|Year : 2018 | Volume
| Issue : 1 | Page : 17-20
Periodontal measurements: A dilemma
Shivani Singh, Kharidi Laxman Vandana
Department of Periodontics, College of Dental Sciences, Davanagere, Karnataka, India
|Date of Web Publication||3-Jul-2018|
Dr. Kharidi Laxman Vandana
Department of Periodontics, College of Dental Sciences, Davanagere - 577 004, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Periodontal measurements are not one-time diagnostic or multiple times prognostic measurements. The important issue pertaining periodontal measurement is to record them as measured and round them to nearest 0.5 mm or a whole number on probe.
Aim and Objective: To resolve this issue, a preliminary attempt is made in the clinical trial on interdental papillary deficiency (IDP) treatment by rounding and nonrounding the periodontal measurements during the 6-month follow-up period.
Materials and Methods: The present study was conducted in 35 interdental papillary deficient sites in eight systemically healthy controls of both sexes in the age group of 25–40 years. UNC 15 probe (Hu-Friedy, Chicago, USA) with modified stent was used to measure the IDP from the stent. First, the actual measurement of IDP (nonrounded measurement) was recorded, and second, the recorded measurement was rounded off to the nearest 0.5 mm.
Results and Conclusion: The current study result demonstrated that both the type of measurements showed no significant difference, suggesting the outcome measurements were similar whether nonrounded or rounded.
Keywords: Nonrounded measurements; periodontal measurements; rounded measurements
|How to cite this article:|
Singh S, Vandana KL. Periodontal measurements: A dilemma. Indian J Multidiscip Dent 2018;8:17-20
| Introduction|| |
The periodontium is an attachment apparatus involving tissues that support and invest the teeth. It consists of bone, periodontal ligament, cementum, and gingiva (Glossary of Periodontal Terms, 2001). Any disturbance to the periodontium may result in periodontal disease, which is a broad term describing a group of disorders that exacerbate an inflammatory response within the periodontium. The severity of periodontal damage can be categorized on the basis of the clinical attachment loss (CAL), gingival recession, and probing depth (PD). As an essential part of the periodontal examination, the CAL of the periodontium surrounding the tooth is measured by probing. The gain or loss in attachment reflects successful therapy or disease progression, respectively.
The use of a periodontal probe has limitations, and probing measurements may be affected by numerous factors. Probe-related factors include the accuracy of the marking intervals and the probe thickness. Examiner-related factors include the angle of the probe, force of probing, accuracy of the reference point, experience of the examiner, and probing pattern. Environmental factors include subgingival obstruction, root anatomy, the condition of the tissue at the deepest part of the pocket, and any pain provoked by probing.,,, To increase the measurement accuracy, the measurement error must be reduced.
Measurement of periodontal pocket depth, a key step in detection and analysis of periodontal diseases, is frequently affected by substantial uncertainty. Estimation of distance between gingival margin and connective ligament, an apparently straightforward measurement task routinely performed with simple probes, entails a fairly complex pattern of single and combined effects. The layout of marks on probe affects readings since when interpolation is involved, operator's experience comes into the picture. Compliance of tissues at pocket bottom implies dependence of probe penetration from insertion force, whose control again is affected by operator's experience. Hazy definition of gingival margin further contributes to scatter in results, liable to lead to diagnostic mistakes and wrong therapeutic decisions.
Periodontal measurements include pocket depth, clinical attachment level, gingival margin position (GMP), and gingival thickness (GT) measurement, etc. As said above, there are various factors which influence these measurements using a periodontal probe. These measurements are not one-time diagnostic or multiple times prognostic measurements. Various issues pertaining to these measurements are intraexaminer and interexaminer variability. The examiner is trained and calibrated to minimize the error. Another important issue pertaining periodontal measurement is to record them as measured and round them to nearest 0.5 mm or a whole number on the probe. Unfortunately, these suggestions are never being specific and clear as to round them to the nearest lower number or higher number markings on the probe. During diagnostic measurements, it is required to score the higher number when the reading lies between two markings of probe so as not to underestimate the disease condition and to treat appropriately. During prognostic measurements, the above suggestion may overestimate the results. Hence in such situations, score the lesser measurement when it lies between two markings.
The author of the paper who is a clinician and academician involved in several projects based on periodontal measurements was not sure of the advantage of rounding of measurement as it is least reasoned out in the literature. The search on this topic using keywords periodontal pocket depth, clinical attachment level, GT, GMP, whole measurement, and rounding of measurement provides no literature to depend on. Hence, the study was taken up with the aim to ascertain whether the periodontal measurements with or without rounding influence the study results.
The measurement of periodontal parameters using conventional periodontal probe is the gold standard from ester years despite the inherent problems associated with the markings and reading of these markings when subjected to measurement. Any measurement cannot be a whole number often. Either it will be between 2 mm markings or at a mark on the probe. In such cases, there are instances of rounding and nonrounding of periodontal measurements in periodontal literature. The visible anatomic landmarks such as gingival margin are easier to be read on periodontal probe unlike hidden cementoenamel junction (without recession) from any given reference point. The need of fixed reference point (FRP) regarding customized acrylic stent is a clinical adjunct to periodontal parameters measurement. The periodontal measurements read at FRP of the stent are much more reliable due to its visibility and accessibility than without it. During any clinical trial, the clinician's dilemma is whether to round or retain the same measurements (without rounding) during the follow-up (prognostic measurement). The outcome measurements are small in regarding1 mm fractions to more than 1 mm which are difficult to measure whether such measurements influenced by rounding were another dilemma. The conflicts in clinician mind whether the rounded and nonrounded measurements change the outcome interpretation. To resolve this issue, a preliminary attempt is made in the clinical trial on interdental papillary deficiency (IDP) deficiency treatment by rounding and nonrounding the periodontal measurements during the 6 months follow-up period.
| Materials and Methods|| |
The present study was conducted in 35 interdental papillary deficient (IDP) sites in eight systemically healthy controls of both sexes in the age group of 25–40 years. The study was strictly conducted in accordance with the Rajiv Gandhi University of Health Sciences (RGUHS) study protocol and approved by the Institutional Ethical Committee and Review Board (CODS/1977/2015-2016) of College of Dental Sciences, Davanagere, India, affiliated to RGUHS.
IDP measurement was performed at baseline, 1, 3, and 6 months using a modified stent (the interdental part of the stent was trimmed to the incisal edge from the labial side) to measure tip of papilla from reference point (apical extent of stent). The lower border of the stent was marked with black pen to facilitate the easy probe readings, i.e. the millimeter markings on the probe coinciding with the black pen mark were recorded from the apical portion of the stent to the tip of the papilla using UNC 15 probe (Hu-Friedy, Chicago, USA). First, the actual measurement of IDP (nonrounded measurement) was recorded [Figure 1], and second, the recorded measurement was rounded off to the nearest 0.5 mm. [Figure 2] Both the measurements were recorded at baseline, 1, 3, and 6 months. The data were subjected to statistical analysis using Students t-test.
|Figure 1: Nonrounding off of the measurement. The black mark of stent coincides the 3 mm marking of probe. Actual measurements were taken without rounding|
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|Figure 2: Rounding off of the measurements. The black mark of stent lies between 2 and 3 mm marking of probe. Measurement was rounded off to the nearest 0.5 mm|
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| Results|| |
In the current study, a total 35 sites were selected for interdental papillary measurement at baseline, 1, 3, and 6 months. The stent measurement of each site was recorded without rounding (nonrounded) and rounded off to the nearest 0.5 mm (rounded). In nonrounded group, measurement at baseline, 1, 3, and 6 months showed the values of 3.7 ± 1.3 mm, 3.2 ± 1.3 mm, 3.2 ± 1.1 mm, and 3.4 ± 1.2 mm, respectively, whereas in rounded off group, values were 3.7 ± 1.3, 3.2 ± 1.2, 3.2 ± 1.1, and 3.5 ± 1.2 mm at baseline, 1, 3, and 6 months, respectively. On the intergroup comparison between the nonrounded and rounded group, nonsignificant (P = 0.9) difference was found at different time intervals [Table 1].
|Table 1: Rounded and nonrounding of stent measurement of interdental papilla height|
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| Discussion|| |
Whether to round off or not to round off, the measurement is always a matter of discussion in periodontal measurements. Till our knowledge, this is the first study where the comparison was done between nonrounding and rounding measurements. In the previous studies, some authors have not rounded the periodontal measurements , whereas some had rounded to the nearest 1 mm , and nearest 0.5 mm.,, The discrepancy is due to limitations in the ability of our eyes to distinguish between such small intervals. In the current study, no statistical difference was found between rounded and nonrounded measurements.
There are some authors who had not rounded off the measurements to the nearest millimeter in their study. Vandana and Gupta 2016 evaluated the gingival margin position (GMP) before and after open flap debridement in different gingival thickness (GT), and the measurements were not rounded off to the nearest millimeter. In addition to other study by Shivani and Vandana, GT was measured in three different periods of dentition and nonrounded measurement was recorded.
The authors who had rounded the measurements to the nearest 1 mm were Kwon et al. and Thomson et al., Kwon et al. in 2016 examined the changes in the alveolar ridge width and the vertical levels of the interproximal bone and papilla following forced eruption. Periodontal examination included the PD and CAL. All measurements were performed with a periodontal probe (Hu-Friedy, Chicago, IL, USA), and the readings were rounded up to the nearest 1 mm. Thomson et al. recorded gingival recession and pocket depth using a National Institute of Dental Research probe. All measurements were rounded down to the nearest whole millimeter at the time of recording.
Some authors had rounded measurements to the nearest 0.5 mm. In Sethna et al. study, the pocket depth and clinical attachment level measurements were rounded to the closest 0.5 mm (up or down), and when the PD measurement was halfway between two marks on the probe, the closest millimeter immediately above the mark was recorded. In another study by Srinivas et al., the periodontal status of the study participants were assessed, and the readings were taken from the nearest mm with 0.5 mm, being the nearest, was rounded off to the lower whole number. Kolte et al. measured the papilla length relative to the alveolar crest. The actual papilla length was measured using Williams graduated probe. Measurements were rounded off to the nearest 0.5 mm.
Interexaminer reproducibility in periodontal measurement depends on type of probe, probe angulation, probe tip dimension, and pocket depth will also affect reproducibility. Errors in visual assessment, rounding off to the nearest millimeter, recording errors, variations in probe markings, and the patient cooperation must also be considered.
| Conclusion|| |
During any clinical projects, there was always a dilemma in the scientific mind to retain the measurements as recorded (without rounding) or round it because of literature information. The current study result demonstrated that both the type of measurements showed no significant difference, suggesting the outcome measurements were similar whether nonrounded or rounded. There is a need to confirm the preliminary study observation in a larger sample. The lack of studies on this issue whether nonrounding and rounding of period measurements indicate that so far this topic has not aroused a doubt on any clinician's mind. However, there is always a need to improving this day-to-day periodontal measurement recording by simple modification of periodontal probe. The rounding of measurements is a matter of convenience although such clinical suggestions are never addressed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]