Applicability of Community Periodontal Index Teeth and Random Half-mouth Examination to Gingival Bleeding Assessment in Untreated Adult Population in Beijing

Jing-hua Zhang＊

Department of Dentistry,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences &Peking Union Medical College,Beijing 100730,China

PERIODONTAL disease and dental caries are 2 major dental diseases. In periodontal diseases,periodontitis is an infective one caused by plaque.Chronic periodontitis is the most common form of destructive periodontal disease in adults in China.1Clinical parameters,including bleeding on probing,are employed to characterize the severity and prevalence of chronic periodontitis.In longitudinal observation,the long-term no-bleeding gums can be a predictor of stable condition of periodontal disease,indicating that the examination of bleeding gums is important for periodontal maintenance.2Most survey methods use full-mouth assessment of periodontal diseases,which involves the examination of 6 sites on all teeth.Data from full-mouth examination are the gold standard for accurate assessment of periodontal disease.However,because of the restraints in time,logistic,and cost of full-mouth assessment,this clinical assessment of periodontal diseases is impractical in epidemiological surveys involving large population samples.3

Community Periodontal Index (CPI) is easy to operate and has good repeatability.It is stored in the World Health Organization (WHO) Global Oral Health Data Bank and is recommended by WHO.4In addition,since periodontal destruction exhibits left-right symmetry,5it is hypothesized that a half-mouth examination provides an appropriate alternative to whole-mouth assessment,with considerable advantage over a more limited partial-mouth assessment of index teeth.Therefore,the present study compared CPI teeth method and random half-mouth method with full-mouth examination in assessing gingival bleeding,to identify an examination which not only can represent but also is suitable for epidemiological investigations of periodontal disease.

SUBJECTS AND METHODS

Subject selection

Inclusion criteria:1.above 18 years;2.having at least 16 teeth viable for the periodontal examination,among which 4 must be molars.Exclusion criteria:1.with chronic systemic diseases or the need of long-term medication due to systemic conditions,and requiring prophylactic use of antibiotics and other drugs before the periodontal examination;2.suffering acute necrotizing gums,apical or periodontal abscess,or extreme teeth loss;3.with orthodontic devices.Each subject signed an informed consent to participate in this study.

Examination methods

The subjects were examined by a dentist with 12 years of clinical experience and qualified by the repetitive calibration inspection (KAPPA value is 0.82),using a plane mouth mirror and CPI probe (Hu-friedy,Chicago,IL,USA).All the subjects’ teeth were examined one by one (except the third molars).Each tooth was examined at 6 sites:mesial,central,and distal sites for both buccal and lingual sides.Residual crown and root,dentures,filling body at dental neck,overcrowding teeth,and other teeth that can not be examined were recorded as 8,and the missing teeth as 9,which were all not used for the numerical calculation.

GBI ranges from 0-3:0,no bleeding;1,bleeding after 30 seconds on probing;2,bleeding immediately on probing;3,spontaneous bleeding before probing.SBI ranges from 0-5:0,gingiva of normal texture and color,no bleeding;1,no bleeding on probing,change in color;2,bleeding on probing,change in color,no edema;3,bleeding on probing,change in color,slight edema;4,bleeding on probing,change in color,obvious edema;5,bleeding on probing and spontaneous bleeding,change in color,marked edema.

Data consolidation

According to the following methods,the data of the full-mouth teeth examination were consolidated in different ways.

CPI teeth method:Calculate the data of all sites for the first central incisors at the upper right and lower left,and the first and second molars at the 4 quadrants (11,16,17,26,27,31,36,37,46,47).

Random half-mouth method:Calculate the data of all sites by any combination of the half-mouth teeth at the upper,lower,left,and right quadrants.There are altogether 6 combinations,namely 1+3 section (the upper right and the lower left quadrants),2+4 section (the upper left and the lower right quadrants),1+4 section,2+3 section,1+2 section,and 3+4 section.

Statistical analysis

Microsoft Excel 2007 was used for statistical analysis,and the data obtained from the 2 different methods were compared with the full-mouth’s data usingt-test,and the α level was 0.05.P＜0.05 was considered statistically significant.

RESULTS

Demographic features of included subjects

GBI group included 123 males and 377 females,the mean age being 28.87±6.89 years.SBI group included 115 males and 385 females,aged at 30.29± 5.74 years.

Comparison of CPI teeth method and full-mouth examination

In both GBI and SBI groups,the differences between the data by CPI teeth and those by full-mouth examination were statistically significant (bothP＜0.05,Table 1).

在已发掘100多处良渚文化遗址中出土了大量极其珍贵的玉器。在所有的史前文化遗址中，无论就量来说，还是就质来说，良渚的玉器都当得上史前玉文化的高峰之一，堪与北方的红山文化相媲美。在史前出土物中，玉器无疑最为珍贵，它是史前精英文化的标志。良渚文化遗址还发现了类似文字的符号、城堡和祭坛的遗存。种种迹象说明良渚文化已经距文明时代不远了。良渚文化称得上文明的曙光，太阳虽然还没有出来，但霞光已经透出云层，将金辉洒在大地了。在蒙昧中昏睡的人们已经睁开了惺忪的睡眼惊奇地打量这浴在晨曦中的美丽的世界。

Table 1.Comparison of the GBI and SBI by CPI teeth method and full-mouth examination§

Comparison of random half-mouth method and full-mouth examination

In GBI group,the data of 1+3 section and 2+4 section by random half-mouth method were not significantly different from those by full-mouth examination (P＞0.05).While compared with the full-mouth examination,the data of the combinations of the ipsilateral upper and lower quadrants(i.e.1+4 section and 2+3 section),the upper right and left quadrants (1+2 section),and the lower right and left quadrants (3+4 section) were significantly different(P＜0.05).

In SBI group,whether it was a diagonal or an ipsilateral combination of the upper and lower quadrants of the mouth,the data calculated by random half-mouth method were similar with those by full-mouth examination (P＞0.05).While for the upper half-mouth or the lower half-mouth,there were significant differences between the data by random half-mouth method and those by full-mouth examination (P＜0.05,Table 2).

Table 2.Comparison of the GBI and SBI by random half-mouth method and full-mouth examination§

DISCUSSION

Periodontal disease is a common oral disease that brings serious impact on oral health among the general population.According to China's third oral epidemiological survey,the incidence of gingival bleeding was 57.7%among 12-year-old adolescents,77.4% in 35-44 age group,and only 13.6% in 65-74 age group,with no pockets or severe periodontal attachment loss.6

The survey of periodontal conditions in the oral is an important means to assess the oral health status and monitor efficacy of a given treatment,by the detection of periodontal clinical parameters,which can be used to evaluate the severity and prevalence of periodontal diseases.There are many indexes to assess periodontal disease,including bleeding on probing,pocket depth,and attachment loss.However,periodontal disease often causes multiple aspects of destruction to the gums,alveolar bone,and periodontal membrane,the clinical manifestations are thus complex.Currently there is no index that can provide a comprehensive quantitative evaluation of the change by all the damages.Most periodontal disease indexes were chosen by researchers for different purposes,making a partial assessment of the periodontal tissue changes.Among those indexes,the examination of bleeding gums is important for periodontal maintenance,the results of which can help clinicians to develop treatment decisions.2

In clinical investigations of periodontal disease,fullmouth examination is the best method for accurate assessment of periodontal status,but it entails a large amount of work,requiring examination of 6 sites of each tooth (168 sites in the full mouth,excluding the third molars),which is time-consuming,laborious,and expensive,thus not suitable for large-scale epidemiological investigations.Therefore,the programs to examine part of teeth are proposed,5such as community periodontal index teeth of need,CPI,and simplified oral hygiene index.Among them,CPI is simple,rapid,reproducible,and suitable for large-scale epidemiological survey of oral diseases.7However,it has been suggested that CPI estimation of the periodontal status was not accurate.Vettore et al8applied both CPI and full-mouth examination to examine the periodontal pocket depth and the degree of periodontal attachment loss,finding that compared with the full-mouth examination,CPI underestimates the incidence,while overestimates the severity of the disease,reaching results significantly different from those by full-mouth examination.A study suggested that CPI teeth could be an appropriate source of samples for the subginginval detection.CPI teeth were showed to be representative of Actinobacillus actinomycetemcomitans subgingival colonization.9Moreover,blood test values tended to be correlated with CPI scores as well.10

A recent study in China compared CPI teeth method and full-mouth examination in examining the periodontal status among the same population,noticing that the results of dental calculus detected by the 2 methods were consistent,while the results of bleeding gums and periodontal pocket detections showed significant differences.11In this study,GBI and SBI were employed to examine and record the status of the full-mouth bleeding gums.The mean value of SBI by CPI teeth method was higher than that by full-mouth examination (P＜0.05),while the mean value of GBI by CPI teeth method was lower (P＜0.05),similar to the results of a previous report.12

SBI examination is characterized by its subtle classification of bleeding,while CPI index include 8 molars,which are the most serious bleeding sites in the full-mouth teeth,thus overestimating the severity of the disease.The lower GBI by CPI teeth method may be because 3 sites of each tooth are examined.The results of both indexes indicate that CPI can not represent bleeding gums status of the full-mouth.In recent years,some studies have shown that periodontal diseases are site-specific,3,13that periodontal destruction does not affect all the teeth in the mouth at the same time,but may occur in a few teeth at one time,and in some other sites at another time.When periodontal disease exists in non-index teeth,using a simple index teeth method may lead to inaccurate estimation of the disease status.

Over the years,periodontal epidemiologists had proposed new programs for periodontal epidemiological investigation.Löe et al14only examined the mesial and central sites of the buccal sides among tea workers in Sri Lanka.Mills et al15compared 8 kinds of simplified index with the full-mouth index,finding no significant difference and good correlation.Silness et al16believed that Ramfjord index had a strong correlation with the full-mouth index in recording plaque,gingivitis,and other periodontal indicators.However,due to the site-specificity of periodontal diseases,a part of the teeth does not fully reflect the status of full-mouth teeth,and there is still no consensus about which specific teeth could replace the CPI teeth.

Because there is right and left symmetry in periodontal damage,5half-mouth teeth method has been used to replace full-mouth examination.17Bentley et al18found that the record of plaque and gingivitis index values by half-mouth method were close to those by full-mouth examination.Some scholars also advocated the use of random diagonal half-mouth program to examine the full-mouth periodontal status in periodontal epidemiology inspection in adults.19Dowsett et al5and Owens et al20suggested that half-mouth index was better than Ramfjord index in evaluating the extent and prevalence of periodontal disease,and Plaque Index,Gingival Index,Probing Depth,and Attechment Level in half-mouth examination had a good consistency with the full-mouth examination.In the present study,for the diagonal and ipsilateral combinations of the upper and lower quadrants (1+3 section,2+4 section,1+4 section,and 2+3 section),SBI by random half-mouth teeth method was similar to those by full-mouth examination (P＞0.05);while in GBI,the similarity between half-mouth and full-mouth examinations was observed in the diagonal combinations (P＞0.05).These results were consistent with a previous report.12

In conclusion,although full-mouth examination is accurate and comprehensive,and has obvious advantages over simplified index,it is not suitable for large-scale epidemiological survey of oral diseases.Despite the recommendation of WHO,the application of CPI as a substitute for full-mouth examination was not supported by the results of the present study.We suggest that different index teeth be selected depending on the purpose of survey so as to not only assesses both the incidence and severity of the disease correctly,but also improve the sensitivity and reduce the bias.Further studies are still needed to provide strong evidence to choose the teeth with the best features in large-scale epidemiological surveys.

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