|Year : 2016 | Volume
| Issue : 3 | Page : 104-109
Evaluation of the prevalence and distribution of bone defects associated with chronic periodontitis using cone-beam computed tomography: A radiographic study
Maya Sanjeev Indurkar, Renu Verma
Department of Periodontology, Government Dental College and Hospital, Aurangabad, Maharashtra, India
|Date of Web Publication||7-Mar-2017|
Department of Periodontology, Government Dental College and Hospital, Aurangabad, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: Evaluation of the prevalence and distribution of bone defects associated with chronic periodontitis using cone-beam computed tomography (CBCT). Materials and Methods: CBCT of 100 patients diagnosed with generalized chronic periodontitis was evaluated for the prevalence and distribution of bone defects based on age groups (<30, 31–39, 40–49, and >50 years), jaw segments, and gender. Results: The prevalence and distribution of bone defects associated with different age groups, jaw segments, and gender was evaluated. Out of 2484 teeth which were examined, 2064 teeth were having bone defect; therefore, the prevalence of bone defects was 83.1%. The degree of bone loss was 57.8% in males and 42.2% in females. Severity of bone defects increases with age. The study showed that bone defects were more in maxillary arch than mandibular and more in posterior segments than the anterior segments. Conclusion: CBCT can assess early detection of periodontal disease, thereby applying all primary preventive measures for periodontal disease. It gives a clear understanding of the morphology of alveolar bone loss in chronic periodontitis patients which helps design appropriate regenerative periodontal therapy, thereby preventing tooth mobility and tooth loss.
Clinical Relevance to Interdisciplinary Dentistry
It is necessary to study the prevalence and distributions of different bone defects by localization as variation in the occurrences of defects is present in the same mouth. It may also provide the clues in determining the pathology behind the particular pattern of occurrences of defects in different segments. according to literatue, as CBCT is accurate as clinical measurement, it can be used for evaluating prevalence and distribution of bone defects
Keywords: Bone defect, cone-beam computed tomography, chronic periodontitis, prevalence
|How to cite this article:|
Indurkar MS, Verma R. Evaluation of the prevalence and distribution of bone defects associated with chronic periodontitis using cone-beam computed tomography: A radiographic study. J Interdiscip Dentistry 2016;6:104-9
|How to cite this URL:|
Indurkar MS, Verma R. Evaluation of the prevalence and distribution of bone defects associated with chronic periodontitis using cone-beam computed tomography: A radiographic study. J Interdiscip Dentistry [serial online] 2016 [cited 2019 Sep 15];6:104-9. Available from: http://www.jidonline.com/text.asp?2016/6/3/104/201647
| Introduction|| |
Periodontal disease is characterized by periods of disease activity, in which dental support structures are destroyed by the action of chemical mediators of inflammation followed by periods of latency. Progression of periodontal disease causes attachment loss, alveolar bone loss, and consequent tooth mobility. These characteristics, associated with the complexity of the disease, grant importance to the use of imaging methods in the detection of such alterations.Radiography plays an important role in periodontal diagnosis mainly because radiographs can reveal the amount and type of damage caused to the alveolar bone., Current approaches to diagnose periodontal disease include probing of gingival tissues and radiographs to evaluate osseous support. Unfortunately, radiographic methods are severely limited by the inherent overlay of anatomic structures and the difficulty to reproduce angles over time. There is ample research demonstrating that funnel-shaped or lingually located defects cannot be detected  and that destruction of the buccal plate can be undiagnosed or undistinguished from lingual defects. Further studies comparing radiographs to presurgical measurements concluded that bone loss can be underestimated by 1.5 mm, with large variations between examiners. Consequently, traditional radiography remains a limited diagnostic tool.
Computed tomography (CT) has been explored because of its capacity to perform precise three-dimensional (3D) registrations, but this technique has some limitations, such as the amount of radiation exposure and equipment size and cost. Recently, cone-beam CT (CBCT) has emerged as a feasible tool in dentistry, providing a lower cost alternative to conventional CT with high-quality images and lower radiation exposure to patients. There are, however, some important disadvantages as well, such as susceptibility to movement artifacts, amalgam and metallic restoration artifacts, low-contrast resolution, limited capability to visualize internal soft tissues, and owing to distortion of Hounsfield units, CBCT cannot be used for the estimation of bone density.
There are few studies conducted on the prevalence and intraoral distribution of infrabony lesions. The objective of the present study was to evaluate the prevalence and distribution of bone defects associated with chronic periodontitis using CBCT in relation to age, sex, arch, and segments so that the prognosis of treatment of bony lesions can be assessed.
| Materials and Methods|| |
The study was designed and conducted in the Department of Periodontics, Government Dental College and Hospital, Aurangabad. The study was approved by the Institutional Ethical Committee. In the study, CBCT (maxilla and mandible) of 100 patients who were already diagnosed with generalized chronic periodontitis was used. Patients were divided into four different age groups: <30, 31–39, 40–49, and >50 years. CBCT images with unclear visibility of anatomical landmarks that is cementoenamel junction (CEJ), alveolar bone crest, or tooth apex were excluded from this study. CBCTs were obtained using CS 9300 3D digital imaging system from Carestream Dental. Data were acquired using 14 s scanning time at 88 KVp and 8 mAs exposure, with voxel size of 250 µm and field of view of 17 cm × 11 cm. Carestream Dental's CS 3D Imaging Software [Figure 1] was used to evaluate the bone defects. The CBCT software had an electronic measuring tool to the nearest hundredth of a millimeter. All the bone defects were measured and evaluated by a single examiner.
In the present study, classification of bony defects given by Papapanou et al. (2000) was used, which differentiated bone defects into:
- Suprabony defects (SB)
- Infrabony defects (IB)
- Interradicular defects (IR).
For classifying the intrabony defects (IT), we used classification system by Goldman and Cohen (1958) which classified the IT defects into:
- Combined bone defects (CB).
Other bone defects (OB) were classified by their topography as:
- Bulbous bone contour (BB)
- Reversed architecture (RA)
- Dehiscence (DH).
Two thousand and four hundred eighty-four teeth were evaluated. In the case of horizontal defects, the defect depth was measured as distance between the CEJ and the alveolar crest (AC). In the case of vertical defects, the defect depth was measured as distance between the CEJ and the base of the defects [Figure 2]. A measurement >2 mm between the CEJ and the AC was adopted to indicate the presence of periodontal bone loss for this study.
In addition, in the case of multirooted teeth, the potentially existing radiological furcation involvement was examined by identifying the furcation upper boundary and furcation lower boundary [Figure 3], and was classified as Subclass A, B, and C according to the classification system by Tarnow and Fletcher (1984), where he added the vertical component to the diagnosis of furcation involvement. Subclass based on the vertical bone resorption from the furcation fornix was added.
|Figure 3: Furcation involvement = Distance from furcation upper boundary to furcation lower boundary|
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- Subclass A: Denotes furcation involvements with vertical bone loss of 3 mm or less
- Subclass B: Denotes furcation involvements with vertical bone loss from 4 to 6 mm
- Subclass C: Presents with bone loss from the fornix of 7 mm or more.
The SB, IB, and OB defects were considered as absolute defects while IR defects were considered as relative defects because IR defects do not depict a particular bone lesion or defect rather they represent the stage in progress of periodontitis, i.e., once the periodontal disease progresses or its severity increases, it is bound to erode the bone between the multirooted teeth and involve the furcation. The data were collected, and master chart was prepared which included the distribution of all the defects. The data from master chart were segregated and tabulated in relation to age, sex, arch, and segments.
| Discussion|| |
CBCT imaging technique is based on a cone-shaped X-ray beam centered on a two-dimensional (2D) detector that performs one rotation around the object, producing a series of 2D images. These images are reconstructed in 3D using a modification of the original cone-beam algorithm developed by Feldkamp et al. in 1984. A more accurate evaluation of alveolar bone height in relation to the CEJ is the primary benefit of radiologic examination in periodontal diagnosis. We evaluated 2484 teeth, out of these 2064 teeth were having bone defect; therefore, the prevalence of bone defects was 83.1%. The degree of bone loss was 57.8% in males and 42.2% in females.
In the present study, [Table 1] shows that the occurrence of SB > IB > OB defects. Study by Persson et al. (1998) was in agreement with the present study, and they found horizontal bone defects to be 91% and vertical bone defects were 9% on radiographic examination. The pattern of distribution that horizontal bone defects were dominant than vertical bone defects was similar to the present study.
|Table 1: Prevalence and distribution of suprabony, infrabony, and other bone defect|
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Among all the IB defects, CR comprised 45% and IT defects comprised 55% [Table 2]. Interdental crater was the most common IB confirms the previous studies by Saari et al. (1968), Manson and Nicholson (1974),, Tal (1984), Vrotsos et al. (1999), and Suefang Kung Wu et al. (2001). In the present study, CR accounted almost half of the total IB defects, which was in agreement with the findings of Vrotsos et al. (1999). While Manson and Nicholson (1974) found that craters represented one-third of all the defects, which is in contrast with our finding.
In the present study, among the IT defects, the prevalence of defects was 2-wall > 3-wall > 1-wall > CB defect [Table 3]. While in the study by Tal H (1984), it was found that among IT, the prevalence of defects was 2-wall > 1-wall > 3-wall defect. Hence, it could be appreciated that 2-wall defect was the dominant defect for both the studies, but there was difference in sequence of other IT defects which might be due to different study design and study population.
In [Table 4], it was inferred that DH > RA > BB [Figure 4].
From [Table 5], it can be inferred that Subclass A > B > C IR defect. Subclass A IR defect comprised half of the IR defects. This finding was also in agreement with most epidemiological surveys which have shown a positive correlation between aging and severity of periodontal disease.
Destructive periodontal disease has been so consistently associated with aging that many authors in the past came to see it as inevitable consequence of growing older. In the present study, patients were segregated into different age groups: <30, 31–39, 40–49, and > 50 years. In [Table 6], it was seen that the prevalence of SB defects for age groups < 30, 31–39, and 40–49 years was similar, but it decreased in age group > 50 years. While IB defects were less for <30 years, were similar for age groups 31–39 and 40–49 years, but they increased for age group >50 years. IT defects increased with aging; this finding of present study was in agreement with the finding of Nielson et al. (1979).
|Table 6: Prevalence and distribution of suprabony, infrabony, and other bone defect according to age|
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In the present study, from [Table 7], it was observed that the severity of IR defects increased with age. This corresponded with studies by Larato (1970) and Svärdström and Wennström (1996). Hence, it can be inferred that as the age increases, severity of IR defects increases, i.e., Subclass A and B IR defect increases.
|Table 7: Prevalence and distribution of relative defects (interradicular) according to age|
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The differences in occurrences of defects were assessed for both males and females to evaluate the variations, if present, in patterns of bone defects among two different sexes. [Table 8] shows that the occurrences of defects were similar for both males and females. Findings of Nielson et al. (1980) were similar to the findings in the present study that there was no statistically significant difference between the prevalence and distribution of defects in males and females.
|Table 8: Prevalence and distribution of absolute defects (suprabony, infrabony, and other bone defect) according to sex|
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[Table 9] shows that the order of prevalence of IR defects in descending order was Subclass A > B > C both for males and females. This finding was in accordance with the study by Svärdström (1996). They also had no significant sex difference in interradicular bone defects, but the severity or advanced furcation involvement was more for men.
|Table 9: Prevalence and distribution of relative defects (interradicular) according to sex|
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It was necessary to study the prevalence and distributions of different bone defects by localization as variation in the occurrences of defects is present in the same mouth. It may also provide the clues in determining the pathology behind the particular pattern of occurrences of defects in different segments. The prevalence and distribution of absolute defects (SB, IB, and OB defects) in four different segments was explored (1010) for maxillary anterior, mandibular anterior, maxillary posterior, and mandibular posterior. From [Table 10], it was observed that the prevalence of defects was highest for maxillary posterior followed by mandibular posterior; thereafter, the maxillary anterior and the lowest prevalence was for the mandibular anterior.
|Table 10: Prevalence and distribution of absolute defects (suprabony, infrabony, and other bone defect) according to segments|
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However, the satisfactory results of the present investigation could serve as guidelines for clinical treatment. Future studies should be conducted to explore the correlation of CBCT with clinical examination to obtain a more accurate diagnosis, thus leading to a correct therapeutic choice in the treatment of both the disease and periodontal bone injury.
| Conclusion|| |
In present study, analysis of CBCT of 100 patients having chronic periodontitis was performed. The prevalence and distribution of bone defects associated with different age groups, jaw segments, and gender was evaluated. Out of 2484 teeth which were examined, 2064 teeth were having bone defect; therefore, the prevalence of bone defects was 83.1%. The degree of bone loss was 57.8% in males and 42.2% in females. Severity of bone defects increases with age. The study showed that bone defects were more in maxillary arch than mandibular and more in posterior segments than the anterior segments. CBCT can assess early detection of the periodontal disease, thereby applying all primary preventive measures for periodontal disease. It gives a clear understanding of the morphology of alveolar bone loss in chronic periodontitis patients which helps design appropriate regenerative periodontal therapy, thereby preventing tooth mobility and tooth loss. Future studies should be conducted correlating CBCT with clinical examination in evaluating the prevalence and distribution of bony defects which will help in planning appropriate periodontal therapy in patients with chronic periodontitis.
I express my sincere gratitude to Dr. S. P. Dange (Dean, Government Dental College and Hospital, Aurangabad) for his kind permission and support in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vandenberghe B, Jacobs R, Yang J. Detection of periodontal bone loss using digital intraoral and cone beam computed tomography images: An in vitro
assessment of bony and/or infrabony defects. Dentomaxillofac Radiol 2008; 37:252–260.
Armitage GC. The complete periodontal examination. Periodontology 2000. 2004;34:22–33.
Brägger U. Radiographic parameters: Biological significance and clinical use. Periodontol 2000 2005;39:73-90.
Ramadan AB, Mitchell DF. A Roentgenographic study of experimental bone destruction. Oral Surg Oral Med Oral Pathol 1962;15:934-43.
Rees T, Biggs NL, Collins CK. Radiographic interpretation of periodontal osseous defects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1971;2:141-53.
Eickholz P, Hausmann E. Accuracy of radiographic assessment of interproximal bone loss in intrabony defects using linear measurements. Ur J Oral Sci 2000;108:70-3.
Hirschmann PN. Radiographic interpretation of chronic periodontitis. Int Dent J 1987;37:3-9.
Misch KA, Yi ES, Sarment DP. Accuracy of cone beam computed tomography for periodontal defect measurements. J Periodontol 2006;77:1261-6.
Alshehri AD, Alamri HM, Alshalhoob MA. CBCT applications in dental practice: A literature review. Oral and maxillofacial surgery. 2010;36:26-86.
Papapanou PN, Tonetti MS. Diagnosis and epidemiology of periodontal osseous lesions. Periodontology 2000;22:8-21.
Goldman HM, Cohen DW. The infrabony pocket: Classification and treatment. J Periodontol 1958; 29: 272- 291.
Karn KW, Shockett HP, Moffitts WC, Gray JL. Topographic classification of deformities of alveolar process. J Periodontol 1984;55:336-40.
Hans-Peter Müller, Martin Ulbrich. Alveolar bone levels in adults as assessed on panoramic radiographs. (I) Prevalence, extent, and severity of even and angular bone loss. Clin Oral Invest 2005;9:98-104.
Fukuda CT, Carneiro SR, Alves VT, Pustiglioni FE, De Micheli G. Radiographic alveolar bone loss in patients undergoing periodontal maintenance. Bull Tokyo Dent Coll 2008;49:99-106.
Fleiner J, Hannig C, Schulze D, Stricker A, Jacobs R. Digital method for quantification of circumferential periodontal bone level using cone beam CT. Clin Oral Investig 2013;17:389-96.
Tarnow D, Fletcher P. Classification of the vertical component of furcation involvement. J Periodontol 1984;55:283-4.
Lorato DC. Furcation involvements: Incidence and distribution. J Periodontol 1970;41:499-501.
Persson RE, Hollender LG, Laurell L, Persson GR. Horizontal alveolar bone loss and vertical bone defects in an adult patient population. J Periodontol 1998;69:348-56.
Saari JT, Hurt WC, Bigg NL. Periodontal bony defects on the dry skull. J Periodontol 1968;39:278-83.
Manson JD, Nickolson K. The distribution of bone defects in chronic periodontitis. J Periodontol 1974;45:88-92.
Manson JD. Bone morphology and bone loss in periodontal disease. J Clin Periodontol 1976;3:14-22.
Vrotsos JA, Parashis AO, Theofanatos GD, Smulow JB. Prevalence and distribution of bone defects in moderate and advanced adult periodontitis. J Clin Periodontol 1999;26:44-8.
Tal H. The prevalence and distribution of intrabony defects in dry mandibles. J Periodontol 1984;55:149-54.
Neilsen IM, Glavind L, Karring T. Interproximal periodontal intrabony defects: Prevalence, localization and etiological factors. J Clin Periodontol 1980;7:187-98.
Svardstrom G, Wennstrom JL. Prevalence of furcation involvements in patients referred for periodontal treatment. J Clin Periodontol 1996;23:1093-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]