Reproducibility of periodontal probing using a conventional manual and an automated force-controlled electronic probe

Level of patient comfort and measurement reproducibility of three different probes: A cross-sectional study

OBJECTIVE

To determine the comfort level and reproducibility assessment of the probing pocket depth obtained with three different probes.

METHODS

A cross-sectional clinical study was conducted in accordance with the STROBE standards. Three different types of periodontal probes were selected: (1) University of North Carolina (UNC) probe, (2) World health organization (WHO) probe and (3) UNC12 COLORVUE probe. Three experienced and calibrated periodontists performed periodontal clinical assessments (probing depth) and pain assessment with the visual analogue scale (VAS).

RESULTS

The clinical evaluations were carried out in 13 volunteers who attended the dental clinic of the Universidad Científica del Sur (Lima, Peru). A total of 2106 periodontal clinical measurements were obtained (702 measurements per examiner). Each examiner evaluated 234 sites for each type of probe. When patient comfort values during the periodontal evaluation performed with the 3 types of probes were compared, the patients evaluated with the UNC12 COLORVUE probe perceived less pain with a mean value of 0.61, followed by the WHO probe and the UNC probe. When evaluating the clinical measurements, the UNC probe was observed to obtain the greatest mean depth on probing 1.4 + 0.5 mm, while with the UNC12 Colorvue probe, the values obtained were 1.1 + 0.3 mm, and with the WHO probe, 1.2 + 0.4 mm.

CONCLUSIONS

Based on the periodontal probe used, experience of the examiner and the patient, we can conclude that the UNC12 Colorvue probe was the instrument that promoted the greatest comfort or the slightest response to pain, followed by the WHO probe. However, the use of the WHO probe resulted in obtaining the lowest reproducibility among depths on probing. The UNC probe produced the highest response to pain in the patients.

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.

Pain perception and dental anxiety during periodontal probing in patients visiting community oral health programme: a cross sectional study

Background

Periodontal probing is one of the basic clinical oral examination procedures. It is carried out to assess the severity of gingival and periodontal disease. The experience of pain during probing may discourage patients. So, this study was conducted to estimate the pain perception and dental anxiety experienced during periodontal probing in patients visiting the community oral health programmes of B. P. Koirala Institute of Health Sciences (BPKIHS).

Methods

A cross-sectional study was conducted among 100 participants of community oral health programmes of BPKIHS. Demographic profile, WHO modified Community Periodontal Index (CPI) 2013, Pain perception via Visual Analogue Scale (VAS Scores) and Short Version of Spielberger State-Trait Anxiety Inventory (STAI) Self-evaluation Questionnaire (Y-6 item) were assessed. Mean ± SD and Spearman correlation for pain and anxiety were computed.

Results

Only 10% of the study participants had healthy gingiva and 12% had periodontal pockets. Pain perception and dental anxiety was present in the participants. The participants experienced very little pain (6.75 ± 10.65) during periodontal probing. The overall anxiety score was 13.37 ± 1.81. There was a very weak correlation between the VAS Scores and the anxiety scores of the participants.

Conclusion

This study concludes that pain perception and anxiety are low during periodontal probing. There was no correlation between bleeding on probing with pain and anxiety among the people visiting community oral health programmes of BPKIHS.

Application of radiopaque micro-particle fillers for 3-D imaging of periodontal pocket analogues using cone beam CT

BACKGROUND

Periodontitis is an infectious/inflammatory disease most often diagnosed by deepening of the gingival sulcus, which leads to periodontal pockets (PPs) conventional manual periodontal probing does not provide detailed information on the three-dimensional (3-D) nature of PPs.

OBJECTIVES

To determine whether accurate 3-D analyses of the depths and volumes of calibrated PP analogues (PPAs) can be obtained by conventional cone beam computed tomography (CBCT) coupled with novel radiopaque micro-particle fillers (described in the companion paper) injected into the PPAs.

METHODS

Two PPA models were employed: (1) a human skull model with artificial gingiva applied to teeth with alveolar bone loss and calibrated PPAs, and (2) a pig jaw model with alveolar bone loss and surgically-induced PPAs The PPAs were filled with controlled amounts of radiopaque micro-particle filler using volumetric pipetting Inter-method and intra-method agreement tests were then used to compare the PPA depths and volumes obtained from CBCT images with values obtained by masked examiners using calibrated manual methods.

RESULTS

Significant inter-method agreement (0.938-0.991) and intra-method agreement (0.94-0.99) were obtained when comparing analog manual data to digital CBCT measurements enabled by the radiopaque filler.

SIGNIFICANCE

CBCT imaging with radiopaque micro-particle fillers is a plausible means of visualizing and digitally assessing the depths, volumes, and 3-D shapes of PPs This approach could transform the diagnosis and treatment planning of periodontal disease, with particular initial utility in complex cases Efforts to confirm the clinical practicality of these fillers are currently in progress.

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.

Is Radiologic Assessment of Alveolar Crest Height Useful to Monitor Periodontal Disease Activity?

The mainstay of periodontal assessment is clinical probing. Radiographic assessment provides quantitative information on the status of tooth-supporting bone. This article reviews methods to assess periodontal structures, including basic radiograph acquisition, assessment of alveolar crest levels, and typical patterns of bone loss. Computer technology to objectively assess loss of alveolar crest from radiographs is reviewed. Developments in computer-assisted quantitation of alveolar crest height are described. Although probing measurements continue to be viewed as more practical than radiographic measurements, radiographic assessment can be made quantitative and is likely easier and more precise than probing for routine assessment of periodontal disease activity.

Reproducibility of probing depth measurement by an experimental periodontal probe incorporating optical fiber sensor

BACKGROUND

An experimental periodontal sensor probe (SP) equipped with an optical fiber for recording function was developed. The aim was to test the intraexaminer reproducibility of probing using the SP and to assess the consistency with the manual probe (MP).

METHODS

The SP was assembled with an external sheath covering the probe tip of an MP. The sheath was slid backward by the free gingival margin while probing and the sliding distance was detected by the sensor. The probing was conducted with the walking stroke at six sites for four first molar teeth in six maintenance patients with the SP and the MP at a 1-hour interval. The deepest reading in the vicinity of each site was recorded. The measurements were rerecorded 1 week later.

RESULTS

The mean depth was 3.03 and 3.08 mm recorded by the MP and SP, respectively. Although no significant difference was found between the probes (P >0.05) in all measurement sites, the mean depth at the lingual site of the upper left first molar was noticeably lower with the SP. For sites ≥7 mm, significantly lower depth was recorded by the SP (P <0.05). Zero discrepancy in duplicate measurements was found in 76% of all sites with MP and 92% with SP.

CONCLUSIONS

The reproducibility of the SP was comparable to that of the MP. The results indicate that for sites of maintenance patients with probing depth <7 mm there was excellent agreement obtained by a single examiner using the SP compared to the MP.

Effects of caloric restriction on inflammatory periodontal disease

OBJECTIVE

Dietary caloric restriction (CR) has been found to reduce systemic markers of inflammation and may attenuate the effects of chronic inflammatory conditions. The purpose of this study was to examine the effects of long-term CR on naturally occurring chronic inflammatory periodontal disease in a nonhuman primate model.

METHODS

The effects of long-term CR on extent and severity of naturally occurring chronic periodontal disease, local inflammatory and immune responses, and periodontal microbiology, were evaluated in a cohort of 81 (35 female and 46 male; 13-40 y of age) rhesus monkeys (Macaca mulatta) with no previous exposure to routine oral hygiene. CR monkeys had been subjected to 30% CR for 13-17 y relative to control-fed (CON) animals starting at 3-5 y of age.

RESULTS

Same sex CR and CON monkeys exhibited similar levels of plaque, calculus, and bleeding on probing. Among CON animals, males showed significantly greater periodontal breakdown, as reflected by higher mean clinical attachment level and periodontal probing depth scores, than females. CR males exhibited significantly less periodontal pocketing, lower IgG antibody response, and lower IL-8 and ss-glucuronidase levels compared to CON males, whereas CR females showed a lower IgG antibody response but comparable clinical parameters and inflammatory marker levels relative to CON females. Long-term CR had no demonstrable effect on the periodontal microbiota.

CONCLUSION

Males demonstrated greater risk for naturally occurring periodontal disease than females. Long-term CR may differentially reduce the production of local inflammatory mediators and risk for inflammatory periodontal disease among males but not females.

Pain levels in patients during periodontal probing and mechanical non-surgical therapy

The purpose of this study was to assess the degree of pain during periodontal probing and mechanical non-surgical therapy according to age, gender, and intersubject variation such as tooth type, tooth surfaces or regions of mouth, probing depth, and bleeding on probing. The study was carried out on 64 patients with chronic periodontitis. Pain/discomfort of patients during both periodontal probing and scaling and root planing (SRP) was measured using a visual analog scale (VAS). During periodontal probing and SRP, VAS scores decreased with increasing age for two procedures (Spearman rho, -0.301 and -0.348, respectively; P < 0.01). VAS scores were considerably lower for oral sites than for facial sites. VAS scores in probing were significantly higher in sites > or =4 mm deep than sites <4 mm deep. Sites bleeding on probing had a significantly higher VAS scores than sites no bleeding on probing (p < 0.05). The results showed that although there is no difference between genders, the intensity of pain during periodontal probing and SRP was different dramatically between patients as well as vary between different locations in the same mouth. If pain responses for probing in different several regions in the same mouth during initial examination were noted into patient chart used for initial examination, the therapist will recognize patients with elevated pain responses. If need be, they will then apply some pain control medication or anesthetic for patients during probing and SRP.

Assessment of Intra- and Inter-examiner Reproducibility of Probing Depth Measurements with a Manual Periodontal Probe

BACKGROUND AND AIMS

The main purpose of this study was to assess intra- and inter-examiner reproducibility of probing depth measurements with a manual periodontal probe.

MATERIALS AND METHODS

In this study, 32 dental students in Tabriz Faculty of Dentistry with normal periodontium were evaluated. Each tooth of the upper right quadrants, except the third molars, was examined. Probing depths were measured in 6 surfaces of each tooth (mesiofacial, midfacial, distofacial, mesiolingual, midlingual and distolingual). Each patient was examined by two examiners (two periodontists) in two sessions with an interval of 7-10 days. A total of 218 teeth and 1295 surfaces were examined.

RESULTS

Intra-examiner measurements showed no statistically significant differences, while the differences of inter-examiner measurements were statistically significant. Intra-examiner reproducibility was more than the inter-examiner one. Measurements for anterior region, facial and mid-facial/mid-lingual surfaces were more reproducible than posterior, lingual and proximal surfaces.

CONCLUSION

Probing depth measurements with a conventional probe have an appropriate reproducibility in clinical settings, although variations between examiners may affect the reproducibility, especially when great accuracy is required.

A thin or thick probe handle: does it make a difference?

OBJECTIVES

The aim of the present study was to assess the probing force exerted when using two manual periodontal probes with different handle diameters in hands of different dental professionals.

METHODS

For this study two periodontal probes with handle diameters of 54 and 92 mm were used. The 11 subjects responsible for the measurements were periodontists, postgraduate periodontal students and dental hygienists. Per measurement session, 20 measurements were performed by each subject. Each probe was used 10 times. After the first baseline measurement session, a second session was performed 1 week later and a last third session another 3 weeks later. Orders for using each probe were randomized for each subject and each session.

RESULTS

The mean overall force with the thin probe was 55.2 g and with the thick probe 59.4 g. The difference of 4.2 g between the two probe types was found to be statistically significant (P = 0.041).

CONCLUSION

The present study showed that the diameter of the probe handle also had an effect on the force exerted with a periodontal probe. However, the clinical relevance of this difference may be minor, when considering the interindividual variance of forces exerted when probing.

Comparison of two automated periodontal probes and two probes with a conventional readout in periodontal maintenance patients

AIM

The aim of the present study was to test in periodontal maintenance patients whether the systems for pressure control that have been commercially developed contribute to more reproducible probing depth measurements as compared with a manual probe.

MATERIAL AND METHODS

In 12 patients duplicate measurements were made at day 0 and 1 week later. In each patient four teeth with the deepest pockets were measured at six sites. In total 288 sites were available for comparisons. The Florida Probe (FP) (159 N/cm(2)), the Jonker Probe (JP) (153 N/cm(2)), the Brodontic probe (BP) (255 N/cm(2)) and the manual probe (MP) were used in a randomized scheme.

RESULTS

Mean probing measurements showed for the FP and the JP lower recordings than for the BP and manual probe. The FP, the BP and the MP showed no differences between the duplicate measurements, except for the JP where the second measurement was deeper. Correlation coefficients between measurements at day 0 and 1 week show for the BP and the MP are 0.90 and 0.89, respectively, while for the FP and the JP they are 0.76 and 0.75, respectively.

CONCLUSION

The BP and the MP appear to be reliable tools for reproducible pocket depth measurements in periodontal maintenance patients.

Reproducibility of Probing Depth Measurements Using a Constant-Force Electronic Probe: Analysis of Inter- and Intraexaminer Variability

BACKGROUND

Probing depth (PD) is a commonly used method to determine periodontal disease severity in both treating and evaluating disease progression. Agreement among examiners collecting data in scientific investigations is necessary to establish reliable criteria for determining levels of periodontal attachment loss. The objective of our study was to evaluate inter- and intraexaminer variability of PD measurements among study examiners using a constant force periodontal probe, and to compare the variability of tooth-mean and quadrant-mean.

METHODS

Three examiners, who had been previously trained and calibrated, performed measurements on 20 volunteers. Intra- and interexaminer variability of sites was determined by means of standard error of measurement (SE). Data analysis included determination of error for both quadrant mean and tooth mean.

RESULTS

PD measurements for the quadrant-mean were used to calculate the intraexaminer variability, resulting in a mean (SD) value for an SE of 0.40 mm (+/- 0.02). Interexaminer variability for quadrant mean was 0.16 mm (+/- 0.02). For tooth-mean SE, the intraexaminer variability values were equal to 0.38 mm (+/- 0.07), and interexaminer variability equal to 0.24 mm (+/- 0.05).

CONCLUSIONS

All three examiners participating in our study were able to obtain reliable measurements for PD, using the constant force electronic probe. Reproducibility did not vary appreciably when using the whole quadrant mean compared to the tooth mean. These trained examiners were able to provide reproducible measures under 0.5 mm.

Partial-Mouth Assessment of Periodontal Disease in an Adult Population of the United States

BACKGROUND

It has been previously demonstrated, using periodontal data from an untreated population, that half-mouth assessment of six sites/tooth provides an appropriate alternative to whole-mouth assessment of periodontal disease status. Since periodontal destruction exhibits left-right symmetry, it was hypothesized that this would be equally applicable to a population with access to routine dental care.

METHODS

Adult subjects (N = 92) with a range of disease levels participated in the study. Probing depths (PDs) and recession (REC) were measured directly on six sites/tooth, on all teeth (excluding third molars), and clinical attachment levels (CALs) were derived. Partial-mouth assessments, i.e., assessment of limited sites and/or teeth, were compared with whole-mouth assessment as follows. Intraclass correlation coefficients (ICCs) were calculated for mean PD, CAL, and REC, and for percentage of sites with disease above a specified threshold, to determine the agreement between the whole- and partial-mouth assessment. The sensitivity of partial-mouth assessment of disease prevalence also was determined.

RESULTS

For assessment of six sites per tooth in one upper and one lower quadrant, ICCs were consistently >0.80. Assessment of two sites per tooth or only Ramfjord teeth generally underestimated disease extent and severity, and prevalence, compared to half-mouth assessment.

CONCLUSIONS

These results support the use of a half-mouth examination of six sites/tooth, to conserve time, limit cost, and reduce patient and examiner fatigue, while providing maximal clinical information. Assessment of only two sites per tooth or the Ramfjord teeth was not suitable for evaluation of either disease extent and severity or prevalence.

Reliability of clinical attachment level recordings: effects on prevalence, extent, and severity estimates

BACKGROUND

Although unreliability of periodontal measurements is considered mainly to concern attempts to detect true changes in longitudinal studies, it is also a source of variability that may substantially decrease the precision of estimates obtained in cross-sectional studies. This study assessed the effects of measurement errors on estimates of prevalence, extent, and severity of clinical attachment loss.

METHODS

Four examiners performed repeat attachment level recordings in 128, 122, 134, and 133 adolescents, respectively, who participated in a study of clinical attachment loss among 9,162 high school students from Santiago, Chile. A total of 48,954 duplicate recordings were made. Two examiner teams carried out repeat examinations among 292 and 254 subjects, respectively, corresponding to a total number of 51,600 duplicate recordings for interexaminer reliability assessment.

RESULTS

A sizeable imprecision was noted regarding prevalence estimates, particularly at the > or = 1 mm level, whereas examiners were reasonably consistent in the assessment of the number of sites with clinical attachment loss. Ninety-five percent of the differences regarding the number of sites with clinical attachment loss > or = 1 mm were in the range from -5 to 5 sites for intraexaminer comparisons, and from -9 to 8 sites for interexaminer comparisons. These differences should be seen in light of the number of sites affected, which ranged from 0 to 85 sites.

CONCLUSIONS

Examiner variation may preclude comparisons of prevalence estimates between studies. Valid comparisons may be made between studies of extent estimates provided that uniform parameters are used to express the extent of periodontal breakdown.

Periimplant probing: positives and negatives

Periodontium in normal dentition is not as it is surrounding an implant area. Thus, periodontal probing with normal dentition is not similar to periimplant probing. The periimplant probing protocol should be different from periodontal probing because of inherent anatomical differences. The aim of this paper is to review the topics related to periimplant probing and to draw inferences to develop a periimplant probing protocol.

Preventive strategies and supportive treatment

There is a preponderance of evidence in the literature that periodontal and other oral diseases, such as caries, can be treated and controlled by thorough mechanical plaque removal by the patient, the use of antimicrobial agents and antibiotics when necessary, and participation with the therapist in a well monitored, long-range program of supportive periodontal therapy. Recent evidence suggests that the control and prevention of oral disease, especially periodontitis, is especially important for patients with various systemic conditions that can be impacted by oral infections. It is far better for patients and therapists to practice primary and even secondary prevention with effective plaque control and regular, consistent supportive periodontal therapy, than having to rely on tertiary prevention for disease that has progressed to a level that requires costly treatment, is time-consuming and carries a greater risk of morbidity.

Non-surgical periodontal therapy with adjunctive topical doxycycline: a double-blind randomized controlled multicenter study

AIM

Evaluation of the clinical effect of topical application of doxycycline adjunctive to non-surgical periodontal therapy.

METHODS

A total of 111 patients suffering from untreated or recurrent moderate to severe periodontitis at 3 different centers (Heidelberg, Frankfurt, Nijmegen) were treated in this double-blind split-mouth study. In each patient, 3 different treatment modalities were assigned randomly to 3 test teeth: scaling and root planing alone (SRP), SRP with subgingival vehicle control (VEH), and SRP with subgingival application of a newly developed biodegradable 15% doxycycline gel (DOXI). At baseline, clinical parameters were measured at all single rooted teeth using a reference splint: PlI, PPD, relative attachment level (RAL-V), GI. 3 strata were generated according to baseline PPD: (i) 5-6 mm, (ii) 7-8 mm, (iii) > or =9 mm. Not more than 50% active smokers were allowed to each stratum. 3 and 6 months after therapy re-examination was performed by examiners blinded to baseline data and test sites. The statistical comparison of RAL-V gain and PPD reduction between the treatments was based on a repeated measures ANOVA with correction according to Huynh & Feldt. The comparison of SRP versus DOXI was considered as the main study question.

RESULTS

110 patients finished the 3 months and 108 the 6 months examination. The study did not show adverse effects of VEH or DOXI except for one singular inflammation that occurred 2 months after application of the doxycycline gel. DOXI provided statistically significantly more favorable PPD reduction (SRP: -2.4+/-1.4 mm, VEH: -2.7+/-1.6 mm, DOXI: -3.1+/-1.2 mm; SRP versus DOXI p=0.0001, VEH versus DOXI p=0.0066) and RAL-V gain (SRP: 1.6+/-1.9 mm, VEH: 1.6+/-2.2 mm, DOXI: 2.0+/-1.7 mm; SRP versus DOXI p=0.027, VEH versus DOXI p=0.038) than SRP and VEH after 6 months.

CONCLUSIONS

Adjunctive topical subgingival application of a biodegradable 15% doxycycline gel was safe and provided more favorable RAL-V gain and PPD reduction than SRP alone and VEH. Thus, by use of topical doxycycline the threshold for surgical periodontal therapy might be moved toward deeper pockets.

An index of clinical oral disorder in elders (CODE)

Attempts to construct an index of oral health or disorder suitable for older adults have been limited in clinical scope or based on the judgement of very few individuals. Consequently, we present here a multidimensional index of Clinical Oral Disorder in Elders (CODE) based on a breadth of clinical measures relevant to elders. The data for the index are derived from a clinical examination of jaw function, dentures, mucosa, teeth, and periodontium. Weighting or ranking for each disorder within the context of an elderly person was established as mild, moderate or severe by experienced dental clinicians and dental hygienists. Subsequently, the index was constructed by transforming the weights into a numerical value for each clinical measure. Individual scores can relate to the heaviest weight identified during the examination or to the sum of the weights assigned throughout the examination, and the average score during a series of examinations will reflect the clinical status of a particular population. Clinical applications in elderly residential-care populations indicate that the index can be constructed efficiently and with reasonable reliability. We suggest, therefore, that the CODE index is suitable for descriptive and comparative research by providing a clinical format for measuring oral disorder in disabled elders, and, when combined with a psychosocial index, it should be very comprehensive indicator of oral dysfunction in older adults.

A comparison of manual and controlled-force attachment-level measurements

This study compared the intra-examiner and inter-examiner error of 2 constant force probes to the reading of a conventional manual probe. 3 examiners made repeated examinations of attachment level using a modified Florida probe and a manual North Carolina probe (read to 1 mm or 0.5 mm); relative attachment level measurements were made using a Florida disk probe. One probe was used in each quadrant in 8 subjects with moderate to advanced periodontitis. Error was calculated as the mean of the absolute value of the difference between each examination, and the correlation between values at each examination calculated. Statistically-significant differences between probe type, examiners, and sites were detected using a repeated measures ANOVA accounting for the nesting within subjects. There was a significant difference in error by probe type (modified Florida probe 0.62 +/- 0.03 mm, r = 0.86; Florida stent probe 0.55 +/- 0.05 mm, r = 0.82; manual probe to 1 mm 0.39 +/- 0.02 mm, r = 0.88; manual probe to 0.5 mm 0.40 +/- 0.02 mm, r = 0.89; (p < 0.001). Significant differences were observed by examiners (p < 0.01). These data indicate that both manual and controlled-force probes can provide measurement within less than 1 mm of error; however, individual calibration of examiners remains important in the reduction of error.

Important differences in clinical data from third, second, and first generation periodontal probes

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

Is periodontal breakdown a fractal process? Simulations using the Weierstrass-Mandelbrot function

This paper introduces a theoretical model of periodontal disease that is multifactorial, cumulative and produces periodontal breakdown in "bursts and remissions". The simulation is based on the generalization of the Weierstrass-Mandelbrot function as an integration of a series of sinusoid fluctuations that facilitate or prevent periodontal breakdown with different frequencies, amplitudes and phases. The breakdown is produced when the integration of the factors reaches a certain threshold and is stopped when it is below it. The zeroset of the function (the set of points of the function in intersection with the time axis) is a self-similar set that corresponds to the instances when the process switches between destructive and non-destructive phases, and its fractal nature indicates that in theory, bursts of destruction do not have a characteristic duration size. If the mechanism of periodontal disease has in principle similarities to the model presented, then accurate site-specific predictions about periodontal destruction may prove an unrealizable task.

Overview of periodontal clinical trials utilizing anti-infective or host modulating agents

Issues in periodontal trials designed to evaluate anti-infective or host modulating agents for the prevention and treatment of periodontal diseases are reviewed in this paper. Clinical trial designs, prevention versus treatment, disease activity, utility of new measurement technologies, ethical and safety issues, selection of outcome variables, and clinical significance are discussed. In general, randomized parallel arm, double-blinded, controlled clinical trials are most appropriate for testing anti-infective and host modulating agents. New measurement technologies may offer increased measurement resolution and automated data capture; but, depending on their specific application and level of examiner reproducibility, these technologies may or may not result in lowered thresholds for declaring change. Mechanical therapy for common plaque-associated gingivitis and adult periodontitis is effective, has low risk, and is widely accepted as a minimum standard of care. New agents for treatment of these diseases must carry minimal risk and have equal or greater effectiveness than this standard of care. Outcome variables for gingivitis trials should include a visual index of gingival inflammation and a separate or component index of gingival bleeding. Prevention studies of periodontitis require a longer duration than treatment studies. Maintenance of mean clinical attachment level should be a primary outcome measure for all prevention studies of adult periodontitis. Maintenance of alveolar bone support is an essential additional outcome for agents specifically acting on bone. The design and conduct of clinical trials for anti-infective and host modulating agents depend on the specific hypothesis to be tested and the ethical demands of providing safe and effective care for all study volunteers.

Reproducibility of attachment level recordings using an electronic and a conventional probe

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

Efficacy of a sonic toothbrush on inflammation and probing depth in adult periodontitis

This single-blind, 8-week study compared the efficacy of a sonic toothbrush and a manual brush in 40 patients with adult periodontitis. Qualitative clinical indices and quantitative laboratory methods were used to monitor the periodontal status of 3 pockets 5 to 7 mm deep in each subject. Patients were randomly assigned either a sonic or manual toothbrush. The two groups were comparable with respect to age, gender, and anatomical location of the test sites. Data were collected from all sites at baseline and at 2, 4, and 8 weeks. Over the 8-week period, both groups showed significant improvements in the clinical indices used. Descriptive statistics indicated the sonic brush group had greater improvement than the manual group in the clinical parameters (gingival index, bleeding index, probing depth, and clinical attachment level). Gingival crevicular fluid (GCF) flow was significantly lower in the sonic brush group (P = 0.018). Considerable variation was present in the levels detected for both inflammatory cytokines tested, however, concentration of interleukin-1 beta was significantly lower in the GCF of sonic group patients (P = 0.05), while concentration of interleukin-6 was significantly reduced in both groups (P < or = 0.05) (t tests). Under these conditions, there is some evidence to suggest that the sonic toothbrush is more beneficial in resolving inflammation in patients with moderate periodontal disease.

Intra - and inter-examiner reproducibility in constant force probing

This study evaluated intra- and inter-examiner reproducibility for a conventional manual probe versus a computer-interfaced force-controlled periodontal probe. 2 examiners recorded probing depths (PD) and relative attachment levels (AL) at 1128 sites in 15 periodontal maintenance patients. Each site was evaluated 2x, 7 to 10 days apart by both examiners. Probing force for the electronic probe was 15 g. PD intra-examiner reproducibility (within +/- 1.0 mm) for shallow sites (PD < or = 3 mm) was 98.6% versus 91.5% for the conventional versus the electronic probe for examiner 1 and 98.5% versus 88.7% for examiner 2. Corresponding values for deeper sites (PD > 3 mm) were 96.4% versus 85.9% for examiner 1 and 95.1% versus 77.0% for examiner 2. Generally, AL intra-examiner reproducibility was 1 to 3% lower than for PD. PD inter-examiner reproducibility (within +/- 1.0 mm) was 99.2% versus 90.7% for the conventional versus the electronic probe, respectively, for shallow sites and 95.4% versus 76.9% for deeper sites. AL inter-examiner reproducibility (within +/- 1.0 mm) was 1 to 5% lower than for PD. Both intra- and inter-examiner reproducibility was higher for anterior than for posterior sites. Mean PD and AL were similar for both examiners. However, the electronic probe consistently recorded 0.1 to 0.2 mm higher values than the conventional probe. Standard deviations indicated a greater variability for electronic than for manual probing. The results suggest that intra- and inter-examiner reproducibility may not necessarily be higher with an electronic, force-controlled periodontal probe than with a conventional manual probe.