Comparison of Gingival Health and Gingival Crevicular Fluid Flow in Children With and Without Diabetes M. L. RINGELBERG, D. 0. DIXON, A. 0. FRANCIS, and R. W. PLUMMER
College of Dentistry, Universit), of Florida, Gainesville, Florida 32610, USA A gingival crevicular fluid (GCF) flow meter was used to measure the GCF flow rate in 56 children with diabetes and 41 children without diabetes. The GCF readings were compared with clinical scores of gingival disease for the same teeth. The children with diabetes had significantly more gingival inflammation than the children without diabetes.
The measurement of early inflammatory changes in the gingiva has lacked reliability because of the inherent subjectivity of the various clinical indexes used. Changing interpretations of the diagnostic criteria used have resulted in both intraexaminer and interexaminer variability. In an effort to develop a measure of inflammation that is less dependent on subjective estimation than the clinical indexes, Brill1 suggested a procedure for measuring the amount of gingival exudate. The amount of fluid released into the gingival crevice was found to be associated with the amount of inflammation present. The gingival crevicular fluid (GCF) could be absorbed by strips of filter paper and then disclosed by a solution of ninhydrin and measured. Egelberg2 found a high positive correlation between the measurement of gingival exudate with the ninhydrin technique and a clinical scoring system in which inflammation was graded from 0 to 3. Other investigators3'4 also found a correlation between the amount of gingival fluid exuded and clinical scoring. A small but consistently measurable amount of GCF flow was found to be present even with clinically healthy gingiva.5 Recently, a flow meter has been developed that measures the amount of GCF. The use of the GCF flow meter was compared with the ninhydrin staining method of quantifying GCF flow and found to be more accurate and reliable.6 The filter paper strips used to absorb the GCF could be inserted for a shorter period Received for publication February 23, 1976. Accepted for publication April 22, 1976.
of time, and repeated measurements were found to give similar flow rates.7 Some investigators have found a greater frequency of gingival disease in children with juvenile diabetes than in children without diabetes.8-10 This study was designed to compare the gingival health of diabetic children with the gingival health of nondiabetic children as measured both by GCF flow meter readings and by the use of a clinical index. It was possible also to determine the correlation between the GCF flow meter readings and the clinical index scores. The use of the GCF flow meter was evaluated as a possibly reliable quantitative measure of early inflammation that could be adapted for use as an epidemiologic measure or as a method that could be of value in the clinical testing of therapeutic or preventive products designed to reduce gingivitis. Materials and Methods A total of 56 children with diabetes were examined at the Camp for Children and Youth with Diabetes, near Melrose, Fl. All of the children had juvenile diabetes and ranged from 10 to 16 years of age. The comparison group was composed of 41 children without diabetes from Fort Clarke Middle School, Gainesville, Fl, who ranged from 10 to 12 years of age. The examinations were conducted with the aid of an artificial light source, mouth mirrors, cotton rolls, and a chip syringe. The clinical index used was a modified gingival index (MGI) adapted from the Ramfjord1' index that scores inflammation on a scale of 0 to 3 with zero representing clinically healthy tissue. The criteria for the index are as follows: 0, absence of signs of inflammation; 1, mild to moderate inflammatory gingival changes, not extending completely around the tooth; 2, mild to moderately severe gingivitis completely circumscribing the tooth; and 3, severe gingivitis characterized by noticeable redness, swelling, tendency to bleed, and ulceration. Examination is limited to six se-
108 Downloaded from jdr.sagepub.com at UNIV OF PITTSBURGH on March 10, 2015 For personal use only. No other uses without permission.
TABLE 1 MEAN GCF I FLOW BY
AGE
METERREADINGS
AND
(yr)
N
SEX Maxillary Mandibular
10.6 6.4
9.8 14.6 17.6 13.9 17.8 11.2
14
13.8
23.6
18
15.8 8.9 22.5 13.7
9 24 8 41 17 24
12
Total Males Females
Without Diabete as 10
3.6 10.2 7.4 8.2
chip syringe.
thus removing
any
residual fluid from the
area
the crevice. After 27 seconds, another strip was inserted at the same location and left for three seconds. This strip was then removed and placed between the calipers of the GCF flow meter and the GCF reading for the maxillary was
recorded for that strip according to
was
repeated on the mandibular arch. All of the recorded by
clinical index
dren with diabetes was 30% male and the group of children without diabetes was 41% male. Results Age-specific GCF readings are given in Table 1. The children with diabetes had higher mean GCF readings at each age except for the readings on the mandibular incisor for the 12year-old children. There was no increase in GCF readings with age. Males had higher readings for the maxillary incisor in both groups and also had higher readings for the mandibular incisor in the group of children without diabetes. There was little difference in mean scores between the sexes among the children with diabetes. A point biserial correlation coefficient (rpb) was calculated for the GCF readings and the MGI score for the same tooth; the results are given in Table 2. The MGI scores were
14.7 3.0 13.1
17
13.9
19.1
Electronics Ltd., Winnipeg, Can.
arch
the manufacturer's directions. The procedure
aminer just before taking the GCF readings. The mean ages for the group of children with diabetes and the group of children with-
2 56
2 6 3
Harco
a
16.1
16.2 22.0 22.2 29.3 15.0 20.1
11
lected teeth: the maxillary right first molar, left central incisor, and left first premolar and the mandibular left first molar, right central incisor, and right first premolar. The soft tissue around each tooth is scored only if these teeth are present or if a permanent tooth distal to a selected tooth is present when the selected tooth is absent or is a deciduous tooth. Only fully erupted teeth are scored if the occlusal or incisal surface has reached the occlusal plane. The Harco* GCF flow meter was used with Har-601 gingival filter paper strips. An intracrevicular technique was used to measure a 30-second flow rate on the maxillary left central incisor and the mandibular right central incisor of each patient. The maxillary anterior *
dried with
of
With diabetes 10 11
Total Males Females
cotton rolls and A filter paper strip was then inserted in the crevice along the distobuccal surface of the tooth. After three seconds, the strip was removed and discarded,
first isolated with
area was
Child's Age
11 12 13 14 15 16
109
GCF FLOW IN CHILDREN WITH DIABETES
Vol. 56 No. 2
out
diabetes
scores
were
respectively. Both
were
11.7
years
groups
and 11.0
were
white and 10% nonwhite. The
group
Maxillary central incisor Children with diabetes Children without diabetes Mandibular central incisor Children with diabetes Children without diabetes
rpb
P
0.34
9.34 8.30
17.64 7.82
-0.02
College of Dentistry, Universit), of Florida, Gainesville, Florida 32610, USA A gingival crevicular fluid (GCF) flow meter was used to measure the GCF flow rate in 56 children with diabetes and 41 children without diabetes. The GCF readings were compared with clinical scores of gingival disease for the same teeth. The children with diabetes had significantly more gingival inflammation than the children without diabetes.
The measurement of early inflammatory changes in the gingiva has lacked reliability because of the inherent subjectivity of the various clinical indexes used. Changing interpretations of the diagnostic criteria used have resulted in both intraexaminer and interexaminer variability. In an effort to develop a measure of inflammation that is less dependent on subjective estimation than the clinical indexes, Brill1 suggested a procedure for measuring the amount of gingival exudate. The amount of fluid released into the gingival crevice was found to be associated with the amount of inflammation present. The gingival crevicular fluid (GCF) could be absorbed by strips of filter paper and then disclosed by a solution of ninhydrin and measured. Egelberg2 found a high positive correlation between the measurement of gingival exudate with the ninhydrin technique and a clinical scoring system in which inflammation was graded from 0 to 3. Other investigators3'4 also found a correlation between the amount of gingival fluid exuded and clinical scoring. A small but consistently measurable amount of GCF flow was found to be present even with clinically healthy gingiva.5 Recently, a flow meter has been developed that measures the amount of GCF. The use of the GCF flow meter was compared with the ninhydrin staining method of quantifying GCF flow and found to be more accurate and reliable.6 The filter paper strips used to absorb the GCF could be inserted for a shorter period Received for publication February 23, 1976. Accepted for publication April 22, 1976.
of time, and repeated measurements were found to give similar flow rates.7 Some investigators have found a greater frequency of gingival disease in children with juvenile diabetes than in children without diabetes.8-10 This study was designed to compare the gingival health of diabetic children with the gingival health of nondiabetic children as measured both by GCF flow meter readings and by the use of a clinical index. It was possible also to determine the correlation between the GCF flow meter readings and the clinical index scores. The use of the GCF flow meter was evaluated as a possibly reliable quantitative measure of early inflammation that could be adapted for use as an epidemiologic measure or as a method that could be of value in the clinical testing of therapeutic or preventive products designed to reduce gingivitis. Materials and Methods A total of 56 children with diabetes were examined at the Camp for Children and Youth with Diabetes, near Melrose, Fl. All of the children had juvenile diabetes and ranged from 10 to 16 years of age. The comparison group was composed of 41 children without diabetes from Fort Clarke Middle School, Gainesville, Fl, who ranged from 10 to 12 years of age. The examinations were conducted with the aid of an artificial light source, mouth mirrors, cotton rolls, and a chip syringe. The clinical index used was a modified gingival index (MGI) adapted from the Ramfjord1' index that scores inflammation on a scale of 0 to 3 with zero representing clinically healthy tissue. The criteria for the index are as follows: 0, absence of signs of inflammation; 1, mild to moderate inflammatory gingival changes, not extending completely around the tooth; 2, mild to moderately severe gingivitis completely circumscribing the tooth; and 3, severe gingivitis characterized by noticeable redness, swelling, tendency to bleed, and ulceration. Examination is limited to six se-
108 Downloaded from jdr.sagepub.com at UNIV OF PITTSBURGH on March 10, 2015 For personal use only. No other uses without permission.
TABLE 1 MEAN GCF I FLOW BY
AGE
METERREADINGS
AND
(yr)
N
SEX Maxillary Mandibular
10.6 6.4
9.8 14.6 17.6 13.9 17.8 11.2
14
13.8
23.6
18
15.8 8.9 22.5 13.7
9 24 8 41 17 24
12
Total Males Females
Without Diabete as 10
3.6 10.2 7.4 8.2
chip syringe.
thus removing
any
residual fluid from the
area
the crevice. After 27 seconds, another strip was inserted at the same location and left for three seconds. This strip was then removed and placed between the calipers of the GCF flow meter and the GCF reading for the maxillary was
recorded for that strip according to
was
repeated on the mandibular arch. All of the recorded by
clinical index
dren with diabetes was 30% male and the group of children without diabetes was 41% male. Results Age-specific GCF readings are given in Table 1. The children with diabetes had higher mean GCF readings at each age except for the readings on the mandibular incisor for the 12year-old children. There was no increase in GCF readings with age. Males had higher readings for the maxillary incisor in both groups and also had higher readings for the mandibular incisor in the group of children without diabetes. There was little difference in mean scores between the sexes among the children with diabetes. A point biserial correlation coefficient (rpb) was calculated for the GCF readings and the MGI score for the same tooth; the results are given in Table 2. The MGI scores were
14.7 3.0 13.1
17
13.9
19.1
Electronics Ltd., Winnipeg, Can.
arch
the manufacturer's directions. The procedure
aminer just before taking the GCF readings. The mean ages for the group of children with diabetes and the group of children with-
2 56
2 6 3
Harco
a
16.1
16.2 22.0 22.2 29.3 15.0 20.1
11
lected teeth: the maxillary right first molar, left central incisor, and left first premolar and the mandibular left first molar, right central incisor, and right first premolar. The soft tissue around each tooth is scored only if these teeth are present or if a permanent tooth distal to a selected tooth is present when the selected tooth is absent or is a deciduous tooth. Only fully erupted teeth are scored if the occlusal or incisal surface has reached the occlusal plane. The Harco* GCF flow meter was used with Har-601 gingival filter paper strips. An intracrevicular technique was used to measure a 30-second flow rate on the maxillary left central incisor and the mandibular right central incisor of each patient. The maxillary anterior *
dried with
of
With diabetes 10 11
Total Males Females
cotton rolls and A filter paper strip was then inserted in the crevice along the distobuccal surface of the tooth. After three seconds, the strip was removed and discarded,
first isolated with
area was
Child's Age
11 12 13 14 15 16
109
GCF FLOW IN CHILDREN WITH DIABETES
Vol. 56 No. 2
out
diabetes
scores
were
respectively. Both
were
11.7
years
groups
and 11.0
were
white and 10% nonwhite. The
group
Maxillary central incisor Children with diabetes Children without diabetes Mandibular central incisor Children with diabetes Children without diabetes
rpb
P
0.34
9.34 8.30
17.64 7.82
-0.02
