Measurement of clinical attachment levels using a constant-force periodontal probe modified to detect the cemento-enamel junction

Changes in oral health during aging in a novel non-human primate model

Oral health plays a significant role in the quality of life and overall well-being of the aging population. However, age-related changes in oral health are not well understood due to challenges with current animal models. In this study, we analyzed the oral health and microbiota of a short-lived non-human primate (i.e., marmoset), as a step towards establishing a surrogate for studying the changes that occur in oral health during human aging. We investigated the oral health of marmosets using cadaveric tissues in three different cohorts: young (aged ≤6 years), middle-aged, and older (>10 years) and assessed the gingival bacterial community using analyses of the V3-V4 variable region of 16S rRNA gene. The oldest cohort had a significantly higher number of dental caries, increased dental attrition/erosion, and deeper periodontal pocket depth scores. Oral microbiome analyses showed that older marmosets had a significantly greater abundance of Escherichia-Shigella and Propionibacterium, and a lower abundance of Agrobacterium/Rhizobium at the genus level. Alpha diversity of the microbiome between the three groups showed no significant differences; however, principal coordinate analysis and non-metric multidimensional scaling analysis revealed that samples from middle-aged and older marmosets were more closely clustered than the youngest cohort. In addition, linear discriminant analysis effect size (LEFSe) identified a higher abundance of Esherichia-Shigella as a potential pathogenic biomarker in older animals. Our findings confirm that changes in the oral microbiome are associated with a decline in oral health in aging marmosets. The current study suggests that the marmoset model recapitulates some of the changes in oral health associated with human aging and may provide opportunities for developing new preventive strategies or interventions which target these disease conditions.

Ultrasound Imaging of the Periodontium Complex: A Reliability Study

Background

Ultrasonography is a noninvasive, low-cost diagnostic tool widely used in medicine. Recent studies have demonstrated that ultrasound imaging might have the potential to be used intraorally to assess periodontal biomarkers.

Objectives

To evaluate the reliability of interlandmark distance measurements on intraoral ultrasound images of the periodontal tissues.

Materials and Methods

Sixty-four patients from the graduate periodontics (n = 33) and orthodontics (n = 31) clinics were recruited. A 20 MHz handheld intraoral ultrasound transducer was used to scan maxillary and mandibular incisors, canines, and premolars. Distances between the alveolar bone crest and cementoenamel junction (ABC-CEJ), gingival thickness (GT), and alveolar bone thickness (ABT) were measured by 3 raters. The intercorrelation coefficient (ICC) and mean absolute deviation (MAD) were calculated among and between the raters. Raters also scored images according to quality.

Results

The ICC scores for intrarater reliability were 0.940 (0.932-0.947), 0.953 (0.945-0.961), and 0.859 (0.841-0.876) for ABC-CEJ, GT, and ABT, respectively. The intrarater MAD values were 0.023 (±0.019) mm, 0.014 (±0.005) mm, and 0.005 (±0.003) mm, respectively. The ICC scores for interrater reliability were 0.872 (95% CI: 0.836-0.901), 0.958 (95% CI: 0.946-0.968), and 0.836 (95% CI: 0.789-0.873) for ABC-CEJ, GT, and ABT, respectively. The interrater MAD values were 0.063 (±0.029) mm, 0.023 (±0.018) mm, and 0.027 (±0.012) mm, respectively.

Conclusions

The present study showed the high reliability of ultrasound in both intrarater and interrater assessments. Results suggest there might be a potential use of intraoral ultrasound to assess periodontium.

Assessment of Negative Gingival Recession: A Critical Component of Periodontal Diagnosis

Accurate measurement of negative gingival recession (GR) is essential to accurately determine the clinical attachment loss, which leads to an accurate diagnosis and optimal therapy of periodontal disease. However, the accuracy of measuring the negative GR has been shown to be low and highly variable between examiners. The position of the gingiva margin in relation to the cemento-enamel junction (CEJ) varies among different stages of passive eruption. The amount of negative GR is about 2 mm on average at the mid-facial sites and ranges from 2 to 3.5 mm at interproximal sites in periodontally healthy patients. Some other clinical conditions may change the gingival dimension coronal to the CEJ, such as altered passive eruption and gingival enlargement. In addition to the traditional approach using a periodontal probe to assess the negative GR, nowadays dental ultrasound imaging may be able to assist in accurately measuring the amount of negative GR. This narrative review will discuss the existing evidence of the dimension of dentogingival tissue and the clinical assessment of negative GR using different clinical tools.

The precision of gingival recession measurements is increased by an automated curvature analysis method

Background

The extent of gingival recession represents one of the most important measures determining outcome of periodontal plastic surgery. The accurate measurements are, thus, critical for optimal treatment planning and outcome evaluation. Present study aimed to introduce automated curvature-based digital gingival recession measurements, evaluate the agreement and reliability of manual measurements, and identify sources of manual variability.

Methods

Measurement of gingival recessions was performed manually by three examiners and automatically using curvature analysis on representative cross-sections (n = 60). Cemento-enamel junction (CEJ) and gingival margin (GM) measurement points selection was the only variable. Agreement and reliability of measurements were analysed using intra- and inter-examiner correlations and Bland–Altman plots. Measurement point selection variability was evaluated with manual point distance deviation from an automatic point. The effect of curvature on manual point selection was evaluated with scatter plots.

Results

Bland–Altman plots revealed a high variability of examiner’s recession measurements indicated by high 95% limits of agreement range of approximately 1 mm and several outliers beyond the limits of agreement. CEJ point selection was the main source of examiner’s variability due to smaller curvature values than GM, i.e., median values of − 0.98 mm^− 1 and − 4.39 mm^− 1, respectively, indicating straighter profile for CEJ point. Scatter plots revealed inverse relationship between curvature and examiner deviation for CEJ point, indicating a threshold curvature value around 1 mm^− 1.

Conclusions

Automated curvature-based approach increases the precision of recession measurements by reproducible measurement point selection. Proposed approach allows evaluation of teeth with indistinguishable CEJ that could be not be included in the previous studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01858-9.

Comparative assessment of conventional periodontal probes and CEJ handpiece of electronic probes in the diagnosis and primary care of periodontal disease

Objectives:

Conventional probes (CPs) have been considered acceptable as diagnostic tools to measure probing pocket depth (PPD) and clinical attachment level (CAL) but are affected by multiple variables. Electronic probes (EPs) provide controlled force, digital readout and data storage in computers. The objectives were to compare the reproducibility in the measurement of PPD and CAL by CP and the newly introduced CEJ handpiece of EP and intra-examiner and inter-examiner errors done in two phases.

Methods and Material:

Selected 720 periodontal sites in 1^st molar of 30 persons with chronic periodontitis ≤4 mm and >4 mm pockets were analysed by two trained investigators in two phases at 2 hours difference by CP and CEJ handpiece of EP. Standard deviation, mean difference, correlation coefficient, P value and student 't' test were done to analyse data.

Results:

The intra- examiner and inter-examiner analyses revealed that Pearson's correlation coefficient was above 0.080 and 0.722 in the ≤4 mm and >4 mm pockets, respectively. Mean difference was not statistically significant in both groups except in the intra- examiner findings in the 2^nd phase. Interprobe analysis depicted a standard error of mean of <0.03 in ≤4 mm pockets, whereas it varied from 0.047–0.056 in >4 mm pockets.

Conclusion:

In conclusion, EP is advantageous for research purposes by providing automatic recording and long-term maintenance of data storage without the need of an assistant and patient education and motivation, whereas CP appears to be more useful in routine periodontal examination.

Comparative Evaluation of Serum Tumor Necrosis Factor α in Health and Chronic Periodontitis: A Case-Control Study

Background

Tumor necrosis factor-alpha (TNF-α), a " major inflammatory cytokine," not only plays an important role in periodontal destruction but also is extremely toxic to the host. Till date, there are not many studies comparing the levels of TNF-α in serum and its relationship to periodontal disease.

Aim

Our study aimed to compare the serum TNF-α among the two study groups, namely, healthy controls and chronic periodontitis patients and establish a correlation between serum TNF-α and various clinical parameters. Hence, an attempt is made to estimate the level of TNF-α in serum, its relationship to periodontal disease and to explore the possibility of using the level of TNF-α in serum as a biochemical " marker" of periodontal disease.

Materials and Methods

Forty individuals participated in the study and were grouped into two subgroups. Group A - 20 systemically and periodontally healthy controls. Group B - twenty patients with generalized chronic periodontitis. The serum samples were assayed for TNF-α levels by enzyme-linked immunosorbent assay method.

Results

The mean serum TNF-α cytokines for Group B Generalized chronic periodontitis (GCP) was 2.977 ± 1.011, and Group A (healthy) was 0.867 ± 0.865. The range of serum TNF-α was from (0.867 to 2.977). Serum TNF-α cytokines had highly significant correlation with all clinical parameters (plaque index, probing pocket depth, clinical attachment loss, and gingival index) among all study participants (P = 0.001).

Conclusion

These observations suggest a positive association between periodontal disease and increased levels of TNF-α in serum. It can be concluded that there is a prospect of using the estimation of TNF-α in serum as a "marker" of periodontal disease in future. However, it remains a possibility that the absence or low levels of TNF-α in serum might indicate a stable lesion and elevated levels might indicate an active site but only longitudinal studies taking into account, the disease "activity" and "inactivity" could suggest the possibility of using TNF-α in serum as an "Indicator" of periodontal disease.

Does Periodontal Inflammation Affect Type 1 Diabetes in Childhood and Adolescence? A Meta-Analysis

The emergence of link between periodontal disease and diabetes has created conditions for analyzing new interdisciplinary approach making toward tackling oral health and systemic issues. As periodontal disease is a readily modifiable risk factor this association has potential clinical implications. The aim of this paper was systematically review the extant literature related to analytics data in order to identify the association between type 1 diabetes (T1DM) in childhood and adolescence with periodontal inflammation. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a database search between 2004 and 2019. A manual search of the literature was conducted as an additional phase of the search process, with the aim of identifying studies that were missed in the primary search. One hundred and thirty-nine records were screened and 10 fulfilled the inclusion criteria. Most studies were of moderate methodological quality. Outcomes included assessments of diabetes and periodontal status. In diabetic populations, compared to healthy subjects, interindividual differences in periodontal status are reflected in higher severity of periodontal inflammation. The most reported barriers to evidence uptake were the intrinsic limits of cross-sectional report data and relevant research, and lack of timely research output. Based on the evidence presented within the literature, the aforementioned biomarkers correlate with poor periodontal status in type 1 diabetic patients. Whilst the corpus of the evidence suggests that there may be an association between periodontal status and type 1 diabetes, study designs and methodological limitations hinder interpretation of the current research.

Clinical instruments and methods for assessing physical oral health: A systematic review

OBJECTIVE

This study aimed at exploring available clinical instruments and methods for assessing physical oral health, and at identifying those with sufficient diagnostic performance.

METHODS

A systematic literature search was conducted in Embase and MEDLINE. Identified instruments and methods were critically appraised, and quality of diagnostic performance was rated by two independent reviewers as A (sufficient diagnostic performance), B (either sufficient reliability or validity) or C (insufficient quality, or empirical results unsatisfactory and/or inconsistent). For all A-rated instruments and methods, an in-depth literature search was conducted to supplement and verify their effectiveness and accuracy.

RESULTS

A total of 141 instruments and methods were identified. Only 12 methods with sufficient diagnostic performance could be rated as A, 72 were rated as B, and 34 received a C-rating. Further 23 instruments and methods could not be rated due to lack of available information on diagnostic performance. Of all A-rated instruments, six were designed for tooth structure, two for periodontium, one for endodontium and three for temporomandibular joints and muscles.

CONCLUSION

Even though some instruments and methods exhibited good to excellent reliability and validity and can be recommended for research and clinical practice, they do not allow assessing all components of physical oral health. There is a need to identify and define standard instruments, and for components of physical oral health where methods with sufficient diagnostic performance are lacking, further research is required.

Comparative evaluation of probing depth and clinical attachment level using a manual probe and Florida probe

Background:

To compare and evaluate the intra- and inter-examiner efficacy and reproducibility of the first-generation manual (Williams) probe and the third-generation Florida probe in terms of measuring pocket probing depth (PD) and clinical attachment level (CAL).

Materials and Methods:

Forty subjects/4000 sites were included in this comparative, cross-sectional study. Group- and site-wise categorizations were done. Based on gingival index, PD, and CAL, patients were divided into four groups, i.e., periodontally healthy, gingivitis, mild to moderate periodontitis, and severe periodontitis. Further, based on these parameters, a total of 4000 sites, with 1000 sites in each category randomly selected from these 40 patients, were taken. Full mouth PD and CAL measurements were recorded with two probes, by Examiner 1 and on Ramfjord teeth by Examiner 2.

Results:

Full mouth and Ramfjord teeth group- and site-wise PD obtained with the manual probe by both the examiners were statistically significantly deeper than that obtained with the Florida probe. The full mouth and Ramfjord teeth mean CAL measurement by Florida probe was higher as compared to manual probe in mild to moderate periodontitis group and sites, whereas in severe periodontitis group and sites, manual probe recorded higher CAL as compared to Florida probe.

Conclusion:

Mean PD and CAL measurements were deeper with the manual probe as compared to the Florida probe in all the groups and sites, except for the mild-moderate periodontitis group and sites where the CAL measurements with the manual probe were less than the Florida probe. Manual probe was more reproducible and showed less interexaminer variability as compared to the Florida probe.

Imaging the Cemento-Enamel Junction Using a 20-MHz Ultrasonic Transducer

The cemento-enamel junction (CEJ), which is the intersection between enamel and cementum, is an important landmark in the diagnosis of periodontal disease. Pulse-echo ultrasound was used to image the CEJs of six porcine lower central incisors with a single 20-MHz transducer. A notch was longitudinally created on the enamel as a stable marker, from which the CEJ was measured. Data were acquired along the tooth's axis at 0.4-mm intervals. Time-distance data were bandpass-filtered to enhance signal-to-noise ratio and record density was increased fourfold to 0.1-mm spacing by a frequency-distance interpolation scheme. Reflections from the CEJ were unambiguously identified along with those from enamel, dentin and cementum. The notch-CEJ distances measured by the ultrasound and micro-computed tomography methods correlated strongly (r = 0.996, p < 0.05) and were in good agreement with the 95% lines of agreement between -0.49 and 0.17 mm, as statistically determined by Bland-Altman analysis. The results indicate the potential of ultrasound to be a reliable and non-ionizing technique to image the CEJ.

Cementoenamel junction: An insight

The location and nature of cemento-enamel junction (CEJ) are more than descriptive terms used simply to describe some aspects of tooth morphology; however, CEJ gains a lot of clinical significance due to various measurements dependent on it. It may be necessary to determine the location and pathological changes occurring at CEJ to make a diagnosis and treat diseases pertaining to epithelial attachment and gingival margin. However, the information related to CEJ is not discussed commonly. Hence, the present review paper provides an insight on CEJ in both primary and permanent dentition.

Comparative evaluation of accuracy of periodontal probing depth and attachment levels using a Florida probe versus traditional probes

BACKGROUND

The current interest in the assessment of Clinical attachment level (CAL) has stimulated recent introduction of novel periodontal probes. CAL is currently the gold standard for diagnosis and monitoring of periodontal disease. The errors inherent to the use of a periodontal probe are variation in probing force, visual errors in identifying the cemento-enamel junction (CEJ), relative attachment level landmarks, fluctuations in gingival inflammation and misrecording measurements. The present study has been undertaken to compare the accuracy of measuring probing depth (PD) and CAL using Florida probe and Williams probe.

METHODS

After random selection of sixty subjects PD and CAL were measured at mandibular first molars region using Williams probe, Florida probe and CEJ probe by two different examiners. The measurements recorded by using three probes were subjected to statistical analysis for comparison of accuracy and reproducibility.

RESULTS

Difference in mean PD with Williams probe and Florida probe were statistically significant with p value of .000. Similarly the CAL measurement achieved by Williams probe and CEJ probe showed significant different results. More consistent results were seen with Florida probe and CEJ probe when the measurements of PD and CAL were done by two different examiners.

CONCLUSION

Florida probe and CEJ probe have been shown to be more accurate and were found to be more consistent which were reproducible by two independent examiners.

Accuracy of probing attachment levels using a new computerized cemento-enamel junction probe

BACKGROUND AND OBJECTIVES

The assessment of clinical attachment level (CAL) represents the gold standard for diagnosing and monitoring periodontal disease. The aim of the present study was to evaluate the performance of the newly introduced cemento-enamel junction (CEJ) probe in detecting CAL, using CEJ as a fixed reference point, and to compare the CEJ probe with the Florida stent probe (FSP) as well as with a standard manual probe, University of North Carolina-15 (UNC-15).

MATERIALS AND METHODS

Three examiners recorded the probing attachment level in 384 sites in case group (chronic periodontitis), and in 176 sites, in control group (healthy periodontal status), using the three probes. Subjects included both the sexes and ranged from 35 to 45 years. The experimental design was structured to balance the intra- and inter-examiner consistency at the same site during the two visits.

RESULTS

CEJ probe showed higher intra-and inter-examiner consistency over both FSP and UNC-15 in both the case and control groups. Frequency distribution of differences of various magnitudes of repeated measurements ≤1 mm was in the higher range of 86.8% to 87.5% for CEJ probe. The FSP was more reproducible than UNC-15 in detecting relative attachment level (RAL).

INTERPRETATION AND CONCLUSION

CEJ automated probe was found to have greatest potential for accuracy and consistency in detecting CAL than FSP and UNC-15. The automated probes appeared to be more reproducible than manual probes.

The location of cemento enamel junction for CAL measurement: A clinical crisis

BACKGROUND

We face various problems while measuring the Clinical attachment level (CAL) from Cemento-enamel junction (CEJ). This study aims to record and compare the CEJ location measurements using a xed reference point (FRP) [Custom made stent] before and after ap elevation.

MATERIALS AND METHODS

A custom made stent and UNC-15 probe were used. Recording of CEJ location was made using a UNC-15 (Hu-Friedy) probe, before (close CEJ) and after (Open CEJ) the reflection of the flap from the lower edge of the stent in those subjects who were indicated for flap surgery, at baseline.

RESULTS

We used statistical analysis involving intra-group comparison done by Paired-'t' test. The close and the open CEJ measurements demonstrated a, statistically, non-significant difference. The equi-measurements of close and open CEJ numerical data were remarkably lower than the under and overestimation of measurements. Thus, despite certain disadvantages of stent, the FRP provides a simple solution for CAL measurement.

CONCLUSION

The results of this study confirms the objective of the study and strongly suggests that CAL measurements done without FRP is subjected to great variation and the diagnostic and prognostic interpretation of CAL should be viewed seriously in periodontics.

Alterations of the marginal soft tissue (gingival margin) following periodontal therapy: A clinical study

Background and Objectives:

The evaluation of gingival margin position (GMP) plays a vital role in periodontal therapy and is critical in esthetic/plastic surgical procedures revolving around restorative dentistry. Comparative evaluations of GMP measurements in various periodontal therapies are scarce. Thus, the objectives of this study are to measure the alteration in the gingival margin position following various therapies, and to compare GMP alterations among different treatment modalities from the baseline to six months after therapy.

Materials and Methods:

The changes in GMP were studied for MB, B, DB, ML, and L sites for SRP, curettage, and flap surgery, and for MB, B, and DB sites for crown lengthening cases at the end of one, three, and six months after therapy. The results were interpreted from baseline to one, three, and six months posttreatment.

Statistical Analysis:

The results were subjected to statistical analysis. Paired ‘t’-test was used for intra-group comparisons and intergroup comparisons were done by one-way ANOVA.

Results:

The GMP changed from baseline in all the sites at different time periods following various therapies. The net results after six months were an apical shift of GMP in SRP, curettage, and flap surgery, and a coronal shift of GMP in crown lengthening.

Conclusion:

GMP shows various patterns of alteration after various periodontal therapies. One should wait for the GMP to become stable before attempting any restorative procedure.

Gingival crevicular fluid levels of calprotectin and myeloperoxidase during therapy for generalized aggressive periodontitis

BACKGROUND

Levels of the inflammation marker calprotectin in gingival crevicular fluid correspond to clinical and biochemical parameters of periodontal inflammation. Neutrophil granulocytes (polymorphonuclear neutrophils: PMNs) are supposed to be the main source of calprotectin in gingival crevicular fluid, but evidence is still lacking. The influence of periodontal therapy on gingival crevicular fluid levels of calprotectin has not yet been determined.

OBJECTIVES

Gingival crevicular fluid levels of calprotectin were monitored during therapy for generalized aggressive periodontitis. Interrelations between calprotectin and the PMN marker myeloperoxidase (MPO) were evaluated.

MATERIAL AND METHODS

Gingival crevicular fluid samples were collected from 23 patients with generalized aggressive periodontitis before and 3 months after non-surgical therapy with an adjunctive antimicrobial medication. Clinical parameters were recorded with a pressure-calibrated electronic probe. Levels of calprotectin and MPO in gingival crevicular fluid were analysed by enzyme-linked immunosorbent assay (ELISA) procedures.

RESULTS

At baseline, levels of calprotectin and MPO were highly correlated. Bleeding and suppurating sites showed significantly higher levels of calprotectin and MPO than non-bleeding, non-suppurating sites. Therapy significantly decreased levels of both biomarkers. These changes of calprotectin and MPO were highly correlated and also related to probing-depth reduction. Three months after therapy, the levels of both markers still showed significant correlations in initially deep sites, whereas in initially shallow sites no significant correlation was found. After therapy, levels of markers in bleeding and non-bleeding sites were comparable.

CONCLUSION

The correlations between calprotectin and MPO indicate that PMNs are a major contributor to the calprotectin content in gingival crevicular fluid of severely affected sites. Calprotectin levels in gingival crevicular fluid and their changes reflect periodontal inflammation as well as the clinical treatment outcome. A prognostic potential of this marker substance remains to be determined.

Accuracy of probing attachment levels using a CEJ Probe versus traditional probes

BACKGROUND

Current interest in the assessment of probing attachment level measurements has been stimulated by recent introduction of novel periodontal probes as well as by the reclassification of periodontal diseases. Clinical attachment level (CAL) is currently the "gold standard" for diagnosing and monitoring periodontal diseases.

AIM

To evaluate the performance of the newly introduced cementoenamel junction (CEJ) Probe in detecting CAL using the CEJ as a fixed reference point, and to compare the CEJ Probe with the Florida Disk Probe and a standard Manual Probe (North Carolina Probe).

MATERIALS AND METHODS

Three examiners probed 12 periodontal patients to determine intra- and inter-consistency of both the probes and the examiners, over a 4-week time interval. Subjects ranged in age from 22 to 74 years. The experimental design was structured to balance the intra- and inter-examiner consistency at the same site during the two visits.

RESULTS

Using the PROC MIXED of SAS, a strong interaction (p<0.001) between the examiner and probes was found. The consistency of probing (repeatability of measurements) depended upon the type of periodontal probe used as well as the skill (experience) of the examiner. Overall, the CEJ Probe displayed a more consistent performance. The CEJ Probe demonstrated greater intra-examiner consistency than the Disk Probe for two examiners (p<0.01). The CEJ Probe also showed increased inter-examiner consistency (p<0.01).

CONCLUSIONS

The CEJ Probe has the potential to offer the dental team an efficient, accurate mechanism to chart and monitor attachment level measurements over time. Additional studies, using large numbers of examiners, are needed to assess more clearly the performance of each individual probe.