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Abstract

Background: Radiographic assessments of alveolar bone height and clinical assessments of clinical attachment level are frequently used to assess the presence and severity of periodontal disease. The present study is aimed to (i) determine prevalence of vertical attachment loss and (ii) reveal tooth groups at higher risk for progression of periodontal disease.

Methods: This retrospective study consisted of 246 patients (age 25-60 years). Records included case histories, UCLA charting and full mouth intraoral periapical (IOPA) radiographs of the patients. Probing depth (PD) recorded at 6 sites per tooth as per UCLA charting. Maximum score of probing depth on buccal and lingual/palatal aspect of each tooth was recorded. Maximum score of probing depth for each tooth was recorded. Alveolar bone level measured from full mouth IOPA radiographs. Alveolar bone level was measured as the distance between cemento-enamel junction (CEJ) and the most coronal level at which the periodontal ligament space retained its normal width with a 0.5 mm graduated ruler. Evaluations were carried out for: (i) Upper Vs Lower arch, (ii) Buccal Vs Palatal/lingual side and (iii) Comparisons were made among different tooth groups: molars, premolars, canines, incisors.

Results: Upper arch has higher probing depth than lower arch in buccal as well as lingual aspect (p<0.05). Upper arch has higher probing depth for premolars, canines and incisors but in molars lower arch shows higher probing depth. Probing depth in decreasing order: molars>premolars>canines>incisors. Among the arch, lower arch has a higher bone loss compared to upper arch, but this difference is not statistically significant (p>0.05). Among the teeth, incisors have the max bone loss followed by molars, canine and premolars respectively.

Conclusion: Within the limitations of this study, it can be concluded that lower molars found to have more probing depth but when compared radiographically incisors found to have more bone loss. Further longitudinal, prospective studies are required to confirm these results.

Keywords: Periodontal disease, prevalence, attachment loss


Introduction

Periodontal disease is clinically characterized by symptoms such as gingivitis, increased probing pocket depth, loss of clinical attachment level, recession of the gingival margin, loss of alveolar bone, increased tooth mobility, tooth migration, tooth loss etc. Destruction of alveolar bone is one of the main features of periodontitis, along with other parameters.

Determination of realistic prognosis and treatment plan for periodontally involved dentitions requires an accurate assessment of the prevalence of periodontitis in each tooth. Understanding the distribution of periodontal disease may reduce the direct and indirect costs of prevention and treatment programs, determine eligibility and coverage for insurance programs, and assists in the development of efficient designs in clinical trials in periodontal disease.1 It may also be needed to better understand oral health disparities among ethnic or racial subpopulations, and for efficient resource allocation to bridge these disparities.2 Cross-sectional studies of adult populations in the United States,3,4 Tanzania,5 Japan6 and Sweden7,8 have revealed that, although most individuals experience a reduction in periodontal tissue support with age, severe periodontal disease seems to affect a comparatively small fraction of the population. In a study carried out in Sri-Lanka, Loe et al. studied the natural history of periodontal disease in man and reported that only about 8% of the subjects examined suffered from advanced destructive periodontitis.9 Wide variation of periodontal destruction exists among different tooth groups. Cross-sectional studies have indicated that some areas or teeth are more severely affected by periodontal break-down than others and with increasing severity with age.10,11,12,13

Two methods are frequently used to assess the presence and severity of periodontal disease, namely radiographic assessments of alveolar bone height and clinical assessments of clinical attachment level. Oral radiological examination of marginal bone level is one way to study progression of periodontal diseases, where marginal alveolar bone is affected giving rise to horizontal and angular defects. Marginal bone height as a marker for progression of periodontal disease has been recorded in some longitudinal studies.11,14 Numerous studies have confirmed a reduction in alveolar bone crest height with age both in healthy subjects and in those with periodontal disease.15,16,17 Wide variations are found in the degree of proximal alveolar crest loss within the same mouth, between individuals and among different types of periodontitis.15,18,19

Periodontal attachment level is the most frequently used clinical variable in determining severity of destruction of the periodontium. Destruction of bone remains the most important criterion for assessing the severity of periodontitis.20 This is primarily diagnosed by radiographic evaluation of inter-dental bone levels loss, associated with deep clinical probing depths and tooth mobility. Awareness of root morphology and the condition of the periodontal tissues is also essential for reliable periodontal pocket probing. Due to improvements in debridement tools and increases in the number of options for scaling and root planing, the applicability of these procedures has been widened. However, the destruction of bone has been found to be responsible for tooth loss.21

Measurement of periodontal disease with radiological examination was evaluated in one study where clinical assessment outcome was compared with radiological examination.22 The authors concluded that underestimation of bone loss ranged from 9% to 20% in periapical radiographs, while probing resulted in a 5% error compared with measurements performed during flap surgery. Renvert & Persson, in examining the relationship between clinical and radiographic periodontal data, concluded that alveolar bone loss could be predicted by the number of teeth lost and the proportions of plaque scores.23

There are a few studies of the vertical attachment loss in different populations, for example: Tanzania, Sweden, and Japan.5,6,8 But not a single study has been carried out in Indian population to determine prevalence of vertical attachment loss. Thus, this study is aimed to (i) determine prevalence of vertical attachment loss and (ii) reveal tooth groups at higher risk for progression of periodontal disease.

Materials and Methods

It is a retrospective study and the source of the data was previous records of the patients who visited Department of Periodontics, Government Dental College & Research Institute, Bangalore, India during the past three years. Records included case histories, UCLA charting and full mouth intraoral periapical (IOPA) radiographs of the patients (246 patients). Subjects were selected on the basis of following inclusion criteria: age group 25-60 years, systemically healthy, should have at least 20 natural teeth, should not have received periodontal therapy previously and systemic/local antimicrobial or anti-inflammatory medication in recent six months. Patients excluded if they are suffering from any systemic disease (e.g. diabetes), smokers, blurred radiographs and radiographs with fog, foreshortened and elongated radiographs.



Methods of recording

Probing depth (PD) recorded at 6 sites per tooth as per UCLA charting. Maximum score of probing depth on buccal and lingual/palatal aspect of each tooth was recorded. Maximum score of probing depth for each tooth was recorded. Alveolar bone level measured from full mouth IOPA radiographs. Alveolar bone level was measured as distance between cemento-enamel junction (CEJ) and the most coronal level at which the periodontal ligament space retained its normal width with a 0.5 mm graduated ruler.24 (measured to the nearest 0.5 mm) Dental restorations, caries masking the CEJ were regarded as non-readable. The average of the two interproximal readings was taken for each tooth. Evaluations were carried out for: (i) Upper Vs Lower arch, (ii) Buccal Vs Palatal/lingual side and (iii) Comparisons were made among different tooth groups: molars, premolars, canines, incisors.



Statistical methods

Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS). To test the hypothesis of equality of means among the different groups Analysis of variance ANOVA was carried out. We carried out multiple comparisons test (Post-Hoc test) using Bonferroni method to find out among which pair of teeth there exists a significant difference. Differences between data sets with a probability of less than 0.05 were regarded as significant.



Results

Analysis of Attachment Loss

In this study we have 3 factors – Arch, Aspect and Teeth. The levels of each factor are given below:

Arch: Arch has two levels – Upper and Lower

Aspect: Aspect has two levels – Buccal and Lingual

Teeth: Teeth have four levels – Molars, Premolars, Canine and Incisors

We studied the effect of each factor, the levels of each factor as well as the interaction (joint effect of different levels of different factors) on the PD (mm). We determined which factor influences the PD (mm) the most and also the other factors respectively. We also determined the contribution of the different levels of each factor towards PD (mm) as well as the interaction.

The descriptive statistics are given in Tables 1 & 2. From the ANOVA (Table 3) we notice that there is a significant difference between upper arch & lower arch and arch is a significant factor influencing probing depth (p <0.05). There is also a significant difference between buccal aspect & lingual aspect and aspect is a significant factor influencing PD (p <0.01). There is a significant difference between the different kinds of teeth and teeth is a significant factor influencing PD (p <0.001).

From the Table 3 we observe that teeth are the most important factor influencing PD followed by aspect and arch. Among the teeth molars have a higher PD followed by premolars and canine. Incisors have the least PD. Among the aspect, buccal aspect has a higher PD compared to lingual aspect and this difference is statistically significant. Among the arch, upper arch has a higher PD compared to lower arch and this difference is statistically significant. From fig.1 we notice upper arch has a higher PD than lower arch in buccal as well as lingual aspect. Upper arch has a higher PD than lower arch in canine, incisors and premolars. But in molars, lower arch has a higher PD than upper arch. Buccal aspect has a higher PD than lingual PD in all the types of teeth.

We carried out multiple comparisons test (Post-Hoc test) using Bonferroni method to find out among which pair of teeth there exists a significant difference. The results are shown in table 4. From the above table 4 we notice that there is no significant difference between molars and premolars (p >0.05). But we notice as significant difference between molars and canine (p <0.01) & molars and incisors (p <0.001). There is no significant difference between premolars and canine (p >0.05) & premolars and incisors (p >0.05). There is no significant difference between canine and incisors (p>0.05).
Analysis of Radiographic Bone Loss

Here we have two factors – Arch and Teeth. The levels of each factor are given below:

Arch – Upper and Lower.

Teeth – Incisors, Canine, Premolars and Molars.

Descriptive statistics are shown in table 5. From the ANOVA (Table 6), we see that there is no significant difference between the two types of arch (p >0.05). Also there is no significant difference between the different types of teeth (p >0.05). The interaction (joint effect) of the arch and teeth is also not significant (p >0.05). Fig. 2 depicts the effect of each factor and the effect of the different levels of each factor on the radiographic bone loss. We notice that radiographic bone loss is influenced mainly by the teeth and then by the arch. Among the teeth, incisors have the maximum bone loss followed by molars, canine and premolars respectively. But this difference is not statistically significant (p >0.05). From the tables 5 & 6, we see that all the teeth have a higher radiographic bone loss in the lower arch when compared to the upper arch, but the difference in the bone loss in each type of teeth in both the arch is not statistically significant (p >0.05).

Discussion

The proper way of analysis of data associated with the prevalence and severity of periodontal disease has been an issue open to debate in the literature. The data obtained in the present retrospective study were analyzed with respect to arch, aspect and tooth type. The levels of each factor are given below:

Arch: Arch has two levels – Upper and Lower

Aspect: Aspect has two levels – Buccal and Lingual

Teeth: Teeth have four levels – Molars, Premolars, Canine and Incisors

We studied the effect of each factor, the levels of each factor as well as the interaction (joint effect of different levels of different factors) on the PD (mm). However, when comparing radiographic bone loss we had only two factors (Arch & tooth type). Distribution of vertical attachment loss varied according to tooth type, aspect and arch. We have found that the maximum PD on buccal aspect of mandibular molars. These results are inconsistent with those of a clinical study in Japan by Yamamato et al. In that study they observed palatal sites exhibited statistically significant vertical attachment loss in maxillary premolars and molars as well as in mandibular canines and premolars.1 In other longitudinal study by Airila Mansson et al., they observed molars in the maxilla lost more marginal bone than all other teeth over time, followed by maxillary canines, and mandibular incisors. Also, they observed that mandibular canines were the most stable tooth group.10 In another longitudinal study in New Zealand population (birth cohort of 26 year olds), Thomson WM et al. found that maximum sites with probing depth 4 mm were the mesiolingual sites in maxilla and distolingual sites in mandible. In both the jaws molars showed the highest extent of probing depth 4 mm followed by premolars, incisors and canines.25 Canines have been reported to have the lowest mortality rate of all teeth.12 Laurell et al. concluded that maxillary molars and lower incisors had a higher risk for periodontal breakdown over time.11 Mandibular incisors in our study were the most affected tooth group. Although, the difference among maxillary and mandibular incisors was not significant. (Mean mandibular incisors showing radiographic bone loss of 5.37 mm compared with maxillary incisors with 5.19 mm) This study was conducted using a large number of samples, but the results may not be comparable with those of clinical epidemiological studies.

Changes in systemic conditions, e.g. diabetes and various hormonal disorders can also have an effect on marginal bone.26 The proportion of sites with a probing pocket depth of >5 mm was consistently higher in smokers in the anterior, premolar and molar regions. Cigarette smoking is a factor associated with deeper periodontal pockets and an intra-oral distribution that is suggestive of a local effect.27 Hence, we excluded such patients from our study.

However, it should be noted that it is not always feasible to compare the prevalence of disease reported by different studies due to differences in sampling and study design and different classifications and diagnostic criteria. In our study we have observed that incisors are having maximum bone loss followed by molars, canines and premolars. The factors attributing to this may be: (i) while in incisors there is thin gingival biotype, also, they have less pericemental area but more access for cleaning. As a result there may be recession instead of periodontal pocket formation and bone loss. (ii) On the contrary, molars have thick gingival biotype, more pericemental area, but are inaccessible for proper cleaning. As a result it leads to pocket formation and attachment loss.

In general, upper molars and lower incisors are, due to their location, more subjected to calculus precipitation, which may favour plaque accumulation and continuous periodontitis progression. In addition, as patients have good access to dental care, repeated periodontal instrumentation for calculus removal may cause trauma-induced bone loss over time, in particular in the lower incisor area where the bone crest is fairly narrow.28

There are certain limitations to our study. This is a retrospective study and we could not measure the true vertical attachment loss. Also, our study includes selection of the patients from low socioeconomic status as our source of patient selection was Governmental Institution. In such patients the overall prevalence of periodontitis might be higher due to poor oral hygiene status. Since, radiography is only two dimensional; it is limited in measuring vertical defects.


Conclusion

Within the limitations of this study, it can be concluded that lower molars found to have more probing depth but when compared radiographically incisors found to have more bone loss. Anterior teeth need to be maintained for esthetic purpose. Thus, the main emphasis should be on preventive measures to maintain healthier dentition and to prevent periodontal destruction in teeth at risk. However, longitudinal, prospective studies are required which would more reliably permit to confirm these results.



References

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  2. Kingman A, Albandar JM. Methodological aspects of epidemiological studies of periodontal diseases Periodontology 2000, 2002;29:11-30.

  3. Burt, B, A., Ismail, A., Eklund, SA. Periodontal disease, tooth loss, and oral hygiene among older Americans. Community Dentistry and Oral Epidemiology 1985;13:93-96.

  4. Miller AJ, Brunelle JA, Carlos JP, Brown LJ, Loe H. Oral health of United States adults. National findings 1987 NIH publication No.87-2868.

  5. Baelum V. Parodontal nedbrydning hos voksne. Fn kritisk gennemgang af litteraturensamt egne undersogeher. Thesis. University of Arhus1985.

  6. Okamoto H, Yoneyama T, Lindhe J, Haffajee AD, Socransky SS. Methods of evaluating periodontal disease data in epidemiologicai research. J Clin Periodontol 1988;15:430-439.

  7. Hugoson A, Jordan T. Frequency distribution of individuals aged 20-70 years according to severity of periodontal disease. Community Dentistry and Oral Epidemiology 1982;10:187-192.

  8. Papapanou PN, Wennstrom JL, Grondahl K. Periodontal status in relation to age and tooth type. A cross-sectional radiographic study. J Clin Periodontol 1988;15:469-478.

  9. Loe H, Anerud A, Boysen H, Morrison E. Natural history of periodontal disease in man. Rapid, moderate and no loss of attachment in Sri Lankan laborers 14 to 46 years of age. J Clin Periodontol 1986;13:431-440.

  10. Airila-Ma°nsson S, So¨der B, Klinge B. Bone height changes in individuals with periodontal disease: a 17-year prospective longitudinal study. J Clin Periodontol 2005;32:822-827.

  11. Laurell L, Romao C, Hugoson A. Longitudinal study on the distribution of proximal sites showing significant bone loss. J Clin Periodontol 2003;30:346-352.

  12. Papapanou PN, Wennstro¨m JL, Gro¨ndahl K. A 10-year retrospective study of periodontal disease progression. J Clin Periodontol 1989;16:403-411.

  13. Albandar J. A 6-year study on the pattern of periodontal disease progression. J Clin Periodontol 1990;17:467-471.

  14. Jansson L, Lavstedt S, Zimmerman M. Prediction of marginal bone loss and tooth loss–a prospective study over 20 years. J Clin Periodontol 2002;29:672-678.

  15. Suomi JD, Plumo J, Barbano JP. A comparative study of radiographs and pocket measurements in periodontal disease evaluation. J Periodontol 1968;39:311-315.

  16. Kelly GP, Cain KJ, Knowles JW, et al. Radiographs in clinical periodontal trials. J Periodontol 1975;46:381-386.

  17. Rohner F, Cimasoni G, Vuagnat P. Longitudinal radiographical study on the rate of alveolar bone loss in patients of a dental school. J Clin Periodontol 1983;10:643-651.

  18. Saari JT, Hurt WC, Biggs NL. Periodontal bony defects in the dry skull. J Periodontol 1968;39:278-283.

  19. Burmeister JA, Best AM, Palcanis FA, et al. Localized juvenile periodontitis and generalized severe periodontitis: clinical findings. J Clin Periodontol 1984;11:181-192.

  20. Novak, J. M. Classification of diseases and conditions affecting the periodontium. In: Newman, MG, Takei HH, Klokkevold P, Carranza FA. (eds). WB Saunders Chicago: Clinical Periodontology, 2007;10th edition:100-109.

  21. Lennon, MA Davies RM. Prevalence & distribution of alveolar bone loss in a population of 15-year-old school children. J Clin Periodontol 1974;1:175-182.

  22. A°kesson, L, Ha°kansson J, Rohlin M. Comparison of panoramic and intraoral radiography and pocket probing for the measurement of the marginal bone level. J Clin Periodontol 1992;19:326-332.

  23. Renvert S, Persson GR. Patient-based assessments of clinical periodontal conditions in relation to alveolar bone loss. J Clin Periodontol 2004;31:208–213.

  24. Bjorn H, Hailing A, Thyberg H. Radiographic assessment of marginal bone loss. Odontologisk Revy 1969;20:165-179.

  25. Thomson WM, Hashim R, Pack RC. The prevalence and intraoral distribution of periodontal attchment loss in a birth control of 26 year-olds 2000;71:1840-1845.

  26. Kinane DF. Periodontitis modified by systemic factors. Annals of Periodontology 1999;4:54-64.

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Table 1

Descriptive statistics for PPD for Upper Arch


Upper Arch

Teeth

Mean

Std. Dev

Buccal

Molars

5.25

1.83

Premolars

5.19

2.02

Canine

4.80

2.21

Incisors

4.51

2.17

Lingual

Molars

4.61

1.70

Premolars

4.46

1.98

Canine

4.12

2.09

Incisors

3.97

1.91


Table 2

Descriptive statistics for PPD for Lower Arch


Lower Arch

Teeth

Mean

Std. Dev

Buccal

Molars

5.24

1.85

Premolars

4.31

1.99

Canine

4.29

2.02

Incisors

4.09

2.05

Lingual

Molars

4.98

1.78

Premolars

4.15

1.65

Canine

3.71

1.88

Incisors

3.65

1.97


Table 3

Analysis of Variance for different Variables


Variables

p-value

Arch (Upper Vs Lower)

0.042*

Aspect (Buccal/Labial Vs Lingual/Palatal)

0.001*

Teeth (Incisors, Canines, Premolars, Molars)

<0.001*

* Statistically significant

Table4

Multiple comparisons test (Post-Hoc test) using Bonferroni method

Teeth groups

p-value

Molars

Premolars

Canines


Incisors

0.14

0.002*


0.000*

Premolars

Molars

Canines


Incisors

0.14

1

0.174



Canines

Molars

Premolars

Incisors


0.002*

1

1



Incisors

Molars

Premolars

Canines


0.000*

0.174


1

* Statistically significant

Table 5

Descriptive statistics for Radiographic Bone Loss


Arch

Teeth

Mean

Std. Dev

Upper

Canine

4.77

2.89

Incisors

5.19

3.04

Molars

4.85

2.75

Premolars

4.65

2.61

Lower

Canine

4.98

3.06

Incisors

5.37

3.14

Molars

5.16

2.37

Premolars

4.95

2.48


Table 6

Analysis of Variance for different Variables for Radiographic Bone Loss


Variables

p-value

Arch (Upper Vs Lower)

0.424

Teeth (Incisors, Canines, Premolars, Molars)

0.701





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