CLINICAL EVALUATION OF GINGIVAL SULCUS DEPTH IN PRIMARY DENTITION BY COMPUTERIZED, PRESSURE- SENSITIVE FLORIDA PROBE

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1 GMJ GULF MEDICAL JOURNAL ORAL PROCEEDINGS CLINICAL EVALUATION OF GINGIVAL SULCUS DEPTH IN PRIMARY DENTITION BY COMPUTERIZED, PRESSURE- SENSITIVE FLORIDA PROBE Anukriti Pathak 1 *, B. Nandlal 2 1Specialist Pediatric Dentist & Adjunct Clinical Faculty, Thumbay Hospital, Dubai; 2 Head of Department, Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, JSS University, Mysore, Karnataka, India *Presenting Author ABSTRACT Introduction: Knowledge of the norms of gingival sulcus depth is essential for the assessment of the extent of periodontal detachment as well as in the treatment of the affected tissue. In the past, the gingival sulcus depth in primary dentition has been measured by conventional periodontal probes and indigenously designed probes for more precise measurements. The periodontal probing system Florida Probe incorporates the advantages of constant probing force, precise electronic measurements, and computer storage of data. Various studies have been conducted using the Florida Probe system in permanent dentition. Objective: The aim of the study is to clinically evaluate the gingival sulcus depth in primary dentition using Florida Probe. Materials & Methods: A single examiner recorded the gingival sulcus depth of the 20 primary teeth, at six sites on each tooth, with computerized, pressure-sensitive Florida Probe. Results: The mean gingival sulcus depth in primary dentition as measured by Florida Probe (0.2 mm precision) was found to be 1.20 mm with a standard deviation of 0.25 mm. Conclusion: Florida Probe could be a better alternative to conventional probes to measure the gingival sulcus depth not only in permanent dentition but also in primary dentition. The advantages of constant force probing, a smaller tip diameter, accurate precision, and acceptance by children render the method appropriate for evaluating the gingival sulcus depth in primary dentition. Keywords: Computerized pressure-sensitive Florida Probe, gingival sulcus depth, primary dentition Citation: Pathak A, Nandlal B. Clinical evaluation of gingival sulcus depth in primary dentition by computerized, pressure-sensitive Florida Probe. Gulf Medical Journal. 2016;5(S1):S43 S51. INTRODUCTION Periodontal diseases in adults are often traced to the early years of life. Gingival diseases found in primary dentition may progress to jeopardize the periodontium of permanent teeth 1. This has aroused considerable interest in the study of gingival and periodontal diseases in children. Early diagnosis is important for successful treatment. Hence, it is imperative that children Correspondence: Dr. Anukriti Pathak, Specialist Pediatric Dentist and Adjunct Clinical Faculty, Thumbay Hospital, Dubai, UAE. dranukritipathak@gmail.com receive periodontal examination as part of their routine dental visits 2. Measuring the gingival sulcus depth is among the prime criteria to determine the onset of periodontal diseases 3. The gingival sulcus is a shallow V shaped groove, bounded by the surface of the tooth on one side and the epithelial lining of the free gingival margin on the other side. It extends around the circumference of the tooth in the cervical region of the crown. The gingiva is attached to the tooth with the help of the junctional epithelium, located at the bottom of the gingival sulcus. The onset of periodontal disease is signified by the loss of attachment of the junctional 43

2 ANUKRITI PATHAK, B. NANDLAL epithelium from the tooth surface, resulting in a deepened gingival sulcus (also known as the periodontal pocket). Hence, measuring variation in the normal sulcus depth is critical in diagnosing periodontal disease. The knowledge of sulcus depth is also helpful in the restorative dentistry of primary teeth for the margin placement of the prefabricated crown below the marginal gingiva so that it does not impinge upon the epithelial attachment 3. The depth of the sulcus or tooth to be treated at the buccal margin should be measured as a baseline to properly trim the crown margins. As the buccal area presents the shallowest sulcus, a simple measurement would help determine how far apically the gingival margin of the crown should be placed to prevent damage to the gingival attachment 4. Thus, knowledge of the norms of gingival sulcus depth is essential not only for the assessment of the extent of periodontal detachment and in the treatment of the affected tissue but also for restorative procedures 3. Gingival sulcus depth has not been studied so extensively in primary dentition as in adult dentition. In 1966, Rosenblum et al. conducted a gingival sulcus depth study using a specially designed instrument on 29 children of 3 years to 6.2 years 5. It was found that the mean gingival sulcus depth for the entire primary dentition was 2.1 mm, with a range of 0.5 mm to 4.6 mm 5. Chawla et al. designed a new instrument made by various modifications in the amalgam carrier; they found the mean gingival sulcus depth to be 1.44 mm, with a range of 0.73 mm to 2.93 mm 3. Bimstein et al. evaluated gingival sulcus depth using a periodontal probe calibrated in millimeters 4. The average gingival sulcus depths around the primary maxillary and primary mandibular teeth were found to be 1.5 mm and 1.3 mm, respectively 4. In 2006, Gomes-Filho et al. evaluated the relationship among the age, gender, race, gingival width, and probing depth of primary teeth 6. The traditional method to record sulcus depth is using manual probing with a graduated periodontal probe. Because of the inaccuracy of manual pocket probing, in 1979, the National Institute of Dental Research (NIDR) in the US requested the development of more sensitive methods 7. The criteria were met by the Florida Research Group, which developed the Florida Probe system. It incorporates the advantages of constant probing force, precise electronic measurements, and computer storage of data 8. The present study is aimed at assessing the gingival sulcus depth in primary dentition by more sensitive methods, i.e., using computerized, pressure-sensitive Florida Probe, and evaluating the relationship among age, gender, and gingival sulcus depth. MATERIALS & METHODS The participants comprised 30 subjects (15 male and 15 female) aged 4 6 years who were randomly selected from JSS Public School in Mysore, India. They were classified into three groups (each with 10 subjects) on the basis of age and further (with five subjects each) on the basis of gender. Systemically healthy children with sets of firm primary teeth that had not undergone scaling and oral prophylaxis in the last six months were included in the study. The exclusion criteria comprised systemic disease; advanced gingivitis or gingival pathologies; pulpal pathogenesis; the evidence of caries at the buccal, lingual, or proximal surface; missing, supplementary, or mobile teeth; mixed dentition; malocclusion; parafunctional habits; and uncooperative children. During the first appointment, oral hygiene instructions were reinforced and recommendations were given for home use of fluoride-containing toothpastes and mouthrinsing solutions. The children were asked to perform oral hygiene measures under the supervision of their parents. The parents were offered an explanation of the study procedure; written informed consent was obtained from those who voluntarily agreed to have their children participate in the study. The study protocol described herein was approved by the college ethical committee concerning the use of human subjects in clinical examinations. 44

3 CLINICAL EVALUATION OF GINGIVAL SULCUS DEPTH IN PRIMARY DENTITION BY FLORIDA PROBE The subjects were recalled after seven days of reinforcement of oral hygiene instructions. A thorough history and complete dental examination were conducted on the recall appointments. Dental caries was recorded according to the Modified Møller s Index (1966) on a computerized proforma 9. The examination was only clinical. Subjects with dental caries grades 0, 1, and 2 at the occlusal surface, but with no evidence of caries at the buccal, lingual, and proximal surface were considered for the study. The Plaque Index (PI) of Silness and Löe (1964) was used to record the plaque 10, 11. Subjects with plaque scores of 0 and (excellent or good) were considered for the study. The Gingival Index (GI) of Löe and Silness (1967) was used to record gingival inflammation 11, 12. Subjects with scores of (healthy gingiva or mild gingivitis) were included in the study. The subjects were balanced for caries, gingivitis, and plaque using the Dental Caries Index, Gingival Index, and Plaque Index, respectively, for all age groups and genders. A custom-made occlusal stent was prepared for the maxillary and mandibular arches. The stent was prepared with self-cure clear resin using the sprinkle-on method on a cast model obtained from an alginate impression of each subject. It was created in a way that it covered the occlusal/incisal one-third on the buccal and lingual sides (thickness of about 2 3 mm). Vertical grooves were made on the stent using a straight fissure bur and contra-angled micromotor handpiece to guide the probes at six sites on each tooth: mesio-buccal (MB), mid-buccal (B), disto-buccal (DB), mesio-lingual (ML), mid-lingual (L), and disto-lingual (DL). The stent was made to fit on the occlusal/incisal surfaces of the teeth, and measurements were made using Florida Probe by placing it in the groove made on the stent. Measurement of Gingival Sulcus Depth with Florida Probe System FP32 version with PD/CEJ standard probe tips (Florida Probe Corporation, Gainesville, USA) were used in this study 13. The Florida Probe system comprises a probe handpiece, displacement transducer with digital readout, foot switch, computer interface, and personal computer. Study Conducted Using Florida Probe System as per Manufacturer s Instructions A single examiner recorded the gingival sulcus depth in 30 subjects (15 male and 15 female) using the Florida Probe system 13. The subjects were made to wear the occlusal stent. Pocket depth was measured at six sites per tooth: three facial and three lingual. To measure pocket depth, the tip of the probe was placed at the base of the sulcus, and the sleeve was brought to the gingival margin. As confirmed by the manufacturers, no changes were required to be made to the angulation or probing pressure of Florida Probe for the primary dentition. Florida Probe Pocket Depth Handpiece products, with a normal tip length of 10.8mm, were used 13. The tips were made from implant-grade titanium and marked with 3 mm, 6 mm, and 9 mm blue bands for visual reference. They were 0.45 mm in diameter and had a straight wire design with a flat bottom and rounded corners. The standard model of the Florida Probe system comes with a 15 gm probing force set in the encoder 13. The Florida Probe software is designed for a maximum of 32 adult teeth. However, the missing tooth mode of the software was used to remove the molar teeth from each subject (leaving 20 teeth totally), to represent the primary teeth set found in children. Data entered directly from the Probe Handpiece products was recorded at 0.2 mm precision (1.2 mm, for example). It is expected that the higher precision numbers obtained from the Florida Probe data would help with increased accuracy and precision over manual probing. Statistical Analysis Statistical calculations were performed using the SPSS software for Windows, Version 16.0 (Statistical Presentation System Software, SPSS Inc., New York). The one-way analysis of variance (ANOVA) procedure was carried out for each tooth type for the purpose of 45

4 ANUKRITI PATHAK, B. NANDLAL comparing any variations in gingival sulcus depth in the age groups of 4, 5, and 6. An independent sample t-test was performed for each tooth type for comparison between genders. A paired sample t-test was conducted for each tooth type to compare the maxillary and mandibular arches. Repeated measures ANOVA was performed in both males and females to compare the differences in the mean values of the gingival sulcus depth between the buccal and lingual surfaces for each tooth type. The significance levels were fixed at 5%, i.e., the 0.05 (significant), 0.01 (significant), or (highly significant) levels. Any probability value above 0.05 was considered nonsignificant. RESULTS Table 1 displays the descriptive data pertaining to the distribution of subjects according to age and gender. Table 1. Distribution of subjects according to age and gender Age groups No. of subjects Gender No. of teeth No. of sites Females Males N n Total Table 2. Age-wise variation of mean gingival sulcus depth by type of primary teeth Tooth Age N n Mean S. D. p value Maxillary central incisor * Mandibular central incisor Overall teeth S. D. Standard deviation, *<0.05 Significant 46

5 CLINICAL EVALUATION OF GINGIVAL SULCUS DEPTH IN PRIMARY DENTITION BY FLORIDA PROBE Significant variations in probing depth were observed among the three age groups for the maxillary second molar. The results were found to be non-significant for all the teeth (Table 2). Females were found to have significantly (p < 0.05) greater sulcus depth for the maxillary central incisors and mandibular second molars. The difference between the overall teeth of males and females was observed to be highly Table 3. Gender-wise variation of mean gingival sulcus depth by type of primary teeth significant (p < 0.001), with females having greater sulcus depth than males (Table 3). Significant differences (p < 0.05) in probing depth were observed for the central incisors. The mean of the probing depth for the maxillary arch was greater than that for the mandibular arch, though not statistically significant (Table 4). Tooth Gender N n Mean S. D. p value Maxillary central incisor M F * M F M F M F M F Mandibular central incisor M F M F M F M F M F * Overall teeth M F *** ***<0.001 Highly significant; *<0.05 Significant Table 4. Arch-wise variation of mean gingival sulcus depth by type of primary teeth Tooth Arch N n Mean S. D. P value Central incisor Maxillary Mandibular * Maxillary Mandibular Maxillary Mandibular Maxillary Mandibular Maxillary Mandibular Overall teeth Maxillary Mandibular *<0.05 Significant 47

6 ANUKRITI PATHAK, B. NANDLAL The overall mean of the gingival sulcus depth for primary teeth in females was 1.24 ± The mean values of the gingival sulcus depth at the buccal and lingual surfaces in each tooth type are mentioned in Table 5. In females, the buccal sulcus depth was found to be shallower than the lingual sulcus depth (nonsignificant difference) for the maxillary central incisors, maxillary lateral incisors, maxillary second molars, mandibular canines, and mandibular second molars. The buccal sulcus depth was observed to be significantly shallower for the maxillary and mandibular first molars. It was found that the buccal sulcus depth was significantly deeper than the lingual sulcus depth for the mandibular central and lateral incisors. It was also deeper for the maxillary canine, but the difference was nonsignificant. The mean of the gingival sulcus depth for primary teeth in males was found to be 1.16 ± The mean values of the gingival sulcus depth at the buccal and lingual surfaces in each tooth type are mentioned in Table 6. In males, the buccal sulcus depth was observed to be shallower than the lingual sulcus depth for the maxillary lateral incisors and first molars with a non-significant difference. The buccal sulcus depth was significantly shallower for the maxillary central incisors and mandibular first molars. The buccal sulcus depth was significantly deeper than the lingual sulcus depth for the maxillary canines. It was also deeper for the maxillary second molars, mandibular central incisors, lateral incisors, canines, and second molars, but the difference was non-significant. The mean gingival sulcus depth for the entire primary dentition was found to be 1.20 ± 0.25 mm. The mean values of the gingival sulcus depth in each primary tooth type are mentioned in Table 7. Table 5. Mean gingival sulcus depth at buccal and lingual surfaces by type of primary teeth in females Tooth type Maxillary Mandibular Buccal Lingual Buccal Lingual Central incisor Table 6. Mean gingival sulcus depth at buccal and lingual surfaces by type of primary teeth in males Tooth type Maxillary Mandibular Buccal Lingual Buccal Lingual Central incisor Table 7. Mean gingival sulcus depth in primary dentition Tooth type Maxillary Mandibular Mean S. D. Mean S. D. Central incisor

7 CLINICAL EVALUATION OF GINGIVAL SULCUS DEPTH IN PRIMARY DENTITION BY FLORIDA PROBE Figure 1. Measuring gingival sulcus depth with Florida Probe Figure 2. Child undergoing Florida Probe examination DISCUSSION A growing amount of research and data emphasize the relevance of the prevention, early diagnosis, and early treatment of periodontal diseases in children. To avoid erroneous diagnoses and unnecessary treatments, the pediatric dentist is required to differentiate between the pathologic processes and normal changes that occur in the periodontium with age 14. The conventional periodontal probe is the standard instrument used for the assessment of probing depth and the clinical attachment level. However, other probes have been introduced to reduce probing errors typically associated with conventional probing. Florida Probe may have some advantages over a conventional probe. Florida Probe applies constant, standardized force during measurement. The system incorporates the use of computer software and a footswitch for efficient data capture, which eliminates transcribing problems. This could reduce bias since examiners would have no knowledge of the measurements obtained using Florida Probe. The 0.2 mm resolution of measurement attainable with Florida Probe eliminates the need for rounding to a higher or lower value. Because of this level of resolution, normal distributions would be more closely approximated, likely reflecting changes in measurement over time. This contrasts the stepfunction of the whole millimeter differences created with conventional probe measurements. Decisions for change might therefore be made at lower cut-off points with Florida Probe than with a conventional probe

8 ANUKRITI PATHAK, B. NANDLAL Age-wise Variation of Mean Gingival Sulcus Depth In the present study, the gingival sulcus depth was observed to increase from the ages of 4 years to 6 years, but the results were significant only for the maxillary second molars. This is contrary to the findings of Gomes-Filho et al., wherein the gingival sulcus depth was found to increase on the basis of age from 4 to 6 years 6. The results were significant in the majority of the teeth. Gender-wise Variation of Mean Gingival Sulcus Depth In the present study, the mean gingival sulcus depth was observed to be greater in females than males, but significant differences were found only for the maxillary central incisors and mandibular second molars. Gomes-Filho et al. did not demonstrate significant gender differences in the majority of the teeth 6. The mean gingival sulcus depth was found to be greater in males than females in a study by Chawla et al., but the difference was noted as statistically insignificant 3. Mean Values of Gingival Sulcus Depth in Primary Dentition In the present study, the mean gingival sulcus depth in primary dentition was noted as 1.20 ± 0.25 mm. The readings were found to be close to those of other studies. Ainamo et al. observed an average gingival sulcus depth of 1 mm in 20 children aged 3 to 10 years 16. Chawla et al., who reported the mean depth as 1.44 mm with a range of 0.73 mm to 2.93 mm, also used a new instrument reading to one-tenth of a millimeter 3 Gomes-Filho et al. noted the probing depth in primary dentition was from 1.03 ± 0.91 mm to 2.08 ± 0.07 mm 6. Conversely, Rosenblum et al. observed higher values of 2.1 mm with a range of 0.5 mm to 4.6 mm 5. The mean gingival sulcus depth in both males and females increased gradually from the primary central incisor to primary second molar (in both the maxillary and mandibular arches) except in the primary first molar, wherein the depth was lesser than in the primary canine (Table 3). These results were in accordance with Chawla et al., Rosenblum et al., and Bimstein et al, who reported similar patterns in their studies 3 5. The shallowest sulcus depth for the first primary molar may be due to the special configuration of the buccal bulge in the tooth. Table 4 indicates the mean gingival sulcus depth for the maxillary teeth (1.22 ± 0.27 mm) was more than that for the mandibular teeth (1.18 ± 0.24 mm). This result was in accordance with the study by Bimstein et al., wherein the average sulcus depth was found to be 1.5 mm around the maxillary teeth and 1.3 mm around the mandibular teeth 4. The fact that the maxillary teeth had a greater sulcus depth than the mandibular teeth may be explained by the differences in the ages of tooth eruption and the eruption process itself. The difference in the gingival sulcus depth at the buccal and lingual surfaces (Tables 5 and 6) may be due to the difference in the tooth morphology of each tooth type and their alignment in the arch. In their study, Newman et al. reported the mean gingival sulcus depth in permanent dentition to be 1.8 mm 1. In the present study, the mean gingival sulcus depth for primary teeth was found to be 1.20 mm. It was observed that the gingival sulcus depth for primary teeth was lesser than for permanent teeth. Similar findings have been reported in other studies. The presence of shallow gingival sulcus in primary dentition may be due to the small size of teeth and jaws, and a less powerful musculature in children. Knowledge of the gingival sulcus depth is helpful in restorative dentistry for primary teeth for the margin placement of a prefabricated crown below the marginal gingival so that it does not impinge upon the epithelial attachment 4. In the present study, the gingival sulcus depths at the three buccal sites of the maxillary and mandibular first molars in females were noted to be 1.23 mm and 1.05 mm (MB), 0.90 mm and 0.81 mm (B), and 1.09 mm and 1.09 mm (DB), respectively. The gingival sulcus depths at the three buccal sites of the maxillary and mandibular first molars in males were 50

9 CLINICAL EVALUATION OF GINGIVAL SULCUS DEPTH IN PRIMARY DENTITION BY FLORIDA PROBE observed to be 1.29 mm and 0.94 mm (MB), 0.89 mm and 0.78 mm (B), and 1.01 mm and 1.03 mm (DB), respectively. The B (mid-buccal) site presents the shallowest sulcus at the buccal margin; the crown margins should be trimmed according to the mid-buccal measurement of the gingival sulcus depth to prevent damage to the gingival attachment. The current study offers cross-sectional data; however, longitudinal studies are required to evaluate the age variations in the gingival sulcus depth in primary dentition. These norms may not be applicable for an individual case, but should be taken into consideration for the diagnosis and treatment of periodontal diseases and restorative procedures. One of the drawbacks of the study is its sample size; a larger epidemiological survey is required to represent the population to establish the norms of the gingival sulcus depth in primary dentition. The present study strongly suggests that Florida Probe could be a better alternative to conventional probes to measure the gingival sulcus depth not only in permanent dentition but also in primary dentition. The advantages of constant force probing, a smaller tip diameter, accurate precision, and acceptance by children render the method appropriate for evaluating the gingival sulcus depth in primary dentition. REFERENCES 1. Newman MG, Takei HH, Carranza FA. Carranza s Clinical Periodontology. 9th ed. Philadelphia: W.B. Saunders Company; Califano JV; American Academy of Periodontology--Research, Science and Therapy Committee; American Academy of Pediatric Dentistry. Periodontal diseases of children and adolescents. Pediatr Dent ;27(7 Suppl): Chawla HS, Vacher BR, Taneja JR. Clinical evaluation of depth of gingival sulcus of primary teeth. J Indian Dent Assoc. 1973;45(7): Bimstein E, Eidelman E. Dimensional differences in the attached gingiva and gingival sulcus in the mixed dentition. ASDC J Dent Child. 1983;50(4): Rosenblum FN. Clinical study of the depth of the gingival sulcus in the primary dentition. J Dent Child. 1966;33(5): Gomes-Filho IS, Miranda DA, Trindade SC, de Souza Teles Santos CA, de Freitas CO, da Cruz SS, et al. Relationship among gender, race, age, gingival width, and probing depth in primary teeth. J Periodontol. 2006;77(6): Gibbs CH, Hirschfeld JW, Lee JG, Low SB, Magnusson I, Thousand RR, et al. Description and clinical evaluation of a new computerized periodontal probe--the Florida Probe. J Clin Periodontol. 1988;15(2): Eley BM, Cox SW. Advances in periodontal diagnosis. 2. New clinical methods of diagnosis. Br Dent J. 1988;184(2): Moller IJ. Clinical criteria for the diagnosis of the incipient carious lesion. Adv Fluorine Res. 1966;4: Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand. 1963;21: Loe H. The gingival index, the plaque index and the retention index systems. J Periodontol. 1967;38(6): Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand. 1964;22: Florida Probe User Manual. Version Gainesville: Florida Probe Corporation; Bimstein E, Matsson L. Growth and development considerations in the diagnosis of gingivitis and periodontitis in children. Pediatr Dent. 1999;21(3): Osborn JB, Stoltenberg JL, Huso BA, Aeppli DM, Pihlstrom BL. Comparison of measurement variability in subjects with moderate periodontitis using a conventional and constant force periodontal probe. J Periodontol. 1992;63(4): Ainamo J, Loe H. Anatomical characteristics of gingiva: a clinical and microscopic study of the free and attached gingiva. J Periodontol. 1966;37(1):