Probing Attachment Level Measurements Research Articles

Evaluating the Validity of Probing Attachment Loss as a Surrogate for Tooth Mortality in a Clinical Trial on the Elderly

Most periodontal trials are based on the assumption that the superior treatment, as judged by short-term intangible changes in probing attachment levels (the surrogate), is also the treatment most likely to affect tooth mortality. This assumption is valid if: (1) the surrogate is informative about tooth mortality, and (2) the surrogate captures a substantial proportion of the treatment effect on tooth mortality (e.g., > 50% or 75%). The goal of this study was to evaluate whether both conditions were satisfied in a randomized controlled trial (RCT) of elders at high risk for dental diseases. The results suggested that the first condition for a valid surrogate was satisfied: Both one- and two-year changes in probing attachment level were informative about tooth mortality risk. A 1-mm loss measured over a one-year period was associated with a 56% increased tooth mortality risk (relative risk = 1.56; 95% confidence interval, 1.08 to 2.26; p = 0.017); a 1-mm loss measured over a two-year period was associated with a 102% increased risk for tooth mortality (relative risk = 2.02; 95% confidence interval, 1.26 to 3.25; p = 0.004). The second condition necessary for a valid surrogate could not be confirmed in the present trial. With 95% confidence, it was concluded that one-year changes in probing attachment level measurements did not capture a significant proportion of the treatment effect (point estimate, 6%; 95% confidence interval;-38% to 53%). No useful statements could be made regarding the proportion of treatment effect captured by two-year changes, due to the width of the confidence interval (point estimate, 18%; 95% confidence interval;-151% to 140%). It is concluded that (1) the evidence surrounding the one-year change in probing attachment level indicates that it can be ruled out as being anything more than a weak surrogate marker for tooth mortality, and (2) further research is required to study the validity of two-year change in probing attachment level as a surrogate marker. Due to characteristics of the population and the treatments investigated, the generalizability of these findings to other RCTs is questionable.

The effect of ketoprofen creams on periodontal disease in rhesus monkeys.

Ketoprofen creams were evaluated for the treatment of periodontal disease in a placebo-controlled, double-blind study in the rhesus monkeys, Macaca mulatta. Two formulations containing ketoprofen (1%), with or without vitamin E, were evaluated against appropriate controls (8 monkeys per group). Two weeks prior to treatment, the animals received prophylaxis on only the left side of the mouth (spontaneous model). Selected teeth on the right side of the mouth were ligated (ligature model). The creams were administered to the gingiva once daily at a standard dose of 1.8 ml per monkey for 6 months. Clinical assessments were made 2 wk before initiation, at baseline and 1, 2, 3 and 6 months post-treatment. The clinical parameters included plaque formation, gingival redness, edema, bleeding on probing and Ramfjord Attachment Level measurements (RAL). Radiographs were taken at 2 wk before initiation, baseline and at 3 and 6 months post-treatment. Digital, subtraction radiography was used to measure vertical linear bone loss along the interproximal root surfaces of the left and right mandibular first molars. Gingival crevicular fluid (GCF) was collected for biochemical assays on PGE2, TxB2, LTB4, IL-1 beta and TNF alpha. There were no significant differences among groups with respect to gingival indices. Radiographic data demonstrated significant positive effects on bone activity in both groups treated with ketoprofen formulations with improvement over time in the ligature model (0.01 < or = p < or = 0.04). The placebo group exhibited bone loss of 1.96 +/- 0.48 and 1.40 +/- 0.56 mm per site at 3 and 6 months, respectively. The group treated with ketoprofen cream showed an apparent bone gain of 0.28 +/- 0.41 and 0.78 +/- 0.47 mm per site at 3 and 6 months, respectively. The group treated with ketoprofen cream containing vitamin E showed a mean bone loss of 0.41-0.48 mm per site at 3 months with improvement to an apparent bone gain of 0.31 +/- 0.44 mm per site at 6 months. The biochemical data demonstrated early and significant suppression of GCF-LTB4 by both ketoprofen formulations at 1 month, which preceded the significant suppression of GCF-PGE2 at 2 and 3 months in the ligature model (p < 0.003) and at 2 to 6 months in the spontaneous model (p < 0.02). We conclude that ketoprofen at 1% level in suitable topical vehicles can effectively inhibit GCF-LTB4 and GCF-PGE2 and positively alter alveolar bone activity in the ligature-induced model of periodontitis in the monkey.

An investigation of the validity of attachment level measurements with an automated periodontal probe.

There is a need for information on the validity of probing depth and attachment level measurements made with automated probes. In this study, 34 teeth in 9 patients were measured with the Florida probe from points marked with a bur prior to extraction. After extraction, connective tissue attachment levels were measured from the same points with a dissecting microscope. Mean measurements of attachment level were similar with probing (5.13 +/- 2.08 mm) and laboratory (5.18 +/- 2.26 mm) assessments. The correlation between these measurements was 0.72 (p < 0.001), and a t-test of the paired measurements showed no difference (t = 0.44; p = 0.66). The Florida probe thus showed satisfactory validity for this group of measurements of advanced periodontitis. However, there was substantial lack of agreement between individual probing measurements and the validity criterion of laboratory attachment level measurements, and the intra-class correlation coefficient was 0.46. It was concluded that the Florida probe was suitable for studies in which measurements were averaged, but not for longitudinal study of individual sites.

Site progression of loss of attachment over 5 years in 14‐to 19‐year‐old adolescents

The aims of this study were (1) to monitor the progression and patterns of progression of loss of attachment > or = 1 mm on a site basis over a 5-year period in adolescents, and (2) to relate the presence of oral deposits and inflammation to the subsequent development and progression of loss of attachment on a site basis. 167 subjects were examined at ages 14, 16 and 19 years. Loss of attachment > or = 1 mm, plaque, subgingival calculus, gingival bleeding and gingival colour change were assessed on the mesio-buccal sites of the 1st molars, 1st premolars and central incisors. Each site was treated separately in the analysis to avoid the problem of within-subject site dependence. Sites were classed as progressing, non-progressing or fluctuating according to the probing attachment level measurements at each of the 3 examinations. During the 5 years of this study, a total of 542 sites in 128 subjects progressed; 1136 sites in 162 subjects did not progress; 43 sites in 30 subjects had fluctuating attachment level measurements. Sites which subsequently progressed had significantly more plaque, subgingival calculus and gingival inflammation than non-progressing sites at the baseline examination and throughout the study (p < 0.001). Between 55-57% of the maxillary 1st molars and 46-49% of the mandibular incisors progressed. In contrast, there was no progression of loss of attachment on over 80% of the maxillary central incisors and mandibular 1st premolars.

Periodontal regeneration of human infrabony defects. III. Diagnostic strategies to detect bone gain.

Assessment of actual treatment outcome by simple and available diagnostic tests represents an important aspect in the evaluation of periodontal regenerative procedures. This report focuses on the diagnostic accuracy of different strategies to detect the original extent of bone loss and bone gain in deep vertical defects following guided tissue regeneration. Characteristics of probing attachment level and radiographic bone linear measurements were compared to a gold standard obtained as intrasurgical clinical measurements at baseline and at the 1 year re-entry operation. Radiographic linear measurements underestimated bone loss (CEJ-BD) in 55% of cases while the estimate was within 1 mm in 25% of cases. The goodness of agreement could be significantly described by a general linear model incorporating measures of defect morphology. The original level of bone loss could be best detected by an approach which consisted of adding 1.5 mm to the measured attachment level loss. Such an approach correctly estimated bone loss within 1 mm in 85% of sites. In terms of ability to detect bone gain, radiographic measurements underestimated bone gain in 55% and overestimated it in 15% of sites. Diagnostic accuracy was assessed at different threshold values of true gain. The sensitivity and specificity plots intersected at a threshold value of 2.7 mm bone gain. Conversely, measures of probing attachment level gain agreed with the gold standard within 1 mm 45% of times. Intersection of the specificity and sensitivity plots occurred at 3 mm. Classification tables are presented for both diagnostic tests at different threshold values.2+é

Subjective criteria and probing attachment loss to evaluate the effects of plaque control and root debridement

Abstract 11 adult patients with moderate to advanced periodontitis were treated with oral hygiene instruction and an initial, single episode of root debridement. Before therapy, 3 independent clinicians examined all patients and identified sites that in their opinion probably would not respond to the therapy and would continue to lose attachment. On 2 occasions, 3 and 12 months later, the clinicians reexamined and reevaluated all patients and all sites. The results of therapy were also monitored by probing attachment level measurements performed every 3rd month. All 11 patients completed 24 months of follow-up, and 6 subjects were available until 36 months. Sites with probing attachment loss after 12, 24 and 36 months were identified using linear regression analysis and compared to the clinicians' prediction of probing attachment loss. The results demonstrated a limited agreement between probing attachment loss determined by linear regression and the clinicians' predictions of probing attachment loss. It appears that the traditional clinical signs and factors used to forecast and identify periodontal disease activity are only moderately associated with probing attachment loss. This suggests that attachment loss may be caused by several factors, at least following initial therapy. The progression of an inflammatory disease of microbial etiology may be only 1 of such causes. Further studies are needed to clarify the nature and cause of probing attachment loss.

Subjective criteria and probing attachment loss to evaluate the effects of plaque control and root debridement

Abstract 11 adult patients with moderate to advanced periodontitis were treated with oral hygiene instruction and an initial, single episode of root debridement. Before therapy, 3 independent clinicians examined all patients and identified sites that in their opinion probably would not respond to the therapy and would continue to lose attachment. On 2 occasions, 3 and 12 months later, the clinicians reexamined and reevaluated all patients and all sites. The results of therapy were also monitored by probing attachment level measurements performed every 3rd month. All 11 patients completed 24 months of follow-up, and 6 subjects were available until 36 months. Sites with probing attachment loss after 12, 24 and 36 months were identified using linear regression analysis and compared to the clinicians' prediction of probing attachment loss. The results demonstrated a limited agreement between probing attachment loss determined by linear regression and the clinicians' predictions of probing attachment loss. It appears that the traditional clinical signs and factors used to forecast and identify periodontal disease activity are only moderately associated with probing attachment loss. This suggests that attachment loss may be caused by several factors, at least following initial therapy. The progression of an inflammatory disease of microbial etiology may be only 1 of such causes. Further studies are needed to clarify the nature and cause of probing attachment loss.

The Relationship Between Probing Attachment Loss and Computerized Radiographic Analysis in Monitoring Progression of Periodontitis

This study attempted to evaluate quantitative changes in radiographic density as an indicator of progression of periodontitis. Twenty-one subjects with a history of periodontitis were monitored at baseline, 3, 6, and 9 months using duplicate probing attachment level (PAL) measurements from stents and computer assisted densitometric image analysis (CADIA) of standardized radiographs. Results indicate that the majority of sites exhibited no PAL change during the 9-month period; however, the percentage of sites with loss increased with time. A mean of 6.1% of the sites/patient exhibited probing attachment loss during the study, as compared to a mean of 38.3% of the sites/patient that exhibited a loss of radiographic density. Due to the two dimensional nature of radiographs, density analysis was calculated in terms of radiographic "complexes" of multiple probing sites. There was significantly more density loss at complexes with greater than or equal to 2 mm of attachment loss than at sites with no change in PAL at 9 months; there was no such difference noted at 3 and 6 months. Also, density loss tended to increase as more sites within each complex experienced PAL. Although there was a significant correlation between mean density and PAL changes during the same time interval, there were wide variations at individual sites. This study suggests that there is a complex relationship between density change on radiographs and PAL change. The difficulties inherent in comparing highly sensitive new technologies to relatively imprecise clinical measurements of the attachment level are discussed.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of Clindamycin Hydrochloride in Refractory Periodontitis: 24‐Month Results

The purpose of this investigation was to evaluate the use of clindamycin hydrochloride in the treatment of adult refractory periodontitis. Thirty patients with a history of unsuccessful treatment with scaling, periodontal surgery, and the use of tetracyclines were entered into the study. Upon entry, the suspected refractory patients were scaled several times and then monitored for the presence of active disease by probing attachment level measurements performed in duplicate. Active disease was defined as a 3.0 mm or greater loss in attachment from the baseline examination or the occurrence of a periodontal abscess. When active disease was detected, patients were treated with scaling and clindamycin 150 mg qid for 7 days. Patients served as their own controls. Twenty four patients demonstrated further attachment loss following scaling alone and were treated with clindamycin hydrochloride. Scaling and clindamycin treatment decreased the incidence of active disease from an annual rate of 8.0% to 0.5% of sites per patient (P less than .001). The mean time required to detect the first active site increased from 4.9 +/- 3.7 months following scaling alone to 16.7 +/- 7.6 months following scaling and clindamycin (P less than 001). Active sites lost an average of 3.1 mm of probing attachment following scaling alone but "gained" back 2.0 mm at 6 months and 1.5 mm at 24 months post-antibiotic and scaling treatment. Bleeding on probing was significantly reduced (P less than .05) from 31.8% of sites pre-clindamycin treatment to 12.3% at 12 months and 17.9% of sites at 24 months post-clindamycin treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Subjective criteria and probing attachment loss to evaluate the effects of plaque control and root debridement

11 adult patients with moderate to advanced periodontitis were treated with oral hygiene instruction and an initial, single episode of root debridement. Before therapy, 3 independent clinicians examined all patients and identified sites that in their opinion probably would not respond to the therapy and would continue to lose attachment. On 2 occasions, 3 and 12 months later, the clinicians re-examined and re-evaluated all patients and all sites. The results of therapy were also monitored by probing attachment level measurements performed every 3rd month. All 11 patients completed 24 months of follow-up, and 6 subjects were available until 36 months. Sites with probing attachment loss after 12, 24 and 36 months were identified using linear regression analysis and compared to the clinicians' prediction of probing attachment loss. The results demonstrated a limited agreement between probing attachment loss determined by linear regression and the clinicians' predictions of probing attachment loss. It appears that the traditional clinical signs and factors used to forecast and identify periodontal disease activity are only moderately associated with probing attachment loss. This suggests that attachment loss may be caused by several factors, at least following initial therapy. The progression of an inflammatory disease of microbial etiology may be only 1 of such causes. Further studies are needed to clarify the nature and cause of probing attachment loss.

Attachment level measurements with a constant force electronic probe.

The purpose of the present investigation was to evaluate the reproducibility of probing attachment level measurements using a newly developed constant force electronic probe. The probing force was preset at 25 g (probe diameter 0.4 mm) and was connected to a computer through a variable differential transformer. The measurements were performed on 10 patients with minimal signs of periodontal disease, using individually made acrylic stents. When the probe was in place and a foot switch depressed, the measurement was stored on the computer to the nearest 0.1 mm. The measurements were performed by one periodontist and one hygienist during one visit, and were then repeated by the same periodontist and another hygienist during a second visit. The results showed high correlations between the periodontist and the hygienist during one visit, between the two visits for the periodontist, and between the two hygienists at two different visits. The subject threshold for attachment loss was calculated according to Haffajee and co-workers, and was found to average 0.84 mm for the measurements performed by the periodontist and the hygienist during the same visit. For the periodontist during two separate visits and for the two different hygienists, the average threshold was 0.99 and 1.02 mm, respectively. Duplicate measurements were also performed by one periodontist at one visit on 10 patients with advanced periodontal disease. The average subject threshold for these patients was 0.60 mm. It may be concluded that with the constant force electronic probe, loss of attachment can be detected earlier than when conventional instruments are used.

Bleeding on probing and probing depth as indicators of the response to plaque control and root debridement.

19 adult periodontitis patients were treated with plaque control and a single episode of root debridement. Results of this treatment were monitored in non-molar sites, molar flat surface sites, and molar furcation sites by probing attachment level measurements every 3rd month for 24 months. After 24 months, sites with probing attachment loss were identified using linear regression analysis. Clinical scores for supragingival plaque, bleeding on probing, suppuration on probing, and probing depth, obtained from these sites during the 24-month study, were analyzed to determine if they could be used diagnostically as indicators of probing attachment loss. The results demonstrated that the diagnostic accuracy for these clinical indicators was generally low at all 3 anatomical site locations. A possible explanation for this limited diagnostic accuracy may be that 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.

Intraclass correlations of periodontal measurements in beagle dogs.

The intraclass correlations of Gingival Index, probing depth, and attachment level scores were estimated in a sample of beagle dogs. These estimates were made over a ten‐week period at the time of ligature placement, eight weeks later at ligature removal, and two weeks postremoval. Estimates of the intraclass correlation were computed for the actual scores and for differences in scores between the first and second, and second and third observation points.All intraclass correlations were of sufficient magnitude to preclude statistical analyses which do not consider the subject as the sampling unit. For all conditions. intraclass correlations decreased upon experimental intervention and were generally larger than those reported in human studies. Intraclass correlations of Gingival Index scores were larger than those of probing depth and attachment level measurements. The results were discussed in terms of sources of variation within and between subjects.

Effect of nonsurgical periodontal therapy. VII. Bleeding, suppuration and probing depth in sites with probing attachment loss.

Incisors, cuspids and premolars in 49 patients with advanced chronic periodontitis were treated with initial, nonsurgical periodontal therapy. The results were monitored by probing attachment level measurements for 6 sites of each tooth every 3rd month during a period of 24 months. Amongst sites with initial probing depth greater than or equal to 4.0 mm, sites with probing attachment loss were identified using regression analysis. Scores for plaque, bleeding, suppuration on probing and probing depth, obtained for these sites during the 24-month study, were analyzed to determine whether any of the scores could be used diagnostically as an indicator of probing attachment loss. Diagnostic sensitivity and predictability were calculated for different levels of each of the scores. The results showed that sites with probing attachment loss were more frequent for sites with high scores for plaque, bleeding, residual probing depth and suppuration than in sites with low scores. However, the diagnostic sensitivity and predictability of these clinical indicators was generally low. Thus, records of plaque, bleeding, suppuration and probing depth do not obviate the need for probing attachment level measurements for identification of sites with probing attachment loss following initial, nonsurgical periodontal therapy.

Effect of non-surgical periodontal therapy. VI. Localization of sites with probing attachment loss.

Incisors, cuspids and premolars in 49 patients with advanced chronic periodontitis were treated with initial, non-surgical periodontal therapy. The results were monitored by probing attachment level measurements at 6 sites of each tooth every 3rd month during a period of 24 months. A series of 9 probing attachment level measurements for each site was subjected to linear regression analysis. The slope of the regression line, the projected probing attachment loss during the 24-month interval (delta y) and the probability level of the slope were calculated for each site. 2 groups of sites with probing attachment loss were identified: group 1: sites with delta y greater than 1.5 mm and p less than 0.05; group 2: sites with delta y greater than 1.0 mm and p less than 0.05. Group 1 included 120 sites (5%) and group 2 included 265 sites (10%) of the total of 2532 available sites. In both groups, probing attachment loss was more frequently noticed for sites with an initial probing depth less than or equal to 3.5 mm than for sites with initial probing depth greater than or equal to 7.0 mm. The finding that the majority of sites with probing, attachment loss was found amongst initially shallow or moderately deep lesions may indicate attachment loss due to trauma associated with therapy rather than loss as a result of a continuing, inflammatory disease process.

Measuring and interpreting increases in probing depth and attachment loss.

Increases in probing depth and attachment level measurements are used by clinicians and clinical scientists for assessing the periodontal status and/or change in status of patients. Interpretation of these measurements has implications with respect to our understanding of periodontal disease, treatment of patients and the implementation of clinical investigations. Measurements of probing depths and attachment loss were made on 204 teeth in 34 patients. The measurements were repeated after short periods of time by different examiners as well as the same examiners. Using these data, sensitivities and specificities of several potential diagnostic thresholds were calculated. It is concluded that observing an increase of probing depth greater than 1 mm serves as a diagnostic test with high sensitivity and specificity.

Effect of nonsurgical periodontal therapy. V. Patterns of probing attachment loss in non-responding sites.

Incisors, cuspids and premolars in 33 patients with advanced chronic periodontitis were treated by plaque control and 1 single episode of supra- and subgingival debridement. The results were monitored by probing attachment level measurements for 6 sites of each tooth every 3rd month during a period of 24 months. A total of 1368 sites were observed. From these were selected 280 "non-responding" sites showing 1.0 mm or more loss of probing attachment at 24 months compared to baseline. Scatter diagrams of the sequence of 9 probing attachment recordings obtained during the 24-month study were produced for each of these 280 sites. Study of these scatter diagrams resulted in identification of 7 different patterns of probing attachment change over time. A linear pattern of gradual loss of probing attachment throughout the 24-month observation period was found for 73% of the non-responding sites. Of the less frequently seen patterns, 3 approximated a linear course and 3 were non-linear. Linear analysis of regression as a statistical method to determine attachment loss for individual sites seems to be suitable for sites with linear patterns and for sites approximating a linear pattern. The insensitivity of regression analysis in non-linear patterns may be acceptable if a cautious analysis is warranted.