supe rirnp OS ed over fhelow

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pnwimal bane meosuien on Ihe mesial surfoce of I
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Bone Loss in Untreated
Periodontal Disease:
A Longitudinal Study
William Becter,
D.D.S, M S.D.
Burton E. Beclter,
D.D.S.
Mr. Lawrence Berg
/Address.
WJIiom Eeclcer, D.D.S.
SOI North Wilmo(
Rood, Sui(e B2
Tucson, A ; S57IÍ
Dental radiographs are used rou-
tinely in establishing a diagnosis of
periodontol diseose. Severol inves-
tigotors hove established the accu-
racy of using bone score measure-
ments in determining interproximal
bone levels. Ramfjord has suggested
thot bone scores can be a valuable
supplement to the accurate clinical
measurement of attachment levels.**
In 1978 we reported our findings on
thirty diagnosed but untreated perio-
dontol patients. These findings were
observed for time periods ranging
from 18 to 115 months. Each patient
had a minimum of two examinations.
25
Our findings dealt with the effecfs of
untreated periodontal diseases on
toath mortality, pocket depth chang-
es and changes in mobility.^
Materials and Methods
V^e thought it might be interesting to
measure bone scores in the untreat-
ed periadontal disease study popu-
lation. This study will present our
findings with respect to bone score
changes in 27 diagnosed but un-
treated periodontal patients. The
patients consisted of 15 male and 12
female patients. The ages ranged
from 25 to 71 years, with a mean
age of 44.6 years.
Fifty-four sets of 18 to 20 periapical
films were examined. The films were
taken with the long-cone technique.
At the second examinations an effort
was made to duplicate the angula-
tions used during the initial examina-
tions. All films were taken at 90
kilovolts (peak) ond 15 milliamperes,
ond were processed using standard
darkroom procedures.
The bone scores were measured
using a technique similar to that
described by ß/orn. Hailing ond Tby-
burg.^ A scale was drawn with black
ink on white cordboard. The coronal
and inferior base lines were 15 inch-
es in length. The short sides were 8
inches and 4 inches respectively. The
scale was divided into twenty equal
horizontal and vertical lines. The
scale was photogrophed, reduced
eight times and printed on Kodalith
transparency film* (Fig. 1), A large
magnifier was used to read eoch
film.
EosfiTian Kodak Compony
Rochesler, NY
 Fig. 3 Mean decrease in
bone score by polienf. Each
padenlhod (wo exominadons
over on 18-115 nion(h penod
26 OF Irme.
n = number of paired sur-
faces measured.

11 —
10 —
9—
8
7 —I
6

4 —

2 —\

30 70%

> 1 st exomination mean b o n e score 49.5 %

• 2nd e x c m i r a t i o n meori b o n e score 43,2 %

n = 1,201; p<01

All bone scores were measured by
the some exominer (WB). The ruler
was alwoys ploced over the film in
such a manner that the number 1
coincided with the apex of the tooth
being measured. The coronol base
line touched the image of the cusp
tip (Fig. 2). The bone scores were
read as a percentage of bone pre-
sent. The optimal bone height wos
considered to be 65 ± 5 percent of
the total tooth length. Measure-
ments were taken on the mesial and
distal surfoces of eoch tooth ex-
cluding the third molars.
The data were analyzed using the
Stotisticol Packoge for the Sociol
Sciences programs.* Bone scores
were anolyzed by patient, tooth sur-
faces, specific groups of teeth and
the relotionship of pocket depth
scores to bone scores.
27
Results
Analysis of Bone Scores
Meosurements were ottempted on
2528 surfaces. On two different oc-
casions 1201 paired surfaces were
measured. Measurements could not
be obtained on 126 surfoces (4.95
percent). The distal surfaces of the
maxillary cuspids and the mesial sur-
faces of the maxillary first bicuspids
were the most difficult areas to ob-
toin bone scores meosurements.
One hundred eleven surface mea-
surements had higher bone scores
on the second examination. When
the bone scores were higher at the
second examination than those re-
corded at the first examination, the
modal difference was 5 percent, or 1
unit on the measurement ruler.
Analysis of Sorte Scores by Patient
The meon bone scores for each of
the 27 patients was calculated. The
averoge first examination score was
49.5%. The mean scores ranged
from 38.5% to 60%. Similorly, mean
bone scares were determined for
each patient at the second examina-
tion. The average second examina-
tion bone score was 43.2%. The
meon scares ranged from 35.4% to
53.4%. A decrease in mean bone
scares was observed for all 27 pa-
tients (Fig. 3)
Analysis of Sane Scores by Jooth
Surfaces
The bone scores were analyzed by
mesial and disfol toath surfaces.
These bone scores were compared
between the first and last examina-
tions. It was found thot the distol
surfaces had an initial overage bone
score of 48.13 percent, while the
mesial tooth surfaces hod an aver-
28

age initial bone score af 50.87 per-

cent. At the second exomination the Table 1 Bone Scores far Teeth Present at Both Examinations by Tooth Type,
mean bone score for the measured
distal surfaces was 42,40 percent. No. of 1st Exam 2nd Exam
The average mesiol bone score at
the last examinotion wos 44,93 per- Surface Mean Mean Relotive
cent. It is interesting to note that Scores Score S.D. Score S.D. Decrease
between examinations there was
close to a 6 percent decrease in Molars 317 45.5 11 36.5 16 19.8% P< .001
bone scores for both the mesial and
Bicuspids 356 52.0 9 46.5 13 10.6% P< .001
distal surfaces. Using the Student t
test the meon difference between Anteriors 528 50.5 8 46.5 10 7.9% P< 001
mesial and distal bone scores at
eoch exomination was significant at
the .001 level of probobllity. Similar-
ly, the changes in measurable bone
scares between examinations was
significant to the same level of prob-
ability.
 29

Bone Scores as Reloted to Tooth Type

Table 2 Mean Changes in Bone Scores Between Examinatians. Teeth are The mean bone scores ot each ex-
Ranked in Ascending Order Accorditig to First Examination Bone Scares. amination were analyzed according
to tooth type (Tables 1 and 2). The
Tooth No. Bone Score % Change molars started out with the lowest
1st 2nd in Score scores at the initial examination, and
Exam Exam hod the greatest relotive change in
scares between examinations (19 87
Molars percent). The bicuspids had a rela-
tive decrease in mean bone scores
15 17 37.Ó 32.4 13,8
of 10,6 percent, while the anterior
3 24 39,7 30.4 23.4
teeth had the least change in bone
2 23 40.0 32.8 18.0
scares [7.9 percent]
14 22 41.5 33.0 20.5
31 20 46.2 38,0 177
18 18 50.7 39.2 22.7
30 25 52.8 41.2 22,0
19 21 53.9 44.4 17.6

Bicuspid

4 23 44.4 37.6 15.3

13 23 47.5 38.6 18.7
12 22 48.2 43.7 9.3
5 22 48.3 41.7 137
20 26 55.2 53.4 3.3
28 24 55,8 51.2 8.2
29 25 5Ó.6 52.0 8.1
21 24 58.0 53.4 7,9

An ten a rs

8 23 46.4 42.8 7.8

7 21 47.3 43.4 8,2
9 23 47.7 42.0 11.9
24 27 48.0 44.0 8.3
10 24 48.4 41.4 14.5
23 25 49.3 47 1 4,5
ó 23 50,1 47.0 6.2
25 26 50,2 45.8 8.8
26 26 52,4 46.7 10.9
11 22 54,1 51,8 4.3
27 26 55.2 51,9 6,0
22 26 55,4 53,6 3,2

' * 1 5 isthe upper efl second moiat.

 fig 4 The lebdonship
30 between mean bone scores
ond rtiean poctel dep(hs ol
eoch e^aminodon.

• é
i

* •

*
n Perc

•
W
LO
3JO

ÍA • • V
<
one

t
• •

_^ • •

»
1 •

2.8 3.2 3.6 4.0 4.4 48 5.2 5.6 6.0 6.4

Mear Pociíet Depths in mm. r = —.54,

Mean Bone Score ail Patients = 46.8%
Mean Pocket Depths = 4.03 mm.
 31

Bone Scores versus Pocket Depth

Table 3 Analysis of Surface Bone Scores by Exominatian
The bone scores for eoch patient at
each exomination were analyzed in
relation to pocket depth scores ob- A. First examination bone scores of N X O
tained at the same examination. The teeth present on second examination
association between bone scores Distal surfoce 583 9.63 2.14
and pocket depths is shown in Fig- Mesial surfoce 618 10.17 2,05
ure 4. The correlation |r--,54) repre-
sents a tendency far packet depths B. First examinations bone scores of
and bone scares to parallel one teeth missing between examinations
another, however, the correlation is Distal surface 48* 7.60 3.85
not significantly large enough to be Mesiol surface 48 7.94 3,40
able to predict bone score changes
from pocket depth scores. C. Second examination bone scores of
teeth present on second examination
Distol surface 583 8.44 2.86
Bone Scores on Teeth which were Lost
Mesial surfoce 618 8,99 2,89
between Exominotians

The bone scores measured on teeth ttest A:B P<0.01 A:C P<0.01
which were present on the first
examination, but which were lost be-
Does not inciude 7 teeth lost from 2 patients who received both exominotions bul for
tween examinotions, were studied whom a second set of X-roys couid not be lound, ond does not include 3 missing third
(Toble 3). From the data it is appar- moiars not inciuded in this sludy
ent that the teeth which were lost n = number of surfaces
hod significantly lower bone scores X = meon
a = stondard deviotion
than did those which were present ot
both examinotions. Bone scores for
the distal and mesiol surfaces of
teeth which were subsequently lost
between examinations had lower
surface scores than did those sur-
faces of teeth which were present ot
both exams.
32
Discussion
The development and progression of
periadontal diseases is generally
considered to be o slow process.
Until recently little has been known
about the rate of progression of the
disease."" Loe and co-workers hove
recently reported their findings on
the rate of periodontol destruction in
individuals 40 years of age ond
younger. The meon loss of attach-
ment in the untreated Sri Lankon
population was 4.50 mm, with o
meon annual rate of progression of
0.20 mm per yeor for the buccal
surfaces and 0.30 mm for interpraxi-
mal surfoces. In their study of
untreated periodontal diseose, it
was found to be progressive. The
rate of progression appeared to be
slow.'
The 27 untreoted periodontal
patients in this study had meon de-
creases in bone scores at the second
examination. This finding would sup-
port the recent study by Loe ond co-
workers thot untreated periodontol
disease results in loss of periodontal
ottachment. The omount of progres-
sion voried from patient to potient
and tended to be age related.
Patients younger thon 44 yeors of
age had greater decreoses in bone
scares than did those individuols in
the older age groups.
When bone scores were compared
between the mesiol and distol sur-
foces, it became evident that the
distal surfaces uniformly had tower
bone scores thon did the mesial
surfaces. This observotion wos
apparent ot both examinations. The
mean difference between the distol
and mesiol bone score measure-
ments wos six percent. This differ-
ence between mesial ond distal
bone scores wos opporent when the
second examinotion scores were
anolyzed. The difference in bane
scores between distal and mesiol
surfaces wos not reported in previ-
ous popers.''^'^ Bprn, Hailing, and
Thyburg measured mesial ond dista!
surfaces and then determined mean
bone scores for individuol teeth and.
patients.^
The molars had the greotest de-
creoses in bone scores between
examinations. The bicuspids and
anteriars respectively had the next
greatest decreoses in bone scores.
The Sri Lankon untreated population
had the greatest loss of attochment
on the buccal aspects of molors ond
bicuspids.^ While the Sri Lonkan
study measured clinical attachment
levels and we measured bone
scores, it is interesting to note than in
both studies the molors and bicu-
spids hod the greatest mean loss of
attachment between exominations.
The moxillary molars, in particulor,
hod the lowest mean bone scores at
bolh exominotions.
When the pocket depth scores for
each potient were compared with
the bone scores for the same exami-
notion there wos an insignificant cor-
relation. Suomi reported a relotion-
ship between rodiographic bone
measurements and surgicol meo-

surements; however, pocket mea-
surements and radiographie bone
measurements were found to have a
high degree of variability.^ It is appa-
rent from our study and the work of
others that there is not o good rela-
tionship between pocket depth and
measurable bone loss, end that nei-
ther can be used to predict chonges
in the other.
It was noted thot in one hundred
eleven measurements the bone
scores at the second examinotion
were higher than those scores
recorded at the first examination.
This finding can either be attributed
to measurement error, or is a result
of spontaneous improvement. This
finding hos not been previously
reported, ond caution is urged in
interpreting its significance. When
observed, the increase in bane
scores amounted to one measurable
unit, or 5 percent.
Interpreting data obtained from
bone score measurements is difficult.
The scores represent mean inter-
proximal bone measurements. There
are obvious differences between
patients and within the same patient,
which affect the scares. Tooth
anatomy, film placement and angu-
lations all affect accurate bane mea-
surement. If these factors are kept in
perspective, the use of bone scoring
techniques can be a valuable aid in
evaluating the progression of
periodontal diseose in epidemialagi-
cal or clinical studies.
Sutnmar/
Twenty-seven diagnosed but un-
treated patients with periadontal dis-
ease were examined a minimum of
two times. Bone score meosure-
ments were determined for each
potient, tooth, and tooth surface. The
mean bone scores decreased for all
twenty-seven patients. The distal sur-
faces at each examination had lower
average bone scores than did the
mesiol surfaces. As a group, the
molars had the lowest initial bone
33
scores and had the greatest de-
creases in bone scores between
examinations. D
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Alveolor, Bone Loss os Relaled to Oral
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Radiographic Determination of Periodontol
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Bprn, H., Haliing, A., and Thyberg, H
Rodiogrophic Assessment ol Morginol
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Ramfiord, S.
J. Periodont. Res. 9; Suppl. 1-1:78, 1974.
Becker, W , Berci, L , Becker, B
Untreated Periodontai Diseose' A Longitud-
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M,
The Naturoi History o\ Periodontal Disease
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