The effect of crown receipt on measures of gingival status.

Although the association between crown margins and increased inflammation and probing depth is well-established, studies examining these effects have been largely post hoc. Change in gingival status measures due to receipt of crowns may affect longitudinal evaluations in clinical trials and epidemiological studies. This study examined the effects of receipt of crowns on the periodontal health of the Ramfjord index teeth. Gingival status descriptors included measures of plaque, gingival inflammation, calculus, probing depth, and gingival recession. Changes in periodontal status scores (1987-89) for teeth receiving crowns among 67 patients were compared with change in scores for teeth not receiving crowns. Teeth that were crowned showed small, but significant, differences. These teeth had greater decreases in calculus scores for both surfaces, increases in inflammation compared with decreases for teeth not receiving crowns, and increased facial probing depths. Change in gingival recession was markedly decreased on facial surfaces among teeth receiving crowns. The results suggest that crown status should be recorded routinely in clinical trials involving gingival status, and that teeth receiving crowns during the course of the study should be eliminated from the analyses.

Effect of crown margins on periodontal conditions in regularly attending patients.

Subgingival margins of cast restorations have been associated with increased gingival inflammation and probing depth, but it is not known if such effects would be seen among patients receiving regular professional care. In this study, 831 regularly attending patients in 35 North Carolina dental practices were examined. Plaque, gingival inflammation, calculus, and probing depth were assessed on facial and mesiofacial surfaces of the Ramfjord teeth. Surface-specific analyses showed significantly greater (p less than 0.05) gingival inflammation and deeper probing depths with subgingival cast restoration margins for nearly all surfaces examined. Less frequently, decreases in plaque and calculus were associated with the presence of crowns. Intact surfaces in patients with cast restorations were not significantly different from the same surfaces in patients without cast restorations. Even among patients receiving regular preventive dental care, subgingival margins are associated with unfavorable periodontal reactions.

Evaluating and influencing periodontal diagnostic and treatment behaviors in general practice.

Providers' periodontal diagnostic and treatment behaviors were assessed in 34 practices in two North Carolina counties. Regularly attending patients had a low prevalence of gingival pocketing on index teeth, moderate attachment loss, and fairly prevalent bleeding and calculus. Treatment frequency and patient knowledge were generally adequate, but the notation of periodontal status in the patient record was insufficient. A continuing education intervention resulted in substantial and significant improvement in notation rates. Changes in rates with which services were provided, and changes in patient periodontal status were smaller and mixed. The study shows that continuing education can be effective in helping some but not all providers adopt needed, appropriate behaviors.

Alveolar bone loss in patients with long-term supportive care.

Radiographic record audits were conducted on 63 patients diagnosed as having periodontitis who had been treated and maintained for 10 years or longer in dental school clinics. Acceptable bite-wing radiographs were available for 50 of these patients. Bite-wing radiographs taken 8 to 34 years apart (mean 14.9 years) were assessed for bone loss. Recall maintenance had been accomplished for 60% of these patients at 6 to 9 month intervals, while 24% had been seen more frequently. The mean annual rate of bone loss was 0.037 mm (range of -0.19 to 0.20). There were no significant differences in bone loss between maxillary/mandibular, molar/premolar, or mesial/distal sites respectively. Alveolar bone loss in this dental school population compares well with other reported studies. Progression of disease as assessed by radiographic bone loss in treated and maintained periodontitis patients is minimal.

Association of dental health knowledge with periodontal conditions among regular patients.

Although routine patient education concerning periodontal disease is recommended as a means of improving oral health, strong associations between oral health knowledge and plaque or gingival inflammation scores have not been demonstrated. This study examined associations between four knowledge scales (likelihood of keeping teeth, signs of disease, role of diet, role of oral hygiene measures) and six periodontal status measures (plaque, gingivitis, calculus, probing depth, attachment loss, missing teeth) among 1088 regularly attending dental patients. In bivariate correlation analyses, there was a weak, direct association between stronger expectations of keeping teeth and better levels of periodontal health, while an inverse association between knowledge of signs of periodontal disease and better periodontal health was noted. Level of knowledge of the role of oral hygiene or of diet in periodontal disease was not associated with level of disease. When effects associated with age, sex, race, and different dental practices were held constant, these patient knowledge scales did not explain substantial proportions of variance in the periodontal disease measures. Among regular utilizers, the effects of receipt of dental care may be more determinative than level of patient knowledge.

The effectiveness of subgingival scaling and root planning. I. Clinical detection of residual calculus.

This study evaluated the ability of clinicians to detect residual calculus following subgingival scaling and root planing and compared the clinical detection to the microscopic presence and surface area occupied by calculus found on teeth extracted after instrumentation. Interexaminer and intraexaminer reproducibility in clinically detecting subgingival calculus was also determined. One hundred one extracted teeth with 476 instrumented tooth surfaces were evaluated stereomicroscopically for the presence of calculus and the percent surface area with calculus was determined by computerized imaging analysis; 57% of all surfaces had residual microscopic calculus and the mean percent calculus per surface area was 3.1% (0 to 31.9%). Shallow sites had greater surface area of calculus than moderate and deep sites. The difference was not significant. The interexaminer and intraexaminer clinical agreement in detecting calculus was low. There was a high false negative response (77.4% of the surfaces with microscopic calculus were clinically scored as being free of calculus) and a low false positive response (11.8% of the surfaces microscopically free of calculus were clinically determined to have calculus). This study indicates the difficulties in clinically determining the thoroughness of subgingival instrumentation.

Tooth loss in patients with moderate periodontitis after treatment and long-term maintenance care.

Records of 63 patients diagnosed as having moderate periodontitis who had been treated and maintained by scaling and root planing for 10 years or longer (mean 13.6 years, range 10 to 34 years) in dental school clinics were reviewed for tooth loss. The patients averaged 45 years of age (range 24 to 67 years) at the initial appointment, and 41 were female. Record audit determined type of periodontal treatment, total tooth loss, periodontally related tooth loss, loss of teeth with furcation invasion, plaque scores, and maintenance interval. Results of therapy were evaluated by groups on the basis of number of teeth lost. At the completion of active periodontal therapy 1,607 teeth were present in the patients. During the maintenance period, 115 teeth (7.1%) were lost and of these 88 (5.0%) were lost due to periodontal reasons. Maxillary and mandibular molar teeth, particularly maxillary second molars, were the teeth lost most frequently to periodontal disease. Of the 164 teeth initially indicated as having furcation invasion, 23% were subsequently lost. This retrospective study confirms the low rate of tooth mortality occurring when patients with periodontal disease are treated and kept on a maintenance program. Canines were the teeth least frequently lost.

Dental patients' knowledge and beliefs about periodontal disease.

The knowledge and beliefs about periodontal disease of 1093 regularly attending patients in 36 North Carolina general dental practices were examined. Patients had a strong positive orientation toward keeping their teeth. Correct information concerning the signs, causes, prevention, and treatment of periodontal disease was widely held. Older patients were more knowledgeable about treatment and signs of periodontal disease, while younger patients expressed more positive beliefs about keeping their teeth for a lifetime. Although patients' knowledge was not perfect, it included few misperceptions that could threaten oral health. Additional education was most needed with respect to the significance of bleeding gums.

Clinical periodontal status of regularly attending patients in general dental practices.

Periodontal status of regular patients of general practitioners in the United States is unknown. A project assessing the effectiveness of continuing professional education in altering provider behavior and patient periodontal health provided the opportunity to clinically examine 1092 patients in the offices of 36 general practitioners. These regularly attending patients were selected by a random start systematic sample of patient records. The examination included recording missing teeth and assessing plaque, gingivitis, calculus, probing depth, and attachment loss on the facial and facial-mesial surfaces of the Ramfjord teeth (PDI). The mean patient age was 48 years, and 63% were female. The mean number of missing teeth, not including third molars, was 3.9. Almost 78% of the patients had no sites with a P1I score greater than 1, but 52% of the patients had at least one site with bleeding. Calculus was present in 62% of the patients. Deepest pocket depth was 4 mm or greater in 9% of patients and 3.8% had sites with 4 mm or greater attachment loss. Mean attachment loss was 1.6 mm across all sites. Although the majority of these regular patients had plaque, calculus, and gingivitis, only a minority exhibited periodontitis at the index sites.

Periodontal status and treatment needs among regular dental patients.

A survey of periodontal status and treatment needs among dental patients was performed using the CPITN criteria, with the worst score per sextant being recorded, based on examination of all surfaces of all teeth. Regularly attending patients (n = 1092) from 36 general dental practices in two North Carolina counties were examined. The most frequently found worst conditions-per-patient across all ages were the presence of calculus (35 per cent) and the presence of 4-5 mm pockets (35 per cent). The most common worst condition-per-sextant was bleeding (32 per cent) followed by calculus (28 per cent). Less than a fifth of all sextants exhibited pocketing, although half of the patients had at least a 4-5 mm pocket. The mean amount of treatment time required for these conditions was 33 minutes, reflecting the general absence of the need for complex periodontal treatment.

Presence of periodontal data in patient records of general practitioners.

It has been reported that little diagnostic information concerning periodontal conditions is entered in patient records of general practitioners, but actual rates for such chart entries are unknown. Records of regular patients, seen at least annually, were randomly selected from the offices of 36 general practitioners in two North Carolina counties. In each office 80 records were selected for audit. After adjustment, the final sample consisted of 2488 audited records. Entries noting the presence or absence of 14 diagnostic conditions were identified for the five previous years and for the patient's most recent examination. The presence of a periodontal diagnosis or periodontal treatment plan was noted. The number of radiographic sets exposed in the previous five years and the age of the most recent set were determined for complete series/panoramic films and for bitewings. Across practices, the most frequent notations (20.5% within the past five years) concerned the presence of probing depths and calculus. Gingival bleeding (13%) and plaque (12%) were noted less frequently. A periodontal diagnosis was recorded in only 16.3% of the records. Annualized rates for radiographic sets were 0.09 for complete series/panoramic films and 0.50 for bitewings. These data suggest that, except for radiographs, the majority of patient records do not contain sufficient diagnostic information to describe patients' periodontal health.

Clinical effectiveness of a dentifrice containing fluoride and a citrate buffer system for treatment of dentinal sensitivity.

Four test dentifrices were evaluated in a double-blind investigation to determine their effect on dentinal sensitivity in 87 adult human participants. Baseline data were obtained by patient questionnaire, dental examination and by soliciting subjective responses to controlled osmotic, thermal and tactile stimuli. The four dentifrices were: (1) a placebo dentifrice, (2) a fluoride dentifrice containing 0.1% fluoride, (3) a 2% citrate buffered dentifrice in a pluronic gel and (4) a dentifrice containing 0.1% fluoride and 2% citrate buffer in a pluronic gel. Precipitated silica provided the abrasive for all dentifrices. Dentifrices were supplied to participants on a random basis, and participants were instructed to brush twice daily for 8 weeks. Responses to the three stimuli as accomplished at baseline were obtained at 2, 4 and 8 weeks on 81 participants. A statistically significant stimulus reduction was found between treatment groups to thermal stimulus at the 2-month interval (P = 0.048) and to the tactile stimulus at 2 weeks (P = 0.019). Both the citrate dentifrice and the citrate/fluoride dentifrices demonstrated significant efficiency in reducing sensitivity.

Effectiveness of a dentifrice containing formalin and sodium monofluorophosphate on dental hypersensitivity.

A double-blind investigation comparing a control dentifrice with one containing active ingredients was conducted to determine their effect on dentinal hypersensitivity in 67 human subjects. Baseline data was obtained by patient questionnaire, dental examination and by soliciting subjective responses to controlled mechanical and thermal stimuli. A calcium carbonate-based toothpaste constituted the base for both the control and active dentifrice. The active dentifrice contained 0.8% sodium monofluorophosphate and 1.3% formalin while the control lacked these ingredients. Dentifrices were supplied to patients on a random basis, and patients were instructed to brush twice each day for 28 days. Mechanical and thermal response as accomplished at baseline were obtained at 14 and 28 days after baseline on 60 subjects. A statistically significant reduction was not obtained in response to mechanical stimulus. The active dentifrice demonstrated a statistically significant reduction (P less than 0.05) to thermal stimulus at both 14 and 28 days.

An evaluation of tricalcium phosphate implants in human periodontal osseous defects of two patients.

This study evaluated the use of tricalcium phosphate (TCP) ceramic implant material in periodontal osseous defects. Thirteen defects in two patients were treated with mucoperiosteal flaps and placement of TCP. The defects were evaluated clinically and radiographically utilizing standardized probe placement and radiographic technique. Clinically, there was a mean probing pocket reduction of 4.5 mm as a result of a mean gain of clinical probing attachment level of 2.0 mm and a mean gingival recession of 2.5 mm. Radiographically, there was a mean "fill" of 1.8 mm. Six teeth were removed by block biopsy for histologic analysis, three at 3 months, one at 6 months and two a 9 months. The TCP particles were well tolerated and encapsulated by fibrous connective tissue, but the particles did not stimulate new bone growth. The junctional epithelium ended 1.62 mm coronal to the apical extent of a reference notch placed at the base of the defect. Although new cementum was observed, there was limited evidence of new attachment.

Occlusal relations and periodontal status in human adults.

A group of 66 adults provided the population for study of relations between various clinical parameters and periodontal status. Dental and habit histories and plaque scores were acquired. Occlusal features included classification of malocclusion, analysis of centric displacement, establishment of patterns of lateral and protrusive excursions, identification of tooth contacts and presence of wear facets. Periodontal analysis included pocket depths, radiographic manifestations and extent of mobility. Class I malocclusion predominated and the majority of patients did not have coincidental centric relation and centric occlusion. Group function is the most common lateral excursive pattern in the adult. Nonfunctional contacts are common as is enamel attrition. Results indicate no significant deleterious influence on the status of the periodontium by occlusal disharmonies.

Effectiveness of sodium fluoride on tooth hypersensitivity with and without iontophoresis.

Effectiveness of iontophoresis with and without electric current and sodium fluoride on tooth hypersensitivity was evaluated. In eleven volunteers, teeth received a 2% neutral sodium fluoride solution applied using an electrode phoresor. Test teeth received the solution with current and control teeth received the solution without current. The subjects were tested at Day 0 and 7 by means of a mechanical stimulating device and a temperature probe. The data were then analyzed using X2 analysis. Statistically, the test teeth demonstrated more improvement than the control teeth.

The effects of citric acid on attachment of laterally positioned flaps.

Citric acid demineralization of root surfaces to enhance new attachment clinically appears to be successful, but histologic evidence of new attachment in humans is lacking. Two recession-like defects were surgically created on the facial aspect of mandibular incisors scheduled for extraction in five patients. Each patient had differing degrees of periodontal disease, but the control and experimental teeth of each were similarly involved. The roots were thoroughly planed and an apical reference notch was inscribed just coronal to crestal bone. One tooth served as the control, while the experimental tooth was treated with citric acid (pH 1) for two minutes. Two full-thickness laterally positioned flaps were done to cover the roots. After healing periods of 1, 2, 4, 12, and 20 weeks, the teeth were removed by block section for histologic evaluation. The type of attachment differed on the teeth with longer healing periods. The control teeth exhibited a long epithelial attachment with no evidence of cementogenesis, whereas the experimental teeth had a connective tissue attachment to newly formed cementum coronal to the reference notch. These observations provide evidence that demineralization of root surfaces may promote increased or accelerated connective tissue attachment of laterally positioned flaps.

Policy implications of the epidemiology of dental diseases for the prevention and control of periodontal disease: the North Carolina studies.

The North Carolina Dental Manpower Study indicated that periodontal disease was widespread and little was being done to control the disease. We have continued to address issues identified by the Dental Manpower Study in order to better understand the high prevalence of periodontal disease. Drawing from the theoretical basis of behavioral science and the clinical and epidemiological knowledge of periodontal disease, we have planned a strategy for testing the feasibility for controlling periodontal disease through dental health services. Only when attention to periodontal disease pervades the thinking and behavior of all segments of the dental care system--professional education, professional certification and regulation, financing mechanisms, consumers, and dental research--will factors be totally conducive to controlling this problem.

Tooth loss in 100 treated patients with periodontal disease. A long-term study.

A population of 100 patients with periodontal disease who had been treated and maintained for 15 years or longer was studied for tooth loss. The patients averaged 43.8 years of age and consisted of 59 females and 41 males. Patients were examined and their dental records were reviewed. On the basis of response to therapy and tooth loss, the patients were classified as Well-Maintained (77), Downhill (15), or Extreme Downhill (8). At the completion of initial treatment, 2,627 teeth were present. Of this number, during the maintenance period, 259 teeth (9.8%) were lost due to periodontal disease, while 40 teeth (1.5%) were lost due to other causes. Evaluation was made as to patterns of tooth loss, loss of questionable teeth, loss of teeth with furcations, surgical vs. nonsurgical therapy, and presence of fixed or removable prostheses. Considerable variation occurred between response groups. Periodontal disease appears to be bilaterally symmetrical and tooth loss response emulated this pattern with greatest loss of maxillary second molars and least loss of mandibular cuspids.