presence of deep PDs.
Recording PDs will frequently provide diagnostic information regarding disease progression.
Recording CAL from the CEJ or any other fixed reference point is the most accurate way to monitor disease progression.
Factors that influence the accuracy of PD and CAL measurement are probing force, angulation of probe insertion, probe width and inflammatory status of the gingival connective tissue.
BOP is more frequent in deeper sites. Deep sites harbor increased levels of pathogens. These sites may be at increased risk for future disease progression.
Good oral hygiene can affect the subgingival microflora in shallow and moderate PDs. Since toothbrushing can penetrate up to 1mm subgingivally, shallow PDs facilitate more effective subgingival bacterial management by patients.
It is more difficult to instrument deep PDs than shallow sites. Non-surgical therapy should be used as long as it provides acceptable results. When non-surgical therapy cannot attain desired results, surgical procedures should be considered. Surgical procedures resulted in greater PD reductions compared to non-surgical in more established/severe conditions.
Moderate and deep PDs tend to rebound. Therefore, it should not be assumed that all deep sites that were reduced will remain shallow.
Sites that remained deep and continue to BOP may be suitable for pocket elimination and/or regeneration. Sites that present increasing PD, continued CAL loss or bone loss, or before prosthetic and orthodontic therapy should be treated aggressively.
Bleeding on Probing in Prognosis
Is bleeding on probing more useful in determining health, presence of disease, or disease activity?
Topic: Disease activity
Title: Relationship of Gingival Bleeding, Gingival Suppuration, and Supragingival Plaque to Attachment Loss
Source: Journal of periodontology, 1990, 61(6), 347-351.
Type: Case study
Rating: Good
Keywords: Gingival bleeding; gingival exudate; dental plaque; periodontal attachment.
P: To evaluate the relationship of gingival bleeding, gingival suppuration, and supra-g plaque to the incidence of probing attachment loss at 3 month appointments during a 2 year period of maintenance treatment.
M&M: Longitudinal study: split mouth design—coronal scaling, RP, MWF, osseous Sx; 75 patients; one calibrated examiner assessed patients for supra-g plaque, gingival suppuration, BOP, and probing attachment levels every 3 months for 2 years following various types of perio treatment. The sensitivity (active sites with a positive test), specificity (inactive sites with a negative test), and positive and negative predictive values were calculated for different frequencies of positive responses for each clinical parameter in relation to sites demonstrating 2mm PALoss.
R: As frequency of BOP increased, the sensitivity decreased, specificity increased, positive and negative predictive value remained constant. As suppuration frequency increased, the sensitivity remained low, specificity remained high, positive predictive value increased and negative predictive value decreased. Supra-g plaque had same results as BOP.
BL: Bleeding and plaque are not good prognosticators for future attachment loss, & gingival suppuration was a weak prognosticator of attachment loss (BOP status was primarily a function of the normal prevalence of a site to bleed irrespective of any association w/ breakdown activity). Both BOP & suppuration had high specificity and negative predictive values, which may help to confirm the absence of disease activity.
D: There are different states of the inflammatory process with some probably being associated with an aggressive destruction of periodontal attachment and some with nonaggression. The bleeding symptom associated with nonaggressive inflammatory status (i.e., "gingivitis") is probably much more frequent and masks the relevance of the bleeding symptom for an aggressive inflammatory state ("Periodontitis").
Cr: This study is based on patients that had their perio treated and were on 3 month recall, not untreated perio patients. No quantification of the bleeding irrespective of its amount or the ease of provocation from the gingival crevice.
Topic: Bleeding on probing
Authors: Van der Velden U, Abbas F. Article
Title: Probing considerations in relation to susceptibility to periodontal breakdown
Source: J. Clin. Periodontol. 1986 Nov;13(10):894-9
Type: Clinical
Rating: good
Keywords: age, experimental gingivitis, prognostic indicator for periodontal breakdown,
Purpose: Review of the research performed on probing findings in relation to individual’s susceptibility to to periodontal disease.
Discussion:
The bleeding/plaque ratio: Two groups used of susceptible (juvenile periodontitis) and non-suscpeptible (older individuals with gross amounts of plaque and no periodontal breakdown) to periodontal breakdown. Oral hygiene, BOP and proning depths evaluated.
Results: Susceptible group had more bleeding and less plaque, suggesting that higher bleeding/plaque ratio may be used as a prognostic indicator for periodontal breakdown.
|
(pediodontal pocket bleeding index) PPBI |
PlI (plaque index) |
PPBI/PlI (bleeding/plaque ratio) |
|
|
Highly susceptible group |
0.74 |
0.60 |
1.64 |
|
Insusceptible group |
0.39 |
1.41 |
0.25 |
2) Experimental gingivitis in relation to suscptibility to periodontal breakdown
Four groups:
Hypothetically susceptible: younger age group without loss of attachment – high bleeding/plaque index (>0.5)
Hypothetically insusceptible: younger age group without loss of attachment – low bleeding/plaque index (<0.2)
Insuscepitble (older age group with presence of gross amounts of plaque, no perio breakdown and low bleeding/plaque ratio)
Susceptible (adult group who prevsiously suffered from severe periodontal disease)
Experimental gingivitis was introduced. First two groups were chosen from first year dental students who were asked to abstain from oral hygiene for 23 days. 3rd and 4th group were asked to abstain form oral hygiene for 33 days. Same parameters with the previous experiment were evaluated.
Results:
Older insuceptible and younger hypothetically insuceptible group developed a comparable low bleeding index.
The younger hypothetically suscptible group developed a much higher bleeding index complared to the susceptible group.
Susceptible group had twice as high mean PPBI (bleeding index) of the insusceptible group. Susceptible group had the highest plque index.
Bleeding/plaque ratio was only estimated in sites without attachment loss.
Conclusion: Bleeding/plaque ratio may act as a prognostic indicator for periodontal breakdown (in this study this ratio was >0.5 in the susceptible group).
Topic: AAP Guidelines
Author: Greenwell, H. No Article
Title: Position Paper: Guidelines for periodontal therapy
Source: J Periodontol. 2001 Nov; 72(11):1624-8
Type: Position Paper
Rating: Good
Keywords: Scope of practice, Diagnosis, Prognosis, Periodontal disease, Periodontal maintenance, Treatment planning
Purpose: To present the AAP guidelines for periodontal therapy.
Discussion: These guidelines will not guarantee a successful outcome or eliminate all complications or post-care problems in periodontal therapy. Ultimately judgments regarding appropriateness of any specific procedure must be made by the practitioner; in light of all circumstances presented by the individual patient.
Scope of periodontics
Periodontics is the specialty of the dentistry that involves prevention, diagnosis and treatment of the supporting and surrounding tissues of teeth and dental implant. The goals of periodontal therapy are to preserve the natural dentition, periodontium and peri- implant tissue, to maintain and improve periodontal and peri-implant health, comfort, esthetics and function. The clinical signs of a healthy periodontium include absence of inflammatory signs of disease such as redness, swelling, suppuration, and bleeding on probing; maintenance of a functional periodontal attachment level; minimal or no recession in the absence of interproximal bone loss; and functional dental implants.
Periodontal examination
A comprehensive periodontal examination needs to be done on each patient, which includes: chief complaint, review of medical and dental history, clinical exam and radiographic analysis. Microbiological, genetic, biomedical or other diagnostic test may be useful, on an individual basis.
Establishing a diagnosis and prognosis
Evaluate the periodontal and peri-implant tissue to determine the stability of the patient. This will help determine which therapy is suitable for the patient, including nonsurgical, surgical, reconstructive and regenerative therapy or dental implant placement.
Periodontal diseases and conditions
Periodontal disease is categorized as gingival disease, periodontitis, necrotizing periodontal disease, abscess of the periodontium and developmental or acquired deformities and conditions.
Development of a treatment plan
Medical consultation or referral for treatment
Periodontal procedures to be performed
Consideration of adjunctive restorative, prosthetic, orthodontic, endodontic consultation /treatmentRe-evaluation
Consideration of chemotherapeutic agents for adjunctive treatment
Consideration of diagnostic testing (microbiological, genetic or biochemical)
Perio maintenance
Informed consent and patient record
Consent should be obtained prior to the commencement of the therapy. The information given to the patient should include: diagnosis, etiology, proposed therapy, alternative treatments, prognosis without the proposed therapy, inherent risks for the procedures, recommendations for referral, the need for periodontal maintenance treatment. A record of the patients consent to the proposed therapy should be maintained.
Treatment procedure
When indicated, treatment should include:
Pt education, training in OH, counseling in control of risk factors
Removal of supra and sub gingival bacterial plaque and calculus and root planning
Finishing procedure includes post tx re-eval and OH reinforcement.
The following courses of treatment should be included in addition to the above outlined procedures:
Chemotherapeutic agents
Ressective procedures
Periodontal regenerative procedures
Periodontal plastic surgery
Occlusal therapy
Preprosthetic periodontal procedure
Selective extraction of teeth, roots or implants
Replacement of teeth by dental implants
Procedures to facilitate orthodontic treatment
Periodontal maintenance therapy
Upon completion of active periodontal therapy, follow-up maintenance therapy should include:
Med history update, evaluate the current extra and intraoral, periodontal and peri-implant soft tissue
Assessment of OH status
Mechanical tooth cleaning
Elimination or mitigation of new or persistent risk and etiological factors
Identification and treatment of new, recurrent, refractory areas
Establishment of an appropriate, individualized interval for perio maintenance
The pt should be kept informed of:
Areas of persistent, recurrent, refractory, or new periodontal disease
Changes in periodontal prognosis
Advisability of further periodontal treatment or retreatment of indicated sites
Status of dental implants
Other oral problems, including carries, defective restorations, and non-periodontal mucosal diseases/conditions
Factors modifying results
The result of periodontal therapy can be adversely affected by circumstances beyond the control of the dentist: systemic disease of the patient, inadequate plaque control, pulpal-periodontal problem, smoking, stress, occlusion or iatrogenic factors.
Evaluation of therapy
Upon completion of planned periodontal treatment the record should document the following:
The patient has been counseled on OH
The accepted therapy has been performed to arrest the progression of periodontal disease
Root planning has left subgingival root surface free of calculus
Gingival crevices are generally without BOP or suppuration
Recommendation has been made to correct any tooth form, position, restoration, or prosthesis considered to be contributing to periodontal disease process
An appropriate perio maintenance program has been recommended
Topic: Bleeding on probing
Authors: Gerber J, Tan W, Balmer T, Salvi G, Lang N No Article
Tittle: Bleeding on probing and pocket probing depth in relation to probing pressure and mucosal health around oral implants.
Source: Clin Oral Implants Res 2009;20:75-78
Type: Clinical Trial
Rating: Good
Keywords: Pathogenesis, periodontitis
Background: The sign of bleeding on probing (BOP) has been implicated as a valuable parameter in the diagnostic process for peri-implant mucositis, while probing depth has been adapted from periodontal diagnosis to assess soft tissue pathology and loss of bony support around osseointegrated oral implants (Isidor 1997; Lang et al. 1997).
Purpose: To assess the BOP tendency and PD when applying various probing forces at implant sites in patients with good oral hygiene and well-maintained peri-implant tissues.
Methods: 17 healthy patients with excellent OH in a maintenance program after having been treated for periodontitis or gingivitis. Missing teeth had been replaced and restored with dental implants. The BOP to the depth of the clinical sulcus or pocket and probing depth (PD) were evaluated using two different probing forces of 0.15 and 0.25N (at the mid-buccal, mid-oral, mesial and distal aspects of the buccal surfaces of each implant). These forces were controlled by an electronic pressure sensitive probe with a point diameter of 0.4mm (Florida Probe). Contralateral teeth were assessed for BOP and PD in the same locations and at the same observation visits. At each visit, implants and contralateral teeth were randomly assigned to one of the standardized probing forces (0.15 or 0.25 N). The second probing force was applied at the repetition of the examination 7 days later.
Results:
Increasing the probing pressure by 0.1 N from 0.15 N to 0.25N resulted in an increase of BOP percentage by 13.7% for implants and 6.6% for contralateral teeth.
Inclination of the regression line was significantly steeper at implant sites than at tooth sitesSSD b/w the mean BOP % at implants and tooth sites when a probing pressure of 0.25 N was applied.
When applying a probing force of 0.15 N NSSD at the implant sites when compared with the tooth sites.
A SS deeper mean PD at implant sites compared with tooth sites was found irrespective of the probing pressure applied.
Conclusion: Probing around implants demonstrated a higher sensitivity compared with probing around teeth. 0.15 N might represent the threshold pressure to be applied to avoid false positive BOP readings around oral implants.
Bleeding on Probing and Histologic Changes
Does clinical bleeding on probing reflect specific histologic status?
Title: Histologic characteristics associated with bleeding after probing and visual signs of inflammation.
Authors: Greenstein G, Caton J, Polson AM Article
Source: J. Periodontol. 52:420-425, 1981.
Type: Clinical study
Rating: Fair
Keywords: bleeding on probing, inflammation
Purpose: To clarify the histologic changes in the gingiva associated with visual signs of inflammation (VSI) and BOP.
Methods: Clinical and histologic study in 26 patients (60 midfacial gingival sites) requiring pocket elimination surgery. VSI (redness and swelling), presence of plaque, probing with a pressure-sensitive probe (25g), and BOP were determined. Gingival biopsies were obtained for histologic analysis to determine the percentages of cell rich-collagen poor connective tissue and blood vessel lumens. A facial reference incision was performed to provide clear orientation of the grid for morphometric analysis.
Results: Mean sulcus depth was 1.8mm (range 1-3mm). Visible signs of inflammation were present in 17 of the specimens, and BOP occurred in 24. In specimens positive for VSI, there was a SSD greater percentage of cell rich-collagen poor CT and a greater percentage of blood vessel lumens. BOP was associated with a SSD greater percentage cell rich-collagen poor CT, but the CT did not present an increase of percentage of blood vessel lumens.
Conclusion: Both VSI and BOP can be used to detect gingival inflammation. In areas inaccessible for visual evaluation (i.e. base of pocket), BOP is a more reliable and objective method of determining inflammation.
Topic: Bleeding on Probing
Authors: Caton J, et al Article
Title: Cell populations associated with conversion from bleeding to nonbleeding gingiva
Source: J. Periodontol. 59:7-11, 1988
Type: Clinical
Rating: Good
Keywords: bleeding on probing, gingivitis
Purpose: To characterize the gingival cell populations associated with the conversion of a bleeding to nonbleeding state.
Materials and methods: Interproximal gingival biopsies were obtained from 33 patients during periodontal surgery. 4 weeks prior to surgery patients’ teeth were scaled and OHI were given. Initial PD and AL were 4mm or less and radiographic bone loss 20% or less. Wooden interdental cleaner was inserted horizontally to depress the papilla 1-2mm and presence or absence of bleeding was recorded within 15 seconds. Sites that bled initially were included to the study. Immediately prior to surgery these sites were evaluated again and 18 of them had converted to nonbleeding sites. (two groups: bleeding group and stopped-bleeding group). Sites were studied histologically and the components that were counted were polymorphonuclear leukocytes, lymphocytes/macrophages/monocytes, plasma cells, fibroblasts/ endothelial cells, collagen, red blood cells/empty lumens, interstitial space and unidentified cells.
Results: The area of infiltrated CT was extensive in bleeding gingiva. It was denser and extended into the midaspect of the CT while in the stopped-bleeding group it was confined primarily to the dental aspect.
Plasma cells, PMNs, lymphocytes/macrophages/monocytes and unidentified cells were more numerous among bleeding specimens while fibroblast/endothelial cells were more numerous in stopped-bleeding sites. Interstitial space was higher in bleeding sites. No significant differences were found for blood vessel lumens/red blood cells.
Conclusion: Conversion of a bleeding interproximal site to nonbleeding was accompanied by a significant increase in the percentage of collagen and fibroblast/endothelial cells and significant decrease in inflammatory cells.
Findings from the present study support the use of interdental bleeding after stimulation for monitoring periodontal therapy.
The Effect of Treatment on Bleeding on Probing
Topic: Comparative study
Authors: Kalkwarf KL, Kaldahl WB, Patil KD, Molvar MP No Article
Title: Evaluation of gingival bleeding following 4 types of periodontal therapy
Source: J. Clin. Periodontol. 16:601-608, 1989.
Type: Clinical
Rating: Good
Keywords: Comparative treatments, osseous surgery, bleeding on probing, scaling, root planing
Purpose : To evaluate the effect of 4 types of periodontal therapy (coronal scaling (CS), root planing (RP), modified Widman Flap (MWF), and flap with osseous resection (Oss sx))and subsequent maintenance care relating to BOP; and evaluating the relationship of BOP to PD and the longitudinal dynamic of the bleeding response.
Materials and methods:
75 patients, split mouth study
Each quadrant in each subject was randomly designated to receive: l) CS only, 2) CS plus root planing (RP), 3) CS/RP followed by MWF, or 4) CS/RP followed by Oss sx.
Pt had to maintain good OH (>80% MOL). Assessed: supragingival plaque, BOP, and PD.
A standardized 25g probing force was used. Exam and data collected at initial visit, 4 weeks after initial therapy, 10 weeks after surgical therapy, and maintenance phase collected annually for two years, with SPT every 3 months.
Results:
All types of therapy reduced the prevalence of BOP for each severity category.
BOP was dynamic in study: with 15-88% of sites changing in BOP status (pos or neg) between any two examination periods
A direct relationship existed between probing depth, and to lesser extent supragingival plaque, to increased prevalence of BOP regardless the type or phase of treatment completed.
Regions with >5mm PDs treated by CS demonstrated a SSD greater prevalence of BOP than region treated with any other modality.
Sites associated with deeper PD exhibited a greater tendency to bleed and sites associated with plaque accumulation bled more frequently
Sites treated by Oss sx had a greater prevalence of bleeding and greater % of non-bleeding sites converting to bleeding only in shallower PDs (1-4mm)
(possible factors: immature healing, increased plaque accumulation)
Conclusion: Incidence of BOP in this study appears to be dependent upon probing depth severity and upon the presence of supragingival plaque at the site. One can infer that accumulation of irritants in deeper sites with result in increased inflammation and greater likelihood of BOP as well as marginal gingival irritation. However, due to the dynamic nature of BOP, it may or may not be a reliable predictor of periodontal breakdown.
Topic: Disease activity
Title: Bleeding on probing and probing depth as indicators of the response to plaque control and root debridement.
Author: Van Ooteghem et al No Article
Source: Journal of clinical periodontology. 1987 Apr 1;14(4):226-30.
Type: Case study
Rating: Good
Keywords: Probing attachment loss, probing depth, bleeding, plaque control, root debridement
P: To estimate the diagnostic accuracy of clinical indicators for identification of sites with deteriorating probing attachment loss (PAL).
M&M: 19 pts with advance periodontitis, 971 non-molar sites, 309 molar flat surfaces, and 150 molar furcation sites. Plaque control and single episode of root debridement was performed. Results of PAL, PD, BOP, suppuration, and PI were recorded every 3 months for 2 yrs. A pressure-sensitive probe set at 0.5N was utilized. SRP of deeper sites and bleeding sites was performed at 15, 18, 21 months. Only sites with initial PD > 4mm included.
R: Presence of supra-g plaque, BOP, suppuration on palpation, and residual PD >7mm, showed limited diagnostic reliability for determining probing AL. Increase PD by 2mm after 24 months provided the best diagnostic accuracy of PALoss, reaching 70%. All of the aforementioned factors all predicted less than 50% future PALoss.
D: A possible explanation for this limited diagnostic accuracy may be that some areas of PALoss following basic periodontal therapy are caused by factors other than the progression of an inflammatory periodontal disease of microbial etiology like: trauma from OH, damage during sub-g instrumentation, remodeling of attachment level during healing, and age-related remodeling. If probing attachment loss following initial therapy is multifactorial, one would not expect inflammatory signs like bleeding and suppuration on probing to show a high diagnostic accuracy.
BL: Presence of supra-g plaque, BOP, suppuration on palpation, and residual PD >7mm showed limited diagnostic reliability for determining probing AL. Increase in PD by 2mm after 24 months provided the best diagnostic accuracy of PALoss (70%). The limited diagnostic accuracy may be because some areas of probing attachment loss following basic periodontal therapy are caused by factors other than the progression of an inflammatory periodontal disease of microbial etiology.
Topic: Bleeding on probing
Authors: Joss A, Lang NP. Article
Title: Bleeding on probing. A parameter for monitoring periodontal conditions in clinical practice
Source: J Clin Periodontol 1994 Jul;21(6):402-8
Type: clinical
Rating: good
Keywords: Bleeding on probing, periodontal disease,
Purpose: To validate BOP as a clinical parameter for determining disease progression or periodontal stability.
Methodse: 39 patients with advanced to severe periodontitis followed over a 53-months maintenance period after initial treatment (SRP and surgery in about 50% of them). Total supportive therapy appointments 7 – 14. BOP was checked in every appointment, re-instrumentation was performed in the bleeding sites, while supragingival plaque was removed from all teeth. Probing depths and attachment levels were recorded at baseline and at the end of the observation period.
Results:
The highest rate of PD increase was observed in the interproximal sites (in 3.1% of the cases, up to 30.4% furcation involvements).
6.9% to 34% of the sites at multirooted teeth lost attachment.
Total of 147 sites (4.2%) lost attachment during the observation period, 123 lost 2 mm, 21 sites 3 mm, 1 site 4 mm and 2 sites 5 mm of probing attachment.
The sites with deepened probing depths demonstrated BOP in 2 out of 3 times, while sites with normal sulcus (1-3 mm) showed a mean BOP approximately 1 out 5 times.
Conclusion: Patients with the highest mean BOP (≥30%) showed the highest number of sites losing probing attachment during the observation period.
Topic: Clinical measurements
Title: Clinical measurements of periodontitis
Source: J Clin Periodontol 13:446-455, 1986.
Type: Discussion article
Rating: Fair
Keywords: Attachment level, attachment loss, attachment gain, autocorrelation, computer algorithm.
Purpose: To discuss clinical measurements of periodontitis and their ability to detect active disease sites.
Methods: In previous studies, 3 different analytical procedures have been used to detect the changes in periodontal sites over time (regression, running median and tolerance methods).
Discussion:
|
Clinical measurements unrelated to attachment level changes |
Clinical measurements related to attachment level changes |
|
*Gingival redness *BOP *Suppuration *Supragingival plaque *Darkfield microscopic bacterial counts |
*Loss of alveolar crest bone *Presence of specific bacterial species |
Clinical measurements that have failed to exhibit association with episodic attachment loss include: gingival redness, BOP, suppuration, supragingival plaque (Haffajee et al 1983) and darkfield microscopic bacterial counts (Dunham et al 1985).
Clinical measurements that have been associated with episodic attachment loss include: loss of alveolar crest bone and the presence of specific bacterial species.
The amount of periodontal destruction is greatly underestimated by radiographic assessment (Lang & Hill 1977).
In a study of treatment for rapidly advancing periodontitis, 97.3% of inactive sites failed to respond to treatment, whereas 37.3% gained 3 mm or more after Widman flap therapy and systemic tetracycline. *Only disease active sites responded to treatment (Goodson et al. 1985)
Since inactive sites (95-97%) outnumber active sites (3-5%), the inclusion of inactive sites in clinical trials, serves to dilute the tx response.
Conclusion: Detection of disease activity appears central to the clinical measurement of periodontitis. Radiographic measurement has proven to be inconsistent, so at this time, the only practical means to measure active disease is from changes in attachment level. Incremental attachment loss rather than attachment level appears to be the preferred clinical measure of periodontal disease activity. Attachment loss at periodontal sites appears to be largely independent of the host. Beneficial therapeutic responses are primarily associated with active disease sites, improvement in the measurement of attachment level and development of a less complex detection system are greatly needed.
Topic: Immunology and pathogenesis
Authors: Silva N, et al. No Article
Title: Characterization of progressive periodontal lesions in chronic periodontitis patients: Levels of chemokines, cytokines, matrix metalloproteinase-13, periodontal pathogens and inflammatory cells.
Source: J Clin Periodotol 2008; 35: 206 - 214
Type: Longitudinal clinical study
Rating: Good
Keywords: cytokines, inflammatory cells, matrix metalloproteinases, periodontal pathogens, progressive periodontitis
Purpose: To determine the levels of chemokines, cytokines, matrix metalloproteinase-13, periodontal pathogens, and inflammatory cells in periodontal sites characterized by active periodontal connective tissue destruction.
Methods: 56 patients with chronic moderate to advanced periodontitis who had received no previous treatment were monitored. Supragingival prophylaxis was performed to allow for probing depth (PD). Clinical parameters evaluated included PD, clinical attachment loss (CAL), plaque accumulation (PI), and bleeding on probing (BOP). Measurements were taken at baseline, 7 days and 2 months. Sites were active if CAL of ≥ 2 mm was noted in the 2 mo. observation period, with 2 such sites required per patient to define an active disease state. Samples of GCF, subgingival plaque and gingival biopsy were collected from one active and one inactive site in these patients (5 males, 13 females).
ELISA was used to assay the collected GCF and determine levels of RANK-L, MCP-1, IL-1β and TNF-α. MMP-13 activity was also measured in the GCF samples. Subgingival plaque samples were treated and plated for detection of P. gingivalis, T. forsythia, and A. actinomycetemcomitans. Immune cells were measured in gingival biopsy samples.
Results: Active sites showed higher mean percentages for P. gingivalis, as well as a higher total amount of RANK-L and IL-1β. Higher basal activity levels of MMP-13 were also found in active sites. CD4+, CD8+, and CD19+ were elevated in active sites.
Conclusion: Active sites showed significantly higher amounts of P. gingivalis and CD4+ T cells. The total amount of RANK-L, IL-1β, and MMP-13 present in GCF of active sites is significantly higher than in inactive sites. MMP-13 could be considered as a marker of activity of periodontal disease progression, and the function and relevance of this MMP should be investigated further.
Topic: Periodontal disease activity asynchronous multiple burst
Authors: Greenstein G, Caton J Article
Title Periodontal disease activity: A critical assessment.
Source: J Periodontol 61: 543-552, 1990
Type: Review
Keywords: Periodontal disease, activity
P: to address concepts and controversies associated with periodontal disease activity (PDA) and discuss their clinical implications.
Temporal Patterns of Destructive Periodontal Disease:
Three concepts: Continuous paradigm, random or episodic burst, and asynchronous multiple burst. It’s possible that features of all three may be occurring. Different patterns of destructions may manifest in different individuals and sites.
Methods to Detect PDA:
Clinically, probing attachment levels using the CEJ is the most common technique.
PD can be misleading (coronal migration of gingival margin due to inflammation, rebound of tissue after surgery, intrusion of teeth)- greater pocket depths can be recorded despite no PDA and loss of attachment can occur without a change or with a decrease in pocket depth.
Frequency, Magnitude, Cycles, and Rate of Attachment Loss
Longitudinal surveillance indicates AL occurred at a small number of sites in relatively few subjects. Continuous monitoring is necessary to detect early manifestations of PDA.
Measurement Error:
Watts described four sources of probing error: observational, tactile, positional, tissue change.
2.3% of reprobed sites showed 3mm variation.
Badersten: 3% frequency that differences of greater than 2mm occurred.
Clark noted a 3mm intraexaminer error 10% of the time when CEJ was used as reference when measuring AL.
Site Specific CAL
There is a controversy regarding whether sites with previous PDA are more prone to additional deterioration than healthy gingival sites.
Not all locations with AL continue to deteriorate, but enough do to warrant high degree of suspicion: PDA does not appear to be random with respect to location.
PDA Associated with Bacterial Invasion of Tissues
Suggested that bacterial invasion into tissues may activate bursts of PDA, but conflicting evidence exists and it is premature to state such a relationship exists.
Saglie et al found a greater number of A.a and P.gingivalis in specimens taken from sites losing attachment than controls. However, all of the inactive sites demonstrated organisms in the epithelium and the connective tissue. It remains unclear if these microorganisms precipitated exacerbations and if they did, what quantity of them or other factors made sites experience PDA.
Predicting PDA
Clinical and laboratory parameters to forecast sites vulnerable to PDA.
Clinical parameters are useful in providing information concerning extent of previous breakdown and current inflammatory status, but are generally poor disease predictors.
Longer monitoring periods may need to be used if clinical signs of disease are to reach meaningful dx values. Bone assessments (radiographs, nuclear medicine, subtraction radiographs) are either poor predictors of PDA or impractical. Microbial determinations are not able to forecast PDA.
Recently it was reported that monitoring crevicular fluid levels of B-glucuronidase or prostaglandins E2 facilitated predicting attachment loss. Both assays need modification if they are going to be used in a clinical setting.
CON: At present the only objective to monitor PDA are longitudinal assessments of probing attachment levels and radiographs. Sites kept free of inflammation usually do not breakdown. Frequent monitoring and maintenance should be implemented to prevent recurrence of inflammation.
Topic: Pathogenesis
Authors: Van Dyke TE, Tohme ZN. No Article
Tittle: Periodontal diagnosis: evaluation of current concepts and future needs.
Source: J Int Acad Periodontol. 2000 Jul;2(3):71-8.
Type: Review
Rating: Good
Keywords: Disease Activity, periodontitis
Purpose: Review article.
Discussion:
Periodontal diseases are multifactorial pathologies that manifest clinically by destruction of the soft and hard tissues.
Bacterial insult has been implicated in the initiation of these diseases, however the degree of destruction is dependent on the host response.
The host response varies from individual to individual depending on many factors including the type of the bacterial insult, the duration of the insult, the local and environmental contributing factors, immunological and inflammatory responses, predisposing genetic factors, and association with systemic diseases.
The classical methods of periodontal diagnosis limited to clinical examination and radiographic evaluation. These methods essentially determine previous destruction, or history of disease.
Evaluation of disease activity has been limited to longitudinal evaluation of these parameters, with limited accuracy, and predictors of future disease activity have not been available.
The goal of new diagnostic methods is the early diagnosis of disease, before significant destruction has occurred, and measures of successful treatment or disease arrest.
Work has begun on genetic predictors of susceptibility, which might be used to implement prevention programs or alter treatment decisions.
Predictors of Disease Activity
Topic: Predictors of disease activity
Authors: Haffajee AD, Socransky SS, Goodson JM Article
Title: Clinical parameters as predictors of destructive periodontal disease activity
Source: J Clin Periodontol 10:257-265, 1983.
Type: Clinical study
Rating: good
Keywords: bleeding on probing, probing depth, predicting periodontal disease activity
Purpose: To evaluate the usefulness of clinical measurements in predicting destructive disease activity.
Method: 22 patients with 3414 sites were monitored; clinical measurements (plaque, redness, suppuration, BOP, pocket depth, attachment levels) were taken every two months for one year. Sites showing active destructive activity (or lack of activity) were determined at each time interval. The use of a clinical parameter or parameters was/were evaluated as predictors of disease activity.
Results: Only 242 occurrences of destructive disease activity were detected in 12,074 site monitoring intervals. Molars and interproximal surfaces were more likely to develop disease activity, and shallow pockets dominated the sites at risk. Sensitivity of clinical measurements of gingival redness, plaque, suppuration and BOP ranged from 0.03 (suppuration) to 0.42 (plaque). Specificity of these measurements were better (0.71 for plaque to 0.97 for suppuration). PD <4 mm was a sensitive diagnostic test for disease activity but was a poor predictor of disease activity.
Conclusion: None of the clinical parameters demonstrated both high sensitivity and high specificity values. None of the clinical parameters used, individually or in combination, were found useful in predicting disease activity at individual sites.
Topic: Disease Activity
Authors: Badersten A, Nilveus R, Egelberg J Article
Title: Scores of plaque, bleeding, suppuration and probing depth to predict probing attachment loss. Five years of observation following nonsurgical periodontal therapy.
Source: J. Clin. Periodontol. 17:102-107, 1990
Type: Clinical
Rating: Fair
Keywords: diagnostic predictability, clinical criteria, re-evaluation, initial periodontal therapy, prognosis
Purpose: To determine the diagnostic value of clinical scores of supragingival plaque, bleeding, suppuration and probing depth to predict attachment loss in patients on maintenance following nonsurgical periodontal therapy.
Materials and methods: Data from subjects that participated in 3 previous studies on nonsurgical periodontal therapy (Badersten 1984a, 1984b, 1985). 39 subjects with 1956 sites were examined and followed for 5 years. Single rooted teeth only were included. All initial treatments were completed 9 months after baseline and starting at 24 months patients had maintenance visits every 6 months. PI, BOP, PD and AL were recorded at 6 sites/tooth.
Results: Longitudinal observations: Plaque scores showed increase from 12-60 months but remained lower than baseline. BOP and PDs remained stable from 12-60 months. Gradual recession was observed.
14% of the sites were found to have undergone attachment loss from 0-60 months (more frequent at initially shallow sites (34%) and buccal sites (36%) than for initially deep sites (4%)).
Diagnostic predictability: Plaque (maximum of 30% predictive value) and bleeding scores had limited relationship with probing attachment loss.
PD≥7mm was a poor predictor of future attachment loss in 6 months but at later intervals half of the sites of this depth had undergone attachment loss.
Increase in PD≥1mm showed high diagnostic predictability (62% after 36 months and 78% after 60 months).
Conclusion: Deepened probing is the most valuable score of those investigated to detect attachment loss.
Topic: Diagnosis
Authors: Claffey N, Nylund K, Kiger R, Garrett S, Egelberg J Article
Title: Diagnostic predictability of scores of plaque, bleeding, suppuration and probing depth for probing attachment loss. 3.5 years of observation following initial periodontal therapy
Source: J. Clin. Periodontol. 17:108-114, 1990
Type: Clinical
Rating: Fair
Keywords: probing, supportive periodontal therapy, diagnostic predictability, clinical criteria, prognosis
Purpose: To evaluate the predictability of plaque, bleeding, and suppuration scores as well as probing depth to diagnose attachment loss over 42 months following initial periodontal therapy.
Materials and methods:
17 patients had 2121 sites monitored for changes of PD, PI, BOP and suppuration over 3.5 years. All patients but 1 had at least 2 molars with clinically detectable furcation involvement.
Patients had received no periodontal treatment in the last 5 years and all had generalized periodontitis with BOP, AL, furcation involvements, and calculus. OHI given as needed, SRP performed.
SPT varied, 4 subjects did not have SPT during the entire period, 13 subjects had SRP with subgingival debridement of deep or bleeding sites between 12 and 27 months. Prior to 12 months and from 30 to 42 months no subgingival debridement was done. Variability of maintenance therapy was explained by the fact that the 17 patients were participating in studies with varying protocols.
Clinical measurements taken at baseline and every 3 months throughout the 42 months; assessed: PI, BOP, suppuration, PD, and CAL. PD and CAL obtained with electronic, pressure sensitive probe with probing force of 0.50 N and stent.
Results:
Plaque scores demonstrated low predictability; bleeding and suppuration scores demonstrated modest predictability.
BOP frequency showed a 41% diagnostic predictability after 42 months.
Suppuration reached a diagnostic predictability of 40%-50%.
Increasing probing depth and deep residual defects had moderate predictive power after 3 and 12 months but showed increasing accuracy in revealing attachment loss over later time intervals. More CAL was noted in deeper and furcated sites than for other subgroups of sites.
BL: Increase in PD, combined with high frequency of BOP showed the highest predictive value for probing attachment loss of all the scores evaluated in this study.
Topic: Disease activity
Title: A systematic review on the use of residual probing depth, bleeding on probing and furcation status following initial periodontal therapy to predict further attachment and tooth loss
Author: Renvert et al No Article
Source: Journal of clinical periodontology. 2002 Dec 1;29(s3):82-9.
Type: Systematic review
Rating: Good
Keywords: initial therapy; periodontal attachment loss; periodontal-pocket; periodontitis therapy; systematic review; tooth loss
B: Untreated chronic periodontitis is often described as a slowly progressive disease affecting individual teeth or tooth sites. Standard diagnostics include PD, radiographic evidence of bone loss, visible signs of gingival inflammation, BOP, suppuration, tooth mobility. These are crude measures of the host response. Initial therapy involves OHI, SRP, and possible use of antimicrobials agents. At the initial follow up visit, one of the major txt objectives is to reduce PD.
P: To assess the predictive value of residual PD, BOP, and furcation involvement (FI) in determining further A Loss and tooth loss following initial perio therapy.
M & M: An electronic search of MEDLINE & EMBASE (Cochrane Oral Health Group specialized register) to ID studies assessing predictive values of PD, BOP & FI on ALoss & tooth loss in chronic perio patients (No Aggressive Perio). Looked at 941 studies, independently screened by 2 reviewers. 47 studies were selected, with a minimum duration of 12 months post re-evaluation appointment. Additional inclusion criteria: CAL > 1.5 mm when compared to re-evaluation appointment or >2 mm using baseline or loss of teeth. After excluding studies that did not meet criteria, only ONE study analyzed: case study on 16 patients followed for at least 42 months by Claffey & Egelberg, 1995.
D: The only significant correlation was found b/w ALoss >2.5 mm and residual PD >6 mm at 3 months following initial therapy (more likely to experience future CAL).
BL: Data from one study suggests that residual PDs of > 6mm are predictive of further disease progression.
CR: Failed to identify study protocols that had ensured a random case selected process to ensure that study subjects represented a large and relevant population with adult chronic periodontitis. The authors then described that this study should have been excluded also, as 12/16 of these patients had subgingival debridement after initial therapy. Studies based on observational designs and without a control group increase the risk for examiner bias.
Topic: IL-1 genotype / perio disease association
Authors: Huynh-Ba G, Lang NP. Article
Title: The association of the composite IL-1 genotype with periodontitis progression and/or treatment outcomes
Source: J Clin Periodontol. 2007 Apr;34(4):305-17, DOI: 10.1111/j.1600-051X.2007.01055.x
Type: systematic review
Rating: good
Keywords: genetic susceptibility, IL-1 gene polymorphism, IL-1 genotype, interleukin-1, periodontal disease, periodontitis
Purpose: To answer the question wether or not the composite IL-1 genotype was associated with periodontitis progression and treatment outcomes in periodontally treated and untreated populations.
Methods: Publications longitudinal in nature. Changes in attachment level, probing depths, BOP and levels of inflammatory mediators in GCF were considered for the assessment of periodontitis progression and treatment outcomes.
Results:
11 longitudenal publications were selected. Due to heterogeneity of the data, meta-analysis was not possible and the data were reported by applying descriptive methods. While findings from some publications rejected a possible role of IL-1 composite genotype on progression of periodontitis after various therapies, other reported a prognostic value for disease progression of the positive IL-1 genotype status. When assessed on a multivariate risk assessment model, several publications concluded that the assessment of the IL-1 composite genotype in conjunction with other covariates (e.g. smoking and presence of specific bacteria) may provide additional information on disease progression. The small sample size of the available publications, however, requires caution in the interpretation of the results. (For characteristics of the 11 publications refer to table 1 in this article.)
The data were described in four groups:
Absence of periodontal therapy: No association found between the positive IL-1 genotype status and peiodontal disease progression. On the other hand, IL-1 genotype status in conjunction with age, smoking, and presence of P.gingivalis was considered a contributory factor for periodontal disease progression
Non-surgical periodontal therapy: The positive composite IL-1 genotype was found to have some prognostic value for periodontal disease progression, assessed as clinical attachment loss or tooth loss when included in a mutli level risk assessment model.
Periodontal regenerative procedures: Association between positive composite IL-1 genotype and indicators of periodontal disease deterioration such as increase in BOP, PPD and CAL.
Supportive periodontal treatment: Knowledge of the IL-1 genotype may prove helpful in customizing the frequency of SPT thereby reducing the risk for future disease progression or tooth loss.
Conclusion: Results from this review were controversial. Screening for IL-1 genotype to determine the risk of periodontitis does not seem to be justified. This genotype is incorporated with smoking, age, systemic condition and specific microbiological conditions in a multilevel risk assessment model.
Topic: Clinical measurements
Author: Hausmann E., Jeffcoat M Article
Title: A perspective on periodontal disease activity measurements
Source: J Clin Periodontol. 15:134-136, 1988
Type: Review
Rating: Good
Keywords: radiographs, subtraction radiography, disease activity
Purpose: This review presents reference to studies which support the theory that adult periodontitis undergoes periods of exacerbation and remission at specific sites.
Discussion: The relationship between infection, host response and disease activity may not be simply described. It is possible that the balance between infection and resistance may be the major determinant of disease activity. Studies done are based on the use of standardized periapical radiographs to measure alveolar bone height, digital subtraction, and changes in clinical probing attachment level. Sequential probing attachment level or radiographic examinations may be an over simplification of the disease process. This method results in clinicians only looking at the total disease activity that occurred between the two measurements, but does not provide an instantaneous measure of activity. This method is unable to detect exacerbations and remissions during this interval.
Bottom Line: An ideal test for disease activity would be an instantaneous measure of disease activity and would not integrate activity over time
Do all periodontal diseases behave in a similar fashion? If not, why?
Topic: Attachment loss
Authors: Haffajee A, Socransky S No Article
Title: Attachment level changes in destructive periodontal diseases.
Source: J. Clin. Periodontol. 13:461-472, 1986.
Type: Review
Rating: Good
Keywords: attachment loss, sites versus subjects, periodontosis, response to therapy, random burst model
Purpose: To summarize some of the features of attachment loss (AL) including measurements employed to detect changes in attachment level, the nature of the destructive disease process, and effects of therapy on AL measurements.
Results: Measurement to evaluate attachment level changes: Radiographs and probing measurements (from CEJ or stent to deepest probeable point) are commonly used but have drawbacks. Probing force, probe angle, shape of tooth, subgingival deposits and patient cooperation can affect probing depth accuracy; however, this is most accurate method available. If 6 measurements are recorded around each tooth, this represents only 12% of the linear attachment apparatus in an individual with 28 teeth.
Nature of destructive periodontal disease: Periodontal disease, rather than progressing in a slow, continuous manner, has been shown to progress at some sites by means of acute bursts of activity, leading to the development of the “random burst model.” Further studies showed that periodontal disease progressed by means of asynchronous burst of activity which occurred more during a finite time in an individual’s life. Number, size, and location of bursts affect the pattern of AL. Three categories of AL were observed:
Group I-localized destruction with no AL at >66% of sites. (30/61 subjects).
Group II- no AL at <66% sites (14/61 subjects).
Group III-no AL at <33% of sites (17/61 subjects).
Group I subjects were younger, had less mean AL, shallower PD and less recession/suppuration. E. corrodens, S intermedius and F. nucleatum were increased in Group II/III subjects in subgingival plaque.
Effects of Therapy on attachment level: Changes in AL measurements is the most widely used way to determine the effect of therapy. Therapy may decrease the amount of active bursts that occur. Patient responses to treatment analyzed in this study varied between patients also depended on initial attachment loss and bacterial species present.
Conclusion: Periodontal disease is site specific and within the same individual, pathogenic and protective species can vary. Deeper pockets have a different distribution of pathogenic bacteria, which can affect treatment. Effective establishment of initial AL, understanding of disease progression, and tailored treatment on a site/patient basis is critical in treating periodontal disease.
Topic: Periodontal disease activity
Authors: Lindhe J, Okamoto H, Yoneyama T, et al Article
Title Periodontal loser sites in untreated adult subjects.
Source: J Clin Periodontol. 16:671-678, 1989.
Type: Clinical
Keywords: Periodontal disease, activty
Purpose: To describe some characteristic features of subjects and sites that lost periodontal attachment between baseline and the re-examinations after 1 and 2 years in patients that received no periodontal therapy.
Materials and methods:
265 Japanese subjects (age groups 20-79) received a baseline, 1 and 2 years examination with no periodontal treatment provided. Threshold for attachment loss was considered >2 mm.
Results:
40% of subjects exhibited loss of attachment > 2mm in 1 or more sites. Of those, the vast majority exhibited disease activity either during the 1st or the 2nd year of monitoring but not both.
70% of the sites deteriorated (loser sites) occurred in 12% of the subjects.
Losing sites were most frequently detected in older subjects and at molar sites.
Most of the loser sites occurred at interproximal surfaces
Sites with previous advanced attachment loss tended to exhibit a somewhat higher risk of further disease progression.
Percentage of sites with attachment loss was 0.7% (0.4% for single rooted teeth, 1.4% for molars).
BL: The features of naturally progressing periodontal disease in the present sample were that:
Advanced progression occurred in a small number of subjects.
Older subjects were more likely to show progression
Most breakdowns occurred at interproximal sites.
Sites with previous advanced attachment loss tended to exhibit a somewhat higher risk of further disease progression.
Topic: Disease Activity
Authors: Breen HJ, Johnson NW, Rogers PA Article
Tittle: Site-specific attachement level change detected by physical probing in untreated chronic adult periodontitis: Review of studies 1982-1997.
Source: J Periodontol. 70:312-328, 1999.
Type: Review
Rating: Good
Keywords: Disease Activity, periodontitis
Purpose: To summarize points from key studies evaluating site-specific AL changes detected by probing in patients with untreated chronic periodontitis.
Methods: Literature between 1982-1997 was reviewed.
Results: 23 studies were summarized according to probe generations and compared according to methods and results.
1) There are few papers addressing the question of site-specific AL changes in untreated chronic periodontitis.
2) Valid comparisons between studies are not possible due to variations in probes used; change in thresholds used; number of measurements, sites and subjects studied; analysis and duration of studies.
3) Only 8/23 papers have adequate data for longitudinal site-specific loss and gain of attachment. Most report only losing sites and ignores many measurements. Only one paper describes losing sites, gaining sites, and sites showing exacerbation/remission patterns of change.
4) Range of changes is so wide that it cannot reliably detect site-specific AL changes by physical probing there is no clear idea of the natural history of the disease.
Conclusion: It is imperative that future studies report all AL changes irrespective of the direction (loss or gain). Site-specific AL change detected by sequential probing is the most common method of determining progression/regression or stability of disease but there are a lot of measurement errors. One-sided observation is untenable: it provides an unbalanced view of the dynamics of the periodontal attachment over time and restricts our knowledge of the natural history of chronic adult periodontitis.
Disease Activity-Histology
Topic: Advanced periodontitis clinical parameters
Authors: Davenport RA, Simpson DM, Hassell TM Article
Title: Histometric comparison of active and inactive lesions of advanced periodontitis
Source: J. Periodontol. 53:285-295, 1982.
Type: Clinical study
Rating: Fair
Keywords: bleeding on probing, suppuration
Purpose: To examine the histopathologic features of advanced periodontal lesions classified as bleeding/suppurating or not bleeding/suppurating after clinical probing.
Methods: Primary criterion for inclusion in the study was the presence of a hopeless tooth exhibiting radiographic evidence of alveolar bone destruction due to chronic perio dz. After the tooth was selected, each lesion was classified on the basis of the presence or absence of bleeding and suppuration on gentle probing on the base of the pocket. After the probe had been removed, the orifice of the pocket was observed for 15sec to determine the presence of bleeding or suppuration or both. Group A: active lesion (BOP/sup) and Group B: inactive (no BOP/sup). 14 advanced lesions, 9 Group A (4/9 had suppuration) and 5 Group B from 12 subjects (31-63 years) were selected for study. GI, PI, PD, & Pocket fluid flow determined. Teeth were extracted as to not damage the area were the pocket was and then the tooth and soft tissue were prepared for serial sections. Measurements obtained: 1.CEJ to apical extent of JE. 2. Gingival margin to base of pocket. 3. Gingival margin to apical extent of JE. 4. Length of JE.5. Apical extent of inflamed CT. Also rete peg proliferation, ulcerations, widening of intercellular spaces in JE and % of infiltrated CT were assessed.
Results: The mean percentage of inflamed CT was consistently greater in bleeding sites than in non-bleeding sites. Bleeding sites had more plasma cells, mononuclear cells (lymphocytes, monocytes, macrophages, blast cells), and extracellular space (connective tissue) than non-bleeding sites. Non- significant differences were found in the # of PMNs, unidentifiable cells, and vessels in the two lesion types. The pocket epithelium of bleeding lesions consistently demonstrated thinned or ulcerated areas. The pocket and JE of bleeding lesions always contained greater # of leukocytes.
Conclusion: There are differences in clinical and histologic parameters between advanced lesions selected by the presence or absence of bleeding/suppuration after probing. So bleeding or bleeding combined with suppuration is indicative of histopathologic changes in advanced periodontal lesions and may be used to determine dz activity.
Topic: Disease Activity
Authors: Carvel RI, Carr RF No Article
Title: Clinico-pathologic correlation of 385 lesions of marginal destructive periodontitis
Source: J. Periodontol. 53:328-333, 1982
Type: Clinical
Rating: Good
Keywords: periodontal disease, plasma cells, inflammation
Purpose: To explore the composition of the pocket’s granulomatous tissue in a large population of adults with chronic periodontitis.
Materials and methods: Granulomatous tissues were moved from 385 pocket lesions of 221 patients. Lesions were diagnosed clinically and radiographically and were classified as 147 Class I (PD 4-6mm) and 238 Class II (PD 7-10mm). 70% of the Class II lesions were associated with infrabony pockets. 10% of the lesions had history of abscesses and some of the biopsies were obtained when these occurred. In some instances, specimens came from recurrent lesions and were compared to specimens obtained from successfully treated sites from the same patients. Sections were observed under light microscope.
Microscopic findings were classified in 5 types according to inflammatory infiltrated composition: Type a, predominantly (80% or more) plasma cells, Type b, predominantly lymphocytes, Type c, approximately equal population of plasma cells and lymphocytes, Type d, predominantly plasma cells and some neutrophils and Type e mixed infiltrate of plasma cells, lymphocytes and neutrophils.
Results: Type a and d infiltrates were almost associated with deeper lesions (class II). Type b were associated with Class I lesion 71% of the times. Type c and e were equally associated with Class I and II lesions.
Conclusion: Infiltrates consisting primarily of plasma cells were associated with more resorption of adjacent hard tissues and a more destructive type of periodontal lesions than were other types of infiltrates.
Designed By Steven J. Spindler, DDS LLC