Introduction
In the introductory literature review, Lang et al (p 590) observed that gingival bleeding on probing commonly reflects gingival inflammation. Further, they noticed that previous studies have provided a strict maintenance program with different recall intervals from one patient to another. In addition, many authors considered recalling patients for regular visits a key practice to successful treatment. Therefore, they designed a 4-year retrospective study of periodontal maintenance in patient treated for advanced periodontal disease. The study looked at bleeding on probing importance as a clinical prognostic indicator to identify risky sites of periodontal breakdown during regular recall maintenance visits.
Materials and methods
The study included 55 patients, 30 females and 25 males; their age range was 24 to 74 years. All patients were referred for treatment of periodontitis and reestablishment of mastication. The authors defined advanced periodontitis as 50% loss of alveolar bone and many missing teeth secondary to periodontal disease. This explains why all patients were referred from the Department of Crown and Bridge Prosthetics and Comprehensive Dental Care, University of Berne, Dental Medical School. Initially, all patients were subjected to careful scaling, root planning procedures and oral hygiene (hygienic phase). One month after completion, reexamination of the plaque, gingival health, probing performed to ascertain pocket surgical therapy. If surgical interference was performed, patients were reexamined one month later and start reconstructive therapy. The maintenance program included regular recall visits for 4 years on 3-5 months intervals, although only evaluations of the last two years (with a minimum of four visits) were included in the study. At each visit, bleeding on probing (BOP) at the bottom of the pocket documented at 4 sites for every tooth. Out of 7704 pockets examined, the authors randomly selected 1054 pockets, divided into 5 categories based on the incidence of BOP at the four sites examined. The 5 categories were grouped further into two according to whether the attachment level was maintained.
Statistical analysis
Chi-square test performed as a statistical significance test, which is useful to compare the distributions of two or more groups whose individuals fall into two or more different classes or categories (Wholey et al, p 289). The authors calculated both sensitivity (an index of test performance) and predictability (a measure of test accuracy) of BOP (Everitt, Pp 86 &195).
Results
The authors inferred that pockets of depth equals or more that 5 mm correlate significantly with BOP incidence. Loosing attachments correlated significantly with 16% or more BOP. Further, patients with BOP 4/4 (at the bottom of the pocket at 4 sites for every tooth) showed 30% possibility of losing attachment, patients with BOP3/4 showed 14% possibility of losing attachment. Besides, patients with BOP 2/4 showed 6% possibility of losing attachment, while patients with BOP 1/4 showed 3% possibility of losing attachment, and finally, patients with BOP 0/4 showed only 1.5% possibility of losing attachment. About sensitivity and predictability, the authors considered BOP, a useful but limited prognostic indicator during maintenance periodontal treatment.
Discussion
First, regarding the efficacy of periodontal maintenance programs, the authors suggested with BOP scores of 16%, there are more residual pockets of 5 mm or more and more sites losing attachments of 2 mm or more. They pointed that with BOP scores of 16%, in this case, they advised shortening the recall visits intervals; although they considered the proof inconclusive and advised further prospective studies.
Second, about significance of BOP scores; the authors suggested as culturing techniques enhance predictability, combining these techniques with the clinical indicators as BOP and pocket depth should provide better predictability of active periodontal disease. Further, in the lights of their sensitivity and predictability results, they suggested that sites that do not show BOP at any site should not be reinstrumented on following recall visits.
Bottom line
Prognostic parameters of periodontal disease like pocket depth and BOP may not be enough to evaluate the risk of attachment loss. Together with risk scores tailored for each patient or group of patients should provide better risk assessment of loosing attachment.
Works Cited
Everitt, B. S, et al. Medical Statistics From A To Z: A Guide For Clinicians And Medical Students. Cambridge: Cambridge University Press, 2006.
Lang, N. P, Joss, A, Orsanic, T, Gusberti, F. A, and Siegrist, B. E. “Bleeding on Probing. A predictor for the progression of periodontal disease?” J Clin Periodontol vol 13 1986. p. 590-596.
Wholey, J. S, Hatry, H. P, and Newcomber, K. E, et al. Handbook Of Practical Program Evaluation. San Francisco: Jossey-bass, 2004.